1. Engagement and burnout among
health professionals: Preliminary
data from 7 countries
Anthony Montgomery, Katerina Georganta
University of Macedonia, Greece
Efharis Panagopoulou, AUTH, Greece
The research leading to these results has received funding from the European Union’s Seventh
Framework Programme [FP7-HEALTH-2009-single-stage] under grant agreement no. [242084].

2. Layout of my talk
 What is the ORCAB project?
 Progress to date
 Looking at the hospital as an organisation
 Reflections

3. ORCAB: Improving quality and safety in the
hospital: The link between organisational culture,
burnout and quality of care
 Relatively little systematic assessment of
organisational culture or quality of care in
hospitals†
 Job burnout is a significant problem in terms
of patient safety and occupational well being*
†
McGowan Y, Humphries N, Morgan K, Conry M, Montgomery A, Vedhara K, Panagopoulou E, McGee H: Defining Quality
of care in hospitals: A ten year systematic review of the literature 2000-2010 (in preparation).
*Montgomery, A.J., Panagopoulou, E., Kehoe, I., Valkanos, E. (2011). Connecting organisational culture and quality of care
in the hospital: Is job burnout the missing link? Journal of Health Organisation and Management, 25, 108-123.

4. Beneficiary name Country Lead Researcher
E. Panagopoulou
Aristoteleio University of
Greece Director of the Professional Development Unit,
Thessaloniki
(lead researcher)
Anthony Montgomery
University of Macedonia Greece
Assistant Professor of Work Psychology
Feride Sacaklioglou
Ege University Turkey
Professor of Public Health
Ana Passos
Centro de Investigação e
Portugal Professor of Social and
Intervenção Social
Organisational Psychology
Babes Bolyai University Adriana Baban
Romania
Romania Professor of Health Psychology
Health Psychology Research Irina Todorova
Bulgaria
Center Director
Medical school University of Jadranka Mustajbegovic
Croatia
Zagreb Professor of Public Health
Jovanka Karadzinska-Bislimovska
The Institute of Occupational
FYROM Director of the WHO Collaborating Center for
Health
Occupational Health
Kavita Vedhara
University of Nottingham UK
Chair of Health Psychology
Royal College of Surgeons in Hannah McGee
Dean, Medical Faculty
Ireland
Ireland

5. How did
it all
start?

6. Do hospital physicians learn?
 We can imagine that continuously updating
education and performance would be
especially desirable for doctors
 Recent review* on the impact of work based
assessment on doctors’ education and
performance found little evidence
 Put simply, there was little evidence that
assessing work performance was leading to
actual behaviour change among doctors
* [BMJ 2010;341:c5064doi:10.1136/bmj.c5064]

7. Evidence of DeLearning
 *Doctors inappropriately self-medicate
and self-treat at alarming high levels (even
for chronic diseases!)
 ^Physicians feel less stressed when they
conceal information
*Montgomery, A.J., Bradley, C., Rochfort , A. & Panagopoulou, E. (2011). Self-treatment:
a neglected occupational hazard for physicians and medical students. Occupational
Medicine, doi:10.1093/occmed/kqr098.
^Panagopoulou, E., Minzitori, G., Montgomery A.J, Kapoukranidou, D., & Benos, A.
(2008). Concealment of information in clinical practice: Is lying less stressful than telling
the truth? Journal of Clinical Oncology, 28, 1175-1177.

8. ORCAB: Improving quality and safety in the
hospital: The link between organisational culture,
burnout and quality of care
 Phase 1: Systematic Reviews
 Phase 2: Focus Groups & Interviews
 Phase 3: Survey
 Organisational culture
 Quality of Care
 Job burnout/engagement
 Phase 4: Action Research

9. Burnout
Emotional Depersonalisation % *Diagnosed
Exhaustion with Burnout
M (sd) M (sd) N (%)
Greece (N = 688) 22.55 (11.53) 6.81 (5.74) 115 (16.7%)
Portugal (N = 152) 16.66 (9.46) 3.73 (4.32) 7 (4.6%)
Bulgaria (N = 200) 23.30 (13.45) 4.73 (5.95) 24 (12%)
Romania (N = 368) 15.42 (10.67) 3.98 (4.78) 22 (6%)
Turkey (N = 501) 27.86 (12.91) 10.00 (7.71) 175 (34.9%)
Croatia (N = 198) 17.33 (10.77) 3.84 (4.29) 8 (4%)
FYROM (N = 325) 15.37 (11.46) 2.76 (4.30) 13 (4%)
*Schaufeli WB, van Dierendonk D. Utrechtse Burnout Schaal (UBOS), handleiding [Utrecht Burnout Scale, manual].
Utrecht: Swets & Zeitlinger 2000.

10. Engagement
Vigour Dedication
M (sd) M (sd)
Greece (N = 688) 4.39 (1.17) 4.43 (1.37)
Portugal (N = 152) 4.22 (1.19) 4.28 (1.37)
Bulgaria (N = 200) 4.30 (1.22) 4.49 (1.39)
Romania (N = 368) 4.57 (1.22) 4.69 (1.40)
Turkey (N = 501) 3.21 (1.31) 3.51 (1.15)
Croatia (N = 198) 4.32 (1.02) 4.55 (1.35)
FYROM (N = 325) 4.96 (1.20) 5.09 (1.31)
*Finnish Nurses (N =261) 4.54 (1.03) 4.97 (1.01)
^Dutch Residents (N = 2115) 3.97 (0.89) 4.47 (0.91)
*Mauno et al, 2007; ^Prins et al, 2010

11. Differences
 Em Ex: Physicians < Nurses & Residents
 Dep: Residents > Physicians & Nurses
 Vigour: Physicians > Nurses & Residents
 Dedication: Physicians > Nurses &
Residents

12. Sub-optimal care
8-item measure* uses a 5-point scale
documenting the frequency of the occurrence
of different types of suboptimal care and
attitudes towards practices
 Item 1: I found myself discharging patients to make the
service manageable because the team was so busy
 Item 5: I did not perform a diagnostic test because of
desire to discharge a patient
*Shanafelt, T., Bradley, K., Wipf, J., & Back, A. (2002). Burnout and self-reported patient care in an
internal medicine residency program. Annals of Internal Medicine, 136, 358–367.

13. Burnout and Sub-optimal care
Negative
Affectivity
+
+
+
Depersonalisation Sub-optimal care
Is this model invariant across countries?

14. Burnout and Sub-optimal care
 Depresonalistation is a consistent predictor in
all countries
Model χ2 df Δχ2 Δdf CFI ΔCFI RMSEA
Country
Configural model 257.14 84 .960 .030
Measurement model 374.11 108 116.97 24 .950 .010 .032
Structural model 472.97 126 215.83 42 .932 .028 .034
N.B. In comparing models, one often should use a measure of fit like the
Tucker-Lewis Index or RMSEA index and not the chi square difference
(David Kenny, http://davidakenny.net/cm/causalm.htm)

15. Engagement and Sub-optimal
care
Positive
Affectivity
+ _
Dedication Sub-optimal care
_
Is this model invariant across countries?

16. No, testing for Invariance*...
 The Model is not invariant across countries
 Dedication predicts Suboptimal care only in:
 Romania
 FYROM
 Turkey

17. Please give your work area/unit in this hospital an
overall grade on patient safety*
Excellent or very Acceptable Poor or failing
good
Greece (N = 688) 80.6% 16.8% 2.6%
Portugal (N = 152) 80.2% 15.7% 4.1%
Bulgaria (N = 200) 75.3% 20.1% 4.6%
Romania (N = 368) 64.1% 33.6% 2.3%
Turkey (N = 501) 37.4% 48.6% 14.0%
Croatia (N = 198) 85.9% 8.5% 5.6%
FYROM (N = 325) 77.5% 17.8% 4.7%
*The Hospital Survey on Patient Safety Culture ; developed by the US Agency for Healthcare Research and Quality
(AHRQ) http://www.ahrq.gov/qual/patientsafetyculture/hospcult1.htm.

18. Please give your work area/unit in this hospital an overall
grade on patient safety
r
Emotional Exhaustion .28**
Depersonalisation .31**
Vigour -.30**
Dedication -.28**
**Correlation is significant at the 0.01 level

19. The Story so far....
 Greece, Bulgaria & Turkey reporting high
burnout levels
 Nurses and residents doing the worst
 DEP Sub-optimal care
 DED associated with less sub-optimal care

20. What’s next?
 Multilevel analysis
 Action Research

21. Where do patients fit in?

22. Reflections
 Ironically, “fitness-to-practice” reviews ignore
the role of organisational culture
 How can we use our burnout and
engagement data to improve patient safety?
 Need to shift the focus away from individuals
and towards [both incident and accident
reporting]

23. Do you have
any questions
for my dad?