Impact of leadership on ICU clinician's burnout
ABSTRACT
Introduction: Global spreads of burnout among healthcare practitioners, particularly within intensive care units (ICUs), has been described as a growing crisis with a variety of unwanted consequences as drawbacks (1).
Aim of the work: Our primary objective was to explore the prevalence of burnout in this area among different healthcare givers; we also focused on identifying the contributing factors as well as the role of empowerment and leadership impact.
Methodology: We employed a cross-sectional descriptive study with purposive sampling. A combined methodological approach (quantitative and qualitative) was used with questionnaires. We used five instrument: Conditions of work effectiveness scale (CWES), Work stress scale (WSS), Maslasch Burnout scale (MBI-HSS), Leadership scale (LS), and Empowerment scale (ES).
Results: We studied 200 healthcare practitioners within medical and surgical ICUs. The case study that focused on Qatari intensive care confirmed a high prevalence of burnout (25.5%), where physicians, nurses, and respiratory therapists were equally at risk (p=0.19). Younger individuals were more likely to burn out (p=0.000). We report a high association of burnout with the instruments that we used. Both positive leadership and empowerment had a negative effect on burnout variance (12.4 and 3.8%, respectively) when considering practitioner burnout.
Conclusion: The reported high burnout rate among practitioners in ICU settings necessitates special attention in terms of positive leadership attitudes; empowerment could serve as an ameliorating factor.
Key words: burnout, ICU, practitioners
Introduction
Care of critically ill patients recognized as highly demanding and challenging profession, it requires extensive effort and communication between the staff during which professionals are exposed to variable degrees of work-related stress. Pressures related from financial demands as well as diagnostic, monitoring and therapeutic techniques put extra burden on intensive care unit (ICU) staff.
According to Miller, et al., (1990 existence of stress and burnout in the workplace as well as related outlay affect many variable levels in the community. The ICU is one of the front lines in dealing with health care related crisis that could place the providers on variable degrees of psychological stress [1]. Staffing in ICU involved multiple specialties (physicians, nurses, respiratory therapists, and clinical pharmacists), and dealing with these diversified practitioners is a difficult task that needs knowledge, skills and proper communication [2].
In an attempt for ICU leaders to get higher performance, burnout problem needs to be looked at with special attention as prophylaxis is better than treatment in medicine and it seems that having burnout oriented field with tools for the early management seems to be attractive goal. It is reasonable that leader empowerment of the staff could have a positive impact on the overall progress, execution and engagement at work.
Burnout could be presented with irritability, insomnia, feeding problems and depressive attitude as well as increased leave requests among staff. Low performance at workplace and high resigning intentions could be attributed to emotional exhaustion. Job satisfaction depends on work and organization; the former is related to workload, social backup, and autonomy while the latter is related to authority and decision-making. Individual characters, work conditions as overload, feeling of valueless job, and disputes predispose to burnout [3].
Linkage between emotional stress and burnout exist as expressed in a study conducted in UK physicians, higher stress associates higher emotional exhaustion. Emotional tiredness, depersonalization, and reduced personal and professional achievements characterized the burnout. The high association in healthcare may result from daily management of complex, stressful situations and intense interpersonal relations [4]. The decision-making could involve conditions of life and death as well as withdrawing and withholding life supportive measures. Staff retention is another risk factor. Nurses are more exposed to burnout than physicians, at least one-third experienced severe burnout syndrome symptoms at certain time. Burnout could be attributed to conflicts at workplace between practitioners and younger age of the practitioners is more susceptible [5].
According to Aiken, et al., (2002) different forms of leadership may be required through professional career development, however complexity in the leadership and burnout relation exists. Protection against the depersonalization could be attributed to transformational leadership [6]. Stress released from the physical and social factors as well as vagueness of roles, but leadership management could significantly lead to increased emotional exhaustion levels. [7].
Leader-empowering attitude significantly enhanced staff approach to empowerment structures that is linked with reduction of the encountered job tension and enhancement of work effectiveness [8]. Nurses working with sounding leaders got significantly lower levels of emotional exhaustion and associated stress, and they got also preferable communication with physicians, superior satisfaction with their leaders and their jobs, which reflected on improvement of patient care demands than did nurses working for discordant leaders [9].
Empowerment as a factor in burnout, that latter affects attraction and retention of the experienced health care staff. Positive work environments rely heavily on the leaders who heavily influence medical staff performance and response to working conditions as well as the quality of care supplied to the customers. Empowerment techniques seem to offer the staff more satisfaction as sharing in decision making, enhancing the work value, facilitating target achievements, trusting high execution, and releasing bureaucratic boundaries to have more autonomy. Leader empowering attitude involved adequate control in terms of clear roles and responsibilities, adequate reward system, fairness and conformity between organization and employee's needs [10].
Empowerment is hypothesized to improve nurses and patients capabilities to convey their requirements that could manage their lives [11]. Wise & Billi (1995) mentioned that implementing, work support methodology should involve clinical leaders to carry the organizational or the governmental messages through endorsing and adopting guidelines in the regional or local circumstances [12].
Objectives of the study
This study predominates at investigating the burnout problem which is poorly estimated in health care; the author aim at the present study the prevalence of burnout within the intensive care settings in a particular institution, and whether the leadership attitude could increase or ameliorate the problem. As well the effect of participant empowerment on ameliorating this condition will be considered.
Methodology
Settings
This study conducted in two intensive care units (ICU), in a tertiary hospital in the Middle East. The number of beds in each ICU was 20 and 12 respectively. The participants were screened for socio-demographic data such as age, gender, profession, marital state, education, native country, years of experience, weekly working hours and salary. The questionnaire were clarified to the potential respondents in order to clear any poor understanding. English used as the official language in the organization; translation of the used instruments to individual mother languages is not required.
Design
Cross-sectional descriptive survey with purposeful sampling. Mixed qualitative and quantitative methodology used in this dissertation. Invitations to participate through the corporate mail, anonymous questionnaire survey were presented to the staff members including physicians, nurses and respiratory therapists who work as full time.
Instrumentation
The used instrumentation is questionnaire that is divided into the following sections:
A) Condition of work effectiveness questionnaire (CWEQ): This scale consisted of 19 items developed by Kanter, (1977) measured by a 5 point Likert type response [13]. B) Occupational stress scale (WSS): A three-point scale was used in which low stress = 1, moderate stress = 2, and extreme stress = 3. The total number of declaration in the scale will be 15 [14]. C) Maslach Burnout Inventory human services survey (MBI-HSS): The scale is a standardized instrument to measure burnout it utilize 9 items related to emotional exhaustion and it is most frequently used in health care researches, the nine items are calculated to get the whole score, scores of 27 and more signaled high burnout [15]. The percentage of high degree of burnout was used for advanced analysis. We got permission to use this scale from (Mindgarden.com, USA). D) Psychological Empowerment Scale (ES): A 12 items scale considering work meaning, efficiency, autonomy, and impact (Spreitzer, 1995). Each of the preceding four components is measured by three items through 7 point Likert scale ranging from very strong disagreement (1 point) to very strong agreement (7 points). Calculating the total 12 items to get the total Psychological Empowerment score. [16].E) Leadership Behaviours scale (LS): The staff discernment of managers’ leadership attitude were measured using the 11 item Manager Action Scale. [17].
The questionnaires were submitted in English form; no need for translation, as health care practitioners in the organization, must practice English that is the official language at workplace. The results of the analysis will be presented using descriptive methods. The quantitative and qualitative data will be analyzed statistically, the relations between the variables will be interpreted, the relation between burnout score and socio-demographic variables, occupational stress score, and empowerment scale will be assessed statistically using (t-test, analysis of variance, correlation efficient and regression).
Ethical Considerations:
Participant identity kept confidential, final report would not contain any identity. Comprehensive explanation for the participants about the questionnaires, the type, purpose of the study and outcome was done, early rejection, or late withdrawal was permissive. Ethical approval was obtained according to the corporate regulations. The ethical consent attached after being approved from university of Liverpool and medical research center. IRB Approval 14281/14 by HMC research center.
Data Collection Procedures
The purpose of the study was explained to the managing directors in the hospitals. Clarifying the study to managers of the units after initial hospital authorization was procured. The questioners (appendix A) were driven through the corporate mail to the respondents. Survey-Monkey was used to deliver the questioners and to receive the responses. The questioners composed of 5 sections (Appendix A).
Statistical analysis
Data were presented as mean ± SD for quantitative data and frequency and proportion for qualitative data. Median and range were calculated for non-normal continuous distributed data. Statistical significance tests included: For quantitative data, the student's t-tests and Mann-Whitney U tests (if data is not non-normally distributed); and Chi-square tests for categorical variables. A P-value of <0.05 (two tailed) was considered the statistical significant level. Multivariate regression analysis performed for significant data in a univariate analysis, both within group agreement (rwg) and interclass correlation
(ICC) assessed. Individual data could not be aggregated to the level of the group if rwg median equal or was less than 0.7. Variability between the groups should be higher that variability within groups (James, Demaree, & Wolf, 1984). Clinical and laboratory data was entered into a database (Microsoft Excel 2013, Redmond, WA, USA) and statistical analyses performed (SPSS Inc., Version 21. Chicago IL, USA).
Results
Descriptive Statistics
The participant's background initially determined all were health care practitioners highly educated. Then the contents were transferred to statements. The validity was established through face validity where questionnaires intention of measurement was addressed, making sure it represent the contents, appropriate for the studied population, and appearance of the instrument look like a questionnaire [18]. A pilot test including 20 subjects who not enrolled in study sample was tested to check the reliability of the questionnaires, the collected data were analyzed by SPSS [18].
Missing Data
The missing data managed statistically; it comprised less than 6% for all scales and most in demographic variables. The “highest degree” was the main missing variable in the demographics ad it was missing 4% of the time.” No specific missing pattern identified after examination with t-test and Chi-square.
Questionnaires were distributed to 390 health care practitioners including physicians, nurses and respiratory therapists working on two inpatient medical and surgical intensive care units. Two hundred practitioners completed and returned the questionnaires, for a 51.8% response rate. The response rates for all participating units reached 200 participants, which was the desired target. The mean ageSD of the participants was 36.36.7, the rest of the demographic characteristics were shown in (table 1)
Validity and reliability of the questionnaires
The validity of the five used instruments demonstrated in previous literatures. However, the design of the survey included a blend of the instruments for which validity needed to confirmation. Reliability is tested by Cronbach’s alpha and ICC. Adequate ICC is .72 but .8 is preferred denoting high-reliability level. The mean rwg (in group agreement) was 0.827 denoting adequate intergroup aggregation above ICC was .60 and the rwg was .70, the instrument was considered to be in composition form [19].
Individual data distribution
The distribution of individual data for the MBI-HSS used instrument was examined to and found to have normally distribution (Figure 1) accordingly parametric statistics were suitable.
Statistical test of hypothesis
The prevalence of burnout in ICU staff is high in our study, we found that 51 respondents (25.5%) suffered a high degree of burnout, while 29 respondent (14.5%) suffered moderate degree of burnout The only significant relation was encountered with the gender distribution (table 3).
The relation between Maslach burnout score for human social services and the rest of the other used instruments was studied using Pearson correlation (table 4). We found significant correlation with age (p=0.000), CWES (p=0.008), WSC (p=0.000), ES (p=0.006), and LS (p=0.000) by 2-tailed test. Linear regression was attempted to draw relation between burnout measured by MBI and work condition subscale (table 5), where significant predictors for burnout accordingly were item 1 (challenging work) p=0.001, item 14 (seeking out ideas from professionals other than physicians) p=0.029, and item 6 (goals of management) p= 0.033. The r2 for this model was 0.309 thus work related conditions account for 37.9% of the variation in burnout. Linear regression was attempted to draw relation between burnout measured by MBS and leadership subscale, where no significant predictors for burnout among the subscale.
Next the leadership influence on high burnout was studied with linear path analysis with burnout measured by MBI as an outcome variable and leadership as a predictor variable. The path coefficient was .35 (p<.001). The result was statistically significant, however, r2 was .124, indicating that leadership accounted for only 12.4% of variance in practitioners burnout (figure 2)
Linear regression was attempted to draw relation between MBS and empowerment subscale (table 7), where significant predictors for burnout accordingly were item 4 (My impact on what happens in my department is large) p=0.004, and item 2 (The work that I do is important to me) p=0.048. Next the empowerment influence on high burnout was studied with linear path analysis with burnout as an outcome variable and empowerment as a predictor variable. . The path coefficient was .35 (p<.006). The result was statistically significant, however, r2 was .038, indicating that leadership accounted for only 3.8% of variance in practitioners burnout (figure 3).