key: cord-0722566-n9fm257q authors: Maghbouli, Nastaran; Fatehi, Farzad; Mafinejad, Mahboobeh Khabaz; Pourhassan, Saeed; Sohrabpour, Amir Ali; Ali, Jemal Haidar title: Burnout and clinical learning environment among residents in Tehran: A cross-sectional study date: 2021-06-08 journal: Heliyon DOI: 10.1016/j.heliyon.2021.e07238 sha: ed1551dc8bb5b6446b4951f433a0a542c3541a5c doc_id: 722566 cord_uid: n9fm257q PURPOSE: This study aimed to evaluate the quality of the educational environment in Tehran University of Medical Sciences across different medical specialties and its correlation with residents’ burnout. MATERIALS AND METHODS: This cross-sectional study was conducted at Tehran University of Medical Sciences among residents drawn from three largest teaching hospitals affiliated. The Maslach Burnout Inventory and Postgraduate Hospital Educational Environment Measure (PHEEM) questionnaire were used to collect data through web-based, as well as paper-and pencil questionnaires. The data was analyzed using SPSS. RESULTS: A total of 221 residents completed the survey, with a response rate of 82%. Burnout was reported by 67.4% of medical residents. The total PHEEM score had a negative correlation with emotional exhaustion (r = - 0.57, P < 0.001), depersonalization (r = - 0.40, P < 0.001), and a positive one with personal accomplishment (r = 0.42, P < 0.001). Perception of social support significantly predicted burnout subscales (P < 0.05). PHEEM subscales also explained a small proportion of variance in emotional exhaustion (R = 0.55, R(2) = 0.308, P < .001). Clinical learning environment independent of personal characteristics was associated with residents' burnout according to multivariate regression analysis [OR = 0.567 (0.170–0.883), P = 0.012]. CONCLUSION: Clinical learning environment independent of personal characteristics was associated with residents' burnout in Iran. We suggest some initiatives to be introduced ranging from improving the clinical environments, reduce workloads and provide social support to all residents as well as encouraging them to involve in other extracurricular activities like music and physical exercise. Residency curricula are designed to ensure that future specialists are well-prepared to deliver high quality care to the patients. Although medical schools hold residency programs to move students toward these goals, some components of the work and learning environment have an unintended and inevitable impact on residents' mental health [1] . Burnout, a psychological phenomenon resulting from emotional exhaustion, depersonalization and diminished sense of accomplishment along with effectiveness that frequently occurring in health care providers related to work stress [2] . Recent studies have demonstrated that a high percentage of medical residents experience severe burnout during their postgraduate medical training [3, 4] . In a survey of Wayne State University residents, on average 50% suffered from burnout ranging from 75% in obstetrics/gynecology to 27% in family medicine [5] . A recent meta-analysis revealed burnout prevalence of 51% among 22,778 residents and confirmed specialties such as neurology, radiology and general surgery with the most burnt-out residents [6] . High prevalence of burnout not only reported among medical residents, but also in other health care providers such as nurses which consequently led to some suggestions on policy changes to improve healthcare quality [7] . In addition to hindering the professional development of residents, burnout may lead to job dissatisfaction, errors in patient care, and impaired job performance [8] . Studies on the causes of burnout in residency training have revealed that time constraints, lack of autonomy, workload compounded by various factors such as future career worrisome among others, are stressors that would cause burnout [9, 10, 11] . This shows that the main factors resulting in burnout within the clinical learning environment, rather than individual characteristics [1, 12] . Other recent studies showed approximately one in three medical students to have anxiety or depression worldwide which is significantly higher than the general population, while case recognition for depression diagnosis and treatment rate was low [13, 14] . Alternatively, in other study focused on Asian undergraduate medical students, depression prevalence of 11% was reported and they concluded that depression in medical schools would lead to burnout [15] . Based on the healthcare priorities, the annual capacity of residency program is nearly 4300 residents in 35 medical universities in Iran. The length of the training programs are similar with other countries and ranging from 3-5 years depending on the types of specialties which is more or less similar most residency programs worldwide though there are some differences. Comparing Iranian residents with Turkish, Canadian, American and Europeans, Iranian residents spend more weekly working hours than Turkish, Canadian and Europeans with less free time for leisure [16, 17] . For example, the duty hours of a 1 st year Iranian internal medicine resident are 92 hr per week, while Canadians and Europeans are 72-84 hr per week. The residency program in Iran includes bed-side rounds and mortality or morning reports as well as lecture-based classes as routine education worldwide. Residents in other countries experience more diverse programs including night float in the American programs and junior attending on clinical teaching unit (CTC) and multidisciplinary clinical teams (MCT) in Canadians [16, 17] . Considering income, the Canadian residents receive the highest yearly income (60,000-74,000 $), while Iranian residents receive 1500-1700 $, one of the least globally. Such huge discrepancies have become an issue and gradually gained momentum to improve the well-being of residents and consequently impact on their work efficiency which led us to investigate the problem contextually and uncover the challenges in our residency trainings is among the significances of this study. Like in elsewhere, we presume our residents are also affected by considerable degrees of burnout due to their responsibilities in teaching hospitals and their unsupported decision-makings [9] and this necessitated our study. This study aimed to evaluate the quality of the educational environment in the tertiary teaching hospitals of Tehran University of Medical Sciences (TUMS) across different medical specialties and its correlation with residents' burnout. Medical school graduates in Iran can apply for residency after achieving adequate scores in the residency entrance exam, which is held annually by the National Center for Evaluation of Medical Education (NCEME). Residency programs for different specialties are applied uniformly for all universities and consists of a three-to-five-year training of major and collateral rotations in specialized hospital wards and divisions as well as clinics and emergency departments according the specialty types. Residency duration for most of specialties are 4 years. For neurosurgery and radio-oncology currently is 5 years, while for pediatrics it is 3 years. 221 medical residents with different specialties participated in this study. Participants included residents of various levels at Tehran University of Medical Sciences' residency programs, ranging from post graduate year (PGY) 1 to PGY4. All specialties were categorized into three subgroups of surgical (general surgery, neurosurgery, gynecology, emergency medicine, otolaryngology, urology and ophthalmology), medical (including internal medicine, neurology, pediatrics, radiooncology and cardiology) and para-clinical (radiology, pathology, and nuclear medicine) [6] . We used the G*Power 3.1.9.7 software to calculate the sample size. A sample of 231 students would be enough The present cross-sectional study was carried out in three main teaching university-affiliated hospitals of Tehran University of Medical Sciences. We distributed questionnaires mostly in December that is far enough from exams and holidays, which could influence results of study. To assess symptoms of burnout among the participants, a Maslach Burnout Inventory (MBI) as well as the Postgraduate Hospital Educational Environment Measure (PHEEM) questionnaire were used to evaluate residents' views towards the clinical environment. To increase response rate, we used both web-based and paper-and-pencil questionnaires. Paper-and-pencil questionnaire was handed out personally to residents by a 6 th year medical student and was collected after few hours. Web-based questionnaires that would expire after 48 hr following two reminders were disseminated among the students. Baseline demographic data including age, gender, and marital status, year of residency training and field of residency were collected from all participants. We used MBI tool which is a self-administered, containing 22 items [18] . Of the 22 items of MBI, 9 of them evaluates emotional exhaustion and the rest five and eight items evaluate depersonalization and personal accomplishments, respectively. Each item's response was rated from 0 to 6 (0 ¼ never; 1 ¼ a few times per year; 2 ¼ once a month; 3 ¼ a few times per month; 4 ¼ once a week; 5 ¼ a few times per week; and 6 ¼ every day). In this study, we considered burnt out of residents as either having emotional exhaustion when the score !27 or depersonalization when the score !13 or personal accomplishment when the score !37. The disaggregates for each dimensions of burnout are listed below; Emotional exhaustion is low when the score is <16, moderate 17-26, high !27 score; Depersonalization is low when the score is 0-6, moderate 7-12, high !13 score; and Personal accomplishment is low when the score is !37, moderate 31-36, high 0-30 score. (8) . The PHEEM questionnaire is a scale to evaluate perception of resident physicians about the quality of educational environment in their hospitals. It has 40 items in three defined subscales consisting of 14 items for perceptions of role autonomy (POR) which includes level of responsibility, tasks, clinical protocols, team working, and practical procedures; 15 items perceptions of teaching (POT) which consists of teachers' expectations, supervision, communication skills, education relevancy, enthusiasm, teaching skills, accessibility, feedback, and encouragement; and 10 items for perceptions of social support (POS) which includes sex discrimination, access to career advice, accommodation quality, environment safety, and counseling opportunities. Item 7 (there is racism in this post) was not applicable as all residents are Iranians of the same racial group [19] . Scores for perceptions of role autonomy are interpreted as the following: 0-14 very poor, 15-28 a negative view of one's role, 29-42 a more positive perception of one's job, 43-56 excellent perception of one's job. Scores for perceptions of teaching are interpreted as: 0-15 very poor quality, 16-30 in need of some retraining, 31-45 moving in the right direction, 46-60 model teachers; and scores for perceptions of social support are interpreted as: 0-11 non-existent, 12-22 not a pleasant place, 23-33 more pros than cons and 34-44 a good supportive environment [20] . Anonymous questionnaires were distributed to all the residents on voluntary basis and were informed that their responses would not influence their educational or practical status in the hospital. Patients or the public were not involved in this study. The protocol of this study was approved by Ethics Committee for research studies of Tehran University of Medical Sciences institutional review board IR.TUMS (97-02-76-32557). After written informed consent was obtained from all participants data were then collected in accordance with relevant guidelines and regulations. This study was also registered to the www.research registry.com (unique identifying code: researchregistry6673). In the next phase of the research, the data was analyzed by SPSS. Kolmogorov-Smirnov test was used to determine whether the PHEEM and MBI total scores were distributed normally or not. Then the Student t test, ANOVA, Pearson correlation coefficient test and linear regression were employed to examine the relationship between PHEEM score (or subscale scores) and gender, marital status, PGY, specialty and MBI score (or subscale scores). Also, we used a multivariate regression analysis for this association by adjusting confounding factors. This manuscript has been reported in line with the STROCSS criteria [21] . The reliability of Persian PHEEM and MBI questionnaire were high with a Cronbach's alpha coefficient of 0.86 and 0.92, respectively. As shown in Figure 1 , of the 270 medical residents who participated, 221 completed both MBI and PHEEM questionnaires with a response rate of 82%. Based on the data from matched pairs analyzed, the mean age was 30.9 AE 4.7 and over half (62.4%), were females and 119 were married (53.9%). Eighty-nine (40.2%) residents were in year 1, 67 (30.3%) in year 2, 44 (19.9%) in year 3, and 21 (9.5%) in year 4 ( Table 1 ). The mean score for perceptions of role autonomy was 39.7 AE 6.7; for perceptions of teaching 43.5 AE 10.7, and for perceptions of social support 29.5 AE 4.9. For total PHEEM score, it was 112.7 AE 20.3. Table 2 represents results of MBI-HSS of sampled population. The proportion of residents that had high score of emotional exhaustion, depersonalization and reduced personal accomplishment was 56.1%, 57.9% and 38.9%, respectively. We used univariate analyses to identify demographic and occupational predictors of burnout. None of the sociodemographic variables including gender (p ¼ 0.51), marital status (p ¼ 0.81), year of residency training (p ¼ 0.31), type of specialty (p ¼ 0.31), and age (p ¼ 0.43) were associated with the level of burnout of the residents. After adjusting for these predictors (gender, specialty, marital status and age) of resident burnout in a multivariate regression analysis, we found an inverse and statistically significant relationship between the PHEEM score and burnout [Odds Ratio: 0.57 (0.17-0.88), p ¼ 0.012]. We found that residents without burnout had significantly higher PHEEM scores (mean AE SD: 126.3 AE 16.7) than residents with burnout (mean AE SD: 106.4 AE 18.6) (95% confidence interval for difference; 14.7-25.0, P < .001). PHEEM score differences between the groups of residents with and without burnout is justifiable by the difference in all the three dimensions of emotional exhaustion, depersonalization and reduced personal accomplishment (Table 3) . Regarding the subscales of the PHEEM, we found that scores of all subscales of perceptions of teaching (POT), perceptions of social support (POS) and perceptions of role autonomy (POR) were significantly higher in residents without burnout compared to those who experienced burnout (Table 4) . Multiple linear regression analysis was used to test if the PHEEM subscales independently predicted burnout in the participants. Accordingly, perceptions of social support significantly predicted emotional exhaustion (Table 5 ). Educational environment, as a modifiable factor can influence medical students' burnout, and contribute to the quality of service for patients in teaching hospitals [11] . In view of this, we assessed the relationship between the perceptions of residents about the educational environment with their burnout contextually and found a relationship between the learning environment and burnout and the predictability of PHEEM subscales for residents' burnout. In this study, the prevalence of burnout among residents was similar with Italians, Dutch and Belgian findings [12, 21, 22] . According to the systematic review done by Low et al, burnout was more prevalent among neurology, radiology and general surgery than psychiatry, oncology and family medicine residents [6] . Such differences however, were not observed when we pooled the results among the various specialty subgroups in our study. Since, we pooled results of some specialties for analysis due to low sample size, this might have masked On the other hand, Tan et al who investigated psychological distress among surgeons in time of COVID-19 was documented that surgeons involved in Head and Neck region surgery to have more psychological distress [23] . Such comparison however was not made since our sample of Head and Neck surgery residents was too limited for interpretation although it is likely. When looked at the COVID-19 pandemicity more burden of clinical work was experienced among internal medicine, infectious diseases and cardiology than specialties such as surgeries and some para-clinical specialties. In the same vein of our study, Chew et al. showed the prevalence of psychological distress among healthcare workers is independent of the burden of COVID-19 cases [24] . In comparing burnout subscale scores, we found significant differences in "personal accomplishment", implying that this huge difference in burnout prevalence is justifiable by a lack of personal accomplishment in Iranian residents. There are several possible explanations for this discrepant result ranging from various factors such as professors with multiple responsibilities, and the crowded environment of educational hospitals which takes the chance of feedback and sense of achievement from residents. Also, the score-oriented culture of the Iranian educational system favors the residents' exam scores to their performance. Long-lasting negative and stressful working environment often lead to depersonalization [25, 26] . In such instances, contact with patients forms cynical attitudes in the patient-physician relationship. To protect against negative experiences in interaction with a patient, the affected person perceives the patient as an object rather than an individual [27] . In our study, however, emotional exhaustion was attributed to insufficient support from seniors and the finding is concordant with West et al findings on the relationship between stressful communications with supervisors and burnout in residents [28] . Other probable attributes for the exhaustion is the nature of the medical training in which case residents are supposed to deliver medical services on top of their training which would lead to exhaustion. A good support team could not only help to reduce stress, but also to improve quality of care [29] . Therefore, stress could be a possible cause of depersonalization and emotional exhaustion in burnout [30] . It is not surprising that residents with a low perception of teaching and social support have achieved high depersonalization and emotional exhaustion scores in our study. Chi square test was used for analysis. As in some other studies [31, 32] and the present study [33, 34] , high scores of role autonomy are correlated with lower burnout. Autonomy is considered essential for personal growth, integration, social development and personal well-being [35, 36] . The feeling by the members of an organization that they are able to make autonomous decisions which would also be potentially supported and trusted by the organization helps create an intrinsic motivation and a sense of belonging to the team [21] . Similarly, insufficient autonomy [31] is associated with burnout in residents and such assertion was underscored by Dyrbye et al. who believed that autonomy is essential for medical students as well as other professions [32, 37] . Another dimension of burnout is Personal accomplishment [38] which is important to improve the residents' role of autonomy and improve supervisory and academic support. This phenomenon would in turn enhance the perceived quality of the learning environment and reduce burnout, and therefore, the responsible organization needs to consider the learning environment together with the personal components. In summary, our findings have some important implications for necessity of developing a support system for residents to receive academic, effective and systemic services from the university. Considering COVID-19 impacts, using internet cognitive behavioral therapy for stressful residents could be a reasonable choice, since its cost-effectiveness and effectiveness in insomnia and eating disorders are approved [39, 40] . In addition to these, revising the assessment system of residents focusing on providing continuous feedback opportunities throughout the course to increase their performance is very essential. Equally important action points are to hold workshops for faculty members in order to communicate effectively with residents, and implementing empowerment courses on time management, well-being, balance between professional and personal life to improve learning environment in relation with burnout. Thus, generalizability of our findings for other same context in Iran is one of the strengths of this study even though confronted with some limitations like measurement issues. Perhaps trainee-related burnout risk changes with demands of differing rotations. Therefore, we tried to administer the questionnaires in off-peak period of major exams. Most of the normative data were made up of teachers and social service workers. Although Maslach et al. suggest that participants, due to the potential over-sensitization to the concept of burnout, should not be informed that the instrument is meant to measure burnout, we introduced questionnaire subject at the beginning of the form according to ethical codes for research. Moreover, because of our study's goal (relationship between burnout and satisfaction with educational environment) and the limited number of available residents in a hospital, we had to use different hospitals for data collection; therefore, educational environment and burnout were affected by different hospitals. We also faced some problems like accessing final-year residents because of their limited availability in the clinical wards due to national board exam preparations. Although we found perceptions of social support significantly predicted emotional exhaustion, R 2 was less than 0.5 and weak. Nearly two in three residents had burnout and this figure is relatively high compared with other studies. Following the observed relationship between the learning environment and burnout in teaching hospitals and the predictability of PHEEM subscales for residents' burnout, we suggest innovative initiatives ranging from improving the clinical environments, reduce workloads and provide social support to all residents as well as encouraging them to involve in other extracurricular activities like listening to music and physical exercises to reduce burnout. These findings may have implications for the design of educational interventions in residency programs to promote the well-being of residents. Perceptions of role autonomy (POR); Perceptions of teaching (POT); and Perceptions of social support (POS). Independent T test was used for analysis. interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data will be made available on request. The authors declare no conflict of interest. No additional information is available for this paper. A narrative review on burnout experienced by medical students and residents Factors associated with burnout among residents in a developing country Burnout in medical students before residency: a systematic review and meta-analysis Burnout among medical students in Cyprus: a cross-sectional study Burnout comparison among residents in different medical specialties Prevalence of burnout in medical and surgical residents: a meta-analysis Global prevalence of burnout symptoms among nurses: a systematic review and meta-analysis Burnout in European family doctors: the EGPRN study Burnout during residency training: a literature review Prevalence and causes of burnout amongst oncology residents: a comprehensive nationwide cross-sectional study Factors associated with burnout during emergency medicine residency The learning environment and resident burnout: a National Study The global prevalence of anxiety among medical students: a meta-analysis Prevalence of depression amongst medical students: a meta-analysis Mental health issues amongst medical students in Asia: a systematic review Assessment of otolaryngology residency training program in Iran: perspectives of faculty members and recently graduated medical students Internal medicine residency program in Iran: exclusive features and an international comparison Examining and adapting the psychometric properties of the Maslach burnout inventory-health services survey (MBI-HSS) among healthcare professionals Validating modified PHEEM questionnaire for measuring educational environment in academic emergency departments Development and validation of an instrument to measure the postgraduate clinical learning and teaching educational environment for hospital-based junior doctors in the UK Correlation between the educational environment and burn-out syndrome in residency programs at a university hospital Resident burnout: evaluating the role of the learning environment Psychological health of surgeons in a time of COVID-19: a global survey Asian-Pacific perspective on the psychological well-being of healthcare workers during the evolution of the COVID-19 pandemic Burnout, depression and depersonalisation-Psychological factors and coping strategies in dental and medical students The epidemiology of depersonalisation and derealisation Depersonalization in a nonclinical population Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents Burnout in medical residents: a study based on the job demands-resources model Stress, burnout, and associated risk factors in medical students Burnout in residents of otolaryngology-head and neck surgery: a national inquiry into the health of residency training Self-determination theory and work motivation Stress, burnout and coping strategies in preclinical medical students Correlation between the educational environment and the burn-out syndrome in Uruguayan Medical Students residency programs Autonomy And Work-Life Balance and Their Effects on Job Satisfaction Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being Medical student distress: causes, consequences, and proposed solutions Factorial structure and psychometric properties of the Maslach Burnout Inventory (MBI) in Greek midwives The efficacy of virtual reality in the treatment of binge-purging eating disorders: a meta-analysis Efficacy of digital cognitive behavioural therapy for insomnia: a meta-analysis of randomised controlled trials We extend our gratitude to all participants for their frank and honest contribution.