Interventions to Prevent and Reduce Burnout Among Undergraduate and Graduate Medical Education Trainees: a Systematic Review

OBJECTIVE

The authors conducted a systematic review of the published literature to identify interventions to prevent and/or reduce burnout among medical students and residents.

METHODS

The authors searched 10 databases (from the start of each through September 21, 2016) using keywords related to burnout, medical education, and prevention. Teams of two authors independently reviewed the search results to select peer-reviewed, English language articles describing educational interventions to prevent and/or reduce burnout among medical students and/or residents that were evaluated using validated burnout measures. They assessed study quality using the Medical Education Research Study Quality Instrument and the Cochrane Risk of Bias Tool.

RESULTS

Fourteen studies met inclusion criteria and all used the Maslach Burnout Inventory as at least one measure of burnout. Four were single group pre-post studies, 6 non-randomized two-group studies, and 4 randomized controlled trials. None of the studies were designed specifically to target burnout prevention. In 12 studies, residents were the targeted learners. Six of the 14 studies reported statistically significant changes in burnout scores: 5 reported improvement and 1 reported worsening of burnout. Of the 5 studies that reported statistically significant benefit, 1 studied a complementary and alternative medicine elective, 1 studied the Respiratory One Meditation method, and 3 studied duty hour changes.

CONCLUSIONS

This review highlights the need for rigorously designed studies in burnout prevention and reduction among residents and especially medical students.

What Is the Impact of Online Training in Mind–Body Skills?

Background.

Mind–body skills (MBS) training is popular, but in-person training can be inconvenient and costly. We assessed the impact of online MBS training on clinicians’ and trainees’ stress, mindfulness, and confidence in providing calm, compassionate care.

Methods.

This was a prospective cohort trial. Trainees entering medical school; graduate programs in nursing, social work, and dietetics; and residencies in family medicine and pediatrics at a large Midwestern academic health center were invited to complete online surveys before and 12 weeks after enrolling in online elective integrative health courses on MBS training or not. The elective offered no course credit and had no mandated deadlines for completion.

Results.

At baseline, the 60 who engaged in MBS training were similar to the 43 who did not in terms of profession, gender, perceived stress levels, mindfulness, resilience, and compassion. MBS participants engaged in a median of 3 of 12 available modules with a bimodal distribution peaking at 1 to 2 and 12 modules. Twelve weeks later, those who participated in MBS showed significantly greater improvements in measures of stress, mindfulness, and confidence in providing calm, compassionate care than those who did not.

Conclusions.

Online elective training offers a feasible strategy to improve mindfulness, stress, and confidence in providing calm, compassionate care. Additional studies are needed to determine the impact of required versus elective courses, the optimal dosage and content of training, and the costs and benefits of online versus in-person training.

Preaching to the choir: comparing health professionals who enroll in mind-body skills versus herbs and dietary supplements training?

BACKGROUND

Observational studies evaluating elective training programs may be biased if learners who enroll differ from nonenrollees. To assess self-selection bias, we compared participants who enrolled in 2 different online courses in complementary and alternative medical therapies.

METHODS

Participants were recruited from entering classes in medicine, nursing, social work, and dietetics, and residencies in family medicine and pediatrics. The 2 electives were (a) herbs and dietary supplements and (b) mind-body skills training. Participants completed standardized questionnaires before training.

RESULTS

The 218 participants had an average age of 28 years; 76% were trainees. There were no significant differences between enrollees in mind-body skills and herbs and dietary supplements with regard to age, gender, stress levels, mind-body training or practice, mindfulness, empathy, compassion, or resilience.

CONCLUSIONS

Those who enroll in mind-body skills are not measurably different than those who enroll in herbs and dietary supplements. There is no evidence of self-selection bias or "preaching to the choir."

Factors associated with well-being and confidence in providing compassionate care

We explored the relationships between potentially modifiable factors (mindfulness and self-compassion), intermediate factors (resilience and stress), and outcomes of interest in a cross-sectional study of medical trainees (compassionate care and clinician well-being). Among the 12 participants, the average age was 27.6 years. Mindfulness and self-compassion were positively associated with confidence in providing calm, compassionate care (r = 0.91 and 0.81, respectively; P < .01); they were also positively correlated with clinician resilience (P < .01), which was correlated with clinician mental health (r = 0.83; P < .01). Perceived stress was strongly and significantly negatively correlated with all measures (rs ranging from -0.62 for flourishing to -0.92 for confidence in delivering calm, compassionate care; P < .05 for all correlations). Given the positive correlations between mindfulness and self-compassion with both clinician well-being and confidence in providing calm, compassionate care, interventional studies are warranted to determine what kind of training most efficiently and effectively improves trainee mindfulness and self-compassion.

Nurses' experiences, expectations, and preferences for mind-body practices to reduce stress

BACKGROUND

Most research on the impact of mind-body training does not ask about participants' baseline experience, expectations, or preferences for training. To better plan participant-centered mind-body intervention trials for nurses to reduce occupational stress, such descriptive information would be valuable.

METHODS

We conducted an anonymous email survey between April and June, 2010 of North American nurses interested in mind-body training to reduce stress. The e-survey included: demographic characteristics, health conditions and stress levels; experiences with mind-body practices; expected health benefits; training preferences; and willingness to participate in future randomized controlled trials.

RESULTS

Of the 342 respondents, 96% were women and 92% were Caucasian. Most (73%) reported one or more health conditions, notably anxiety (49%); back pain (41%); GI problems such as irritable bowel syndrome (34%); or depression (33%). Their median occupational stress level was 4 (0 = none; 5 = extreme stress). Nearly all (99%) reported already using one or more mind-body practices to reduce stress: intercessory prayer (86%), breath-focused meditation (49%), healing or therapeutic touch (39%), yoga/tai chi/qi gong (34%), or mindfulness-based meditation (18%). The greatest expected benefits were for greater spiritual well-being (56%); serenity, calm, or inner peace (54%); better mood (51%); more compassion (50%); or better sleep (42%). Most (65%) wanted additional training; convenience (74% essential or very important), was more important than the program's reputation (49%) or scientific evidence about effectiveness (32%) in program selection. Most (65%) were willing to participate in a randomized trial of mind-body training; among these, most were willing to collect salivary cortisol (60%), or serum biomarkers (53%) to assess the impact of training.

CONCLUSIONS

Most nurses interested in mind-body training already engage in such practices. They have greater expectations about spiritual and emotional than physical benefits, but are willing to participate in studies and to collect biomarker data. Recruitment may depend more on convenience than a program's scientific basis or reputation. Knowledge of participants' baseline experiences, expectations, and preferences helps inform future training and research on mind-body approaches to reduce stress.

Improving the well-being of nursing leaders through healing touch training

INTRODUCTION

Chronic stress adversely affects performance. We evaluated the effect of Healing Touch training on subjective and objective measures of stress in nursing leaders in an academic health center.

MATERIALS AND METHODS

In this quasi-experimental single group pretest-post-test study, we recruited nursing leaders at an academic health center and provided 17.5 hours of Healing Touch training over 2 days. We measured subjective measures of stress using visual analog scales as well as heart rate variability 1-2 weeks before and 4 weeks after the training.

RESULTS

Target enrollment was exceeded within 2 weeks; all participants were women and the mean age was 47 years. Of the 26 enrollees, 24 completed training, and 20 (77%) completed all pre- and post-training measures. There was significant improvement in self-reported stress, depression, anxiety, relaxation, well-being, and sleep. Heart rate variability changes were also significant for total power, high- and low-frequency power, and coherence, suggesting improved autonomic function consistent with greater well-being.

CONCLUSIONS

Training nurse leaders in an academic health center in Healing Touch is associated with significant improvements in subjective and objective measures of stress. Additional studies are needed to compare the impact of this training versus stress management training on the nurses themselves and on the quality of care.