Burnout Syndrome Evidence Based Project

Critical Appraisal Tool Worksheet Template Evaluation Table Use this document to complete the evaluation table requirement of the Module 4 Assessment, Evidence-Based Project, Part 4A: Critical Appraisal of Research Article #1 Article #2 Article #3 Article #4 Full APA formatted citation of selected article. Evidence Level * (I, II, or III) Conceptual Framework Describe the theoretical basis for the study (If there is not one mentioned in the article, say that here).** Design/Method Describe the design and how the © 2018 Laureate Education Inc. 1 study was carried out (In detail, including inclusion/exclusion criteria). Sample/Setting The number and characteristics of patients, attrition rate, etc. Major Variables Studied List and define dependent and independent variables Measurement Identify primary statistics used to answer clinical questions (You need to list the actual tests done). Data Analysis Statistical or Qualitative findings (You need to enter the actual numbers determined by the statistical tests or qualitative data). Findings and Recommendations General findings and recommendations of the research Appraisal and Study Quality © 2018 Laureate Education Inc. 2 Describe the general worth of this research to practice. What are the strengths and limitations of study? What are the risks associated with implementation of the suggested practices or processes detailed in the research? What is the feasibility of use in your practice? Key findings Outcomes General Notes/Comments © 2018 Laureate Education Inc. 3 *These levels are from the Johns Hopkins Nursing Evidence-Based Practice: Evidence Level and Quality Guide

• Level I Experimental, randomized controlled trial (RCT), systematic review RTCs with or without meta-analysis • Level II Quasi-experimental studies, systematic review of a combination of RCTs and quasi-experimental studies, or quasi-experimental studies only, with or without metaanalysis • Level III Nonexperimental, systematic review of RCTs, quasi-experimental with/without meta-analysis, qualitative, qualitative systematic review with/without meta-synthesis • Level IV Respected authorities’ opinions, nationally recognized expert committee/consensus panel reports based on scientific evidence • Level V Literature reviews, quality improvement, program evaluation, financial evaluation, case reports, nationally recognized expert(s) opinion based on experiential evidence **Note on Conceptual Framework • The following information is from Walden academic guides which helps explain conceptual frameworks and the reasons they are used in research. Here is the link https://academicguides.waldenu.edu/library/conceptualframework • Researchers create theoretical and conceptual frameworks that include a philosophical and methodological model to help design their work. A formal theory provides context for the outcome of the events conducted in the research. The data collection and analysis are also based on the theoretical and conceptual framework. • As stated by Grant and Osanloo (2014), “Without a theoretical framework, the structure and vision for a study is unclear, much like a house that cannot be constructed without a blueprint. By contrast, a research plan that contains a theoretical framework allows the dissertation study to be strong and structured with an organized flow from one chapter to the next.” • Theoretical and conceptual frameworks provide evidence of academic standards and procedure. They also offer an explanation of why the study is pertinent and how the researcher expects to fill the gap in the literature.

• Literature does not always clearly delineate between a theoretical or conceptual framework. With that being said, there are slight differences between the two. © 2018 Laureate Education Inc. 4 References The Johns Hopkins Hospital/Johns Hopkins University (n.d.). Johns Hopkins nursing dvidence-based practice: appendix C: evidence level and quality guide. Retrieved October 23, 2019 from https://www.hopkinsmedicine.org/evidence-basedpractice/_docs/appendix_c_evidence_level_quality_guide.pdf Grant, C., & Osanloo, A. (2014). Understanding, Selecting, and Integrating a Theoretical Framework in Dissertation Research: Creating the Blueprint for Your” House”. Administrative Issues Journal: Education, Practice, and Research, 4(2), 12-26. Walden University Academic Guides (n.d.). Conceptual & theoretical frameworks overview. Retrieved October 23, 2019 from https://academicguides.waldenu.edu/library/conceptualframework © 2018 Laureate Education Inc. 5 Anaesthesia and Intensive Article Burnout syndrome and its association with anxiety and fear of medical errors among intensive care unit physicians: A cross-sectional study Care Anaesthesia and Intensive Care 2020, Vol. 48(2) 134–142 ! The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0310057X20902780 journals.sagepub.com/home/aic Polychronis Voultsos1, Maria Koungali2, Konstantinos Psaroulis3 and Afroditi K Boutou4 Abstract Burnout is a work-specific syndrome with high incidence among intensive care unit personnel. Although several risk factors have been proposed, data regarding the association of anxiety and burnout among intensive care unit physicians are scarce. The aim of this study is to investigate the incidence of burnout and its association with state and trait anxiety and other sociodemographic, behavioural and occupational-related parameters, among intensivists. A population of intensive care physicians was evaluated using the self-completed Maslach Burnout Inventory and the State-Trait Anxiety Inventory Form Y, and data regarding sociodemographic and occupational-related variables were also recorded. From the 98 intensive care physicians addressed, 80 returned fully completed questionnaires; 26.9% of them presented with high emotional exhaustion, 37.5% with high depersonalisation and 41.5% with low personal accomplishment scores.

Trait anxiety, fear of having committed a medical error and self-reporting difficulty when having to act accurately were independently associated with high burnout. In conclusion, burnout is common among intensivists and is associated with specific behavioural characteristics and personality traits, but not with work-related factors. Keywords Burnout, intensive care physicians, trait anxiety, medical error Introduction Burnout syndrome (BOS) is usually described as an emotional condition characterised by mental fatigue, physical fatigue, frustration and disengagement.1–4 It is a work-specific syndrome of emotional exhaustion, depersonalisation and a reduced sense of personal accomplishment among individuals who work with people in some capacity5 and is more likely to occur when goals and expectations are too high, or reality is too low,1 resulting in an imbalance between invested and gained resources. BOS has a clearly relational character, especially affecting people working in highly demanding jobs in which they develop intense relationships; given the characteristics of the work in an intensive care unit (ICU), which is a highly demanding task engaging life or death decisions, it is expected that ICU practitioners are exposed at a high risk of burnout. Published literature data confirm that ICU physicians constitute a high-risk population, reporting a burnout prevalence up to 50%,6 although incidence might be somehow overestimated or underestimated, mainly because diagnosis is based on subjective and self-reporting criteria.1 Although heavy workloads, workplace environment, issues related to patient care and end-of-life decisions have been previously 1 Laboratory of Forensic Medicine and Toxicology, Aristotle University of Thessaloniki, Thessaloniki, Greece 2 Department of Public Health, Administration of Central Makedonian Region, Thessaloniki, Greece 3 Intensive Care Unit, Agios Dimitrios General Hospital, Thessaloniki, Greece 4 Department of Respiratory Medicine, G Papanikolaou Hospital, Thessaloniki, Greece Corresponding author: Afroditi K Boutou, Department of Respiratory Medicine, G Papanikolaou Hospital, Exohi, Thessaloniki, 57010, Greece. Email: afboutou@yahoo.com Voultsos et al. associated with the presence of burnout among critical care personnel,6,7 published literature varies widely regarding the identification of independent risk factors related to burnout occurrence among ICU physicians. The ICU is a complex working environment characterised by a high level of work-related stress.8 As Maslach and Leiter have recently highlighted, BOS is the result of prolonged interpersonal stressors at work.9 However, under the same working conditions, some individuals burn out and some others have no symptomatology;10 therefore, a person’s reaction to work stressors might range from minor to significant stimulation.11 This varies employees’ reactions to working in a stressful environment and might be due to different personality characteristics.11 Personality can either involve to a coping mechanism that allows individuals to acquire and/or conserve resources and protect themselves from deviant behaviour or it can make someone more susceptible and vulnerable to stressors.12

One crucial psychological phenomenon that is related to personality is anxiety.11 Although anxiety is a psychological condition that acts as a protective factor against threatening situations, prolonged anxiety might result in psychological distress affecting an individual’s everyday functioning.13 Anxiety is further divided into two related components: trait and state anxiety.14 In more detail, trait anxiety is a stable characteristic of an individual’s personality and the degree to which they perceive stressful situations as threatening. In contrast, state anxiety is the individual’s reaction toward a situation after having appraised it as threatening.15 In other words, an individual’s proneness to anxiety reflects trait anxiety, whereas an individual’s reaction after a situation has been characterised as threatening is state anxiety.11 Previous published studies have reported an association between occupational burnout and increased anxiety in various populations, such as healthcare workers,16 nurses17 and medical residents,18–20 with emotional exhaustion being the burnout dimension that established the strongest correlation to anxiety. However, to the authors’ knowledge, literature data exploring such an association among ICU physicians is scarce. Nevertheless, establishing such a relationship is important for the identification of the physicians at ‘higher risk’ for burnout and, consequently, for the prevention, follow-up and adequate treatment of the disorder. Thus, we conducted a cross-sectional study aiming to investigate: (a) the incidence of BOS, (b) the potential association between the three dimensions of BOS and the levels of anxiety, as assessed by the State-Trait Anxiety Inventory (STAI), and (c) the potential association of BOS with other individual and occupational-related factors, in a population of 135 intensivists employed in ICUs of two European countries. Materials and methods Study design and study population This is a cross-sectional, multicentre, noninterventional study that was conducted in seven adult ICUs in Greece and two adult ICUs in Cyprus, which had a similar structure and treated both surgical and medical patients. All physicians employed in these ICUs (either consultants or ICU medicine residents) were considered eligible for participation. The health system in these two European countries is similar, as is the organisational structure of the ICUs in general. The participation was voluntary and the ethics committees of the relevant institutions in Greece and Cyprus approved the conduct of the study. Data collection A detailed letter describing the purpose of the study and the data collection procedure along with a sufficient number of questionnaires were mailed to each ICU, addressing all employed physicians.

All completed and anonymised questionnaires (each one placed in a closed envelope) were collected in a separate file and were either mailed back to a given address or picked up from the ICU by MK, depending on the personnel’s convenience. A total of three reminder mails were sent to each ICU within a two-month time frame to increase the response rate. Each participant was administered the following questionnaires: 1. Questionnaire 1 recorded sociodemographic data, occupational data and data regarding the structure of the ICU (e.g. number of ICU beds, working hours per week, number of shifts per month, etc.). 2. Questionnaire 2 comprised 15 separate questions that investigated the specific circumstances and working conditions that physicians: (a) wished to be different or (b) find difficult to cope with (e.g. ‘Do you find it difficult to cope when you have to rush into decisions? (yes/no)’). 3. Questionnaire 3 recorded information on hobbies, smoking and alcohol consumption, and leisure time. 4. Questionnaire 4 was the STAI Form Y 21, which is a 40-item self-completed questionnaire, comprising two subscales (Y-1 and Y-2). The STAI Form Y-1 consists of 20 items that measure transient stress, which is the stress at the time of the survey (state anxiety), and the STAI Form Y-2 consists of another 20 items that measure permanent stress as a personality trait (trait anxiety). All items are rated on a 136 four-point Likert-type scale. The scoring weights for the anxiety-present items are the same as the blackened numbers on the test form. The scoring weights for the anxiety-absent items are reversed.21 The total score ranges from 20 to 80 for each STAI subscale and the higher the score, the higher the stress. The STAI has been previously translated and validated in the Greek population.22 5. Questionnaire 5 was the Maslach Burnout Inventory-Human Services SurveyTM (MBI-HSS) used under licence from Mind Garden (granted 6 April, 2014). MBI is a 22-item self-completed questionnaire that assesses the three dimensions of burnout: Emotional Exhaustion (EE) (nine items), Depersonalization (DEP) (five items) and Personal Accomplishment (PA) (eight items).23 Each item is scored on a 0–6 point Likert-type scale. The MBI evaluates the attitudes, feelings and perceptions of physicians concerning their work environment. It is the most widely employed measure, it has high reliability and validity6 and has been previously translated and validated for the Greek population.24 The MBI-HSS authors have validated the following definitions of low, moderate and high scores for each of the burnout dimensions: EE: high
27, moderate: 19–26 and low 18; DEP: high
10, moderate: 6– 9 and low 5; and PA: low 33, moderate: 34–39 and high
40 (the latter is an inverse scale). High, moderate and low levels of EE or DEP, or low, moderate and high levels of PA are used to indicate high, moderate and low levels of burnout, correspondingly.23 Statistical analysis All analyses were conducted using the SPSS Edition 18 for Windows XP. The Shapiro–Wilk test of normality was utilised to evaluate the normality of distribution of values; P
0.05 indicated a normal distribution. Continuous variables are presented as mean (standard deviation) or median (range), according to their distribution of values and categorical variables as percentages. As MBI is a norm-referenced scale, one-third of respondents are expected to score high in each subscale.23 Thus, the observed number of responses were compared to the expected ones, using a Chi-square test to define whether the number of respondents with high levels of burnout were significantly different than the expected one. All subjects with high levels of burnout based on the score of any of the three subscales (high BOS group) were compared to the rest of the subjects (non–high BOS group); the independent sample student’s t-test or Mann–Whitney U test were utilised to compare continuous variables and Chi-square or Fisher’s exact test were used to compare categorical Anaesthesia and Intensive Care 48(2) variables between these two groups, according to the distribution of their values. The Bonferroni correction for multiple comparisons was applied and a level of P < 0.025 (after correction) was considered significant for group comparisons.

Univariate logistic regression analyses were conducted to identify potential associations between the establishment of high BOS and (a) the two dimensions of the STAI questionnaire and (b) any of the rest of the recorded parameters. Variables that were found to be univariately associated with high BOS were then entered in a multivariate logistic stepwise regression analysis model for potential predictors of BOS to be identified. Correlations between the STAI subscales and the three dimensions of MBI-HSS were further studied using the Pearson correlation coefficient, r. Odds ratios (OR) and corresponding 95% confidence intervals (CI) were calculated for all multivariate predictors; a level of P < 0.05 was considered significant for all regression analyses. Results Eighty fully completed questionnaires were returned out of 98 sent, which corresponded to a response rate of 81.6%. Burnout Syndrome Evidence Based Project

Respondents comprised of 40.2% (n1 ¼ 33) male and 59.8% (n2 ¼ 49) female physicians aged an average of 43 (32–65) years. BOS incidence and group differences High BOS, established as a high score in either EE or DEP or low score in PA dimension, was present among 68.8% (N ¼ 55/80) of physicians. High EE was present among 21 physicians (26.9%), high DEP among 30 (37.5%), whereas PA was low among 34 (41.5%) of them. However, as the expected count for a high score in each MBI dimension for this population was 26.7, these numbers were not significantly different from the expected population norm (P ¼ 0.197). Five physicians (6.3%) had high EE and high DEP and low PA, whereas in 25 subjects (31.3%) two out of three MBI dimensions corresponded to a high BOS. All subjects with high levels of burnout, based on the score of any of the three dimensions, constituted the high BOS group, whereas the rest of the subjects were the non–high BOS group. Baseline differences in sociodemographic data, occupational data, habits and leisure time between the two groups (high BOS and non–high BOS) are presented in Table 1. Data regarding the level of anxiety, job satisfaction and physicians’ feelings regarding specific work-related circumstances are presented in Table 2. Overall, physicians who had high (or low for PA) score in any BOS dimension were no different in terms of age, sex and marital status. Most working conditions were also similar because the numbers of ICU beds, Voultsos et al. 137 Table 1. Burnout Syndrome Evidence Based Project

Sociodemographic, occupational and leisure time data among physicians with and without high burnout. Variable Sex, N (%) Male Female Age (years) Marital status, N (%) Without partner With partner Having children, N (%) No Yes Years of working in ICU Number of treated patients per shifta Working hours per week Number of shifts per month Number of weekends off work last year Number of ICU beds Number of employed physicians in the ICU Number of nurses per ICU bed Another job outside ICU, N (%) No Yes Having enough leisure time, N (%) No Yes Having hobbies, N (%) No Yes Current smoking, N (%) No Yes Regular alcohol consumption, N (%) No Yes Non-high BOS High BOS 8 (25.8%) 17 (34.7%) 43 (32–59) 23 (74.2%) 32 (65%) 42 (33–65) 6 (26.1%) 19 (33.3%) 17 (73.9%) 38 (66.7%) 26 48 5 9 58 6 30 9 10 2.5 2 4 5 11 60 6 25 8 8 2.8 P-value 0.615 0.642 0.602 0.990 (92.9%) (92.3%) (0–26) (1–18) (35–80) (0–8) (2–52) (2–15) (2–15) (1–3.5) (7.1%) (7.7%) (0–27) (1–30) (8–100) (0–12) (2–52) (4–21) (3–20) (1.5–4.5) 19 (27.5%) 6 (54.5%) 50 (72.5%) 5 (45.5%) 17 (28.3%) 8 (40%) 43 (71.7%) 12 (60%) 13 … Burnout Syndrome Evidence Based Project