Burnout, ethical climate and work organization in covid-19 intensive care units: mixed method study

Dorneles, Ademir Jones Antunes; Dalmolin, Graziele de Lima; Barlem, Edison Luiz Devos; Silveira, Rosemary Silva da; Andolhe, Rafaela; Camponogara, Silviamar; Magnago, Tânia Solange Bosi de Souza; Costa, Valdecir Zavarese da

doi:10.1590/0034-7167-2022-0684

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ORIGINAL ARTICLE • Rev. Bras. Enferm. 76 (Suppl 3) • 2023 • https://doi.org/10.1590/0034-7167-2022-0684 copy

Burnout, ethical climate and work organization in covid-19 intensive care units: mixed method study

Agotamiento profesional, clima ético y organización del trabajo en unidades de cuidados intensivos de covid-19: estudio de método mixto

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objectives:

to analyze the association between burnout and the perception of the ethical climate in nursing professionals in the covid-19 Intensive Care Unit and the relationship with the organization of work from the perspective of managers of these units.

Methods:

mixed method study conducted in three university hospitals in southern Brazil from December 2021 to March 2022. A cross-sectional study was developed with 110 nursing professionals, followed by an exploratory-descriptive study through semi-structured interviews with six managers. Descriptive and analytical statistics and discursive textual analysis were used.

Results:

the prevalence of burnout was 10% and the perception of negative ethical climate was 24.5%. The association between burnout and ethical climate revealed overload and fatigue during working hours, related to tension, fear, and stress that emerged from the consequences of the organization and relations of work in the covid-19 Intensive Care Unit.

Conclusions:

there was an association between burnout and ethical climate and elements of the work organization.

Descriptors:
Burnout; Occupational; COVID-19; Intensive Care Units; Nursing; Occupational Health

	n	Peers			Patients			Managers			Hospital			Physicians			Overall EC
	n	Md	IQR	U	Md	IQR	U	Md	IQR	U	Md	IQR	U	Md	IQR	U	Md	IQR	U
EE	Low (77)	3.75	0.63	811.50^* * p < 0.05; U - Mann-Whitney test.	3.75	0.75	741.50^* * p < 0.05; U - Mann-Whitney test.	3.83	0.75	894.50^* * p < 0.05; U - Mann-Whitney test.	3.67	0.67	856.00^* * p < 0.05; U - Mann-Whitney test.	3.67	0.67	902.50^* * p < 0.05; U - Mann-Whitney test.	3.73	0.64	806.50^* * p < 0.05; U - Mann-Whitney test.
EE	High (33)	4.25	0.88	811.50^* * p < 0.05; U - Mann-Whitney test.	4.25	0.88	741.50^* * p < 0.05; U - Mann-Whitney test.	4.15	0.83	894.50^* * p < 0.05; U - Mann-Whitney test.	4.00	0.58	856.00^* * p < 0.05; U - Mann-Whitney test.	4.00	1.25	902.50^* * p < 0.05; U - Mann-Whitney test.	4.08	0.80	806.50^* * p < 0.05; U - Mann-Whitney test.
DP	Low (70)	4.00	0.50	916.50^* * p < 0.05; U - Mann-Whitney test.	4.00	0.75	898.00^* * p < 0.05; U - Mann-Whitney test.	4.00	0.83	842.50^* * p < 0.05; U - Mann-Whitney test.	3.83	0.67	930.00^* * p < 0.05; U - Mann-Whitney test.	3.92	0.71	885.50^* * p < 0.05; U - Mann-Whitney test.	3.96	0.67	849.50^* * p < 0.05; U - Mann-Whitney test.
DP	High (40)	3.75	0.75	916.50^* * p < 0.05; U - Mann-Whitney test.	3.50	0.69	898.00^* * p < 0.05; U - Mann-Whitney test.	3.67	0.67	842.50^* * p < 0.05; U - Mann-Whitney test.	3.67	0.67	930.00^* * p < 0.05; U - Mann-Whitney test.	3.50	0.67	885.50^* * p < 0.05; U - Mann-Whitney test.	3.62	0.62	849.50^* * p < 0.05; U - Mann-Whitney test.
PA	Low (27)	3.75	0.50	822.50^* * p < 0.05; U - Mann-Whitney test.	3.50	0.50	799.00^* * p < 0.05; U - Mann-Whitney test.	3.67	0.67	800.50^* * p < 0.05; U - Mann-Whitney test.	3.50	0.67	736.50^* * p < 0.05; U - Mann-Whitney test.	3.50	0.83	827.50^* * p < 0.05; U - Mann-Whitney test.	3.62	0.43	741.50^* * p < 0.05; U - Mann-Whitney test.
PA	High (83)	4.00	0.75	822.50^* * p < 0.05; U - Mann-Whitney test.	4.00	0.75	799.00^* * p < 0.05; U - Mann-Whitney test.	4.00	0.67	800.50^* * p < 0.05; U - Mann-Whitney test.	3.83	0.67	736.50^* * p < 0.05; U - Mann-Whitney test.	3.83	0.83	827.50^* * p < 0.05; U - Mann-Whitney test.	3.93	0.67	741.50^* * p < 0.05; U - Mann-Whitney test.
SB	Absent (99)	4.00	0.75	322.50^* * p < 0.05; U - Mann-Whitney test.	3.75	0.75	311.00^* * p < 0.05; U - Mann-Whitney test.	4.00	0.67	331.50^* * p < 0.05; U - Mann-Whitney test.	3.83	0.67	284.50^* * p < 0.05; U - Mann-Whitney test.	3.83	0.67	219.00^* * p < 0.05; U - Mann-Whitney test.	3.85	0.65	263.00^* * p < 0.05; U - Mann-Whitney test.
SB	Present (11)	3.50	0.50	322.50^* * p < 0.05; U - Mann-Whitney test.	3.50	0.75	311.00^* * p < 0.05; U - Mann-Whitney test.	3.50	0.67	331.50^* * p < 0.05; U - Mann-Whitney test.	3.50	1.33	284.50^* * p < 0.05; U - Mann-Whitney test.	3.17	0.67	219.00^* * p < 0.05; U - Mann-Whitney test.	3.52	0.83	263.00^* * p < 0.05; U - Mann-Whitney test.

1. MAIN TOPIC: Burnout and perception of the ethical climate in covid-19 ICU nursing professionals and the relationship with the organization of work from the perspective of managers of these units.
2. INTEGRATION: QUAN+qual
Burnout prevalence: high emotional exhaustion, n=33 (30%), high depersonalization, n=40 (36.4%), low professional achievement, n=27 (24.5%). Burnout: n=11(10%). Nurses: n= 5 (17,2 %) and Nursing technicians: n=6 (7,4%).
Factor Concept (Olson, 1998)	EC Mean (SD)	Examples of participants’ speeches	Meta-inferences
Peers: It covers how supportive and transparent the relationships between colleagues are, reflecting on the quality of care.	3.88 (0.57)	1- The covid unit came, so we increased the number of employees to manage this new unit, many new employees started. (X2) 2- A nursing team very engaged in care, they didn’t go to the bathroom, didn’t have a snack, worked long shifts with no breaks, we left there exhausted, with emotional and physical fatigue, serving and managing the new routines; impotence generated great anguish... because the number of deaths was very high. (X3)	Convergences The Peers factor associated with the dimensions of burnout, especially in emotional exhaustion, reveals work relationships marked by differences in professional experience, a great number of new hires in the institutions and teamwork permeated by a difficult nursing care routine in a pandemic scenario with a high level of stress among people and exhaustion of professionals. The uncertainties caused by changes in the work organization process (new protocols) in covid-19 ICU influenced the emergence of professional exhaustion and the perception of the EC in this scenario.
Patients: Reflects how much information is shared between health professionals and patients	3.82 (0.57)	1- Arriving at the shift with a crowded unit and seeing there were few technicians, a colleague was crying. The atmosphere was always one of apprehension, patients walked in and left in black bags. We could only show a picture of the death, it wasn’t pleasant, but it was the alternative to show that their relative was in that bag. (X4)	The organization of work and the relationship with patients was marked by the instability surrounding covid-19, which caused tension, fear, stress and exhaustion (overload) of professionals.
Managers: They refer to the immediate leadership and general leadership of the organization, addressing aspects related to the respect and support from managers to nurses.	3.92 (0.59)	1- Some nursing technicians and nurses with morbidities; fear led to excessive care, causing conflicts in the team. (X1) 2- Although we had a very valid structure, there were things the unit needed, but nobody entered, it was shielded. (X5) 3- Working in an environment of death was the downside of covid-19. (X3) 4- The impotence was that of needing to do more, but not having the opportunity, those were endless weeks. (X6)	The Managers factor was related to the coordination and relationship with nursing professionals, revealing management in a scenario of uncertainties with new technical and administrative needs, lack of nursing workers given the sick notes or the greater demand for care, generating overload in the role of manager of the nursing team. The commitment of managers in this scenario was demonstrated with a positive EC mean, although with favorable elements to the occurrence of burnout.
Hospital: Presents the relationship between health professionals and hospital management, about the institution’s mission.	3.72 (0.53)	1- If the pandemic lasted longer, I don’t know if we would have financial, physical and mental conditions. (X4) 2- We needed someone from the care team to go to the meetings and inform about our covid-19 ICU needs. (X5)	The Hospital factor highlighted the need for a closer relationship between frontline professionals and institutional managers in order to assess and understand the work situation that constituted an environment of high emotional tension, mainly because of the work overload arising from the growing technical and material needs.
Physicians: Work climate between physicians and nurses. Shared relationship of knowledge and how ethical are the decisions made together.	3.76 (0.58)	1- Physicians without experience anchored in physicians with experience; sometimes there was mistrust, difficulties in making decisions, some cases of difficulty also in terms of professional respect between teams, causing stress; I guess because there were several teams working, so these conflicts always end up getting near me, I go there and talk to those responsible, together we improve work. (X1)	The Physicians factor showed elements of professional exhaustion in relation to trust and respect between physicians and nurses in decision-making, demonstrating the still distant relationship with physicians.

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[1] Corresponding author: Graziele de Lima Dalmolin, E-mail: grazi.dalmolin@gmail.com