Complex interplay between moral distress and other risk factors of burnout in ICU professionals: findings from a cross-sectional survey study

Moral distress was positively associated for both emotional exhaustion and depersonalisation, as seen in the ‘univariate’ column in table 2, and in the multivariable model. Moral distress was not associated with personal accomplishment once other variables were added to the model. Men and physicians appear particularly prone to feelings of depersonalisation, while older people were less likely to feel depersonalised. Neuroticism was associated with emotional exhaustion. The agreeableness, conscientiousness and extraversion personality traits appear to incite a heightened sense of accomplishment. Frequent spillovers of negative experiences from work to private life and vice versa were associated with greater emotional exhaustion and depersonalisation. These associations had reasonably large coefficients indicating a significant influence. For example, an increase of one z-score on the work-to-home spillover scale was associated with a 0.36 increase in the emotional exhaustion scale. In contrast, a z-score increase on the moral distress scale was associated with a 0.18 increase on this scale. This suggests that ICU professionals who are experiencing some negative work-to-home spillovers can more quickly slide into an unhealthy emotionally exhausted state. The regression analysis showed that higher scores on emotional exhaustion can only be reached through a combination of contributing risk factors. For examples, see box 1.

Box 1 Examples of associations between burnout, moral distress and other risk factors of burnout

The regression model in table 2 has this form, where Y can be any of the three burnout components; ẞ0 is the constant; ẞ1 is the coefficient for moral distress and X1 is its value. Each subsequent ẞ stands for each other variable in the model, denoted by i. Lastly, the ε is the error term.

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The constant in each of the burnout component scales corresponds to the value of a respondent that is a male physician who works on ICU 1, without care duties for a young child, and that scores a mean value on every continuous variable. This respondent scores a 1.33 on the emotional exhaustion subscale that ranges from 0 to 6. Previously, we have demonstrated that the 22.7% respondents with burnout symptoms on average score a 2.23 on emotional exhaustion, with an SD of 0.86. The male physician from our example would thus need a 0.90 increase in his score to reach the mean level of emotional exhaustion within the subgroup of respondents with burnout symptoms.

This will most likely only be reached by a combination of high scores on moral distress, neurotic personality, work-to-home spillovers and home-to-work spillovers. If this physician would, for instance, score 1 z-score on moral distress and both work-to-home spillovers and home-to-work spillovers, this would be associated with a score on emotional exhaustion of 1.98—which comes close to the mean value for respondents with burnout but is still below average for this group.

The same male physician would have a troubling score on depersonalisation if he scored 1 z-score on all three risk factors: moral distress, work-to-home and home-to-work spillovers. Then, the associated value for depersonalisation would be 1.75, well above the average score of 1.52 within the subgroup of respondents with burnout symptoms.

The physician’s value on personal accomplishment would be 4.42, while the subgroup of respondents with burnout symptoms score, on average, 3.60 on personal accomplishment. The magnitude of the associations between risk factors of burnout and personal accomplishment is much smaller and most associations are not significant. Without taking statistical significance into account, we see that being a female nurse is, for instance, associated with lower levels of personal accomplishment. A personality type high in agreeableness, conscientiousness and extraversion is conducive of personal accomplishment.

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