A Survey Evaluating Burnout, Health Status, Depression, Reported Alcohol and Substance Use, and Social Support of Anesthesiologists Steve Alan Hyman, MD,* Matthew S. Shotwell, PhD,† Damon R. Michaels, MMHC, BS,* Xue Han, MPH, MS,‡ Elizabeth Borg Card, MSN, APN, FNP-BC, CPAN, CCRP,§ Jennifer L. Morse, MS,† and Matthew B. Weinger, MD*‖¶# BACKGROUND: Burnout affects all medical specialists, and concern about it has become common in today’s health care environment. The gold standard of burnout measurement in health care professionals is the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), which measures emotional exhaustion, depersonalization (DP), and personal accomplishment. Besides affecting work quality, burnout is thought to affect health problems, mental health issues, and substance use negatively, although confirmatory data are lacking. This study evaluates some of these effects. METHODS: In 2011, the American Society of Anesthesiologists and the journal Anesthesiology cosponsored a webinar on burnout. As part of the webinar experience, we included access to a survey using MBI-HSS, 12-item Short Form Health Survey (SF-12), Social Support and Personal Coping (SSPC-14) survey, and substance use questions. Results were summarized using sample statistics, including mean, standard deviation, count, proportion, and 95% confidence intervals. Adjusted linear regression methods examined associations between burnout and substance use, SF-12, SSPC-14, and respondent demographics. RESULTS: Two hundred twenty-one respondents began the survey, and 170 (76.9%) completed all questions. There were 266 registrants total (31 registrants for the live webinar and 235 for the archive event), yielding an 83% response rate. Among respondents providing job titles, 206 (98.6%) were physicians and 2 (0.96%) were registered nurses. The frequency of high-risk responses ranged from 26% to 59% across the 3 MBI-HSS categories, but only about 15% had unfavorable scores in all 3. Mean mental composite score of the SF-12 was 1 standard deviation below normative values and was significantly associated with all MBI-HSS components. With SSPC-14, respondents scored better in work satisfaction and professional support than in personal support and workload. Males scored worse on DP and personal accomplishment and, relative to attending physicians, residents scored worse on DP. There was no significant association between MBI-HSS and substance use. CONCLUSIONS: Many anesthesiologists exhibit some high-risk burnout characteristics, and these are associated with lower mental health scores. Personal and professional support were associated with less emotional exhaustion, but overall burnout scores were associated with work satisfaction and professional support. Respondents were generally economically satisfied but also felt less in control at work and that their job kept them from friends and family. The association between burnout and substance use may not be as strong as previously believed. Additional work, perhaps with other survey instruments, is needed to confirm our results. (Anesth Analg 2017;XXX:00–00)
From the Departments of *Anesthesiology and †Biostatistics, Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville, Tennessee; ‡Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington; §Department of Nursing Research, Vanderbilt Nursing, Vanderbilt University Medical Center, Nashville, Tennessee; Departments of ‖Biomedical Informatics and ¶Medical Education, Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville, Tennessee; and #Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee. Accepted for publication May 9, 2017.
Funding: Vanderbilt Institute for Clinical and Translational Research (VICTR, #VR8248). The authors declare no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Steve Alan Hyman, MD, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Dr, Nashville, TN 37205. Address e-mail to [email protected]. Copyright © 2017 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000002298
T
he term “burnout” has come into common parlance in this day of economic unrest and job uncertainty. Since its coinage in the 1970s by Herbert Freudenberger,1,2 burnout has come to represent the negative result of worklife imbalance, high stress, job disengagement, and job dissatisfaction. Although Freudenberger was originally describing the plight of child mental health workers in free clinics in New York City, the phenomenon of burnout has been recognized and extensively studied in airline workers3–6 and in health care workers. Burnout is not an isolated entity; it does not exist in a vacuum and probably modulates (and is modulated by) other factors in each burned-out person. The potential for burnout exists in everyone, but the same interactions between personal characteristics and situational characteristics that might lead to burnout in some people might leave others unaffected. Dr Christina Maslach,7,8 a social scientist and leading researcher on burnout, describes burnout as “an individual experience that is specific to the work context.”
XXX 2017 • Volume XXX • Number XXX www.anesthesia-analgesia.org 1
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Burnout, Social Support, and Substance Abuse
Careful consideration of Dr Maslach’s description of burnout leads to more questions. Is there an explanation for the individual differences in burnout? Are there differences in the coping abilities of individuals? Are there differences in social situations that alter one’s abilities to adapt to work stresses? Are there mental or physical processes that influence coping abilities? Do burned-out people tend to use or abuse controlled substances more? Physicians, nurses, and other health care workers are not immune to the woes of burnout, health issues, social ills, or substance abuse. Numerous articles describe burnout in medical specialists,9–12 and there are reported associations with physical and mental health problems,13 social issues,14 and substance use.15,16 However, there are no firm data confirming such relationships. For about 30 years, the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) has been the most commonly used tool in quantifying burnout risk in health-related fields.7 Subjects answer 22 questions and from the results are calculated 3 aspects of burnout: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). EE occurs when an individual becomes so stressed and psychologically depleted that he or she does not have the personal capacity to respond to a client’s needs. DP refers to a situation where the provider has a cynical dehumanizing approach to patients. PA refers to a personal sense of the value of one’s work.7,8 In a previous study,17 we used MBI-HSS to study burnout in a group of volunteers, including resident physicians, attending physicians, nurses, nurse anesthetists, and nonlicensed personnel at a single academic medical center. In addition to studying burnout, we were interested in how work and home environments affected its development. Therefore, we developed the Social Support and Personal Coping (SSPC) survey. The SSPC survey probes such areas as health, personal and professional support, work satisfaction, and outside activities. Both instruments were included in a single anonymous survey. Results showed that physicians (particularly residents) are more prone to burnout than are nurses and that health concerns, personal support, and workload have a more deleterious effect on residents than on attending physicians or nurse anesthetists. In 2011, we participated in a webinar on the subject of burnout cosponsored by the American Society of Anesthesiologists (ASA) and the journal Anesthesiology. As part of the webinar experience, we were asked to administer our burnout survey to attendees. We planned to assess burnout risk, social support, and coping skills and to test the hypothesis that burnout is associated with physical health issues, mental health issues, and substance abuse. We enhanced the previous survey questions with the addition of the 12-item Short Form Health Survey (SF-12) and the National Institute on Drug Abuse Modified Alcohol, Smoking, and Substance Involvement Screening Test (NM ASSIST). This was done to test the relationships of burnout risk with mental health, physical health, and substance use. The SF-12 has a long history18 and allows physical and mental health to be estimated from a series of 12 simple questions. The NM ASSIST is a tool used by physicians primarily to help identify which of their patients might be at risk for substance abuse. We present here the results of our ASA webinar project.
2 www.anesthesia-analgesia.org
METHODS Using an electronic survey of at least 60 questions, we addressed the magnitude of burnout risk, physical health problems, mental health problems, social support, and substance use among a sample of webinar participants. The number of survey questions varied because we used branching logic to eliminate questions that were not applicable to an individual participant or to add questions that were applicable to an individual participant. The survey included the 22-question MBI-HSS,7 the SF-12,18 26 questions that focused on the availability and impact of social support systems and coping strategies and approximately 8 (depending on branching logic) focusing on substance use. The SF-12 and the substance use questions were the only additions to our previous survey instrument.17 The Institutional Review Board Behavioral Sciences Committee at Vanderbilt University approved the study. To minimize potential bias, potential participants were not informed of the specific purpose of the study. The act of completing and submitting the web-based questionnaire implied consent. Given the intimate nature of some of the questions and the potential revelation of undesirable behaviors, it was important that individual participants not be identifiable. To assure complete anonymity, we did not ask any identifying questions. This article adheres to the applicable EQUATOR (Enhancing the Quality and Transparency of Health Research) guidelines.
Survey Distribution Although ASA membership was not mandatory, potential webinar participants had to be registered on the ASA website to receive information regarding the webinar and survey. The ASA did all recruitment for the webinar, and beyond the initial invitation there were no additional recruitment efforts (eg, sequential invitations17,19). Once enrolled in the webinar, participants had the opportunity to complete the survey as part of their webinar experience and received a link to the survey hosted by Vanderbilt’s REDCap (Research Electronic Data Capture)20 server application. Survey questions are listed in Supplemental Digital Content 1, Appendix 1, http://links. lww.com/AA/B871.
Survey Questions Maslach Burnout Inventory-Human Services Survey (MBIHSS). The MBI-HSS8 has become the gold standard to assess burnout in health-related fields. As noted previously, it evaluates the 3 aspects of burnout—EE, DP, and PA. MBIHSS consists of 22 questions, of which 9 evaluate EE, 5 evaluate DP, and 8 evaluate PA. Subjects give their answers with a 7-point Likert scale (encoded using the integers 0–6). The composite scores for the 3 aspects of burnout were computed by averaging the scores for the corresponding questions. We report PA as “LPA” (lack of personal accomplishment—the inverse of PA) so all 3 aspects of burnout get scored in the same direction, that is, greater values indicate greater risk of burnout. Physical Health/Mental Health (SF-12). The SF-12 is a validated subset of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)18,21 used to assess
ANESTHESIA & ANALGESIA
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
physical and mental status when a lower response burden is desired. The SF-12, which can be completed in 2 minutes or less, has been used extensively to evaluate health-related quality of life issues,22 work-related stress,23 and response to disease24 in a variety of professions (including medical) and in patients. From the 12 questions, physical (PCS) and mental (MCS) composite scores are calculated, with scores ranging from 0 (worst health state) to 100 (best health state). Composite scores are compared to national norms such that positive differences indicate a better health status and negative differences a worse health status. Controls are not matched controls, but since values can change over a lifetime, age-specific controls are available. Social Support and Personal Coping (SSPC-14). The Social Support and Personal Coping (SSPC-25) survey, developed and used in our prior work,17 is intended to elucidate an individual’s coping strategies and social support system. With the addition of the SF-12 to the present survey, we eliminated the 11 health and wellness questions to create the SSPC-14 survey. These remaining 14 questions fall into 4 natural groupings—work satisfaction, workload and control, professional support, and personal support. Each question is scored with a 9-point scoring system where, for most questions, a higher score represents better coping/ support. Tobacco, Alcohol, and Cannabis Use. Starting with the established NM ASSIST tool,25 we refined a list of 22 short questions to focus specifically on the use of tobacco, alcohol, and cannabis and their impact on respondents’ lives and work. There were no questions about legitimate prescription medicines or substances that might be available in the workplace. The questions included 3 response timescales: use in the last year, use in the last 5 years, and lifetime use. The option of “prefer not to answer” was also included. This tool can be completed quickly for initial assessment of substance use.
Honesty Survey During the process of data analysis, we were concerned that survey participants would not answer substance abuse questions with the same honesty as the other questions. Even among our own research group, we were concerned that such sensitive questions would not garner the same honesty as less sensitive ones. In light of this, we sent a short institutional review board–approved questionnaire (see Supplemental Digital Content 2, Appendix 2, http:// links.lww.com/AA/B872) to the perioperative service at our hospital. This included all physicians and nurses that work in the surgical flow loop (preoperative holding, operating room, and postanesthesia care unit). While these are not the same people who participated in the webinar, they do represent a large community of nurses and doctors who work in a very busy surgical unit in a large hospital where stress and burnout are not unknown.
Statistical Analysis Respondent characteristics were summarized using sample statistics, including the mean, standard deviation, count, proportion, and 95% confidence intervals,
as appropriate. When comparing estimates to published control values, statistical significance was indicated when the 95% confidence interval for the estimated quantity failed to include the published quantity. Adjusted linear regression methods were used to test the associations between each aspect of burnout and reported substance use, components of the SF-12 and the SSPC14, and respondent demographics. Graphical residual diagnostics were used to assess the validity of regression assumptions. Ninety-five percent confidence intervals and P values were used to summarize the results of regression. P values
From the Departments of *Anesthesiology and †Biostatistics, Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville, Tennessee; ‡Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington; §Department of Nursing Research, Vanderbilt Nursing, Vanderbilt University Medical Center, Nashville, Tennessee; Departments of ‖Biomedical Informatics and ¶Medical Education, Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville, Tennessee; and #Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee. Accepted for publication May 9, 2017.
Funding: Vanderbilt Institute for Clinical and Translational Research (VICTR, #VR8248). The authors declare no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Steve Alan Hyman, MD, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Dr, Nashville, TN 37205. Address e-mail to [email protected]. Copyright © 2017 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000002298
T
he term “burnout” has come into common parlance in this day of economic unrest and job uncertainty. Since its coinage in the 1970s by Herbert Freudenberger,1,2 burnout has come to represent the negative result of worklife imbalance, high stress, job disengagement, and job dissatisfaction. Although Freudenberger was originally describing the plight of child mental health workers in free clinics in New York City, the phenomenon of burnout has been recognized and extensively studied in airline workers3–6 and in health care workers. Burnout is not an isolated entity; it does not exist in a vacuum and probably modulates (and is modulated by) other factors in each burned-out person. The potential for burnout exists in everyone, but the same interactions between personal characteristics and situational characteristics that might lead to burnout in some people might leave others unaffected. Dr Christina Maslach,7,8 a social scientist and leading researcher on burnout, describes burnout as “an individual experience that is specific to the work context.”
XXX 2017 • Volume XXX • Number XXX www.anesthesia-analgesia.org 1
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Burnout, Social Support, and Substance Abuse
Careful consideration of Dr Maslach’s description of burnout leads to more questions. Is there an explanation for the individual differences in burnout? Are there differences in the coping abilities of individuals? Are there differences in social situations that alter one’s abilities to adapt to work stresses? Are there mental or physical processes that influence coping abilities? Do burned-out people tend to use or abuse controlled substances more? Physicians, nurses, and other health care workers are not immune to the woes of burnout, health issues, social ills, or substance abuse. Numerous articles describe burnout in medical specialists,9–12 and there are reported associations with physical and mental health problems,13 social issues,14 and substance use.15,16 However, there are no firm data confirming such relationships. For about 30 years, the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) has been the most commonly used tool in quantifying burnout risk in health-related fields.7 Subjects answer 22 questions and from the results are calculated 3 aspects of burnout: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). EE occurs when an individual becomes so stressed and psychologically depleted that he or she does not have the personal capacity to respond to a client’s needs. DP refers to a situation where the provider has a cynical dehumanizing approach to patients. PA refers to a personal sense of the value of one’s work.7,8 In a previous study,17 we used MBI-HSS to study burnout in a group of volunteers, including resident physicians, attending physicians, nurses, nurse anesthetists, and nonlicensed personnel at a single academic medical center. In addition to studying burnout, we were interested in how work and home environments affected its development. Therefore, we developed the Social Support and Personal Coping (SSPC) survey. The SSPC survey probes such areas as health, personal and professional support, work satisfaction, and outside activities. Both instruments were included in a single anonymous survey. Results showed that physicians (particularly residents) are more prone to burnout than are nurses and that health concerns, personal support, and workload have a more deleterious effect on residents than on attending physicians or nurse anesthetists. In 2011, we participated in a webinar on the subject of burnout cosponsored by the American Society of Anesthesiologists (ASA) and the journal Anesthesiology. As part of the webinar experience, we were asked to administer our burnout survey to attendees. We planned to assess burnout risk, social support, and coping skills and to test the hypothesis that burnout is associated with physical health issues, mental health issues, and substance abuse. We enhanced the previous survey questions with the addition of the 12-item Short Form Health Survey (SF-12) and the National Institute on Drug Abuse Modified Alcohol, Smoking, and Substance Involvement Screening Test (NM ASSIST). This was done to test the relationships of burnout risk with mental health, physical health, and substance use. The SF-12 has a long history18 and allows physical and mental health to be estimated from a series of 12 simple questions. The NM ASSIST is a tool used by physicians primarily to help identify which of their patients might be at risk for substance abuse. We present here the results of our ASA webinar project.
2 www.anesthesia-analgesia.org
METHODS Using an electronic survey of at least 60 questions, we addressed the magnitude of burnout risk, physical health problems, mental health problems, social support, and substance use among a sample of webinar participants. The number of survey questions varied because we used branching logic to eliminate questions that were not applicable to an individual participant or to add questions that were applicable to an individual participant. The survey included the 22-question MBI-HSS,7 the SF-12,18 26 questions that focused on the availability and impact of social support systems and coping strategies and approximately 8 (depending on branching logic) focusing on substance use. The SF-12 and the substance use questions were the only additions to our previous survey instrument.17 The Institutional Review Board Behavioral Sciences Committee at Vanderbilt University approved the study. To minimize potential bias, potential participants were not informed of the specific purpose of the study. The act of completing and submitting the web-based questionnaire implied consent. Given the intimate nature of some of the questions and the potential revelation of undesirable behaviors, it was important that individual participants not be identifiable. To assure complete anonymity, we did not ask any identifying questions. This article adheres to the applicable EQUATOR (Enhancing the Quality and Transparency of Health Research) guidelines.
Survey Distribution Although ASA membership was not mandatory, potential webinar participants had to be registered on the ASA website to receive information regarding the webinar and survey. The ASA did all recruitment for the webinar, and beyond the initial invitation there were no additional recruitment efforts (eg, sequential invitations17,19). Once enrolled in the webinar, participants had the opportunity to complete the survey as part of their webinar experience and received a link to the survey hosted by Vanderbilt’s REDCap (Research Electronic Data Capture)20 server application. Survey questions are listed in Supplemental Digital Content 1, Appendix 1, http://links. lww.com/AA/B871.
Survey Questions Maslach Burnout Inventory-Human Services Survey (MBIHSS). The MBI-HSS8 has become the gold standard to assess burnout in health-related fields. As noted previously, it evaluates the 3 aspects of burnout—EE, DP, and PA. MBIHSS consists of 22 questions, of which 9 evaluate EE, 5 evaluate DP, and 8 evaluate PA. Subjects give their answers with a 7-point Likert scale (encoded using the integers 0–6). The composite scores for the 3 aspects of burnout were computed by averaging the scores for the corresponding questions. We report PA as “LPA” (lack of personal accomplishment—the inverse of PA) so all 3 aspects of burnout get scored in the same direction, that is, greater values indicate greater risk of burnout. Physical Health/Mental Health (SF-12). The SF-12 is a validated subset of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)18,21 used to assess
ANESTHESIA & ANALGESIA
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
physical and mental status when a lower response burden is desired. The SF-12, which can be completed in 2 minutes or less, has been used extensively to evaluate health-related quality of life issues,22 work-related stress,23 and response to disease24 in a variety of professions (including medical) and in patients. From the 12 questions, physical (PCS) and mental (MCS) composite scores are calculated, with scores ranging from 0 (worst health state) to 100 (best health state). Composite scores are compared to national norms such that positive differences indicate a better health status and negative differences a worse health status. Controls are not matched controls, but since values can change over a lifetime, age-specific controls are available. Social Support and Personal Coping (SSPC-14). The Social Support and Personal Coping (SSPC-25) survey, developed and used in our prior work,17 is intended to elucidate an individual’s coping strategies and social support system. With the addition of the SF-12 to the present survey, we eliminated the 11 health and wellness questions to create the SSPC-14 survey. These remaining 14 questions fall into 4 natural groupings—work satisfaction, workload and control, professional support, and personal support. Each question is scored with a 9-point scoring system where, for most questions, a higher score represents better coping/ support. Tobacco, Alcohol, and Cannabis Use. Starting with the established NM ASSIST tool,25 we refined a list of 22 short questions to focus specifically on the use of tobacco, alcohol, and cannabis and their impact on respondents’ lives and work. There were no questions about legitimate prescription medicines or substances that might be available in the workplace. The questions included 3 response timescales: use in the last year, use in the last 5 years, and lifetime use. The option of “prefer not to answer” was also included. This tool can be completed quickly for initial assessment of substance use.
Honesty Survey During the process of data analysis, we were concerned that survey participants would not answer substance abuse questions with the same honesty as the other questions. Even among our own research group, we were concerned that such sensitive questions would not garner the same honesty as less sensitive ones. In light of this, we sent a short institutional review board–approved questionnaire (see Supplemental Digital Content 2, Appendix 2, http:// links.lww.com/AA/B872) to the perioperative service at our hospital. This included all physicians and nurses that work in the surgical flow loop (preoperative holding, operating room, and postanesthesia care unit). While these are not the same people who participated in the webinar, they do represent a large community of nurses and doctors who work in a very busy surgical unit in a large hospital where stress and burnout are not unknown.
Statistical Analysis Respondent characteristics were summarized using sample statistics, including the mean, standard deviation, count, proportion, and 95% confidence intervals,
as appropriate. When comparing estimates to published control values, statistical significance was indicated when the 95% confidence interval for the estimated quantity failed to include the published quantity. Adjusted linear regression methods were used to test the associations between each aspect of burnout and reported substance use, components of the SF-12 and the SSPC14, and respondent demographics. Graphical residual diagnostics were used to assess the validity of regression assumptions. Ninety-five percent confidence intervals and P values were used to summarize the results of regression. P values
