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Burnout is a concept in industrial and organizational psychology for "an excessive stress reaction to one's occupational or professional environment. It is manifested by feelings of emotional and physical exhaustion coupled with a sense of frustration and failure".[1] Burnout has three dimensions[2]:

  • Emotional exhaustion
  • Depersonalization (cynicism)
  • Diminished personal accomplishment (inefficacy)

Subsequent research suggests the third dimension, personal accomplishment, better fits with the concept of professional engagement rather than with burnout.[3]

Workaholism more closely correlates with burnout than with engagement, although workaholism correlated with both (weakly negatively with engagement [via absorption])[4].

Engagement may not simply be the opposite of burnout[5]. Engagement and burnout may be related more specifically[6]:

  • Emotional exhaustion may be the opposite of vigor
  • Cynicism may be the opposite of dedication

OR

"Vigor and dedication are the direct positive opposites of exhaustion and cynicism, respectively."[5]

According to Schaufeli[5] , the "Energetic Process" is based on Hockey's model of compensatory control and when "perceived demands are too high to be met by the usual working effort, two options are open:

  • Strain coping mode leading to fatigue and irritability
  • Passive coping mode leading to disengagement


The distinction between burnout and depression is not clear[7].

Prevalence

The prevalence of burnout in the general, employed population of the United States, aged is (measured by MBI except where noted)[8][9][10]:

  • General, employed U.S. population
    • (2010): aged 31-47 30%[8], aged 29-65 29%[9]
    • (2014): aged 31-65 28%[10]
    • (2017): aged 29-65 28%[11]
    • (2021): during COVID epidemic in Japan: 31% (measured by Mini-Z)[12]
  • College graduates 2010: aged 31-47 36%[8]

Health care workers

As of 2017, 44% of physicians have have burnout[11] Previously, in 2014, as many as 50% of physicians in practice may have burnout.[10] General practitioners seem to have low job control and the highest proportion of burnout cases[13].

For physicians in training, rates of burnout (emotional exhaustion) for students, residents and fellows is about 50% while the rate is 36% in similarly aged college graduates.[8]

Causes

Burnout is due to loss of control at work, and also "burnout is mainly predicted by job demands but also by lack of job resources"[14].

Curiously, a study of physicians found, "High levels of personal accomplishment increased stress levels (beta=0 080), whereas depersonalisation lowered stress levels (beta=-0 105)"[15] The study also found that

Different underlying factors may lead to varying phenotypes of burnout[16][17] One study found[16]:

  • Burnout (high on all three dimensions)
  • Engagement (low on all three)
  • Overextended (high on exhaustion only)
  • Disengaged (high on cynicism only). Also called depersonalization by Leiter[16] which may be the same as mental distance used by the World Health Organization[18].
  • Ineffective (high on inefficacy only)

Regarding the possible connection of burnout with autonomy, burnout is more common in[19]:

  • chaotic practices[19]
  • larger practices[19]
  • accountable care organizations[19]

Burnout in physicians in training is associated with perceived harassment[20]. In one survey of 24 American medical schools, harassment occurring at least one time was reported by 83% of students[20]. In this study, harassment was more commonly reported being perpetrated by residents[20]. The rates of burnout among students responding to the survey were[20]:

  • All students 34%
  • Those reporting recurrent harassment by faculty 57%
  • Those not reporting recurrent harassment by faculty 32%

Job demands-resources model of burnout

Several items, specifically workload, are reflected in the job demands-resources model of burnout[21].

These findings are reflected in the Demand-Control theory of job stress. [22]

Areas of Worklife Survey (AWS)

Leiter and Maslach found the following antecedents from the Areas of Worklife Survey (AWS) using factor analysis:[23]

  • Workload
  • Fairness
  • Control
  • Community
  • Values
  • Rewards

Of these causes, workload is the strongest correlate of emotional exhaustion[23] but loss of control may be the initial factor. Perceived control or autonomy and fairness correlate with cynicism.[23][24]

  • 16% of burnout is attributed to perceived control at the worksite.[25]

Leiter et al found that workload relates more to exhaustion while values incongruency relates more to cynicism[26].

Leadership quality

Leadership affects both burnout and work fulfillment. A study at the Mayo Clinic found that the "average leadership behaviour score of physicians’ work unit supervisor explained 11% of the variation in burnout and 47% of the variation in workplace satisfaction"[27].

In a second study across 11 healthcare organizations, the rates of burnout by tercile of leadership ratings of effectiveness by their direct reports[28]:

  • 18%
  • 35%
  • 47%

According to the yearly survey of recent medical school graduates by the Association of American Medical Colleges, the following are reported [29]:

  • Occasional public embarrassment 20%
  • Occasional public humiliation 8%

Burnout is now being studied in its reported antitheses, job satisfaction, job engagement and thriving. Thriving may protect against burnout[30][31]. Engagement is both negatively associated with burnout, but also unhealthy engagement may lead to burnout.[32]

Measurement

Several burnout inventories are available including the Maslach, Copenhagen, and Oldenburg[33][34].

Maslach Burnout Inventory

The Maslach Burnout Inventory is a well-studied measurement of burnout that was first published in 1981. Maslach and her colleague Jackson first identified the construct "burnout" in the 1970s, and developed a measure that weighs the effects of on three scales[2]:

  • Emotional exhaustion (nine items)
  • Depersonalization (five items)
  • Personal accomplishment (eight items)

The Maslach Burnout Inventory (MBI) has several versions:

  • Human Services Survey (MBI-HSS) is 22-tems and for jobs such as 'clergy, police, therapists, social workers, medical'[35]
    • MBI-HSS without the Personal Accomplishment subscale is 14 items.
  • General Survey (MBI-GS) a 16-items for more general, non-social jobs as well[36]
    • MBI-GS without the Professional Efficacy subscale is 10 items.

Eckleberry-Hunt in 2017 raised the question that burnout is being over-reported by deeming burnout present if either emotional exhaustion or depersonalization are present.[37]

2-item Maslach Burnout Inventory

In this survey, abnormal is defined as symptoms weekly or more on either item.[38][39][40]

1. I feel burned out from my work[40] or How often do you feel burned out from your work?[39]

  • Never
  • A few times a year or less
  • Once a month
  • A few times a month
  • Once a week
  • A few times a week
  • Every day

This item correlates with emotional exhaustion subscale of the Maslach Burnout Inventory (minus the single item being tested)[38]:

  • 0.76 to 0.83 across the four samples[38]

2. I have become more callous toward people since I took this job[40] or How often do you feel you’ve become more callous toward people since you started your residency?[39]

  • Never
  • A few times a year or less
  • Once a month
  • A few times a month
  • Once a week
  • A few times a week
  • Every day

This item correlates with depersonalization subscale of the Maslach Burnout Inventory (minus the single item being tested)[38]:

  • 0.61 to 0.72 across the four samples[38]

The two-item score correlates with the overall MBI with a correlation of 0.65[41] which is under the threshold recommended for group crrelations[42]

The two-item format has been used in national surveys in 2011[9] and its follow-up survey in 2014[10].

Mini Z

Single item burnout question (SIBOQ) variations[43][43][44]
Schmoldt, 1994[43] AMA / STEPSforward[44]
Most studies do not report the stem. Veninga using a 1 to 10 scale used for the stem,
"On the following scale, indicate by circling a number where you feel you are."[45] 		"Using your own definition of “burnout,” please circle one of the answers below"
or
“Overall, based on your definition of burnout, how would you rate your level of burnout?”[46]
I enjoy my work. I have no symptoms of burnout. I enjoy my work. I have no symptoms of burnout.
Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out.
I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion. I am definitely burning out and have one or more symptoms of burnout, e.g., emotional exhaustion.
The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot. The symptoms of burnout that I am experiencing won’t go away. I think about work frustrations a lot.
I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help. I feel completely burned out. I am at the point where I may need to seek help.

The 10‑item Zero Burnout Program survey, or called the Mini Z[47], was adapted from the earlier Northwest Permanente (NWP) and Ohio Permanente Medical Group (OPMG) by Freeborn[48] and Schmoldt[43] which based this single question on earlier work by Veninga[45]. The SIBOQ was then used by later version of the Physician Worklife Survey[49]. The SIBOQ was first validated against the MBI by Rohland in 2004[50]. The SIBOQ was later used by the Minimizing Error, Maximizing Outcomes (MEMO)[51] studies used the self-definition format.

The Mini Z is a single item (burnout is defined as answers c, d, or e) that correlates with the emotional exhaustion scale of the Maslach[50]:

  • The Northwest Permanente (NWP) and Ohio Permanente Medical Group (OPMG) by Schmoldt, Freeborn and Klevit[48][43] stated[43] that the NWP also used the self-diagnosis item of Veninga that started in 1991 used the format:
    • The tedium index of Pines[52]
    • The self-diagnosis of burnout item of Veninga where the respondent chooses a number between 1 ("Not burned out") and 10 ("completely burned out").[45]

Structure

1. Using your own definition of “burnout,” please circle one of the answers below: a. I enjoy my work. I have no symptoms of burnout. b. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out. c. I am definitely burning out and have one or more symptoms of burnout, e.g., emotional exhaustion. d. The symptoms of burnout that I am experiencing won’t go away. I think about work frustrations a lot. e. I feel completely burned out. I am at the point where I may need to seek help.

2. The Mini-Z also contains the relevant dimensions:

  • Workload
    • My control over my workload is...
    • Sufficiency of time for documentation is...
    • The amount of time I spend on the electronic health record (EHR) at home is...
  • Cynicism:
    • My professional values are well aligned with those of my department leaders...

The Mini Z is promoted by the American Medical Association's Steps Forward campaign.[44]

The Mini Z may report lower prevalence of burnout than when measured by the full Maslach Burnout Inventory (MBI).[53]

Burnout Assessment Tool

A newer survey is the Burnout Assessment Tool (BAT)[54] developed by Schaufeli and others[55]. The BAT has four subscales:

  • Exhaustion
  • Mental distance
  • Emotional impairment
  • Cognitive impairment

The BAT versions are:

  • Full version with 23 items
  • Short version with 12 items[56]

Copenhagen Burnout Inventory

The Copenhagen Burnout Inventory has 19 items and was developed in 2005.[57]

Oldenburg Burnout Inventory

The Oldenburg Burnout Inventory has 16 items and was developed by Demerouti and others and has two scales[58][59]:

  • Disengagement scale. The highest loading item is "I find my work to be a positive challenge" and the second highest loading item is "I always find new and interesting aspects in my work"[60].
  • Exhaustion scale. The highest loading item is "After my work, I usually feel worn out and weary"[60].

Professional Fulfillment Index (PFI) (Stanford)

The PFI contains relevant dimensions including interpersonal disengagement[61]:

  • "Less empathetic with my patients"
  • "Less empathetic with my colleagues"

Physician Well-Being Index (PWBI)

The PWBI contains 7 items, one of which queries burnout in a yes/no response format. Its development[62] and application[63] have been reported.

Scales include disengagement:

  • "Have you worried that your work is hardening you emotionally?"

Professional Quality of Life (ProQOL)

The ProQOL has 30 items over three scales[64]:

  • Compassion satisfaction (CS)
  • Burnout (BO)
  • Compassion fatigue (CF)

The ProQOL does not include depersonalization.

The ProQO moderately correlates with the single-item burnout question from the Mini-Z[65].

The ProQOL is available at https://proqol.org/.

Prevention

Thriving[30][31] and engagement[66][3] are negatively correlated with, and thus may be protective, against burnout. However, unhealthy engagement may lead to burnout.[32]

Perceived control or autonomy and fairness correlate with cynicism.[23][24]

Successful teamwork may be important[67][68].

Religion, spirituality

Spirituality may be projective against burnout in medical students[69][70], medical residents/faculty[71][72], nurses[73] UK general practioners[74], and emergency medicine physicians[75].

Consequences

Burnout is associated with many clinical outcomes and personnel outcomes, but the relationships have much statistical heterogeneity[76].

Burnout may be associated with operating margins[77].

Treatment

Institutional and individual strategies to reduce burnout have been reviewed[78]. Of 15 studies, 12 were "individual-focused" and only 3 addressed " structural interventions within the work environment"ref name="pmid27692469"/>.

Physicians may not be aware that they are burned out and providing awareness may increase engagement with addressing burnout[79].

Meditation and Dhyana

Trauma-informed yoga may help[80].


Transcendental Meditation may help[81].

Art therapy

Randomized controlled trials of art therapy yield mixed and heterogeneous results[82][83].

See also

References

  1. ↑ Anonymous (2024), Professional Burnout (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ 2.0 2.1 Maslach, Christina; Jackson, Susan E. (1981). "The measurement of experienced burnout". Journal of Organizational Behavior. Wiley-Blackwell. 2 (2): 99–113. doi:10.1002/job.4030020205. ISSN 0894-3796.
  3. ↑ 3.0 3.1 Schaufeli, Wilmar B.; Bakker, Arnold B.; Salanova, Marisa (2016). "The Measurement of Work Engagement With a Short Questionnaire". Educational and Psychological Measurement. 66 (4): 701–716. doi:10.1177/0013164405282471. ISSN 0013-1644.
  4. ↑ Schaufeli, Wilmar B.; Taris, Toon W.; van Rhenen, Willem (April 2008). "Workaholism, Burnout, and Work Engagement: Three of a Kind or Three Different Kinds of Employee Well-being?". Applied Psychology. 57 (2): 173–203. doi:10.1111/j.1464-0597.2007.00285.x. eISSN 1464-0597. ISSN 0269-994X.
  5. ↑ 5.0 5.1 5.2 Schaufeli, W.B. and Bakker, A.B. (2004), Job demands, job resources, and their relationship with burnout and engagement: a multi‐sample study. J. Organiz. Behav., 25: 293-315. doi:10.1002/job.248
  6. ↑ González-Romá, Vicente; Schaufeli, Wilmar B.; Bakker, Arnold B.; Lloret, Susana (February 2006). "Burnout and work engagement: Independent factors or opposite poles?". Journal of Vocational Behavior. 68 (1): 165–174. doi:10.1016/j.jvb.2005.01.003. ISSN 0001-8791.
  7. ↑ Sen S (2022). "Is It Burnout or Depression? Expanding Efforts to Improve Physician Well-Being". N Engl J Med. 387 (18): 1629–1630. doi:10.1056/NEJMp2209540. PMID 36317749 Check |pmid= value (help).
  8. ↑ 8.0 8.1 8.2 8.3 Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J; et al. (2014). "Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population". Acad Med. 89 (3): 443–51. doi:10.1097/ACM.0000000000000134. PMID 24448053.
  9. ↑ 9.0 9.1 9.2 Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D; et al. (2012). "Burnout and satisfaction with work-life balance among US physicians relative to the general US population". Arch Intern Med. 172 (18): 1377–85. doi:10.1001/archinternmed.2012.3199. PMID 22911330.
  10. ↑ 10.0 10.1 10.2 10.3 Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J; et al. (2015). "Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014". Mayo Clin Proc. 90 (12): 1600–13. doi:10.1016/j.mayocp.2015.08.023. PMID 26653297.
  11. ↑ 11.0 11.1 Shanafelt TD, West CP, Sinsky C, Trockel M, Tutty M, Satele DV | display-authors=etal (2019) Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017. Mayo Clin Proc 94 (9):1681-1694. DOI:10.1016/j.mayocp.2018.10.023 PMID: 30803733
  12. ↑ Matsuo T, Yoshioka T, Okubo R, Nagasaki K, Tabuchi T (2022) Burnout and its associated factors among healthcare workers and the general working population in Japan during the COVID-19 pandemic: a nationwide cross-sectional internet-based study. BMJ Open 12 (11):e064716. DOI:10.1136/bmjopen-2022-064716 PMID: 36424113
  13. ↑ Taris TW, Stoffelsen J, Bakker AB, Schaufeli WB, van Dierendonck D (2005). "Job control and burnout across occupations". Psychol Rep. 97 (3): 955–61. doi:10.2466/pr0.97.3.955-961. PMID 16512316.
  14. ↑ Schaufeli, W. B., & Bakker, A. B. (2004). Job demands, job resources, and their relationship with burnout and engagement: A multi‐sample study. Journal of Organizational Behavior: The International Journal of Industrial, Occupational and Organizational Psychology and Behavior, 25(3), 293-315doi:10.1002/job.248
  15. ↑ McManus IC, Winder BC, Gordon D (2002). "The causal links between stress and burnout in a longitudinal study of UK doctors". Lancet. 359 (9323): 2089–90. doi:10.1016/s0140-6736(02)08915-8. PMID 12086767.
  16. ↑ 16.0 16.1 16.2 Leiter, Michael P.; Maslach, Christina (2016-12-01). "Latent burnout profiles: A new approach to understanding the burnout experience". Burnout Research. 3 (4): 89–100. doi:10.1016/j.burn.2016.09.001. ISSN 2213-0586. Retrieved 2022-06-26.
  17. ↑ Leiter MP, Frank E, Matheson TJ (2009). "Demands, values, and burnout: relevance for physicians". Can Fam Physician. 55 (12): 1224–1225, 1225.e1–6. PMC 2793232. PMID 20008605.
  18. ↑ Amonymous (2019). Burn-out an "occupational phenomenon": International Classification of Diseases Available at https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases
  19. ↑ 19.0 19.1 19.2 19.3 Edwards ST, Marino M, Solberg LI, Damschroder L, Stange KC, Kottke TE; et al. (2021). "Cultural And Structural Features Of Zero-Burnout Primary Care Practices". Health Aff (Millwood). 40 (6): 928–936. doi:10.1377/hlthaff.2020.02391. PMID 34097508 Check |pmid= value (help).
  20. ↑ 20.0 20.1 20.2 20.3 Cook AF, Arora VM, Rasinski KA, Curlin FA, Yoon JD (2014). "The prevalence of medical student mistreatment and its association with burnout". Acad Med. 89 (5): 749–54. doi:10.1097/ACM.0000000000000204. PMC 4401419. PMID 24667503.
  21. ↑ Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB (2001). "The job demands-resources model of burnout". J Appl Psychol. 86 (3): 499–512. PMID 11419809.
  22. ↑ Karasek, Robert (1990). Healthy work : stress, productivity, and the reconstruction of working life. New York: Basic Books. ISBN 0-465-02897-7.
  23. ↑ 23.0 23.1 23.2 23.3 Leiter, Michael P., and Christina Maslach. "Areas of worklife: A structured approach to organizational predictors of job burnout." Emotional and physiological processes and positive intervention strategies. Emerald Group Publishing Limited, 2003. 91-134. doi:10.1016/S1479-3555(03)03003-8
  24. ↑ 24.0 24.1 Fernet, Claude; Austin, Stéphanie; Trépanier, Sarah-Geneviève; Dussault, Marc (2013). "How do job characteristics contribute to burnout? Exploring the distinct mediating roles of perceived autonomy, competence, and relatedness". European Journal of Work and Organizational Psychology. Informa UK Limited. 22 (2): 123–137. doi:10.1080/1359432x.2011.632161. ISSN 1359-432X.
  25. ↑ Taris, Toon W., et al. "Job control and burnout across occupations." Psychological Reports 97.3 (2005): 955-961. doi:10.2466/pr0.97.3.955-961
  26. ↑ Leiter, Michael P; Maslach, Christina. "AREAS OF WORKLIFE: A STRUCTURED APPROACH TO ORGANIZATIONAL PREDICTORS OF JOB BURNOUT". Research in Occupational Stress and Well-being. Emerald (MCB UP ). pp. 91–134. doi:10.1016/S1479-3555(03)03003-8. ISSN 1479-3555.
  27. ↑ Shanafelt TD, Gorringe G, Menaker R, Storz KA, Reeves D, Buskirk SJ; et al. (2015). "Impact of organizational leadership on physician burnout and satisfaction". Mayo Clin Proc. 90 (4): 432–40. doi:10.1016/j.mayocp.2015.01.012. PMID 25796117.
  28. ↑ Mete M, Goldman C, Shanafelt T, Marchalik D (2022). "Impact of leadership behaviour on physician well-being, burnout, professional fulfilment and intent to leave: a multicentre cross-sectional survey study". BMJ Open. 12 (6): e057554. doi:10.1136/bmjopen-2021-057554. PMC 9171269 Check |pmc= value (help). PMID 36691255 Check |pmid= value (help).
  29. ↑ Association of American Medical Colleges. Medical School Graduation Questionnaire: All Schools Summary Report. Association of American Medical Colleges; Washington, DC
  30. ↑ 30.0 30.1 Porath, Christine, et al. "Thriving at work: Toward its measurement, construct validation, and theoretical refinement." Journal of Organizational Behavior 33.2 (2012): 250-275. doi:10.1002/job.756
  31. ↑ 31.0 31.1 Hildenbrand K, Sacramento CA, Binnewies C (2016). "Transformational Leadership and Burnout: The Role of Thriving and Followers' Openness to Experience". J Occup Health Psychol. doi:10.1037/ocp0000051. PMID 27631555.
  32. ↑ 32.0 32.1 Vinje HF, Mittelmark MB (2007). "Job engagement's paradoxical role in nurse burnout". Nurs Health Sci. 9 (2): 107–11. doi:10.1111/j.1442-2018.2007.00310.x. PMID 17470184.
  33. ↑ Dyrbye L et al (2018). A Pragmatic Approach for Organizations to Measure Health Care Professional Well-Being. National Academy of Medicine
  34. ↑ Anonymous, Valid and Reliable Survey Instruments to Measure Burnout, Well-Being, and Other Work-Related Dimensions, retrieved 3 October 2021
  35. ↑ Maslach, C. T., Jackson, S. E. (1 April 1981). "The measurement of experienced burnout". Journal of Organizational Behavior. 2 (2): 99–113. doi:10.1002/job.4030020205. ISSN 1099-1379. Retrieved 1 May 2017.
  36. ↑ Taris, T. W., Schreurs, P. J. G., Schaufeli, W. B. (July 1999). "Construct validity of the Maslach Burnout Inventory-General Survey: A two-sample examination of its factor structure and correlates". Work & Stress. 13 (3): 223–237. doi:10.1080/026783799296039. ISSN 1464-5335 0267-8373, 1464-5335 Check |issn= value (help). Retrieved 18 September 2022.
  37. ↑ Eckleberry-Hunt J, Kirkpatrick H, Barbera T (2017). "The Problems With Burnout Research". Acad Med. doi:10.1097/ACM.0000000000001890. PMID 28817432.
  38. ↑ 38.0 38.1 38.2 38.3 38.4 West CP, Dyrbye LN, Sloan JA, Shanafelt TD (2009). "Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals". J Gen Intern Med. 24 (12): 1318–21. doi:10.1007/s11606-009-1129-z. PMC 2787943. PMID 19802645.
  39. ↑ 39.0 39.1 39.2 West CP, Shanafelt TD, Kolars JC (2011). "Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents". JAMA. 306 (9): 952–60. doi:10.1001/jama.2011.1247. PMID 21900135.
  40. ↑ 40.0 40.1 40.2 West CP, Dyrbye LN, Satele DV, Sloan JA, Shanafelt TD (2012). "Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment". J Gen Intern Med. 27 (11): 1445–52. doi:10.1007/s11606-012-2015-7. PMC 3475833. PMID 22362127.
  41. ↑ Li-Sauerwine S, Rebillot K, Melamed M, Addo N, Lin M (2020). "A 2-Question Summative Score Correlates with the Maslach Burnout Inventory". West J Emerg Med. 21 (3): 610–617. doi:10.5811/westjem.2020.2.45139. PMC 7234685 Check |pmc= value (help). PMID 32421508 Check |pmid= value (help).
  42. ↑ HealthMeasures. PROMIS® Instrument Development and Validation Scientific Standards Version 2.0 (revised May 2013). Available at https://www.healthmeasures.net/images/PROMIS/PROMISStandards_Vers2.0_Final.pdf
  43. ↑ 43.0 43.1 43.2 43.3 43.4 43.5 Schmoldt RA, Freeborn DK, Klevit HD (1994). "Physician burnout: recommendations for HMO managers". HMO Pract. 8 (2): 58–63. PMID 10135263.
  44. ↑ 44.0 44.1 44.2 Linzer, Mark; Guzman-Corrales, Laura; Poplau, Sara. "Preventing physician burnout - STEPS Forward". STEPSforward.org. Retrieved 2017-05-24.
  45. ↑ 45.0 45.1 45.2 Veninga, Robert L.; Spradley, James P. (1981). The work/stress connection : how to cope with job burnout. Boston, Mass.: Little, Brown. ISBN 0-316-80747-8. OCLC 7205249.
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  82. ↑ Ho AHY, Tan-Ho G, Ngo TA, Ong G, Chong PH, Dignadice D; et al. (2021). "A Novel Mindful-Compassion Art-Based Therapy for Reducing Burnout and Promoting Resilience Among Healthcare Workers: Findings From a Waitlist Randomized Control Trial". Front Psychol. 12: 744443. doi:10.3389/fpsyg.2021.744443. PMC 8566679 Check |pmc= value (help). PMID 34744918 Check |pmid= value (help).
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