Morale and job perception of community mental health professionals in Berlin and London

Second victim experience in Spanish psychiatrists coping with patient suicide: A call for postvention

BACKGROUND

Losing a patient by suicide may lead to psychological distress and mid/long-term personal and professional consequences for psychiatrists, becoming second victims.

MATERIAL AND METHODS

The validated Spanish version of the Second Victim Experience and Support Tool (SVEST-E) questionnaire and a 30-item questionnaire created ad-hoc was administered online to psychiatrists from all over Spain to evaluate how patient suicide affects mental health professionals.

RESULTS

Two hundred ninety-nine psychiatrists participated in the survey, and 256 completed the SVEST-E questionnaire. The results of the SVEST-E questionnaire revealed a negative impact of suicide on emotional and physical domains, although this seemed not to lead to work absenteeism. Most respondents desired peer support from a respected colleague and considered institutional support, although desirable, lacking. Almost 70% of surveyed stated that an employee assistance program providing free counseling to employees outside of work would be desirable. The ad-hoc questionnaire showed that up to 88% of respondents considered some suicides unavoidable, and 76% considered the suicide unexpected. Almost 60% of respondents reported no changes in the approach of patients with suicidal ideation/behavior, after losing a patient. However, up to 76% reported performing more detailed clinical evaluations and notes in the medical record. Up to 13% of respondents considered leaving or changing their job or advancing retirement after losing a patient by suicide.

CONCLUSIONS

After a patient's suicide, psychiatrists often suffer the feelings of second victim, impacting personal and professional areas. The study results indicate the need for postvention strategies to mitigate the negative impact of patient suicide.

Job morale of physicians and dentists in Kazakhstan: a qualitative study

BACKGROUND

Job morale is thought to be particularly low in Kazakhstan, adversely affecting job motivation, job satisfaction and burnout rates. Previous research suggests that high job morale has a better effect on patient outcomes and care quality. We, therefore, conducted a qualitative study to explore experiences underpinning positive and negative job morale, and to generate potential strategies for improving job morale of physicians and dentists working in public healthcare settings in Kazakhstan prior to the COVID-19 pandemic.

METHODS

Three focus groups containing 23 participants and 30 individual interviews were conducted, evidencing respondents' explanations of what affects job morale, and possible strategies to improve it. Data was synthesised using a thematic analysis.

RESULTS

The themes about what influences job morale were: being unfairly rewarded for work; feeling vulnerable and undervalued; poor working styles and practices; and high internal value-based motivation. Various strategies were identified by participants to improve job morale, and these included: ensuring adequate and equitable financial income; improving the current malpractice system; eliminating poor working styles and practices; and creating a shared responsibility for health.

CONCLUSIONS

The current study has found that despite prevailing threats, job morale amongst physicians and dentists working in public healthcare settings in Astana have been prevented from becoming negative by their strong sense of calling to medicine and the satisfaction of helping patients recover. Emphasising this rather traditional understanding of the role of physicians and dentists may be a way to improve job morale throughout training and practice.

Prevalence of burnout among psychiatrists: A systematic review and meta-analysis

BACKGROUND

Burnout is a consequence of chronic occupational stress exposure. Psychiatrists are prone to burnout due to specific work-related factors. This study examined the burnout prevalence among psychiatrists.

METHODS

The study protocol was registered in PROSPERO (CRD42020204615). We searched MEDLINE, EMBASE, CENTRAL, PsycINFO, Web of Science, ClinicalTrials.gov, and OpenGrey for relevant publications. Random-effect meta-analysis was performed. We used subgroup analysis and meta-regression to reveal any association of geographical region, survey year, participants' age, gender, and response rate with burnout.

RESULTS

Thirty-six studies involving 5481 participants were included. The prevalence of overall burnout was 25.9% [11.1%-40.7%] as measured by a Maslach Burnout Inventory (MBI) and 50.3% [30.9%-69.8%] as measured by a Copenhagen Burnout Inventory (CBI). The pooled prevalence was 43.5% [27.9%-59%] for high emotional exhaustion (EE), 28.2% [17.5%-38.9%] for high depersonalization (DP), and 32.4% [3.4%-61.3%] for low personal accomplishment (PA). The mean scores of 22-item MBI subscales were 21.51 [18.64%-24.38%] for EE, 6.57 [5.53%-7.62%] for DP, and 31.83 [25.73%-37.94%] for PA. European psychiatrists revealed (p = 0.045) lower EE score (20.82; 95% CI 7.24-24.41) measured by 22-item MBI compared to their non-European colleagues (24.99; 95% CI 23.05-26.94). Other results include mean scores for 16-item MBI-General Survey, burnout rates, and scores in CBI subscales.

LIMITATIONS

The main limitation was high heterogeneity in terms of statistics, screening methods, burnout definitions, and cut-off points utilized in included studies.

CONCLUSIONS

Burnout is highly prevalent among psychiatrists. Future research should focus on finding consensus on burnout screening, longitudinal evaluation of psychiatrists' burnout predictors, and development of effective intervention strategies.

Organizational conditions that influence work engagement and burnout: A qualitative study of mental health workers

Objective: Clinician burnout in healthcare is extensive and of growing concern. In mental health and rehabilitation settings, research on interventions to improve burnout and work engagement is limited and rarely addresses organizational drivers of burnout. This study sought to elaborate on the organizational influence of burnout and work engagement in mental health. Methods: We randomly selected 40 mental health clinicians and managers who were participating in a burnout intervention and conducted semi-structured interviews to understand their views of organizational conditions impacting burnout and work engagement. Data were analyzed using a thematic analytical approach. Results: Analyses yielded three major themes where organizational contexts might reduce burnout and increase work engagement: (a) a work culture that prioritizes person-centered care over productivity and other performance metrics, (b) robust management skills and practices to overcome bureaucracy, and (c) opportunities for employee professional development and self-care. Participants also referenced three levels of the organizational context that they believed influenced burnout and work engagement: front-line supervisors and program managers, organizational executive leadership, and the larger health system. Conclusions and Implications for Practice: Findings point to several possible targets of intervention at various organizational levels that could guide the field toward more effective ways to reduce burnout and improve work engagement. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

[Burnout Among Physicians Working in Psychiatric and Psychosomatic Care]

OBJECTIVE

Burnout is considered to be a major risk factor that can contribute secondary disorders due to persistent work related stress. International studies showed that physicians working in psychiatric care are more frequently affected by burnout than physicians working in somatic care. Studies from Germany are lacking.

METHODS

In a cross-sectional study all physicians 40 years and younger and registered with the State Chamber of Physicians of Saxony, Germany, received an anonymous paper-pencil questionnaire. Burnout was measured using the Maslach Burnout Inventory.

RESULTS

Physicians working in psychiatric/psychosomatic care did not differ from physicians working in somatic care regarding the subscales emotional exhaustion and depersonalization. Physicians working in psychiatric/psychosomatic care reported higher personal accomplishment. Working in psychiatric/psychosomatic care was associated with a lower likelihood for a high degree of burnout on the subscale personal accomplishment.

CONCLUSION

Previous studies suggesting a higher prevalence of burnout among physicians working in psychiatric care could not be confirmed.

Job morale: a scoping review of how the concept developed and is used in healthcare research

Background

The job morale of healthcare staff is widely seen as an important factor for the quality of care. Yet, there are different understandings of what constitutes job morale, which hinders systematic research and comparisons. We therefore conducted a scoping review of how the concept of job morale has developed over time and how it is used in healthcare research.

Methods

A scoping review was conducted to identify relevant literature. Data were gathered on study design and context, objectives, definitions of morale, outcome measures and key findings. Data was synthesised using a descriptive analytical framework.

Results

Ninety-three unique studies met eligibility criteria for the present review. The literature outlines four main periods of the evolution of the concept of job morale: The First World War and the interwar years; Second World War; Aftermath of the Second World War; and Contemporary period. The concept of job morale originated in a military context and was later applied to and specified in the healthcare literature. The concept has been applied to individuals and groups. The understandings used in healthcare vary, but overlap. Methods for assessing job morale in healthcare include quantitative scales, indirect measurements of consequences and predictors of morale, and qualitative approaches. Existing studies have mainly focused on the job morale of general practitioners, nurses and mental health professionals in high-income countries.

Conclusions

Although the understandings of job morale in healthcare are heterogeneous and inconsistent, the concept appears to have been useful over longer periods of time and in different contexts. Which precise understanding of job morale is useful, depends on the given research purpose, and studies should make explicit which exact understanding they apply. Systematic research on job morale is required to facilitate measures to improve and maintain high levels of morale across different professional groups, including professionals in low- and middle-income countries.

Burnout in consultants in child and adolescent mental health services (CAMHS) in Ireland: a cross-sectional study

Physician burnout has reached epidemic levels in many countries, contributing to adverse personal, patient and service outcomes. Adverse socioeconomic conditions, such as the economic downturn in the Ireland post 2008, contribute to a situation of increased demand but inadequate resources. Given a recent unprecedented increase in referrals to Irish child and adolescent mental health services (CAMHS), coupled with a fragmented and poorly resourced service, it is important to reflect on consultant child psychiatrists' well-being.

OBJECTIVES

To report on the level of burnout among consultants working in CAMHS in Ireland using a cross-sectional design.

SETTING

Community CAMHS in Ireland.

PARTICIPANTS

An online questionnaire was sent to all consultant child psychiatrists registered with the Irish Medical Council (n=112). Fifty-two consultants replied (46% response rate).

PRIMARY OUTCOME MEASURES

Questions assessed demographic and occupational details, career satisfaction and perceived management, government and public support. The Copenhagen Burnout Inventory measured personal, work and patient-related burnout.

RESULTS

The prevalence of moderate or higher levels of work-related and personal burnout was 75% and 72.3%, respectively. Fewer (n=14, 26.9%) experienced patient-related burnout. There was a strong correlation between work burnout and personal (r=0.851, n=52, p<0.001) and patient-related burnout (r=0.476, n=52, p<0.001). Lack of confidence in government commitment to investment in CAMHS (p<0.001) and perceived ineffective management by health authorities (p=0.002) were associated with higher burnout scores. Few consultants (n=11, 21%) felt valued in their job. The majority (n=36, 69%) had seriously considered changing jobs, and this was positively associated with higher burnout (p<0.001). Higher burnout scores were present in those (n=15, 28.8%) who would not retrain in child psychiatry (p=0.002).

CONCLUSION

The high level of burnout reported by respondents in this study, and ambivalence about child psychiatry as a career choice has huge professional and service implications. Urgent organisational intervention to support consultant psychiatrists' well-being is required.

Indicators Associated With Job Morale Among Physicians and Dentists in Low-Income and Middle-Income Countries: A Systematic Review and Meta-analysis

IMPORTANCE

Improving health care in low- and middle-income countries (LMICs) requires a workforce with positive job morale. However, the level of job morale in this population remains unclear.

OBJECTIVE

To analyze studies measuring the job morale of physicians and dentists working in LMICs, using levels of job burnout, job satisfaction, and job motivation as indicators of job morale.

DATA SOURCES

A comprehensive search of Scopus, PubMed, PsycINFO, EMBASE, Web of Science, and the Cochrane Library, from database inception to October 30, 2018, and gray literature was performed.

STUDY SELECTION

Studies were eligible if at least 50% of the sample were qualified physicians and/or dentists working in public health care settings in LMICs. Three indicators of job morale in this population were used: job burnout, job satisfaction, and job motivation. Of 12 324 records reviewed, 79 studies were included in the systematic review and 59 were eligible for the meta-analysis.

DATA EXTRACTION AND SYNTHESIS

Data were extracted independently by several investigators in accordance with the Meta-analyses of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Random-effects meta-analyses, planned subgroup analyses, and metaregression were performed. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess bias.

MAIN OUTCOMES AND MEASURES

Levels of job burnout, job satisfaction, and job motivation as indicators of job morale.

RESULTS

Overall, 12 324 records were identified. Of them, 80 records, representing 79 studies and involving 45 714 participants across 37 LMICs, met the inclusion criteria for the review; however, only 3 were from low-income countries. In 21 studies with 9092 participants working mainly in middle-income countries, 32% (95% CI, 27%-38%; I2 = 95.32%; P < .001) reported job burnout, and in 20 studies with 14 113 participants, 60% (95% CI, 53%-67%; I2 = 98.21%; P < .001) were satisfied with their job overall. Sufficient data were not available for a meta-analysis of job motivation.

CONCLUSIONS AND RELEVANCE

The findings suggest that, among physicians and dentists working mainly in middle-income countries, more than half reported having positive job morale. Positive job morale among physicians and dentists may help with recruitment and retention and thus support programs for improving health care in LMICs.

Job morale of physicians in low-income and middle-income countries: a systematic literature review of qualitative studies

OBJECTIVES

To systematically review the available literature on physicians' and dentists' experiences influencing job motivation, job satisfaction, burnout, well-being and symptoms of depression as indicators of job morale in low-income and middle-income countries.

DESIGN

The review was reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for studies evaluating outcomes of interest using qualitative methods. The framework method was used to analyse and integrate review findings.

DATA SOURCES

A primary search of electronic databases was performed by using a combination of search terms related to the following areas of interest: 'morale', 'physicians and dentists' and 'low-income and middle-income countries'. A secondary search of the grey literature was conducted in addition to checking the reference list of included studies and review papers.

RESULTS

Ten papers representing 10 different studies and involving 581 participants across seven low-income and middle-income countries met the inclusion criteria for the review. However, none of the studies focused on dentists' experiences was included. An analytical framework including four main categories was developed: work environment (physical and social), rewards (financial, non-financial and social respect), work content (workload, nature of work, job security/stability and safety), managerial context (staffing levels, protocols and guidelines consistency and political interference). The job morale of physicians working in low-income and middle-income countries was mainly influenced by negative experiences. Increasing salaries, offering opportunities for career and professional development, improving the physical and social working environment, implementing clear professional guidelines and protocols and tackling healthcare staff shortage may influence physicians' job morale positively.

CONCLUSIONS

There were a limited number of studies and a great degree of heterogeneity of evidence. Further research is recommended to assist in scrutinising context-specific issues and ways of addressing them to maximise their utility.

PROSPERO REGISTRATION NUMBER

CRD42017082579.

Job satisfaction and associated factors among psychiatric nurses in tertiary psychiatric hospitals: Results from a nationwide cross-sectional study

AIMS

To investigate the job satisfaction among psychiatric nurses in China and to explore its associated factors.

DESIGN

A cross-sectional survey among a nationwide sample from 32 tertiary psychiatric hospitals in 29 provincial capitals in China.

METHODS

Nurses (N = 9.907) were targeted for this survey in December 2017. In all, 8,493 responded (response rate = 85.7%) and 7,881 (79.5%) were included in the analysis. An online questionnaire was used to collect demographics and factors related to the work environment. The short version of the Minnesota Satisfaction Questionnaire was used to assess job satisfaction. Multilevel regression was used to examine the association between job satisfaction and these factors.

RESULTS

The mean job satisfaction score was 73.7. The multiple regression analysis indicated that self-rated health, monthly income, medical liability insurance coverage, perceived respect from patients, social recognition, nurse-physician collaboration, and trust were significantly associated with higher job satisfaction scores, while age, work hours, and directly experiencing patient-initiated violence were negatively associated with job satisfaction (p < .05).

CONCLUSION

Overall, Chinese psychiatric nurses are closer to satisfied than neutral and some demographics and factors related to stressful work environments were associated with nurses' job satisfaction scores.

IMPACT

This study examined factors associated with the job satisfaction of Chinese psychiatric nurses in a nationwide sample and indicated that to improve nurses' job satisfaction, the government and hospital administrators could consider ways to promote nurses' personal health and to modify the stressful work environments, such as improving income, reducing work hours, promoting the psychiatric nursing specialty in ways that increase the public's respect for it, increasing awareness of medical liability insurance coverage, and protecting nurses from patients' violence.

Update on Addressing Mental Health and Burnout in Physicians: What Is the Role for Psychiatry?

PURPOSE OF REVIEW

To highlight an emerging understanding of burnout and physician mental health. This review will provide a discussion of conceptual and diagnostic issues of the burnout syndrome with its relevance to psychiatry, and how psychiatry may interface with other medical disciplines to provide support in creating burnout prevention and treatment programs.

RECENT FINDINGS

Descriptive data of burnout correlations and risk factors are available while an understanding of burnout best practices is lacking but growing. Two recent meta-analyses provide efficacy data along with key subgroup analyses that point to greater efficacy among systemic/organizational over individual level interventions. Among individual interventions, groups work better than individual therapy and the incorporation of Mindfulness-Based Stress Reduction and/or Cognitive Behavioral Therapy modalities provide greater efficacy over other therapies. Ultimately, addressing burnout will be an iterative process specific to institutional cultures and therefore should be thought of as quality improvement initiatives involving leadership to adopt the quadruple aim of physician wellness and to seek institution-specific collaboration and feedback. Psychiatry is uniquely positioned to help change institutional cultures regarding the burnout syndrome, which has been labeled a national crisis. Combinatorial strategies that combine efficacious individual-level interventions with systemic-level interventions that enhance workflow will likely provide the most sustainable model for preventing and treating burnout. Psychiatry should be involved, especially at the level of the liaison psychiatrist to assist with how these types of interventions may be best implemented in specific institutions.

Psychiatrist burnout: a meta-analysis of Maslach Burnout Inventory means

BACKGROUND

Doctors are known to have poor mental health compared with the general population. Psychiatrists are exposed to a number of unique stressors that may increase the risk of poor mental health. The aim of this study was to undertake a meta-analysis of burnout rates in psychiatrists.

METHODS

Electronic databases (including MEDLINE, PsycINFO and Embase) were searched. Only studies published since 1999 and using the 22-item Maslach Burnout Inventory were included in the analysis. A meta-analysis was conducted using the Comprehensive Meta-Analysis software.

RESULTS

A total of 11 studies, across nine publications, were included in the final analysis. Studies were significantly heterogenous but there was no indication of publication bias. The pooled mean for emotional exhaustion was 22.03 (95% confidence interval (CI): 19.71-24.34, tau = 3.74). For depersonalisation, the pooled mean was 7.41 (95% CI: 5.91-8.90, tau = 2.45). The pooled mean for personal accomplishment was 30.00 (95% CI: 24.75-35.27, tau = 8.87).

CONCLUSIONS

The high level of psychiatrist emotional exhaustion is a significant concern. Further research is needed to consider the role of modifiable risk factors in the aetiology of psychiatrist burnout.

Personal resilience in psychiatrists: systematic review

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

Perceptions vs Reality of Patient Flow and Workflow in a Primary Care Setting

BACKGROUND AND OBJECTIVE

Evaluating the time taken at each step in a patient office visit is important for physicians and clinical staff for clinic workflow improvements. Very little data exists on efficiency that is not self-reported by physicians. Employees often have perceptions of the efficiency of a clinic without supporting data. This study examined whether employee perceptions of the amount of patient time spent at various points in the visit matched observed times.

METHODS

Observational cohort study methods and a cross-sectional survey were used in the fall of 2017 in a family practice residency outpatient clinic. Clinical staff (physicians and support staff) were surveyed for their perceptions of patients' time spent at each checkpoint in an office visit. A total of 885 visits were recorded, with 705 being included after review. Time spent at various steps, appointment type, and clinician years of experience were assessed with t-test for statistical significance.

RESULTS

The anonymous clinic survey had a 75.5% response rate (37/49) and showed "rooming patients" and "waiting in the exam room to be seen" were the two areas that took longer than expected. The observed data confirmed this perception, showing that rooming and waiting in the exam room each took longer than the staff expected. These values were also greater than available national average times. There was a significant correlation between physician training year and visit length. There was no correlation for nursing experience and patient visit times.

CONCLUSIONS

The staff-perceived inefficiencies correlated with observed inefficiencies. Addressing these problems would improve patient care and overall clinic workflow.

Burnout in mental health professionals: A systematic review and meta-analysis of prevalence and determinants

This study aimed to estimate the level of burnout in mental health professionals and to identify specific determinants of burnout in this population. A systematic search of MEDLINE/PubMed, PsychINFO/Ovid, Embase, CINAHL/EBSCO and Web of Science was conducted for original research published between 1997 and 2017. Sixty-two studies were identified as meeting the study criteria for the systematic review. Data on the means, standard deviations, and prevalence of the dimensions of burnout were extracted from 33 studies and included in the meta-analysis (n = 9409). The overall estimated pooled prevalence for emotional exhaustion was 40% (CI 31%-48%) for depersonalisation was 22% (CI 15%-29%) and for low levels of personal accomplishment was 19% (CI 13%-25%). The random effects estimate of the mean scores on the Maslach Burnout Inventory indicate that the average mental health professional has high levels of emotional exhaustion [mean 21.11 (95% CI 19.98, 22.24)], moderate levels of depersonalisation [mean 6.76 (95% CI 6.11, 7.42)] but retains reasonable levels of personal accomplishment [mean 34.60 (95% CI 32.99, 36.21)]. Increasing age was found to be associated with an increased risk of depersonalisation but also a heightened sense of personal accomplishment. Work-related factors such as workload and relationships at work, are key determinants for burnout, while role clarity, a sense of professional autonomy, a sense of being fairly treated, and access to regular clinical supervision appear to be protective. Staff working in community mental health teams may be more vulnerable to burnout than those working in some specialist community teams, e.g., assertive outreach, crisis teams.

Building The Mental Health Workforce Capacity Needed To Treat Adults With Serious Mental Illnesses

There are widespread shortages of mental health professionals in the United States, especially for the care of adults with serious mental illnesses. Such shortages are aggravated by maldistribution of mental health professionals and attractive practice opportunities treating adults with less severe conditions. The Affordable Care Act (ACA) and legislation extending mental health parity coverage are contributing to an increasing demand for mental health services. I consider four policy recommendations to reinvigorate the mental health workforce to meet the rising mental health care demand by adults with serious mental illnesses: expanding loan repayment programs for mental health professionals to practice in underserved areas; raising Medicaid reimbursement for treating serious mental illness; increasing training opportunities for social workers in relevant evidence-based psychosocial services; and disseminating service models that integrate mental health specialists as consultants in general medical care. Achieving progress in attracting mental health professionals to care for adults with serious mental illnesses will require vigorous policy interventions.

A comparative study of job satisfaction among nurses, psychologists/psychotherapists and social workers working in Quebec mental health teams

BACKGROUND

This study identified multiple socio-professional and team effectiveness variables, based on the Input-Mediator-Output-Input (IMOI) model, and tested their associations with job satisfaction for three categories of mental health professionals (nurses, psychologists/psychotherapists, and social workers).

METHODS

Job satisfaction was assessed with the Job Satisfaction Survey. Independent variables were classified into four categories: 1) Socio-professional Characteristics; 2) Team Attributes; 3) Team Processes; and 4) Team Emergent States. Variables were entered successively, by category, into a hierarchical regression model.

RESULTS

Team Processes contributed the greatest number of variables to job satisfaction among all professional groups, including team support which was the only significant variable common to all three types of professionals. Greater involvement in the decision-making process, and lower levels of team conflict (Team Processes) were associated with job satisfaction among nurses and social workers. Lower seniority on team (Socio-professional Characteristics), and team collaboration (Team Processes) were associated with job satisfaction among nurses, as was belief in the advantages of interdisciplinary collaboration (Team Emergent States) among psychologists. Knowledge sharing (Team Processes) and affective commitment to the team (Team Emergent States) were associated with job satisfaction among social workers.

CONCLUSIONS

Results suggest the need for mental health decision-makers and team managers to offer adequate support to mental health professionals, to involve nurses and social workers in the decision-making process, and implement procedures and mechanisms favourable to the prevention or resolution of team conflict with a view toward increasing job satisfaction among mental health professionals.

Provider-agency fit in substance abuse treatment organizations: implications for learning climate, morale, and evidence-based practice implementation

Background

Substance abuse agencies have been slow to adopt and implement evidence-based practices (EBPs), due in part to poor provider morale and organizational climates that are not conducive to successful learning and integration of these practices. Person-organization fit theory suggests that alignment, or fit, between provider- and agency-level characteristics regarding the implementation of EBPs may influence provider morale and organizational learning climate and, thus, implementation success. The current study hypothesized that discrepancies, or lack of fit, between provider- and agency-level contextual factors would negatively predict provider morale and organizational learning climate, outcomes shown to be associated with successful EBP implementation.

Methods

Direct service providers (n = 120) from four substance abuse treatment agencies responded to a survey involving provider morale, organizational learning climate, agency expectations for EBP use, agency resources for EBP use, and provider attitudes towards EBP use. Difference scores between combinations of provider- and agency-level factors were computed to model provider-agency fit. Quadratic regression analyses were conducted to more adequately and comprehensively model the level of the dependent variables across the entire “fit continuum”.

Results

Discrepancies, or misfit, between agency expectations and provider attitudes and between agency resources and provider attitudes were associated with poorer provider morale and weaker organizational learning climate. For all hypotheses, the curvilinear model of provider-agency discrepancies significantly predicted provider morale and organizational learning climate, indicating that both directions of misfit (provider factors more favorable than agency factors, and vice-versa) were detrimental to morale and climate. However, outcomes were most negative when providers viewed EBPs favorably, but perceived that agency expectations and resources were less supportive of EBP use.

Conclusions

The current research benefits from a strong theoretical framework, consistent findings, and significant practical implications for substance abuse treatment agencies. Comprehensive attempts to strengthen outcomes related to EBP implementation must consider both provider- and agency-level characteristics regarding EBP use. Organizational efforts to more closely align provider attitudes and agency priorities will likely constitute a key strategy in fostering the implementation of EBPs in substance abuse treatment organizations.

Aspects of Sustainability: Cooperation, Job Satisfaction, and Burnout among Swiss Psychiatrists

PURPOSE

Greater sustainability in mental health services is frequently demanded but seldom analyzed. Levels of cooperation, job satisfaction, and burnout are indicators of social sustainability in this field and are of particular importance to medical staff. Because registered psychiatrists play a central role, we assessed the status quo and interactions between these three factors among registered psychiatrists in Switzerland.

METHOD

A postal survey with three standardized questionnaires about cooperation, job satisfaction, and burnout was conducted among all registered psychiatrists in the German-speaking part of Switzerland (n = 1485). Addresses were provided by the Swiss Medical Association.

RESULTS

Response rate was 23.7% (n = 352), yielding a largely male sample (62.8%; n = 218) aged 55.5 ± 8.7 years old. Quantity (47 ± 56.2 contacts over 3 months) and duration (91.1 ± 101.6 min per week) of cooperation was found to be diverse depending on the stakeholder. Quality of cooperation was greatest in general practitioners (81.5%) while it was worst in community mental health providers (54.9%). Overall job satisfaction was assessed rather high (3.7 ± 0.8), and burnout rates were below crucial values (Emotional Exhaustion, 2.9 ± 0.8; Depersonalization, 1.9 ± 0.5). Both were positively influenced by cooperation. The strongest correlation was found between job satisfaction and burnout, and both had significant inverse relationships in all dimensions.

CONCLUSION

To foster sustainability in outpatient mental health care regarding cooperation, job satisfaction, and burnout, personal aspects such and age or years of registration, organizational aspects, such as networking and practice setting, as wells as supportive aspects such as psychotherapy, and self-help groups, must be considered. Quality of cooperation should be reinforced in particular. Because Integrated and Managed Care models cover several of these factors, the models should be more strongly embedded in health care systems.

Work engagement supports nurse workforce stability and quality of care: nursing team-level analysis in psychiatric hospitals

Research in healthcare settings reveals important links between work environment factors, burnout and organizational outcomes. Recently, research focuses on work engagement, the opposite (positive) pole from burnout. The current study investigated the relationship of nurse practice environment aspects and work engagement (vigour, dedication and absorption) to job outcomes and nurse-reported quality of care variables within teams using a multilevel design in psychiatric inpatient settings. Validated survey instruments were used in a cross-sectional design. Team-level analyses were performed with staff members (n = 357) from 32 clinical units in two psychiatric hospitals in Belgium. Favourable nurse practice environment aspects were associated with work engagement dimensions, and in turn work engagement was associated with job satisfaction, intention to stay in the profession and favourable nurse-reported quality of care variables. The strongest multivariate models suggested that dedication predicted positive job outcomes whereas nurse management predicted perceptions of quality of care. In addition, reports of quality of care by the interdisciplinary team were predicted by dedication, absorption, nurse-physician relations and nurse management. The study findings suggest that differences in vigour, dedication and absorption across teams associated with practice environment characteristics impact nurse job satisfaction, intention to stay and perceptions of quality of care.

Burnout in mental health services: a review of the problem and its remediation

Staff burnout is increasingly viewed as a concern in the mental health field. In this article we first examine the extent to which burnout is a problem for mental health services in terms of two critical issues: its prevalence and its association with a range of undesirable outcomes for staff, organizations, and consumers. We subsequently provide a comprehensive review of the limited research attempting to remediate burnout among mental health staff. We conclude with recommendations for the development and rigorous testing of intervention approaches to address this critical area.

Staff engagement as a target for managing work environments in psychiatric hospitals: implications for workforce stability and quality of care

AIMS AND OBJECTIVES

To examine relationships between practice environment ratings, workload, work engagement, job outcomes and assessments of quality of care in nursing personnel in psychiatric hospitals.

DESIGN

Cross-sectional survey.

BACKGROUND

A broad base of research studies in health care reveals important links between work environment factors, staff burnout and organisational outcomes that merit examination in inpatient mental healthcare settings. Work engagement, a positively framed parallel construct for burnout, may offer an additional insight into the impacts of work on staff.

METHODS

A sample of 357 registered nurses (65·5%), licensed practical nurses (23·5%) and non-registered caregiver (10·6%) of two Belgian psychiatric hospitals were surveyed. A causal model was tested using structural equation modelling, whereby it was proposed that work engagement would be influenced by work environment factors and itself impact perceived quality of care and staff job outcomes such as job satisfaction and turnover intentions.

RESULTS

An adjusted model was confirmed. Practice environment features influenced staff vigour and dedication and demonstrated positive effects on job satisfaction, turnover intentions and perceived quality of care through their effects on absorption.

CONCLUSION

The findings of this study suggest that work engagement is a likely direct consequence of practice environments that may ultimately have impacts on both staff and patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

Leaders, nurse managers, clinicians as well as nurses themselves should be aware of the importance of work environments in mental healthcare facilities that favour engagement. Future efforts should focus on developing and sustaining practice environments that engage mental healthcare workers within interdisciplinary teams with the goal of creating a stable workforce possessing optimal possible knowledge, skills and abilities for delivering care.

Morale in the English mental health workforce: questionnaire survey

BACKGROUND

High-quality evidence on morale in the mental health workforce is lacking.

AIMS

To describe staff well-being and satisfaction in a multicentre UK National Health Service (NHS) sample and explore associated factors.

METHOD

A questionnaire-based survey (n = 2258) was conducted in 100 wards and 36 community teams in England. Measures included a set of frequently used indicators of staff morale, and measures of perceived job characteristics based on Karasek's demand-control-support model.

RESULTS

Staff well-being and job satisfaction were fairly good on most indicators, but emotional exhaustion was high among acute general ward and community mental health team (CMHT) staff and among social workers. Most morale indicators were moderately but significantly intercorrelated. Principal components analysis yielded two components, one appearing to reflect emotional strain, the other positive engagement with work. In multilevel regression analyses factors associated with greater emotional strain included working in a CMHT or psychiatric intensive care unit (PICU), high job demands, low autonomy, limited support from managers and colleagues, age under 45 years and junior grade. Greater positive engagement was associated with high job demands, autonomy and support from managers and colleagues, Black or Asian ethnic group, being a psychiatrist or service manager and shorter length of service.

CONCLUSIONS

Potential foci for interventions to increase morale include CMHTs, PICUs and general acute wards. The explanatory value of the demand-support-control model was confirmed, but job characteristics did not fully explain differences in morale indicators across service types and professions.

Qualified and Unqualified (N-R C) mental health nursing staff--minor differences in sources of stress and burnout. A European multi-centre study

BACKGROUND

Unqualified/non-registered caregivers (N-R Cs) will continue to play important roles in the mental health services. This study compares levels of burnout and sources of stress among qualified and N-R Cs working in acute mental health care.

METHODS

A total of 196 nursing staff --124 qualified staff (mainly nurses) and 72 N-R Cs with a variety of different educational backgrounds--working in acute wards or community mental teams from 5 European countries filled out the Maslach Burnout Inventory (MBI), the Mental Health Professional Scale (MHPSS) and the Psychosocial Work Environment and Stress Questionnaire (PWSQ).

RESULTS

(a) The univariate differences were generally small and restricted to a few variables. Only Social relations (N-R Cs being less satisfied) at Work demands (nurses reporting higher demands) were different at the .05 level. (b) The absolute scores both groups was highest on variables that measured feelings of not being able to influence a work situation characterised by great demands and insufficient resources. Routines and educational programs for dealing with stress should be available on a routine basis. (c) Multivariate analyses identified three extreme groups: (i) a small group dominated by unqualified staff with high depersonalization, (ii) a large group that was low on depersonalisation and high on work demands with a majority of qualified staff, and (iii) a small N-R C-dominated group (low depersonalization, low work demands) with high scores on professional self-doubt. In contrast to (ii) the small and N-R C-dominated groups in (i) and (iii) reflected mainly centre-dependent problems.

CONCLUSION

The differences in burnout and sources of stress between the two groups were generally small. With the exception of high work demands the main differences between the two groups appeared to be centre-dependent. High work demands characterized primarily qualified staff. The main implication of the study is that no special measures addressed towards N-R Cs in general with regard to stress and burnout seem necessary. The results also suggest that centre-specific problems may cause more stress among N-R Cs compared to the qualified staff (e.g. professional self-doubt).

Job satisfaction and burnout among staff working in community-based personality disorder services

AIMS

To examine levels of burnout among staff working in community-based services for people with personality disorder (PD) and to explore factors which add to or lower the risk of burnout among people working in such services.

METHODS

In-depth interviews with staff working at 11 dedicated community-based personality disorder services in England together with a cross-sectional staff survey using the Maslach Burnout Inventory.

RESULTS

Levels of burnout were generally lower than those reported in previous studies among mental health workers and levels of personal accomplishment were higher. Staff reported positive as well as negative experiences of working with people with PD. Strong team-work, clear leadership and opportunities for reflective practice were thought to protect staff from burnout.

CONCLUSIONS

The low levels of burnout we found may reflect the early stage of the development of these services. However, it is also possible that working with people with PD does not in itself lead to burnout, especially when services are organized to share and contain work-related anxiety.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Satisfaction and burnout among staff of crisis resolution, assertive outreach and community mental health teams. A multicentre cross sectional survey

BACKGROUND

The NHS Plan required extensive changes in the configuration of mental health services in the UK, including introduction of crisis resolution teams, CRTs. Little is known about the effects of these changes on mental health staff and their recruitment and retention.

AIMS

To assess levels of burnout and sources of satisfaction and stress in CRT staff and compare them with assertive outreach team (AOT) and community mental health team (CMHT) staff.

METHOD

Cross sectional survey using questionnaires, including the Maslach Burnout Inventory, the Minnesota Satisfaction Scale and global job satisfaction item from the Job Diagnostic Survey. All staff in 11 CRTs in 7 London boroughs were included.

RESULTS

One hundred and sixty-nine questionnaires were received (response rate 78%). CRT staff were moderately satisfied with their jobs and scores for the three components of burnout were low or average. Their sense of personal accomplishment was greater than in the other types of team.

CONCLUSION

Our results suggest that CRTs may be sustainable from a workforce morale perspective, but longer term effects will need to be assessed.

Clinicians' attitudes to the employment of people with psychosis

BACKGROUND

Negative staff attitudes have been cited as a factor in explaining the low rates of employment in people with psychosis. We aimed to conduct the first systematic survey of staff attitudes in UK community mental health teams.

METHODS

A questionnaire survey of clinicians working in community mental health teams in North London, UK.

RESULTS

Clinicians believed that many more people with psychosis were capable of working than were actually doing so. Nevertheless they believed that about two thirds of their caseloads were either incapable of working or able only to do voluntary or sheltered work. The work roles they saw as suitable tended to be ones requiring lower levels of technical skills. Clinicians saw helping people get back to work as a core part of their role, but felt they had little relevant training and limited confidence in the vocational services currently available for their clients.

CONCLUSIONS

In this London catchment area, clinicians believed the majority of people with psychosis to be capable of some kind of work, albeit not always open market, but they had few resources available to them to facilitate this. They give priority to the development of place and support vocational services.

Individual unmet needs for care: are they sensitive as outcome criterion for the effectiveness of mental health services interventions?

BACKGROUND

Mental health interventions should demonstrate an effect on patients' functioning as well as his/her needs, in particular on unmet needs whose assessment depends on the perspective of either the patient or the clinician. However, individual met and unmet needs appear to change over time, qualitatively and quantitatively, raising questions about their sensitivity to change and about the association between level of needs and treatment.

METHODS

Data on baseline and follow-up need assessment in community mental health services in four European countries in the context of a cluster randomised trial on a novel mental health service intervention were used, which involved 102 clinicians with key worker roles and 320 patients with schizophrenia or related psychotic disorders. Need assessment was performed with the Camberwell assessment of needs short appraisal schedule (CANSAS) among patients as well as clinicians. Focus is the sensitivity to change in unmet needs over time as well as the concordance between patient and clinician ratings and their relationship with treatment condition.

RESULTS

At follow-up 294 patients (92%) had a full need assessment, while clinician rated needs were available for 302 patients (94%). Generally, the total number of met needs remained quite stable, but unmet needs decreased significantly over time, according to patients as well as to clinicians. Sensitivity to change of unmet needs is quite high: about two third of all unmet needs made a transition to no or met need, and more than half of all unmet needs at follow-up were new. Agreement between patient and clinician on unmet needs at baseline as well as follow-up was rather low, without any indication of a specific treatment effect.

CONCLUSIONS

Individual unmet needs appear to be quite sensitive to change over time but as yet less suitable as outcome criterion of treatment or specific interventions.

Towards structural quality indicators for intensive community-based care programmes for substance abusers

Although the importance of structure for the quality of intensive community-based care was already acknowledged in the 1980s, the subject has not received much attention since. The object of this study was to identify the perceived structural quality indicators for intensive community-based care for substance abusers and expand a classification system in order to enable meaningful effect studies and to substantiate structure--outcome links. Using concept mapping based on a purposive sample of experts, seven clusters of structural quality indicators were identified. Finally, the validity of the classification system is discussed.

Constraints perceived by psychiatrists working in community mental health services. Development and pilot study of a novel instrument

An inventory of institutional constraints perceived as limiting therapeutic choices was developed and completed by psychiatrists working in Italian public mental health services. Constraints considered most limiting were social and institutional pressures toward social control, violence risk assessment and prevention, and lack of control over workload. The total mean score of the perceived constraints instrument was significantly negatively correlated with ratings of perceived freedom in therapeutic choices and with overall job satisfaction. Reliability was good (alpha = 0.85). Addressing perceived constraints may result in more choice options to reach therapeutic goals in a collaborative framework with patients, and improve job satisfaction.

Sources of stress and burnout in acute psychiatric care: inpatient vs. community staff

BACKGROUND

Professionals who work alone or in small teams often provide services for people with serious mental health problems in community settings. Stress is common in community teams and this may cause burnout and threaten the quality and stability of the services. This study compares levels of burnout and sources of stress among community and acute ward staff in six European centres.

METHODS

A total of 6 acute ward (N = 204) and community staff (N = 209) in 5 different European countries filled out the Maslach Burnout Inventory (MBI), the Mental Health Professional Scale (MHPSS) the Agervold Questionnaire for psychosocial work environment (QPWES) in addition to a comprehensive demographic questionnaire.

RESULTS

In the univariate analyses, except for Emotional Exhaustion (MBI), there were no differences in burnout between the two groups of staff. Community teams reported more organisational problems, higher work demands, less contact with colleagues, but also better social relations and more control over their work. The ward staff was more satisfied with the organisational structure and access to colleagues, but complained about lack of control over operating conditions at work. The multivariate analyses identified four groups of staff: (1) a Control-dissatisfied and Contact satisfied group (N = 184) with 2/3 coming from the wards. (2) A Contact-satisfied and Work-demand dissatisfied group (N = 147) with (3/4) from the community staff. (3) A Control- and Contact dissatisfied group (N = 47) with a majority from community teams, and (4) a Contact- and Work demand satisfied group (N = 37) with a majority from the wards.

CONCLUSION

Burnout as measured was not a serious problem among community and ward staff members, and did not differentiate between the two groups. Acute ward working implied lack of control but much contact with colleagues, whereas community work entailed more control but demanding work in terms of difficult task and hard-to-find-solutions.

Assessing morale in community mental health professionals: a pooled analysis of data from four European countries

BACKGROUND

While there is a need to assess morale in community mental health professionals, it still remains to be determined how to obtain and interpret data in a sound and meaningful way. The aims of the present study were to assess the extent to which levels of morale are sensitive to differences between professional groups and health care systems, and identify factors influencing morale across groups and settings.

METHODS

A literature search of electronic databases was undertaken to identify studies measuring morale in different groups of community mental health professionals. Data was subjected to a pooled analysis. Differences between groups and sites were tested using factorial ANOVA and respective effect sizes were estimated based on Cohen's [1] work.

RESULTS

Data of four studies and a total of 723 professionals (from Austria, Germany, Italy and United Kingdom) were combined in a pooled analysis. Significant differences of morale levels were found between professional groups and study sites, and differences between professional groups varied significantly by study site. Effect sizes estimated for differences between particular groups of different health care systems ranged from small to large. Age was found to be a factor independently associated with morale.

CONCLUSIONS

Staff in community mental health care show substantial differences in morale levels depending on the professional group and context. These differences can often be identified even if in sample sizes of only 30 participants per group. Levels of morale need to be established specifically for different professional groups and context, and age should be controlled as an influential factor. The findings show a discriminant validity of assessment instruments for staff morale in community mental health care, and underline the rationale for such assessments in research and routine care.

Evaluating STORM skills training for managing people at risk of suicide

AIM

This paper reports a study evaluating the Skills Training On Risk Management (STORM) training initiative in three mental health services in the North-West of England, UK.

BACKGROUND

Training for health workers has been widely advocated as a key route to suicide prevention. However, reports of evaluations are scarce in the literature. In previous research, we have demonstrated that the STORM intervention results in acquisition of new skills and can be disseminated in a community setting.

METHOD

The training was delivered during a 6-month period in 2002 by three mental health nurses who were seconded part-time to the project. The quantitative evaluation, which assessed change in attitudes, confidence, acquisition of skills and satisfaction, used a pretest/post-test design, with participants acting as their own controls. Qualitative interviews were conducted with a purposive sample of 16 participants to explore the impact on clinical practice, and with the three trainers at the end of the study.

FINDINGS

Data from 458 staff members were collected during a 6-month period. Positive changes in attitudes and confidence were shown, but previous evidence of skill acquisition was not replicated. Qualitative interviews revealed important insights into changes in clinical practice, particularly for less experienced or unqualified nursing staff, but also concerns about the lack of an educational culture to foster and support such interventions in practice within the organizations.

CONCLUSION

STORM training for the assessment and management of suicide risk is both feasible and acceptable in mental health trusts. However, we remain uncertain of its longer-term impact, given the lack of engagement of senior staff in the enterprise and the absence of linked supervision and support from the organizational management to reinforce skill acquisition and development. We consider that regular supervision that links STORM training to actual clinical experience would be the ideal.

The community psychiatrist of the future

PURPOSE OF REVIEW

The potential contributions of the community psychiatrist are described, via the interdisciplinary team, to individuals and families dealing with mental illness, and to the communities of the future, along with the opportunities for, and barriers to, effective teamwork and community collaborations.

RECENT FINDINGS

Health and medical training systems still provide perverse incentives deterring psychiatrists from becoming adequately trained in community psychiatry and full members of interdisciplinary teams, and skilled partners in improving the mental health of the whole community. Sources of potential role conflict should be resolved, and advantages of community collaborations, interdisciplinary leadership, support of teamwork, division of labour, cross-fertilization and hybrid vigour should be realized.

SUMMARY

Truly essential and desirable roles and the skill base of community psychiatrists in interdisciplinary teams and local communities could be developed and strengthened by changes in basic and advanced psychiatric training, and by psychiatric professional bodies and training programmes placing greater emphasis and value upon the roles of a community psychiatrist.

Challenges to implementing and sustaining comprehensive mental health service programs

The President's New Freedom Commission recently concluded that the nation's mental health service delivery system is ill equipped to meet the complex needs of persons with mental illness. A major contributor to this service quality crisis has been the longstanding divergence of research efforts and clinical programs. In this article, the authors begin by describing the unique needs of persons with serious and persisting psychiatric disorders and the evolution of the mental health service system that has attempted to meet these needs. They then discuss recent efforts to upgrade services by emphasizing the use of evidence-based practices (EBPs) and the research underlying their development. Next, they describe the difficulties of using traditional research methods to develop and test interventions for persons receiving services at public mental health agencies. Finally, they outline the challenges confronted when trying to disseminate these EBPs to the wider clinical community.