An Approach to Addressing Trainee Burnout: Revising Fellow Shift Scheduling in the Intensive Care Unit

Namita Jayaprakash; Craig E Daniels; Courtney E Bennett; Kianoush Kashani

doi:10.4103/jtccm.jtccm_14_19

ORIGINAL ARTICLE

Year : 2019 | Volume : 1 | Issue : 3 | Page : 103-108

An Approach to Addressing Trainee Burnout: Revising Fellow Shift Scheduling in the Intensive Care Unit

Namita Jayaprakash¹, Craig E Daniels², Courtney E Bennett³, Kianoush Kashani⁴
¹ Department of Emergency Medicine, Division of Pulmonary and Critical Care, Henry Ford Hospital, Detroit, MI, USA
² Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
³ Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
⁴ Department of Medicine, Division of Pulmonary and Critical Care Medicine; Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA

Date of Submission	09-Aug-2019
Date of Acceptance	20-Aug-2020
Date of Web Publication	28-Oct-2020

Correspondence Address:
Dr. Kianoush Kashani
200 First St Sw, Rochester, MN 55905
USA

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jtccm.jtccm_14_19

Abstract

Introduction: Rotating shift patterns and night shifts are associated with fatigue and sleep deprivation, which in turn contribute to burnout. The aim of this quality improvement initiative at Mayo Clinic Rochester critical care fellowship programs was to implement a new critical care fellow shift schedule in the medical intensive care unit while evaluating the impact on self-reported burnout scores. Materials and Methods: Focus groups of fellows weighed pros and cons of the existing schedule and selected a revision of the schedule in which night shifts were grouped into blocks with limited frequency and incorporated a recovery period. Baseline self-reported burnout amongst critical care fellows was assessed using an abbreviated Maslach burnout inventory (MBI) screening questionnaire and re-evaluated at the end of the implementation period. Results: At baseline, 33 of 45 (73%) fellows responded to a survey with the abbreviated Maslach Burnout Index questionnaire. Median (IQR) scores for each of the domains were 10 (6-12) emotional exhaustion, 3 (1-9) depersonalization, and 15 (13-17) personal accomplishment. For the post-intervention survey, 17 out of 24 (71%) responded. The median (IQR) score for critical care internal medicine and pulmonary and critical care fellows was 7 (4-11), P=.06 and 9 (7-11), P=0.5 for emotional exhaustion; 3 (0-6), P=.07 and 5 (0-11), P=1.0 for depersonalization score; and 16 (11-17), P=.31 and 15 (12-17), P=.75 for personal accomplishment score. Discussion: Reducing the number of day-night rotations, incorporating a scheduled recovery period, and limiting the number of recurrent consecutive nights resulted in a trend towards improvement of self-reported burnout amongst critical care fellows.

Keywords: Burnout, education, intensive care training

How to cite this article:
Jayaprakash N, Daniels CE, Bennett CE, Kashani K. An Approach to Addressing Trainee Burnout: Revising Fellow Shift Scheduling in the Intensive Care Unit. J Transl Crit Care Med 2019;1:103-8

How to cite this URL:
Jayaprakash N, Daniels CE, Bennett CE, Kashani K. An Approach to Addressing Trainee Burnout: Revising Fellow Shift Scheduling in the Intensive Care Unit. J Transl Crit Care Med [serial online] 2019 [cited 2023 Mar 31];1:103-8. Available from: http://www.tccmjournal.com/text.asp?2019/1/3/103/299475

Introduction

Burnout affects up to 50% of physicians, including critical care physicians and trainees.^[1],[2],[3] The development of burnout syndrome has a direct impact on patient outcomes because it adversely affects the delivery of patient care.^[3] An increasing prevalence of this syndrome, reaching epidemic rates, prompted the Critical Care Societies Collaborative to issue a “call for action” statement in 2016 on burnout syndrome, which addressed the need to increase awareness.^[3]

Contrary to common perceptions, younger physicians, have twice as much burnout as their older colleagues, potentially starting as early as residency.^[3],[4] Rotating shift patterns and night shifts are associated with fatigue and sleep deprivation. One observational study reported that as trainees progressed from night 1–5, they tended to sleep more before their shifts, and the greatest risk for significant fatigue was associated with the first night shift.^[5]

The implementation of resident duty hours, with oversight from the Accreditation Council for Graduate Medical Education (ACGME), has resulted in a transition to shift work in many intensive care units for trainees.^[6],[7] Shift work disrupts the circadian rhythm, affects the quality and quantity of sleep, and possibly affects the innate and acquired immune system.^[8] These combined factors impact burnout.

The Mayo Clinic Critical Care fellowship programs recognized the potential risk for trainees to suffer burnout due to sub-optimal night shift scheduling during the medical intensive care unit (MICU) rotation. The MICU critical care fellow schedule consists of 12-hour rotating shifts beginning at 6 am or 6 pm. A lack of consistent patterns in the day-night switches and lack of built-in recovery periods following consecutive night shifts led to a sense of dissatisfaction amongst fellows. Thus, we recognized an opportunity to address fellow wellness by improving efficacy in the shift schedule. The primary aim of this quality improvement initiative was to optimize the MICU shift schedule for critical care fellows by reducing the number of day–night rotations, limiting the number of recurrent consecutive nights and incorporating a scheduled recovery period, while evaluating the impact on fellow burnout.

Methods

This single-center quality improvement initiative was conducted at Mayo Clinic in Rochester, Minnesota, and was exempt from IRB review. The Standards for Quality Improvement Reporting Excellence Guidelines are followed for reporting this study.

At Mayo Clinic Rochester, there are four related but distinct critical care fellowship programs, including 1-year critical care anesthesia (CCA), 2-year critical care internal medicine (CCIM), 3-year pulmonary, and critical care medicine (PCCM), and 2-year neurocritical care (NCC). During the 2015–2016 academic years, 45 fellows were enrolled in these programs. Each fellowship requires a number of MICU rotations as either a core rotation or elective.

Intervention

Suspected fatigue and emerging critical care fellow burnout with the existing MICU schedule were the large driving forces behind this quality improvement initiative. The Mayo Clinic MICU critical care fellow schedule template, [Figure 1], included multiple rotations of night and day shifts throughout a 4-week block. Each shift totaled 12 h in duration from 6 am– 6 pm or 6 pm– 6 am. Multiple small focus groups of critical care fellows met to assess the pros and cons of the existing MICU fellow schedule. Concerns raised revolved around frequent switches from night to day and a lack of recovery period after multiple nights before having to return to a day shift. Following input from the focus groups, four potential revisions to the schedule were developed. The revisions incorporated the input provided by the focus groups and consideration for recovery periods following night shifts. All of the critical care fellows were surveyed to identify their preferred choice of revised scheduled to be implemented during a pilot period. [Figure 2] revised MICU critical care fellow schedule, the preferred choice of fellows. In this revised schedule, night shifts were incorporated into designated blocks of four-or five-nights with a scheduled day of “recovery” followed by one to two “off” days allowing for a transition back to days. The number of nights was limited to one set per 1-month rotation, minimizing transitions from day-to-night.

Figure 1: Original medical intensive care unit critical care fellow shift schedule

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Figure 2: Revised medical intensive care unit critical care fellow schedule

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Implementation of the revised schedule followed a series of plan-do-study-act (PDSA) cycles. Fellows were surveyed and asked to respond to an abbreviated Maslach Burnout Index (MBI) screening tool.^[9] This tool has been previously used for the evaluation of burnout of health-care professionals.^{[10],[11],[12],[13]} The abbreviated version of the MBI includes 9 questions for each of the three domains of emotional exhaustion, depersonalization, and personal accomplishment with a score range from 0 to 18 [Table 1]: Abbreviated Maslach Burnout Index screening questionnaire].

Table 1: Modified and abbreviated Maslach Burnout Index questionnaire

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Each fellow was asked to respond on a 7-point Likert scale where 0 was “never;” 1, “a few times a year;” 2, “once a month or less;” 3, “a few times a month;” 4, “once a week;” 5, “a few times a week;” and 6, “every day.” Survey results were collected and managed using Research Electronic Data Capture (REDCap) tools hosted at Mayo Clinic and supported by the Center for Clinical and Translational Science grant support (UL1 TR000135). REDCap is a secure, web-based application designed to support data capture for research studies, providing (1) an intuitive interface for validated data entry; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; (4) procedures for importing data from external sources.^[14]

The selected schedule was implemented over a 1-month pilot period. At the end of the month critical care fellows, nurse practitioners, physician assistants, and attending physicians were surveyed using the REDCap tool to assess the qualitative performance of the pilot schedule in terms of counterbalance measures of impact on workload and minimization of disruptions to workflow.

The final analysis and last PDSA cycle involved a 3-month rollout period. The aim of this period was to evaluate the impact of the new schedule on the perception of burnout. At the end of each of these month rotation blocks, fellows who participated were asked to once again respond to the abbreviated MBI screening questionnaire to evaluate the impact on self-reported burnout.

Statistical plan

The primary outcome of interest was the difference in self-reported abbreviated MBI domain scores. Critical care fellows were asked to respond to questions on a 7 point Likert scale of 0–6. Each of the domains of emotional exhaustion, depersonalization, and personal accomplishment had three questions for a score range of 0–18. Respondents were asked to identify the year and type of fellowship and responses matched by type of fellowship: CCA, CCIM, PCCM, and NCC. Counts and percentages were used for categorical variables. Continuous variables are reported as median (interquartile range [IQR]). Wilcoxon signed-rank test was used to test the difference in median ranks pre- and post-intervention.

Results

This quality improvement initiative aimed at revising and optimizing the critical care fellow MICU shift schedule and evaluating self-reported burnout using an abbreviated MBI screening questionnaire. All 45 fellows in the 2015–2016 academic year were surveyed at baseline with a 73% response rate. The median (IQR) in the domains of emotional exhaustion was 10 (6–12); depersonalization, 3 (1–9); personal accomplishment, 15 (13–17). [Table e1][Additional file 1]: Baseline modified and abbreviated Maslach Burnout Index scores by the fellowship of the supplemental online content displays baseline abbreviated MBI scores by fellowship program and domain.

[Table e2][Additional file 2]: Results following pilot implementation– assessment of counterbalance measures of the supplemental online content outlines impressions from fellows, the nurse practitioner, and physician assistant group, and attending physicians during pilot implementation regarding the impact on workload and workflow. No effect was noted on the counterbalance measures of impact on workflow or workload, while preference was indicated for the revised pilot schedule.

The full implementation of the revised schedule was limited to the final quarter of the academic year. As a result, during this final PDSA cycle, only CCIM and PCCM fellows were assigned to the MICU and therefore included in the analysis. During this period, 18 fellows were surveyed with 8 CCIM fellows and 4 PCCM fellows responding. The results of the pre- and post-intervention abbreviated MBI score by domain are represented in [Table 2]. Among CCIM fellows, burnout seemed to improve following the intervention, although statistical significance was achieved. The median (IQR) emotional exhaustion score for these fellows was 7 (4–11), P = 0.06; depersonalization score was 3 (0–6), P = 0.07; personal accomplishment was score 16 (11–17), P = 0.31.

Table 2: Burnout amongst critical care fellows pre- and post-intervention

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Discussion

This single-center quality improvement initiative, involving an organization level initiative that focused on reducing the number of day-night rotations, limiting the number of recurrent consecutive nights and incorporating a scheduled recovery period, evaluated the impact on self-reported burnout amongst critical care fellows in training. The intervention was mindful of reducing stressor to the circadian rhythm. An improvement was noted (without statistical significance) in emotional exhaustion scores among our CCIM fellows.

The domain of emotional exhaustion, utilized in the majority of burnout studies, is considered a central aspect of burnout.^[15] In our study, among CCIM fellows, the median (IQR) emotional exhaustion scores improved most significantly from 10 (6–14) to 7 (4–11), P = 0.06. The CCIM fellows have a greater proportion of MICU rotations compared to PCCM fellows, and this may be the reason why we saw our greatest impact in this group. There were no detrimental effects on the fellows' sense of personal accomplishment during this intervention, and in fact, among CCIM, the median score increased by one point.

The sequelae of burnout have significant detrimental effects on the health-care system. Critical care providers have reportedly suffered posttraumatic stress disorder and alcohol abuse as severe consequences of burnout syndrome.^[2],[3] Early physician retirement and decreased physician productivity contribute substantially to health-care system costs.^[16],[17] Physician burnout impacts patients through a potential increase in the rate of medical errors. Increases in self-perceived medical errors and emotional exhaustion are associated with trainee fatigue and sleepiness.^[6],[18]

Shifts, in particular, night shifts, are associated with disruptions of the circadian rhythm^[19] and adverse health outcomes.^[20],[21] The associated increased fatigue and sleep deprivation contribute to burnout.^{[4],[5],[22],[23]} The body's natural diurnal rhythm influences core body temperature peaks and troughs. If sleep commences during the early morning hours when our core temperature is typically higher, then the quality and duration of sleep are reduced.^[22] Therefore, night shift workers are subject to both continual sleep deprivation during their consecutive nights and cumulative sleep deprivation from decreased sleep quality and quantity when working consecutive days and nights.^[8],[22] The recovery time following a set of night shifts is crucial to the restoration of the circadian rhythm. A Korean study of shift workers showed that the shorter the night shift rotation interval, the lower the quality and duration of sleep.^[24]

Interventions that focus on reducing burnout have centered on both physician and organizational directed interventions. Organizational directed interventions have the most significant impact, particularly on emotional exhaustion.^[15] Interestingly, the majority of organizational directed methods have focused on physician's schedules and workload as in ours. In our study, implementing a change in the schedule by minimizing day-to-night shift rotations, adding a period of recovery, and limiting the number of recurrent consecutive nights in a month showed improvements in self-reported burnout among critical care fellows. These findings are suggestive that careful thought should be given when designing shift work schedules for critical care trainees.

This project is limited by its single-center design; however, it provides an example of the potential impact that can be made by organizational level solutions to tackling physician burnout by implementing relevant quality improvement projects. In addition, the sample size of the trainees who enrolled in this study was small, which may have led to type II error. As this project is considered a quality improvement and showed trends towards lower burnout, authors believe the impact of our findings remains important. It is important to highlight that as the result of this quality improvement project the medical ICU schedule has changed for the past few years, which also highlights importance of our findings. A survey-based approach to acquiring data on self-reported burnout is subject to a response bias with regard to the potential for perceived impact on the implementation of schedule revisions. As the fellows themselves selected, the revised schedule that was implemented a response bias may be present related to the fear that a negative impact on the survey may lead to failure of the continuation of the new revised schedule. The majority of currently available data regarding burnout, however, is survey-based secondary to the nature of the condition. The data collection of this quality improvement initiative was also limited in its final PDSA cycle with the concurrent timing of the end of the academic year. Thus, the statistical significance of our results may be impacted by our sample size.

Conclusions

This single-center quality improvement initiative consisted of minimizing the number of day-to-night shift rotations, incorporating a scheduled recovery period, and limiting the number of recurrent consecutive nights. This organization-level initiative evaluated the impact on burnout at our center among critical care fellows and showed some improvement in the self-reported emotional exhaustion domain of burnout. The change in the schedule did not affect our counterbalance measures of impact on the MICU workflow or workload. This is a simple initiative that could be considered in other critical care fellowship programs.

Acknowledgments

The authors would like to acknowledge the Mayo Clinic CCIM fellowship and the Critical Care Education Committee for its support of this pilot project.

The use of the REDCap tool at Mayo Clinic is supported by a Center for Clinical and Translational Science grant support (UL1 TR000135).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Lancet 2016;388:2272-81.
2.	Pastores SM. Burnout syndrome in ICU caregivers: Time to extinguish! Chest 2016;150:1-2.
3.	Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. An official critical care societies collaborative statement-Burnout syndrome in critical care health-care professional, a call for action. Chest 2016;150:17-26.
4.	Chuang CH, Tseng PC, Lin CY, Lin KH, Chen YY. Burnout in the intensive care unit professionals: A systematic review. Medicine (Baltimore) 2016;95:e5629.
5.	Lancman B. Night shift fatigue among anesthesia trainees at a major metropolitan teaching hospital. Anaesth Intensive Care 2016;44:364-70.
6.	Institute of Medicine. Resident Duty Hours: Enhancing Sleep, Supervision and Safety. Washington, D. C: Institute of Medicine; 2008.
7.	Pastores SM, O'Connor MF, Kleinpell RM, Napolitano L, Ward N, Bailey H, et al. The Accreditation Council for Graduate Medical Education resident duty hour new standards: History, changes, and impact on staffing of intensive care units. Crit Care Med 2011;39:2540-9.
8.	Almeida CM, Malheiro A. Sleep, immunity and shift workers: A review. Sleep Sci 2016;9:164-8.
9.	McClafferty H, Brown OW, Section on Integrative Medicine, Committee on Practice And Ambulatory Medicine, Section on Integrative Medicine. Physician health and wellness. Pediatrics 2014;134:830-5.
10.	Hyman SA, Michaels DR, Berry JM, Schildcrout JS, Mercaldo ND, Weinger MB. Risk of burnout in perioperative clinicians: A survey study and literature review. Anesthesiology 2011;114:194-204.
11.	McManus IC, Jonvik H, Richards P, Paice E. Vocation and avocation: Leisure activities correlate with professional engagement, but not burnout, in a cross-sectional survey of UK doctors. BMC Med 2011;9:100.
12.	McManus IC, Keeling A, Paice E. Stress, burnout and doctors' attitudes to work are determined by personality and learning style: A twelve year longitudinal study of UK medical graduates. BMC Med 2004;2:29.
13.	McManus IC, Winder BC, Gordon D, The causal links between stress and burnout in a longitudinal study of UK doctors. Lancet 2002 2002;359:2089-90.
14.	Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) – A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377-81.
15.	Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, et al. Controlled Interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Intern Med 2017;177:195-205.
16.	Dewa CS, Jacobs P, Thanh NX, Loong D. An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC Health Serv Res 2014;14:254.
17.	Dewa CS, Loong D, Bonato S, Thanh NX, Jacobs P. How does burnout affect physician productivity? A systematic literature review. BMC Health Serv Res 2014;14:325.
18.	West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA 2009;302:1294-300.
19.	Wever RA. Phase shifts of human circadian rhythms due to shifts of artificial zeitgebers. Chronobiologia 1980;7:303-27.
20.	Vetter C, Devore EE, Wegrzyn LR, Massa J, Speizer FE, Kawachi I, et al. Association between rotating night shift work and risk of coronary heart disease among women. JAMA 2016;315:1726-34.
21.	Tenkanen L, Sjöblom T, Kalimo R, Alikoski T, Härmä M. Shift work, occupation and coronary heart disease over 6 years of follow-up in the Helsinki Heart Study. Scand J Work Environ Health 1997;23:257-65.
22.	Muecke S. Effects of rotating night shifts: Literature review. J Adv Nurs 2005;50:433-9.
23.	Cheng WJ, Cheng Y. Night shift and rotating shift in association with sleep problems, burnout and minor mental disorder in male and female employees. Occup Environ Med 2016;74:483-8.
24.	Kim JY, Chae CH, Kim YO, Son JS, Kim JH, Kim CW, et al. The relationship between quality of sleep and night shift rotation interval. Ann Occup Environ Med 2015;27:31.