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      Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review

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          Abstract

          Objective

          To determine whether there is an association between healthcare professionals’ wellbeing and burnout, with patient safety.

          Design

          Systematic research review.

          Data Sources

          PsychInfo (1806 to July 2015), Medline (1946 to July 2015), Embase (1947 to July 2015) and Scopus (1823 to July 2015) were searched, along with reference lists of eligible articles.

          Eligibility Criteria for Selecting Studies

          Quantitative, empirical studies that included i) either a measure of wellbeing or burnout, and ii) patient safety, in healthcare staff populations.

          Results

          Forty-six studies were identified. Sixteen out of the 27 studies that measured wellbeing found a significant correlation between poor wellbeing and worse patient safety, with six additional studies finding an association with some but not all scales used, and one study finding a significant association but in the opposite direction to the majority of studies. Twenty-one out of the 30 studies that measured burnout found a significant association between burnout and patient safety, whilst a further four studies found an association between one or more (but not all) subscales of the burnout measures employed, and patient safety.

          Conclusions

          Poor wellbeing and moderate to high levels of burnout are associated, in the majority of studies reviewed, with poor patient safety outcomes such as medical errors, however the lack of prospective studies reduces the ability to determine causality. Further prospective studies, research in primary care, conducted within the UK, and a clearer definition of healthcare staff wellbeing are needed.

          Implications

          This review illustrates the need for healthcare organisations to consider improving employees’ mental health as well as creating safer work environments when planning interventions to improve patient safety.

          Systematic Review Registration

          PROSPERO registration number: CRD42015023340.

          Related collections

          Most cited references42

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          Burnout and self-reported patient care in an internal medicine residency program.

          Burnout is a syndrome of depersonalization, emotional exhaustion, and a sense of low personal accomplishment. Little is known about burnout in residents or its relationship to patient care. To determine the prevalence of burnout in medical residents and explore its relationship to self-reported patient care practices. Cross-sectional study using an anonymous, mailed survey. University-based residency program in Seattle, Washington. 115 internal medicine residents. Burnout was measured by using the Maslach Burnout Inventory and was defined as scores in the high range for medical professionals on the depersonalization or emotional exhaustion subscales. Five questions developed for this study assessed self-reported patient care practices that suggested suboptimal care (for example, "I did not fully discuss treatment options or answer a patient's questions" or "I made...errors that were not due to a lack of knowledge or inexperience"). Depression and at-risk alcohol use were assessed by using validated screening questionnaires. Of 115 (76%) responding residents, 87 (76%) met the criteria for burnout. Compared with non-burned-out residents, burned-out residents were significantly more likely to self-report providing at least one type of suboptimal patient care at least monthly (53% vs. 21%; P = 0.004). In multivariate analyses, burnout--but not sex, depression, or at-risk alcohol use--was strongly associated with self-report of one or more suboptimal patient care practices at least monthly (odds ratio, 8.3 [95% CI, 2.6 to 26.5]). When each domain of burnout was evaluated separately, only a high score for depersonalization was associated with self-reported suboptimal patient care practices (in a dose-response relationship). Burnout was common among resident physicians and was associated with self-reported suboptimal patient care practices.
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            Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study.

            Medical errors are associated with feelings of distress in physicians, but little is known about the magnitude and direction of these associations. To assess the frequency of self-perceived medical errors among resident physicians and to determine the association of self-perceived medical errors with resident quality of life, burnout, depression, and empathy using validated metrics. Prospective longitudinal cohort study of categorical and preliminary internal medicine residents at Mayo Clinic Rochester. Data were provided by 184 (84%) of 219 eligible residents. Participants began training in the 2003-2004, 2004-2005, and 2005-2006 academic years and completed surveys quarterly through May 2006. Surveys included self-assessment of medical errors and linear analog scale assessment of quality of life every 3 months, and the Maslach Burnout Inventory (depersonalization, emotional exhaustion, and personal accomplishment), Interpersonal Reactivity Index, and a validated depression screening tool every 6 months. Frequency of self-perceived medical errors was recorded. Associations of an error with quality of life, burnout, empathy, and symptoms of depression were determined using generalized estimating equations for repeated measures. Thirty-four percent of participants reported making at least 1 major medical error during the study period. Making a medical error in the previous 3 months was reported by a mean of 14.7% of participants at each quarter. Self-perceived medical errors were associated with a subsequent decrease in quality of life (P = .02) and worsened measures in all domains of burnout (P = .002 for each). Self-perceived errors were associated with an odds ratio of screening positive for depression at the subsequent time point of 3.29 (95% confidence interval, 1.90-5.64). In addition, increased burnout in all domains and reduced empathy were associated with increased odds of self-perceived error in the following 3 months (P=.001, P<.001, and P=.02 for depersonalization, emotional exhaustion, and lower personal accomplishment, respectively; P=.02 and P=.01 for emotive and cognitive empathy, respectively). Self-perceived medical errors are common among internal medicine residents and are associated with substantial subsequent personal distress. Personal distress and decreased empathy are also associated with increased odds of future self-perceived errors, suggesting that perceived errors and distress may be related in a reciprocal cycle.
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              Association of resident fatigue and distress with perceived medical errors.

              Fatigue and distress have been separately shown to be associated with medical errors. The contribution of each factor when assessed simultaneously is unknown. To determine the association of fatigue and distress with self-perceived major medical errors among resident physicians using validated metrics. Prospective longitudinal cohort study of categorical and preliminary internal medicine residents at Mayo Clinic, Rochester, Minnesota. Data were provided by 380 of 430 eligible residents (88.3%). Participants began training from 2003 to 2008 and completed surveys quarterly through February 2009. Surveys included self-assessment of medical errors, linear analog self-assessment of overall quality of life (QOL) and fatigue, the Maslach Burnout Inventory, the PRIME-MD depression screening instrument, and the Epworth Sleepiness Scale. Frequency of self-perceived, self-defined major medical errors was recorded. Associations of fatigue, QOL, burnout, and symptoms of depression with a subsequently reported major medical error were determined using generalized estimating equations for repeated measures. The mean response rate to individual surveys was 67.5%. Of the 356 participants providing error data (93.7%), 139 (39%) reported making at least 1 major medical error during the study period. In univariate analyses, there was an association of subsequent self-reported error with the Epworth Sleepiness Scale score (odds ratio [OR], 1.10 per unit increase; 95% confidence interval [CI], 1.03-1.16; P = .002) and fatigue score (OR, 1.14 per unit increase; 95% CI, 1.08-1.21; P < .001). Subsequent error was also associated with burnout (ORs per 1-unit change: depersonalization OR, 1.09; 95% CI, 1.05-1.12; P < .001; emotional exhaustion OR, 1.06; 95% CI, 1.04-1.08; P < .001; lower personal accomplishment OR, 0.94; 95% CI, 0.92-0.97; P < .001), a positive depression screen (OR, 2.56; 95% CI, 1.76-3.72; P < .001), and overall QOL (OR, 0.84 per unit increase; 95% CI, 0.79-0.91; P < .001). Fatigue and distress variables remained statistically significant when modeled together with little change in the point estimates of effect. Sleepiness and distress, when modeled together, showed little change in point estimates of effect, but sleepiness no longer had a statistically significant association with errors when adjusted for burnout or depression. Among internal medicine residents, higher levels of fatigue and distress are independently associated with self-perceived medical errors.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                8 July 2016
                2016
                : 11
                : 7
                : e0159015
                Affiliations
                [1 ]School of Psychology, University of Leeds, Leeds, West Yorkshire, England
                [2 ]Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, West Yorkshire, England
                [3 ]Department of Health Sciences, University of York, York, North Yorkshire, England
                [4 ]Leeds City Council, Leeds, West Yorkshire, England
                University of Stirling, UNITED KINGDOM
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: LHH JJ IW DBO. Performed the experiments: LHH JJ AT IW DBO. Analyzed the data: LHH JJ IW DBO. Contributed reagents/materials/analysis tools: LHH JJ IW AT DBO. Wrote the paper: LHH JJ IW DBO.

                Article
                PONE-D-16-10334
                10.1371/journal.pone.0159015
                4938539
                27391946
                64536a6e-2731-402a-96a5-acce099ca5c3
                © 2016 Hall et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 18 March 2016
                : 24 June 2016
                Page count
                Figures: 2, Tables: 1, Pages: 12
                Funding
                This research was undertaken as part of a PhD funded by the University of Leeds, UK ( www.leeds.ac.uk), and National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) under the Evidence Based Transformation Theme ( www.clahrcpp.co.uk).
                Categories
                Research Article
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Psychological Stress
                Biology and Life Sciences
                Psychology
                Psychological Stress
                Social Sciences
                Psychology
                Psychological Stress
                Research and Analysis Methods
                Database and Informatics Methods
                Database Searching
                Research and Analysis Methods
                Research Assessment
                Systematic Reviews
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Medicine and Health Sciences
                Health Care
                Health Services Research
                Research and Analysis Methods
                Research Design
                Survey Research
                Surveys
                Research and Analysis Methods
                Research Design
                Prospective Studies
                Medicine and Health Sciences
                Health Care
                Quality of Life
                Custom metadata
                All relevant data are within the paper and the Supporting Information files.

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