Is wellbeing at work related to professional recognition: a pilot intervention.

The aim of this pilot study was to design, implement and evaluate an intervention aiming at increasing professional recognition among health-care professionals working in primary care. Professional recognition was operationalized at three levels: self, co-workers and patients/recipients of care. Thirty-six (n = 36) residents and consultants working in primary health-care settings in Greece participated in the study. Emotional states of participants were measured before and after the intervention with the Self-Assessment Manikin, Positive and Negative Affect Schedule, and an open-ended question. Results showed significantly higher levels of dominance after the intervention (t(35) = -3.014, p= .005), higher levels of excitement (t(37) = -2.158, p= .038), feelings of being proud (t(37) = -2.485, p= .018) and being inspired (t(37) = -2.490, p= .017). Furthermore, the analysis of open-ended responses using the Pleasure-Arousal-Dominance model showed that participants reported higher levels of positive emotions and lower levels of arousal emotions after receiving the intervention (χ2(4, N = 36) = 35.526, p < .001). To our knowledge, this is the first intervention targeting professional recognition implemented in health-care settings. Results indicate significant changes on the emotional states of participants after receiving the intervention. Future research is needed to examine the feasibility of positive psychology interventions in primary health-care settings.

Does empathy change during undergraduate medical education? - A meta-analysis.

Purpose: The aim of this meta-analysis was to synthesize the existing evidence examining how empathy changes during undergraduate medical education and assess whether different types of measures produce different results. Method: Three electronic bibliographic databases were last searched on 28 November 2018. Quantitative studies including a measure of empathy in medical undergraduate students and a comparison of the results among the different years of study were included. All analyses were guided by Lipsey and Wilson and conducted using Comprehensive Meta-Analysis software. Results: The overall sample size for the twelve studies (n = 12) was 4906 participants. Results indicate a significant effect (g = 0.487, SE = 0.113, 95% CI = 0.265, 0.709), suggesting that there is moderate evidence that empathy scores changed. Studies using the Jefferson's Scale for Physician Empathy (JSPE) reported higher effect sizes (g = 0.834, SE = 0.219, 95% CI = 0.406, 1.263), while the effect size for studies using other scales was smaller and non-significant (g = 0.099, SE = 0.052, 95% CI = -0.003, 0.201). Conclusions: This review indicated significant evidence that self-ratings of empathy changed across the years of medical education. However, we need to be cautious because this effect was only significant when empathy was assessed using the JSPE.

Resilience in nursing: The role of internal and external factors.

Recent evidence shows that resilience can buffer the negative impact of workplace stressors on nurses and is linked to favourable patient outcomes. However, the comparative effectiveness of different contributing factors to nurses' resilience has not yet been examined. Our objective was to examine and compare the impact of individual characteristics, external factors and coping strategies on nurses' resilience. A descriptive cross-sectional study was conducted. Data were collected from 1,012 Greek nurses working in eight hospitals in northern Greece. Resilience, anxiety and depression, were measured using existing validated self- report instruments. In terms of coping strategies, this study used the "Mental Preparation Strategies Scale" to assess the mental preparation strategies employed by nurses before the beginning of their shift. Educational level, anxiety and the overall use of mental preparation strategies were the main predictors of nurse's resilience ([F = 52.781, p = 0.000, R2  = 0.139, Adjusted R2  = 0.137]). Resilient nurses were better educated {(b = 0.094. 95% confidence interval [CI] 0.038, 0.162)}, had lower anxiety ([b = -0.449, 95% CI -0.526, -0.372]) and used more often mental preparation strategies before the beginning of their shift ([b = 0.101, 95% CI 0.016, 0.061]). Findings provide information about which subgroups of nurses are more vulnerable in terms of resilience, i.e. less educated nurses, or nurses working in internal medicine wards.

Playing music improves well-being of oncology nurses.

BACKGROUND: Nurses experience high levels of stress associated with the demands of their workplace. Anxiety and depression symptoms are common in this occupational group and the necessity of supportive actions is vital. This is especially true for nurses working in high intensity and demanding settings such as oncology units. AIM: This study examined the effects of a music intervention on anxiety, depression, and psychosomatic symptoms of oncology nurses. METHODS: Forty-eight oncology nurses, were randomized to either an intervention group (n = 22) attending four consecutive weekly 1-h music classes or a control group with no intervention (n = 26) who maintained their usual lifestyle habits, for one month. Intervention group played and improvised music using percussion instruments. Courses consisted of varied multitask exercises of progressive difficulty, sometimes involving team playing, or individual performances. Depression, anxiety, and physical symptoms were measured before and after the end of the intervention. Anxiety and depression were assessed with the Hospital Anxiety and Depression Scale. Psychosomatic symptoms were assessed with Pennebaker Inventory οf Limbic Languidness. RESULTS: Anxiety, depression and psychosomatic symptoms significantly reduced for the intervention group at the end of the study. No statistical significant change was observed for the control group in any of the three psychological indicators. CONCLUSION: The findings of our study highlight the fact that music can be a cost-effective resource in developing interventions to reduce stress and improve well-being. Playing music can be the next step for further investigation, since we already know that listening to music is beneficial.

Managing diagnostic uncertainty in primary care: a systematic critical review.

BACKGROUND: Diagnostic uncertainty is one of the largest contributory factors to the occurrence of diagnostic errors across most specialties in medicine and arguably uncertainty is greatest in primary care due to the undifferentiated symptoms primary care physicians are often presented with. Physicians can respond to diagnostic uncertainty in various ways through the interplay of a series of cognitive, emotional and ethical reactions. The consequences of such uncertainty however can impact negatively upon the primary care practitioner, their patients and the wider healthcare system. Understanding the nature of the existing empirical literature in relation to managing diagnostic uncertainty in primary medical care is a logical and necessary first step in order to understand what solutions are already available and/or to aid the development of any training or feedback aimed at better managing this uncertainty. This review is the first to characterize the existing empirical literature on managing diagnostic uncertainty in primary care. METHODS: Sixteen databases were systematically searched from inception to present with no restrictions. Hand searches of relevant websites and reference lists of included studies were also conducted. Two authors conducted abstract/article screening and data extraction. PRISMA guidelines were adhered to. RESULTS: Ten studies met the inclusion criteria. A narrative and conceptual synthesis was undertaken under the premises of critical reviews. Results suggest that studies have focused on internal factors (traits, skills and strategies) associated with managing diagnostic uncertainty with only one external intervention identified. Cognitive factors ranged from the influences of epistemological viewpoints to practical approaches such as greater knowledge of the patient, utilizing resources to hand and using appropriate safety netting techniques. Emotional aspects of uncertainty management included clinicians embracing uncertainty and working with provisional diagnoses. Ethical aspects of uncertainty management centered on communicating diagnostic uncertainties with patients. Personality traits and characteristics influenced each of the three domains. CONCLUSIONS: There is little empirical evidence on how uncertainty is managed in general practice. However we highlight how the extant literature can be conceptualised into cognitive, emotional and ethical aspects of uncertainty which may help clinicians be more aware of their own biases as well as provide a platform for future research. TRIAL REGISTRATION: PROSPERO registration: CRD42015027555.

Are Burnt-out Doctors Prone to Seek Cosmetic Surgery? A Cross-Sectional Study.

INTRODUCTION: Studies have so far examined several psychosocial factors associated with an interest in aesthetic plastic surgery. Among them, gender, teasing history, marital status, education, social networks and body dysmorphic disorders are all predictors of interest in cosmetic surgery. Given the fact that professional status can influence health-related attitudes, our objective was firstly to identify if medical professionals are more likely to express interest in plastic surgery compared to non-medical professionals. Secondary, given the high rate of burn-out among physicians, the study examined the association between burn-out and interest in plastic surgery. MATERIALS AND METHODS: One hundred doctors and 100 non-medical professionals with a University degree completed a questionnaire regarding their interest in undergoing cosmetic plastic surgery, in particular minimally invasive procedures and 9 specific aesthetic operations. Additionally, doctors completed the standardized Maslach burn-out inventory. The sample consisted of 40.5% men and 59.5% women (mean age = 34 years). RESULTS: Data analysis using the Mann-Whitney test revealed that women and medical professionals were more likely to express interest in cosmetic plastic surgery (p < 0.001 and p = 0.035, respectively). Regarding the medical profession and interest in specific operations, there has not been found any association except for liposuction (p < 0.001). Results also showed a significant positive correlation between interest in cosmetic procedures and burn-out syndrome (r = 0.53 p < 0.001). CONCLUSION: The original finding that doctors are prone to seek elective plastic surgery may be attributed to their familiarity with invasive procedures. The correlation between burn-out syndrome and interest in cosmetic surgery could reveal a way of coping with the work demands. Results of this study can be used for the development of clinical tools for the screening of patients for elective cosmetic surgery. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Burnout and health behaviors in health professionals from seven European countries.

OBJECTIVES: Within an underlying health-impairing process, work stressors exhaust employees' mental and physical resources and lead to exhaustion/burnout and to health problems, with health-impairing behaviors being one of the potential mechanisms, linking burnout to ill health. The study aims to explore the associations between burnout and fast food consumption, exercise, alcohol consumption and painkiller use in a multinational sample of 2623 doctors, nurses and residents from Greece, Portugal, Bulgaria, Romania, Turkey, Croatia and Macedonia, adopting a cross-national approach. METHODS: Data are part of the international cross-sectional quantitative ORCAB survey. The measures included the Maslach Burnout Inventory and the Health Behaviors Questionnaire. RESULTS: Burnout was significantly positively associated with higher fast food consumption, infrequent exercise, higher alcohol consumption and more frequent painkiller use in the full sample, and these associations remained significant after the inclusion of individual differences factors and country of residence. Cross-national comparisons showed significant differences in burnout and health behaviors, and some differences in the statistical significance and magnitude (but not the direction) of the associations between them. Health professionals from Turkey, Greece and Bulgaria reported the most unfavorable experiences. CONCLUSIONS: Burnout and risk health behaviors among health professionals are important both in the context of health professionals' health and well-being and as factors contributing to medical errors and inadequate patient safety. Organizational interventions should incorporate early identification of such behaviors together with programs promoting health and aimed at the reduction of burnout and work-related stress.

(How) do medical students regulate their emotions?

BACKGROUND: Medical training can be a challenging and emotionally intense period for medical students. However the emotions experienced by medical students in the face of challenging situations and the emotion regulation strategies they use remains relatively unexplored. The aim of the present study was to explore the emotions elicited by memorable incidents reported by medical students and the associated emotion regulation strategies. METHODS: Peer interviewing was used to collect medical students' memorable incidents. Medical students at both preclinical and clinical stage of medical school were eligible to participate. In total 104 medical students provided memorable incidents. Only 54 narratives included references to emotions and emotion regulation and thus were further analyzed. RESULTS: The narratives of 47 clinical and 7 preclinical students were further analyzed for their references to emotions and emotion regulation strategies. Forty seven out of 54 incidents described a negative incident associated with negative emotions. The most frequently mentioned emotion was shock and surprise followed by feelings of embarrassment, sadness, anger and tension or anxiety. The most frequent reaction was inaction often associated with emotion regulation strategies such as distraction, focusing on a task, suppression of emotions and reappraisal. When students witnessed mistreatment or disrespect exhibited towards patients, the regulation strategy used involved focusing and comforting the patient. CONCLUSIONS: The present study sheds light on the strategies medical students use to deal with intense negative emotions. The vast majority reported inaction in the face of a challenging situation and the use of more subtle strategies to deal with the emotional impact of the incident.

The 'switch on-switch off model': Strategies used by nurses to mentally prepare and disengage from work.

There is considerable research on the experience of nurses during both their work and non-work time. However, we know relatively little about the strategies nurses use immediately before and immediately after their shift. This crossover period, from one shift to another, has critical impact for patient outcomes. The aim of this qualitative study was to explore strategies nurses employ to mentally prepare for their shift (switch on), and mentally disengage after the end of it (switch off). Eleven Greek hospital nurses were recruited for the study. Interviews were audio-taped and analysed using a content analysis approach. Five themes were identified as strategies nurses use to mentally prepare and disengage from their shift: (i) personal care/grooming; (ii) religious rituals; (iii) nicotine/caffeine; (iv) social interaction; and (v) listening to music. Nurses reported using the same strategies before and after their shift, but for different purposes. The authors propose a 'switch on-switch off' model to describe the process of mental preparation and mental disengagement from work. The switch-on/off approach represents an opportunity to increase nurses' resilience and identify individual and organizational factors that contribute to patient outcomes.

A systematic review of the factors predicting the interest in cosmetic plastic surgery.

BACKGROUND: A systematic review of the literature was performed to clarify the psychosocial characteristics of patients who have an interest in cosmetic plastic surgery. METHODS: Medical literature was reviewed by two independent researchers, and a third reviewer evaluated their results. RESULTS: Twelve studies addressing the predictors of interest in cosmetic surgery were finally identified and analysed. Interest in cosmetic surgery was associated with epidemiological factors, their social networks, their psychological characteristics, such as body image, self-esteem and other personality traits and for specific psychopathology and found that these may either positively or negatively predict their motivation to seek and undergo a cosmetic procedure. CONCLUSIONS: The review examined the psychosocial characteristics associated with an interest in cosmetic surgery. Understanding cosmetic patients' characteristics, motivation and expectation for surgery is an important aspect of their clinical care to identify those patients more likely to benefit most from the procedure.

Unmet Needs in the Process of Chemotherapy Provision in Pancreatic Cancer Patients from the Healthcare Provider Perspective: A Phenomenological Study in Greece.

Introduction: Pancreatic cancer is the fourth leading cause of cancer death overall, with 1.5 years life expectancy and minimal therapeutic progress in the last decades. Despite the burden it causes, there is little research on the needs of this specific population. This study aimed to explore healthcare professionals' views on providing care and patients' unsatisfied needs. Methods: This qualitative descriptive study was carried out at a cancer hospital in Northern Greece. A total of 12 participants (6 physicians and 6 nurses), treating patients with pancreatic cancer undergoing chemotherapy, were recruited through purposive sampling and underwent face-to-face semi-structured interviews. Data were analyzed through the thematic analysis method in NVivo12 software. Results: The analysis highlighted two themes: "needs of patients with pancreatic cancer" consisted of 6 subthemes ("daily activities", "symptoms management", "psychological support", "information needs", "multidisciplinary care" and "end-of-life care") and "needs of healthcare professionals" had 3 subthemes ("psychological support", "education" and "organizational support"). Several symptoms are identified and affect the daily activities of these patients, and psychological support is important for the majority of them, even at the time of diagnosis. The participants express dissatisfaction with the absence of palliative care structures and services and stated that an interdisciplinary approach would improve the quality of care. Conclusions: Healthcare professionals report a wide range of unsatisfied needs of patients with pancreatic cancer, with the majority expressing their concerns about the complete lack of patient support in the last stages of their lives.

Biases towards different patients groups. How do they differ during medical education?

OBJECTIVE: This cross-sectional study was a first to attempt to assess how biases towards age, gender and sexual orientation differ during the years of undergraduate medical education. METHODS: 600 medical students from the first, third and sixth year of study participated in the study. Three questionnaires were used: The Ambivalent Sexism Inventory scale (ASI), the Fraboni Scale of Ageism (FSA) and the Homophobia scale (HSc). RESULTS: Results showed statistical significant differences between the three groups in the total scores of ageism and homophobia. Students in the last year of studies reported more ageist and more homophobic biases than students in the first year of their studies. CONCLUSIONS: Our results demonstrate a need for education to reduce/address/mitigate bias in medical students. Τhe finding that biases increase in students who are farther along in their education needs further investigation. This warrants particular attention to determine if this is a change due to the medical education process itself. PRACTICE IMPLICATIONS: Medical education should teach students about diversity and acceptability with updated curriculums and designed interventions.

Informal caregivers' experiences of supporting patients with pancreatic cancer: A qualitative study in Greece.

PURPOSE: The purpose of the present study was to explore informal caregivers' experiences of supporting family members with pancreatic cancer. METHODS: A qualitative descriptive study was conducted with individual semi-structured telephone interviews and inductive thematic analysis. Data were collected from 10 informal caregivers in the only cancer hospital in Northern Greece. RESULTS: The findings of the thematic analysis highlighted three themes, "supportive needs of patients with pancreatic cancer", "supportive needs of informal caregivers" and "evaluation of provided care". In the first theme, four individual subcategories of themes emerged: "psychological support", "managing symptoms and side effects", "daily activities" and "participation in decision-making". The theme "supportive needs of informal caregivers" consists of five sub-themes, "psychological support", "support in care activities", "financial support", "communication with the patient" and "information". Finally, the theme "evaluation of provided care" three sub-categories of topics were reported, "staff evaluation", "process evaluation" and "palliative care". CONCLUSION: Pancreatic cancer patients and their informal caregivers experience multiple unmet needs. The health system, lacking an efficient treatment for this type of cancer, should provide a basis for improving the quality of life of these families with targeted support interventions.

A 10 year (2000-2010) systematic review of interventions to improve quality of care in hospitals.

BACKGROUND: Against a backdrop of rising healthcare costs, variability in care provision and an increased emphasis on patient satisfaction, the need for effective interventions to improve quality of care has come to the fore. This is the first ten year (2000-2010) systematic review of interventions which sought to improve quality of care in a hospital setting. This review moves beyond a broad assessment of outcome significance levels and makes recommendations for future effective and accessible interventions. METHODS: Two researchers independently screened a total of 13,195 English language articles from the databases PsychInfo, Medline, PubMed, EmBase and CinNahl. There were 120 potentially relevant full text articles examined and 20 of those articles met the inclusion criteria. RESULTS: Included studies were heterogeneous in terms of approach and scientific rigour and varied in scope from small scale improvements for specific patient groups to large scale quality improvement programmes across multiple settings. Interventions were broadly categorised as either technical (n = 11) or interpersonal (n = 9). Technical interventions were in the main implemented by physicians and concentrated on improving care for patients with heart disease or pneumonia. Interpersonal interventions focused on patient satisfaction and tended to be implemented by nursing staff. Technical interventions had a tendency to achieve more substantial improvements in quality of care. CONCLUSIONS: The rigorous application of inclusion criteria to studies established that despite the very large volume of literature on quality of care improvements, there is a paucity of hospital interventions with a theoretically based design or implementation. The screening process established that intervention studies to date have largely failed to identify their position along the quality of care spectrum. It is suggested that this lack of theoretical grounding may partly explain the minimal transfer of health research to date into policy. It is recommended that future interventions are established within a theoretical framework and that selected quality of care outcomes are assessed using this framework. Future interventions to improve quality of care will be most effective when they use a collaborative approach, involve multidisciplinary teams, utilise available resources, involve physicians and recognise the unique requirements of each patient group.

Resilience interventions in physicians: A systematic review and meta-analysis.

The aim of this review was to evaluate the effectiveness of interventions in promoting resilience among physicians. Previous reviews concerning resilience did not assess effectiveness in a systematic way using meta-analytic methods. PubMed, PsycINFO, and Cochrane Register of Controlled Trials were searched from inception to January 31, 2020. Randomized clinical trials, non-randomized clinical trials, and repeated-measures studies of intervention designs targeting at resilience in physicians were included. Eleven studies were included in the review (n = 580 physicians). Research findings suggest that interventions for resilience in physicians were associated with small but significant benefits. Subgroup analyses suggested small but significantly improved effects for emotional-supportive-coping interventions (Hedges's g = 0.242; 95% CI, 0.082-0.402, p = .003) compared with mindfulness-meditation-relaxation interventions (Hedges's g = 0.208; 95% CI, 0.131-0.285, p = .000). Interventions that were delivered for more than a week indicated higher effect (Hedges's g = 0.262; 95% CI, 0.169-0.355, p = .000) compared with interventions delivered for up to a week (Hedges's g = 0.172; 95% CI, -0.010 to 0.355, p = .064). Results were not influenced by the risk of bias ratings. Findings suggest that physicians can benefit in their personal levels of resilience from attending an intervention specifically designed for that reason for more than a week. Moreover, policy-makers should view current results as a significant source of redesigning healthcare systems and promoting attendance of resilience interventions by physicians. Future research should address the need for more higher-quality studies and improved study designs.

Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis.

OBJECTIVE: To examine the association of physician burnout with the career engagement and the quality of patient care globally. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline, PsycINFO, Embase, and CINAHL were searched from database inception until May 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Observational studies assessing the association of physician burnout (including a feeling of overwhelming emotional exhaustion, feelings of cynicism and detachment from job defined as depersonalisation, and a sense of ineffectiveness and little personal accomplishment) with career engagement (job satisfaction, career choice regret, turnover intention, career development, and productivity loss) and the quality of patient care (patient safety incidents, low professionalism, and patient satisfaction). Data were double extracted by independent reviewers and checked through contacting all authors, 84 (49%) of 170 of whom confirmed their data. Random-effect models were used to calculate the pooled odds ratio, prediction intervals expressed the amount of heterogeneity, and meta-regressions assessed for potential moderators with significance set using a conservative level of P<0.10. RESULTS: 4732 articles were identified, of which 170 observational studies of 239 246 physicians were included in the meta-analysis. Overall burnout in physicians was associated with an almost four times decrease in job satisfaction compared with increased job satisfaction (odds ratio 3.79, 95% confidence interval 3.24 to 4.43, I2=97%, k=73 studies, n=146 980 physicians). Career choice regret increased by more than threefold compared with being satisfied with their career choice (3.49, 2.43 to 5.00, I2=97%, k=16, n=33 871). Turnover intention also increased by more than threefold compared with retention (3.10, 2.30 to 4.17, I2=97%, k=25, n=32 271). Productivity had a small but significant effect (1.82, 1.08 to 3.07, I2=83%, k=7, n=9581) and burnout also affected career development from a pooled association of two studies (3.77, 2.77 to 5.14, I2=0%, n=3411). Overall physician burnout doubled patient safety incidents compared with no patient safety incidents (2.04, 1.69 to 2.45, I2=87%, k=35, n=41 059). Low professionalism was twice as likely compared with maintained professionalism (2.33, 1.96 to 2.70, I2=96%, k=40, n=32 321), as was patient dissatisfaction compared with patient satisfaction (2.22, 1.38 to 3.57, I2=75%, k=8, n=1002). Burnout and poorer job satisfaction was greatest in hospital settings (1.88, 0.91 to 3.86, P=0.09), physicians aged 31-50 years (2.41, 1.02 to 5.64, P=0.04), and working in emergency medicine and intensive care (2.16, 0.98 to 4.76, P=0.06); burnout was lowest in general practitioners (0.16, 0.03 to 0.88, P=0.04). However, these associations did not remain significant in the multivariable regressions. Burnout and patient safety incidents were greatest in physicians aged 20-30 years (1.88, 1.07 to 3.29, P=0.03), and people working in emergency medicine (2.10, 1.09 to 3.56, P=0.02). The association of burnout with low professionalism was smallest in physicians older than 50 years (0.36, 0.19 to 0.69, P=0.003) and greatest in physicians still in training or residency (2.27, 1.45 to 3.60, P=0.001), in those who worked in a hospital (2.16, 1.46 to 3.19, P<0.001), specifically in emergency medicine specialty (1.48, 1.01 to 2.34, P=0.042), or situated in a low to middle income country (1.68, 0.94 to 2.97, P=0.08). CONCLUSIONS: This meta-analysis provides compelling evidence that physician burnout is associated with poor function and sustainability of healthcare organisations primarily by contributing to the career disengagement and turnover of physicians and secondarily by reducing the quality of patient care. Healthcare organisations should invest more time and effort in implementing evidence-based strategies to mitigate physician burnout across specialties, and particularly in emergency medicine and for physicians in training or residency. SYSTEMATIC REVIEW REGISTRATION: PROSPERO number CRD42021249492.

Connecting organisational culture and quality of care in the hospital: is job burnout the missing link?

PURPOSE: To date, relatively little evidence has been published as to what represents an effective and efficient way to improve quality of care and safety in hospitals. In addition, the initiatives that do exist are rarely designed or developed with regard to the individual and organisational factors that determine the success or failure of such initiatives. One of the challenges in linking organisational culture to quality of care is to identify the focal point at which a deficient hospital culture and inadequate organisational resources are most evident. The accumulated evidence suggests that such a point is physician burnout. This paper sets out to examine this issue. DESIGN/METHODOLOGY/APPROACH: The paper reviews the existing literature on organisational culture, burnout and quality of care in the healthcare sector. A new conceptual approach as to how organisational culture and quality of care can be more effectively linked through the physician experience of burnout is proposed. FINDINGS: Recommendations are provided with regard to how future research can approach quality of care from a bottom-up organisational change perspective. In addition, the need to widen the debate beyond US and North European experiences is discussed. ORIGINALITY/VALUE: The present paper represents an attempt to link organisational culture, job burnout and quality of care in a more meaningful way. A conceptual model has been provided as a way to frame and evaluate future research.

Do critical incidents lead to critical reflection among medical students?

CONTEXT: Medical students are exposed during their training to a wide range of experiences and behaviors that can affect their learning regarding professionalism and their behavior and attitudes towards patient-centered care. The aim of the study is to explore learning associated with critical incidents and levels of critical reflection among medical students. APPROACH: Medical students' were invited to narrate a critical incident and reflect on the learning associated with it. All students' narratives were audio-recorded and analyzed thematically. Mezirow's theory of transformative learning was used to analyze the level of reflection reached in students' narratives. FINDINGS: For the present analysis critical incidents narrated by 70 clinical students (4th-6th year) were included. Fifty-two of them were females. Students' experiences are derived from three types of interactions: observed interactions between doctors and patients, personal interactions between students and patients, and interactions between doctors and students. Reflections deriving from the experiences included: behaving to patients as humans not as cases, emotional aspects of care, doctors as role models, skills needed when working under pressure, 'tasting' the real profession, emotional management, the importance of communication skills, teaching qualities of doctors, becoming a doctor, and reflections of future practice. Analyzing the actual level of reflection indicated that only 32 (45.7%) students were categorized as reflectors. CONCLUSIONS: Student interactions with doctors and patients provide insights about; the daily experience of being a doctor, the most common challenges, what qualities are necessary for being a doctor and what do they need to develop their professional identity. However, it is noteworthy that while the majority of students shared a critical incident crucial to their professional development, there is little evidence of critical reflection.

Burnout and Cognitive Performance.

The aim of this study was to investigate the relationship between burnout and cognitive functioning. The associations of depression, anxiety and family support with burnout and cognitive functioning were also examined both independently and as potential moderators of the burnout-cognitive functioning relationship. Seven different cognitive tasks were administered to employees of the general working population and five cognitive domains were assessed; i.e., executive functions, working memory, memory (episodic, visuospatial, prospective), attention/speed of processing and visuospatial abilities. Burnout, depression, anxiety and family support were assessed with the Maslach Burnout Inventory-General Survey, the Hospital Anxiety and Depression Scale and the Family Support Scale respectively. In congruence with the first and fourth (partially) Hypotheses, burnout and perceived family support are significantly associated with some aspects of cognitive functioning. Moreover, in line with the third Hypothesis, perceived family support is inversely related to burnout. However, in contrast to the second and fourth Hypotheses, depression, anxiety and perceived family support do not moderate the burnout-cognitive functioning relationship. Additional results reveal positive associations between burnout depression and anxiety. Overall findings suggest that cognitive deficits, depression and anxiety appear to be common in burnout while they underpin the role of perceived family support in both mental health and cognitive functioning. Implications for practice are discussed.