The relationship between three different performance measures and burnout was explored in 20 Dutch Intensive Care Units (ICUs). Burnout (i.e. emotional exhaustion and depersonalization) proved to be significantly related to nurses' perceptions of performance as well as to objectively assessed unit performance. Subjective performance measures relate negatively to burnout levels of nurses, whereas an objective performance measure relates positively to burnout. Furthermore, subjectively assessed personal performance (i.e. personal accomplishment) is more strongly related to burnout than subjectively assessed unit performance. A model test of the relationship between both types of subjective performance and burnout reveals that nurses' perception of unit performance is indirectly related to burnout through perception of personal performance. This model holds similarly for objectively well-and poor-performing ICUs.

A stranger on entering an ICU is at once bombarded with a massive array of sensory stimuli, some emotionally neutral but many highly charged. Initially the greatest impact comes from the intricate machinery with its flashing lights, buzzing and beeping monitors, gurgling suction pumps and whooshing respirators. Simultaneously one sees many people rushing around busily performing life saving tasks. The atmosphere is not unlike that of a tension charged strategic war bunker. One becomes aware of desperately ill, sick and injured human beings and they are hooked up to the machinery. And in addition to the mechanical stimuli one can discern moaning, crying, screaming and the last gasps of life. Sights of blood, vomitus, excreta, exposed genitals, mutilated and wasted bodies, and unconscious and helpless people assault the sensibilities. Many are neither alive nor dead. Most have tubes in every orifice. Their sounds and action or inaction are almost inhuman. (Hay & Oken, 1972, p. 112) This vivid, impressionistic observation suggests that working in a n intensive care unit (ICU) is stressful. ICU staff are confronted with human suffering, grief, and death and are exposed to distasteful, degrading, and sometimes even disgusting sights. What is perhaps even more characteristic for ICUs, however, is the surreal environment that is dominated by sophisticated equipment. More than other hospital wards, ICUs have developed into high-tech environments that require complex cognitive skills such as monitoring the equipment and responding to alarms, in addition to traditional nursing (Fitter, 1987).Aside from emotional demands and the use of advanced technology, various stressors have been identified in ICUs, such as conflicting communications with physicians, administrators, and other nurses; heavy workload; inadequate knowledge and skill; ethical problems; and responsibility for life and death decisions (for a review, see Caldwell & Weiner, 1981). Viewed from this perspective, it is not surprising that, one decade ago, burnout was listed among the top research priorities for ICUs (Lewandowski & Kositsky, 1983).Burnout is considered to be a long-term stress reaction (Maslach & Schau-