Boundary Objects as Dialogical Learning Accelerators for Social Change in Design for Health: Systematic Review.

BACKGROUND: Boundary objects can add value for innovative design and implementation research in health care through their organizational focus and the dynamic structure between ill-structured and tailored use. However, when innovation is approached as a boundary object, more attention will need to be paid to the preimplementation phase. Research and design thinking pay attention to the preimplementation stage but do not have a social or organizational focus per se. The integration of boundary objects in design methodologies can provide a more social and organizational focus in innovative design projects by mapping out the mechanisms that occur at boundaries during design. Four dialogical learning mechanisms that can be triggered at boundaries have been described in the literature: identification, coordination, reflection, and transformation. These mechanisms seem suitable for integration in innovative design research on health. OBJECTIVE: Focusing on innovation in health, this study aims to find out whether the different learning mechanisms can be linked to studies on health innovation that mention boundary objects as a concept and assess whether the related mechanisms provide insight into the stage of the design and implementation or change process. METHODS: The following 6 databases were searched for relevant abstracts: PubMed, Scopus, Education Resources Information Center, PsycINFO, Information Science and Technology Abstracts, and Embase. These databases cover a wide range of published studies in the field of health. RESULTS: Our initial search yielded 3102 records; after removing the duplicates, 2186 (70.47%) records were screened on the title and abstract, and 25 (0.81%) papers were included; of the 13 papers where we identified 1 mechanism, 5 (38%) described an innovation or innovative project, and of the 12 papers where we identified more mechanisms, 9 (75%) described the development or implementation of an innovation. The reflective mechanism was not identified solely but was present in papers describing a more successful development or implementation project of innovation. In these papers, the predetermined goals were achieved, and the process of integration was relatively smoother. CONCLUSIONS: The concept of boundary objects has found its way into health care. Although the idea of a boundary object was introduced to describe how specific artifacts can fulfill a bridging function between different sociocultural sites and thus have a social focus, the focus in the included papers was often on the boundary object itself rather than the social effect. The reflection and transformation mechanisms were underrepresented in the included studies but based on the findings in this review, pursuing to trigger the reflective mechanism in design, development, and implementation projects can lead to a more fluid and smooth integration of innovation into practice.

The Development of an Escape Room-Based Serious Game to Trigger Social Interaction and Communication Between High-Functioning Children With Autism and Their Peers: Iterative Design Approach.

BACKGROUND: Children with autism spectrum disorder (ASD) have social deficits that affect social interactions, communication, and relationships with peers. Many existing interventions focus mainly on improving social skills in clinical settings. In addition to the direct instruction-based programs, activity-based programs could be of added value, especially to bridge the relational gap between children with ASD and their peers. OBJECTIVE: The aim of this study is to describe an iterative design process for the development of an escape room-based serious game as a boundary object. The purpose of the serious game is to facilitate direct communication between high-functioning children with ASD and their peers, for the development of social skills on the one hand and strengthening relationships with peers through a fun and engaging activity on the other hand. METHODS: This study is structured around the Design Research Framework to develop an escape room through an iterative-incremental process. With a pool of 37 children, including 23 children diagnosed with ASD (5 girls) and 14 children (7 girls) attending special primary education for other additional needs, 4 testing sessions around different prototypes were conducted. The beta prototype was subsequently reviewed by experts (n=12). During the design research process, we examined in small steps whether the developed prototypes are feasible and whether they have the potential to achieve the formulated goals of different stakeholders. RESULTS: By testing various prototypes, several insights were found and used to improve the design. Insights were gained in finding a fitting and appealing theme for the children, composing the content, and addressing different constraints in applying the goals from the children's and therapeutic perspectives. Eventually, a multiplayer virtual escape room, AScapeD, was developed. Three children can play the serious game in the same room on tablets. The first test shows that the game enacts equal cooperation and communication among the children. CONCLUSIONS: This paper presents an iterative design process for AScapeD. AScapeD enacts equal cooperation and communication in a playful way between children with ASD and their peers. The conceptual structure of an escape room contributes to the natural emergence of communication and cooperation. The iterative design process has been beneficial for finding a constructive game structure to address all formulated goals, and it contributed to the design of a serious game as a boundary object that mediates the various objectives of different stakeholders. We present 5 lessons learned from the design process. The developed prototype is feasible and has the potential to achieve the goals of the serious game.

Design of a Digital Comic Creator (It's Me) to Facilitate Social Skills Training for Children With Autism Spectrum Disorder: Design Research Approach.

BACKGROUND: Children with autism spectrum disorder (ASD) often face difficulties in social situations and are often lagging in terms of social skills. Many interventions designed for children with ASD emphasize improving social skills. Although many interventions demonstrate that targeted social skills can be improved in clinical settings, developed social skills are not necessarily applied in children's daily lives at school, sometimes because classmates continue to show negative bias toward children with ASD. Children with ASD do not blame the difficult social situations they encounter on their lack of social skills; their main goal is to be accepted by peers. OBJECTIVE: This study aims to design a comic creator-It's me-that would create comics to serve as transformational boundary objects to facilitate and enact a horizontal interaction structure between high-functioning children with ASD and their peers, aiming to increase mutual understanding between children at school. METHODS: This research project and this study are structured around the Design Research Framework in order to develop the comic through an iterative-incremental process. Three test sessions, which included 13, 6, and 47 children, respectively, were initiated where the focus shifted in time from usability during the first two tests to the initial assessment of acceptance and feasibility in the third session. A stakeholder review, which included six experts, took place after the second test session. RESULTS: A digital comic creator, It's me, was produced within this study. Children can create their own personal comic by filling in a digital questionnaire. Based on concepts of peer support, psychoeducation, and horizontal interaction, It's me has a rigorous base of underlying concepts that have been translated into design. Based on the first test sessions, the comic has shown its potential to initiate personal conversations between children. Teachers are convinced that It's me can be of added value in their classrooms. CONCLUSIONS: It's me aims to initiate more in-depth conversations between peers, which should lead to more mutual understanding and better relationships between children with ASD and their peers. The first test sessions showed that It's me has the potential to enact horizontal interaction and greater understanding among peers. It's me was designed as a boundary object, aiming to connect the objectives of different stakeholders, and to trigger reflection and transformation learning mechanisms. The applied design research approach might be of added value in the acceptance and adoption of the intervention because children, professionals, and teachers see added value in the tool, each from their own perspectives.

Reliability of residents' assessments of their postgraduate medical education learning environment: an observational study.

BACKGROUND: Even in anonymous evaluations of a postgraduate medical education (PGME) program, residents may be reluctant to provide an honest evaluation of their PGME program, because they fear embarrassment or repercussions from their supervisors if their anonymity as a respondent is endangered. This study was set up to test the hypothesis that current residents in a PGME program provide more positive evaluations of their PGME program than residents having completed it. We therefore compared PGME learning environment evaluations of current residents in the program to leaving residents having completed it. METHODS: This observational study used data gathered routinely in the quality cycle of PGME programs at two Dutch teaching hospitals to test our hypothesis. At both hospitals, all current PGME residents are requested to complete the Scan of Postgraduate Education Environment Domains (SPEED) annually. Residents leaving the hospital after completion of the PGME program are also asked to complete the SPEED after an exit interview with the hospital's independent residency coordinator. All SPEED evaluations are collected and analysed anonymously. We compared the residents' grades (on a continuous scale ranging from 0 (poor) to 10 (excellent)) on the three SPEED domains (content, atmosphere, and organization of the program) and their mean (overall department grade) between current and leaving residents. RESULTS: Mean (SD) overall SPEED department grades were 8.00 (0.52) for 287 current residents in 39 PGME programs and 8.07 (0.48) for 170 leaving residents in 39 programs. Neither the overall SPEED department grades (t test, p = 0.53, 95% CI for difference - 0.16 to 0.31) nor the department SPEED domain grades (MANOVA, F(3, 62) = 0.79, p = 0.51) were significantly different between current and leaving residents. CONCLUSIONS: Residents leaving the program did not provide more critical evaluations of their PGME learning environment than current residents in the program. This suggests that current residents' evaluations of their postgraduate learning environment were not affected by social desirability bias or fear of repercussions from faculty.

Maximizing Authentic Learning and Real-World Problem-solving in Health Curricula Through Psychological Fidelity in a Game-Like Intervention: Development, Feasibility, and Pilot Studies.

High fidelity is regarded as a hallmark of educational games and simulations for health education. Mainly physical and functional fidelity are associated with authenticity, resulting in the pursuit of a true-to-life simulation and suggesting the imposition of a generally accepted and often unintentional design rationale that assumes that the greater the fidelity of a game or simulation to the real world, the more authentic the intervention is perceived as. Psychological fidelity receives significantly less attention, although it correlates strongly to credibility, suspension of disbelief, and engagement. The BABLR simulator reduces physical and functional fidelity to a minimum and explores the use of psychological fidelity as the main carrier of an authentic learning experience. BABLR was assessed using 26 participants with varying backgrounds in health innovation and social work. In several pilot studies, we collected data on perceived realisticness and real-world relevance. Results show that experts, as well as participants, attest to BABLR's engagement, immersiveness, and motivational qualities. Practical implications of these findings for future research into developing low-fidelity simulations with high psychological fidelity will be discussed.

The relationship between burnout, personality traits, and medical specialty. A national study among Dutch residents.

Purpose: To examine the associations between residents' personality traits, type of specialty, and symptoms of burnout. Method: A cross-sectional online survey among Dutch residents was conducted (see Supplementary Material ). The 20-item Dutch translation of the Maslach Burnout Inventory was used to ascertain burnout. Personality traits were assessed with the 44-item Dutch Big Five Inventory. Logistic regression analyses, including all five personality traits, were used to assess associations with burnout. Analyses were stratified by specialties. Results: One thousand two hundred thirty one residents participated, 185 (15.0%) of whom met the criteria for burnout. Neuroticism was significantly associated with resident burnout in all specialties, more strongly in supportive (odds ratio (OR) 6.19, 95% CI 2.12-18.12) and surgical (OR 4.37, 95% CI 1.76-10.86) than in medical residents (OR 1.99, 95% CI 1.22-3.24). Extraversion was significantly associated with less burnout in surgical residents (OR 0.26, 95% CI 0.13-0.58). These findings remained highly significant after controlling for gender, overtime, autonomy at work, satisfaction between work and private life, and the perceived quality of the learning environment. Conclusions: Burnout risk was associated with personality traits in residents. Consistently, residents scoring high on neuroticism reported more burnout. Extraverted surgical residents were less susceptible to burnout. Residents scoring high on neuroticism may require more intense monitoring during their training years.

The learning environment and resident burnout: a national study.

INTRODUCTION: Concerns exist about the negative impact of burnout on the professional and personal lives of residents. It is suggested that the origins of burnout among residents are rooted in the learning environment. We aimed to evaluate the association between the learning environment and burnout in a national sample of Dutch residents. METHODS: We conducted a cross-sectional online survey among all Dutch residents in September 2015. We measured the learning environment using the three domain scores on content, organization, and atmosphere from the Scan of Postgraduate Educational Environment Domains (SPEED) and burnout using the Dutch version of the Maslach Burnout Inventory (UBOS-C). RESULTS: Of 1,231 responding residents (33 specialties), 185 (15.0%) met criteria for burnout. After adjusting for demographic (age, gender and marital status) and work-related factors (year of training, type of teaching hospital and type of specialty), we found a consistent inverse association between SPEED scores and the risk of burnout (aOR 0.54, 95% CI 0.46 to 0.62, p < 0.001). DISCUSSION: We found a strong and consistent inverse association between the perceived quality of the learning environment and burnout among residents. This suggests that the learning environment is of key importance in preventing resident burnout.

Improving Spiritual Care in Hospitals in the Netherlands: What Do Health Care Chaplains Involved in an Action-Research Study Report?

Health care chaplains participated in a multicenter trial to explore an implementation strategy for the Dutch multidisciplinary guideline for spiritual care. The intervention was concise spiritual care training for hospital staff of departments where patients in curative and palliative trajectories are treated. Data were collected in semistructured interviews with chaplains who acted as trainers, before and after the intervention. Results based on nine preintervention and eleven post-intervention interviews are presented. During preintervention interviews, chaplains describe the baseline situation of palliative care in Dutch hospitals, barriers, and opportunities for improving spiritual care. In the postintervention interviews, characteristics of the training, effects, and critical success factors were identified. Positive effects such as lowering barriers, increasing health care professionals' competences, and increasing health care chaplains' profile are possible. Chaplain-led, multidisciplinary spiritual care training is a feasible method to start implementation of spiritual care in hospitals, as described in the multidisciplinary guideline.

Multidisciplinary Training on Spiritual Care for Patients in Palliative Care Trajectories Improves the Attitudes and Competencies of Hospital Medical Staff: Results of a Quasi-Experimental Study.

OBJECTIVES: Patients value health-care professionals' attention to their spiritual needs. However, this is undervalued in health-care professionals' education. Additional training is essential for implementation of a national multidisciplinary guideline on spiritual care (SC) in palliative care (PC). Aim of this study is to measure effects of a training program on SC in PC based on the guideline. METHODS: A pragmatic multicenter trial using a quasi-experimental pretest-posttest design as part of an action research study. Eight multidisciplinary teams in regular wards and 1 team of PC consultants, in 8 Dutch teaching hospitals, received questionnaires before training about perceived barriers for SC, spiritual attitudes and involvement, and SC competencies. The effect on the barriers on SC and SC competencies were measured both 1 and 6 months after the training. RESULTS: For nurses (n = 214), 7 of 8 barriers to SC were decreased after 1 month, but only 2 were still after 6 months. For physicians (n = 41), the training had no effect on the barriers to SC. Nurses improved in 4 of 6 competencies after both 1 and 6 months. Physicians improved in 3 of 6 competencies after 1 month but in only 1 competency after 6 months. SIGNIFICANCE OF RESULTS: Concise SC training programs for clinical teams can effect quality of care, by improving hospital staff competencies and decreasing the barriers they perceive. Differences in the effects of the SC training on nurses and physicians show the need for further research on physicians' educational needs on SC.

The Role of Transfer in Designing Games and Simulations for Health: Systematic Review.

BACKGROUND: The usefulness and importance of serious games and simulations in learning and behavior change for health and health-related issues are widely recognized. Studies have addressed games and simulations as interventions, mostly in comparison with their analog counterparts. Numerous complex design choices have to be made with serious games and simulations for health, including choices that directly contribute to the effects of the intervention. One of these decisions is the way an intervention is expected to lead to desirable transfer effects. Most designs adopt a first-class transfer rationale, whereas the second class of transfer types seems a rarity in serious games and simulations for health. OBJECTIVE: This study sought to review the literature specifically on the second class of transfer types in the design of serious games and simulations. Focusing on game-like interventions for health and health care, this study aimed to (1) determine whether the second class of transfer is recognized as a road for transfer in game-like interventions, (2) review the application of the second class of transfer type in designing game-like interventions, and (3) assess studies that include second-class transfer types reporting transfer outcomes. METHODS: A total of 6 Web-based databases were systematically searched by titles, abstracts, and keywords using the search strategy (video games OR game OR games OR gaming OR computer simulation*) AND (software design OR design) AND (fidelity OR fidelities OR transfer* OR behaviour OR behavior). The databases searched were identified as relevant to health, education, and social science. RESULTS: A total of 15 relevant studies were included, covering a range of game-like interventions, all more or less mentioning design parameters aimed at transfer. We found 9 studies where first-class transfer was part of the design of the intervention. In total, 8 studies dealt with transfer concepts and fidelity types in game-like intervention design in general; 3 studies dealt with the concept of second-class transfer types and reported effects, and 2 of those recognized transfer as a design parameter. CONCLUSIONS: In studies on game-like interventions for health and health care, transfer is regarded as a desirable effect but not as a basic principle for design. None of the studies determined the second class of transfer or instances thereof, although in 3 cases a nonliteral transfer type was present. We also found that studies on game-like interventions for health do not elucidate design choices made and rarely provide design principles for future work. Games and simulations for health abundantly build upon the principles of first-class transfer, but the adoption of second-class transfer types proves scarce. It is likely to be worthwhile to explore the possibilities of second-class transfer types, as they may considerably influence educational objectives in terms of future serious game design for health.

The relationship between work and home characteristics and work engagement in medical residents.

INTRODUCTION: Work engagement is important for medical residents and the healthcare organizations they work for. However, relatively little is known about the specific predictors of work engagement in medical residents. Therefore, we examined the associations of work and home characteristics, and work-home interference with work engagement in male and female residents. METHODS: This study was conducted on a nationwide sample of medical residents. In 2005, all Dutch medical residents (n = 5245) received a self-report questionnaire. Path analysis was used to examine the associations between the potential predictors and work engagement. RESULTS: In total, 2115 (41.1%) residents completed the questionnaire. Job characteristics, home characteristics and work-home interference were associated with work engagement. Important positive contributing factors of work engagement were opportunities for job development, mental demands at work, positive work-home interference and positive home-work interference. Important negative contributing factors were emotional demands at work and negative home-work interference. The influence of these factors on work engagement was similar in male and female residents. DISCUSSION: Opportunities for job development and having challenging work are of high relevance in enhancing work engagement. Furthermore, interventions that teach how to deal skilfully with emotional demands at work and home-work interference are expected to be the most effective interventions to enhance work engagement in medical residents.

Training hospital staff on spiritual care in palliative care influences patient-reported outcomes: Results of a quasi-experimental study.

BACKGROUND: Spiritual care is reported to be important to palliative patients. There is an increasing need for education in spiritual care. AIM: To measure the effects of a specific spiritual care training on patients' reports of their perceived care and treatment. DESIGN: A pragmatic controlled trial conducted between February 2014 and March 2015. SETTING/PARTICIPANTS: The intervention was a specific spiritual care training implemented by healthcare chaplains to eight multidisciplinary teams in six hospitals on regular wards in which patients resided in both curative and palliative trajectories. In total, 85 patients were included based on the Dutch translation of the Supportive and Palliative Care Indicators Tool. Data were collected in the intervention and control wards pre- and post-training using questionnaires on physical symptoms, spiritual distress, involvement and attitudes (Spiritual Attitude and Involvement List) and on the perceived focus of healthcare professionals on patients' spiritual needs. RESULTS: All 85 patients had high scores on spiritual themes and involvement. Patients reported that attention to their spiritual needs was very important. We found a significant ( p = 0.008) effect on healthcare professionals' attention to patients' spiritual and existential needs and a significant ( p = 0.020) effect in favour of patients' sleep. No effect on the spiritual distress of patients or their proxies was found. CONCLUSION: The effects of spiritual care training can be measured using patient-reported outcomes and seemed to indicate a positive effect on the quality of care. Future research should focus on optimizing the spiritual care training to identify the most effective elements and developing strategies to ensure long-term positive effects. This study was registered at the Dutch Trial Register: NTR4559.

The contribution of work characteristics, home characteristics and gender to burnout in medical residents.

Burnout is highly prevalent in medical residents. In order to prevent or reduce burnout in medical residents, we should gain a better understanding of contributing and protective factors of burnout. Therefore we examined the associations of job demands and resources, home demands and resources, and work-home interferences with burnout in male and female medical residents. This study was conducted on a nation-wide sample of medical residents. In 2005, all Dutch medical residents (n = 5245) received a self-report questionnaire on burnout, job and home demands and resources and work-home interference. Path analysis was used to examine the associations between job and home characteristics and work-home interference and burnout in both males and females. In total, 2115 (41.1 %) residents completed the questionnaire. In both sexes emotional demands at work and the interference between work and home were important contributors to burnout, especially when work interferes with home life. Opportunities for job development appeared to be an important protective factor. Other contributing and protective factors were different for male and female residents. In females, social support from family or partner seemed protective against burnout. In males, social support from colleagues and participation in decision-making at work seemed important. Effectively handling emotional demands at work, dealing with the interference between work and home, and having opportunities for job development are the most essential factors which should be addressed. However it is important to take gender differences into consideration when implementing preventive or therapeutic interventions for burnout in medical residents.

iLift: A health behavior change support system for lifting and transfer techniques to prevent lower-back injuries in healthcare.

OBJECTIVE: Lower back problems are a common cause of sick leave of employees in Dutch care homes and hospitals. In the Netherlands over 40% of reported sick leave is due to back problems, mainly caused by carrying out heavy work. The goal of the iLift project was to develop a game for nursing personnel to train them in lifting and transfer techniques. The main focus was not on testing for the effectiveness of the game itself, but rather on the design of the game as an autogenous trigger and its place in a behavioral change support system. In this article, the design and development of such a health behavior change support system is addressed, describing cycles of design and evaluation. METHODS: (a) To define the problem space, use context and user context, focus group interviews were conducted with Occupational Therapists (n=4), Nurses (n=10) and Caregivers (n=12) and a thematic analysis was performed. We interviewed experts (n=5) on the subject of lifting and transferring techniques. (b) A design science research approach resulted in a playable prototype. An expert panel conducted analysis of video-recorded playing activities. (c) Field experiment: We performed a dynamic analysis in order to investigate the feasibility of the prototype through biometric data from player sessions (n=620) by healthcare professionals (n=37). RESULTS: (a) Occupational Therapists, Nurses and Caregivers did not recognise a lack of knowledge with training in lifting and transferring techniques. All groups considered their workload, time pressure and a culturally determined habit to place the patient's well being above their own as the main reason not to apply appropriate lifting and transferring techniques. This led to a shift in focus from a serious game teaching lifting and transferring techniques to a health behavior change support system containing a game with the intention to influence behavior. (b) Building and testing (subcomponents of) the prototype resulted in design choices regarding players perspective, auditory and visual feedback, overall playability and perceived immersiveness. This design process also addressed the behavior shaping capacities of the game and its place within the health behavior change support system. An expert panel on lifting and transferring techniques validated the provoked in-game activities as being authentic. (c) Regression analysis showed an increase of the game score and dashboard score when more sessions were played, indicating an in-game training effect. A post-hoc test revealed that from an average of 10 playing sessions or more, the dashboard score and the game score align, which indicates behavioral change towards executing appropriate static lifting and transferring techniques. CONCLUSIONS: Data gathered in the final field test shows an in-game training effect, causing players to exhibit correct techniques for static lifting and transferring techniques but also revealed the necessity for future social system development and especially regarding intervention acceptance. Social system factors showed a strong impact on the games persuasive capacities and its autogenous intent.

Burnout and engagement among resident doctors in the Netherlands: a national study.

OBJECTIVES: This study was performed in order to gather insight into the well-being of Dutch medical residents. METHODS: In 2005, all Dutch residents registered through the Medical Registration Committee (n = 5245) were sent a self-report questionnaire to assess socio-demographic and work-related characteristics, burnout and engagement. RESULTS: Of the 5140 eligible residents, 2115 completed the questionnaire (41%). Of those, 21% fulfilled the criteria for moderate to severe burnout and 27% were highly engaged with their work. Women reported more emotional exhaustion and less depersonalisation than men; age was weakly but significantly related to depersonalisation, and married residents and parents reported less depersonalisation than their single or childless counterparts. More men than women were found to be highly engaged and men specifically reported more vigour. Number of years in training was weakly but significantly related to absorption. With regard to occupational risk factors, significant between-group differences were found for the effects of clinical setting on emotional exhaustion, engagement, vigour and absorption. Residents in training in a mental health clinic were most emotionally exhausted and those in a rehabilitation centre were least engaged. General surgery represented the specialty with the lowest number of residents suffering from burnout, followed by obstetrics and gynaecology and any supportive specialty. General surgery residents were also found to be more highly engaged, vigorous, dedicated and absorbed than others. CONCLUSIONS: As more than a fifth of the medical residents who responded could be diagnosed as suffering from burnout, we conclude that this problem needs addressing in the Dutch health care system, especially given that a relationship was proven between burnout and suboptimal patient care. We must look for solutions and interventions which will improve the work situation of medical residents. Striving for healthy workers in health care has to become daily practice.

Suicidal thoughts among medical residents with burnout.

OBJECTIVES: Recent research showed that medical residents have a high risk for developing burnout. The present study investigates the prevalence of burnout and its relationship with suicidal thoughts among medical residents. METHODS: All Dutch medical residents (n = 5126) received a self-report questionnaire. Burnout was measured with the Maslach Burnout Inventory. Residents were asked about the frequency of suicidal thoughts. RESULTS: Response rate was 41.3% (n = 2115). 432 Residents (20.6%) were classified as burnout. 12% reported having suicidal thoughts at least 1 time during their residency, and 1% many times. Suicidal thoughts were substantially more prevalent in the group with burnout in comparison to non-burnout (20.5% vs. 7.6%; chi(2) = 182.9, p < .001). CONCLUSION: Knowledge about the relationship between burnout and suicidal thoughts among these young medical professionals could be important for suicide prevention.

The relationship between reciprocity and burnout in Dutch medical residents.

OBJECTIVE: This study examined reciprocity in medical residents' relationships with supervisors, fellow residents, nurses and patients, and associations between reciprocity and burnout. Furthermore, we considered if a discrepancy between the perceived and preferred levels of reciprocity influenced the level of burnout complaints. METHODS: In 2003, self-report questionnaires were sent to the homes of all 292 medical residents at the University Medical Centre Groningen (UMCG), Groningen, the Netherlands. Reciprocity was measured with a single-item reciprocity scale based on the Hatfield Global Measure of Equity Scale. The Utrecht Burn-Out Scale (UBOS/MBI-HHS) was used to measure burnout. RESULTS: A total of 158 residents participated in the study. Those who reported under-benefiting in the relationship with supervisors perceived significantly more emotional exhaustion and depersonalisation than those who perceived a reciprocal relationship. Residents who indicated that they over-benefited in the relationship with nurses reported more emotional exhaustion than residents who perceived a reciprocal relationship and less personal accomplishment than residents who perceived a reciprocal relationship or under-benefit. No differences on the burnout subscales were found between residents who perceived their relationships with patients and fellow residents to be reciprocal and those who considered they under- or over-benefited. The greater the discrepancy between perceived and preferred reciprocity in the relationship with the supervisor, the more emotional exhaustion residents reported. CONCLUSIONS: Perceptions of reciprocity in relationships with supervisors and nurses had particular influence on the level of burnout complaints among residents. The discrepancy between the impacts of perceived and preferred reciprocity on burnout was negligible and the only significant relationship to emerge concerned that with emotional exhaustion.

Burnout in medical residents: a review.

OBJECTIVES: This study aimed to review current knowledge on burnout in medical residents, including reported prevalence rates, and to establish which risk and resistance factors contribute to or prevent burnout in medical residents. METHODS: We conducted a comprehensive search of the literature published between 1975 and 2005, using the Medline, EMBASE (from 1989) and PsychINFO databases. RESULTS: A total of 19 studies met our inclusion criteria. Only 5 studies appeared to meet more than 2 of the Cochrane quality criteria. The different studies report widely varying burnout rates among medical residents, ranging from 18% to 82%. Predictors of burnout can be characterised as either occupational or individual. Inconsistent results were reported with regard to the effects of some of these factors on burnout. Four of the 16 occupational risk factors appeared to be strongly related to burnout. The 11 individual risk factors examined were only weakly or moderately related to burnout. CONCLUSIONS: Research on burnout among medical residents is scarce. The weak quality of the studies, the wide variety and limited predictive power of the predictor variables included and the inconsistent findings illustrate the need for a more systematic design with regard to future research among medical residents. A future research model should take account of the individual, occupational and training demands experienced by medical residents.