Caregiver Burnout Tied to NICU Size, EHR Use

Diana Phillips

April 19, 2017

More than one quarter of neonatal intensive care unit (NICU) providers report symptoms of burnout, a new study shows. The risk is particularly high among those who work in large, busy units and those with long-standing use of electronic health records (EHRs).

Nurses are especially vulnerable to the organizational influences that contribute to burnout in the NICU, Daniel S. Tawfik, MD, from the Department of Pediatrics at Stanford University School of Medicine and Lucile Packard Children's Hospital in Palo Alto, California, and colleagues report in an article published online April 18 and in the May issue of Pediatrics.

To assess the prevalence of NICU provider burnout and the contributing effect of organizational factors, the investigators analyzed responses to the four-question emotional exhaustion subset of the Maslach Burnout Inventory from physicians, nurses, and respiratory therapists in 41 California NICUs between June and September 2011.

Of 1934 survey respondents, 26.7% reported symptoms consistent with burnout, with the prevalence ranging from 7.5% to 42.9% within each NICU, the authors report.

When considered in the context of organizational factors, burnout prevalence was positively and significantly associated with average daily admission rates (r = 0.53; P < .001) and with the number of NICU beds (r = 0.55; P < .001). Burnout prevalence was also significantly higher in NICU units with the highest vs the lowest occupancy (28.1% ± 8.1% vs 19.9% ± 8.4%; P = .02).

Notably, NICUs with 2 or more years of EHR use had significantly higher burnout prevalence than those that did not use EHRs (28.3% ± 10.1% vs 18.4% ± 6.6%; P = .015), independent of the number of licensed beds or average daily admissions, the authors report.

"EHR use was associated with higher burnout prevalence, particularly among NICUs with the most long-standing EHR use, suggesting against unfamiliarity and initial inefficiency as primary drivers of any such association," the authors write. "Beyond the increased time necessary for documentation, reliance on an EHR for health care delivery may limit providers' experience with interpersonal interactions or direct patient care."

This finding is consistent with those of other studies recently reported by Medscape Medical News that have linked provider burnout to the administrative burden of EHRs among physicians and medical residents.

Looking at the association between organizational factors and burnout by provider type, multivariable regression analyses showed stronger associations between burnout and organizational factors among nurses than physicians.

In the nursing cohort, significant relationships were observed between burnout prevalence and average daily admissions, nursing hours per patient day, the proportion of infants transferred into the NICU after 7 days of life (late transfers), mortality per 1000 infants, the proportion of high-risk infants, and average occupancy. In the physician cohort, only late transfer proportion and average daily admissions were significantly associated with burnout prevalence.

Unlike organizational factors, many of the patient-specific characteristics, such as birth weight, gestational age, need for assisted ventilation, and other makers of patient acuity, did not influence the prevalence of provider burnout, "suggesting that individual patient factors play a minor role, if any, in the propensity for providers to develop burnout symptoms," the authors write. Similarly, neither teaching hospital status nor the presence of an in-house attending physician were significantly associated with burnout prevalence.

The authors hypothesize that "NICU size may drive burnout by decreasing personal satisfaction among providers if they prefer to represent a larger relative contribution to the overall unit functioning." It is also possible that the quality of interpersonal interactions between colleagues may be decreased in larger NICUs with more employees, they suggest.

The link between nursing burnout with average number of daily admissions "suggests that the nursing workload associated with a new admission may be underappreciated, creating the potential for relative understaffing," the authors write.

On the basis of the study findings, "large, complex NICUs need to be particularly vigilant for signs of burnout and implement interventions to combat its development," the authors write. They point to system-based initiatives "such as the Mayo Clinic Physician Well-Being Program and the Stanford Medicine WellMD Center," which focus on improving caregivers' emotional well-being and professional fulfillment to prevent and reduce signs and symptoms of burnout.

The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The authors have disclosed no relevant financial relationships.

Pediatrics. 2017;139(5):e20164134. Abstract

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