Nursing Editorial: Advanced Practice Provider Burnout in the Pediatric Cardiac Intensive Care Unit

Burnout is real, personal, and costly for all involved in the health care system. Pediatric Cardiac Intensive Care (PCICU) Advanced Practice Providers (APP) consistently practice in a high-pace, high-stress environment putting them at high risk for the emotional, mental, and physical manifestations of burnout.  The World Health Organization defined nurse burnout as an occupational phenomenon related to the high-stress workplace associated with, but not limited to, the emotional and mental strain of caring for patients with critical illness, the physical demands of the workload, inappropriate staffing ratios, poor team communication, and a lack of APP representation in organizational nursing leadership. In addition, the personal effects of burnout are staggering. Mental health, physical well-being, insomnia, fatigue, irritability, anxiety, depression, and post-traumatic stress disorder are common personal manifestations of burnout.  The resulting turnover serves to perpetuate the precipitating causes of burnout.

Demands on PCICU APP have escalated due to the complexity of surgical procedures and CICU acuity, advances in medical technology, a growing population of adults with congenital heart disease, and the increased need for access to care. Reduction in resident/fellow work hours and subspecialty trainees (ACGME, 2014) have led to provider-patient gaps and the proliferation of PCICU APP. The Society of Critical Care Medicine (2011) recommended APP participation in the multidisciplinary approach to care and delegation of care to APP with specialized pediatric intensive care training by attending physicians. As APP presence became more common, accepted, and desired, studies demonstrated the APP ability to increase access to care, decrease the workload on attending physicians and trainees while providing increased time for teaching, decrease length of stay and cost, provide high patient-family satisfaction, and maintain of low patient morbidity and mortality with outcomes commensurate to those of trainees.

Efforts to address APP burnout are vital to maintain patient/family quality of care, for attendings/trainees/APPs to manage workload issues, and for the institution to address financial considerations, including the cost of APP turnover. The following list highlights the most common etiologies of APP burnout and strategies to address this important reality.

• Hiring and orientation
  • Orientation should aim to bridge the gap in knowledge and practice to subspecialty PCICU care
  • Orientation should be leveled, phased, and contain didactic and simulation components
  • New APPs should receive frequent feedback and mentoring from trainees, APPs, and attendings
  • Hospitals should hire APPs that meet education and practice requirements for critical/acute care practice
• Autonomous practice
  • Unrestricted Scope of Practice without state-to-state variation
  • Models of care that require full responsibility of patient/family assignment, functioning within the multidisciplinary care team, to the APP
  • Direct APP revenue generation and billing
• Role clarity
  • Roles and responsibilities should be clearly stated and shared broadly with all stakeholders
  • Attending physicians should model valuing of APP contribution
  • APPs should present their patients in debrief situations, case presentations, and family conversations
  • Undifferentiated fellow/APP relationships should be immediately addressed by attending physicians, APP leadership, and hospital administration
• Cognitive overload from constant high-pressure, high-paced clinical situations
  • Maintain competence with continuing education with and independent of fellow education/conferences
  • Support to “take a break”
  • Personal activities and hobbies should be encouraged and supported
• Professional development
  • Protected time for professional undertakings
  • Mentoring and partnering with APPs, nurse researchers, and fellows/attendings in QI and research activities
  • Financial support for professional conferences and supported time to attend
  • Clinical ladders for professional advancement
  • Faculty appointments, adjunct faculty positions
• Moral/ethical dilemmas
  • Palliative care teams should be consulted early and often to assist APPs in communicating with patients/families
  • Institutional support and wellness care should be available and provided as needed
  • Debriefing high stress/high complexity situations with appropriate personnel, including mental health personnel, should occur on a routine basis
  • Debriefing of code or critical events should include the entire multidisciplinary team, with APP presentation of APP patients
• Workload/retention
  • Hiring and orientation aimed at retention
  • Focus of hospital administration and nursing recruitment/retention on APP retention efforts and debriefing when an APP leaves the role
  • Appropriate APP-patient care staffing ratios
• Diversity, Equity, and Inclusion (DEI)
  • Hiring practices should reflect the patient/family population served, as possible
  • Development of educational programs for APP education to reach underserved areas and increase access to quality care providers
  • Identification of APP DEI issues and development of strategies to address them
• Work-life/Personal life balance
  • Strategies for APP scheduling are needed to promote eventual limitation of shift rotation, weekends, and holidays
  • APP off shift/holiday/weekend financial incentive built into APP contract
  • Institutional assurance of personal time off for vacations, holidays, life events, or other unanticipated life occurrences

Burnout is real, likely to happen to everyone at some point, and can affect the quality of care as well as institutional efficiencies. The journey back is personal. We should all invest in avoiding the pitfalls and protecting our patients, teams, institutions, and ourselves.

References:

Accreditation Council for Graduate Medical Education. (2003). Resident duty hours. Retrieved from http://acgme.org

Accreditation Council for Graduate Medical Education. (2014 ACGME common program requirements. Retrieved from http://www.acgme.org/acgmeweb/Portals/Q/PFAssess/ProgramRequirements/CPRs_07012015.pdf

APRN Consensus Work Group and National Council of State Board of Nurses. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification and education. http://www.ncsbn.org/7_23_08_consensus_APRN_final_pdf

Brilli R., Spervetz A., Branson R., Campbell G., Cohen H., Dasta J., & Rudis M. (2001). Critical care delivery in the intensive care unit: defining clinical roles and the best practice model.Critical Care Medicine; 29(10)

Foster C. B., Simone S., Bagdure D., Garber N. A. & Adnan B. (2016). Optimizing team dynamics: an assessment of physician trainees and advanced practice providers collaborative practice. Pediatric Critical Care Medicine; 17(9), e430-e436

Gigli K. H. & Martsolf G. R. (2021). Implications of state scope-of-practice regulations for pediatric intensive care unit nurse practitioner roles. Policy, Politics, & Practice; 22(3), 221-229

Grabenkort W. R., Meissen H.M., Gregg S. R. & Coopersmith C. M. (20170. Acute care nurse practitioners and physician assistants in critical care: Transforming education and practice. Critical Care Medicine; 45, 1111-1114

Haut C. & Madden M. (2015). Hiring appropriate providers for different populations: acute care nurse practitioners. American Association of Critical-Care Nurses; 35(3), e1-e9

Justice L. B., Callow L., Loomba R., Harvey J., Fitzgerald M., & Cooper D. S. (2019) Evaluation of pediatric cardiac ICU advanced practice provider education and practice variation. Pediatric Critical Care Medicine; 20(12), 1164-1169

Landsperger J. S., Semler M. W., Wang L., Byrne D. W. & Wheeler A. P. (2016). Outcomes of nurse practitioner-delivered critical care: a prospective study cohort. Chest; 149(5), 1146-1154

Scherzer R., Dennis M.P., Swan B. A., Kavuru M. S., & Oxman D. A. (2016). A comparison of usage and outcomes between nurse practitioner and resident-staffed medical ICUs. Critical Care Medicine; www.ccmjournal.org

World Health Organization. Burn-Out an “Occupational Phenomenon”: International Classification of Diseases. World Health Organization; Geneva, Switzerland: 2019. Available online: https://wwwwhoint/ment_health/evidence/burn-out/en/