What makes psychiatry such a stressful profession? A qualitative study

Burnout, stress and intentions to leave work in New Zealand psychiatrists; a mixed methods cross sectional study

BACKGROUND

Demand for mental health services in New Zealand and internationally is growing. Little is known about how psychiatrists are faring in this environment. This study aimed to investigate wellbeing of psychiatrists working in the public health system in New Zealand, identify the main risk factors for work-related stress, gauge perceptions of how workload has changed over time, assess job satisfaction and whether individuals intend or desire to leave their work.

METHODS

Psychiatrists working in New Zealand who were also members of the Association of Salaried Medical Specialists were invited to participate in an online survey. Main outcome measures were degree of burnout and stress experienced at work. Supplementary measures included perceived workplace demands and levels of support. Predictor variables included perceptions of changes to workloads over time, degree of job satisfaction and intentions to leave work. Logistic regression assessed characteristics associated with burnout and job satisfaction as well as intentions to leave work. Free text comments were analysed thematically alongside quantitative trends.

RESULTS

368/526 responded (70% response rate). 34.6% met the criteria for burnout and 35.3% scored with high work stress. There were no significant patterns of association with demographic variables but significant correlation with all but one predictor variable; having experienced a change to the demands of the on-call workload. 45% agreed they would leave their current job if able and 87% disagreed that they are working in a well-resourced mental health service. Respondents emphasised the impact of growing workloads and expressed concerns about their ability to provide optimal care in these circumstances.

CONCLUSIONS

High burnout appears to affect one in three psychiatrists in New Zealand. Many attribute their feelings of burnout to demand for their services. These findings may assist with better workforce planning for psychiatry and emphasises potential consequences of demand for and poor resourcing of mental health services for the retention and wellbeing of doctors in psychiatry worldwide.

Exploring burnout among psychiatric trainees at a South African university

Background

The mental health of doctors is increasingly topical, internationally and locally. Of importance is the phenomenon of burnout, a far-reaching repercussion of chronic work-related stress. Psychiatrists are more vulnerable to stress, burnout and suicide in comparison with other medical specialities. There is a void in published research relating to South African psychiatric trainees.

Aim

The study aimed to investigate burnout and associated factors among psychiatric registrars at a South African university.

Setting

Department of Psychiatry at the University of the Witwatersrand.

Methods

This was a cross-sectional study via an anonymous self-administered questionnaire. The questionnaire comprised three sections: demographics; the Maslach Burnout Inventory Human Services Survey (MBI-HSS) and questions relating to contributing factors, protective factors and consequences of burnout. The MBI-HSS is recognised as the leading measure of burnout, consisting of three subscales: emotional exhaustion (EE), depersonalisation (DP) and personal accomplishment (PA).

Results

The questionnaire was completed by 33 out of 55 psychiatric registrars (60.0% response rate). Data from 31 registrars were used in the analyses, as two registrars did not provide informed consent. Among participants, EE was the most commonly affected, followed by DP and lastly PA. The majority (67.8% or n = 21) had scores in the high category for any one of the three subscales (EE/DP/PA). Significant factors associated with burnout included poor work and non-professional life balance (p = 0.017), utilising annual leave days for work-related tasks (p < 0.001), irregular holidays (p = 0.003) and financial debt (p = 0.026). A possible protective factor was an amicable relationship with fellow psychiatric registrars.

Conclusion

There is evidence of some degree of burnout in more than two-thirds of participants. Associated factors lie largely at an organisational level, and while optimising individual resilience is important, systemic support plays a key role.

Personal resilience in psychiatrists: systematic review

Aims and methodThe concept of personal resilience is relevant to physician well-being, recruitment and retention, and to delivering compassionate patient care. This systematic review aims to explore factors affecting personal resilience among psychiatrists, in particular, those that may impair well-being and those that facilitate resilience practice. A literature search was performed of the Ovid®, Embase®, CINAHL and PsycINFO databases, using keywords to identify empirical studies involving psychiatrists that examined resilience, stress and burnout from the past 15 years. RESULTS: Thirty-three international English language studies were included, showing that a combination of workplace, personal and non-workplace factors negatively and positively influenced well-being and resilience.Clinical implicationsGiven that workplace factors were the most commonly cited, it would appear that any resilience package that predominantly targets interventions at the workplace level would be particularly fruitful. Future research, however, needs to address the absence of a universal measurement of well-being and its moderators so that any potential interventions are better evaluated.Declaration of interestNone.

Adaptation of Medical Students During Clinical Training: Effects of Holistic Preclinical Education on Clerkship Performance

THEORY

Taiwan's medical undergraduate program at a university or medical center is a continuation of 12 years of compulsory citizenship education rooted in holistic philosophies. Students acquire both technical knowledge and nontechnical attributes, which are necessary for success in further work and life. The early clinical learning experiences of medical students are primarily acquired through clerkships. These clerkships require medical students to apply and extend what they learned during their preclinical education; however, previous studies have explored this issue through examining fragmentary factors such as preclinical course grades and traits but not undertaking comprehensive, whole-person investigations.

HYPOTHESES

To account for the potential benefits of a holistic approach in medical students' learning, we propose three hypotheses: Medical students' preclinical performance on Taiwan's technical and nontechnical higher education assessments are positively associated with their clinical competence (Hypothesis 1) and psychological well-being (Hypothesis 2) during clerkships, and medical students' psychological well-being during clerkships is positively associated with their clinical competence (Hypothesis 3).

METHOD

We studied a cohort of 65 medical students engaged in clerkships from September 2013 to April 2015. Their preclinical technical knowledge scores-formal curricular grades received from course instructors-were obtained from their medical school's archival dataset. Their nontechnical attributes-moral and social performance scores received from student mentors and physical performance scores received from course instructors-were also obtained from the school's archival data set. The medical students' competence in their 2-year clinical clerkships was measured using the objective structured clinical examination scores from the end of both clerkship years. The medical students' psychological well-being during their 2-year clerkships was measured according to burnout level, which was determined using routine online surveys that employed validated, structured, and self-administered questionnaires at each specialty rotation. Multiple regressions and linear mixed-effects model were employed for statistical analysis.

RESULTS

Our study revealed that higher preclinical technical knowledge predicted superior clinical competence and a higher level of burnout during clerkships. By contrast, higher preclinical nontechnical attributes (i.e., higher preclinical moral, social, and physical performance) predicted lower level of burnout. However, no relationship was discovered between clerkship burnout and the clinical competence of the medical students.

CONCLUSIONS

Our study verified the value of a holistic education that encompasses both technical knowledge and nontechnical attributes during the preclinical learning stage for medical students. Our findings can serve as a reference for medical educators designing preclinical educational programs for medical students.

Burnout in Indian Psychiatrists

BACKGROUND

Individuals associated with service providing and decision-taking are prone for stress leading to burnout.

AIM

The aim of this study is to find out the details of burnout among Psychiatrists in India.

MATERIALS AND METHODS

Copenhagen Burnout Inventory (CBI) with structured biodata sheet was sent to the representative sample of psychiatrists by e-mail. Basic statistical analysis was done to find out prevalence, analyze response pattern, and differences between those with and without burnout.

RESULTS

The number of psychiatrists that responded to survey was 110-81 (74%) male and 29 (26%) female. The number of burnout cases in one or other spheres was 51 in 35 psychiatrists accounting for the prevalence of 46%. 32% of psychiatrists have burnout. Four psychiatrists have burnout in all three dimensions, nine in two dimensions, and 22 in one dimension. Personal burnout topped in the three dimensions (63%) followed by work burnout (24%). Patient burnout was least at 14%.

CONCLUSIONS

Burnout, though not very high, is to be taken seriously by Indian psychiatrists and protective and preventive measures are in order.

Understanding the burnout experience: recent research and its implications for psychiatry

The experience of burnout has been the focus of much research during the past few decades. Measures have been developed, as have various theoretical models, and research studies from many countries have contributed to a better understanding of the causes and consequences of this occupationally-specific dysphoria. The majority of this work has focused on human service occupations, and particularly health care. Research on the burnout experience for psychiatrists mirrors much of the broader literature, in terms of both sources and outcomes of burnout. But it has also identified some of the unique stressors that mental health professionals face when they are dealing with especially difficult or violent clients. Current issues of particular relevance for psychiatry include the links between burnout and mental illness, the attempts to redefine burnout as simply exhaustion, and the relative dearth of evaluative research on potential interventions to treat and/or prevent burnout. Given that the treatment goal for burnout is usually to enable people to return to their job, and to be successful in their work, psychiatry could make an important contribution by identifying the treatment strategies that would be most effective in achieving that goal.

Content Comparison of Patient-Reported Outcome Instruments Used to Measure Burnout

The aim of this article is to compare the content of patient-reported outcome (PRO) burnout measures and to examine the degree of overlap between them and psychosocial difficulties (PSD) experienced by persons with burnout. The most frequently used PRO and qualitative studies were identified in two systematic literature reviews. Psychosocial difficulties identified in both sources were standardized and a qualitative content comparison was performed. Seven PROs and seven qualitative studies were selected. Energy and drive, emotional functions and work were key themes of both sources. Disparities were observed for problems in areas such as sleep, attention or family relationships, which were reported in several qualitative studies, but are seldom addressed in PROs. Several areas important to persons with burnout, such as family relationships, are seldom measured by currently used PROs. From a biopsychosocial perspective, these instruments cannot therefore be considered comprehensive enough to capture the whole experience of burnout and should be improved.

"I always viewed this as the real psychiatry": provider perspectives on community psychiatry as a career of first choice

The US needs engaged and skilled psychiatrists to support the recovery of people with severe mental illnesses and we are currently facing a shortage. This paper examines what attracts providers to community psychiatry and what sustains them in their work. Focus groups and interviews were used to elicit the perspectives of prescribing clinicians in three community mental health clinics in the US. Community psychiatry has inherent challenges, including facing high-risk decisions, encountering intense affects, and occasionally witnessing bad outcomes. Psychiatrists are motivated and sustained in this work by (1) cultivating relationships with patients and colleagues, (2) focusing on the mission of promoting recovery, and (3) engaging with clinical practice as intellectually stimulating work. Administrators support the engagement and morale of psychiatrists by creating workflows that allow psychiatrists to meaningfully apply their expertise to support patients' recovery. These findings hold implications for recruiting and retaining a new generation of physicians.

Risk of burnout among early career mental health professionals

Burnout is a stress-related syndrome that often affects mental health professionals (MHPs) and may have serious consequences on personal well-being as well as on the quality of provided psychiatric care. Established literature shows a high risk to develop burnout among MHPs. Few data are available on the incidence and on the clinical implications of the burnout syndrome in the early phases of MHP professional career. We confirmed the presence of burnout among early career MHPs: early career psychiatrists showed a lower sense of personal accomplishment, while non-medical MHPs tended to have more depersonalization and suffered from higher levels of depression. Specific programmes to identify the presence of the burnout syndrome and to cope with it should be taught within mental health training curricula. Burnout is a stress-related syndrome that often affects professionals working in emotionally loaded and highly interpersonal environments. Mental health professionals (MHPs) are long known to be at high risk to develop the burnout syndrome, but this has rarely been investigated in professionals in an early phase of career. The aim of the present study was to evaluate the presence of the burnout syndrome and of depressive symptoms among early career psychiatrists and 'non-medical' MHPs. One hundred MHPs (including 50 psychiatrists and 50 non-medical MHPs) were screened for the presence of burnout and depression, with the Maslach Burnout Inventory and the Beck Depression Inventory - revised, respectively. The relationships of burnout with socio-demographical and professional characteristics were also explored. We confirmed the presence of burnout among both groups of early career MHPs, but psychiatrists had a significantly higher degree of emotional exhaustion and a lower sense of personal accomplishment, while non-medical MHPs adopted more frequently depersonalization as a coping strategy and had higher scores for depression, which is associated with higher level of burnout. The risk of developing burnout should be properly addressed in training curricula and strategies to overcome it should be systematically taught, in order to promote personal well-being and efficient team work in mental health settings.

The experience of working on a locked acute psychiatric ward

This study's aim was to elucidate health-care staff experience of working on a locked acute psychiatric ward. In many countries changes in health care has contributed to fewer beds available in inpatient care, and a concentration of patients with severe psychiatric conditions. This implies a changing work environment in acute psychiatric care. Qualitative interviews with health-care staff (n= 10) were carried out on a ward for patients with affective disorder and eating disorder in a Swedish hospital. Qualitative content analysis was used. Four themes were identified from the data: 'undergoing changes in care delivery', 'feeling a need for security and control', 'managing the demands at work' and 'feeling a sense of responsibility'. This study adds to earlier research into how a sense of responsibility can place a significant burden on health-care staff working on a locked psychiatric ward and also contribute to increased control of patients. This study also shows that relationships and power structures among health-care staff need to be addressed when organizational changes are made in care delivery. Further research is needed to reach a comprehensive understanding of care on locked acute psychiatric wards, including a development of nursing and medicine as knowledge domains in one common context.

The medical director and the use of power: limits, challenges and opportunities

The organizational leadership in mental health agencies frequently resides in executives who are not psychiatrists and who may or may not have clinical backgrounds. Psychiatrists who are medical directors (MDs) of organizations with this structure are responsible for the success of the clinical programs, but are subordinate to the executive director (ED). The MD/ED relationship therefore is an example of the complexities and challenges of a relationship in which supervisor and supervisee have different types of power, but are mutually dependent on each other for the organization's success. Clarity and differentiation of the types of power of the MD and ED can be helpful in determining appropriate boundaries and facilitating a cooperative relationship that allows the organizational mission to be well served. Raven's model of the bases of social power (French and Raven, Studies in Social Power, 1959; Raven, Analyses of Social Issues and Public Policy 8(1):1-22, 2008) provides a useful framework to explore this relationship and the challenges and opportunities inherent in it.

Working conditions and job satisfaction of Argentinian psychiatrists: initial results of a comprehensive survey

Working in psychiatry is generally rewarding. However, it can also lack job satisfaction and be detrimental to personal life. Research findings indicate high rates of burnout (Kumar et al, 2007), impaired health status of practitioners (Korkeila et al, 2003), negative effects of violence in the workplace (Inoue et al, 2006) and lack of job satisfaction (Fischer et al, 2007; Bressi et al, 2009).

Stresses experienced by psychiatrists and their role in burnout: a national follow-up study

BACKGROUND

Many studies have looked at sources of stress in psychiatrists, yet the role played by different factors in the causation of burnout in psychiatrists remains unclear. We had two aims, first, to develop a predictive model for the onset of burnout. Second, we aimed to study the differences in the perception of what caused stress between psychiatrists who rated themselves high on Emotional Exhaustion compared to those who rated themselves as low on Emotional Exhaustion.

METHODS

A previously described questionnaire that identified stressors relevant to consultant psychiatrists was mailed out to 426 psychiatrists, with 240 replies. Scores on the Emotional Exhaustion dimension of the Maslach Burnout Inventory were available for 131 respondents.

RESULTS

Based on an earlier literature review, the Sources of Stress Questionnaire (SOS-Q) used in the study had 45 factors, categorized into predisposing, precipitating, perpetuating and protective factors for burnout in psychiatrists. Of these, factor analysis identified 11 non-correlated factors which were used in the final analysis of this study. Four factors emerged as associated with burnout in psychiatrists in New Zealand: too much work; working long hours; an aggressive administrative environment; and lacking support from management. Two factors negatively correlated with Emotional Exhaustion were a high level of job satisfaction and/or enjoyment, and low pay compared to other countries.

CONCLUSIONS

Most factors associated with burnout are preventable and can be managed jointly between psychiatrists and administrators. Service providers need to address burnout seriously.

The relationship between the medical director and the executive director: guidelines for success

The positional leadership of mental health care organizations commonly is in the hands of an executive director who has had administrative experience, but who may or may not have had clinical experience. The medical director of the mental health organization is a psychiatrist who reports to the executive director despite their different backgrounds and areas of expertise. The relationship between these two leaders is the responsibility of both, and is crucial to the success of the organization. This paper is concerned specifically with approaches that can be taken by the medical director to foster a successful working alignment with the executive director. The situation has some similarities (and significant differences) with that described by Gabarro and Kotter in "Managing Your Boss" (1993). A series of guidelines to enhance the potential success of the medical director in this supervisor/supervisee relationship is presented.

Influence of perceived organisational factors on job burnout: survey of community mental health staff

BACKGROUND

Staff burnout is a critical issue for mental healthcare delivery, as it can lead to decreased work performance and, ultimately, to poorer treatment outcomes.

AIMS

To explore the relative weight of job-related characteristics and perceived organisational factors in predicting burnout in staff working in community-based psychiatric services.

METHOD

A representative sample of 2000 mental health staff working in the Veneto region, Italy, participated. Burnout and perceived organisational factors were assessed by using the Organizational Checkup Survey.

RESULTS

Overall, high levels of job distress affected nearly two-thirds of the psychiatric staff and one in five staff members suffered from burnout. Psychiatrists and social workers reported the highest levels of burnout, and support workers and psychologists, the lowest. Burnout was mostly predicted by a higher frequency of face-to-face interaction with users, longer tenure in mental healthcare, weak work group cohesion and perceived unfairness.

CONCLUSIONS

Improving the workplace atmosphere within psychiatric services should be one of the most important targets in staff burnout prevention strategies. The potential benefits of such programmes may, in turn, have a favourable impact on patient outcomes.

A measure of daily distress in practising medicine

OBJECTIVE

Existing measures of stress either focus on burnout or frustration and fatigue factors, often referred to as job strain. The objectives of this study were to: establish a reliable measure of distress that is sensitive enough to identify job strain at lower levels of distress and risk of burnout at higher levels of distress; and document levels of distress among the major medical specialties and across varying patterns of clinical practice.

METHODS

A stratified cross-sectional survey of physicians in Canada was conducted in 2004. Among the eligible population, 2810 physicians (56.7%) responded. Response bias was negligible. Responding physicians completed a 13-item measure of distress. Confirmatory factor analysis was used to establish the measure. Scheffe tests were used to document differences in the levels of distress among specializations and by clinical practice profile.

RESULTS

Factor analysis revealed reliable dimensions of: fatigue (alpha = 0.75) and reaction (alpha = 0.73). The distress measure was reliable (alpha = 0.82). Emergency physicians (n = 4.51), surgeons (n = 4.35), and general practitioners (n = 4.33) reported the highest levels of distress, while administrative physicians (n = 3.30), community health (n = 3.35), and clinical specialists (n = 3.46) reported the lowest levels of distress. Physicians with clinical and administrative responsibilities reported the highest levels of distress (n = 4.40), compared with purely clinical physicians (n = 3.94) and clinician-academics (n = 3.98).

CONCLUSIONS

Some specializations are associated with more distress than others. Administrative duties appear to add to distress for all physicians. Counterintuitively, adding academic as well as administrative responsibilities appears to add less distress than adding administrative duties alone. Academic duties are viewed as advancing medicine.

Psychiatrically impaired medical practitioners: better care to reduce harm and life impact, with special reference to impaired psychiatrists

OBJECTIVE

The aims are to briefly review treatment outcomes for impaired practitioners, and to explore how preventive and early intervention, and the accessing of and retention within treatment systems for impaired medical practitioners, and particularly psychiatrists, could be improved to maximize the doctors' chances of full recovery and to minimize danger to self and others.

METHODS

The literature on the treatment and care of medical practitioner impairment due to mental illness, and substance use, with special reference to impaired psychiatrists is briefly reviewed. The implications of deficiencies of usual clinical management of doctors impaired by mental illness and opportunities for improvement in services for them are explored, including the impact of the experience of being an impaired medical practitioner under psychiatric treatment. The roles of medical boards and advisory services are examined.

RESULTS

Medical practitioner impairment due to mental illness has a severe impact on doctors' lives and the lives of their families due to both the effects of the disorder and the experience of communal, professional and self stigma and discrimination. Deficiencies in usual practice in the treatment and rehabilitation of such individuals are identified, and alternatives explored.

CONCLUSIONS

Prevention, early detection, intervention, and treatment programs that are more continuous more sensitive to the needs of impaired practitioners, that are more continuous, better structured, and rehabilitation and recovery focused, may be more likely to produce a positive outcome.