Stress is an integral part of modern life. All people respond differently to many varied stresses in their life. Stress is not unique to emergency or ICU health workers. In fact all emergency workers including police officers, firefighters, dispatchers and rescue workers by the nature of their jobs are predisposed to job related stresses.In ancient Greece, the philosopher Epictetus described stress on the psychological basis as “ people are disturbed not by things but by the views they take of them”. Stress occurs as an internal response to disturbing stimuli, especially when the demands exceed the internal limit. Not all stress is bad. Actually most stress we feel is eustress (i.e. good stress). Eustress keeps people sharp ontheir job. It is the stress that produces human progress. When individuals exceed their ability to manage the stress, they start down the slippery slope of distress or bad stress. If an individual is distressed severely or for too long it can result in a burnout.<sec id="sec002"><title>What is Burnout?

Journal of Neonatology

0971-2179

National Neonatology Forum

jn-20-4-005

REVIEW ARTICLE

Stress and burnout in neonatal intensive care unit personnel

Saili

Arvind

*Kumar

Ajay

Division of Neonatology, Deptt of Pediatrics, Lady Hardinge Medical College, New Delhi 110001.

*E-mail: sailiarvind@gmail.com

10–122006

204338342

Stress is an integral part of modern life. All people respond differently to many varied stresses in their life. Stress is not unique to emergency or ICU health workers. In fact all emergency workers including police officers, firefighters, dispatchers and rescue workers by the nature of their jobs are predisposed to job related stresses.In ancient Greece, the philosopher Epictetus described stress on the psychological basis as “ people are disturbed not by things but by the views they take of them”. Stress occurs as an internal response to disturbing stimuli, especially when the demands exceed the internal limit. Not all stress is bad. Actually most stress we feel is eustress (i.e. good stress). Eustress keeps people sharp ontheir job. It is the stress that produces human progress. When individuals exceed their ability to manage the stress, they start down the slippery slope of distress or bad stress. If an individual is distressed severely or for too long it can result in a burnout.<sec id="sec002"><title>What is Burnout?

This psychiatric morbidity is one of the major occupational risk for health workers specially those working in Intensive Care Settings. The incidence of suicide, alcohol abuse, drug addiction and divorce among them are higher than in the general population (1). The term “burnout” was first used in the medical arena by Herbert Freudenberger in 1974 (2). ‘Burnout’ is defined as ‘physical, mental and emotional exhaustion’ caused by long term involvement in emotionally demanding situations. It is a progressive condition whereby there is loss of idealism, energy and purpose. Burnout can impair the quality of care delivered to the patients as well as have serious consequences for the personal life of the caregiver.

Is it common?

In a study done in Australia, 27% of the neonatologists and 32% of the NICU nurses had General Health Quotient Scores indicating psychological dysfunction (3). This is not only a condition afflicting the developed countries alone. Many districts and regional hospitals in less developed countries have units with severely ill patients cared separately for, although major intensive care units are only found in large hospitals of urban or metropolitan areas. High workload, low wages and risk of occupational infections explain burnout syndrome and low motivation in some health care workers (4). Burnout has been identified in every health care specialty studied including critical care (5), family practitioners (6), radiologists, surgeons and gastroenterologists (7).

What is the genesis?

There is general agreement in the medical literature that some degree of obsessionality of personality is extremely common in health personnel. This quality combined with high intelligence results in conscientiousness and commitment, which are considerable assets in any endeavor. However it is also a source of vulnerability. The work related stress could be defined by the principles of occupational psychology (Appendix-1).

The Karasek's model of “demand-control imbalance” states that the jobs are stressful if they combine high demands with no power or authority to alter the situation (8). It has been seen by Siegrist that the “effort-reward imbalance” is also a powerful source of work related ill health (9). The concept of “support” is added to capture the right notion of having the right tools for the job and supportive relationship in the work place (10). The various factors responsible for stress in NICU personnel have been summarized in Appendix-2. Burnout in NICU personnel in its end form can lead to attrition from neonatal practice and the need to find another source of livelihood or take early retirement. The important stresses in neonatal practice are;

Shift Duties: Shift duties at work are the single most important stressor in NICU practice. The basic problem with the shift work is the discrepancy between the need to sleep during the day when everything else tells the body to be awake. Day sleep is always shorter; this cuts off the amount of rapid eye movement (REM) sleep and leads to moodiness and irritability.

Lack of appreciation: The fishbowl nature of the NICU work is a continual stressor because every case that worsens or dies is subject to retrospective scrutiny of colleagues and seniors. They rarely hear about their successes but are always chided when they miss out on something.

Medicolegal threats and risk of litigation: Risk of malpractice action is serious stressor. This stress has been compounded by the fact that a judgment or settlement can create barrier to future employment or malpractice insurance. The initial reaction of the personnel is anger followed by feeling of isolation and despair. Doubts surface about one's ability and choice of profession. Physical illness, depression, burnout, negative repercussion on the family, disillusionment and plans for early retirement result from malpractice action.

Female NICU Personnel: Female personnel face additional stress. They are sometimes sexually harassed at the place of work. They report much higher incidence of depression than their male colleagues do. For them the family issues are at the forefront. Career demands conflict with the more traditional roll in the home.

Bullying: Bullying is “the deliberate, repeated, hurtful mistreatment of one person (the Target) by a perpetuator (the Bully) whose destructive actions are fuelled by the bully's need to control the target”. The incidence of bullying in health care ranges from 5% among doctors and nurses in Finland (11) to 80% for Australian nurses (12).

How does Stress and Burnout manifest?

While one may feel worn out by work at times, burnout is when one feels so chronically ground down that one's life and work suffer. In its more severe form burnout leads to lack of interest in work, complete disillusionment, hostility to patients, and feeling of hopelessness.

Symptoms of burnout

Loss of energy

Loss of interest in work

Loss of optimism

Feeling resentful

Hostility to patients or parents

Feeling of ‘Nothing’ left to give

Dreading going to work

Diagnosis

According to Maslach et al. (13) ‘burnout’ has three dimensions: 1). Emotional exhaustion, in which the overwhelming work demands deplete the individual's energy; 2). Depersonalization and cynicism, in which the individual detaches from the job; 3). and a feeling of inefficacy, in which an individual perceives a lack of personal achievement. These dimensions can coexist in different degrees. The 22-item Maslach Burnout Inventory (MBI) measures all three burnout dimensions. Each dimension receives an MBI score, which relative to normative scores for the work population, is categorized as low, medium or high. A high sub-score in emotional exhaustion or depersonalization is indicative of a clinically significant burnout. The MBI score has now become the gold standard for identifying burnout (13).

Prevention and Management

The first strategy for preventing burnout is to be aware of it as a potential problem. One should be able to recognize the “predictors of risk” and “red flags” for impairment. Then one must be better prepared as an individual and organization to treat early signs of distress.

Red Flags

The red flags indicating impairment are

Increasing incidence of complaints against/by the individual

Uncharacteristic interpersonal or other behavior

Falling standards and clinical errors

Failure to keep abreast of administrative demands

Lack of responsiveness and poor punctuality when called

Overt sign and symptoms of substance misuse or psychiatric illness

Management of Job Stress

It is believed that the “job stress” is a much greater problem than job dissatisfaction (14). The management of job stress can be divided into personal, professional and organizational levels.

Personal Management

Self-monitoring: Some argue that pressure is good as it can improve performance. This is true upto a point. Buus et al. highlighted this well in a editorial entitled, “If you didn't care it wouldn't hurt” (15). However, one must be able to recognize warning signs of over work and stress and slow down.

Identify main stressors: One should identify the things, which cause the stress. A problem solving approach is useful. Doing something about a problem can make one feel better.

Stress reduction: Small innovations can make a lot of difference. A quiet sitting room in the neonatal unit with music and coffee can provide a more relaxed and informal atmosphere.

Reviewing expectations and obligations: One's commitments need regular review and pruning in order to prevent overload. One can prioritize the work and go about doing it. Assertiveness and negotiating skills are needed to protect oneself from over commitment. Being clear with people makes them less likely to have expectations that one can't meet.

A positive emotional bank balance: There are things that “nourish” one self and the things that “drain”. One should list the aspect of one's life that drains and another list of those aspects that one needs in order to thrive. Paying attention to one's needs is not selfish, it is essential maintenance that allows one continue to function.

Experiencing success: One of the things that makes one happy is the experience of success. It is important to have clear goals that are achievable at work. One should also have a way of knowing when these goals are met. Certain degree of autonomy depending on level of confidence, knowledge, skill and experience of the staff should be encouraged.

Effective coping mechanism: Many coping behaviors may assist ICU care-givers in the process of caring for themselves. Staff support group, inter-disciplinary meeting to discuss difficult cases and bringing trained personnel into the ICU to offer staff training in communication and conflict resolution skills may help out (16). Exercise is well known to reduce stress and relieve depression. Sabbaticals, vacation, personal time, flexible schedules, shared positions and prioritizing family time will go a long way in alleviating burnout.

Professional Management

Difficulties in coping are often perceived as personal failure. One should have a supporting team. An effective health care team that provides clinical and emotional support for the team members can reduce the prevalence of burnout. An important part of team building is to be able to recognize stress in others and take appropriate action. They assure that one is not alone in having these problems. Informal discussion with the peers can resolve most of the troubling issues.

Benefits can be gained by clarifying the team roles, establishing team support meetings and extending the team to include other multidisciplinary members e.g. community clergy and volunteers.

Management at Organizational level

For many health professionals, organizational issues are complex and extremely frustrating. Burnout is a problem not just of individuals, but also of health care teams and services. A support system must be in place for the support and rehabilitation of dysfunctional health personnel.

Lack of training in communication and management skills can be one of the reasons of burnout. A modification in the teaching curriculum of doctors and nurses will go a long way in equipping them to cope with the demands of modern health care system like NICU.

Burn out is contagious

The burnout tends to pass from one doctor or nurse to another in the intensive care unit (17). It is hence, essential that the symptomatology is promptly diagnosed and addressed for early containment of the condition.

Conclusions

Stress in NICU personnel is a product of interaction between the demanding nature of their work and obsessive, conscientious and committed personalities.

In the face of extremely demanding work pressures, subjective lack of control and insufficient rewards are powerful source of stress.

If the demands continue to rise and adjustments are not made, then inevitably correction in the form of burnout or physical and/or mental impairment occurs.

Burnout is likely to increase in future with great parental/public expectations and increasing workload amongst NICU personnel.

All NICU personnel should be aware of the predictors of risk and early signals of impairment in their colleagues as well as about the available avenues of assistance.

Relevant medical organizations and the health administrators need to develop effective response pathways for assisting these impaired personnel at the earliest.

References1Anon., Burnished or burnt out: the delights anddangers of working in health. Lancet, 1994; 344: 1583–1584.2Freudenberger

. Staff burnout. J Social Issues, 1974; 30: 159–165.3Astbury

. Determinants of stress for staff in neonatal intensive care units. Arch Dis Child, 1982; 57: 108–111.4Dunser

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. Professional stress amongfamily physicians. J Fam Pract, 1985; 20: 165–171.7Ramirez

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. Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet, 1996; 347: 724–728.8Karasek

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<sec id="sec016"><title>Appendix-1: Application of Models of Occupational Psychology to Define Strain at the Work Place

Demand-Control Imbalance

Demand: Insufficient time, conflicting demand, high expectations, emotional intensity of the work

Control: Decision latitude (insufficient authority or seniority to make decisions), Skill discretion (insufficient training and practice to give a sense of mastery)

*Hence, strain results from simultaneous high demands and low control

Effort-Reward Imbalance

Effort: Demands (extrinsic), Coping (Intrinsic)

Reward: Work satisfaction, remuneration, recognition, esteem, status

*Strain results from lack of reciprocity between effort and reward

Support Systems

Instrumental Support: Physical environment, effective infrastructure.

Relational Support: Agreeable and supportive work colleagues and appreciative superiors.

*Strain results from inadequate physical and social support

<sec id="sec017"><title>Appendix-2: Sources of Stress in NICU Personnel

Intense and conflicting demands

The gravity, emotional intensity and responsibility entailed in the job

Insufficient resources, specially in the public sector

Constraints and demands (interference) of various agencies specially in private sector

Requirement for retraining and professional development

Medicolegal threats and risk of litigation

Demanding, hostile and emotionally difficult parents and even threat of violence

Soured relationship with the colleagues and staffs within the work environment

Loss of traditional status as a healer and negative media coverage

After hours and on call work

Interference with family life

Poor remuneration compared with the hard work involved

Lack of appreciation

Bullying tactics by seniors and/or administrators Adapted from Astbury and Yu (3).