02160 Zip Code
Lavonda Busing
Burnout for doctors-in-training is increasingly cause for concern. Our objectives were to assess the feasibility, acceptability and impact of a novel intervention to reduce burnout and improve wellbeing. This is the first wellbeing intervention for medical doctors to include strategies for work-life boundary management and digital wellbeing.
Twenty-two doctors participated in face-to-face workshops which included group discussion of challenges experienced and strategies to enhance self-care and wellbeing. A pre-post-test mixed-methods evaluation was undertaken. Questionnaire measures were the Oldenburg Burnout Inventory, Warwick-Edinburgh Mental Wellbeing Scale and the boundary control subscale of the Work-Life Indicator (i.e., the degree of perception of control of the boundaries between work and personal life). Paired t-tests examined whether there were statistically significant differences. Eleven doctors also participated in post-intervention semi-structured interviews. Transcripts were analysed using thematic analysis.
The intervention was well-received, with all trainees finding the workshop useful and saying they would recommend it to others. At baseline most participants had scores indicative of burnout on both the disengagement (82%) and exhaustion (82%) subscales of the Oldenburg Burnout Inventory. One month post-intervention, participants had a statistically significant reduction in burnout (both disengagement and exhaustion) and improvement in boundary control. Wellbeing scores also improved, but differences were not statistically significant. Qualitative analysis indicated participants had welcomed a safe space to discuss stressors and many had implemented digital wellbeing strategies to manage their smartphone technology, and increased self-care such as mindfulness practice and walking in green space.
In addition to didactic instruction, the workshop included group discussion, experiential and reflective exercises. At the end of the workshops, participants were encouraged to set two SMART (Specific, Measurable, Achievable, Realistic, Timely) goals; one regarding self-care and the other regarding microboundaries. Refreshments were available and participants received a certificate of participation. Participants were given a copy of the iWARDS booklet containing the strategies covered in the workshops, which can be downloaded from the iWARDS website (available here: ).
Trainees were recruited via medical education departments and social media (Twitter and Eventbrite). Upon sign-up, participants were sent an email link with the questionnaire containing the OLBI, WEMWBS, WLI measures and basic demographics, via the online survey platform Qualtrics. Six two-hour workshops were held in 2018 with 22 trainees in three London hospitals (University College London Hospital, The Whittington Hospital and The Royal Free Hospital). Following the workshop, trainees completed a feedback form to determine the usefulness and acceptability of the workshop and an online questionnaire 1 month post-workshop that included the OLBI, WEMWBS and WLI measures.
Care was taken to ensure the quality of the qualitative research by employing the criteria of credibility, transferability, dependability, and confirmability as defined by Lincoln and Guba [33]. Three forms of triangulation were employed to establish credibility and confirmability. Firstly, data triangulation; data was collected at multiple sites and at different time periods. Secondly, method triangulation; multiple methods of data collection were employed, through the use of questionnaires and interviews. Thirdly, investigator triangulation; multiple researchers were used to code, analyse and interpret the qualitative data. Concerning reflexivity, an aspect of confirmability, the investigators discussed how personal and research values may influence the research. Care was taken for the researchers involved in qualitative analysis to have different professional backgrounds which included psychology (AR) and medicine (AA) thus bringing different perspectives to minimise potential bias. A further mechanism of confirmability and dependability was the engagement with an experienced qualitative researcher external to the study (RV, linguist) who examined the data and corroborated the interpretation, thus bringing an outside perspective to minimise potential bias. Regarding transferability, it is hoped the authors have presented in sufficient detail and transparently all aspects of the study for the reader to assess whether the findings would be transferable to similar contexts.
The workshops provided time and space for self-reflection, which was typically not possible due to the intensity of work and/or due to simply being exhausted, there was not the mental energy available. Through dedicated time, the workshops gave doctors the opportunity to develop greater self-awareness of the impact of work on their wellbeing, the importance of self-care and motivation for change.
The structure of the workshop involved interactive exercises, sharing experiences and listening to one another. The workshops created a safe space where trainees could speak openly about their experiences, without fear of being judged. The expectation that doctors should be resilient was discussed by one doctor in light of colleagues who had sadly committed suicide, highlighting the importance of a safe place where personal experiences could be discussed openly.
Most participants commented on the usefulness of creating stronger boundaries between work and non-work roles with the use of technology. Doctors commented on the practical tips they had gained from the session. This tended to be with their smartphone and/or email.
Ten out of the 11 participants who were interviewed made self-care commitments. Many of the self-care behaviours participants had adopted were regarding physical activity (e.g., walking in green spaces). Two participants chose to adopt mindfulness. One participant made a commitment to be more self-compassionate, and another participant had developed a "no-list" and set greater boundaries at work. Participants described positive outcomes as a result of changes in their self-care behaviours. The benefits were wide-ranging, including feeling more relaxed, happier and experiencing an increase in self-esteem from a sense of achievement.
The most popular microboundary goals concerned social media and messaging apps (e.g., WhatsApp). Goals included disabling notifications to reduce interruptions, turning off awareness cues (e.g. read receipts) to manage expectations of availability, and device management to reduce access to or appeal of social media apps (e.g. moving all social media apps in a folder away from the home screen). Participants reported a myriad of positive outcomes as a result of implementing microboundary strategies including reduced stress, better boundaries between work and personal life, increased productivity and increased control.
Many of the participants expressed the desire to continue with the strategies they found useful, where the changes had already become routine. For some participants, the workshops stimulated deeper reflection, prompting them to consider seeking psychotherapy. Another participant discussed the value of self-care and wanting to embed it into their work for the future when they became a Consultant, expressing the desire to communicate the value of self-care to their junior doctors.
A couple of participants expressed a desire for more practical instruction regarding how to implement the microboundary strategies, suggesting they would have liked to have implemented some of the microboundary strategies on their electronic devices during the workshop but had been unable, mentioning lack of sufficient time and detailed instruction as obstacles. Participants were asked whether they would like the intervention to be available online, such as via an app and were generally keen for this alternative, given the difficulties of attending face-to-face workshops due to lack of time.
This is the first known study that has integrated education about the use of microboundaries for digital wellbeing [22] with more traditional stress-reduction techniques such as mindfulness and self-care strategies, self-compassion and physical activity, in a wellbeing intervention for doctors in training. Prior to the intervention the majority of trainees reported symptoms of burnout. Post intervention, there was a statistically significant improvement in boundary control and in both the emotional exhaustion and disengagement components of burnout, although not for mental wellbeing. Previous work which evaluated microboundary strategies, found a significant reduction in perceived stress, along with a significant increase in boundary control [24]. One possible explanation for the non-significant result in this study is that mental wellbeing encompasses several aspects, not just the absence of stress, as defined by WHO [36]. Triangulation with the qualitative findings provides insight into the factors contributing to the success of the intervention. Trainees described their working environment as a culture where challenges to wellbeing are rarely discussed, with an intense workload that resulted in little time and energy for reflection on their stressors. The workshops were welcomed because they provided a unique opportunity to hear the explicit message that doctors need to take care of themselves and by providing time and space which gave the opportunity to reflect on their wellbeing, stressors and identify areas they would like to change. Being in a non-judgemental environment, and participating in group exercises which involved sharing and hearing experiences of others, was highly valued. Given their working environment tends not to welcome open communication about perceived weaknesses, sharing experiences openly with other trainees in a non-judgemental, safe space was felt to be particularly important.
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