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Chiel L, Gans HA, Bales M, King S, Mason K, Schwartz A, Kesselheim J, Boyer D. A Pilot Survey on the Perceptions of Pediatric Subspecialty Fellows and Program Directors on Virtual Compared with In-Person Interview Experiences. J Pediatr 2024; 270:114019. [PMID: 38514003 DOI: 10.1016/j.jpeds.2024.114019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/25/2024] [Accepted: 03/14/2024] [Indexed: 03/23/2024]
Abstract
Pediatric fellowship programs have conducted virtual interviews since the start of the COVID-19 pandemic in 2020. In this national survey of fellowship program directors and fellows interviewed in-person and virtually, fellowship program directors and fellows formed accurate impressions, regardless of format, but our data did not clearly support one interview format over another.
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Affiliation(s)
- Laura Chiel
- Instructor, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Hayley A Gans
- Stanford University Medical Center, Department of Pediatrics, Center for Academic Medicine, Palo Alto, CA
| | - Melissa Bales
- Pediatric Subspecialty Program Coordinator, Department of Pediatric, Riley Hospital for Children at Indiana University School of Medicine, Indianapolis, IN
| | - Sarah King
- Director of Fellowship Programs, Department of Graduate Medical Education, Children's Mercy Kansas City, Kansas City, MO
| | - Katherine Mason
- Assistant Dean Faculty Development, Warren Alpert Medical School at Brown University, Vice Chair of Education, Department of Pediatrics, Providence, RI
| | - Alan Schwartz
- The Michael Reese Endowed Professor of Medical Education, Department of Medical Education, University of Illinois at Chicago, Chicago, IL; Research Professor, Department of Pediatrics, University of Illinois at Chicago, Chicago, IL; Director, Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network (APPD LEARN), McLean, VA
| | - Jennifer Kesselheim
- Associate Professor and Designated Institutional Official, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Debra Boyer
- Designated Institutional Official and Chief Medical Education Officer, Nationwide Children's Hospital, Columbus, OH
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2
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Scioscia A, Rakkar J, Pelletier JH, Ghassemzadeh R, Hamilton MF, Fuhrman DY. Virtual Learning Improves Attendance for Critical Care Education During the COVID-19 Pandemic. J Pediatr Intensive Care 2023; 12:325-329. [PMID: 37970144 PMCID: PMC10631843 DOI: 10.1055/s-0041-1735868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022] Open
Abstract
The COVID-19 pandemic has pushed medical educators and learners to adapt to virtual learning (VL) in an expedited manner. The effect of VL for critical care education has not yet been evaluated. In a quantitative analysis of survey data and attendance records, we sought to determine the association of VL with conference attendance and work-life balance. Attending physicians, fellows, and advanced practice providers (APP) at a pediatric critical care department at a quaternary children's hospital participated in the study. Attendance records were obtained before and after the adaption of a VL platform. In addition, an electronic, anonymous survey to evaluate current satisfaction and the strengths and weaknesses of VL as well as its impact on work-life balance was administered. In total, 31 learners (17 attending physicians, 13 fellows, and 1 APP) completed the survey. A total of 83.9% (26/31) of participants were satisfied, and 77.4% (24/31) found VL to be similar or more engaging than non-VL. However, 6.5% (2/31) of learners reported difficulty in using the new platform, 87% (27/31) of participants supported VL as an effective learning tool, and 83.3% (25/30) reported a positive impact on work-life balance. Additionally, median monthly conference attendance increased significantly from 85 to 114 attendees per month ( p < 0.05). Our results suggest that a virtual model has advantages for overall attendance and work-life balance. We anticipate VL will continue to be an integral part of medical education. Future work evaluating the impact of VL on interdepartmental and interinstitutional collaborations is needed.
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Affiliation(s)
- Andrea Scioscia
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Jaskaran Rakkar
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Jonathan H. Pelletier
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Rod Ghassemzadeh
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Melinda F. Hamilton
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Dana Y. Fuhrman
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
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Min YS, Lee HA, Kwon SC, Lee I, Kim K, Kim JS, Han JH, Lee HY. Occupational and Psychological Factors Associated With Burnout in Night Shift Nurses. Psychiatry Investig 2023; 20:904-911. [PMID: 37899213 PMCID: PMC10620334 DOI: 10.30773/pi.2023.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/12/2023] [Accepted: 06/16/2023] [Indexed: 10/31/2023] Open
Abstract
OBJECTIVE Providing inpatient nursing care inevitably involves night shift work. However, night shift work nurses often face psychiatric health problems such as burnout. If night shift work is an essential work type for nurses, it is necessary to select personnel suitable for night shift work or establish improvement measures such as psychiatric intervention through psychiatric evaluation. The objective of this study was to identify factors that could be interventional among factors affecting burnout in shift-working nurses. METHODS A total of 231 night shift female nurses participated in this study. A questionnaire survey was given to assess their general characteristics. To assess burnout, the Maslach Burnout Inventory-General Survey Korean version was adopted. In addition, several mental health scales were used to identify individual psychological characteristics. To identify variables associated with the presence of burnout, odds ratios were calculated using a logistic regression model taking three dimensions of burnout as a dependent variable after adjusting for psychological and occupational factors. RESULTS High resilience was a significant preventive factor in the three dimensions of burnout. Regarding occupational factor, the longer the duration of employment, the higher depersonalization, but the professional efficacy was good. CONCLUSION Our results indicate that resilience and social support could be prevention factors for burnout. This study is meaningful in examining items that require active intervention and support for burnout targeting night shift nurses who are indispensable for patient care.
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Affiliation(s)
- Young-Sun Min
- Department of Occupational and Environmental Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Hyeon-Ah Lee
- Department of Psychiatry, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Soon-Chan Kwon
- Department of Occupational and Environmental Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Inho Lee
- Department of Occupational and Environmental Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Kiseok Kim
- Department of Occupational and Environmental Medicine, Cheonan Woori Hospital, Cheonan, Republic of Korea
| | - Ji Sun Kim
- Department of Psychiatry, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Jae Hyun Han
- Department of Psychiatry, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Hwa-Young Lee
- Department of Psychiatry, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
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Whitehead IO, Moffatt S, Warwick S, Spiers GF, Kunonga TP, Tang E, Hanratty B. Systematic review of the relationship between burn-out and spiritual health in doctors. BMJ Open 2023; 13:e068402. [PMID: 37553194 PMCID: PMC10414094 DOI: 10.1136/bmjopen-2022-068402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 05/03/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVE To investigate the relationship between burn-out and spiritual health among medical doctors. DESIGN Systematic literature review and narrative synthesis of cross-sectional studies. SETTING Any setting, worldwide. DATA SOURCES Five databases were searched from inception to March 2022, including Medline, Embase, PsycINFO, Scopus and Web of Science. ELIGIBILITY CRITERIA Any study design that involved medical doctors (and other healthcare staff if assessed alongside medical doctors), that measured (in any way) both burn-out (or similar) and spiritual health (or similar) medical doctors. DATA EXTRACTION AND SYNTHESIS All records were double screened. Data extraction was performed by one reviewer and a proportion (10%) checked by a second reviewer. Quality was assessed using the Appraisal of Cross-sectional Studies tool. Due to the heterogeneity of the included studies, a narrative review was undertaken without a meta-analysis. RESULTS Searches yielded 1049 studies. 40 studies met eligibility criteria and were included in this review. Low reported levels of spirituality were associated with high burn-out scores and vice versa. Religion was not significantly associated with lower levels of burn-out. Few studies reported statistically significant findings, few used validated spiritual scores and most were vulnerable to sampling bias. CONCLUSIONS Published research suggests that burn-out is linked to spiritual health in medical doctors but not to religion. Robust research is needed to confirm these findings and develop effective interventions. PROSPERO REGISTRATION NUMBER CRD42020200145.
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Affiliation(s)
| | - Suzanne Moffatt
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stephanie Warwick
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Gemma F Spiers
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Eugene Tang
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Tjoeng YL, Myers C, Irving SY, Esangbedo I, Wheeler D, Musa N. The Current State of Workforce Diversity and Inclusion in Pediatric Critical Care. Crit Care Clin 2023; 39:327-340. [PMID: 36898777 DOI: 10.1016/j.ccc.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Literature suggests the pediatric critical care (PCC) workforce includes limited providers from groups underrepresented in medicine (URiM; African American/Black, Hispanic/Latinx, American Indian/Alaska Native, Native Hawaiian/Pacific Islander). Additionally, women and providers URiM hold fewer leadership positions regardless of health-care discipline or specialty. Data on sexual and gender minority representation and persons with different physical abilities within the PCC workforce are incomplete or unknown. More data are needed to understand the true landscape of the PCC workforce across disciplines. Efforts to increase representation, promote mentorship/sponsorship, and cultivate inclusivity must be prioritized to foster diversity and inclusion in PCC.
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Affiliation(s)
- Yuen Lie Tjoeng
- Division of Pediatric Critical Care, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way Northeast M/S RC.2.820, Seattle, WA 98105, USA.
| | - Carlie Myers
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, Location G, Cincinnati, OH 45229, USA
| | - Sharon Y Irving
- Department of Family and Community Health, Children's Hospital of Philadelphia, University of Pennsylvania School of Nursing, 418 Curie Boulevard, Office 415, Philadelphia, PA 19104, USA; Department of Nursing and Clinical Services, Critical Care, Philadelphia, PA, USA
| | - Ivie Esangbedo
- Division of Pediatric Critical Care, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way Northeast M/S RC.2.820, Seattle, WA 98105, USA
| | - Derek Wheeler
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 1, Chicago, IL 60611, USA
| | - Ndidiamaka Musa
- Division of Pediatric Critical Care, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way Northeast M/S RC.2.820, Seattle, WA 98105, USA
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Bajaj N, Reed SM. Thematic analysis comparing stressors for pediatric residents and subspecialty fellows at a large children's hospital. Ann Med 2022; 54:3333-3341. [PMID: 36411680 PMCID: PMC9683061 DOI: 10.1080/07853890.2022.2148731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Pediatric residents and subspecialty fellows experience a significant number of stressors during training, but they have rarely been self-reported or compared between groups. This qualitative study aimed to identify and compare themes of stressors experienced by pediatric residents and subspecialty fellows at a single large children's hospital. MATERIALS AND METHODS Using an open-ended survey at single time point for each group, we asked residents and fellows to list the stressors they face in training. The survey data was iteratively analyzed using thematic analysis then quantified by its frequency in each group and compared using a chi-square distribution or a Fisher's exact test, as appropriate. RESULTS Twenty-eight of 159 residents (18%) and 38 of 180 fellows (21%) answered the survey question, and an average of 2.8 stressors were identified by each resident and fellow. Two major themes and five major subthemes were shared between both groups. The theme Stressors at Home included the subthemes Difficulty Maintaining Overall Health and External Stressors. The theme Stressors at Work encompassed the subthemes Clinical Stressors Innate to Patient Care, Demanding Workload and Schedule, and Stressors Related to Culture of Work Environment. Within the subthemes, there were differences in categories of stressors between the groups. While there was no statistically significant difference in the distribution of themes, subthemes, or categories of stressors mentioned between groups, in general residents identified stressors associated with lack of autonomy and control whereas fellows focused on clinical uncertainty and complex situations. CONCLUSIONS While residents and fellows shared similar themes and subthemes for stressors, there was variability between individual categories. This study identified individual self-reported stressors that can be used by programs to design interventions to improve trainee well-being, but it also implies that programmatic support at different levels of training should be tailored to the target group.KEY MESSAGEAt our hospital, we found that some self-reported stressors facing pediatric residents and fellows were common and some unique.Stressors included those that can be eliminated or diminished as well as those that cannot.With knowledge that these disparities exist, training programs should use unique strategies to provide support for the two groups and their stressors.
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Affiliation(s)
- Nimisha Bajaj
- Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Suzanne M Reed
- Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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Zhang X, Jiang X, Ni P, Li H, Li C, Zhou Q, Ou Z, Guo Y, Cao J. Association between resilience and burnout of front-line nurses at the peak of the COVID-19 pandemic: Positive and negative affect as mediators in Wuhan. Int J Ment Health Nurs 2021; 30:939-954. [PMID: 33893718 PMCID: PMC8251287 DOI: 10.1111/inm.12847] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/31/2020] [Accepted: 01/22/2021] [Indexed: 12/13/2022]
Abstract
The outbreak of coronavirus disease 2019 (COVID-19) is having a dramatic effect on the mental health of healthcare workers (HCWs). Upon the emergence of the COVID-19 pandemic, the Chinese government dispatched about 42 000 HCWs to Wuhan City and Hubei Province to fight this pandemic. This study briefly examines front-line nurses who experienced burnout, with the main objective of investigating the mediating roles of positive and negative affect in the relationship between resilience and burnout in Wuhan hospitals at the peak of the COVID-19 pandemic. A total of 180 front-line nurses voluntarily participated via a social media group. They completed the online questionnaires, including the Maslach Burnout Inventory-General Survey (MBI-GS), the Positive and Negative Affect Schedule (PANAS), the Connor-Davidson Resilience Scale (CD-RISC), demographics, and work-related characteristics. Structural equation modelling (SEM) analysis was used to examine the mediating effect of positive and negative affect on the relationship between resilience and burnout. The total prevalence of burnout was 51.7%, of which 15.0% were severe burnout. These preliminary results revealed that positive and negative affect fully mediated the effects of resilience on burnout, emotional exhaustion, depersonalization, and reduced personal accomplishment of front-line nurses. It is necessary to know the impact of resilience on HCWs with burnout through the positive and negative affect of individual backgrounds and situations, and how policymakers can deploy resilience interventions to support front-line HCWs.
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Affiliation(s)
- Xiaoning Zhang
- School of Nursing, Xuzhou Medical University, Xuzhou, China.,School of Nursing, Capital Medical University, Beijing, China.,Department of Neonatology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.,Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
| | - Xue Jiang
- School of Nursing, Xuzhou Medical University, Xuzhou, China
| | - Pingping Ni
- School of Nursing, Xuzhou Medical University, Xuzhou, China.,Department of Neonatology, Suqian First Hospital, Suqian, China
| | - Haiyang Li
- Development Planning Office, Xuzhou Medical University, Xuzhou, China
| | - Chong Li
- Graduate School, Xuzhou Medical University, Xuzhou, China
| | - Qiong Zhou
- School of Nursing, Xuzhou Medical University, Xuzhou, China
| | - Zhengyan Ou
- School of Nursing, Xuzhou Medical University, Xuzhou, China
| | - Yuqing Guo
- School of Nursing, Xuzhou Medical University, Xuzhou, China
| | - Junli Cao
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
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Matsuishi Y, Mathis BJ, Masuzawa Y, Okubo N, Shimojo N, Hoshino H, Enomoto Y, Inoue Y. Severity and prevalence of burnout syndrome in paediatric intensive care nurses: A systematic review. Intensive Crit Care Nurs 2021; 67:103082. [PMID: 34340889 DOI: 10.1016/j.iccn.2021.103082] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study is to identify burnout syndrome severity and prevalence in paediatric intensive care unit nurses. DESIGN Systematic review. SETTING Paediatric intensive care unit. MAIN OUTCOME MEASURES A librarian was consulted on methodology before the search process. MEDLINE (via PubMed), EMBASE, the Cochrane Library, CINAHL, and PsycINFO were searched for full-text studies published before September 2019 in any language. Only those observational studies exploring burnout syndrome, including paediatric intensive care unit nurses, were included. Two authors independently screened studies. We assessed the risk of bias within each study based on the Office of Health Assessment and Translation tool. RESULT After screening 1238 articles, we identified six studies which met the systematic review criteria. All studies included were published after 2012 and participant sample sizes were between 35 and 195 nurses. Three studies were conducted in the United States of America while the others were from the United Kingdom, Turkey and Taiwan. Prevalence of burnout syndrome in pediatric intensive care unit nurses was reported in these studies as between 42% and 77%. The assessment tools used in these studies were the (abbreviated) Maslach Burnout Inventory, Abbreviated Maslach Burnout Inventory, Occupational Burnout Inventory, and Professional Quality of Life Scale Version 5. We could not conduct a meta-analysis due to the lack of studies. CONCLUSION Our systematic review identifies that a low number (6 total) of relevant studies focused on burnout syndrome for pediatric intensive care unit nurses with a prevalence of burnout syndrome in paediatric intensive care unit nurses of between 42% and 77%.
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Affiliation(s)
- Yujiro Matsuishi
- Neuroscience Nursing, St. Luke's International University, Tokyo, Japan
| | - Bryan J Mathis
- International Medical Center, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Yuko Masuzawa
- Department of Health Informatics, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Nobuko Okubo
- Neuroscience Nursing, St. Luke's International University, Tokyo, Japan
| | - Nobutake Shimojo
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Haruhiko Hoshino
- Adult Health Nursing, Department of Nursing, International University of Health and Welfare, Narita, Japan
| | - Yuki Enomoto
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yoshiaki Inoue
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
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Toward a Better Understanding of Burnout Syndrome: Lump less, Split More. Crit Care Med 2021; 48:930-931. [PMID: 32433084 DOI: 10.1097/ccm.0000000000004320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Rodriguez IS, Santos PCP, Delgado AF, Carvalho WBD. Burnout in pediatric critical care medicine: more challenging days during the COVID-19 pandemic. ACTA ACUST UNITED AC 2020; 66:1016-1017. [PMID: 32935789 DOI: 10.1590/1806-9282.66.8.1016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Isadora Souza Rodriguez
- . Instituto da Criança e do Adolescente (ICr), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brasil
| | - Pollyana Coelho Pessoa Santos
- . Instituto da Criança e do Adolescente (ICr), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brasil
| | - Artur Figueiredo Delgado
- . Instituto da Criança e do Adolescente (ICr), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brasil
| | - Werther Brunow de Carvalho
- . Instituto da Criança e do Adolescente (ICr), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brasil
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