by Maria Grazia Maggio, PsyD; Alfredo Manuli, MSc; Adriana Andaloro, BS; Antonio Chirieleison, MSc; Gianluca La Rosa, MSc; Francesca Sciarrone, Msc; Antonia Trinchera, MD; and Rocco Salvatore Calabrò, MD, PhD

Drs. Maggio, Manuli, Andaloro, Chirieleison, La Rosa, Sciaronne, Trinchera, and Calabrò are with IRCCS Centro Neurolesi Bonino Pulejo in Messina, Italy.

FUNDING: No funding was provided for this study. 

DISCLOSURES: The author has no conflicts of interest relevant to the content of this article.

ABSTRACT: Background. Work stress (WS) is a set of harmful physical and emotional reactions that occur when the demands coming from work are not adequate to the skills, resources, or needs of the worker. This causes physical, mental, psychological, or social suffering and dysfunction, which can lead to burnout syndrome.

Objective. The aim of this study is to evaluate WS in the healthcare professions, evaluating the effectiveness of a professional stress prevention program to promote a reduction in WS.

Methods. Thirty-three healthcare professionals of the Multiple Sclerosis (MS) rehab ward of the IRCCS Neurolesi (Messina, Italy) were enrolled in this study. The professional stress prevention program was based on group support activities, as well as individual support.

Results. At baseline, we found a high burnout risk in physiotherapists, physicians, and other healthcare professionals. At the end of the meetings, we found a normalization in WS, with a higher sense of personal realization in all of the health-professions, and a greater use of functional coping strategies.

Conclusion. The occupational stress-reducing intervention in healthcare teams can promote a reduction of stress and anxiety, encouraging more functional coping strategies to face work difficulties. 

Keywords: Burnout, work stress, well-being, healthcare system, rehabilitation team

Innov Clin Neurosci. 2021;19(7–9):21-28

Psychological stress is a syndrome of adaptation to the stimuli (stressors) of the internal and/or external environment. The stress reaction depends on the cognitive evaluation of the stressful event.1 Stress is caused by the perception of an “imbalance between available individual resources and environmental needs,” and it is often found in working contexts.2 Work stress (WS) is a set of harmful physical and emotional reactions that occur when the demands coming from work are not adequate to the skills, resources, or needs of the worker.3 WS causes physical, mental, psychological, or social suffering and dysfunction, which can lead to burnout syndrome. 

Burnout syndrome is often found in demanding jobs and in people who care for others, such as teachers and healthcare workers.4 “Helping professions” have an emotionally demanding relationship with users who are in need of care and/or somehow disadvantaged. According to Maslach and Jackson,5 burnout is characterized by emotional exhaustion, the feeling of being emotionally emptied and drained from relationships with others; depersonalization, with negative and cynical attitudes towards users; and reduced personal realization, as a feeling of inadequacy and low professional self-esteem. The Maslach Burnout Inventory (MBI) is the most frequently used questionnaire for investigating burnout in the medical research literature.6

The healthcare system is characterized by the presence of numerous psychosocial and emergency risk factors for workers, such as shift work, the management of emergencies, and the high emotional load due to the constant contact with severe ailing situations.7 Healthcare workers, especially doctors and nurses, are exposed to high levels of persistent tension, which can lead to tiredness and psychological and/or physical discomfort. It has been shown that burnout syndrome can increase the risk of medical errors and reduce job satisfaction, which encourages early retirement.7–9 According to Cooper and Marshall,10 WS and burnout can cause individual and organizational illnesses, such as strikes, frequent and serious accidents, inefficiency, and low productivity. It is noteworthy that all healthcare environments can be potentially at risk of WS. The risk of stress changes considerably in relation to the environments and areas of intervention, the structural aspects, and the organizational choices within the healthcare structures. Stress can result from heavy work hours, uncomfortable shifts, excessive workloads, inadequate work organization, and infrastructure deficiencies (e.g., poor lighting, uncomfortable temperatures, insufficient spaces).11–14 As a consequence, the perception of high WS by healthcare professionals can cause human errors, illnesses, accidents, high turnover, and absenteeism, with immediate damage to the healthcare system.10,15 WS also affects society; the European Commission has calculated that the cost of WS is about 20 billion euros/year, supporting the idea that WS contributes to a considerable increase in health, legal, and social security costs. Furthermore, it can cause deviant changes that can produce violent reactions and criminal acts,16 which might harm possible users of the service. 

Healthcare professionals work in a complex and high-risk system, and they are exposed to the risk of unsafe actions in the care process daily.17 To prevent errors and consequent potential negative health outcomes, both technical and nontechnical skills are essential for healthcare professionals.7 Technical skills refer to professional knowledge and skills, whereas nontechnical skills refer to communication, teamwork, and coping strategies.18,19 Some studies highlighted that nontechnical skills are important key competencies for healthcare professionals to help in preventing mistakes.20,21

WS has repercussions on both healthcare professions (causing a worsening of the quality of the product/service and economic and image damage) and healthcare system (causing a considerable increase in health, legal, and social security costs).22,23 Thus, it would be necessary to recognize critical problems of the healthcare staff in order to identify the measures to improve the problem. Numerous studies have explored WS among healthcare professions in many countries, involving nurses, doctors,4 social workers,24 occupational therapists, and physiotherapists.25 A high prevalence of burnout has been found among practicing doctors, with one-third of doctors having experienced burnout in their careers.26 In a recent study conducted in the United States, 45.8 percent of doctors reported having at least one symptom of burnout.26 A recent systematic review and meta-analysis investigating the prevalence of burnout symptoms in nurses worldwide found that burnout symptoms were present in 11.23 percent of nurses.27 Nurses are the most exposed profession to burnout because they work in direct contact with patients, family members, and multidisciplinary teams.28,29 

Some authors highlighted the importance of educational-training interventions for the prevention of stress and burnout in healthcare teams, especially in neurological and acute wards.30,31 Gillman et al31 carried out a review to identify the most effective strategies to better prepare nurses for practice and to maintain their psychological well-being. The authors found that these procedures should: a) encourage connections within the team; b) provide education and training to develop behaviors that help control or limit the intensity of stress or promote recovery; and c) help process emotions and learning from experiences. Therefore, a series of formal and informal supports to the healthcare team are needed to promote adaptability and resilience. Various studies have shown that professional development activities in the workplace can increase feelings of personal fulfillment and minimize burnout.25 Thus, stress and awareness management programs have proven to be extremely important for preventing and treating burnout by reducing anxiety, exhaustion, and psychological distress and encouraging empathy and mental and physical well-being. In other words, multidisciplinary actions that include changes in environmental work factors, together with stress management programs that teach people how to better cope with stressful events, have shown promising solutions to manage burnout.4 

Chesi et al32 carried out a study to evaluate the quality of life of 105 neurologists and nurses from 30 Italian multiple sclerosis (MS) centers. The authors observed that the healthcare team had compassion fatigue and professional anguish due to the patients’ continued exposure to suffering and distress, which can cause a low sense of realization and severe emotional exhaustion. Indeed, taking care of patients suffering from progressive, degenerative pathologies, such as MS, could cause physical and psychological distress in healthcare workers, with negative repercussions on the healthcare service.33 MS is a chronic, disabling disease that affects the central nervous system (brain, spinal cord, and optic nerves), with severity and symptoms that vary from person to person. The symptoms can appear in an acute or progressive form, producing physical, psychological, and social needs, also considering the mean young age of the patients at onset. MS requires a multiprofessional healthcare team, both for the complexity and variety of the symptoms and for the type of therapies used to slow the progression of the disease.33–37 Healthcare professionals have to adapt to the healthcare needs of MS patients, addressing the failure of the care provided or the distressing experience, as a result of the suffering of young patients.38,39 The complexity of the patient’s care pathway highlights the need for healthcare professions to collaborate and communicate “early and clearly” with each other, as it is well known that teamwork is an important element of patient care in these medical settings. Moreover, functional communication is a protective factor against the manifestation of burnout syndrome.30–32,40 However, operators’ WS influences the relationships and care provided in the healthcare setting, affecting patient satisfaction and therapeutic adherence.41 Indeed, some studies show that patients with MS with low therapeutic satisfaction do not adhere to the treatment plan and can discontinue therapy. Thus, we argue that addressing the discomfort associated with healthcare work might reduce the risk of burnout in healthcare professionals, with positive influences on the healthcare service and greater patient satisfaction.

The aim of this study is to evaluate distress and burnout in the healthcare workers in the MS rehabilitation ward, investigating the effectiveness of a professional stress prevention program to promote a reduction in WS.

Methods

Study population, outcomes, and setting. Thirty-three members of the healthcare staff (mean±standard deviation (SD): 36.74±7.7) of the MS rehabilitation ward of the IRCCS Neurolesi Bonino Pulejo were enrolled in this study, from January 2018 to January 2019. This study was conducted in accordance with the 1964 Helsinki Declaration. Participants provided informed consent for the participation and the publication of the results. Healthcare professionals were included in the study if they had been working in the rehabilitation ward for at least one year and had both day shifts (7am to 1pm or 1pm to 8pm) and night shifts (8pm to 7am). Participants had graduated from high school or completed college and were relatively experienced in work with MS.

The study was based on focus groups involving three physicians (2 neurologists and 1 physiatrist), seven physiotherapists, three speech therapists, 12 nurses, and eight social-health operators (SHO). Two psychologists took care of managing and planning the meetings and implementing the individual support sessions for the healthcare workers. A more detailed description of the group is in Table 1. 

All participants filled out anonymous questionnaires at the beginning (T1) and at the end (T2) of the training. The two questionnaires of the same participant (i.e., the one completed at T1 and that at T2) were matched by using assigned codes, which guaranteed the participant’s anonymity. The questionnaires were filld out anonymously with an informed consent statement (Legislative Decree no. 196 of 30 June 2003 “Personal Data Protection Code”). The participants were evaluated before (T0) and after the training (T1). The following questionnaires were used: MBI; Perceived Stress Scale; State Trait Anxiety Inventory (STAI) Y1 (state) and Y2 (trait); and Coping Orientation to Problems Experienced-New Italian Version (COPE-NVI) (Table 2).

The MS ward, with its 14 dedicated beds, is unique in Italy, having advanced healthcare pathways in robotic and cognitive neurorehabilitation, psychological support, neuropsychological assessment, home automation laboratory, telemedicine monitoring, advanced neuroimaging, neurophysiology advanced tools, and neuro-ophthalmology. All patients with MS, according to their disability, undergo intensive neurorehabilitation training. After a diagnostic-therapeutic work-up, the patients performed a rehabilitation treatment that includes conventional physiotherapy, speech therapy, psychological support, and cognitive rehabilitation, in addition to robotic rehabilitation, advanced cognitive rehabilitation approaches, or virtual reality. Depending on the problems and needs of the patients, the hospitalization lasts for up to two months. 

Study design and intervention. The main difficulty of healthcare workers is to balance the personal (coping strategies, communication, and emotions) and professional (relationships with the team, responsibilities, and professional skills) components during work with consequent anguish and stress.4,42 For this reason, our intervention to reduce stress at work considered two levels, the individual and the environmental (healthcare teams). The latter was based on group support activities to improve the commitment, involvement, empowerment, and recognition of the team’s mutual professionalism. For individual intervention, all operators requested a consultation with the psychologist at least once a month to deepen the management of emotional difficulties related to stress (Table 3).

Twenty-four “Focus Group” meetings were conducted by a psychologist, and each 60-minute meeting was held once a week. During the meetings, the team discussed the main events occurring in the week, with regards to the difficulties emerging in relationships with the patients, considering the emotional and practical aspects of working with patients with MS. The psychologist indicated the functional strategies for taking care of the patient, and the psychological training was based on three aspects. First, the meetings focused on communication styles. It has been shown that effective communication is essential for providing high quality and safe healthcare.43,44 Indeed, the complexity of healthcare and the inherent limitations of human performance makes it extremely important that healthcare professionals have standardized communication tools to speak, discuss, and express concerns among team members and with patients and family members. Effective communication depends on the situation or personality of the healthcare worker, hence why we considered it important to implement communication skills, favoring assertive and effective communication. We encouraged the development of assertive communication, that is, the ability to express positive and negative ideas and feelings in an open, honest, and direct way; it is a psychological and behavioral anti-stress factor to express needs and act positively on the stressful behaviors of others (colleagues or patients). It allows the healthcare worker to take responsibility for their self without judging or blaming other people.45 Assertive communication was potentiated through the recognition of emotional reactions and the ability to express opinions competently and without overpowering others. Moreover, the meetings focused on cognitive schemes (i.e., the idea of one’s own and others’ behavior). Cognitive techniques have been shown to have a significant effect on the prevention and treatment of burnout by healthcare professionals.4,46 Thus, each operator was able to manage events with greater awareness, understanding better the emotional and behavioral reactions of other people.

Finally, the meetings increased the functional coping styles to effectively face stressful situations and encouraged cognitive methods, such as planning, behavioral approach, individual resources (e.g., optimism, control of beliefs about events), and environmental issues. During the meetings, effective, task-oriented coping strategies that favor emotional management and solving daily problems proactively to encourage resilience, health, well-being, and better job satisfaction, were promoted.

Statistical analysis. Data were analyzed using SPSS version 18.0, considering a p<0.05 to be statistically significant. Descriptive statistics were analyzed and expressed as mean±SD or as median±first third quartile for continuous variables, as appropriate; frequencies (%) were used for categorical variables. The normality of the variables was analyzed using the Kolmogorov-Smirnov test. Since most of the target variables were non-normal distributed, a nonparametric analysis was performed. Thus, the Wilcoxon signed-rank test was used to compare the group between baseline and the end of the study (intra-group analysis). 

Results

All participants completed the study. The Wilcoxon signed-rank test results showed significant differences in some domains we evaluated (Table 4). In fact, significant pre-and post-training differences emerged, with an improvement in the perceived personal achievement index (MBI-PR<0.01), reduction of stress (SSP=0.03) and anxiety (STAI Y1/Y2<0.001), and managing stressful events (COPE) (Figures 1, 2, and 3). Concerning the  “perceived stress at work,” a low level of personal achievement was observed in all of the healthcare professionals (Figure 1). In particular, there was a greater burnout risk at the baseline in physiotherapists, as they had a high level of perceived stress (SSP 17.6±1.6), with greater emotional exhaustion (MBI-EE 18.6±8.3) and depersonalization (MBID 5.0±4.3), and medium personal realization (MBI-PR 38.4±7.0). Medium-high levels of stress were observed in physicians and nurses (SSP 22.0±1.2 and 15.1±3.1, respectively), and medium-low levels of personal realization (MBI-PR 25.0±4.6 and 37.5±5.9, respectively).

Also, we observed that there was a significantly low personal realization in speech therapists (MBI-PR 26.3±6.6). In SHO, there was high emotional exhaustion (MBI-EE 23.0±0.3). At the end of the meetings, we found a normalization in the perceived stress levels, with a greater sense of personal realization in all of the health professions (Figure 1). Moreover, the high levels of anxiety (especially among physicians, physiotherapists, and speech therapists) observed in the initial phase decreased at the end of the project (Figure 2). Finally, coping strategies at T1 were more functional, with a reduction in avoidance strategies (COPE-A<0.001) and transcendent orientation strategies (COPE-TO=0.02), and an increase in social support strategies (COPE-SS=0.01) (Figure 3).

Discussion

To the best of our knowledge, this is the first study carrying out an intervention on various healthcare professionals involved in an MS inpatient care ward. Our data support the idea that WS-reducing intervention can be helpful in decreasing burnout risk, as well as in improving mood and adaptation to the work environment of healthcare professionals. In our sample, all professional figures presented one or more risk indices for work-related stress and burnout. In particular, the most at-risk healthcare workers were physiotherapists, who had high scores both in the MBI and SSP, followed by doctors and nurses. While various studies have observed similar results in nurses and doctors, few studies have dealt with other health categories, such as physiotherapists. Indeed, Schlenz et al highlighted that burnout risk is high in this latter category and is directly related to the nature of the work done.25 We believe that one of the strengths of our study was to involve the whole multidisciplinary team, adopting group discussions to encourage stress reduction. The group discussion, with the enhancement of personal resources and the strengthening of and coping strategies, allows the normalization of emotional states and the use of more functional strategies for managing work difficulties. 

According to a previous study, we have shown that measuring and intervening in WS can promote working well-being, with positive effects both at a personal and relational level, and can reduce burnout-risk. Therefore, our data highlight the need to consider the well-being and stress of workers through the recognition of needs and the prevention of psychosocial risks, since these aspects represent an essential objective of the process of personal and organizational growth and development, in particular for the healthcare context.15,48,49 However, our data confirm the importance of incentivizing both technical and nontechnical skills, such as communication, teamwork, and coping strategies, through adequate focus group programs to reduce stress and burnout and promote the well-being of the operators, with possible positive repercussions in the assistance provided as well. Various systematic reviews have reported that intervention on psychological and cognitive behavioral skills of healthcare professionals is useful in the reduction and prevention of WS, especially if group treatments are used, being more convenient and beneficial than individual counseling.50–54 Krasner and colleagues assessed the effects of an intensive educational program that included self-awareness exercises, clinical experience narratives, teaching materials, and group discussions. Participants demonstrated improvements in awareness, general mood, empathy (emotional exhaustion), personal achievement, and personality during the training with sustained effects of up to 15 months.54 

In our focus group, the emergence of adaptive schemes had been urged through group discussion and psychoeducational techniques, which allowed useful skills and competencies to overcome critical situations more effectively.25 The meetings increased the functional coping styles to effectively face stressful situations. Some studies have shown that healthcare professionals using productive coping strategies tend to experience lower levels of emotional exhaustion and stress4 and present better health and well-being, longevity of work, and quality of patient’s care.4,31,34 The interventions promoting personal skills can reduce stress, improve relationships, and support the self-reflection needed to provide patient-centered care, with greater patient satisfaction. According to Lazzari,33 there is a close correlation between WS and patient satisfaction, and more disabling conditions may cause higher levels of WS. It is well known that WS and burnout depend on the nature of the work itself; operators in emergency departments or in contact with patients with acute or degenerative diseases are at greater risk of burnout.7,32,41 In our study, we highlighted that an operational project that involves all the healthcare professionals of an MS ward can be useful to improve social support, sharing, and acceptance of the points of view of each operator.5,22,46 Furthermore, the psychological support provided to the operators can provide a better way to face the sufferings of the patients and draw positive work experiences.55–56

Overall, our study underlined the importance of intervention on the psychophysical well-being of the whole healthcare team in daily contact with the suffering of patients with neurological diseases. All the therapists faced serious risk for burnout. In addition, all operators benefitted from the stress reduction intervention due to both the individual support and the focus group. In particular, the group context has proven an important resource for involving all operators, even the most reluctant ones, by encouraging participation and involvement in work dynamics. At the end of the intervention, all participants presented high levels of personal realization. The open discussion and comparison of the problems encountered gave value to each member of the team, resulting in recognition of individual responsibilities and mutual competences. We have also observed a higher satisfaction and cohesion in the ward among the patients, who have verbalized appreciation for the team and maintained contacts with the structure and operators after discharge. In the future, it might be important to evaluate the degree of satisfaction of users with specific tests to validate our observations. 

Limitations. The main limitation of the study is the small sample size. Healthcare professionals who participated in the project were self-selected, and the sample cannot be considered representative of the department’s population. Those who responded were people who are motivated and interested in the topic or more exposed to burnout risk, potentially leading to a sampling bias. Another limitation of the study is the lack of a control group. We had some difficulty defining a comparison group, given the circumstances of this study; however, in the future, new studies could be conducted using a control group (e.g., receiving supportive therapy) to better evaluate the effectiveness of our WS intervention.

Conclusion

Occupational stress-reducing intervention in healthcare teams can promote a reduction of stress and anxiety, encouraging more functional coping strategies to face work difficulties. These aspects could be fundamental to stimulate the psychological well-being of healthcare professionals and the healthcare environment, with possible positive repercussions on patient satisfaction. Further studies with larger samples and longer follow-up periods are needed, also evaluating the degree of patients’ satisfaction, to confirm our promising results.

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