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    ASCO2020进展:医务人员的Burnout!耗竭!

    2020-05-15

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    作者: 杨学宁 医师

    大概在2014年参加一个欧洲的肿瘤大会,发现有个报告关于年轻肿瘤医师的Professional burnout。当时听了一阵,索然无味,心想这应该是很正常的吧。

    然而,调查发现,此种疾病对于医务人员的身心健康和医疗质量都有不小的影响,于是,研究人员现在盯上医务人员的“Burnout”(Burn-out)问题!

    定义

    职业倦怠(burnout)指个体在工作重压下产生的身心疲劳与耗竭的状态。最早由F reudenberger 于1974 年提出, 他认为职业倦怠是一种最容易在助人行业中出现的情绪性耗竭的症状。 随后M aslach 等人把对工作上长期的情绪及人际应激源做出反应而产生的心理综合症称为职业倦怠。一般认为, 职业倦怠是个体不能顺利应对工作压力时的一种极端反应, 是个体伴随于长时期压力体验下而产生的情感、 态度和行为的衰竭状态。(见百度百科“职业倦怠”

    First described in the 1970s, BOS is a work-related constellation of symptoms that usually occurs in individuals without any prior history of psychological or psychiatric disorders. BOS is triggered by a discrepancy between the expectations and ideals of the employee and the actual requirements of their position. In the initial stages of BOS, individuals feel emotional stress and increasing job-related disillusionment. 

    Subsequently, they lose the ability to adapt to the work environment and display negative attitudes toward their job, their co-workers, and their patients. Ultimately, three classic BOS symptoms develop: exhaustion, depersonalization, and reduced personal accomplishment.

    Professional burnout 

    is an important issue for the healthcare systems with potentially relevant consequences in the quality of patient care. Young oncologists are a special risk population, due to high workload, academic pressure and other specific factors related to cancer care. Work life and lifestyle factors are related with burnout levels and may define specific interventions to reduce and prevent burnout.

    Burn-Out Syndrome (BOS) 

    有人译为"心身耗竭综合征"(burn-out syndrome,BS),够震憾!

    is defined by

     (1) emotional and physical exhaustion; 

    (2) cynicism and depersonalization; 

    and (3) no personal nor professional fulfillment. 


    表现症状

    职业倦怠最常表现出来的症状有三种:

    1. 对工作丧失热情,情绪烦躁、易怒,对前途感到无望,对周围的人、事物漠不关心。

    2. 工作态度消极,对服务或接触的对象越发没耐心、不柔和,如教师厌倦教书,无故体罚学生,或医护人员对工作厌倦而对病人态度恶劣等等。

    3. 对自己工作的意义和价值评价下降,常常迟到早退,甚至开始打算跳槽甚至转行。


    分类

    职业倦怠一般包括以下三方面:

    1. 情感衰竭(Exhaustion):指没有活力,没有工作热情,感到自己的感情处于极度疲劳的状态。它被发现为职业倦怠的核心纬度,并具有最明显的症状表现。

    2. 去人格化(Depersonalization):指刻意在自身和工作对象间保持距离,对工作对象和环境采取冷漠、忽视的态度,对工作敷衍了事,个人发展停滞,行为怪僻,提出调度申请等。

    3. 无力感或低个人成就感(Reduced personal accomplishment):指倾向于消极地评价自己,并伴有工作能力体验和成就体验的下降,认为工作不但不能发挥自身才能,而且是枯燥无味的繁琐事物。

    Individuals with BOS may also develop non-specific symptoms including feeling frustrated, angry, fearful, or anxious. They may also express an inability to feel happiness, joy, pleasure, or contentment. BOS can be associated with physical symptoms including insomnia, muscle tension, headaches, and gastrointestinal problems.

    流行病学

    It affects up to 78% of oncology-related workers (doctors, nurses and nurse-assistants, among others)(多吓人的发生率!不过,另外一个研究中(11010 )报告发生率在肿瘤内科住院医师为28.24%,年轻肿瘤科医师为19.79%)

    This may decrease quality in both patient assistance and institutional processes.

    Healthcare professionals at the front line of care (family medicine, emergency medicine, general internal medicine, and critical care) report the highest rates of BOS; in excess of 40%. Working in an Intensive Care Unit (ICU) can be especially stressful due to high patient morbidity and mortality, challenging daily work routines, and routine encounters with traumatic and ethical issues. This level of nearly continuous stress can rapidly accelerate when caregivers perceive that there is insufficient time or limited resources to properly care for patients. Unfortunately, critical care healthcare professionals have one of the highest rates of BOS. Based upon multiple studies, approximately 25-33% of critical care nurses manifest

    symptoms of severe BOS, and up to 86% have at least one of the three classic symptoms. When compared to other types of nurses, BOS occurs more commonly in critical care nurses. BOS is also common in critical care physicians. Up to 45% of critical care physicians reported symptoms of severe BOS. Among pediatric critical care physicians the prevalence of BOS is 71%, more than twice the rate in general pediatricians.

    诊断和评估:

    有研究使用“Maslach Burnout Inventory Human Services Survey(MBI-HSS MP) ”问卷进行。见:Elena Elez. Identifying burnout in young oncologists: The sooner the better. (11010 )

    How to Measure and Detect BOS

    Burnout syndrome is most commonly measured with the Maslach Burnout Inventory (MBI-HS). The MBI-HS is a 22-item self-report questionnaire that consists of three independently scored dimensions (emotional exhaustion, depersonalization and a lack of personal accomplishment). The questions on the MBI- HS classify feelings related to an individual’s work environment on a 7-point Likert scale. The emotional exhaustion scale includes 9 items and identifies individuals who are emotionally exhausted or who feel overextended at work, the depersonalization scale includes 5 items and identifies those who have an impersonal response to patients they are taking care of and the personal accomplishment scale includes 8 items and assesses a lack of accomplishment and success related to work.

    高危人群

    Both individual and organizational risk factors are associated with an increased susceptibility to develop BOS.

    Individual risk factors:

    • having poor self-esteem

    • maladaptive coping mechanisms

    • younger   adults with an idealistic worldview

    • unrealistically   high expectations

    • having financial issues

    Organizational risk factors:

    • heavy workload

    • conflicts with coworkers

    • diminished resources

    • lack of   control or input

    • effort-reward imbalance

    • understaffing

    • rapid   institutional changes

    Specific to the critical care environment, risk factors for nurses:

    • variability   in work schedules

    • rapid turnover of patients

    • end-of-life events

    Critical care physicians share many of the same risk factors as nurses but struggle most with the amount of uninterrupted work they are expected to complete (weekend and night coverage).

    后果和影响

    BOS in critical care healthcare professionals may result in post-traumatic stress disorder (PTSD), alcohol abuse, and even suicidal ideation. PTSD is manifest by intrusion, avoidance, negative alterations in cognition and mood, and marked alterations in arousal and reactivity. PTSD can occur in response to one catastrophic event or after chronic or repetitive exposure to traumatic episodes. Between 22-29% of critical care nurses have symptoms of PTSD, and up to 18% of critical care nurses meet the diagnostic criteria for PTSD.

    The development of BOS may result in healthcare professionals leaving their profession. Excessive turnover rates increase healthcare costs, decrease productivity, diminish staff morale, and reduce the overall quality of care as experienced professionals who leave the ICU must be replaced. In ICU nurses, turnover occurs frequently with reported annual rates ranging between 13-20%: the 2013 U.S. average annual turnover rate for all types of employees was 10.4%.

    BOS also results in decreased clinical effectiveness and poor work performance that may impact patient care. BOS in nurses is associated with lower quality of care, lower patient satisfaction, increased number of medical errors, increased rates of health-care associated infections, and higher 30-day mortality rates. There is a strong “dose-response” and “bi- directional” relationship between burnout scores and medical errors: errors lead to distress and distress leads to errors.

    影响

    1.资源缺乏、时间压力和工作量的增加都会导致职业倦怠。你会发现你正在试图离职,你不时地请病假,却仍然遭受着焦虑和抑郁。而职业倦怠不仅影响你的思想,最近的研究发现,职业倦怠甚至与2型糖尿病有联系。当你处在持续的压力和不健康的状态之下时,你身体里的胰岛素也会不正常。

    2.具有倦怠现象的人还会表现出一种慢性衰竭。包括深度疲劳、失眠、头昏眼花、恶心、过敏、呼吸困难、肌肉疼痛和僵直、月经不调、腺体肿胀、咽喉痛、反复得流感、传染病、感冒、头痛、消化不良和后背痛。其中,呼吸系统传染病和头痛会持续很长时间,有些人还会出现更为严重的肠胃问题、溃疡和高血压。

    3.除了身体上的症状之外,还会出现睡眠紊乱的状况。有些人失眠,他们感到紧张、亢奋、不能放松下来,头脑中总是出现那些令他们忧虑的事情;有些人又睡眠过多,几乎所有的业余时间都用来睡觉。



    预防/治疗:

    心理干预!包括叙事治疗等。

    Evidence-based interventions to treat and prevent BOS are currently not available in critical care healthcare professionals. Interventions focused on both the individual and organizational interventions should be developed. Resilience is a psychological characteristic that enables an individual to adjust in a healthy way after a traumatic event. Resilience has been recognized as a mechanism to mitigate symptoms of and the development of PTSD following trauma and may prevent and treat of BOS. While there are innate or inherent qualities of resilience, there are qualities of resilience that can be learned. Examples of resiliency techniques include: being optimistic, developing cognitive flexibility, establishing and maintaining a supportive social network, mindfulness training, and exercising.

    Organizational interventions should be aimed at sustaining a healthy work environment. The American Association of Critical Care Nurses (AACN) has identified six standards to establish and sustain a healthy work environment that could be targeted to prevent and treat BOS. The six standards include:

    •having skilled communication

    •appropriate staffing

    •collaboration

    •meaningful recognition

    •effective decision-making

    •authentic leadership

    A small randomized controlled trial of  resilience  training was conducted in ICU nurses. Validated surveys were used  to measure resilience, PTSD, anxiety, depression and burnout syndrome. The intervention arm included a two-day educational workshop, written exposure therapy, mindfulness- based stress reduction (MBSR), exercise and event triggered cognitive behavioral therapy sessions. The control arm did not have any interventions dictated by the protocol. The results suggested the intervention was feasible and acceptable. There was also improvement in resilience scores, PTSD symptom scores and symptoms of depression. Larger randomized controlled trials are needed that are powered to reach statistical significance.

    Additional research is needed to identify strategies and interventions that prevent and treat burnout syndrome and other psychological disorders such as PTSD, anxiety and depression in pulmonary and critical care healthcare professionals.


     小处方:

    1.  Understand that there are ways you can manage your work- related stressors that put you at risk for burnout syndrome.

    2.  Engage the support of management, co-workers and friends that may help you cope with stress at work and burnout syndrome.

    3.  Take breaks from work. Go outside for a walk or fresh air. Exercise is known to enhance your physical state and mood.

    4.  Understand what you enjoy about work and focus on your interests and passions.

    5.  Practice techniques such as reframing and optimism when dealing with stressful work experiences. 


    【参考文献】

    Meredith Mealer, PhD. What is Burnout Syndrome (BOS)?



    ASCO 2020摘要 

    Cancer Prevention, Risk Reduction, and Genetics

    Developmental Therapeutics—Immunotherapy

    Developmental Therapeutics—Molecularly Targeted Agents and Tumor Biology

    Lung Cancer— Other Thoracic Cancers

    Lung Cancer—Non-Small Cell Metastatic

    Symptoms and Survivorship

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