Physician burnout: an examination of personal, professional, and organizational relationships

Interventions to reduce stress and prevent burnout in healthcare professionals supported by digital applications: a scoping review

Aim

Healthcare professionals are at increased risk of burnout, primarily due to workplace-related stressors. The COVID-19 pandemic has further increased this risk. Different interventions exist with varying degrees of effectiveness; little is reported on the content and implementation of such programs. This review fills this gap, with attention to recent programs using digital components.

Methods

PubMed, Embase, PsycInfo, and Google Scholar were searched between January 24th and 28th, 2022, limited to the last 5 years (≥2017). Articles were included if they (1) focused on stress reduction or burnout prevention for nurses and medical doctors within workplace health promotion for nurses or medical doctors, (2) included a digital program component, (3) were conducted in high-income country contexts, and (4) were clinical studies published in English or German. Data was extracted using a priori designed spreadsheets. A group of at least 2 authors at each stage carried out the screening, selection, and data extraction.

Results

The search strategy identified 153 articles, all except 7 were excluded. Two studies were conducted in the USA, two in Spain, one in the Netherlands, Poland, and Korea each. Four studies used a randomized study design, all but one had a control group. A wide range of outcome measures was used. The types of interventions included an adapted mindfulness-based stress reduction program combined with aspects of behavioral therapies, cognitive behavioral therapy, or acceptance and commitment therapy. The digital components used were apps (4 studies), a digital platform, blended learning, and a web-based intervention (1 study each). Six studies focused on individual interventions, one included organizational interventions.

Conclusion

Despite an acute burnout crisis in the healthcare sector, only seven recent interventions were found that integrated digital components. Several problems emerged during the implementation of the interventions that made it clear that organizational support is urgently needed for successful implementation. Although interventions for stress reduction and burnout prevention should combine individual and organizational measures to be as successful as possible, this was only partially the case in one of the intervention programs. The results of this scoping review can be used to further develop or optimize stress and burnout prevention programs.

Scoping Review of Restorative Justice in Academics and Medicine: A Powerful Tool for Justice Equity Diversity and Inclusion

Purpose

Restorative Justice (RJ) as a practice and mindset is growing within academic medicine and health care. The authors aim to categorize the extent to which RJ training and practices have been researched, explored, and applied within health care, medicine, and academic contexts.

Methods

In July 2021, the authors conducted a scoping literature review, searching four databases for peer-reviewed articles and book chapters discussing RJ. Authors also used bibliography searches and personal knowledge to add relevant work. Reviewers independently screened article titles and abstracts, assessing the full texts of potentially eligible articles with inclusion and exclusion criteria. From each included article, authors extracted the publication year, first author's country of origin, specific screening criteria met, and the depth with which it discussed RJ.

Results

From 599 articles screened, 39 articles, and books were included (published 2001-2021). Twenty-five (64%) articles discussed RJ theory with few describing application practices with substantial depth. Ten (26%) articles only referenced the term "restorative justice" and seven (18%) discussed legal applications in health care. Fifty-four percent were from outside the United States. Articles tended to describe RJ uses to address harm and often missed the opportunity to explore RJ's capacity to proactively build community and culture that helps prevent harm.

Conclusions

RJ in health care is a rapidly expanding field that offers a framework capable of building stronger communities, authentically preventing and responding to harm, inviting radical inclusion of diverse participants to build shared understanding and culture, and ameliorate some of the most toxic and unproductive hierarchical practices in academics and medicine. Most literature calls to RJ for help to respond to harm, although there are very few well-designed and evaluated implementations. Investment in RJ practices holds significant promise to steer our historically hierarchical, "othering" and imperfect systems to align with values of justice (vs. punishment), equity, diversity, and inclusion.

Balancing Clinician Workload Through Strategic Patient Panel Designs

BACKGROUND AND OBJECTIVES

Clinician workload is a key contributor to burnout and well-being as well as overtime and staff shortages, particularly in the primary care setting. Appointment volume is primarily driven by the size of patient panels assigned to clinicians. Thus, finding the most appropriate panel size for each clinician is essential to optimization of patient care.

METHODS

One year of appointment and panel data from the Department of Family Medicine were used to model the optimal panel size. The data consisted of 82 881 patients and 105 clinicians. This optimization-based modeling approach determines the panel size that maximizes clinician capacity while distributing heterogeneous appointment types among clinician groups with respect to their panel management time (PMT), which is the percent of clinic work.

RESULTS

The differences between consecutive PMT physician groups in total annual appointment volumes per clinician for the current practice range from 176 to 348. The optimization-based approach for the same PMT physician group results in having a range from 211 to 232 appointments, a relative reduction in variability of 88%. Similar workload balance gains are also observed for advanced practice clinicians and resident groups. These results show that the proposed approach significantly improves both patient and appointment workloads distributed among clinician groups.

CONCLUSION

Appropriate panel size has valuable implications for clinician well-being, patients' timely access to care, clinic and health system productivity, and the quality of care delivered. Results demonstrate substantial improvements with respect to balancing appointment workload across clinician types through strategic use of an optimization-based approach.

A Quality Improvement Initiative to Reduce Pediatrician Burnout Led by the American Academy of Pediatrics Section on Internal Medicine and Pediatrics (Med-Peds)

Physician burnout impacts care (of self and patient), productivity, longevity of career, and overall cost to the system. While burnout rates for pediatricians are lower than average, they have not improved significantly over time. While strategies at the system level have been more successful than those at the individual level, both aspects are vital. This quality improvement study explores physician wellness and burnout trends of a sample population of pediatricians at the 2018 and 2019 AAP National Conference and Exhibition (NCE), using the Physician Health and Wellness Booth (PHWB). A rapid cycle approach with the Plan-Do-Check-Act (PDCA) framework was utilized. The aim was to observe if reported burnout decreased by 20% over six months. Of the pediatricians who interacted with the PHWB, 56 were randomly selected to participate. This included men and women and those in various practice settings, ranging from resident physicians to providers in practice for over 20 years. Baseline surveys included elements from a modified Maslach Burnout Inventory and the Stanford Physician Wellness Survey, focusing on burnout components (emotional exhaustion, depersonalization, and fulfillment) and wellness activities. Individual-based interventions were provided at the PHWB, including adult preventative health guidelines, resources on sleep, stress mitigation, and complementary medicine. Participants received a movie ticket and Starbucks gift card. Follow-up included six monthly newsletters with strategies from seven wellness domains. Post-intervention surveys at six months assessed all baseline questions plus the effectiveness of monthly newsletters. A second PDCA cycle was conducted from the 2019 NCE. All individual-based interventions continued with an added aromatherapy oil station. Additional system-based resources included sample institutional wellness initiatives and burnout cost analyses, all focusing on advocating for cultural change at their respective home organizations. Interactive monthly wellness calendars addressing seven wellness domains were emailed for six months follow-up.  Results from 10 post-intervention surveys (10/56=18% of respondents) from the initial cohort reported an average of 25% decrease in burnout (p=0.09). This was measured on a scale of 1-10 (from "never" burned out to "very often") and improved from 6.68 ("sometimes" to "often" burned out) to 5.0 ("rarely" to "sometimes" burned out). Results from Cohort 2 reflected a decrease in burnout from 4.94 ("rarely" to "sometimes" burned out) to 2.85 ("never" to "rarely" burned out) in return from 20 post-intervention surveys (20/48=42% of respondents, p=0.003). Participants noted a lack of control over work schedules and a disconnect with organizational values as drivers of burnout. Both the PHWB and monthly newsletters were rated as valuable as reminders about wellness practices. Limitations included low response rate, which was notable, and inability to prove causation of improvement from our intervention. Future steps include utilizing subject identification numbers to allow for anonymity in a prospective cohort study with a third PDCA cycle. This would allow anonymous but matched same-subject comparison of pre- and post-survey results despite the small sample size. Follow-up incentives could be beneficial. Lastly, data from both cohorts revealed the highest level of burnout in early career physicians within 10 years of training, paving an opportunity for future study.

Factors associated with emotional exhaustion in healthcare professionals involved in the COVID-19 pandemic: an application of the job demands-resources model

PURPOSE

The purpose of the present cross-sectional study is to investigate the role of perceived COVID-19-related organizational demands and threats in predicting emotional exhaustion, and the role of organizational support in reducing the negative influence of perceived COVID-19 work-related stressors on burnout. Moreover, the present study aims to add to the understanding of the role of personal resources in the Job Demands-Resources model (JD-R) by examining whether personal resources-such as the professionals' orientation towards patient engagement-may also strengthen the impact of job resources and mitigate the impact of job demands.

METHODS

This cross-sectional study involved 532 healthcare professionals working during the COVID-19 pandemic in Italy. It adopted the Job-Demands-Resource Model to study the determinants of professional's burnout. An integrative model describing how increasing job demands experienced by this specific population are related to burnout and in particular to emotional exhaustion symptoms was developed.

RESULTS

The results of the logistic regression models provided strong support for the proposed model, as both Job Demands and Resources are significant predictors (OR = 2.359 and 0.563 respectively, with p < 0.001). Moreover, healthcare professionals' orientation towards patient engagement appears as a significant moderator of this relationship, as it reduces Demands' effect (OR = 1.188) and increases Resources' effect (OR = 0.501).

CONCLUSIONS

These findings integrate previous findings on the JD-R Model and suggest the relevance of personal resources and of relational factors in affecting professionals' experience of burnout.

The Initial Positive and Negative Impacts of the COVID-19 Pandemic on Rural Healthcare Providers: Associations With Team Culture and Leadership

EXECUTIVE SUMMARY

This study aimed to use qualitative and quantitative methods to (1) understand the initial positive and negative impacts of the COVID-19 pandemic on rural healthcare providers; (2) explore associations between team culture and leadership and provider distress and job satisfaction after the initial impact of the COVID-19 pandemic; and (3) determine whether changes occurred in perceived stress and burnout. Participants included 213 providers working in rural Pennsylvania. The researchers administered an electronic survey to participants 10 days after the organization issued directives to cancel routine care appointments. Descriptive statistics were used to examine sample characteristics. The researchers used thematic analysis to assess open-ended responses. Correlational analyses were used to examine associations among perceived stress, team culture, job satisfaction, COVID-19 engagement, and team leadership. Most providers reported that the pandemic had the greatest effect on them psychologically, followed by professionally (i.e., changes in workload and conflicts with coworkers) and financially. Statistically significant positive associations were observed among leadership, provider distress, and team culture. Identification of the psychological impact highlights the need to support healthcare providers and address their psychological needs. Moreover, understanding ways in which leaders can effectively lead may help personnel better prepare for a public health crisis.

Construct Validity and Differential Item Functioning of the PHQ-9 Among Health Care Workers: Rasch Analysis Approach

PURPOSE

The Patient Health Questionnaire (PHQ-9) is a widely used self-report questionnaire to screen depression. Its psychometric property has been tested in many populations including health care workers. We used Rasch measurement theory to examine the psychometric properties of PHQ-9 regarding item difficulty, item fit and the differences between subgroups of respondents classified by sex, age, education and alcohol user status, based on the same overall location of participants.

PATIENTS AND METHODS

In total, 3204 health care workers of Maharaj Nakorn Chiang Mai Hospital participated and were administered the PHQ-9. Rating scale Rasch measurement modeling was used to examine the psychometric properties of the PHQ-9.

RESULTS

The data fitted well to the Rasch model and no violations of the assumption of unidimensionality were observed. All 9 items could form a unidimensional construct of overall depressive severity. Suicidal ideation was the least endorsed while sleep problem was the most. No disordered category and threshold of the rating response were observed. No locally dependent items were observed. No items were found to show differential item functioning across age, sex, education and alcohol consumption. The item-person Wright map showed that the PHQ-9 did not target well with the sample, and a wide gap suggesting few or no items exist to differentiate participants at a certain ability level among the PHQ-9 items.

CONCLUSION

The PHQ-9 can be used as a screening questionnaire for major depressive disorder as its psychometric property was verified based on Rasch measurement model. The findings are generally consistent with related studies in other populations. However, the PHQ-9 may be unsuitable for assessing depressive symptoms among health care workers who have low levels of depression.

[Association between Safety Culture and Risk of Burnout: A Survey of Non-Medical Rescue Workers]

BACKGROUND

Stressors such as safety culture in organizations that increase the risk of burnout have been studied in nursing and inpatient care settings. However, investigations in the setting of preclinical emergency medical services (EMS) are still limited. The study aims at (1) investigating burnout in health care workers in preclinical EMS and their perceived safety culture, and (2) analyzing the association between the two.

METHODS

Using the Maslach Burnout Inventory (MBI) and the Emergency Medical Services - Safety Attitudes Questionnaire (EMS-SAQ), an online survey was conducted with non-medical health care workers in preclinical EMS. Descriptive analyses were performed using frequencies, mean values, percentages and the Pearson correlation coefficient. A logistic regression model was used to determine the relationship between safety culture and the risk of burnout.

RESULTS

A total of 1,101 questionnaires was considered for analysis. Most of the participants were male (86.2%) and younger than 40 years (73.2%). A high risk of burnout for participants was found for the dimensions of emotional exhaustion and depersonalization (EE 26.3% and DP 40.2%). In the context of measuring safety culture, especially management, working conditions, and safety climate were negatively perceived by the participants. Furthermore, high stress recognition (EE: OR=3.317, p<0.01; DP: OR=1.910, p<0.01), negative job satisfaction (EE: OR=0.297, p<0.01; DP: OR=0.576, p<0.01) and negatively perceived working conditions (EE: OR 0.598, p<0.05; DP: 0.937, p<0.05) were significantly associated with a high risk of burnout.

CONCLUSION

This is the first large scale study investigating burnout among non-medical health care workers in preclinical EMS and their perceived safety culture in Germany as well as the association between the two. The results show the necessity to focus on perceived dimensions of safety culture in organizations, to develop measures reducing stress and improve job satisfaction and working conditions. In the context of increasing skills shortage, this is especially relevant with regard to the challenges of patient safety and quality of outcomes in care.

Surgical Locker room Environment: Understanding the Hazards (SLEUTH) study

BACKGROUND

Anecdotal evidence reveals that medical equipment are easily found in hospital changing rooms. Access to potentially lethal drugs and intravenous access equipment may put vulnerable medical staff at risk. The aims are to quantify the burden of medical equipment found in this environment, calculate the associated cost burden and to raise clinician awareness about a potential health hazard.

METHODS

We prospectively collected data on the medical paraphernalia found in surgical changing rooms from one private and two public hospitals in South Australia over 2 months. We systematically searched open surgical lockers, benches and floors in male and female lockers rooms. Item costs were calculated from Imprest and the Pharmacy Department.

RESULTS

During the study period, we found a total of 537 items. There were 280 sharps, including 185 scalpels found in one open locker. There were 78 items of intravenous paraphernalia, 38 surgical tapes, 70 bandages and 73 miscellaneous items. In addition, there were six medications found including 3 × 5 mL vials of 1% lignocaine, one vial of lignocaine with adrenaline, one ketorolac suppository and 5 mL fentanyl. There were 529 (98.5%) items within their date of expiry. The total cost of the items was 2358 Australian dollars (AUD), with an estimated annual cost of 14 148 AUD over the three sites and 424 400 AUD over South Australia.

CONCLUSION

The burden of available medical supplies found in the theatre changing room is high and worrisome. Strategies for appropriate disposal and safe storage of medical equipment are required.

Association Between Difficulty with VA Patient-Centered Medical Home Model Components and Provider Emotional Exhaustion and Intent to Remain in Practice

BACKGROUND

The patient-centered medical home (PCMH) model is intended to improve primary care, but evidence of its effects on provider well-being is mixed. Investigating the relationships between specific PCMH components and provider burnout and potential attrition may help improve the efficacy of the care model.

OBJECTIVE

We analyzed provider attitudes toward specific components of PCMH in the Veterans Health Administration (VA) and their relation to emotional exhaustion (EE)-a central component of burnout-and intent to remain in VA primary care.

DESIGN

Logistic regression analysis of a cross-sectional survey.

SUBJECTS

116 providers (physicians; nurse practitioners; physician assistants) in 21 practices between September 2015 and January 2016 in one VA region.

MAIN MEASURES

Outcomes: burnout as measured with the emotional exhaustion (EE) subscale of the Maslach Burnout Inventory and intent to remain in VA primary care for the next 2 years; predictors: difficulties with components of PCMH, demographic characteristics.

KEY RESULTS

Forty percent of providers reported high EE (≥ 27 points) and 63% reported an intent to remain in VA primary care for the next 2 years. Providers reporting high difficultly with PCMH elements were more likely to report high EE, for example, coordinating with specialists (odds ratio [OR] 8.32, 95% confidence interval [CI] 3.58-19.33), responding to EHR alerts (OR 6.88; 95% CI 1.93-24.43), and managing unscheduled visits (OR 7.53, 95% CI 2.01-28.23). Providers who reported high EE were also 87% less likely to intend to remain in VA primary care.

CONCLUSIONS

To reduce EE and turnover in PCMH, primary care providers may need additional support and training to address challenges with specific aspects of the model.

Structural relationships among occupational dysfunction, stress coping, and occupational participation for healthcare workers

BACKGROUND AND OBJECTIVE

Occupational dysfunction is frequent among healthcare workers, but little is known about factors related to occupational participation and stress coping behavior among healthcare workers. This cross-sectional study aimed to analyze structural relationships among occupational dysfunction, stress coping, and occupational participation in healthcare workers.

METHODS

Participants were 601 healthcare workers in 13 facilities. Data were collected with participant profile, Classification and Assessment of Occupational Dysfunction (CAOD), Coping Scale (CS), and Self-completed Occupational Performance Index (SOPI). Data were analyzed by descriptive statistics, item response theory (IRT), confirmatory factor analysis (CFA), correlation analysis, and path analysis.

RESULTS

CFAs of CAOD, CS, and SOPI indicated good fit to the predicted models. In IRT, CAOD and SOPI showed conformity, but two items of CS showed nonconformity. The correlation between CAOD-SOPI was high to moderate (-0.486 to -0.246; p < 0.001), whereas that between CAOD and emotion-focused coping was weakly negative. SOPI and CS were negatively associated with occupational dysfunction (p < 0.000).

CONCLUSIONS

This model demonstrated that SOPI and CS had a negative structural relationship with occupational dysfunction. Therefore, it seems important to encourage occupational participation (in the areas of self-care, productivity, and leisure) to reduce occupational dysfunction in healthcare workers.

A 2-Question Summative Score Correlates with the Maslach Burnout Inventory

Introduction

There is a high prevalence of burnout among emergency medicine (EM) residents. The Maslach Burnout Inventory - Human Services Survey (MBI-HSS) is a widely used tool to measure burnout. The objective of this study was to compare the MBI-HSS and a two-question tool to determine burnout in the EM resident population.

Methods

Based on data from the 2017 National Emergency Medicine Resident Wellness Survey study, we determined the correlation between two single-item questions with their respective MBI subscales and the full MBI-HSS. We then compared a 2-Question Summative Score to the full MBI-HSS with respect to primary, more restrictive, and more inclusive definitions of burnout previously reported in the literature.

Results

Of 1,522 residents who completed the survey 37.0% reported “I feel burned out from my work,” and 47.1% reported “I have become more callous toward people since I took this job” once a week or more (each item >3 on a scale of 0–6). A 2-Question Summative Score totaling >3 correlated most closely with the primary definition of burnout (Spearman’s rho 0.65 [95% confidence interval 0.62–0.68]). Using the summative score, 77.7% of residents were identified as burned out, compared to 76.1% using the full MBI-HSS, with a sensitivity and specificity of 93.6% and 73.0%, respectively.

Conclusion

An abbreviated 2-Question Summative Score correlates well with the full MBI-HSS tool in assessing EM resident physician burnout and could be considered a rapid screening tool to identify at-risk residents experiencing burnout.

Burnout, job satisfaction, and work-family conflict among rural medical providers

Rural medical providers may be particularly susceptible to burnout and additional demands on personal time, due to the increased demands of health-care shortages in rural areas. The purpose of this study was to examine the prevalence of perceived stress and burnout among rural medical providers, and associations with job satisfaction, work-family conflict, and amount of work completed during personal time. Electronic surveys were completed by 151 medical providers. Multiple linear regression was used to further examine associations between work during personal time and work-family conflict, predicted perceived job satisfaction, perceived stress, and burnout. Primary hypotheses were supported, and work-family conflict and work during personal time were negatively correlated with job satisfaction and positively correlated with perceived stress and burnout. Examining these findings could aid in designing interventions that might assist with provider shortages in rural healthcare.

An Organizational Intervention to Reduce Physician Burnout

EXECUTIVE SUMMARY

Burnout is an individual's specific, personal, and intimate stress reaction to the workplace, characterized by emotional exhaustion, depersonalization, and reduced self-efficacy. Even though it particularly affects the helping professions, there has been relatively little exploration into the causes and determinants of burnout among physicians; instead, the focus has been on documenting the prevalence and consequences of physician burnout. Furthermore, while the theory of burnout is based on the relationship between the individual and his or her workplace, interventions have focused on improving the resilience of an individual to withstand this imbalance rather than identifying and ameliorating the cause.This study observed a natural experiment to measure changes in primary care providers' burnout before and after the implementation of a workload intervention that changed the work process within primary care clinics. Four clinics received the intervention, while four others served as comparisons. Among physicians in clinics receiving the intervention, the results show significant impacts, with an improvement in workload of 0.61 units (p = 0.037) and a decrease in the emotional exhaustion dimension of burnout of 6.989 units (p = 0.039).Self-care interventions are inconsistent with the theory of burnout; success of such interventions may be due to participants self-selecting these interventions, and individuals' inability to change their workplace without management approval. Leaders need to consider the impact of the workplace itself on physicians, in addition to results or outcomes.

Evidence Relating Health Care Provider Burnout and Quality of Care: A Systematic Review and Meta-analysis

BACKGROUND

Whether health care provider burnout contributes to lower quality of patient care is unclear.

PURPOSE

To estimate the overall relationship between burnout and quality of care and to evaluate whether published studies provide exaggerated estimates of this relationship.

DATA SOURCES

MEDLINE, PsycINFO, Health and Psychosocial Instruments (EBSCO), Mental Measurements Yearbook (EBSCO), EMBASE (Elsevier), and Web of Science (Clarivate Analytics), with no language restrictions, from inception through 28 May 2019.

STUDY SELECTION

Peer-reviewed publications, in any language, quantifying health care provider burnout in relation to quality of patient care.

DATA EXTRACTION

2 reviewers independently selected studies, extracted measures of association of burnout and quality of care, and assessed potential bias by using the Ioannidis (excess significance) and Egger (small-study effect) tests.

DATA SYNTHESIS

A total of 11 703 citations were identified, from which 123 publications with 142 study populations encompassing 241 553 health care providers were selected. Quality-of-care outcomes were grouped into 5 categories: best practices (n = 14), communication (n = 5), medical errors (n = 32), patient outcomes (n = 17), and quality and safety (n = 74). Relations between burnout and quality of care were highly heterogeneous (I2 = 93.4% to 98.8%). Of 114 unique burnout-quality combinations, 58 indicated burnout related to poor-quality care, 6 indicated burnout related to high-quality care, and 50 showed no significant effect. Excess significance was apparent (73% of studies observed vs. 62% predicted to have statistically significant results; P = 0.011). This indicator of potential bias was most prominent for the least-rigorous quality measures of best practices and quality and safety.

LIMITATION

Studies were primarily observational; neither causality nor directionality could be determined.

CONCLUSION

Burnout in health care professionals frequently is associated with poor-quality care in the published literature. The true effect size may be smaller than reported. Future studies should prespecify outcomes to reduce the risk for exaggerated effect size estimates.

PRIMARY FUNDING SOURCE

Stanford Maternal and Child Health Research Institute.

Live to Work or Work to Live? An Age-Moderated Mediation Model on the Simultaneous Mechanisms Prompted by Workaholism Among Healthcare Professionals

The "aging population" implies an increased proportion of older professionals and a growing demand for healthcare services. Healthcare professionals are often highly committed to their work which can be reflected in high levels of workaholism, being a double-edged sword that can prompt both positive and negative mechanisms, differently affecting younger and older healthcare workers. The present study aims to gain insights into the relationships between healthcare professionals' age, workaholism and job satisfaction, by estimating the sequential mediating roles of workload perceptions and emotional exhaustion. We used original survey data, including information on 750 healthcare professionals. Overall, the negative relationship between workaholism and job satisfaction was shown to be sequentially (and partially) mediated by workload perceptions and emotional exhaustion. Multi-Group SEM analyses revealed differences across three age groups (under 35; between 35 and 50; over 50). Only in the two younger age groups, we found a direct and positive relationship between workaholism and job satisfaction. In all age groups, we found the negative relationship between workaholism and job satisfaction to be sequentially (and partially) mediated by workload perceptions and emotional exhaustion. The indirect effects were relatively stronger in the younger age group. Workaholism can prompt both a "gain spiral" and "a loss spiral" among healthcare professionals. The first reflects workaholism to function as a job resource fostering job satisfaction (only for the two younger age groups). The second reflects workaholism to function as a job demand reducing job satisfaction. This mechanism was shown to be stronger with an increasing age.

Gender differences in career satisfaction, moral distress, and incivility: a national, cross-sectional survey of Canadian critical care physicians

PURPOSE

In a national cross-sectional survey, we aimed to i) characterize work profile, workload, and income, ii) evaluate work satisfaction, work-life integration, burnout, incivility, mentorship, and promotion, iii) gauge future physician resource requirements, and iv) assess for differences by gender and specialty (adult vs pediatric).

METHODS

We developed, tested, and administered an electronic questionnaire.

RESULTS

We analyzed 265 fully and 18 partially completed questionnaires. Respondents were predominantly men (192; 72.5%) and adult intensivists (229; 87.7%). Most intensivists (226/272; 83.1%) were somewhat satisfied or strongly satisfied with their career. Over one third of respondents felt that their daily intensive care unit (ICU) clinical work (113/270; 41.9%), yearly non-ICU clinical work (86/248; 34.7%), administrative work (101/264; 38.3%), and in-house call coverage (78/198; 39.4%) were somewhat high or very high. Nearly half (129/273; 47.3%) felt that their work schedule did not leave enough time for personal/family life. Twenty-seven percent (74/272) of respondents were experiencing at least one symptom of burnout when surveyed and 171/272 (63%) experienced burnout symptoms more than once a month. Ten percent planned to retire in the next five years and 17-20% retired each five-year interval thereafter. Compared with men, women felt that their work schedule left significantly less time for personal/family life (χ² [4] = 11.36, P < 0.05, odds ratio [OR] = 0.55), experienced more frequent and severe burnout symptoms (F [1,120.91] = 8.04, P < 0.01, OR = 2.0; F [1,112.80] = 4.91, P < 0.05, OR = 1.9), and more incivility in their division (χ² [1] = 13.73, P < 0.001, OR = 2.8), hospital (χ² [1] = 8.11, P < 0.01, OR = 2.2), and university (χ² [1] = 4.91, P < 0.05, OR = 2.3).

CONCLUSIONS

Although most intensivists were satisfied with their careers, many were dissatisfied with their workload, experienced work-life integration challenges, and acknowledged burnout symptoms. Women intensivists were significantly less satisfied with their careers, experienced greater work-life integration challenges, more frequent and severe burnout symptoms, and greater incivility.

Prevalence of burnout among German general practitioners: Comparison of physicians working in solo and group practices

Background

Studies from general practitioner (GP) populations from various European countries show a high prevalence of burnout, yet data from Germany are scarce and there are no data comparing GPs from solo versus group practices.

Methods

This cross-sectional survey addressed all GPs from a German network of family medicine practices comprising 185 practices. Participants were asked to fill in a self-administered questionnaire addressing socio-demographic and job-related characteristics. The German version of the Maslach Burnout Inventory was used to measure the dimensions emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Each participant was categorized as having high EE, high DP and low PA following pre-defined cut-offs.

Results

A total of 214 GPs from 129 practices participated: 65.9% male, 24.8% solo practice. Of all GPs, 34.1% (n = 73) scored high for EE, 29.0% (n = 62) high for DP, 21.5% (n = 46) low for PA and 7.5% (n = 16) for all three dimensions. A higher risk for EE was found among female physicians, those unsatisfied with their job, those using few stress-regulating measures regularly and those reporting bad work-life balance. Burnout prevalence was higher in GPs in group than in solo practices (37.9% vs. 28.8% had high EE, 33.1% vs. 18.9% had high DP and 22.8% vs. 18.9% had low PA). A significantly higher prevalence of burnout symptoms was found in group practice employees compared to group practice owners.

Conclusion

Burnout prevalence was higher among physicians in group practices compared to solo practices. In group practices, employed, young, female and part-time working physicians showed a higher burnout risk.

Occupational Burnout among Otolaryngology–Head and Neck Surgery Trainees in Australia

Objectives

Surgical trainee burnout has gained attention recently as a significant factor leading to poorer quality of patient care, decreased productivity, and personal dysfunction. As a result, we aimed to determine the prevalence and associated risk factors for burnout among otolaryngology–head and neck surgery (OHNS) trainees in Australia.

Study Design

Cross-sectional survey.

Setting

National cohort of accredited OHNS trainees in Australia.

Subjects and Methods

Participants completed the Maslach Burnout Inventory (MBI). Trainee burnout was defined if any threshold of the 3 MBI domains—emotional exhaustion, depersonalization, or personal accomplishment—reached an established high threshold. Demographic data on potential predictors of burnout, such as stressors, workload, satisfaction, and support systems, were collected from survey responses. Predictors were compared with the burnout status.

Results

Of 67 OHNS trainees, 60 responded (66.7% men). Burnout was common among respondents, with 73.3% suffering from burnout in at least 1 of the 3 MBI domains (70.0%, emotional exhaustion; 46.7%, depersonalization; 18.3%, personal accomplishment). Trainee burnout was significantly influenced by training location (chi-square, P = .05), living geographically apart from social supports (odds ratio [OR], 3.49; chi-square, P = .007), number of years trained rurally or away from social supports (Kendall’s tau-B, P = .03), difficulty balancing work and nonwork commitments (OR, 10.0; chi-square, P = .03), training negatively affecting their partner or family (OR, 14.30; chi-square, P = .05), and feeling uncomfortable approaching a supervisor (OR, 2.50; chi-square, P < .0001).

Conclusion

Burnout was found to be very common among OHNS trainees in Australia. The statistically significant predictors identified should be addressed to minimize trainee burnout.

Prevalence of Burnout Among Physicians: A Systematic Review

Importance

Burnout is a self-reported job-related syndrome increasingly recognized as a critical factor affecting physicians and their patients. An accurate estimate of burnout prevalence among physicians would have important health policy implications, but the overall prevalence is unknown.

Objective

To characterize the methods used to assess burnout and provide an estimate of the prevalence of physician burnout.

Data Sources and Study Selection

Systematic search of EMBASE, ERIC, MEDLINE/PubMed, psycARTICLES, and psycINFO for studies on the prevalence of burnout in practicing physicians (ie, excluding physicians in training) published before June 1, 2018.

Data Extraction and Synthesis

Burnout prevalence and study characteristics were extracted independently by 3 investigators. Although meta-analytic pooling was planned, variation in study designs and burnout ascertainment methods, as well as statistical heterogeneity, made quantitative pooling inappropriate. Therefore, studies were summarized descriptively and assessed qualitatively.

Main Outcomes and Measures

Point or period prevalence of burnout assessed by questionnaire.

Results

Burnout prevalence data were extracted from 182 studies involving 109 628 individuals in 45 countries published between 1991 and 2018. In all, 85.7% (156/182) of studies used a version of the Maslach Burnout Inventory (MBI) to assess burnout. Studies variably reported prevalence estimates of overall burnout or burnout subcomponents: 67.0% (122/182) on overall burnout, 72.0% (131/182) on emotional exhaustion, 68.1% (124/182) on depersonalization, and 63.2% (115/182) on low personal accomplishment. Studies used at least 142 unique definitions for meeting overall burnout or burnout subscale criteria, indicating substantial disagreement in the literature on what constituted burnout. Studies variably defined burnout based on predefined cutoff scores or sample quantiles and used markedly different cutoff definitions. Among studies using instruments based on the MBI, there were at least 47 distinct definitions of overall burnout prevalence and 29, 26, and 26 definitions of emotional exhaustion, depersonalization, and low personal accomplishment prevalence, respectively. Overall burnout prevalence ranged from 0% to 80.5%. Emotional exhaustion, depersonalization, and low personal accomplishment prevalence ranged from 0% to 86.2%, 0% to 89.9%, and 0% to 87.1%, respectively. Because of inconsistencies in definitions of and assessment methods for burnout across studies, associations between burnout and sex, age, geography, time, specialty, and depressive symptoms could not be reliably determined.

Conclusions and Relevance

In this systematic review, there was substantial variability in prevalence estimates of burnout among practicing physicians and marked variation in burnout definitions, assessment methods, and study quality. These findings preclude definitive conclusions about the prevalence of burnout and highlight the importance of developing a consensus definition of burnout and of standardizing measurement tools to assess the effects of chronic occupational stress on physicians.

Mental disorders among workers in the healthcare industry: 2014 national health insurance data

Background

Numerous studies have shown that healthcare professionals are exposed to psychological distress. However, since most of these studies assessed psychological distress using self-reporting questionnaires, the magnitude of the problem is largely unknown. We evaluated the risks of mood disorders, anxiety disorders, sleep disorders, and any psychiatric disorders in workers in healthcare industry using Korea National Health Insurance (NHI) claims data from 2014, which are based on actual diagnoses instead of self-evaluation.

Methods

We used Korea 2014 NHI claims data and classified employees as workers in the healthcare industry, based on companies in the NHI database that were registered with hospitals, clinics, public healthcare, and other medical services. To estimate the standardized prevalence of the selected mental health disorders, we calculated the prevalence of diseases in each age group and sex using the age distribution of the Korea population. To compare the risk of selected mental disorders among workers in the healthcare industry with those in other industries, we considered age, sex, and income quartile characteristics and conducted propensity scored matching.

Results

In the matching study, workers in healthcare industry had higher odds ratios for mood disorders (1.13, 95% CI: 1.11–1.15), anxiety disorders (1.15, 95% CI: 1.13–1.17), sleep disorders (2.21, 95% CI: 2.18–2.24), and any psychiatric disorders (1.44, 95% CI: 1.43–1.46) than the reference group did. Among workers in healthcare industry, females had higher prevalence of psychiatric disorders than males, but the odds ratios for psychiatric disorders, compared to the reference group, were higher in male workers in healthcare industry than in females.

Conclusions

The prevalence of mood disorders, anxiety disorders, sleep disorders, and all psychiatric disorders for workers in the healthcare industry was higher than that of other Korean workers. The strikingly high prevalence of sleep disorders could be related to the frequent night-shifts in these professions. The high prevalence of mental health problems among workers in healthcare industry is alarming and requires prompt action to protect the health of the “protectors.”

Thriving in scrubs: a qualitative study of resident resilience

Background

Physician well-being impacts both doctors and patients. In light of high rates of physician burnout, enhancing resilience is a priority. To inform effective interventions, educators need to understand how resilience develops during residency.

Methods

A qualitative study using grounded theory examined the lived experience of resilience in residents. A cohort of obstetrics and gynecology residents were selected as a purposive, intensity sample.. Eighteen residents in all years of training participated in semi-structured interviews. A three-phase process of open coding, analytic coding and thematic analysis generated a conceptual model for resilience among residents.

Results

Resilience among residents emerged as rooted in the resident’s calling to the work of medicine. Drive to overcome obstacles arose from personal identity and aspiration to professional ideals. Adversity caused residents to examine and cultivate coping mechanisms. Personal connections to peers and mentors as well as to patients and the work helped buffer the stress and conflicts that present. Resilience in this context is a developmental phenomenon that grows through engagement with uncertainty and adversity.

Conclusion

Resilience in residents is rooted in personal and professional identity, and requires engagement with adversity to develop. Connections within the medical community, finding personal fulfillment in the work, and developing self-care practices enhance resilience.

Burnout of Physicians Working in Primary Health Care Centers under Ministry of Health Jeddah, Saudi Arabia

Introduction

The levels of physicians' job satisfaction and burnout directly affect their professionalism, punctuality, absenteeism, and ultimately, patients' care. Despite its crucial importance, little is known about professional burnout of the physicians in Saudi Arabia. The objectives of this research are two-fold: (1) To assess the prevalence of burnout in physicians working in primary health care centers under Ministry of Health; and (2) to find the modifiable factors which can decrease the burnout ratio.

Methodology

Through a cross-sectional study design, a representative sample of the physicians working in primary health care centers (PHCCs) Jeddah (n=246) was randomly selected. The overall burnout level was assessed using the validated abbreviated Maslach burnout inventory (aMBI) questionnaire. It measures the overall burnout prevalence based on three main domains i.e., emotional exhaustion, depersonalization, and personal accomplishment. Independent sample T-test, analysis of variance (ANOVA), and multivariate regression analysis were performed using Statistical Package for the Social Sciences (SPSS Version 22, IBM, Armonk, NY).

Results

Overall, moderate to high burnout was prevalent in 25.2% of the physicians. Emotional exhaustion was noted in 69.5%. Multivariate regression analysis showed that patient pressure/violence (p <0.001), unorganized patients flow to clinics (p=0.021), more paperwork (p<0.001), and less co-operative colleague doctors (p=0.045) were the significant predictors for high emotional exhaustion. A positive correlation was noted between the number of patients per day and burnout. The patient’s pressure/violence was the only significant independent predictor of overall burnout.

Conclusion

Emotional exhaustion is the most prominent feature of overall burnout in the physicians of primary health care centers. The main reasons include patient’s pressure/violence, unorganized patient flow, less cooperative colleague doctors, fewer support services at the PHCCs, more paperwork, and less cooperative colleagues. Addressing these issues could lead to a decrease in physician’s burnout.

Nonreassuring Status: Improving Obstetrician-Gynecologist Wellness

Physician wellness directly affects patient and physician health and has broader implications for our health systems. A summary of what is known about physician wellness in medicine, and obstetrics and gynecology in particular, identifies several areas for future focus. To change our culture and the structure of our academic health centers in a way that promotes resilience, we suggest greater attention to preparedness for practice and attention to work-life integration as well as mentoring and professional development.

The Association of Team-Specific Workload and Staffing with Odds of Burnout Among VA Primary Care Team Members

BACKGROUND

Work-related burnout is common in primary care and is associated with worse patient safety, patient satisfaction, and employee mental health. Workload, staffing stability, and team completeness may be drivers of burnout. However, few studies have assessed these associations at the team level, and fewer still include members of the team beyond physicians.

OBJECTIVE

To study the associations of burnout among primary care providers (PCPs), nurse care managers, clinical associates (MAs, LPNs), and administrative clerks with the staffing and workload on their teams.

DESIGN

We conducted an individual-level cross-sectional analysis of survey and administrative data in 2014.

PARTICIPANTS

Primary care personnel at VA clinics responding to a national survey.

MAIN MEASURES

Burnout was measured with a validated single-item survey measure dichotomized to indicate the presence of burnout. The independent variables were survey measures of team staffing (having a fully staffed team, serving on multiple teams, and turnover on the team), and workload both from survey items (working extended hours), and administrative data (patient panel overcapacity and average panel comorbidity).

KEY RESULTS

There were 4610 respondents (estimated response rate of 20.9%). The overall prevalence of burnout was 41%. In adjusted analyses, the strongest associations with burnout were having a fully staffed team (odds ratio [OR] = 0.55, 95% CI 0.47-0.65), having turnover on the team (OR = 1.67, 95% CI 1.43-1.94), and having patient panel overcapacity (OR = 1.19, 95% CI 1.01-1.40). The observed burnout prevalence was 30.1% lower (28.5% vs. 58.6%) for respondents working on fully staffed teams with no turnover and caring for a panel within capacity, relative to respondents in the inverse condition.

CONCLUSIONS

Complete team staffing, turnover among team members, and panel overcapacity had strong, cumulative associations with burnout. Further research is needed to understand whether improvements in these factors would lower burnout.

Physicians' job satisfaction and motivation in a public academic hospital

BACKGROUND

Physician shortage is a global issue that concerns Brazil's authorities. The organizational structure and the environment of a medical institution can hide a low-quality life of a physician. This study examines the relationship between the hospital work environment and physicians' job satisfaction and motivation when working in a large public academic hospital.

METHODS

The study was restricted to one large, multispecialty Brazil's hospital. Six hundred hospital physicians were invited to participate by e-mail. A short version of the Physician Worklife Survey (PWS) was used to measure working satisfaction. Physicians were also asked for socio-demographic information, medical specialty, and the intention to continue working in the hospital.

RESULTS

Data from 141 questionnaires were included in the analyses. Forty-five physicians graduated from the hospital's university, and they did not intend to leave the hospital under any circumstance (affective bond). The motivating factor for beginning the career at the hospital and to continue working there were the connection to the medical school and the hospital status as a "prestigious academic hospital"; the physicians were more satisfied with the career than the specialty. Only 30% completely agreed with the statement "If I had to start my career over again, I would choose my current specialty," while 45% completely agreed with the statement "I am not well compensated given my training and experience." The greater point of satisfaction was the relationship with physician colleagues. They are annoyed about the amount of calls they are requested to take and about how work encroaches on their personal time. No significant differences between medical specialties were found in the analysis.

CONCLUSIONS

The participants were satisfied with their profession. The fact that they remained at the hospital was related to the academic environment, the relationship with colleagues, and the high prestige in which society holds the institution. The points of dissatisfaction were inadequate remuneration and the fact that work invaded personal time. Routinely, there is a need for organizations to examine the impact of their structures, policies, and procedures on the stress and quality of life of physicians.

Medical student satisfaction, coping and burnout in direct-entry versus graduate-entry programmes

CONTEXT

There is ongoing debate regarding the optimal length of medical training, with concern about the cost of prolonged training. Two simultaneous tracks currently exist in Australia: direct entry from high school and graduate entry for students with a bachelor degree. Medical schools are switching to graduate entry based on maturity, academic preparedness and career-choice surety. We tested the assumption that graduate entry is better by exploring student preferences, coping, burnout, empathy and alcohol use.

METHODS

From a potential pool of 2188 participants, enrolled at five Australian medical schools, a convenience sample of 688 (31%) first and second year students completed a survey in the middle of the academic year. Participants answered questions about demographics, satisfaction and coping and completed three validated instruments.

RESULTS

Over 90% of students preferred their own entry-type, though more graduate-entry students were satisfied with their programme (82.4% versus 65.3%, p < 0.001). There was no difference between graduate-entry and direct-entry students in self-reported coping or in the proportion of students meeting criteria for burnout (50.7% versus 51.2%). Direct-entry students rated significantly higher for empathy (concern, p = 0.022; personal distress, p = 0.031). Graduate-entry students reported significantly more alcohol use and hazardous drinking (30.0% versus 22.8%; p = 0.017).

CONCLUSIONS

Our multi-institution data confirm that students are generally satisfied with their choice of entry pathway and do not confirm significant psychosocial benefits of graduate entry. Overall, our data suggest that direct-entry students cope with the workload and psychosocial challenges of medical school, in the first 2 years, as well as graduate-entry students. Burnout and alcohol use should be addressed in both pathways. Despite studies showing similar academic outcomes, and higher total costs, more programmes in Australia are becoming graduate entry. Further research on non-cognitive issues and outcomes is needed so that universities, government funders and the medical profession can decide whether graduate entry, direct entry, or a mix, is ideal.

Job Stress and Job Satisfaction among Health-Care Workers of Endoscopy Units in Korea

Background/Aims:

The management of job-related stress among health-care workers is critical for the improvement of healthcare services; however, there is no existing research on endoscopy unit workers as a team. Korea has a unique health-care system for endoscopy unit workers. In this study, we aimed to estimate job stress and job satisfaction among health-care providers in endoscopy units in Korea.

Methods:

We performed a cross-sectional survey of health-care providers in the endoscopy units of three university-affiliated hospitals in Korea. We analyzed the job stress levels by using the Korean occupational stress scale, contributing factors, and job satisfaction.

Results:

Fifty-nine workers completed the self-administered questionnaires. The job stress scores for the endoscopy unit workers (46.39±7.81) were relatively lower compared to those of the national sample of Korean workers (51.23±8.83). Job stress differed across job positions, with nurses showing significantly higher levels of stress (48.92±7.97) compared to doctors (42.59±6.37). Job stress and job satisfaction were negatively correlated with each other (R²=0.340, p<0.001).

Conclusions:

An endoscopy unit is composed of a heterogeneous group of health-care professionals (i.e., nurses, fellows, and professors), and job stress and job satisfaction significantly differ according to job positions. Job demand, insufficient job control, and job insecurity are the most important stressors in the endoscopy unit.

The Suicide Prevention, Depression Awareness, and Clinical Engagement Program for Faculty and Residents at the University of California, Davis Health System

OBJECTIVE

The authors replicated a program developed by UC San Diego, identified medical staff at risk for depression and suicide using a confidential online survey, and studied aspects of that program for 1 year.

METHODS

The authors used a 35-item, online assessment of stress and depression depression developed and licensed by the American Foundation for Suicide Prevention that aims to identify and suicide risk and facilitate access to mental health services.

RESULTS

During 2013/2014, all 1864 UC Davis residents/fellows and faculty physicians received an invitation to take the survey and 158 responded (8% response rate). Most respondents were classified at either moderate (86 [59%]) or high risk for depression or suicide (54 [37%]). Seventeen individuals (11%) were referred for further evaluation or mental health treatment. Ten respondents consented to participate in the follow-up portion of the program. Five of the six who completed follow-up surveys reported symptom improvement and indicated the program should continue.

CONCLUSIONS

This program has led to continued funding and a plan to repeat the Wellness Survey annually. Medical staff will be regularly reminded of its existence through educational interventions, as the institutional and professional culture gradually changes to promptly recognize and seek help for physicians' psychological distress.

Religion, Spirituality, and the Hidden Curriculum: Medical Student and Faculty Reflections

CONTEXT

Religion and spirituality play an important role in physicians' medical practice, but little research has examined their influence within the socialization of medical trainees and the hidden curriculum.

OBJECTIVES

The objective is to explore the role of religion and spirituality as they intersect with aspects of medicine's hidden curriculum.

METHODS

Semiscripted, one-on-one interviews and focus groups (n = 33 respondents) were conducted to assess Harvard Medical School student and faculty experiences of religion/spirituality and the professionalization process during medical training. Using grounded theory, theme extraction was performed with interdisciplinary input (medicine, sociology, and theology), yielding a high inter-rater reliability score (kappa = 0.75).

RESULTS

Three domains emerged where religion and spirituality appear as a factor in medical training. First, religion/spirituality may present unique challenges and benefits in relation to the hidden curriculum. Religious/spiritual respondents more often reported to struggle with issues of personal identity, increased self-doubt, and perceived medical knowledge inadequacy. However, religious/spiritual participants less often described relationship conflicts within the medical team, work-life imbalance, and emotional stress arising from patient suffering. Second, religion/spirituality may influence coping strategies during encounters with patient suffering. Religious/spiritual trainees described using prayer, faith, and compassion as means for coping whereas nonreligious/nonspiritual trainees discussed compartmentalization and emotional repression. Third, levels of religion/spirituality appear to fluctuate in relation to medical training, with many trainees experiencing an increase in religiousness/spirituality during training.

CONCLUSION

Religion/spirituality has a largely unstudied but possibly influential role in medical student socialization. Future study is needed to characterize its function within the hidden curriculum.

Preventing occupational stress in healthcare workers

BACKGROUND

Healthcare workers can suffer from occupational stress as a result of lack of skills, organisational factors, and low social support at work. This may lead to distress, burnout and psychosomatic problems, and deterioration in quality of life and service provision.

OBJECTIVES

To evaluate the effectiveness of work- and person-directed interventions compared to no intervention or alternative interventions in preventing stress at work in healthcare workers.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, NIOSHTIC-2 and Web of Science up to November 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions aimed at preventing psychological stress in healthcare workers. For organisational interventions, interrupted time-series and controlled before-and-after (CBA) studies were also eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We used Standardised Mean Differences (SMDs) where authors of trials used different scales to measure stress or burnout. We combined studies that were similar in meta-analyses. We used the GRADE system to rate the quality of the evidence.

MAIN RESULTS

In this update, we added 39 studies, making a total of 58 studies (54 RCTs and four CBA studies), with 7188 participants. We categorised interventions as cognitive-behavioural training (CBT) (n = 14), mental and physical relaxation (n = 21), combined CBT and relaxation (n = 6) and organisational interventions (n = 20). Follow-up was less than one month in 24 studies, one to six in 22 studies and more than six months in 12 studies. We categorised outcomes as stress, anxiety or general health.There was low-quality evidence that CBT with or without relaxation was no more effective in reducing stress symptoms than no intervention at one month follow-up in six studies (SMD -0.27 (95% Confidence Interval (CI) -0.66 to 0.13; 332 participants). But at one to six months follow-up in seven studies (SMD -0.38, 95% CI -0.59 to -0.16; 549 participants, 13% relative risk reduction), and at more than six months follow-up in two studies (SMD -1.04, 95% CI -1.37 to -0.70; 157 participants) CBT with or without relaxation reduced stress more than no intervention.CBT interventions did not lead to a considerably greater effect than an alternative intervention, in three studies.Physical relaxation (e.g. massage) was more effective in reducing stress than no intervention at one month follow-up in four studies (SMD -0.48, 95% CI -0.89 to -0.08; 97 participants) and at one to six months follow-up in six studies (SMD -0.47; 95% CI -0.70 to -0.24; 316 participants). Two studies did not find a considerable difference in stress between massage and taking extra breaks.Mental relaxation (e.g. meditation) led to similar stress symptom levels as no intervention at one to six months follow-up in six studies (SMD -0.50, 95% CI -1.15 to 0.15; 205 participants) but to less stress in one study at more than six months follow-up. One study showed that mental relaxation reduced stress more effectively than attending a course on theory analysis and another that it was more effective than just relaxing in a chair.Organisational interventions consisted of changes in working conditions, organising support, changing care, increasing communication skills and changing work schedules. Changing work schedules (from continuous to having weekend breaks and from a four-week to a two-week schedule) reduced stress with SMD -0.55 (95% CI -0.84 to -0.25; 2 trials, 180 participants). Other organisational interventions were not more effective than no intervention or an alternative intervention.We graded the quality of the evidence for all but one comparison as low. For CBT this was due to the possibility of publication bias, and for the other comparisons to a lack of precision and risk of bias. Only for relaxation versus no intervention was the evidence of moderate quality.

AUTHORS' CONCLUSIONS

There is low-quality evidence that CBT and mental and physical relaxation reduce stress more than no intervention but not more than alternative interventions. There is also low-quality evidence that changing work schedules may lead to a reduction of stress. Other organisational interventions have no effect on stress levels. More randomised controlled trials are needed with at least 120 participants that compare the intervention to a placebo-like intervention. Organisational interventions need better focus on reduction of specific stressors.

Preventing occupational stress in healthcare workers

BACKGROUND

Healthcare workers can suffer from occupational stress as a result of lack of skills, organisational factors, and low social support at work. which may lead to distress, burnout and psychosomatic problems, and deterioration in quality of life and service provision.

OBJECTIVES

To evaluate the effectiveness of work- and person-directed interventions compared to no intervention or alternative interventions in preventing stress at work in healthcare workers.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, NIOSHTIC-2 and Web of Science up to November 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions aimed at preventing psychological stress in healthcare workers. For organisational interventions, interrupted time-series and controlled before-and-after (CBA) studies were also eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We used Standardised Mean Differences (SMDs) where authors of trials used different scales to measure stress or burnout. We combined studies that were similar in meta-analyses. We used the GRADE system to rate the quality of the evidence.

MAIN RESULTS

In this update, we added 39 studies, making a total of 58 studies (54 RCTs and four CBA studies), with 7188 participants. We categorised interventions as cognitive-behavioural training (CBT) (n = 14), mental and physical relaxation (n = 21), combined CBT and relaxation (n = 6) and organisational interventions (n = 20). Follow-up was less than one month in 24 studies, one to six in 22 studies and more than six months in 12 studies. We categorised outcomes as stress, anxiety or general health.There was low-quality evidence that CBT with or without relaxation was no more effective in reducing stress symptoms than no intervention at one month follow-up in six studies (SMD -0.27 (95% Confidence Interval (CI) -0.66 to 0.13; 332 participants). But at one to six months follow-up in seven studies (SMD -0.38, 95% CI -0.59 to -0.16; 549 participants, 13% relative risk reduction), and at more than six months follow-up in two studies (SMD -1.04, 95% CI -1.37 to -0.70; 157 participants) CBT with or without relaxation reduced stress more than no intervention.CBT interventions did not lead to a considerably greater effect than an alternative intervention, in three studies.Physical relaxation (e.g. massage) was more effective in reducing stress than no intervention at one month follow-up in four studies (SMD -0.48, 95% CI -0.89 to -0.08; 97 participants) and at one to six months follow-up in six studies (SMD -0.47; 95% CI -0.70 to -0.24; 316 participants). Two studies did not find a considerable difference in stress between massage and taking extra breaks.Mental relaxation (e.g. meditation) led to similar stress symptom levels as no intervention at one to six months follow-up in six studies (SMD -0.50, 95% CI -1.15 to 0.15; 205 participants) but to less stress in one study at more than six months follow-up. One study showed that mental relaxation reduced stress more effectively than attending a course on theory analysis and another that it was more effective than just relaxing in a chair.Organisational interventions consisted of changes in working conditions, organising support, changing care, increasing communication skills and changing work schedules. Changing work schedules (from continuous to having weekend breaks and from a four-week to a two-week schedule) reduced stress with SMD -0.55 (95% CI -0.84 to -0.25; 2 trials, 180 participants). Other organisational interventions were not more effective than no intervention or an alternative intervention.We graded the quality of the evidence for all but one comparison as low. For CBT this was due to the possibility of publication bias, and for the other comparisons to a lack of precision and risk of bias. Only for relaxation versus no intervention was the evidence of moderate quality.

AUTHORS' CONCLUSIONS

There is low-quality evidence that CBT and mental and physical relaxation reduce stress more than no intervention but not more than alternative interventions. There is also low-quality evidence that changing work schedules may lead to a reduction of stress. Other organisational interventions have no effect on stress levels. More randomised controlled trials are needed with at least 120 participants that compare the intervention to a placebo-like intervention. Organisational interventions need better focus on reduction of specific stressors.

Preventing occupational stress in healthcare workers

Background Healthcare workers can suffer from occupational stress as a result of lack of skills, organisational factors, and low social support at work.which may lead to distress, burnout and psychosomatic problems, and deterioration in quality of life and service provision.Objectives To evaluate the effectiveness of work- and person-directed interventions compared to no intervention or alternative interventions in preventing stress at work in healthcare workers.Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL,NIOSHTIC-2 and Web of Science up to November 2013.Selection criteria Randomised controlled trials (RCTs) of interventions aimed at preventing psychological stress in healthcare workers. For organisational interventions, interrupted time-series and controlled before-and-after (CBA) studies were also eligible.Data collection and analysis Two review authors independently extracted data and assessed trial quality. We used Standardised Mean Differences (SMDs) where authors of trials used different scales to measure stress or burnout. We combined studies that were similar in meta-analyses. We used the GRADE system to rate the quality of the evidence.Main results In this update, we added 39 studies, making a total of 58 studies (54 RCTs and four CBA studies), with 7188 participants. We categorised interventions as cognitive-behavioural training (CBT) (n = 14), mental and physical relaxation (n = 21), combined CBT and relaxation (n = 6) and organisational interventions (n = 20). Follow-up was less than one month in 24 studies, one to six in 22 studies and more than six months in 12 studies. We categorised outcomes as stress, anxiety or general health. There was low-quality evidence that CBT with or without relaxation was no more effective in reducing stress symptoms than no intervention at one month follow-up in six studies (SMD -0.27 (95% Confidence Interval (CI) -0.66 to 0.13; 332 participants). But at one to six months follow-up in seven studies (SMD -0.38, 95% CI -0.59 to -0.16; 549 participants, 13% relative risk reduction),and at more than six months follow-up in two studies (SMD -1.04, 95% CI -1.37 to -0.70; 157 participants) CBT with or without relaxation reduced stress more than no intervention.CBT interventions did not lead to a considerably greater effect than an alternative intervention, in three studies.Physical relaxation (e.g. massage) was more effective in reducing stress than no intervention at one month follow-up in four studies(SMD -0.48, 95% CI -0.89 to -0.08; 97 participants) and at one to six months follow-up in six studies (SMD -0.47; 95% CI -0.70 to-0.24; 316 participants). Two studies did not find a considerable difference in stress between massage and taking extra breaks.Mental relaxation (e.g. meditation) led to similar stress symptom levels as no intervention at one to six months follow-up in six studies(SMD -0.50, 95% CI -1.15 to 0.15; 205 participants) but to less stress in one study at more than six months follow-up. One study showed that mental relaxation reduced stress more effectively than attending a course on theory analysis and another that it was more effective than just relaxing in a chair.Organisational interventions consisted of changes in working conditions, organising support, changing care, increasing communication skills and changing work schedules. Changing work schedules (from continuous to having weekend breaks and from a four-week to a two-week schedule) reduced stress with SMD -0.55 (95% CI -0.84 to -0.25; 2 trials, 180 participants). Other organisational interventions were not more effective than no intervention or an alternative intervention.We graded the quality of the evidence for all but one comparison as low. For CBT this was due to the possibility of publication bias,and for the other comparisons to a lack of precision and risk of bias. Only for relaxation versus no intervention was the evidence of moderate quality.Authors' conclusions There is low-quality evidence that CBT and mental and physical relaxation reduce stress more than no intervention but not more than alternative interventions. There is also low-quality evidence that changing work schedules may lead to a reduction of stress. Other organisational interventions have no effect on stress levels.More randomised controlled trials are needed with at least 120 participants that compare the intervention to a placebo-like intervention. Organisational interventions need better focus on reduction of specific stressors.

Burnout syndrome in oral and maxillofacial surgeons: a critical analysis

The aim of this study was to determine the prevalence of burnout syndrome among Brazilian oral and maxillofacial surgeons and its relationship with socio-demographic, clinical, and habit variables. The sample of this study comprised 116 surgeons. The syndrome was quantified using the Maslach Burnout Inventory (General Survey), which defines burnout as the triad of high emotional exhaustion, high depersonalization, and low personal accomplishment. The criteria of Grunfeld et al. were used to evaluate the presence of the syndrome (17.2%). No significant differences between the surgeons diagnosed with and without the syndrome were observed according to age (P=0.804), sex (P=0.197), marital status (P=0.238), number of children (P=0.336), years of professional experience (P=0.102), patients attended per day (P=0.735), hours worked per week (P=0.350), use of alcohol (P=0.148), sports practice (P=0.243), hobbies (P=0.161), or vacation period per year (P=0.215). Significant differences occurred in the variables sex in the emotional exhaustion subscale (P=0.002) and use or not of alcohol in the personal accomplishment subscale (P=0.035). Burnout syndrome among Brazilian surgeons is average, showing a low personal accomplishment.

The role of lack of reciprocity, supervisory support, workload and work-family conflict on exhaustion: evidence from physicians

Emotional exhaustion, argued to be burnout's core dimension, can manifest itself as decreased productivity and job dissatisfaction. This study aims to determine how lack of reciprocity, lack of supervisory support, high workload, and work-family conflict affect emotional exhaustion. Data were collected from 295 physicians working at private and public hospitals in Antalya and İstanbul, Turkey. The survey included lack of reciprocity, supervisory support, workload, WFC items, and exhaustion subscale of Maslach Burnout Inventrory: General Survey (MBI:GS). The proposed model was tested using AMOS 17, which enables assessment of hypothesized relations and degree of fit between data and model. Workload and lack reciprocity were found to increase emotional exhaustion, while supervisory support alleviated the exhaustion physicians experienced. As expected, workload increased work-family conflict. Quite unexpectedly, workload was associated with lack of reciprocity; meaning, physicians more likely perceive their efforts go unappreciated and their patient relationships are inequitable (i.e. investing more than receiving) when they perceive a high workload. In addition, supervisory support was also associated with lack of reciprocity. Physicians experiencing inadequate supervisory support tend to describe their patient relationships in negative terms and perceive inequitable relations. Physicians who do not receive either adequate supervisory support or patient appreciation tend to feel emotionally exhausted. Moreover, both workload and work-family conflict increase physicians' exhaustion. Suggestions to reduce workload and social problems in hospitals are offered to reduce exhaustion.

A comprehensive medical student wellness program--design and implementation at Vanderbilt School of Medicine

Research suggests that student burnout and mental illness are increasing in U.S. medical schools. In response, students and administrators developed the Vanderbilt Medical Student (VMS) Wellness Program to promote student health and well-being through coordination of many new and existing resources. This program consists of three core components: The Advisory College Program, The Student Wellness Committee, and VMS LIVE. Each of the core components includes separate and unique individual programs, but each of these three components collaborates with the other two to accomplish the broad wellness goal of maximizing student health, happiness, and potential. The VMS Wellness Program has had early success with substantial growth and outstanding student buy-in since its inception in 2005. Preliminary data indicate that nearly every student has participated in at least two components of the VMS Wellness Program. In addition to participation, student response has been highly satisfactory, as evidenced by their positive feedback. The VMS Wellness Program is the first published model of a comprehensive medical student wellness initiative. The development and design of the program described in this article may serve as a framework for other institutions.

Mental health and occupational wellbeing of Australian gynaecologic oncologists

OBJECTIVE

To investigate the prevalence of psychiatric morbidity and occupational burnout among Australian gynaecologic oncologists and to assess job stress and job satisfaction in this group.

METHOD

Anonymous, self-report questionnaires containing validated measures were sent to all practicing Australian gynaecologic oncologists in October 2008.

RESULTS

The response rate was 78.4% (N=29). More than one-third (35.7%) had high levels of emotional exhaustion, the central component of burnout. In the past 6 months, 42.9%, 57.1%, and 28.6% had seriously considered leaving for another position, reducing the number of hours worked, and taking early retirement, respectively. The most commonly reported source of stress (80.8%) was home-life disruption due to work. Compared to general population data and recommended national guidelines, rates of alcohol consumption were high. Psychological morbidity, global job stress and burnout were significantly correlated and each was associated with harmful alcohol use. Other factors associated with burnout were administrative/organizational demands and patient volume. More than half of respondents (58.6%) had high levels of job satisfaction and most had high levels of personal accomplishment (70.4%). Perceived adequacy of the training curriculum and proposed changes to the curriculum are reported.

CONCLUSION

Australian gynaecologic oncologists experience considerable occupational distress while possessing high levels of personal accomplishment and job satisfaction. To maintain a healthy workforce, it is important to build on existing supports while conducting further research to identify suitable evidence-based strategies for improving the mental health of these surgeons.

Burnout in European family doctors: the EGPRN study

INTRODUCTION

The aim of this study was to determine the prevalence of burnout, and of associated factors, amongst family doctors (FDs) in European countries. Methodology. A cross-sectional survey of FDs was conducted using a custom-designed and validated questionnaire which incorporated the Maslach Burnout Inventory Human Services Survey (MBI-HSS) as well as questions about demographic factors, working experience, health, lifestyle and job satisfaction. MBI-HSS scores were analysed in the three dimensions of emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA).

RESULTS

Almost 3500 questionnaires were distributed in 12 European countries, and 1393 were returned to give a response rate of 41%. In terms of burnout, 43% of respondents scored high for EE burnout, 35% for DP and 32% for PA, with 12% scoring high burnout in all three dimensions. Just over one-third of doctors did not score high for burnout in any dimension. High burnout was found to be strongly associated with several of the variables under study, especially those relative to respondents' country of residence and European region, job satisfaction, intention to change job, sick leave utilization, the (ab)use of alcohol, tobacco and psychotropic medication, younger age and male sex.

CONCLUSIONS

Burnout seems to be a common problem in FDs across Europe and is associated with personal and workload indicators, and especially job satisfaction, intention to change job and the (ab)use of alcohol, tobacco and medication. The study questionnaire appears to be a valid tool to measure burnout in FDs. Recommendations for employment conditions of FDs and future research are made, and suggestions for improving the instrument are listed.