key: cord-0893581-rvryiuwj authors: Zhang, Xiu-jie; Song, Yingqian; Jiang, Tongtong; Ding, Ning; Shi, Tie-ying title: Interventions to reduce burnout of physicians and nurses: An overview of systematic reviews and meta-analyses date: 2020-06-26 journal: Medicine (Baltimore) DOI: 10.1097/md.0000000000020992 sha: d7fe15c5d1b2c50f714e7322e707ebea2a4f7d8f doc_id: 893581 cord_uid: rvryiuwj OBJECTIVE: Numerous systematic reviews and meta-analyses on the interventions to reduce burnout of physicians and nurses have been published nowadays. This study aimed to summarize the evidence and clarify a bundled strategy to reduce burnout of physicians and nurses. METHODS: Researches have been conducted within Cochrane Library, PubMed, Ovid, Scopus, EBSCO, and CINAHL published from inception to 2019. In addition, a manual search for relevant articles was also conducted using Google Scholar and ancestral searches through the reference lists from articles included in the final review. Two reviewers independently selected and assessed, and any disagreements were resolved through a larger team discussion. A data extraction spreadsheet was developed and initially piloted in 3 randomly selected studies. Data from each study were extracted independently using a pre-standardized data abstraction form. The the Risk of Bias in Systematic reviews and assessment of multiple systematic reviews (AMSTAR) 2 tool were used to evaluate risk of bias and quality of included articles. RESULTS: A total of 22 studies published from 2014 to 2019 were eligible for analysis. Previous studies have examined burnout among physicians (n = 9), nurses (n = 6) and healthcare providers (n = 7). The MBI was used by majority of studies to assess burnout. The included studies evaluated a wide range of interventions, individual-focused (emotion regulation, self-care workshop, yoga, massage, mindfulness, meditation, stress management skills and communication skills training), structural or organizational (workload or schedule-rotation, stress management training program, group face-to-face delivery, teamwork/transitions, Balint training, debriefing sessions and a focus group) and combine interventions (snoezelen, stress management and resiliency training, stress management workshop and improving interaction with colleagues through personal training). Based on the Risk of Bias in Systematic reviews and AMSTAR 2 criteria, the risk of bias and methodological quality included studies was from moderate to high. CONCLUSIONS: Burnout is a complicated problem and should be dealt with by using bundled strategy. The existing overview clarified evidence to reduce burnout of physicians and nurses, which provided a basis for health policy makers or clinical managers to design simple and feasible strategies to reduce the burnout of physicians and nurses, and to ensure clinical safety. Burnout refers to a prolonged response to chronic emotional and interpersonal stressors caused by work, manifested as emotional exhaustion, depersonalization, and reduced personal accomplishment. [1] Burnout prevalence data were extracted from 182 studies involving 109628 physicians in 45 countries, where overall prevalence ranged from 0% to 80.5%, emotional The current overview for systematic reviews (SRs) and metaanalyses was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria and exclusion were seen in Table 1 . Databases including Cochrane Library, PubMed, Ovid, Scopus, EBSCO and CINAHL database were chosen and searched for publications from inception to December 2019 with no restriction on language, which covered a wide range of subjects including medicine, psychosociology and nursing. In addition, a manual search for relevant articles was also conducted using Google Scholar and ancestral searches through the reference lists of articles included in the final review. The search strategy included combinations of 3 key blocks of terms (burnout; physicians and nurses; interventions) using medical subject headings (MESH terms) and text words. Consultation has been conducted between the project team and information specialists before finalizing the search strategy (see Additional file 1). Search results were exported from Endnote X7 and duplicates were removed. Study selection was completed in 2 stages. Titles and abstracts of the studies were screened and subsequently full texts of the selected studies were accessed and further screened against the eligibility criteria. The title and abstract screening were undertaken by XJ. Z and YQ. S. Two reviewers independently selected and evaluated, and any disagreements were resolved through a larger team discussion. A data extraction spreadsheet was developed and initially piloted in 3 randomly selected studies. Following data were retrieved from articles included in this review: study characteristics (eg, first author, year of publication, country, search period, and number of primary studies included), participant characteristics (eg, sample size), outcome measures (eg, MBI, JSS, PSS, ESS, BP and HR), and study methods (eg, interventions in experimental/ control groups). Data from each study were extracted independently using a pre-standardized data abstraction form. The Risk of Bias in Systematic reviews (ROBIS) and AMSTAR 2 scale were used to evaluate risk of bias (RoB) and methodological quality of the included systematic reviews and/or meta-analyses, which were evaluated independently by 2 authors. The ROBIS [25] is a tool to assess RoB of SRs which comprised phase 2 (4 domains) and phase 3. Four domains in phase 2 are study eligibility criteria, identification and selection of studies, data collection and study appraisal, and synthesis and findings. The results of each domain and phase 3 were rated as high risk, low risk, or unclear risk. The AMSTAR 2 [26] includes 16 items and is not designed to generate an overall 'score'. A high score may disguise critical weaknesses in specific domains, such as an inadequate literature search or a failure to assess RoB within individual studies that were included in a systematic review. In making an overall rating of systematic review, it is important to take account of flaws in critical domains, which may greatly weaken the confidence that can be placed in a systematic review. Ethics approval is not required in overview of SRs and metaanalyses. The search strategy yielded 841 potential studies. After removing duplications (n = 334) and eliminating 486 by a first pass through the titles and abstracts, the potentially relevant literature was screened in 2 rounds and resulted in 22 studies from 2014 to 2019 (Fig. 1 ). [15, 16, [18] [19] [20] [21] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] The included researchers are from the USA (n = 7), UK (n = 4), Australia (n = 3), China (n = 2), Italy (n = 2), Germany, Iran, Finland and Malaysia. The search period of included research was from the inception to 2019. The 38.10% included research were meta-analyzed. The measurement instruments used in the literature are shown in Table 2 , and MBI is the most widely used questionnaire to evaluate burnout. Follow-up time ranged from 0 to 7 years. The detailed characteristics of the included research are presented in Table 2 . The RoB of the included studies was assessed by ROBIS. Table 3 presents the results of assessment. The first domain aims to assess Table 2 Characteristics of the included systematic reviews/ meta-analysis on the use of interventions for reducing burnout of physicians and nurses. Author Transitions: Data-guided interventions a nd systematic improvement processes that included (1) leadership valuing physician well-being equal to quality of care and financial stewardship, (2) physicians identifying factors that influenced well-being, followed by plans for improvement with accountability, and (3) whether primary study eligibility criteria were prespecified, clear, and appropriate to the review question. [25] 12 out of 22 studies were rated low risk and 3 were unclear risk. The second domain aims to assess whether any primary studies that would have met the inclusion criteria were not included in the review. 8 out of 22 studies were rated low risk. The third domain aims to assess whether bias may have been introduced through the data collection or risk of bias assessment processes. 17 studies were of low risk while 5 studies were graded as high risk. The fourth domain aimed to assess whether the data was combined from the included primary studies. Only 8 studies rated low risk of bias. The final phase considers whether the systematic review as a whole is at risk of bias, 14 studies were rated high risk and 8 were low. The quality of included studies was assessed by AMSTAR 2 (Table 4) , which is not designed to generate an overall 'score' to avoid disguising critical weaknesses in specific domains, such as an inadequate literature search or are a failure to assess risk of bias with individual studies that were included in an overview. [26] 12 of the 16 items were reported over 60% of compliance, which were as followed: the research questions and inclusion criteria for the review include the components of PICO (item 1); explain their selection of the study designs for inclusion in the review (item 3); use a comprehensive literature search strategy (item 4); perform study selection in duplicate (item 5); perform data extraction in duplicate (item 6); provide a list of excluded studies and justify the exclusions (item 7); describe the included studies in adequate detail (item 8); use a satisfactory technique for assessing the RoS in individual studies that were included in the review (item 9); account for RoB in individual studies when interpreting/ discussing the results of the review (item 13); provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review (item 14); carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review (item 15) and report any potential sources of conflict of interest, including any Table 3 Risk of bias of included systematic reviews/ meta-analysis. Zhang et al. Medicine (2020) 99:26 Medicine Table 4 Quality assessment (AMSTAR 2) of included systematic reviews/ meta-analysis. 1. Did the research questions and inclusion criteria for the review include the components of PICO? Did the report of the review contain an explicit statement that the review methods were established prior to conduct of the review and did the report justify any significant deviations from the protocol? . Did the review authors use a comprehensive literature search strategy? Did the review authors perform study selection in duplicate? Did the review authors perform data extraction in duplicate? Did the review authors provide a list of excluded studies and justify the exclusions? Did the review authors describe the included studies in adequate detail? . Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review? funding they received for conducting the review (item 16). 4 items with compliance lower than 40% were the main reporting limitations to be blamed: contain an explicit statement that the review methods were established prior to conduct of the review and did the report justify any significant deviations from the protocol (item 2, 27.27%); report on the sources of funding for the studies included in the review (item 10, 0.00%); use appropriate methods for statistical combination of results (item 11, 36.36%); and assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis (item 12, 36.36%). As a whole, the methodological quality and quality of included studies was from moderate to high. Previous studies have reported on the content, intensity, form, evaluation, and timepoint of follow-up of interventions to reduce the burnout of physician and nurses ( Table 2 ). There were three types of interventions: individual-focused, structural or organizational, and combine interventions. Emotion regulation was an important psychological variable, which associated with burnout. The self-regulatory or emotion regulation skills such as mindfulness was used to reduce the doctors' burnout. [28] Individual-focused interventions included self-care workshops, [19, 31, 40] stress management skills [31, 37, 39, 42] and communication skills training. [19, 20, 42] Other interventions such as yoga, [16, 32, 33] massage, [15] mindfulness [16, 18, 20, 31, 37, 39, 42] and meditation [16, 19, 35, 40] have been reported. Structural or organizational interventions included workload or schedule-rotation, [19, 31] stress management training program, [27] group face-to-face delivery, [19, 27, 31] teamwork/transitions, [30, 42] Balint training, [20, 40] debriefing sessions and a focus group. [19, 20, 31] Team-based primary care redesign, "Primary Care 2.0", with the goal of addressing the Quadruple Aim of health care (ie, the Triple Aim plus reducing workforce burnout) with the following components: (1) an expanded "care coordinator" role for medical assistants including scribing, population health management, and between-visit care management, (2) health coaching and motivational interviewing, (3) "lean" quality improvement to support a Learning Health System, (4) telehealth, (5) protected physician time for care coordination, and (6) an onsite extended interdisciplinary care team (ie, mental health, pharmacy, physical therapy). [30] Combine individual-focused and structural or organizational interventions included Snoezelen, [21] stress management and resiliency training, [34] stress management workshops [18, 20] and improving interaction with colleagues through personal training. [34] Training and follow-up were conducted by face-toface, [27, 31] phone, [20, 31, 35] e-mail, [27] video [20, 31] or online, [18, 20] and the timepoint of follow-up ranged from 0 to 7 years (Table 2 ). The purpose of this study was to summarize the evidence and clarify a bundled strategy to reduce burnout of physicians and nurses. According to ROBIS, 12 research were in low risk in domain 1, 8 in domain 2, 17 in domain 3, and 8 in phase 3. By using AMSTAR 2 to assess the methodological quality and Burnout Wellness Physician + Nurse Resilience quality of included research, most of those were considered as relatively good quality. Burnout of physicians and nurses has become a global public health problem. This overview analyzed the contents of 22 papers with results that physician-directed interventions are associated with small reductions in symptoms of common mental health disorders among physicians. Organizational interventions that ignore individual factors cannot really reducing burnout of physicians and nurses. Therefore, based on theories and studies, when physicians and nurses face stressors caused by work, they will make different coping strategies. [43] Coping refers to the "cognitive and behavioral efforts to manage specific external and/ or internal demands that are appraised as taxing or exceeding the resources of the person". [44] Emotional intelligence theory suggests that emotion regulation skills facilitate the maintenance of appropriate emotions, reducing or adapting undesirable emotions in oneself and others. [28] Physicians and nurses constantly alternate between exhaustion and happiness, Resilience is the bridge from burnout to wellness. [45, 46] Based on previous theories and studies, physicians and nurses experience a dynamic change between burnout and wellness. If positive intervention strategies can be adopted to enhance resilience, the incidence of burnout of physicians and nurses is greatly reduced and the wellness improved (Fig. 2 ). This research included studies in different settings, which brought to light the range of interventions, which could provide the direction for further research. The current overview clarified evidence to reduce burnout of physicians and nurses, which provide a basis for health policy makers or clinical managers to design simple and feasible strategies to reduce the burnout of physicians and nurses, and to ensure clinical safety. Considering partial databases selected and gray literature not included, the results are used only as an overview of the field. This overview has included 22 systematic reviews and metaanalyses to summarize the relevant studies of interventions to reduce the burnout of physicians and nurses and form an evidence resource, which provides reliable evidence support for further intervention. It is an urgent need to implement and evaluate the long-term effect of bundle strategy. XJZ, YQS and TYS designed, performed and analyzed the research. XJZ, YQS, TYS and TTJ advised on article inclusion and exclusion. XJZ and ND designed the Tables. XJZ, YQS and TTJ wrote the manuscript. XJZ, YQS, TTJ, ND and TYS read and revised the manuscript. All authors read and approved the final manuscript. 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If meta-analysis was performed did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?