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Anales de la Facultad de Medicina
On-line version ISSN 2301-1254
Anfamed vol.11 no.2 Montevideo Dec. 2024 Epub Dec 01, 2024
https://doi.org/10.25184/anfamed2024v11n2a12
Articles
Organizational strategy to improve the medical well-being of an academic gynecology unit in Uruguay.
1. Unidad Académica Clínica Ginecotocológica A. Facultad de Medicina, Universidad de la República (Uruguay). Correos electrónicos: fernandanozar@gmail.om, sartucio@gmail.com, dahianasanchez02@gmail.com, leobriozzo@hotmail.com
2, Programa de Bienestar de Profesionales de la Salud. Administrado por la Fundación Manuel Pérez. Facultad de Medicina, Universidad de la República (Uruguay) Correos electrónicos: jdapueto@bienestarensalud.uy eklasse@bienestarensalud.uy
3 Unidad Académica de Psicología Médica. Facultad de Medicina, Universidad de la República (Uruguay). Correos electrónicos: jimenaboffa@gmail.com, mercedesvieraaspiroz@gmail.com
Introduction:
Physician well-being has gained relevance in health care, especially in the face of the "burnout epidemic." This study aims to evaluate the implementation and effectiveness of a program to improve the well-being of the staff of the Academic Unit of Gynecology and Obstetrics A of the Faculty of Medicine of the University of the Republic, Uruguay.
Method:
A descriptive study was developed following a logical model of program evaluation. An organizational strategy focused on identifying stress factors and promoting well-being was implemented. The intervention included qualitative surveys, focus groups, and the formation of a Well-Being Referent Team (ERB), trained to guide the continuous improvement process.
Results:
Priorities were identified in the dimensions of workload, resources, community at work, organizational culture, and work-life balance. Throughout the process, key actions were implemented to improve the work environment and team effectiveness. The commitment of unit leaders and collaborative work with external consultants were fundamental to the success of the program.
Discussion:
Organizational interventions, although more complex, appear to be more effective in promoting well-being. The changes achieved at this initial stage suggest a positive impact, although long-term monitoring is required to ensure the sustainability of improvements.
Conclusions:
The innovative experience presented offers a roadmap for improving the well-being of health personnel in academic and healthcare contexts, highlighting the importance of leadership and collaboration in these processes.
Key words: professional burnout; work engagement; occupational stress; academic medical center; Obstetrics and Gynecology Department; Hospital; Uruguay;
Introducción:
El bienestar médico ha cobrado relevancia en la atención de la salud, especialmente frente a la "epidemia de burnout". Este estudio se propone evaluar la implementación y efectividad de un programa para mejorar el bienestar del personal de la Unidad Académica de Ginecología y Obstetricia A de la Facultad de Medicina de la Universidad de la República, Uruguay.
Método:
Se desarrolló un estudio descriptivo siguiendo un modelo lógico de evaluación de programas. Se implementó una estrategia organizacional focalizada en la identificación de factores de estrés y la promoción del bienestar. La intervención incluyó encuestas cualitativas, grupos focales y la conformación de un Equipo de Referentes de Bienestar (ERB), capacitado para guiar el proceso de mejora continua.
Resultados:
Se identificaron prioridades en las dimensiones de carga laboral y exigencias en el trabajo, eficiencia y recursos, comunidad en el trabajo, cultura organizacional e integración trabajo-vida personal. A lo largo del proceso, se implementaron acciones clave para mejorar el ambiente laboral y la efectividad del equipo. El compromiso de los líderes de la unidad y el trabajo colaborativo con consultores externos fueron fundamentales para el éxito del programa.
Discusión:
Las intervenciones organizacionales, aunque más complejas, parecen ser más efectivas en la promoción del bienestar. Los cambios alcanzados en esta etapa inicial sugieren un impacto positivo, aunque se requiere un seguimiento a largo plazo para asegurar la sostenibilidad de las mejoras.
Conclusiones:
La experiencia innovadora presentada ofrece una hoja de ruta para la mejora del bienestar del personal de salud en contextos académicos y asistenciales, destacando la importancia del liderazgo y colaboración en estos procesos.
Palabras clave: agotamiento profesional; compromiso laboral; estrés laboral; centros médicos académicos; Servicio de Ginecología y Obstetricia en Hospital; Uruguay
Introdução:
O bem-estar médico ganhou relevância na área da saúde, especialmente face à “epidemia de esgotamento”. Este estudo tem como objetivo avaliar a implementação e eficácia de um programa para melhorar o bem-estar do pessoal da Unidade Acadêmica de Ginecologia e Obstetrícia A da Faculdade de Medicina da Universidade da República, Uruguai.
Método:
Foi desenvolvido um estudo descritivo seguindo um modelo lógico de avaliação de programas. Foi implementada uma estratégia organizacional focada na identificação de fatores de stress e na promoção do bem-estar. A intervenção incluiu pesquisas qualitativas, grupos focais e a formação de uma Equipe de Referência em Bem-Estar (ERB), treinada para orientar o processo de melhoria contínua.
Resultados:
Foram identificadas prioridades nas dimensões carga de trabalho, recursos, comunidade no trabalho, cultura organizacional e equilíbrio entre vida pessoal e profissional. Ao longo do processo, foram implementadas ações-chave para melhorar o ambiente de trabalho e a eficácia das equipes. O compromisso dos líderes das unidades e o trabalho colaborativo com consultores externos foram fundamentais para o sucesso do programa.
Discussão:
As intervenções organizacionais, embora mais complexas, parecem ser mais eficazes na promoção do bem-estar. As mudanças alcançadas nesta fase inicial sugerem um impacto positivo, embora seja necessário um acompanhamento a longo prazo para garantir a sustentabilidade das melhorias.
Conclusões:
A experiência inovadora apresentada oferece um roteiro para melhorar o bem-estar do pessoal de saúde em contextos académicos e de saúde, destacando a importância da liderança e da colaboração nestes processos.
Palavras-chave: Esgotamento Profissional; Engajamento no Trabalho; Estresse Ocupacional; centros médicos acadêmicos; Serviço de Ginecología e Obstetrícia em Hospital; Uruguai
Introduction
Promoting medical well-being has become a priority in the health field. In Uruguay, efforts have been made to promote good professional practices and foster the well-being of the health team, both in the Faculty of Medicine1 and in the Medical College of Uruguay2.
Burnout and professional commitment have become key objectives for health institutions due to what has been called the "burnout epidemic"3. Gynecology is not immune to this reality, facing stress conditions exacerbated by training and health care demands, and limited resources4 In turn, there is evidence that job burnout affects the educational climate and academic results5.
The objective of this work was to study:
1) the feasibility of implementation and identify difficulties and achievements in the process and
2) the effectiveness in achieving results, of a program aimed at improving the well-being of the staff of the Academic Unit of Gynecology and Obstetrics A of the Faculty of Medicine of the University of the Republic, Uruguay, in 2023.
The working hypothesis was that the implementation of a strategy with an organizational, multimodal, structured approach could detect and correct weaknesses and reinforce the strengths of the work organization in the academic unit in a timely manner and contribute to the design of an improvement plan. It was then defined to study the feasibility of implementation, identifying difficulties and achievements in the process and the effectiveness of the implementation of a program aimed at improving the well-being of the staff of the Academic Unit (UA) Gynecological Clinic of the Faculty of Medicine of the University of the Republic, Uruguay, in 2023.
A descriptive study of the most relevant aspects in the development and implementation process of the program is presented, following the logical model for program evaluation 6. The conceptual framework, the context, the description of activities are reviewed and some products are presented.
Methodology
Conceptual framework
Physician well-being is a multidimensional state in which healthcare professionals experience satisfaction, motivation, and energy in their work, while being able to cope with work stress without compromising their physical and emotional health. This well-being is based on both individual factors and organizational support, including effective leadership, a culture that encourages self-care and self-reflection, and the availability of resources to prevent burnout8,9. Furthermore, physician well-being depends on a sustainable balance between professional demands and personal resources10, as well as a culture that enables physicians to seek help when needed2,11.
Burnout 7,12 or burnout syndrome13 is understood as a health condition resulting from work stress that has not been successfully processed, which manifests itself as exhaustion, emotional discomfort, cynicism regarding work. Professional fulfillment 14 is expressed as the sense of commitment, reward and satisfaction with the career.
Interventions to improve well-being can be directed at individuals, groups or organizations, with a growing emphasis on systemic approaches that consider these three types of interventions together. Actions are distinguished at the primary level (modifying stress-generating factors), secondary level (addressing personal or group situations of work-related discomfort) and tertiary level (addressing established mental health problems) (15.
Context
The UA Gynecotocological Clinic A (UA GineA) of the Faculty of Medicine (FM) of the Universidad de la Republica (Udelar) carries out teaching functions at the undergraduate and graduate levels, assistance, research and outreach to society. It has its original physical base at the Women's Hospital of the Pereira Rossell Hospital Center, but also in several Associated Teaching Centers (CEDA), in Montevideo and the interior of the country, which adds complexity to the operation of the UA, both in its structure and in the labor relationship of its members16.
At the time of implementing the intervention, 63 active members of the UA (25 teachers and 38 residents) were also invited to participate; in addition, 13 residents who had completed their training in April 2023 were invited to participate, a total of 76 people.
Program Features and Activities
Following the holding of workshops with members of the UA in 2022 and the evaluation of the intervention through a survey with open questions, it was concluded that a certain level of recognition of the problem of occupational burnout had been achieved and that there were opportunities to implement the proposed solutions effectively and to address the problem as a whole.
Thus, it was proposed, within the central objectives to be developed in 2023, to carry out an institutional strategy to improve well-being to be implemented in the UA GineA both in the CHPR and in the CEDA.
To this end, a collaborative work environment was created between the team of the Fundación Bienestar de Profesionales de la Salud - Bienestar en Salud, - a non-profit organization dedicated to promoting medical well-being - and the management team of the UA. GineA. It was decided to develop an organizational strategy focused on the primary level of intervention, consisting of the identification of high-priority factors generating work-related stress, which were acting at the level of individuals, the functioning of clinical units, the healthcare organization - including the relationship with other academic units, associated disciplines and other sectors of the hospital -, and the health system. The Bienestar en Salud training team carried out an agreement with the management of the service, coordinated all group instances, implemented the research for the diagnosis of the situation, processed the data in order to ensure confidentiality and generated the reports for the referents, for the management of the UA and for the staff.
Leaders with an executive profile and high commitment were identified to form a Wellbeing Referent Team (WRT). The external advisory team from Bienestar en Salud (EAT) provided advice and training to this group in order to guide in the implementation of improvement strategies and leave installed capacities in the Service to give continuity to the process. The EAT and the WRT worked interactively with face-to-face sessions, virtual meetings and in discussion forums and presentation of reading materials through the educational platform Moodle on topics of professional wellbeing, burnout, resilience and to clearly define the roles, dedication, recognition expected by the referents and which tasks were outside their role17.
The model suggested by Shanafelt et al. (18) was followed, which includes: recognizing and assessing the problem, capitalazing on the influence of leaders, designing a roadmap with definition of high priority areas, and developing and implementing interventions in specific work units.
Once the plan was developed, it was presented publicly at a meeting that involved the entire UA. The qualitative research on work stress factors and occupational burnout began with an initial survey with open questions, interviews with the WRT considered as qualified informants, and was complemented with two focus groups, one for residents and one for teachers. The exchange material was analyzed based on emerging themes with support from categories developed from the initial survey.
Participation was voluntary and individuals agreed to participate and to have the session recorded confidentially. The material was used to identify emerging issues from different work units (care areas at the CHPR, guards, operation of equipment in different CEDAs), as well as proposals for changes. A quantitative survey was also included to identify and describe work conditions and risk factors at work with items taken from the CoPsoQ-istas21 Method Manual18 shown in Table 2.
Ethical considerations.
This study was approved by the CHPR Research Ethics Committee.
Participation in all these events was voluntary and anonymous. Participants gave their prior consent to each of the activities. Personal data was processed confidentially and personal data protection requirements were met.
Results.
Of the total number of UA members invited to participate in the intervention, 61 responded to the quantitative survey (response rate = 80.3%). The response rate by group and the sociodemographic characteristics of the staff who responded to the survey appear in Table 1 (n=61). The median age was 32 years (range: 26 - 65 years), residents were evenly distributed between the CHPR and the CEDA; of the teachers who responded, 28% held assistant or adjunct professor positions (with fixed-term contracts) and only 7% held stable positions (full professor and associate professors). The majority (61%) worked professionally in other institutions. The perception of occupational risk factors is shown in Table 2.
Table 1: SOCIODEMOGRAPHIC DATA
Mean (SD) | Median | Range | |||
---|---|---|---|---|---|
Age (years) | 32 | 26-65 | |||
Number of Children | 0 | 0-3 | |||
Days with health problems | 3.51(5.37) | 2 | 0-30 | ||
Stop doing usual tasks due to health problems | 0.93(2.28) | 0 | 0-10 | ||
Gender | (N) | (%) | |||
Female | 50 | 82 | |||
Male | 11 | 18 | |||
Marital status: | |||||
Single | 29 | 47 | |||
Married | 15 | 25 | |||
Unmarried couple | 16 | 26 | |||
Divorced | 1 | 2 | |||
Live alone or with other person(s) | |||||
Alone | 13 | 21 | |||
With another person | 48 | 79 | |||
Position held | |||||
CHPR Residents | 21 | 34 | |||
CEDA residents | 19 | 31 | |||
Teaching Assistant | 11 | 18 | |||
Assistant Professors | 6 | 10 | |||
Associate Professors and Professor | 4 | 7 | |||
Develop professional tasks in other institutions | |||||
Yes | 37 | 61 | |||
No | 24 | 39 |
SD: Standard deviation. CHPR: Pereira Rossell Hospital Center; CEDA: Associated Teaching Centers
Source: own elaboration
Table 2: WORKING CONDITIONS AND RISK FACTORS AT WORK
(N) | (%) | |||
---|---|---|---|---|
Overall job satisfaction (total responses 61) | ||||
Very dissatisfied | 0 | 0 | ||
Dissatisfied | 6 | 10 | ||
Satisfied | 45 | 74 | ||
Very satisfied | 10 | 16 | ||
Type of work shifts (total responses 61) | ||||
Fragmented workday (morning and afternoon) | 34 | 56 | ||
Fixed shift tomorrow | 9 | 15 | ||
Rotating shifts except night | 2 | 3 | ||
Rotating shifts, including night shifts | 16 | 26 | ||
How often do they change your start and end times or work days? (total responses 61) | ||||
Always | 2 | 3.3 | ||
Many times | 11 | 18 | ||
Sometimes | 10 | 16.4 | ||
Only once | 19 | 31.1 | ||
Never | 19 | 31.1 | ||
What is the margin of adaptation in the entry and exit times? (total responses 61) | ||||
No margin | 34 | 55.7 | ||
You can choose from several pre-established fixed schedules | 6 | 9.8 | ||
You have 30 minutes of tolerance | 11 | 18 | ||
It has between 30 and 60 minutes of tolerance | 3 | 4.9 | ||
You have more than an hour to spare | 7 | 11.5 | ||
How many Saturdays do you work per month? (total responses 61) | ||||
None | 2 | 3.3 | ||
Some exceptionally | 2 | 3.3 | ||
One a month | 5 | 8.2 | ||
Two a month | 9 | 14.8 | ||
Three or more a month | 43 | 70.5 | ||
How many Sundays do you work per month? (total responses 61) | ||||
None | 3 | 4.9 | ||
Some exceptionally | 7 | 11.5 | ||
One a month | 13 | 21.3 | ||
Two a month | 23 | 37.7 | ||
Three or more a month | 15 | 24.6 | ||
Cla leave your workplace for at least one hour for personal or family reasons? (total responses 61) | ||||
Always | 16 | 26.2 | ||
Many times | 20 | 32.8 | ||
Sometimes | 12 | 19.7 | ||
Only once | 11 | 18 | ||
Never | 2 | 3.3 |
Source: own elaboration
Preparation of the roadmap
The priority problems and proposals for change arising from the situation diagnosis (initial survey and focus groups) complemented with the data from the survey of work conditions and risk factors were summarized and systematized by the EAT based on the dimensions proposed by Shanafelt et al.8: to adapt the workload and job demands, promote efficiency and improve resources, modify those negative aspects of the prevailing culture of medicine and promote organizational values, generate instances of social support and community at work, improve work-life integration, increase control and flexibility in relation to tasks, adapt the expectations of the organization while respecting the meaning that work has for the person. In each of these dimensions, those individual factors, those of the work unit, those of the healthcare organization and those of the health system that could be modified were identified. Each week, the EAT presented this information to the WRT through the educational platform with priority and feasible proposals for change. The following dimensions were identified as priority areas: workload and work demands, efficiency and resources, support and community at work, organizational culture and work-life integration. The dimensions control and flexibility and meaning of work did not appear as priorities in the perception of the staff, so no actions were implemented at this stage. At the end of this process, two intensive work sessions of three hours each were allocated to create the final roadmap. Despite this schedule, the WRT managed to implement actions throughout the process.
The dimensions identified as priorities, the proposed actions and some results of implementation are presented in Chart 1.
Discussion
Systematic review studies suggest that health workers benefited from different types of workplace well-being improvement interventions, aimed at both the secondary - people-focused - and primary - organization-focused - levels15 . In our case, we opted to implement an intervention at the organizational level, seeking greater effectiveness even at the cost of greater complexity15,19 .
From the perspective of the Job Demand-Resource Model (JD-R) (10,14, the following aspects were promoted:
a) a decrease in job demands or requirements (less pressure regarding certain care or academic objectives,
b) greater regulation of the physical and emotional overload of the role of resident or teacher),
c) an improvement in work resources in terms of interpersonal and social relationships (greater support from supervisors and coworkers, proposals to improve team climate),
d) changes in work organization (greater role clarity, participation in decision-making) and
e) the level of the task (performance feedback, variety of skills, importance of the task, task identity, autonomy). Although the goals were not fully met or with the same degree of development, relevant changes and a greater awareness of the importance of continuing to work on these areas are observed.
The commitment of the UA leadership and a team of well-being experts with a high level of commitment and execution capabilities were key to achieving the proposed goals. These types of processes are not possible without the agreement and collaboration of the organization's leaders. Working with an external consulting team made it possible to provide resources to install a process of continuous improvement of the health care areas, training of human resources, as well as cultural change of the teams.
We recognize several limitations in this work. The changes presented in the roadmap are in an initial phase of implementation, so it cannot be assured that they will be sustained over time. A quantitative evaluation of results from the perspective of the members of the UA is still pending, which is in process.
However, we believe that, as an innovative experience without precedents in the region, the work scheme presented can serve as a guide for professionals involved in improving the conditions of healthcare teams.
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Editor's note: The editor responsible for the publication of this work was the Editorial Committee of AnFaMed in collaboration with Adriana Fernández
Authorial contribution: All authors contributed equally to the preparation of the manuscript: conceptualization, data curation, formal analysis, methodology, validation and writing: original draft, review and editing.
Data availability: This is a research with qualitative methodology so it is not possible to make the data available without affecting the confidentiality and anonymity of the people.
Received: August 02, 2024; Accepted: November 19, 2024