A hybrid inductive-abductive analysis of health workers' experiences and wellbeing during the COVID-19 pandemic in the United States

The COVID-19 pandemic puts health workers at increased risk of adverse mental health outcomes. However, no studies have assessed health workers' experiences using qualitative methods during the COVID-19 outbreak in the United States to identify novel factors that could relate to their mental health. In May 2020, we distributed an online survey to health workers across 25 medical centers throughout the United States. The Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Primary Care-Post-Traumatic Stress Disorder, and Alcohol Use Disorders Identification Test-Concise and associated cutoff values were used to assess rates of probable major depression, generalized anxiety disorder, post-traumatic stress disorder, and alcohol use disorder, respectively. To provide insight into the factors shaping these and other mental health conditions, we included two open-ended questions asking respondents to recount their most upsetting and hopeful experiences during the COVID-19 pandemic and how it made them feel. Using a hybrid inductive-abductive approach and thematic content analysis, we created a Social Ecological Model to represent themes among health workers' experiences within five ecological levels: individual, interpersonal, organization, community, and public policy. Of the 1,132 participants who completed the survey, 14.0% had probable major depression, 15.8% probable generalized anxiety disorder, 23.1% probable post-traumatic stress disorder, and 42.6% probable alcohol use disorder. Individual level themes included participants' personal health and self-care behaviors. Interpersonal level themes included the health of their social circle, family functioning, and social support. Organization level themes included their hospital's management, resources, patient care, routine, and teams. Themes in the community level included the media, scientific knowledge about COVID-19, morale, behavior, and support of health workers. Lastly, government and health system leadership and shelter-in-place policy were themes within the public policy level. Our findings provide insights into novel factors that have impacted health workers' wellbeing during the COVID-19 pandemic. These factors should be further explored to inform interventions and public policy that mitigate mental health morbidities among health workers during this and future outbreaks.

Sleep disturbances among physicians during COVID-19 pandemic

OBJECTIVES

To assess prevalence and related factors of sleep disturbances among Saudi physicians during COVID-19 pandemic. Data were collected through a questionnaire including items about demographic characters, knowledge about covid-19 and items to assess sleep quality that were extracted from Pittsburgh Sleep Quality Index (PSQI) scale.

RESULTS

Prevalence of sleep disorders was 43.9%, doctors in the age group of 31-40 years, associate consultants had a significant higher prevalence of sleep disorders. Medical interns and laboratory/pathology/microbiology doctors had a significant more difficulty in fall asleep during COVID-19, and internists and surgeons had a significant higher percent of those who used sleeping pills. Resident doctors had a significant higher percent of having trouble in staying awake, and residents and consultants had a significant higher percent of those who suffered decreased sleep duration. Sleep quality during COVID-19 was very good, fair good and very bad in 23.4%, 60% and 3.5% of HCW respectively. The study observed a negative impact of COVID-19 pandemic on HCW sleep quality. Hospitals administrations should provide optimal working hours with enough break and employ more doctors during the pandemic. Doctors experiencing sleep problems should have mandatory leaves.

[Fatigue and mental workload among workers: about social distancing.]

BACKGROUND

Covid-19 is a latent threat; a sector of the population with a labor obligation carries out its work not in person in an unplanned context due to the extraordinary social distancing expressed in remote work, without previous experience in many cases and with health exposure due to psychosocial risk factors conditioning stress. Our objective was to describe the fatigue and mental burden in teleworkers through a bibliographic review, of interest for occupational health, public health, clinical research, psychology and other areas of knowledge. We also intend to inform the community about these issues to promote safe telework and ensure a balanced quality of life.

METHODS

Structured information on the topics of fatigue and mental load was presented, based on the analysis of international literature, mainly from recent years, obtained from the search engine reviews of scientific publications Ebsco, PubMed, and supplemented with Google Scholar, according to recognized thesauri, in English and Spanish.

RESULTS

There are also psychosocial risks in teleworking; work-related stress can be linked to fatigue, which should also be addressed as a psychosocial risk. Fatigue, although multi-causal, can be occupational in origin and may be conditioned by various aspects of labour, such as the mental workload, which is pernicious at its extremes.

CONCLUSIONS

We conclude that both fatigue and mental workload must be watched, their extremes threaten the quality of work life.

Pilot Study Using Neurofeedback as a Tool to Reduce Surgical Resident Burnout

BACKGROUND

Burnout is prevalent among surgical residents. Neurofeedback is a technique to train the brain in self-regulation skills. We aimed to assess the impact of neurofeedback on the cognitive workload and personal growth areas of surgery residents with burnout and depression.

STUDY DESIGN

Fifteen surgical residents with burnout (Maslach Burnout Inventory [MBI] score > 27) and depression (Patient Health Questionnaire-9 Depression Screen [PHQ-9] score >10), from 1 academic institution, were enrolled and participated in this institutional review board-approved prospective study. Ten residents with more severe burnout and depression scores were assigned to receive 8 weeks of neurofeedback treatments, and 5 others with less severe symptoms were treated as controls. Each participant's cognitive workload (or mental effort) was assessed initially, and again after treatment via electroencephalogram (EEG) while the subjects performed n-back working memory tasks. Analysis of variance (ANOVA) tested for significance between the degree of change in the treatment and control groups. Each subject was also asked to rate changes in growth areas, such as sleep and stress.

RESULTS

Both groups showed high cognitive workload in the pre-assessment. After the neurofeedback intervention, the treatment group showed a significant (p < 0.01) improvement in cognitive workload via EEG during the working memory task. These differences were not noted in the control group. There was significant correlation between time (NFB sessions) and average improvement in all growth areas (r = 0.98) CONCLUSIONS: Residents demonstrated high levels of burnout, correlating with EEG patterns indicative of post-traumatic stress disorder. There was a notable change in cognitive workload after the neurofeedback treatment, suggesting a return to a more efficient neural network.

Effect of the Wingman-Connect Upstream Suicide Prevention Program for Air Force Personnel in Training: A Cluster Randomized Clinical Trial

IMPORTANCE

Suicide has been a leading manner of death for US Air Force personnel in recent years. Universal prevention programs that reduce suicidal thoughts and behaviors in military populations have not been identified.

OBJECTIVES

To determine whether the Wingman-Connect program for Airmen-in-training reduces suicidal ideation, depression, and occupational problems compared with a stress management program and to test the underlying network health model positing that cohesive, healthy units are protective against suicidal ideation.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized clinical trial was conducted from October 2017 to October 2019 and compared classes of personnel followed up for 6 months. The setting was a US Air Force technical training school, with participants studied to their first base assignment, whether US or international. Participants in 216 classes were randomized, with an 84% retention rate. Data analysis was performed from November 2019 to May 2020.

INTERVENTIONS

The Wingman-Connect program used group skill building for cohesion, shared purpose, and managing career and personal stressors (3 blocks of 2 hours each). Stress management training covered cognitive and behavioral strategies (2 hours). Both conditions had a 1-hour booster session, plus text messages.

MAIN OUTCOMES AND MEASURES

The primary outcomes were scores on the suicidal ideation and depression scales of the Computerized Adaptive Test for Mental Health and self-reports of military occupational impairment. Class network protective factors hypothesized to mediate the effect of Wingman-Connect were assessed with 4 measures: cohesion assessed perceptions that classmates cooperate, work well together, and support each other; morale was measured with a single item used in other studies with military samples; healthy class norms assessed perceptions of behaviors supported by classmates; and bonds to classmates were assessed by asking each participant to name classmates whom they respect and would choose to spend time with.

RESULTS

A total of 215 classes including 1485 individuals (1222 men [82.3%]; mean [SD] age, 20.9 [3.1] years) participated; 748 individuals were enrolled in the Wingman-Connect program and 737 individuals were enrolled in the stress management program. At 1 month, the Wingman-Connect group reported lower suicidal ideation severity (effect size [ES], -0.23; 95% CI, -0.39 to -0.09; P = .001) and depression symptoms (ES, -0.24; 95% CI, -0.41 to -0.08; P = .002) and fewer occupational problems (ES, -0.14; 95% CI, -0.31 to -0.02; P = .02). At 6 months, the Wingman-Connect group reported lower depression symptoms (ES, -0.16; 95% CI, -0.34 to -0.02; P = .03), whereas the difference in suicidal ideation severity was not significant (ES, -0.13; 95% CI, -0.29 to 0.01; P = .06). The number needed to treat to produce 1 fewer participant with elevated depression at either follow-up point was 21. The benefits of the training on occupational problems did not extend past 1 month. The Wingman-Connect program strengthened cohesive, healthy class units, which helped reduce suicidal ideation severity (estimate, -0.035; 95% CI, -0.07 to -0.01; P = .02) and depression symptom scores (estimate, -0.039; 95% CI, -0.07 to -0.01; P = .02) at 1 month.

CONCLUSIONS AND RELEVANCE

Wingman-Connect is the first universal prevention program to reduce suicidal ideation and depression symptoms in a general Air Force population. Group training that builds cohesive, healthy military units is promising for upstream suicide prevention and may be essential for ecological validity. Extension of the program to the operational Air Force is recommended for maintaining continuity and testing the prevention impact on suicidal behavior.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04067401.

The short-term impact of COVID-19 pandemic on spine surgeons: a cross-sectional global study

Purpose

The outbreak of COVID-19 erupted in December 2019 in Wuhan, China. In a few weeks, it progressed rapidly into a global pandemic which resulted in an overwhelming burden on health care systems, medical resources and staff. Spine surgeons as health care providers are no exception. In this study, we try to highlight the impact of the crisis on spine surgeons in terms of knowledge, attitude, practice and socioeconomic burden.

Methods

This was global, multicentric cross-sectional study on 781 spine surgeons that utilized an Internet-based validated questionnaire to evaluate knowledge about COVID-19, availability of personal protective equipment, future perceptions, effect of this crisis on practice and psychological distress. Univariate and multivariate ordinal logistic regression analyses were used to evaluate the predictors for the degree of COVID-19 effect on practice.

Results

Overall, 20.2%, 52% and 27.8% of the participants were affected minimally, intermediately and hugely by COVID-19, respectively. Older ages (β = 0.33, 95% CI 0.11–0.56), orthopedic spine surgeons (β = 0.30, 95% CI 0.01–0.61) and those who work in the private sector (β = 0.05, 95% CI 0.19–0.61) were the most affected by COVID-19. Those who work in university hospitals (β = − 0.36, 95% CI 0.00 to − 0.71) were affected the least. The availability of N95 masks (47%) and disposable eye protectors or face shields (39.4%) was significantly associated with lower psychological stress (p = 0.01). Only 6.9%, 3.7% and 5% had mild, moderate and severe mental distress, respectively.

Conclusion

While it is important to recognize the short-term impact of COVID-19 pandemic on the practice of spine surgery, predicting where we will be standing in 6–12 months remains difficult and unknown. The COVID-19 crisis will probably have an unexpected long-term impact on lives and economies.

Healthcare workers experience in dealing with Coronavirus (COVID-19) pandemic

Objectives:

To analyze healthcare workers experiences in dealing with the Coronavirus (COVID-19) pandemic.

Methods:

An anonymous open web-based survey study was conducted among healthcare workers from the March 2020 to April 2020. A total of 24 relevant questions were asked based on participants’ characteristics, obligations, and preparedness in healthcare workers in the event of COVID-19 pandemic.

Results:

Approximately 1036 healthcare workers participated in this study with high response rate. Out of all the participants, 70% were women, 52% belonged to the 26-34 year age range, 50% were nurses, 33.7% were clinicians, 74.3% agreed to work overtime, 93.1% understand why they should stay past their shift end, 97.7% thought that preventing illness among healthcare workers and providing safety to family members, nearly 94% thought that personal protective equipment (PPE) for employees will enhance their willingness to report to work. Approximately 89.3% express a desire for incentives and financial support for family members.

Conclusion:

We recommend that providing PPE, reducing psychological stress, financial support and safety to family members of healthcare workers will increase the willingness to report to work.

Nurses' Stress Associated with Nursing Activities and Electronic Health Records: Data Triangulation from Continuous Stress Monitoring, Perceived Workload, and a Time Motion Study

As health IT has become overloaded with patient information, provider burnout and stress has accelerated. Studies have shown that EHR usage leads to heightened cognitive workload for nurses, and increases in cognitive workload can result in stronger feelings of exhaustion and burnout. We conducted a time motion study in an oncology division to examine the relationships between nurses' perceived workload, stress measured by blood pulse wave (BPw), and their time spent on nursing activities, and to identify stress associated with EHR use. We had a total of 33 observations from 7 nurses. We found that EHR-related stress is associated with nurses' perceived physical demand and frustration. We also found that nurses' perceived workload is a strong predictor of nurses' stress as well as how they spent time with their patients. They also experienced higher perceived mental demand, physical demand, and temporal demand when they were assigned to more patients, regardless of patient acuity. Our study presents a unique data triangulation approach from continuous stress monitoring, perceived workload, and a time motion study.

A grounded theory study on work related stress in professionals who provide health & social care for people who exhibit behaviours that challenge

Providing direct health and social care services for people who exhibit behaviours that challenge can be a highly stressful occupation. Existing literature has suggested that there is a need to develop further theoretical understanding of how work related stress can be reduced in professions that consist of providing care for people who exhibit behaviours that challenge. The aim for this study was to use a Classic Grounded Theory approach to develop a theoretical framework to illustrate a common issue that could influence work related stress levels experienced when managing behaviours that challenge in health and social care settings. A series of focus groups and 1:1 semi-structured interviews were conducted to explore the articulated experiences of 47 health/social care professionals who provide care for people who exhibit behaviours that challenge. This led to the development of Therapeutic Engagement Stress Theory (TEST), which illustrates that the perceived capacity to therapeutically engage with people who exhibit behaviours that challenge is an issue that can influence the levels of stress experienced by health/social care professionals. TEST provides a framework that could be applied to identify specific factors that inhibit staff to successfully deliver caring interventions for people who exhibit behaviours that challenge, and also inform bespoke support mechanisms to reduce stress in health/social care professionals.

Work-Related Stress Induced Takotsubo Cardiomyopathy

Aim To report a case of Takotsubo cardiomyopathy secondary to a verbal altercation in an employee who presented with chest pain. Methods The clinical history was obtained from the patient's occupational health record and correspondence from her treating cardiologist. Results The patient was diagnosed with Takotsubo cardiomyopathy following investigations for chest pain. Her echocardiogram was diagnostic. She was treated with beta blockers and advised to have complete rest; she remained out of work for six months. Conclusion There are few published cases of work related Takotsubo cardiomyopathy; it poses a challenge to physicians to be cognisant of this condition in a case of chest pain following emotional turmoil.

Experiences among firefighters and police officers of responding to out-of-hospital cardiac arrest in a dual dispatch programme in Sweden: an interview study

OBJECTIVES

The objective of this study was to explore firefighters' and police officers' experiences of responding to out-of-hospital cardiac arrest (OHCA) in a dual dispatch programme.

DESIGN

A qualitative interview study with semi-structured, open-ended questions where critical incident technique (CIT) was used to collect recalled cardiac arrest situations from the participants' narratives. The interviews where transcribed verbatim and analysed with inductive content analysis.

SETTING

The County of Stockholm, Sweden.

PARTICIPANTS

Police officers (n=10) and firefighters (n=12) participating in a dual dispatch programme with emergency medical services in case of suspected OHCA of cardiac or non-cardiac origin.

RESULTS

Analysis of 60 critical incidents was performed resulting in three consecutive time sequences (preparedness, managing the scene and the aftermath) with related categories, where first responders described the complexity of the cardiac arrest situation. Detailed information about the case and the location was crucial for the preparedness, and information deficits created stress, frustration and incorrect perceptions about the victim. The technical challenges of performing cardiopulmonary resuscitation and managing the airway was prominent and the need of regular team training and education in first aid was highlighted.

CONCLUSIONS

Participating in dual dispatch in case of suspected OHCA was described as a complex technical and emotional process by first responders. Providing case discussions and opportunities to give, and receive feedback about the case is a main task for the leadership in the organisations to diminish stress among personnel and to improve future OHCA missions.

Examining the Mental Well-Being of Australian Sport Coaches

Background: Research has highlighted the multitude of factors that are negatively associated with coach mental well-being but has failed to investigate how the determinants of mental well-being can affect the coach both positively and negatively. Accordingly, the aim of this study was to investigate levels of mental well-being among sport coaches and assess whether areas of work life—specifically workload and control—are related to levels of mental well-being. Method: An online survey comprising demographic and coaching experience details, the Areas of Work Life Scale (AWS), and the Warwick–Edinburgh Mental Well-Being Scale was completed by 464 Australian coaches involved in a range of sports. Differences in coach mental well-being according to key demographic and coaching-related subgroups were assessed using separate t-test and ANOVA analyses and the magnitude of effects was determined using Cohen’s d and the eta-squared (ή²) statistics. Multiple linear regression was used to examine relationships between both workload and control and mental well-being after controlling for age, gender, coaching setting and weekly coaching activity. Results: The findings indicate poorer mental well-being among both male and younger coaches and indicate that coach mental well-being is related to the ability to self-manage the workload associated with their role as a coach as well as greater autonomy over coaching-related tasks and activities. Specifically, a one-unit increase in AWS workload and AWS control were associated with ~three- and ~four-unit increases in coach mental well-being, respectively. Conclusion: Greater provision of resources and education is required to assist coaches to manage their own mental well-being, while being supported by the organisation they coach for. Enabling coaches to balance their coaching requirements and to have control over their environment will improve their ability to constantly coach at a high standard.

Cascades of Care After Incidental Findings in a US National Survey of Physicians

IMPORTANCE

Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally.

OBJECTIVE

To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians.

DESIGN, SETTING, AND PARTICIPANTS

Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019.

MAIN OUTCOMES AND MEASURES

Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades.

RESULTS

This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions.

CONCLUSIONS AND RELEVANCE

The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.

The relationship between empathy and stress: a cross-sectional study among undergraduate medical students

PURPOSE

Empathy is critical for medical doctors, as it enables them to conduct good patient-centred care. Medical students are expected to learn this ability as part of their education and training.

METHODS

Using a cross-sectional design, the present study was conducted to identify whether the empathy levels of medical students are affected by their stress levels. A translated version of the Perceived Stress Scale-10 was used to measure the students' stress levels, while the Jefferson Scale of Physician Empathy was used to measure their empathy levels.

RESULTS

A total of 464 students from one medical school in Indonesia participated in the study. Stress levels among medical students peak in their first year of study and maintain a downward trend over the following years. The students' empathy levels increased during their first 3 years, declined significantly upon entering the first clinical year, and increased during the second clinical year. However, no correlations were found between stress level and empathy level.

CONCLUSION

These findings suggest that there may be other underlying factors that contribute to empathy decline among medical students upon entering their first clinical year. Further research should be conducted to identify these factors. The bounced-back of empathy level to a higher level in the second year highlights the importance of student adaptation in the clinical learning environment and the support system.

Systematic review of the impact of patient death on surgeons

BACKGROUND

The death of a patient is experienced at some time by most surgeons. The aim of this review was to use existing literature to establish how surgeons have dealt with the death of patients.

METHODS

A systematic review of the medical literature was performed. MEDLINE/PubMed, Ovid, Web of Science, Embase, and Google Scholar were searched for qualitative and quantitative studies on surgeon reactions when facing death or a dying patient. This systematic review was performed following the recommendations of the Cochrane collaboration and reported following the PRISMA guidelines. Individual and interview-based opinions were summarized and synthesized.

RESULTS

An initial search found 652 articles. After exclusion of articles that did not satisfy the inclusion criteria, 20 articles remained and seven were included. Two of these articles were personal opinion of the author and five were interviews or surveys. The main findings were that facing death routinely induces a strong psychological burden and that surgeons are more at risk than the general population to develop psychological morbidity.

CONCLUSION

Although it is a frequent and emotional subject in the surgical world, the impact of patient death on surgeons is not abundantly studied in the literature. Dealing with patient death or taking care of a dying patient might have long-lasting psychological impact on surgeons.

Psychological morbidities amongst house officers in Sarawak General Hospital Kuching

INTRODUCTION

Psychological morbidities are common amongst healthcare professionals particularly among junior house officers (HO) who are in a transitional stage from being a medical student to a doctor. They undergo many stressors during this period and hence might suffer from higher psychological morbidities such as depression, anxiety and stress.

OBJECTIVES

To determine the prevalence of depression, anxiety and stress among HO in Sarawak General Hospital (SGH), Kuching, Sarawak. The socialdemographic factors were also evaluated to identify the high-risk groups.

MATERIALS AND METHODS

This is a descriptive cross-sectional study involving 227 house officers in SGH over a period of three months. The social-demographic data such as age, sex, marital status, current posting, duration of posting, place of graduate and state of origin were obtained from interviews with the respondents. The Depression, Anxiety and Stress scale (DASS) questionnaire was completed to assess the psychological morbidities.

RESULTS

HO were found to have high prevalence of psychiatric morbidities such as depression (42%), anxiety (50%) and stress (42.7%). Foreign graduates showed a significantly higher odds of depression (odds ratio, OR: 3.851; 95% confidence interval, 95%CI: 2.165, 6.851), anxiety (OR: 2.427; 95%CI: 1.394, 4.225) and stress (OR: 2.524; 95%CI: 1.439, 4.427) as compared to local graduates.. Further, non-Sarawakians were observed to have higher odds of developing anxiety (OR: 1.772; 95%CI: 1.022, 3.073) as compared to the Sarawakians.

CONCLUSION

HO in SGH had high prevalence of depression, anxiety and stress. Therefore, psychiatric morbidities should be screened regularly amongst the HOs in Malaysia.

Surgical team workload comparison for 4-port and single-port laparoscopic cholecystectomy procedures

Advanced minimally invasive procedures may cause postural constraints and increased workload and stress for providers. This study compared workload and stress across surgical team roles for 48 laparoscopic cholecystectomies (4-port vs single-port) using a task load index (NASA-TLX), a procedural difficulty question, and salivary stress hormones. Statistical analyses were performed based on the presence intra-cluster correlation within team roles, at α=0.05. The single-port technique resulted in an 89% increase in physical workload for the surgeon and 63% increase for the assistant (both p<0.05). The surgeon had significantly higher salivary stress hormones during single-port surgeries. The degree of procedural difficulty was positively correlated between the surgeon and most roles: resident (r=0.67), assistant (r=0.81), and technician (r=0.81). There was a statistically significant positive correlation between the surgeon and assistant for all selfreported workload measures (p<0.05). The single-port technique requires further improvement to balance surgical team workload for optimal patient safety and satisfaction.

Characteristics of Health Care Organizations Associated With Clinician Trust: Results From the Healthy Work Place Study

Importance

There is new emphasis on clinician trust in health care organizations but little empirical data about the association of trust with clinician satisfaction and retention.

Objective

To examine organizational characteristics associated with trust.

Design, Setting, and Participants

This prospective cohort study uses data collected from 2012 to 2014 from 34 primary care practices employing physicians (family medicine and general internal medicine) and advanced practice clinicians (nurse practitioners and physician assistants) in the upper Midwest and East Coast of the United States as part of the Healthy Work Place randomized clinical trial. Analyses were performed from 2015 to 2016.

Main Outcomes and Measures

Clinician trust was measured using a 5-item scale, including belonging, loyalty, safety focus, sense of trust, and responsibility to clinicians in need (range, 1-4, with 1 indicating low and 4 indicating high; Cronbach α = 0.77). Other metrics included work control, work atmosphere (calm to chaotic), organizational culture (cohesiveness, emphases on quality and communication, and values alignment; range, 1-4, with 1 indicating low and 4 indicating high), and clinician stress (range, 1-5, with 1 indicating low and 5 indicating high), satisfaction (range, 1-5, with 1 indicating low and 4 indicating high), burnout (range, 1-5, with 1 indicating no burnout and 5 indicating very high feeling of burnout), and intention to leave (range, 1-5, with 1 indicating no intention to leave and 5 indicating definite intention to leave). Analyses included 2-level hierarchical modeling controlling for age, sex, specialty, and clinician type. Cohen d effect sizes (ESs) were considered small at 0.20, moderate at 0.50, and large at 0.80 or more.

Results

The study included 165 clinicians (mean [SD] age, 47.3 [9.2] years; 86 [52.1%] women). Of these, 143 (87.7%) were physicians and 22 (13.3%) were advanced practice clinicians; 105 clinicians (63.6%) worked in family medicine, and 60 clinicians (36.4%) worked in internal medicine. Compared with clinicians with low levels of trust, clinicians who reported high levels of trust had higher mean (SD) scores for work control (2.49 [0.52] vs 2.18 [0.45]; P < .001), cohesiveness (3.11 [0.46] vs 2.51 [0.51]; P < .001), emphasis on quality vs productivity (3.12 [0.48] vs 2.58 [0.41]; P < .001), emphasis on communication (3.39 [0.41] vs 3.01 [0.44]; P < .001), and values alignment (2.61 [0.59] vs 2.12 [0.52]; P < .001). Men were more likely than women to express loyalty (ES, 0.35; 95% CI, 0.05-0.66; P = .02) and high trust (ES, 0.31; 95% CI, 0.01-0.62; P = .04). Compared with clinicians with low trust at baseline, clinicians with high trust at baseline had a higher mean (SD) satisfaction score (3.99 [0.08] vs 3.51 [0.07]; P < .001; ES, 0.70; 95% CI, 0.39-1.02). Compared with clinicians in whom trust declined or remained low, clinicians with improved or stable high trust reported higher mean (SD) satisfaction (4.01 [0.07] vs 3.43 [0.06]; P < .001; ES, 0.98; 95% CI, 0.66-1.31) and lower stress (3.21 [0.09] vs 3.53 [0.09]; P = .02; ES, -0.39; 95% CI, -0.70 to -0.08) scores and had approximately half the odds of intending to leave (odds ratio, 0.481; 95% CI, 0.241-0.957; P = .04).

Conclusions and Relevance

Addressing low levels of trust by improving work control and emphasizing quality, cohesion, communication, and values may improve clinician satisfaction, stress, and retention.

Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues

First responders are regularly confronted with exposure to traumatic events, including potentially life-threatening situations as well as the grave injuries and deaths of colleagues and civilians. Evidence indicates that the prevalence of posttraumatic stress disorder (PTSD) is substantially higher among first responders than the general population. This article provides information about the outpatient trauma services at McLean Hospital's LEADER (Law Enforcement, Active Duty, Emergency Responder) program to assist clinicians who encounter these first responders in their practices or who are specifically interested in working with this patient population. We begin by synthesizing the literature on the prevalence of PTSD in first responders following work-related exposure to traumatic stress, and by addressing the occupation-specific risk factors and the third-variable risk factors that may contribute to potentiated risk. We then discuss assessment strategies and treatment options used in our program, which is tailored for individuals who are dealing with mental health issues stemming from occupation-specific traumatic-stress exposure. We also address the unique challenges of treating traumatized first responders with more complex issues such as traumatic stress exposure across the lifespan and safety issues, including acute suicidality. We conclude by discussing notable gaps in the literature, including the need to investigate why and how women present with different PTSD symptoms than men and how these differences need to be taken into account in determining appropriate treatment for women.

Psychosocial stressors at work and well-being of male employees

INTRODUCTION

Psychosocial stressors appear to alter the state of mind and adoption of overeating behaviour, resulting in high body mass index. This study was conducted to determine the magnitude of psychosocial stressors on male employees' well-being.

METHOD

This study used secondary data retrieved from a cross-sectional study involving 492 male employees' completed data. Eligible participants completed validated questionnaires of the Psychosocial Safety Climate (PSC-12) scale, short version Demand Induced Strain Compensation (DISQ 2.1), Oldenburg Burnout Inventory - Emotional Exhaustion domain and the Three Eating Factor Questionnaire (TEFQ) -Uncontrolled Eating domain; assessing psychosocial safety climate, job demands and job resources, emotional exhaustion, and uncontrolled eating behaviour, respectively. Body mass index (BMI) was calculated based on weight and height. The research statistical model was tested by two-steps of assessment replicating partial least squares structural equation modelling (PLS-SEM).

RESULT

The results show that psychosocial stressors (psychosocial safety climate, job demands and job resources) had significant effects on emotional exhaustion (β= -0.149, p=0.004; β= 0.223, p<0.001; β= -0.127, p=0.013). Emotional exhaustion predicted by work stressors may act as a chain reaction which could result in uncontrolled eating (β=0.138, p=0.005) and high BMI (β=0.185, p<0.001). Emotional exhaustion does mediate the relationship between PSC and uncontrolled eating behaviour (β= -0.021 [95% boot CI bias corrected: -0.048, -0.002]).

CONCLUSION

The psychosocial stressors at work are significant factors for emotional exhaustion, which further signifies the positive effect on uncontrolled eating behaviour and BMI among Malaysian male employees.

Occupational Stress in Helicopter Emergency Service Pilots From 4 European Countries

OBJECTIVE

Working conditions are known to affect motivation, well-being, and ultimately work performance. Helicopter emergency medical services (HEMS) pilots' work is highly demanding and safety critical, but virtually no published data on occupational stress and strain symptoms in HEMS pilots are available. We investigated work stressors and resources and their association with work engagement, subjective well-being, and energy levels in European HEMS pilots.

METHODS

Cross-sectional questionnaire data were collected consecutively from 72 European HEMS pilots (24 Western European and 48 Eastern European, mean age = 51.9 years). We examined the stressor, resource, and strain symptom levels by age group and region of origin and the association of stressors and resources with work engagement, well-being, and energy.

RESULTS

Although the responses differed notably between the Eastern and Western European pilots, their overall profile was quite favorable. At the same time, those stressor/resource variables, which on average had the most favorable ratings, were the most strongly associated with (reduced) well-being and energy.

CONCLUSION

On the whole, the HEMS pilots' perception of their work situation appears to be positive, and they are highly engaged in their work. The pilots' strong identification with their work should be taken into account in pilot mental health support systems.

Stressors, allostatic load, and health outcomes among women hotel housekeepers: A pilot study

Hotel housekeepers are exposed to stressors at work and outside of work. A minimal amount is known about these workers' pathophysiological responses to those stressors. Allostatic load is a concept increasingly used to understand pathophysiologic manifestations of individuals' bodily response to stress. The purpose of this study was to examine the associations between work and nonwork stressors, allostatic load, and health outcomes among hotel housekeepers. Work and nonwork stressors (e.g., the number of traumatic events, everyday discrimination, and job strain) and health outcomes (e.g., general health status, physical and mental health, and chronic diseases) were measured. Biometric and anthropometric measures and fasting blood specimens were collected. Blood biomarkers included CRP, HbA1c, HDL, and cortisol. Descriptive analyses, correlations, regressions, and t-tests were conducted. Forty-nine women hotel housekeepers participated, with a mean age of 40 years. One-fifth reported high job strain and more than 40% had at least one traumatic event. Chronic conditions were commonly reported, with about 78%, 55%, and 35% reporting one, two, and three chronic conditions, respectively. Correlation analyses showed that reports of high job strain and everyday discrimination were significantly associated with high ALI quartile score (r = 0.39, p = 0.011; r = 0.41, p = 0.004). Job strain and everyday discrimination had medium to large effect sizes on ALI quartile scores. High ALI quartile score was significantly associated with having at least one chronic disease (r = 0.40, p = 0.005), and it had a large effect size on chronic diseases. To our knowledge, this is the first study to explore allostatic load among hotel housekeepers. Hotel housekeepers have high exposure to stressors within and outside of their work and experience poor chronic conditions. Allostatic load had strong associations with both stressors and health outcomes. Despite this worker group being a hard-to-reach worker group to participate in research studies, this study demonstrates the feasibility of accessing, recruiting and collecting survey data and blood samples among them to determine health risks and guide future targeted interventions.