Maslach Burnout Inventory Depersonalization Research Articles

Psychosocial Loads Caused by Covid-19 Pandemic on Obstetricians and Gynecologists. A Scale Study

Introduction: The novel coronavirus infection (COVID-19) has caused a worldwide pandemic. The pandemic created a heavy psychological burden on healthcare workers. Healthcare providers in obstetrics and gynecology faced similar challenges. Aim: This study studied obstetricians' and gynecologists' psychosocial burdens and concerns due to the COVID-19 pandemic. Methods: Participants of the study consisted of obstetricians and gynecologists. They reached through social media using the snowball sampling technique. This is a survey and scale study. The researchers created the survey. The survey questioned the demographic characteristics of the participants and the problems caused by the COVID-19 pandemic. In addition, three different scales were applied to the participants: Maslach Burnout Inventory, Coronavirus Anxiety Scale, and Depression Anxiety Stress Scale-21. Results: The statistically significant difference was found for Maslach Burnout Inventory Personal Achievement and Maslach Burnout Inventory General. Maslach Burnout Inventory Depersonalization and Coronavirus Anxiety Scale scores of the participants working in pandemic hospitals were statistically significantly higher than those not working in these hospitals. According to the MANOVA results, independent variables explained 35% of the variance in the Maslach Burnout Inventory General scale, 51% in the Coronavirus Anxiety Scale, and 53% in the overall Depression Anxiety Stress Scale. Conclusion: Healthcare personnel who provide obstetric and gynecologic services have faced unique challenges during the COVID-19 pandemic, and to the difficulties experienced by other healthcare workers.

Burnout, Resilience, and Mindfulness in Healthcare Workers in a Medically Underserved Region during the COVID-19 Pandemic.

To evaluate employee burnout, work conditions, resilience, and mindfulness at an academic medical center in a US medically underserved region during the coronavirus disease 2019 pandemic. We surveyed employees from August 7, 2020 to January 17, 2021. Respondents completed the Maslach Burnout Inventory (MBI), the Areas of Worklife Survey, the Connor-Davidson Resilience Scale, and the Philadelphia Mindfulness Scale (PHLMS) and answered a question about intention to stay in the present job until retirement. We performed exploratory stepwise logistic regression to evaluate associations between variables and intention to stay. We evaluated associations between variables with a structural equation model (SEM). The 655 respondents mostly were White women providers, aged 50 years and younger, who worked in inpatient wards, emergency departments, or intensive care units. Respondents had high mean MBI emotional exhaustion (35 ± 12) and moderate MBI depersonalization (12 ± 6), despite high MBI personal accomplishment (43 ± 8), middle-range Areas of Worklife Survey results, and middle to high Connor-Davidson Resilience Scale scores (29 ± 5), PHLMS awareness scores (37 ± 6), and PHLMS acceptance scores (30 ± 8). There were 408 respondents (62%) with MBI latent profiles consistent with being burned out, but 447 respondents (68%) were willing to stay in their present job. Older age was associated with intention to stay (coefficient 1.1 ± 0.1; P < 0.001). The latent variable burnout structural equation model (burnout-SEM) constructed from the MBI subscales inversely predicted intention to stay (coefficient - 0.33; P < 0.001), and this relationship was mediated by age. Burnout was prevalent despite substantial personal accomplishment, resilience, and mindfulness.

Do incoming residents vary in measures of emotional status even prior to residency training?

To determine whether Empathy, Emotional Intelligence, and Burnout scores differ by specialty in incoming residents. This is a single-site, prospective, cross-sectional study. Three validated survey instruments, the Jefferson Scale of Physician Empathy, Maslach Burnout Inventory, and Emotional and Social Competency Inventory, were written into a survey platform as a single 125-question Qualtrics survey. Over three academic years, 2015-2017, 229 incoming residents across all specialties were emailed the survey link during orientation. Residents were grouped by incoming specialty with anonymity assured. A total of 229 responses were included, with 121 (52.8%) identifying as female. Statistical analysis was performed using the Analysis of Variance or Kruskal-Wallis test, Chi-Square or Fisher's Exact test, and Independent Samples t-test or Mann Whitney U test. A Bonferroni correction was applied for pairwise comparisons. Family Medicine had a higher median Jefferson Scale of Physician Empathy score (127) compared to Emergency Medicine (115), (U=767.7, p=0.0330). Maslach Burnout Inventory depersonalization and personal accomplishment subcategory scores showed a significant difference between specialties when omnibus tests were performed, but pairwise comparisons with emergency medicine residents showed no differences. Differences were found in the Maslach Burnout Inventory categories of Depersonalization (χ2(8, N=229) =15.93, p=0.0434) and Personal Accomplishment level (χ2(8, N=229) =20.80, p=0.0077) between specialties. Differences in measures of well-being exist across specialties, even prior to the start of residency training. The implication for educators of residency training is that some incoming residents, regardless of specialty, already exhibit troublesome features of burnout, and resources to effectively deal with these residents should be developed and utilized.

Burnout among early career psychiatrists in Russia – results of a cross-sectional study

IntroductionDespite the long history of burnout studies, the problem of burnout among psychiatric specialists in Russia is insufficiently studied. The risk of burnout is the highest among psychiatrists in the first 10 years of their career.ObjectivesTo assess the prevalence and severity of burnout in early career psychiatrists (ECPs) in Russia.MethodsAn anonymous online survey of ECPs in Russia was conducted in July-August 2019 with a screening for burnout using the Maslach Burnout Inventory (MBI). The final sample consisted of 165 people (61.2% women; mean age 31.05±3.88). 95.2% of respondents lived in urban areas.ResultsA high level of burnout according to at least one of the MBI scales was revealed in 71.5% of ECPs: in 79 (78.2%) women and 39 (60.9%) men (χ2(1)=5.74; p=0.017). Mean values of the MBI Emotional Exhaustion scale corresponded to 23.33±8.97 and 17.97±8.49 (U=1999.5; p=0.003), the MBI Depersonalization scale – 10.46±4.81 and 9.16±4.22 (U=2598.5; p=0.083), and the MBI Personal Accomplishment scale – 33.02±5.98 and 35.32±5.75 (U=2409.5; p=0.026) for women and men, respectively. The following risk factors for professional burnout were identified: female sex (OR=3.54 [95% CI: 1.96; 6.39], p&lt;0.001), overlapping of several working positions (OR=2.44 [95% CI: 1.36; 4.37], p=0.003), difficulties in work due to changes in documentation requirements introduced since the start of career (OR=2.32 [95% CI: 1.31; 4.11], p=0.004).ConclusionsA high frequency of burnout among ECPs in Russia was revealed which suggests the urgent need for studies assessing the ways to prevent burnout in psychiatrists in Russia.DisclosureNo significant relationships.

Work‐life balance and burnout in financial planning profession

AbstractThis study examines the work environment outcomes in the financial planning profession, job‐related burnout, and work‐life balance satisfaction, using a convenience sample of survey respondents employed in the financial planning profession. The study compares subgroups based on gender, job role, firm size, and their CFP® certification controlling for relevant factors such as type of industry, weekly working hours, work‐life conflict, the flexibility provided by the employer, and demographics. Results indicated that the women in smaller firms are more satisfied with work‐life balance. In general, smaller firm sizes are associated with lower personal accomplishment, higher satisfaction from work‐life balance, and lower impersonal response toward clients measured by Depersonalization scores of Maslach Burnout Inventory (MBI). MBI Depersonalization scores are higher for CEOs and owners of the firms. In addition, the CFP® certification is associated with greater satisfaction from work‐life balance. The results build on previous research to provide insight into aspects that can improve participation in the profession. Future research should find ways to attract diverse participants to improve success and satisfaction outcomes for all professionals and firm sizes.

Characteristics and determinants of professional burnout among early career psychiatrists in Russia — results of a cross-sectional study

The aim of the present study was to examine the characteristics of early career psychiatrists’ (ECP) work in Russia and to assess the prevalence and severity of burnout in them. Material and methods. The Early Career Psychiatrists Council of the Russian Society of Psychiatrists conducted an anonymous online survey of ECP in Russia in July-August 2019, consisted of a structured survey and screening for professional burnout using the Maslach Burnout Inventory (MBI). The final sample consisted of 165 people. Results. A high level of burnout according to at least one of the MBI scales was revealed in 79 (78.2%) women and 39 (60.9%) men (p=0.017). Mean values of the MBI Emotional Exhaustion scale corresponded to 23.33±8.97 and 17.97±8.49 (p=0.003), the MBI Depersonalization scale — 10.46±4.81 and 9.16±4.22 (p=0.083), and the MBI Personal Accomplishment scale — 33.02±5.98 and 35.32±5.75 (p=0.026) for women and men, respectively. The following risk factors for professional burnout were identified: female sex, overlapping of several working positions, difficulties in work due to changes in documentation requirements introduced since the start of professional career. Protective factors of burnout development were: work in private clinic, satisfaction with work atmosphere, subjective estimation of quality of life as above average or as good as possible. Conclusion. Burnout was established in 71.5% of ECP in Russia, which corresponds to one of the highest burnout rates in psychiatrists according to international and national studies. Further research is needed to assess the prevalence and severity and ways to prevent burnout in psychiatrists in Russia.

COVID-19 Patient Care Leading to Occupational Burnout in Resident Doctors: A Follow-up Study.

Burnout during residency may require reorganization of health services during the COVID-19 pandemic. This study mainly aimed to compare the burnout levels between resident doctors who cared and those who did not care for COVID-19 patients at the …. University Hospital, which has been serving as a pandemic hospital during the COVID-19 outbreak. The study was designed as a cross-sectional study. One hundred resident doctors were recruited to the first phase of the current study between April 1, 2020 and June 30, 2020 (T1).These participants were then followed-up and re-called to participate in the second phase of the study between October 30, 2020 and November 30, 2020 (T2). Eighty-four resident doctors were available and agreed to participate in the second phase of the study. Once the participants accepted to participate in the study, they were asked to complete "the Evaluation Form," "the Patient Health Questionnaire-9 (PHQ-9)," "the Beck Anxiety Inventory (BAI)," and "the Maslach Burnout Inventory (MBI)." In both T1 and T2 periods, the resident doctors who provided care to COVID-19 patients had significantly higher BAI and PHQ-9 scores compared to the scores of those who did not care for COVID-19 patients (P < .05). Moreover, in the T2 period, the Maslach Burnout Inventory-Emotional Exhaustion (MBI-EE) and Maslach Burnout Inventory-Depersonalization (MBI-DP) scores of the resident doctors who cared for COVID-19 patients were detected as significantly higher than the scores of those who did not care for COVID-19 patients. This study demonstrated that resident doctors who cared for COVID-19 patients face increased problems of burnout, anxiety, and depression levels.

Incidence of a negative hidden curriculum, cynicism, and burnout within pharmacy resident education: A nationwide survey

IntroductionThe term “hidden curriculum” (HC) is a set of ethical, moral, and value-based teachings communicated in a non-explicit manner. Recent literature has described increasing awareness of the prevalence of the HC and potential negative impact on medical learners; however, this information is lacking in pharmacy resident education. Consequently, we conducted a survey study of United States pharmacy residents to learn their perceptions concerning the HC in pharmacy residency training. MethodsA nationwide survey of pharmacy residents was conducted in June 2019. The survey assessed the following: presence of negative HC (score 0 to 80), cynicism (score 0 to 25), burnout via Maslach Burnout Inventory depersonalization (MBI-D) (range 0 to 30), and emotional exhaustion via Maslach Burnout Inventory emotional exhaustion (MBI-EE) (range 0 to 54). Higher scores represent increased occurrences of each domain. ResultsThe mean HC score was 20 (SD 14.7), mean cynicism score was 9 (SD 5.5), MBI-D was 5.5 (SD 4.5), and MBI-EE was 24.2 (SD 12.4). Of those completing an MBI score, 40.4% (82/203) reported burnout in one area, while 15.8% (32/203) reported burnout in both areas. Residents reporting burnout had higher mean HC and cynicism scores. ConclusionsAwareness to develop and grow cultures that minimize the presence of a negative HC is essential to improve postgraduate pharmacy training.

Establishing Crosswalks Between Common Measures of Burnout in US Physicians

BackgroundPhysician burnout is often assessed by healthcare organizations. Yet, scores from different burnout measures cannot currently be directly compared, limiting the interpretation of results across organizations or studies.ObjectiveTo link common measures of burnout to a single metric in psychometric analyses such that group-level scores from different assessments can be compared.DesignCross-sectional survey.SettingUS practices.ParticipantsA total of 1355 physicians sampled from the American Medical Association Physician Masterfile.Main MeasuresWe linked the Stanford Professional Fulfillment Index (PFI) and Mini-Z Single-Item Burnout (MZSIB) scale to the Maslach Burnout Inventory (MBI) in item response theory (IRT) fixed-calibration and equipercentile analyses and created crosswalks mapping PFI and MZSIB scores to corresponding MBI scores. We evaluated the accuracy of the results by comparing physicians’ actual MBI scores to those predicted by linking and described the closest cut-point equivalencies across scales linked to the same MBI subscale using the resulting crosswalks.Key ResultsIRT linking produced the most accurate results and was used to create crosswalks mapping (1) PFI Work Exhaustion (PFI-WE) and MZSIB scores to MBI Emotional Exhaustion (MBI-EE) scores and (2) PFI Interpersonal Disengagement (PFI-ID) scores to MBI Depersonalization (MBI-DP) scores. The commonly used MBI-EE raw score cut-point of ≥27 corresponded most closely with respective PFI-WE and MZSIB raw score cut-points of ≥7 and ≥3. The commonly used MBI-DP raw score cut-point of ≥10 corresponded most closely with a PFI-ID raw score cut-point of ≥9.ConclusionsOur findings allow healthcare organizations using the PFI or MZSIB to compare group-level scores to historical, regional, or national MBI scores (and vice-versa).

A simple screening tool for occupational burnout among dentists

BackgroundNearly 40% of US physicians experience occupational burnout. The actual prevalence rate of burnout among US dentists remains unknown. The authors examined a simplified 2-item burnout screening tool based on the Maslach Burnout Inventory (MBI) to identify possible occupational burnout among dentists. MethodsData were obtained from a survey of pediatric dentists (n = 540) in the United States. The full MBI items from the data set were used to determine and categorize emotional exhaustion and depersonalization. Responses to 2 MBI items, 1 for emotional exhaustion and 1 for depersonalization, were analyzed separately and risk of experiencing high MBI emotional exhaustion and depersonalization was calculated using all subscale items for these 2 burnout dimensions. Spearman correlations were used to compare responses to the 2 MBI items and MBI emotional exhaustion and depersonalization. ResultsBased on frequency of at least once per week, 18% of respondents had positive response to MBI item “I feel burned out from my work” and had high MBI emotional exhaustion, and 9% had positive response to MBI item “I have become more callous toward people since I took this job” along with high MBI depersonalization. The risk of experiencing the burnout dimensions of high emotional exhaustion and depersonalization increased with positive frequency score for the respective MBI items. There were strong positive correlations between responses to the 2 MBI items and emotional exhaustion and depersonalization scores, respectively. ConclusionsA simple 2-item burnout screening tool can be used to identify potential occupational burnout among dentists. Practical ImplicationsImproving awareness about occupational burnout can help mitigate its detrimental consequences.

Developing Emotional Intelligence Through a Longitudinal Leadership Curriculum in UME: Combating the Decline in Medical Student Empathy.

We report on a novel curriculum (Scholarly Excellence, Leadership Experiences, Collaborative Training [SELECT]) in an allopathic medical school designed to prepare students to be physician leaders while remaining empathetic by combating burnout. SELECT students were surveyed annually. The survey contained the Jefferson Scale of Empathy (JSE) and Maslach Burnout Inventory (MBI). In this cohort, empathy did not decrease, as measured by the JSE, and SELECT students' MBI Depersonalization burnout scores decreased after year 3. In summary, in this allopathic US medical school utilizing a novel curriculum, there was no significant decline in empathy after the third year of medical school. The SELECT program appears to mitigate the decline in empathy and increased Depersonalization burnout levels often seen at the end of the third year of medical school.

From Resilience to Burnout: Psychological Features of Italian General Practitioners During COVID-19 Emergency.

During the COronaVIrus Disease 2019 (COVID-19) pandemic in Italy, general practitioners (GPs) are ensuring continued access to primary care for citizens while also absorbing more of the impact of the crisis than most professional groups. The aim of this study is to explore the relationships between dimensions of burnout and various psychological features among Italian GPs during the COVID-19 emergency. A group of 102 GPs completed self-administered questionnaires available online through Google Forms, including Maslach Burnout Inventory (MBI), Resilience Scale, Intolerance of Uncertainty Scale Short Form (IU), and Coping Inventory for Stressful Situations (CISS). Cluster analysis highlighted four distinct burnout risk profiles: Low Burnout, Medium Risk, High Risk, and High Burnout. The High Burnout group showed both lower Resilience and lower CISS Task-oriented coping strategy than the Medium Risk group and higher IU Prospective than the Low Burnout group. Results of a linear regression analysis confirmed that CISS Emotion-oriented style positively predicted MBI Emotional Exhaustion, CISS Task-oriented and Emotion-oriented emerged as significant predictors (negatively and positively, respectively) of MBI Depersonalization, and Resilience positively predicted MBI Personal Accomplishment. In conclusion, the results showed that the COVID-19 emergency had a significant impact on GPs’ work management. Implementing task-oriented problem management, rather than emotional strategies, appears to protect against burnout in these circumstances. It is possible that the emotions related to the pandemic are too intense to be regulated and used productively to manage the professional issues that the COVID-19 pandemic presents.

Burnout and Protective Factors: Are They the Same Amid a Pandemic?

Burnout and Protective Factors: Are They the Same Amid a Pandemic?

Wellness Principles Correlate With More Favorable Burnout Scores in Junior Anesthesiology Residents

Strategies to prevent or reduce burnout for anesthesiology residents remain relatively unexplored. We aimed to determine if participation in a wellness course would be associated with lower burnout. A prospective, case-control survey/questionnaire study was implemented within a single anesthesiology residency in a large academic medical center program. One class participated in an inaugural wellness course (n = 15) promoting particular wellness principles 4 months into their postgraduate year (PGY)-1, while another class with no course participation served as controls (n = 13). Both groups completed the Maslach Burnout Inventory (MBI) 6 months into their PGY-2 year. In addition, a survey measuring their perceived ability to implement wellness principles (regardless of course participation) as well as validated questionnaires measuring stress, depression, and sleep quality were administered. Course participants had a trend toward lower MBI depersonalization scores; however, this was not statistically significant (MBI score 7 versus 12, P = .078, Cohen d 0.71). In a multivariable model, course participation yielded lower exhaustion scores (P = .011) whereas higher stress yielded higher exhaustion scores (P = .013), and higher depression scores yielded higher depersonalization scores (P = .019). A higher perceived ability to implement the wellness principles resulted in significantly better scores in all 3 burnout components (exhaustion P = .049, depersonalization P = .004 achievement P = .001). Residents who felt they could implement wellness principles had lower burnout, regardless of course participation. Our brief course exposure had only marginal independent effects, suggesting that more longitudinal and repeated exposures to wellness training are likely required to produce a more effective outcome for mitigating burnout.

Burnout and cognitive impairment: Associated with serum BDNF in a Chinese Han population

BackgroundSome studies have demonstrated that subjects with chronic burnout showed cognitive impairments; however, cognitive performance in burnout has been under-investigated. Increasing evidence show that brain-derived neurotrophic factor (BDNF) plays a critical role in cognitive function. We hypothesized that decreased BDNF may be associated with cognitive impairments in burnout, which has not been investigated yet. The aim of the present study was to examine the association of BDNF with cognitive impairment in burnout. MethodUsing a cross-sectional design, 712 healthy subjects were recruited from a general hospital and they were all measured with the Maslach Burnout Inventory (MBI). We assessed part of subjects on the repeatable battery for the assessment of neuropsychological status (RBANS) (n=192) and serum BDNF levels (n=127). Results30.5% of the subjects had burnout. Compared to those non-burnout subjects, the burnout subjects were younger, had significant lower BDNF levels (p=0.003) and scored lower on immediate memory, RBANS total score and attention (all p<0.05). Interestingly, after the Bonferroni correction, there were negative correlations between BDNF and MBI total score or reduced professional accomplishment (PA). Moreover, BDNF was positively associated with immediate memory, attention and RBANS total score. Further multiple regression analysis showed that BDNF was an independent contributor to the RBANS total score and attention, and BDNF and MBI depersonalization (DP) were independent contributors to immediate memory. In addition, there was mediating effect of BDNF in the relation between burnout and cognitive impairments. ConclusionsOur results suggest that burnout is associated with significant cognitive impairments and decreased BDNF. Moreover, decreased BDNF is associated with cognitive impairments in burnout.

The Effect of the Hidden Curriculum on Resident Burnout and Cynicism

Residents learn and participate in care within hospital cultures that 5 tolerate unprofessional conduct and cynical attitudes, labeled the "hidden curriculum." We hypothesized that this hidden curriculum 5 have deleterious effects on residents' professional development and investigated whether witnessing unprofessional behavior during residency was associated with burnout and cynicism. We surveyed internal medicine residents at 2 academic centers for 3years (2008-2010). Hidden curriculum items assessed exposure to unprofessional conduct. We used regression analyses to examine if hidden curriculum scores were associated with cynicism and the Maslach Burnout Inventory depersonalization and emotional exhaustion domain scores. The response rate was 48% (337 of 708). In the 284 surveys analyzed, 45% of respondents met burnout criteria and had significantly higher hidden curriculum scores (26 versus 19, P < .001) than those not meeting criteria. In cross-sectional analyses, the hidden curriculum score was significantly associated with residents' depersonalization, emotional exhaustion, and cynicism scores. Cynicism scores were also associated with burnout. Exposure to unprofessional conduct was associated with higher burnout and cynicism scores among internal medicine residents. We also found that cynicism and burnout were significantly associated and 5 be measures of similar but not necessarily identical responses to the challenges posed by residency. Measuring the hidden curriculum and cynicism 5 provide direction for educators attempting to reform hospital culture and improve resident well-being.

High frequency of the cancer-predisposing TP53 mutation R337H in the population of south Brazil – evidence for a founder effect

Some studies have demonstrated that subjects with chronic burnout showed cognitive impairments; however, cognitive performance in burnout has been under-investigated. Increasing evidence show that brain-derived neurotrophic factor (BDNF) plays a critical role in cognitive function. We hypothesized that decreased BDNF may be associated with cognitive impairments in burnout, which has not been investigated yet. The aim of the present study was to examine the association of BDNF with cognitive impairment in burnout.Using a cross-sectional design, 712 healthy subjects were recruited from a general hospital and they were all measured with the Maslach Burnout Inventory (MBI). We assessed part of subjects on the repeatable battery for the assessment of neuropsychological status (RBANS) (n = 192) and serum BDNF levels (n = 127).30.5% of the subjects had burnout. Compared to those non-burnout subjects, the burnout subjects were younger, had significant lower BDNF levels (p = 0.003) and scored lower on immediate memory, RBANS total score and attention (all p < 0.05). Interestingly, after the Bonferroni correction, there were negative correlations between BDNF and MBI total score or reduced professional accomplishment (PA). Moreover, BDNF was positively associated with immediate memory, attention and RBANS total score. Further multiple regression analysis showed that BDNF was an independent contributor to the RBANS total score and attention, and BDNF and MBI depersonalization (DP) were independent contributors to immediate memory. In addition, there was mediating effect of BDNF in the relation between burnout and cognitive impairments.Our results suggest that burnout is associated with significant cognitive impairments and decreased BDNF. Moreover, decreased BDNF is associated with cognitive impairments in burnout.

Psychiatric Morbidity and Burnout in the Medical Profession: An Italian Study of General Practitioners and Hospital Physicians

Background: Burnout and psychological stress symptoms represent a major problem among health care professionals. The aim of this study was to investigate the prevalence of and the relationship between psychiatric morbidity and burnout among a convenience sample of Italian primary care physicians (GPs) and hospital physicians (HPs). Method: The sample consisted of 328 physicians (182 GPs and 146 HPs) who completed the 12-item version of the General Health Questionnaire and the Maslach Burnout Inventory (MBI). Results: The global prevalence of psychiatric morbidity was 22.3% (20.3% among GPs and 24.6% among HPs). Symptoms of emotional exhaustion were reported by 27.5% of the participants (GPs: 32.4%; HPs: 21.2%), depersonalization by 25.6% (GPs: 27.4%; HPs: 22.6%) and low personal accomplishment by 12.8% (GPs: 13.1%; HPs: 12.3%). No significant difference was found between the two groups, except higher levels of emotional exhaustion among GPs. Female GPs reported lower scores on MBI depersonalization and female HPs lower scores MBI personal accoplishment than male GPs and HPs, respectively. Conclusions: The study underscores the significant problem of stress among physicians and indicates the need for supporting health professionals in order to improve their psychological well-being and, possibly, the quality of their relationship with the patients.