Physician assistants (PAs) work in complex and rapidly changing healthcare delivery systems alongside physicians, nurses, and other healthcare professionals. As critical team members, PAs are relied upon to improve access to care and provide care to patients in a variety of settings.1,2 Although PAs generally report high job satisfaction, the field faces many challenges, including an aging patient population that brings with it an increasing prevalence of chronic disease, multiple comorbidities, and demands for services.3-8 Additional stressors include rising documentation requirements, cost-reduction strategies, quality metric reporting, meaningful use of electronic medical records, and prior authorization requirements.9-11
Within this environment, a high prevalence of physician burnout and dissatisfaction with work-life integration has been documented.12,13 A national study reported that 57% of US physicians were dissatisfied with their work-life integration and 44% experienced substantial symptoms of burnout as measured by the Maslach Burnout Inventory (MBI), widely considered the gold standard for burnout assessment given its robust validity data.13-15 After adjusting for age, sex, relationship status, and work hours, physicians were more likely to have burnout and less likely to be satisfied with their work-life integration than other US workers.14 Burnout originates from work-related stress and is characterized by emotional exhaustion and depersonalization (for example, feeling callous or detached toward patients).16 In studies of physicians, factors that contribute to burnout include excessive workload; work inefficiencies; declines in meaning in work, control, and autonomy; social isolation at work; conflicts between personal values and organizational values; and difficulties with work-life integration.17 Burnout has been associated with increased likelihood of medical errors, malpractice litigation suits, healthcare-associated infections, patient mortality, job turnover, and lower productivity.18-26 Despite extensive evidence on physician burnout, less is known about rates of burnout, contributing factors, and its potential consequences among PAs.
The American Academy of PAs' 2018 Salary Survey suggested that 32.6% of PAs had symptoms of burnout.27 Burnout in that study, however, was measured by the Professional Fulfillment Index, making it difficult to compare the results with studies using the MBI in other healthcare professionals.28 Studies of PAs using the MBI have been limited, and include a study of 161 rural PAs, 160 PAs working in an ED, 250 PAs in oncology, and 366 PAs in Minnesota.5,10,29,30 In these studies, the prevalence of high emotional exhaustion was 30.4% to 46%, high depersonalization was 17.6% to 46%, and overall burnout was 34.8%.5,10,29,30 None of these studies conducted multivariable analysis to identify factors associated with burnout. Additionally, to our knowledge, no large national study has yet explored rates of burnout, as measured by the MBI and satisfaction with work-life integration among PAs, and compared rates of burnout and satisfaction with work-life integration among PAs with rates for workers in other fields. Comparing the experience of PAs to other US workers provides an opportunity to explore whether their prevalence of burnout and satisfaction with work-life integration differs from societal trends at large.
The objective of our study was to determine the incidence of burnout, explore personal and professional factors independently associated with burnout and work-life integration, and compare the prevalence of burnout and satisfaction with work-life integration among PAs with other US workers.
METHODS
The Mayo Clinic and Stanford institutional review board approved this study.
Participants
The PA sample was drawn from the 60,478 PAs with e-mail and postal addresses listed in the Redi-Data database (a company that maintains information from all state licensing data, more information available at: www.redidata.com/healthcare-lists/mailing-email-lists/state-licensed-nurses-rns-mailing-email-lists). In November 2016, we sent e-mail invitations containing the survey link to a random sample of 2,100 PAs from this list. Those who did not respond to the online survey after three reminders were mailed a paper survey. Of those invited, we were unable to reach 69 PAs who did not have a functional e-mail or valid postal address, resulting in 2,031 PAs receiving an invitation to participate in the study. Participation was elective and all responses were anonymous.
For the sample of other US workers, we partnered with KnowledgePanel, which identified a probability-based panel designed to be representative of US workers in October 2017.14 Workers were scientifically selected by a random selection of telephone numbers and residential addresses and invited by telephone or by mail to participate. Those who agreed to participate completed the survey online. For those who did not have internet access, a laptop computer and internet service were provided at no cost. Physicians were excluded from the population sample.
Study measures
The PA and US worker survey included questions about demographics (including age, sex, and relationship status), work hours, burnout, and satisfaction with work-life integration (Tables 1 and 2). The PA survey also included items about parental status, practice characteristics (medical and surgical inpatient, intensive care, operating/recovery room, obstetrics, ambulatory/outpatient clinic, hospice, home health, nonclinical such as management, public health), specialty area, satisfaction with autonomy, satisfaction with collaborating physician(s), and control over workload. Respondents who indicated they were very satisfied or satisfied were considered to be satisfied with their autonomy, collaborating physician partner(s), and control over work.
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TABLE 1.: Demographic characteristics of 600 PAsBecause of missing data, some overall totals do not equal 600.
TABLE 2.: Personal and professional characteristics of 600 PAs
Burnout
PAs were asked to complete the full 22-item MBI Human Services Survey.31 The MBI has three subscales: emotional exhaustion, depersonalization, and personal accomplishment.31 Consistent with other studies, PAs were considered to have burnout if they scored high on the emotional exhaustion (score of 27 or greater), or depersonalization (score of 10 or greater) subscale, or on both.12,13
We used two items from the full MBI (“I feel burned out from my work” and “I've become more callous toward people since I started this job”) to measure burnout in PAs and US workers. We selected this approach due to the length and cost of using the full 22-item MBI. Previous studies involving several samples of more than 10,000 healthcare professionals have demonstrated that these two items have strong psychometric properties and stratify the risk of burnout.32,33 For example, the areas under the receiver operating characteristic curve for the emotional exhaustion and depersonalization single items, in comparison to the full MBI domain scores, were 0.94 and 0.93, respectively.32,33 Consistent with previous national studies of physicians and other workers, respondents with a high score (an indicated frequency of weekly or more often) on either item were considered to have symptoms of burnout.13,32-34
Satisfaction with work-life integration
Similar to previous studies of healthcare professionals, the item “My work schedule leaves enough time for my personal/family life” was used to measure satisfaction with work-life balance.12,13,24,35,36 Those who indicated they strongly agree or agree were considered to be satisfied with their work-life integration.
Statistical analysis
Basic summary statistics were reported. Univariate comparisons were made using chi-square or Kruskal-Wallis tests, as appropriate. Multivariable analyses were conducted to identify factors independently associated with burnout and satisfaction with work-life integration. First, models were analyzed in the PA sample. Each model included the following variables: age (for each year older), sex (referent: male), relationship status (referent: married), parental status (referent: have children), work hours in the past 7 days (for each additional hour), years as a PA (for each additional year), practice setting (referent: hospital-based, which included medical and surgical inpatient, intensive care, and operating/recovery room), current specialty area (referent: primary care, which included family medicine, general internal medicine, and general pediatrics), and years in current specialty area (referent: 5 or fewer years). Satisfaction with work-life integration, autonomy, collaborating physician partner(s), and control over work were added to the model for burnout (referent: satisfied or very satisfied). Next, we performed a fully saturated pooled multivariable logistic regression analysis of PAs and US workers in other fields to identify factors associated with burnout and satisfaction with work-life integration. For comparisons with the population sample, PA data were restricted to responders who were between ages 29 and 65 years, to match the population sample. Analyses were conducted at the level of the individual and clustered data were not addressed. We used a 5% type I error rate and a two-sided alternative. We used SAS version 9 for all analysis.
RESULTS
PAs
Among those who received the survey, 600 of 2,031 (29.5%) PAs responded (Tables 1 and 2). The mean age of responders was 45.6 years and 68.5% were women. Most respondents (77.9%) were married and had children (78.5%). On average, responders worked 38.9 hours per week and had 16.1 years of experience as a PA. The cohort of responding PAs was similar to US PAs with respect to sex.37 The responding cohort was somewhat older and less likely to be hospital-based.
When assessed using the 22-item MBI, 30.5% had high emotional exhaustion, 24.5% had high depersonalization, and 13% had low sense of personal accomplishment. In aggregate, 41.4% had high emotional exhaustion or high depersonalization and were considered to have substantial symptoms of burnout. When determined using the two-item MBI measure, the estimated burnout rate was 35.8%, a slightly more conservative estimate relative to the gold standard 22-item MBI. Nearly two-thirds (65.3%) of PAs were satisfied with their work-life integration. The vast majority of PAs were satisfied with their autonomy (91.5%) and collaborating physician(s) (89.3%); 67% were satisfied with their control over workload.
PAs with burnout tended to work more hours per week on average than those without burnout (mean [SD], 40.1 [10.96] versus 38.1 [10.3], P = .047). Although no relationship was found between prevalence of high depersonalization and work hours, a statistically significant relationship was found in the expected direction between the prevalence of high emotional exhaustion and work hours (P < .01; Figure 1A). Similarly, the prevalence of satisfaction with work-life integration decreased as work hours increased (P < .001; Figure 1B).
FIGURE 1.: Relationship between weekly work hours and (A) high emotional exhaustion and high depersonalization and (B) satisfaction with work-life integration among 600 PAs
After adjusting for age, sex, relationship status, parent status, work hours in the past week, years as a PA, practice setting, specialty area, years in current specialty area, and satisfaction with work-life integration, autonomy, collaborating physician partner(s), and control over work, differences were found in the prevalence of burnout across specialties, with those who worked in the emergency medicine appearing at higher risk (overall P value .006, referent: primary care; emergency medicine OR 2.73, 95% CI 1.30-5.75; other direct care specialty OR 1.69, 95% CI 0.76-3.77; other/unknown work area OR 0.96, 95% CI 0.53-1.73; pediatric or internal medicine subspecialty OR 0.51, 95% CI 0.22-1.19; surgical area OR 0.88, 95% CI 0.48-1.63; Table 3). PAs who had children were less likely to have burnout (having children versus not; OR 0.38, 95% CI 0.21-0.66, P < .001). PAs who reported not being satisfied with their work-life integration also were more likely to have burnout (OR 2.92, 95% CI 1.85-4.60, P < .001) as were those who were neutral or not satisfied with their control over their workload (OR 4.21, 95% CI 2.67-6.63, P < .001). Age, sex, relationship status, work hours, years as a PA, practice setting, years in current specialty area, and satisfaction with autonomy and collaborating physician partner(s) were not found to be independent predictors of burnout.
TABLE 3.: Factors associated with burnout on multivariable analysis (N = 558)
Few differences were found in the prevalence of satisfaction with work-life integration on multivariate analysis (Table 4). Among the professional characteristics, only work hours were associated with satisfaction with work-life integration (for each additional hour, OR 0.95, 95% CI 0.93-0.96, P < .0001). Relative to men, women had lower odds of being satisfied with their work-life integration (referent male: female, OR 0.52, 95% CI 0.34-0.82, P = .004).
TABLE 4.: Factors associated with satisfaction with work-life integration on multivariable analysis∗ (N = 566)
PAs compared with other workers
Demographic differences between responding PAs and other workers are shown in Table 5, along with the prevalence of burnout on the two-item burnout measure and satisfaction with work-life integration. Compared with other workers, PAs were more likely to be female, younger, and married. On average, PAs worked a median of 2 more hours per week than other US workers; 12% of PAs and 6.2% of other US workers reported working 60 or more hours per week. No statistically significant differences in satisfaction with work-life integration were found between PAs and other US workers. On the two-item burnout measure, PAs were more likely to have high depersonalization (19.3% versus 13.5%, P < .001) and overall burnout (35.5% versus 28.0%, P < .001) than other US workers.
TABLE 5.: Comparison of 557 PAs in the sample ages 29-65 years with a probability-based same-age sample of 5,179 employed US adults
TABLE 5.: (Continued)
TABLE 5.: (Continued)
In the pooled multivariable analysis (including PAs and other US workers) adjusting for age, sex, relationship status, hours worked per week, and satisfaction with work-life integration, older age was associated with lower odds of burnout (for each year older, OR 0.99, 95% CI 0.98-0.99, P < .001; Table 6). Differences also were found in the odds of burnout by sex and relationship status, with women (OR 1.23, 95% CI 1.09-1.39, P = .001) and those who were single at higher risk (overall P value .002, referent married; partnered OR 1.09, 95% CI 0.81-1.45; single OR 1.31, 95% CI 1.14-1.50; and widowed OR 1.19, 95% CI 0.75-1.89). Being neutral or dissatisfied with work-life integration also was an independent predictor of burnout (OR 2.86, 95% CI 2.52-3.24, P < .001). Compared with other workers, PAs were more likely to have burnout (OR 1.38, 95% CI 1.13-1.69, P = .002) after adjusting for other factors.
TABLE 6.: Pooled multivariable analysis of PAs (N = 557) and US workers (N = 5,197) exploring factors associated with burnout and satisfaction with work-life integration
Finally, we performed a pooled multivariable analysis to identify factors independently associated with satisfaction with work-life integration after adjusting for age, sex, relationship status, and hours worked per week (Table 6). Greater work hours was associated with lower odds of being satisfied with work-life integration (OR 0.94, 95% CI 0.94-0.95, P < .001). PAs were more likely to be satisfied with their work-life integration than other workers (OR 1.51, 95% CI 1.23-1.85).
DISCUSSION
Results from this national study of PAs suggest that more than 40% had burnout symptoms and fewer than two-thirds were satisfied with their work-life integration. Working in emergency medicine and not being satisfied with control over workload were associated with higher odds of burnout; having children was associated with lower odds of burnout. Not being satisfied with work-life integration also was independently associated with burnout. After adjusting for hours worked per week and other factors, PAs were more likely to have burnout than other US workers, but did not have greater struggles with work-life integration.
In this cohort, PAs had a 38% increased odds of burnout relative to other US workers. The prevalence of burnout, high emotional exhaustion, and high depersonalization among PAs in this cohort was slightly lower than the respective prevalence of burnout (43.9%), high emotional exhaustion (38.7%), and high depersonalization (27.3%) reported in a recent national study of more than 5,100 physicians using the same measure.14 However, the higher prevalence of burnout among PAs compared with other US workers mirrors findings in several studies of physicians, with the most recent of these surveys (conducted in 2017-2018) reporting physicians have a 39% increased odds of burnout compared with other workers after adjusting for age, sex, relationship status, and hours worked per week.12-14 In sum, these findings suggest that the high prevalence of burnout documented in PAs and physicians does not simply reflect societal trends.
PAs working in emergency medicine had more than twofold increased odds of burnout after controlling for other professional and personal characteristics. Previous studies also have found higher odds of burnout among physicians working in emergency medicine.14 Additional studies are needed to explore differences in work tasks and stressors for PAs working in emergency medicine compared with other specialties. Such work is important, as burnout is associated with turnover, lower productivity, and absenteeism, and because one in eight PAs works in the ED, this workforce is critical to meeting the healthcare system's need for acute care services.37-44
Although burnout risk was higher among female PAs, this estimate did not reach the threshold of significance after adjusting for other factors. In studies of physicians and in this study's pooled multivariable analysis (of PAs and other workers), being female was an independent predictor of increased risk for burnout.12-14 Larger studies are needed to better define the sex association with burnout among PAs.
PAs who were not satisfied with their work-life integration were nearly threefold more likely to have burnout. A similar relationship has been found in studies of physicians and nurses.45-49 Although PAs in this sample were overall more satisfied with their work-life integration (65.3%) than US physicians (42.7%), as measured using the same item, further improvement in satisfaction with work-life integration is worthwhile and may facilitate PA retention.14 Reducing work hours and enhancing control of work schedules may be useful strategies for improving work-life integration and reducing the risk of burnout.50,51
How do these results compare with other healthcare professionals? In this study, PAs were more likely to experience burnout but also had higher satisfaction with their work-life integration than other US workers. A recent national study of more than 8,600 nurses found the reverse: the prevalence of burnout among nurses was similar to that of other US workers but nurses were less likely to be satisfied with their work-life integration.52 National studies of US physicians have consistently shown that both the prevalence of burnout and satisfaction with work-life integration are worse among physicians than workers in other fields.12-14 These studies as well as data showing differences in these and other dimensions of distress by specialty and practice setting suggest that the challenges and distress being experienced by healthcare workers are distinct and vary by profession. Accordingly, it is important to not oversimplify the problem and suggest that the issues, drivers, and solutions are the same for all healthcare professionals. An appropriate response is to use the evidence to prioritize and begin to address the unique needs of each discipline to make progress.
LIMITATIONS
This study has several limitations. First, the response rate was 29.5%. It is unknown if PAs who responded to our study were more or less likely to experience burnout than PAs who did not respond. Overall, such response bias has not been evident in previous national studies of physicians.14 In this study, the participating cohort was similar to national data for sex, but also older and less hospital-based.37 These factors should be considered when evaluating the applicability of the results broadly.
Second, we are unable to determine causation as this is a cross-sectional study. Third, we explored a limited number of professional and personal characteristics likely related to burnout and satisfaction with work-life integration.
Fourth, individuals in the sample of population controls were older and less likely to be female and married. Although we adjusted for these differences in the multivariable analysis, other unmeasured confounders may exist. Fifth, the PA survey and other US workers survey were conducted about 11 months apart. However, previous studies using similar methodology have reported no change in the prevalence of burnout or satisfaction with work-life integration among a probability-based sample of general US workers between 2011 and 2017.12,14
Major strengths of this study include a national sample of PAs with representation from various practice settings and specialty areas and inclusion of the full 22-item MBI. We also surveyed a large probability sample of US workers, providing an ability--for the first time--to interpret the work experience of PAs relative to other workers.
CONCLUSION
Burnout was common among PAs, particularly for those working in emergency medicine, and more prevalent than among other US workers. Not being satisfied with work-life integration increased the risk of burnout. PAs who worked more hours and were female reported greater difficulty with work-life integration, though PAs were overall more likely to be satisfied with their work-life integration than other US workers. Given the well-documented implications of burnout among healthcare professionals, research is needed to further understand contributing factors that can inform much needed intervention research to support PA well-being.53
REFERENCES
1. Pavlik D, Sacchetti A, Seymour A, Blass B. Physician assistant management of pediatric patients in a general community emergency department: a real-world analysis.
Pediatr Emerg Care. 2017;33(1):26–30.
2. Roy CL, Liang CL, Lund M, et al. Implementation of a physician assistant/hospitalist service in an academic medical center: impact on efficiency and patient outcomes.
J Hosp Med. 2008;3(5):361–368.
3. Hooker RS, Kuilman L, Everett CM. Physician assistant job satisfaction: a narrative review of empirical research.
J Physician Assist Educ. 2015;26(4):176–186.
4. Hoff T, Carabetta S, Collinson GE. Satisfaction, burnout, and turnover among nurse practitioners and physician assistants: a review of the empirical literature.
Med Care Res Rev. 2019;76(1):3–31.
5. Tetzlaff ED, Hylton HM, DeMora L, et al. National study of burnout and career satisfaction among physician assistants in oncology: implications for team-based care.
J Oncol Pract. 2018;14(1):e11–e22.
6. Graeff EC, Leafman JS, Wallace L, Stewart G. Job satisfaction levels of physician assistant faculty in the United States.
J Physician Assist Educ. 2014;25(2):15–20.
7. LaBarbera DM. Gender differences in the vocational satisfaction of physician assistants.
JAAPA. 2010;23(10):33–39.
8. Dall TM, Gallo PD, Chakrabarti R, et al. An aging population and growing disease burden will require a large and specialized health care workforce by 2025.
Health Aff (Millwood). 2013;32(11):2013–2020.
9. Dyrbye LN, Shanafelt TD. Physician burnout: a potential threat to successful health care reform.
JAMA. 2011;305(19):2009–2010.
10. Bell RB, Davison M, Sefcik D. A first survey. Measuring burnout in emergency medicine physician assistants.
JAAPA. 2002;15(3):40–52.
11. Coplan B, McCall TC, Smith N, et al. Burnout, job satisfaction, and stress levels of PAs.
JAAPA. 2018;31(9):42–46.
12. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
Arch Intern Med. 2012;172(18):1377–1385.
13. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
Mayo Clin Proc. 2015;90(12):1600–1613.
14. Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017.
Mayo Clin Proc. 2019;94(9):1681–1694.
15. National Academy of Medicine. Valid and reliable survey instruments to measure burnout, well-being, and other work-related dimensions.
https://nam.edu/valid-reliable-survey-instruments-measure-burnout-well-work-related-dimensions. Accessed February 7, 2020.
16. Maslach C, Jackson SE, Leiter MP.
Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.
17. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions.
J Intern Med. 2018;283(6):516–529.
18. Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and health care-associated infection.
Am J Infect Control. 2012;40(6):486–490.
19. Welp A, Meier LL, Manser T. Emotional exhaustion and workload predict clinician-rated and objective patient safety.
Front Psychol. 2015;5:1573.
20. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study.
JAMA. 2006;296(9):1071–1078.
21. West CP, Tan AD, Habermann TM, et al. Association of resident fatigue and distress with perceived medical errors.
JAMA. 2009;302(12):1294–1300.
22. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons.
Ann Surg. 2010;251(6):995–1000.
23. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator.
Lancet. 2009;374(9702):1714–1721.
24. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons.
Ann Surg. 2009;250(3):463–471.
25. Balch CM, Oreskovich MR, Dyrbye LN, et al. Personal consequences of malpractice lawsuits on American surgeons.
J Am Coll Surg. 2011;213(5):657–667.
26. Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
Mayo Clin Proc. 2016;91(4):422–431.
27. American Academy of PAs. Are PAs burned out?
www.aapa.org/news-central/2018/05/pas-report-low-burnout. Accessed February 7, 2020.
28. Trockel M, Bohman B, Lesure E, et al. A brief instrument to assess both burnout and professional fulfillment in physicians: reliability and validity, including correlation with self-reported medical errors, in a sample of resident and practicing physicians.
Acad Psychiatry. 2018;42(1):11–24.
29. Benson MA, Peterson T, Salazar L, et al. Burnout in rural physician assistants: an initial study.
J Physician Assist Educ. 2016;27(2):81–83.
30. Osborn M, Satrom J, Schlenker A, et al. Physician assistant burnout, job satisfaction, and career flexibility in Minnesota.
JAAPA. 2019;32(7):41–47.
31. Maslach C, Jackson SE, Leiter MP.
Maslach Burnout Inventory. 4th ed.
www.mindgarden.com; 2016.
32. West CP, Dyrbye LN, Satele DV, et al. Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment.
J Gen Intern Med. 2012;27(11):1445–1452.
33. West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals.
J Gen Intern Med. 2009;24(12):1318–1321.
34. West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents.
JAMA. 2011;306(9):952–960.
35. Shanafelt TD, Raymond M, Kosty M, et al. Satisfaction with work-life balance and the career and retirement plans of US oncologists.
J Clin Oncol. 2014;32(11):1127–1135.
36. Dyrbye LN, Shanafelt TD, Balch CM, et al. Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex.
Arch Surg. 2011;146(2):211–217.
37. National Commission on Certification of Physician Assistants. 2017 Statistical Profile of Certified Physician Assistants: An Annual Report of the National Commission on Certification of Physician Assistants.
https://prodcmsstoragesa.blob.core.windows.net/uploads/files/2017StatisticalProfileofCertifiedPhysicianAssistants%206.27.pdf. Accessed February 7, 2020.
38. Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction.
JAMA. 2002;288(16):1987–1993.
39. Pantenburg B, Luppa M, König HH, Riedel-Heller SG. Burnout among young physicians and its association with physicians' wishes to leave: results of a survey in Saxony, Germany.
J Occup Med Toxicol. 2016;11:2.
40. Fida R, Laschinger HKS, Leiter MP. The protective role of self-efficacy against workplace incivility and burnout in nursing: a time-lagged study.
Health Care Manage Rev. 2018;43(1):21–29.
41. Shanafelt T, Sloan J, Satele D, Balch C. Why do surgeons consider leaving practice.
J Am Coll Surg. 2011;212(3):421–422.
42. Windover AK, Martinez K, Mercer MB, et al. Correlates and outcomes of physician burnout within a large academic medical center.
JAMA Intern Med. 2018;178(6):856–858.
43. Hamidi MS, Bohman B, Sandborg C, et al. Estimating institutional physician turnover attributable to self-reported burnout and associated financial burden: a case study.
BMC Health Serv Res. 2018;18(1):851.
44. Parker PA, Kulik JA. Burnout, self- and supervisor-rated job performance, and absenteeism among nurses.
J Behav Med. 1995;18(6):581–599.
45. Anandarajah AP, Quill TE, Privitera MR. Adopting the quadruple aim: the University of Rochester Medical Center experience: moving from physician burnout to physician resilience.
Am J Med. 2018;131(8):979–986.
46. McAbee JH, Ragel BT, McCartney S, et al. Factors associated with career satisfaction and burnout among US neurosurgeons: results of a nationwide survey.
J Neurosurg. 2015;123(1):161–173.
47. Oskrochi Y, Maruthappu M, Henriksson M, et al. Beyond the body: a systematic review of the nonphysical effects of a surgical career.
Surgery. 2016;159(2):650–664.
48. Boamah SA, Read EA, Spence Laschinger HK. Factors influencing new graduate nurse burnout development, job satisfaction and patient care quality: a time-lagged study.
J Adv Nurs. 2017;73(5):1182–1195.
49. Proost K, De Witte H, De Witte K, Evers G. Burnout among nurses: extending the job Demand-Control-Support model with work-home interference.
Psychologica Belgica. 2004;44:269–288.
50. Shanafelt TD, Dyrbye LN, West CP, Sinsky CA. Potential impact of burnout on the US physician workforce.
Mayo Clin Proc. 2016;91(11):1667–1668.
51. Peters V, Houkes I, de Rijk AE, et al. Which resources moderate the effects of demanding work schedules on nurses working in residential elder care? A longitudinal study.
Int J Nurs Stud. 2016;58:31–46.
52. Dyrbye LN, West CP, Johnson PO, et al. Burnout and satisfaction with work-life integration among nurses.
J Occup Environ Med. 2019;61(8):689–698.
53. Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care.
https://nam.edu/burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat-to-safe-high-quality-care. Accessed February 11, 2020.
