American Journal of Respiratory and Critical Care Medicine

Rationale: Burnout syndrome (BOS) associated with stress has been documented in health care professionals in many specialties. The intensive care unit (ICU) is a highly stressful environment. Little is known about BOS in critical care nursing staff.

Objectives: To identify determinants of BOS in critical care nurses.

Methods: We conducted a questionnaire survey in France. Among 278 ICUs contacted for the study, 165 (59.4%) included 2,525 nursing staff members, of whom 2,392 returned questionnaires with complete Maslach Burnout Inventory data.

Measurements and Main Results: Of the 2,392 respondents (82% female), 80% were nurses, 15% nursing assistants, and 5% head nurses. Severe BOS-related symptoms were identified in 790 (33%) respondents. By multivariate analysis, four domains were associated with severe BOS: (1) personal characteristics, such as age (odds ratio [OR], 0.97/yr; confidence interval [CI], 0.96–0.99; p = 0.0008); (2) organizational factors, such as ability to choose days off (OR, 0.69; CI, 0.52–0.91; p = 0.009) or participation in an ICU research group (OR, 0.74; CI, 0.56–0.97; p = 0.03); (3) quality of working relations (1–10 scale), such as conflicts with patients (OR, 1.96; CI, 1.16–1.30; p = 0.01), relationship with head nurse (OR, 0.92/point; CI, 0.86–0.98; p = 0.02) or physicians (OR, 0.81; CI, 0.74–0.87; p = 0.0001); and (4) end-of-life related factors, such as caring for a dying patient (OR, 1.39; CI, 1.04–1.85; p = 0.02), and number of decisions to forego life-sustaining treatments in the last week (OR, 1.14; CI, 1.01–1.29; p = 0.04).

Conclusion: One-third of ICU nursing staff had severe BOS. Areas for improvement identified in our study include conflict prevention, participation in ICU research groups, and better management of end-of-life care. Interventional studies are needed to investigate these potentially preventive strategies.

Scientific Knowledge on the Subject

The reality of burnout syndrome in critical care nurses has been suggested, but never demonstrated in large cross-sectional surveys.

What This Study Adds to the Field

Burnout syndrome is frequent in ICU nursing staff.

Burnout syndrome (BOS) was identified in the early 1970s in human service professionals, most notably health care workers (1). BOS has been described as an inability to cope with emotional stress at work (2) or as excessive use of energy and resources leading to feelings of failure and exhaustion (3). Although depression affects nearly every aspect of the person's life, symptoms of burnout occur only at work; however, BOS also decreases overall well-being (4). Maslach and Jackson developed the Maslach Burnout Inventory (MBI) for detecting and measuring the severity of BOS. The scale evaluates three domains, namely, emotional exhaustion, depersonalization (negative or cynical attitudes toward patients), and loss of a feeling of personal accomplishment at work (1). Clinical symptoms of BOS are nonspecific and include tiredness, headaches, eating problems, insomnia, irritability, emotional instability, and rigidity in relationships with other people.

Wide variations in the prevalence of BOS in health care professionals have been reported across specialties, both in doctors (5) and in nurses (6). Workplace climate and workload were determinants of BOS (7). However, higher levels of severe BOS were found in oncologists (811), anaesthesiologists (12), physicians caring for patients with AIDS (13), and physicians working in emergency departments (14).

Intensive care units (ICUs) are characterized by a high level of work-related stress (15), a factor known to increase the risk of BOS (16). High rates of severe BOS were reported in ICU nurses as early as 1987 (17). BOS is associated with decreased well-being among nursing staff members (18), decreased quality of care (1921), and costs related to absenteeism and high turnover (22), all of which have particularly devastating consequences in the ICU. Few studies have addressed the prevalence and determinants of BOS in ICUs. A study based on the MBI showed a high rate of BOS among ICU physicians, with determinants being related to both patient care and inadequate support (23). Similarly, studies in ICU nurses indicated that BOS was common and preventive strategies were urgently needed (24, 25). However, these studies did not identify independent risk factors for BOS, which is a crucial step toward developing preventive strategies.

To look for potentially modifiable precursors to BOS, we conducted a large nationwide study in 2,392 nursing staff members working in 165 ICUs throughout France. Our results show a high level of BOS and identify determinants of BOS that suggest preventive strategies.

Nurses in France are graduates of a 3-year diploma program, and ICU nurses receive the same training as nurses in other specialties. At first arrival in the ICU, the nurse receives 3 months of specific training. Nurses work 35 hours a week in two or three daily shifts of 8 to 12 hours each. Each ICU has a head nurse, who usually holds a Bachelor's or Master's of Science in Nursing. The patient-to-nurse ratio is 2.5 to 3 in most ICUs and the patient-to-nursing assistant ratio is 4. Nursing assistants help nurses in patients' care, but they do not care directly for the patients. Staff meetings are held by physicians, nurses, and nursing assistants to discuss patient care. In some ICUs, physicians and nurses participate in research groups to investigate specific issues.

The ethics committee of the French Society for Critical Care approved the current study in December 2004. An invitation letter and a study draft were sent to the head nurses of the 286 ICUs that were affiliated with the French Society for Critical Care (which account for half the ICUs in France) and that met the following criteria: located in a not-for-profit hospital, more than six beds and more than two attending physicians, and at least one physician on site 24 hours a day. The head nurses were invited to give a questionnaire to each nurse and nursing assistant in the ICU. Questionnaires were completed anonymously. Head nurses completed an additional questionnaire on the ICU (Table 1). Staff meetings were defined for the study as meetings held at least once a week by physicians and nurses to discuss patient care.


Median (25th–75th) or numbers (%)
University hospital52 (31.5)
Type of ICU
 Medical32 (19.4)
 Surgical17 (10.3)
 Medical-surgical116 (70.3)
Number of ICU beds10 (8–15)
Number of patients admitted per year415 (315–439)
Length of ICU stay7 (5.8–9)
SAPS II41.5 (35–45)
Observed mortality22.5 (16–46)
Number of patients per nurse3 (2–4)
Number of nurses21 (16–32)
Number of nursing assistants12 (8–18)
Number of attending physicians4 (2–5)
Number of residents1 (0–3)
Full-time psychologist28 (17)
Debriefing meetings between physicians and nurses on a regular basis51 (30.9)
Participation in an ICU research group
84 (50.0)

Definition of abbreviations: ICU = intensive care unit; SAPS = Simplified Acute Physiologic Score.

*n = 165.

The questionnaire was three pages long and was accompanied by a letter explaining that the goal of the study was to investigate well-being in ICU nurses and that the questionnaire was to be completed anonymously and returned in a sealed envelope. The first page of the questionnaire included items on demographics and the work-related factors listed in Table 2. Participation in an ICU research group depends on the organization of each ICU and is usually coordinated by the head nurse and one of the senior intensivists. Conflict was not defined in the questionnaire and was therefore evaluated according to the perceptions of each respondent. In addition, nurses were asked to grade their relationship with other nurses, head nurses, and physicians on a 0 to 10 scale, where 0 indicated the worst possible relationship and 10 the best possible relationship. The second page of the questionnaire included the 22 items of the MBI (Human Services version, validated in French [13]), as well as eight items designed to assess the impact of BOS on daily life (1). Recognized for over a decade as the leading measure of burnout, the MBI incorporates the extensive research that has taken place in the 15 years since its initial publication (1). The MBI measures burnout as it manifests itself in staff members in human services institutions and health care occupations, such as nursing, social work, psychology, ministry, and various other socially related occupations (1, 26, 27). Previous studies in the critical care setting have pointed out that the MBI was reliable for measuring burnout in critical care staff (23, 25, 28). The MBI comprises three subscales: emotional exhaustion (9 items), depersonalization (5 items), and personal accomplishment (8 items). High scores of emotional exhaustion and depersonalization and low scores of personal accomplishment result in high scores of BOS. Each item is scored from 0 (never) to 6 (every day). The third and last page of the questionnaire included the 22 items of the Center for Epidemiological Studies Scale for Depression (CES-D), as previously recommended when studying BOS (29).


All Respondents (n = 2,392, 100%)

Respondents with Severe BOS (n = 785, 32.8%)

Respondents without Severe BOS (n = 1,607, 67.2%)

p Value
Respondent's age31 (27 to 39)31 (26 to 38)33 (27 to 40)0.02
Female sex1,963 (82.1)648 (82.5)1,315 (81.8)0.55
Months in the ICU40 (17 to 96)43 (17 to 96)40 (17 to 96)0.14
Single842 (35.2)285 (36.3)557 (34.7)0.60
Number of work hours per day10 (8 to 12)10 (8 to 12)10 (8 to 12)0.79
Number of work days per month16 (13 to 20)17 (14 to 20)16 (12 to 20)0.60
Number of work nights per 6 months15 (0 to 30)14 (0 to 30)15 (0 to 30)0.81
Able to schedule days off according to personal wishes1,359 (56.8)377 (48)980 (61)< 0.0001
Believed that the work schedule was changed too often741 (31)280 (35.8)461 (28.7)0.0006
Participation in a working group within the ICU1,129 (47.2)334 (42.5)795 (49.5)0.02
Respondent was off on the day before the study1,076 (45)329 (42)747 (46.5)0.06
Respondent reports current conflict with another nurse254 (10.6)126 (16)128 (8)< 0.0001
Grade (1–10) given to the relationship with other nurses8 (7 to 9)7.5 (7 to 8)8 (8 to 9)< 0.0001
Grade (1–10) given to the relationship with the head nurse8 (6 to 9)7 (5 to 8)8 (7 to 9)< 0.0001
Respondent reports current conflict with physicians227 (9.5)106 (13.5)121 (7.5)< 0.0001
Grade (1–10) given to the relationship with physicians7 (6 to 8)6.5 (5 to 8)7 (6 to 8)< 0.0001
Respondent reports current conflict with patients146 (6.1)74 (9.5)72 (4.5)< 0.0001
Respondent reports current conflict with family members105 (4.4)55 (7)50 (3.1)< 0.0001
Respondent is caring for a dying patient863 (36.1)341 (43.4)522 (32.5)< 0.0001
Respondent participated in an end-of-life decision on the study day325 (13.6)112 (14.3)213 (13.2)0.59
Respondent had patients who died in the last week990 (41.4)354 (45.1)636 (39.6)0.02
Respondent was involved in an end-of-life decision in the last week782 (32.7)272 (34.6)510 (31.7)0.22
Number of DFLSTs in the last week0 (0 to 1)1.5 (0 to 2)0 (0 to 1)0.09
Maslach Burnout Inventory total score
−16 (−26 to −5)
−23 (−30 to −16)
1 (−4 to 10)
< 0.0001

Definition of abbreviations: BOS = burnout syndrome; DFLSTs = decisions to forego life-sustaining therapies; ICU = intensive care unit.

Values shown are medians (25th–75th) or numbers (%).

*n = 2,392.

The sealed envelopes containing the individual questionnaires were collected by the head nurse in each ICU and sent back to the main investigators. No data were recorded on nursing staff members who declined to answer. The questionnaires were audited by the senior authors of this article (M.C.P., P.T., and E.A.), and missing data on ICU characteristics were collected by phone calls and e-mail contact with head nurses.

Statistical Analysis

Questionnaires with no missing MBI data were included in the analysis. We determined each of the three MBI subscale scores and the total score. We defined severe BOS as a total MBI score greater than −9, in accordance with Maslach and colleagues (1).

Results are reported as medians (interquartile range [IQR]) or as numbers (%). Categorical variables were compared using the chi-square test or Fisher exact test, as appropriate, and continuous variables using the nonparametric Wilcoxon test or Kruskal-Wallis test. Presence of “severe BOS” was the outcome variable of interest. We performed univariate logistic regression analyses to identify variables that significantly influenced the likelihood of severe BOS, as measured by the estimated odds ratio (OR) with the 95% confidence interval (95% CI). All variables whose p values were less than 0.20 were introduced in a multivariable stepwise logistic regression model. All tests were two-sided, and p values smaller than 0.05 were considered statistically significant. Analyses were performed using the SAS 9.1 software package (SAS Institute, Cary, NC).

As reported in Figure 1, 165 (57.7%) of the 286 invited ICUs participated in the study and sent questionnaires completed anonymously by 2,497 nursing staff members. ICUs who agreed to participate were not significantly different than ICUs who declined to participate, in terms of location in France, unit size (number of beds), teaching versus community hospitals, and case mix. The head nurses reported that 237 nursing staff members declined to participate in the study. Questionnaires that had complete MBI data were returned by 2,392 respondents (1,937 [81%] nurses, 359 [15%] nursing assistants, and 96 [4%] head nurses). Characteristics of the participating ICUs are presented Table 1. Time from nursing school graduation to questionnaire completion was a median of 40 months (IQR, 17–96 mo), and time in the ICU was 36 months (IQR, 17–58 mo). Work schedule was 16 days (IQR, 13–20 d) per month, 10 hours (IQR, 8–12 h) per day, and 36 hours (IQR, 35–40 h) per week. Patient–nurse ratio was 3 (IQR, 3–3).

Severe BOS (MBI < −9) was identified in 785 (32.8%) respondents, with no significant differences between nurses, nursing assistants, and head nurses. Among the characteristics of the participating ICUs, only the type of hospital was associated with the rate of severe BOS, which was higher in teaching hospitals than in other hospitals (36 vs. 31%, p = 0.01). Characteristics of the respondents and factors significantly associated with severe BOS in the univariate analysis are shown in Figures 1 and 2 and Table 2. In the multivariable analysis (Table 3), four groups of characteristics were associated with severe BOS, namely, personal characteristics of the respondent, such as age (OR, 0.97/yr; 95% CI, 0.96–0.99); organizational factors, such as days off scheduled as wished (OR, 0.69; 95% CI, 0.52–0.91) and participation in an ICU working group (OR, 0.73; 95% CI, 0.56–0.97); quality of working relationships, such as conflicts with patients (OR, 1.96; 95% CI, 1.16–3.30), relationship with head nurses (OR, 0.92; 95% CI, 0.86–0.98) and physicians (OR, 0.81; 95% CI, 0.74–0.87); and end-of-life-related factors, such as caring for a dying patient (OR, 1.39; 95% CI, 1.04–1.85) and larger number of decisions to forego life-sustaining treatments within the last week (OR, 1.14; 95% CI, 1.01–1.29).


Odds Ratio

95% Confidence Interval

p Value
Respondent's age (per additional year)0.970.96–0.990.0008
Able to schedule days off according to personal wishes0.690.52–0.910.009
Participates in an ICU research group0.730.56–0.970.03
Conflicts with patients1.961.16–3.300.01
Grade (1–10) given to the relationship with head nurses0.920.86–0.980.02
Grade (1–10) given to the relationship with physicians0.810.74–0.870.0001
Respondent caring for a dying patient1.391.04–1.850.02
Number of DFLSTs in the last week

Definition of abbreviations: DFLSTs = decisions to forego life-sustaining therapies; ICU = intensive care unit.

Figure 4 shows the prevalence of symptoms designed to assess the impact of BOS on daily life, and of depressive symptoms as measured by the CES-D. These symptoms were significantly more common in respondents with severe BOS than in the other respondents. Symptoms of depression on the CES-D scale were noted in 287 (12%) respondents, including 223 (28.4%) respondents with severe BOS and 64 (4%) respondents without severe BOS (p < 0.0001). Furthermore, 458 (60%) respondents with severe BOS reported thinking about changing to another profession, compared with only 468 (29.9%) of the other respondents (p < 0.0001).

The ICU is a highly stressful environment and may therefore be associated with a high rate of BOS in staff members (15, 17). The cost of BOS includes decreased quality of care (19, 3032), absenteeism and high turnover rates (22), and poor communication with families (19). We report the first large multicenter study of the prevalence of severe BOS in ICU nursing staff members, as measured by the MBI scale for human service professionals. In the 165 participating ICUs, 2,392 nursing staff members completed the MBI, including 785 (32.8%) with severe BOS. Several factors associated with severe BOS were identified, thereby opening up avenues for research into preventive strategies.

Both personal characteristics and work-related factors have been associated with BOS (18, 30). Among work-related factors, workplace climate and workload influence the risk of BOS (7). We identified four groups of variables that were independently associated with severe BOS; however, the number of hours worked was not among them. Our finding that choosing days off and participating in research groups decreased the risk of severe BOS agrees with earlier data (6) and suggests simple preventive strategies. In keeping with data in residents (19, 31), our results suggest that younger and less experienced nursing staff members might benefit the most from preventive strategies. Job satisfaction is increased when individuals receive positive feedback indicating that their work is valued and significant. Interventions such as research groups (33), stress management workshops (34, 35), and training in communication and stress management (36) have been found to decrease stress and BOS in health care workers. In addition, staff meetings were not associated with a significant reduction in the rate of severe BOS in our study, suggesting a need for evaluating and improving debriefing techniques (37).

Perceived conflicts with patients, families, or other staff members increased the risk of BOS in our study. Emotional exhaustion is a direct consequence of conflict that leads to depersonalization and to loss of a sense of personal accomplishment (1). In our study, both perceived conflicts and perceived poor relationships with other staff members were strong independent risk factors for severe BOS. In keeping with this finding, having poor relations with patients was associated with a higher risk of BOS among physicians in an earlier study (5). Preventing conflicts and improving communication in the ICU may therefore decrease the risk of BOS. Conflicts in the ICU are being increasingly studied (38). Physicians and nurses differ in their perceptions of work relationships (39), and of decisions to forego life-sustaining treatments (DFLSTs) (4042), which may lead to conflicts and decreased quality of care (4345). Further work is needed to clarify the interactions between conflicts and BOS. Interventional studies of conflict prevention should include an evaluation of BOS in participants.

DFLSTs are made for most of the patients who die in the ICU (46) and may lead to conflicts (4042) and increased stress (18). High BOS rates have been reported in staff caring for dying patients (47), most notably in oncology nurses (48). Sharing the decision with the physicians (49) and being actively involved in the decision-making process were major goals reported by nurses (50). Previous studies showed that nurses provided compassionate care and effective assistance to dying patients and their relatives (51, 52). Several studies identified differences between ICU nurses and physicians regarding the provision of futile care (28, 43) or the assessment of treatment goals (39, 52). In our study, caring for a dying patient and a larger number of DFLSTs were independent determinants of BOS. In recent years, considerable effort has been expended to improve end-of-life care (53), improve communication, and share discussions and decisions with patients and family members in the ICU (54). Our results suggest a need for expanding these efforts toward the nursing staff (43, 55). Intensive communication between nurses and physicians about DFLSTs may help nurses to feel that the work they do is valued and to escape from feelings of guilt.

Our study has several limitations. First, France and other countries may differ regarding factors associated with BOS, such as relationships between physicians and nurses (55). However, our sample was large and representative of different types of ICUs. Moreover, previous studies found similar rates of BOS in France and other countries (56). Second, a semistructured interview might have produced different results from the self-administered MBI questionnaire used in our study. However, the MBI has been validated as a tool for detecting BOS in health care professionals. Third, the questionnaire did not define conflicts, which may have biased one of the major findings of this study. By not supplying a definition, we collected data on perceived conflicts, which are probably those relevant to the occurrence of BOS. Fourth, nursing assistants and head nurses represented 20% of the total nursing staff surveyed. However, even though these respondents had the same level of BOS than the nurses, strategies to address their burnout might be different. Further studies will need to identify specific needs from each group in the nursing staff (57). Last, as reported in Figure 4, severe symptoms that disrupt everyday life occurred also in respondents who did not have severe BOS. These respondents may have had moderate BOS or other sources of distress, either personal or work related, that were not explored in our study. Similarly, qualitative analysis of depressive symptoms in critical care nurse might reflect another domain needed to be studied.

In conclusion, severe BOS was common in a large group of ICU nurses and nursing assistants. The development of ICU research groups may hold promise for preventing BOS, together with conflict prevention and improvements in communication within the ICU caregivers during the end-of-life decision-making process.

1. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:397–422.
2. Pines A, Maslach C. Characteristics of staff burnout in mental health settings. Hosp Community Psychiatry 1978;29:233–237.
3. Freudenberger HJ. The issues of staff burnout in therapeutic communities. J Psychoactive Drugs 1986;18:247–251.
4. Iacovides A, Fountoulakis KN, Moysidou C, Ierodiakonou C. Burnout in nursing staff: is there a relationship between depression and burnout? Int J Psychiatry Med 1999;29:421–433.
5. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet 1996;347:724–728.
6. Lu H, While AE, Barriball KL. Job satisfaction among nurses: a literature review. Int J Nurs Stud 2005;42:211–227.
7. 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.
8. Lyckholm L. Dealing with stress, burnout, and grief in the practice of oncology. Lancet Oncol 2001;2:750–755.
9. Armstrong J, Holland J. Surviving the stresses of clinical oncology by improving communication. Oncology 2004;18:363–368.
10. Graham J, Ramirez A. Improving the working lives of cancer clinicians. Eur J Cancer Care (Engl) 2002;11:188–192.
11. Grunfeld E, Whelan TJ, Zitzelsberger L, Willan AR, Montesanto B, Evans WK. Cancer care workers in Ontario: prevalence of burnout, job stress and job satisfaction. CMAJ 2000;163:166–169.
12. Nyssen AS, Hansez I, Baele P, Lamy M, De Keyser V. Occupational stress and burnout in anaesthesia. Br J Anaesth 2003;90:333–337.
13. Lert F, Chastang JF, Castano I. Psychological stress among hospital doctors caring for HIV patients in the late nineties. AIDS Care 2001;13:763–778.
14. Weibel L, Gabrion I, Aussedat M, Kreutz G. Work-related stress in an emergency medical dispatch center. Ann Emerg Med 2003;41:500–506.
15. Donchin Y, Seagull FJ. The hostile environment of the intensive care unit. Curr Opin Crit Care 2002;8:316–320.
16. Bakker AB, Le Blanc PM, Schaufeli WB. Burnout contagion among intensive care nurses. J Adv Nurs 2005;51:276–287.
17. Soupios MA, Lawry K. Stress on personnel working in a critical care unit. Psychiatr Med 1987;5:187–198.
18. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002;288:1987–1993.
19. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358–367.
20. Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA 2005;294:1025–1033.
21. Lockley SW, Cronin JW, Evans EE, Cade BE, Lee CJ, Landrigan CP, Rothschild JM, Katz JT, Lilly CM, Stone PH, et al. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med 2004;351:1829–1837.
22. Ackerman AD. Retention of critical care staff. Crit Care Med 1993;21:S394–S395.
23. Guntupalli KK, Fromm RE Jr. Burnout in the internist–intensivist. Intensive Care Med 1996;22:625–630.
24. Sawatzky JA. Stress in critical care nurses: actual and perceived. Heart Lung 1996;25:409–417.
25. Chen SM, McMurray A. “Burnout” in intensive care nurses. J Nurs Res 2001;9:152–164.
26. Mallett K, Price JH, Jurs SG, Slenker S. Relationships among burnout, death anxiety, and social support in hospice and critical care nurses. Psychol Rep 1991;68:1347–1359.
27. Fagin L, Carson J, Leary J, De Villiers N, Bartlett H, O'Malley P, West M, McElfatrick S, Brown D. Stress, coping and burnout in mental health nurses: findings from three research studies. Int J Soc Psychiatry 1996;42:102–111.
28. Meltzer LS, Huckabay LM. Critical care nurses' perceptions of futile care and its effect on burnout. Am J Crit Care 2004;13:202–208.
29. Iacovides A, Fountoulakis KN, Kaprinis S, Kaprinis G. The relationship between job stress, burnout and clinical depression. J Affect Disord 2003;75:209–221.
30. Gelfand DV, Podnos YD, Carmichael JC, Saltzman DJ, Wilson SE, Williams RA. Effect of the 80-hour workweek on resident burnout. Arch Surg 2004;139:933–938. (Discussion 938–940.)
31. McElearney ST, Saalwachter AR, Hedrick TL, Pruett TL, Sanfey HA, Sawyer RG. Effect of the 80-hour work week on cases performed by general surgery residents. Am Surg 2005;71:552–555. (Discussion 555–556.)
32. Thomas NK. Resident burnout. JAMA 2004;292:2880–2889.
33. Williamson GR, Dodds S. The effectiveness of a group approach to clinical supervision in reducing stress: a review of the literature. J Clin Nurs 1999;8:338–344.
34. McCue JD, Sachs CL. A stress management workshop improves residents' coping skills. Arch Intern Med 1991;151:2273–2277.
35. Hodgkins C, Rose D, Rose J. A collaborative approach to reducing stress among staff. Nurs Times 2005;101:35–37.
36. Taormina RJ, Law CM. Approaches to preventing burnout: the effects of personal stress management and organizational socialization. J Nurs Manag 2000;8:89–99.
37. Jenkins H, Allen C. The relationship between staff burnout/distress and interactions with residents in two residential homes for older people. Int J Geriatr Psychiatry 1998;13:466–472.
38. Studdert DM, Mello MM, Burns JP, Puopolo AL, Galper BZ, Truog RD, Brennan TA. Conflict in the care of patients with prolonged stay in the ICU: types, sources, and predictors. Intensive Care Med 2003;29:1489–1497.
39. Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med 2003;31:956–959.
40. Ferrand E, Lemaire F, Regnier B, Kuteifan K, Badet M, Asfar P, Jaber S, Chagnon JL, Renault A, Robert R, et al. Discrepancies between perceptions by physicians and nursing staff of intensive care unit end-of-life decisions. Am J Respir Crit Care Med 2003;167:1310–1315.
41. Abbott KH, Sago JG, Breen CM, Abernethy AP, Tulsky JA. Families looking back: one year after discussion of withdrawal or withholding of life-sustaining support. Crit Care Med 2001;29:197–201.
42. Breen CM, Abernethy AP, Abbott KH, Tulsky JA. Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med 2001;16:283–289.
43. Asch DA. The role of critical care nurses in euthanasia and assisted suicide. N Engl J Med 1996;334:1374–1379.
44. Sexton JB, Holzmueller CG, Pronovost PJ, Thomas EJ, McFerran S, Nunes J, Thompson DA, Knight AP, Penning DH, Fox HE. Variation in caregiver perceptions of teamwork climate in labor and delivery units. J Perinatol 2006;26:463–470.
45. Pronovost PJ, Weast B, Holzmueller CG, Rosenstein BJ, Kidwell RP, Haller KB, Feroli ER, Sexton JB, Rubin HR. Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Qual Saf Health Care 2003;12:405–410.
46. Prendergast TJ. Withholding or withdrawal of life-sustaining therapy. Hosp Pract (Minneap) 2000;35:91–92, 95–100, 102.
47. Jezuit DL. Suffering of critical care nurses with end-of-life decisions. Medsurg Nurs 2000;9:145–152.
48. Morita T, Akechi T, Sugawara Y, Chihara S, Uchitomi Y. Practices and attitudes of Japanese oncologists and palliative care physicians concerning terminal sedation: a nationwide survey. J Clin Oncol 2002;20:758–764.
49. Jenkins R, Elliott P. Stressors, burnout and social support: nurses in acute mental health settings. J Adv Nurs 2004;48:622–631.
50. Papadatou D, Anagnostopoulos F, Monos D. Factors contributing to the development of burnout in oncology nursing. Br J Med Psychol 1994;67:187–199.
51. Prendergast TJ, Puntillo KA. Withdrawal of life support: intensive caring at the end of life. JAMA 2002;288:2732–2740.
52. Puntillo KA, Benner P, Drought T, Drew B, Stotts N, Stannard D, Rushton C, Scanlon C, White C. End-of-life issues in intensive care units: a national random survey of nurses' knowledge and beliefs. Am J Crit Care 2001;10:216–229.
53. Truog RD, Cist AF, Brackett SE, Burns JP, Curley MA, Danis M, DeVita MA, Rosenbaum SH, Rothenberg DM, Sprung CL, et al. Recommendations for end-of-life care in the intensive care unit: the Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 2001;29:2332–2348.
54. Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, Hinds C, Pimentel JM, Reinhart K, Thompson BT. Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Med 2004;30:770–784.
55. Yaguchi A, Truog RD, Curtis JR, Luce JM, Levy MM, Melot C, Vincent JL. International differences in end-of-life attitudes in the intensive care unit: results of a survey. Arch Intern Med 2005;165:1970–1975.
56. Golembiewski RT. Perspectives on psychological burnout, VII. Part 4: replications in overseas populations—a symposium. J Health Hum Serv Adm 1999;22:3–6.
57. American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments: a journey to excellence. Am J Crit Care 2005;14:187–197.
Correspondence and requests for reprints should be addressed to Élie Azoulay, M.D., Ph.D., Service de Réanimation Médicale, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France. E-mail:


No related items
American Journal of Respiratory and Critical Care Medicine

Click to see any corrections or updates and to confirm this is the authentic version of record