Lower Likelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups.

PURPOSE: We investigated whether physician race and ethnicity were associated with burnout among a nationally representative sample of family physicians. METHODS: We undertook a cross-sectional observational study using survey data from 1,510 American Board of Family Medicine recertification applicants in 2017 and 1,586 respondents to the 2017 National Graduate Survey. Of the 3,096 total family physicians, 450 (15%) were from racial and ethnic groups underrepresented in medicine. We used structural equation models to test the effects of underrepresented status on single-item measures of emotional exhaustion and depersonalization. RESULTS: Family physicians underrepresented in medicine were significantly less likely than their non-underrepresented counterparts to report emotional exhaustion (adjusted odds ratio = 0.82; 95% CI, 0.69-0.99; total effect) and depersonalization (adjusted odds ratio = 0.54; 95% CI, 0.41-0.71; total effect). The underrepresented physicians were more likely than non-underrepresented peers to practice in more racially and ethnically diverse counties and less likely to practice obstetrics, both of which partly mediated the protective effect of underrepresented status on depersonalization. CONCLUSIONS: Although factors such as racism might be expected to adversely affect the well-being of underrepresented clinicians, underrepresented family physicians reported a lower frequency of emotional exhaustion and depersonalization. The mediating protective effect of working in more racially and ethnically diverse counties is consistent with evidence of the beneficial effect of cultural diversity on health outcomes for minorities. Because physician burnout is a known predictor of job turnover and may also be associated with poorer quality of care, the lower burnout observed among underrepresented family physicians may be an asset for the health care system as a whole.

Racial and ethnic variations in caregiving-related physical, emotional, and financial strain during COVID-19 among those caring for adult cancer patients.

PURPOSE: Cancer caregiving is shown to be a burdensome experience in typical times. The purpose of this study was to describe cancer caregivers' emotional, physical, and financial strain during the COVID-19 pandemic and compared to preCOVID-19, and explore racial and ethnic variations in caregiver strain. METHODS: We conducted a cross-sectional online survey using Lucid, LLC, incorporating quotas for race, ethnicity, gender and age. Caregivers had to be adults living in the USA and currently providing unpaid care to an adult cancer patient (i.e., during COVID-19) and prior to the pandemic. We assessed the caregivers' emotional, physical, and financial strain and asked them to compare to preCOVID-19 caregiving. Analyses included descriptive and linear regression adjusting for sociodemographic and caregiving-related variables. RESULTS: A total of 285 caregivers met eligibility, and most were nonHispanic white (72.3%) and female (59.6%). Based on a scale of "1: Much lower" to "5: Much higher", the financial, physical and emotional strain/stress experienced by caregivers compared to preCOVID-19 was, on average, 3.52 (SD: 0.82; range: 1-5) for financial strain, 3.61 (SD: 0.86; range: 1-5) for physical strain, and 3.88 (SD: 0.89; range: 1-5) for emotional stress. NonHispanic black caregivers were significantly more likely than nonHispanic white caregivers to indicate that caregiving-related financial strain was higher than preCOVID-19. Moreover, Hispanic caregivers compared to nonHispanic white caregivers reported caregiving-related emotional stress was higher than preCOVID-19. CONCLUSION: These findings suggest a need to be attentive to racial and ethnic variations in emotional and financial strain and provide targeted support in clinical care and via public policy during a public health crisis.

Anxiety symptoms and burnout among Chinese medical staff of intensive care unit: the moderating effect of social support.

BACKGROUND: Social support can be a critical resource to help medical staff cope with stressful events; however, the moderating effect of social support on the relationship between burnout and anxiety symptoms has not yet been explored. METHODS: The final sample was comprised of 514 intensive care unit physicians and nurses in this cross-sectional study. Questionnaires were used to collect data. A moderated model was used to test the effect of social support. RESULTS: The moderating effect of social support was found to be significant (b = - 0.06, p = 0.04, 95%CI [- 0.12, - 0.01]). The Johnson-Neyman technique indicated that when social support scores were above 4.26 among intensive care unit medical staff, burnout was not related to anxiety symptoms. CONCLUSIONS: This is the first study to test the moderating effect of social support on the relationship between burnout and anxiety symptoms among intensive care unit staff.

Comparison of Burnout and Empathy Among Millennial and Generation X Residents and Fellows: Associations with Training Level and Race but Not Generation Affiliation.

OBJECTIVE: The authors examine the associations of generational affiliation on empathy and burnout in a sample of millennial (born between 1982 and 2000) and Generation X (born between 1965 and 1981) residents and fellows. METHODS: At a single large institution during the 2013-2014 academic year, residents and fellows were asked to complete the Jefferson Scale of Physician Empathy and Maslach Burnout Inventory (MBI). Responses were combined with GME database content. Multivariable regression analysis included generation affiliation, race, gender, and post-graduate year (PGY) as covariates. RESULTS: The study sample included 388 millennial (mean age = 29.3) and 200 Generation X trainees (mean age = 34.6), with the response rate being 96.5%. Groups were statistically different by gender (p < 0.001) and PGY level (p < 0.001). After adjustment for gender, race, and PGY level, no statistically significant differences were found between millennial and Generation X groups in mean scores of empathy or burnout. Empathy was associated with PGY level (p = 0.0008) and race (p < 0.0001), with decreased empathy in advanced training levels and increased empathy in Hispanic/Latino race. Burnout rate was associated with PGY level (p = 0.001) but not generational affiliation (p = 0.6). The MBI depersonalization subscale was associated with PGY level (p < 0.001) and race (p = 0.0034), with decreased depersonalization in advanced training levels and Hispanic/Latino race. The emotional exhaustion and personal accomplishment MBI subscales did not demonstrate any significant associations in the multivariable regression model. CONCLUSIONS: In a compared sample of millennial and Generation X residents and fellows, PGY level and Hispanic/Latino race (though not generation affiliation) were significantly associated with both empathy and MBI depersonalization subscale scores, while only PGY level was significantly associated with burnout rate. This study presents further evidence of de-escalating burnout and declining empathy over the course of medical residency.

Exploring the Influence of Self-Efficacy, School Context and Self-Esteem on Job Burnout of Iranian Muslim Teachers: A Path Model Approach.

This study tested the influence of self-efficacy, school context and self-esteem on job burnout of Iranian Muslim teachers. Job burnout was taken to be composed of three components: emotional exhaustion, depersonalization and personal accomplishment. A sample of 212 secondary school teachers completed a packet of scales that measure self-efficacy, school context, self-esteem and job burnout. The relationships between the variables were examined via path analysis. Path analysis showed self-efficacy to have a significant direct negative effect on depersonalization (ß = - 0.25, p < 0.01) and reduced personal accomplishment (ß = - 0.31, p < 0.01). School context had a significant direct effect on emotional exhaustion (ß = - 0.36, p < 0.01), depersonalization (ß = - 0.23, p < 0.01) and reduced personal accomplishment (ß = - 0.17, p < 0.01). Self-esteem had a significant direct effect on emotional exhaustion (ß = - 0.36, p < 0.01), depersonalization (ß = - 0.15, p < 0.01) and reduced personal accomplishment (ß = - 0.26, p < 0.01). The proposed model explained 47% of total variance of "emotional exhaustion," 28% of "depersonalization" and 54% of "reduced personal accomplishment."

Parental career expectations: effect on medical students' career attitudes over time.

BACKGROUND: Motivation to become a doctor has typically been conceived as arising from personal interests. However, it is not uncommon, particularly amongst those from collectivist cultures, for career choice to be motivated by a desire or need to fulfil parent expectations. Whether or not this motivation has longer term effects on the career satisfaction and performance of medical students is unknown. METHODS: Using three waves of survey data collection, applicants to medical school (n = 370) reported parent career expectations, parent career support and physician career values. Those who gained a student place (n = 90) reported attitudes to their career at the end of their first year of study. Burnout and intentions regarding practice location were assessed during the fifth and final year of study (n = 81). Examination marks in Years 1 and 5 assessed academic performance. RESULTS: Those with more highly educated parents reported more support, but parent support had no relationship with students' academic performance or attitudes to their career. Perceived parent career expectation was higher amongst younger applicants and those from a non-Western background. Expectations had a small positive correlation with applicants' valuing of prestige and a small negative correlation with valuing service. Medical students with high parent expectation at selection had, a year later, more negative attitudes to medicine as a career. Parent expectation had a significant indirect effect on Year-5 burnout. Higher parent expectation was related to lower Year-5 academic grades, but after Year-1 grades were accounted for, this relationship was no longer significant. CONCLUSIONS: Medical students who perceive that their parents expect them to choose a prestigious career in line with family or cultural values may be more ambivalent about their career choice once in medical school. They may also be more likely to experience longer term burnout but there was little evidence that they might have lower academic performance.

Psychometric properties of the Copenhagen Burnout Inventory-Chinese version.

The Copenhagen Burnout Inventory is a measurement scale that assesses the degree of burnout in the personal, work, and client domains. The aim of this study was to examine the psychometric properties of the inventory's Chinese version (CBI-C) in a sample of 312 human service workers in Hong Kong with follow-up assessment for 245 participants. The results of confirmatory factor analyses show the revised three-factor model to have an adequate fit in the baseline and cross-validation samples. The CBI-C demonstrates good degrees of internal consistency, test-retest reliability, and concurrent validity, and appears to be a valid and reliable measurement tool of burnout in the Chinese context.

Psychometric properties of the Hebrew version of the Dutch Work Addiction Scale (DUWAS-10).

The present study examined the psychometric properties of the Hebrew version of the Dutch Work Addiction Scale (DUWAS-10), developed by Schaufeli, Shimazu, and Taris (2009). Three hundred fifty-one employees completed a questionnaire measuring workaholism; of these, 251 employees completed questionnaires measuring work engagement, job satisfaction, overcommitment, and burnout. The results confirmed the expected two-factor structure of workaholism: working excessively and working compulsively. Strong correlations were obtained between self-reports and peer-reports, and satisfactory correlations were obtained between the first and second administrations of the DUWAS-10. Furthermore, DUWAS-10 scores showed predictable relations with actual number of hours worked per week, work engagement, job satisfaction, overcommitment, and burnout. Interestingly, despite working fewer hours per week, women reported higher levels of workaholism in comparison to men, and managers reported higher levels of workaholism in comparison to nonmanagerial employees.

Personality and emotional intelligence in teacher burnout.

This paper aims to investigate the relationship between teacher's personality types, emotional intelligence and burnout and to predict the burnout levels of 147 teachers in the city of Mashhad (Iran). To this end, we have used three inventories: Maslach Burnout Inventory (MBI), NEO Five Factor Inventory (NEO-FFI), and Emotional Quotient Inventory (EQ-I). We used Homogeneity Analysis and Multiple Linear Regression to analyze the data. The results exhibited a significant relationship between personality types and emotional intelligence and the three dimensions of burnout. It was indicated that the best predictors for emotional exhaustion were neuroticism and extroversion, for depersonalization were intrapersonal scale of emotional intelligence and agreeableness, and for personal accomplishment were interpersonal scale and conscientiousness. Finally, the results were discussed in the context of teacher burnout.

Bias in the nursing workplace: implications for Latino(a) nurses.

The nursing shortage coupled with health inequities makes it imperative to retain nurses from diverse backgrounds in the workplace. Since Latinos are the fastest growing racial/ethnic group in the U.S., the issue is of particular importance. Thus, the purpose of this study was to measure the prevalence of bias in the nursing workplace as experienced by Latino(a) nurses. This descriptive study of Latino(a) nurses measured the prevalence of bias, its relationship to nurse retention in the nursing workplace, and additional factors in the workplace that were associated with bias. Results included that Latino(a) nurses both experienced and witnessed bias on a regular basis, along with negative comments by peers about their ethnicity. Significant correlations were found between experiences of bias and the study variables of witnessing bias, perceived levels of support, and time planning to remain in the workplace. As the nursing shortage continues and increases in severity, retaining nurses becomes as important as creating new nurses. Nurse managers, hospital administrators, and nurse educators must develop strategies to educate staff and promote non-biased interactions between nurses in the workplace, as well as to support nurses from diverse backgrounds.

Burnout among foreign-born and native Swedish women: a longitudinal study.

The authors of this study addressed burnout experiences (generally defined as chronic depletion of an individual's energetic resources') over time in relation to other factors (e.g., distress, sleep difficulties, job demands, etc.) among foreign-born women and Swedish native women living in Stockholm. The study design was a longitudinal panel survey with two waves one year apart. In the first wave, 3,616 of 6,000 randomly selected women took part, and 2,300 of the initial 3,616 women also participated in the second wave; 427 were foreign-born women, and 1,873 were Swedish native women. Baseline/emerging distress, emerging sleep difficulties, worsening general social support, job demands at baseline/escalating during the assessment period, emerging unemployment, constraints in social support at work, and sustained/emerging financial strain were associated with future burnout, regardless of background. More foreign-born women than Swedish native women reported burnout, with these differences maintained at one-year follow-up. The factors related to burnout were largely the same in both groups, but smoking and cardiovascular disease were related to burnout only among foreign-born women. Younger age, job demands, and working hours were associated with burnout among Swedish native women. The authors found that the women had concurrent problems such as burnout, distress, and sleep problems, but foreign background was not independently related to burnout.

Secondary traumatic stress and burnout in child welfare workers: a comparative analysis of occupational distress across professional groups.

This study describes predictors of secondary traumatic stress and burnout in a national sample of helping professionals, with a specific focus on the unique responses of child welfare (CW) workers. Specific worker and exposure characteristics are examined as possible predictors of these forms of occupational distress in a sample of 669 professionals from across the country who responded to mailed (e-mail and post) invitations to participate in an online survey. E-mail and home mailing addresses were secured from licensure boards and professional membership organizations in six states from across the country that had high rates of child related deaths in 2009. Respondents completed the Professional Quality of Life IV (Stamm, 2005) to ascertain compassion fatigue (CF) and burnout symptoms. Being male, young, Hispanic, holding rural residence, and endorsing a lack of religious participation were significant predictors of secondary traumatic stress. Similarly, being male and young predicted high burnout rates, while actively participating in religious services predicted lower burnout. CW worker job status as a professional was significantly more likely to predict CF and burnout compared to all other types of behavioral healthcare professionals. Based on the findings from this study, this paper proposes strategies for enhancing self-care for CW workers, and describes the essential elements of a trauma-informed CW agency that addresses secondary traumatic stress and burnout.

Primary language and cultural background as factors in resident burnout in medical specialties: a study in a bilingual US city.

OBJECTIVE: The aim of this study was to identify the degree of burnout among resident physicians enrolled in seven postgraduate training programs at Texas Tech University Health Sciences Center (TTUHSC), Paul L. Foster School of Medicine, El Paso, Texas, as it related to residents' age, gender, marital status, number of hours worked per week, primary language, race/ethnicity, and cultural background. METHOD: : The Maslach Burnout Inventory Human Service Survey (MBI) was administered to measure the level of burnout according to the prevalence of emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA). RESULTS: : Eighty-one percent of the residents at TTUHSC participated in the study. Residents raised in the United States or Canada comprised 28% and 35% of the study, and all reported English as their primary language. The EE scale was significant for obstetrics/gynecology (OB/GYN) residents (prevalence odds ratio [POR] = 13.55, P = 0.02) and psychiatry (PSY) residents (POR = 6.50, P = 0.03). Emergency medicine (EM) residents (POR = 23.35, P = 0.002), OB/GYN (POR = 10.89, P = 0.02), and general surgery (GS) (POR = 6.24, P = 0.03) residents had high DP. Internal medicine (IM) residents (primarily Spanish-speaking) reported significantly low EE (POR = 0.22, P = 0.03) and PA (POR = 0.09, P = 0.001) scores. Residents from the United States or Canada who reported English as their primary language and noted their race as white, had high EE (POR = 3.06, P = 0.03; POR = 5.61, P = 0.0001; POR = 2.91, P = 0.004), DP (POR = 3.19, P = 0.02; POR = 8.34, P < or = 0.0001; POR = 4.70, P < or = 0.0001) and PA (POR = 2.61, P = 0.02; POR = 2.35, P = 0.05, POR 0.29, P = 0.3) scores. CONCLUSION: Using valid measures, this pilot study identified a statistically significant relationship between burnout and residents' race/ethnicity, primary language, and cultural background. Larger studies with similar focus would be necessary to generalize these findings. At-risk residents in bilingual locations should be provided with cultural awareness workshops, language assistance programs, as well as senior resident and faculty mentors.

The factorial validity of the Maslach Burnout Inventory-Student Survey in China.

The dimensional structure of the Maslach Burnout Inventory-Student Survey (MBI-SS) was investigated using data collected from three samples of Chinese students in two high schools, a university, and a nursing school, respectively (total N = 1,499; 36% males, 64% females; M age 19.0 yr., SD = 1.3). Single group Confirmatory Factor Analyses corroborated the hypothesized three-factor model for the composite sample as well as for the three independent samples. Subsequent multigroup analyses revealed that the three-dimensional structure of the MBI-SS is partially invariant across three samples. It is concluded that the MBI-SS can be used to assess burnout in Chinese students.

Social support, burnout syndrome and occupational exhaustion among Mexican traffic police agents.

The consequences of work-related stress on health are worrisome, and by the same token, so is Burnout Syndrome. However, it has been shown that social support can prevent, reduce or even combat individuals' responses to stress. A descriptive, transverse study was carried out with the objective of determining the prevalence of both Burnout Syndrome and receiving social support for traffic police in Mexico. 875 traffic police participated in the study, men and women alike, from all work shifts, day and night. Three questionnaires were administered: one to record sociodemographic and professional data, as well as the Maslach Burnout Inventory and the modified Diaz Veiga Social Resources Inventory. Our data analysis obtained frequencies and percentages and also identified associations between the study's variables. The prevalence of Burnout Syndrome was found to be 54.9% among the study's participants. The social support networks designated as "low or poor" were shown to be associated with Burnout Syndrome, with p values less than .05, an odds ratio (OR) greater than 1 and a confidence interval that did not include the number one. In spite of the strong network of social support reported by participants, it seems that those social effects were not strong enough to combat Burnout Syndrome, and some resolution strategy ought to be implemented at the individual, group and organizational levels.

Violence breeds violence: burnout as a mediator between patient violence and nurse violence.

The present study examines whether patient-perpetrated violence triggers anger, hatred and other negative emotions that, under certain circumstances, might motivate nurses to behave violently with patients. In doing so, this study considers burnout as a mediator in the patient violence-nurse violence relationship. To test the causal paths, data were collected from 182 nurses working in two government-sector teaching hospitals of Pakistan's Punjab province. Results confirm that patient violence toward nurses leads to nurse violence toward patients through the mediating effect of burnout. The study advises hospitals to provide wellness and stress management programs to nurses who regularly experience events involving patient violence. Hospitals may consider allowing nurses to take short breaks after an encounter with violently behaving patients. In addition, hospitals should conduct empathy-promoting training, emotional intelligence training and 'lens of the patient' training programs to sensitize their nursing staff.

Association of Racial Bias With Burnout Among Resident Physicians.

Importance: Burnout, a syndrome characterized by emotional exhaustion, depersonalization, and a decreased sense of efficacy, is common among resident physicians, and negative emotional states may increase the expression of prejudices, which are associated with racial disparities in health care. Whether racial bias varies by symptoms of burnout among resident physicians is unknown. Objective: To assess the association between burnout and explicit and implicit racial biases toward black people in resident physicians. Design, Setting, and Participants: This cohort study obtained data from surveys completed by first-year medical students and resident physicians in the United States as part of the Cognitive Habits and Growth Evaluation Study. Participants were followed up from enrollment in 2010 to 2011 through 2017. Participants completed questionnaires at year 4 of medical school as well as at the second and third years of residency. Only data from resident physicians who self-identified as belonging to a racial group other than black (n = 3392) were included in the analyses because of scarce evidence of racial bias in the care provided to black patients by black physicians. Resident physicians training in radiology or pathology were excluded because they provided less direct patient interaction. Main Outcomes and Measures: Burnout symptoms were measured by 2 single-item measures from the Maslach Burnout Inventory. Explicit attitudes about white and black people were measured by a feeling thermometer (FT, from 0 to 100 points, ranging from very cold or unfavorable [lowest score] to very warm or favorable [highest score]; included in the second-year [R2] and third-year [R3] questionnaires). The R2 Questionnaire included a racial Implicit Association Test (IAT; range: -2 to 2). Results: Among the 3392 nonblack resident physician respondents, 1693 (49.9%) were male, 1964 (57.9%) were younger than 30 years, and 2362 (69.6%) self-identified as belonging to the white race. In this cohort, 1529 of 3380 resident physicians (45.2%) had symptoms of burnout and 1394 of 3377 resident physicians (41.3%) had depression. From this group, 12 did not complete the burnout items and 15 did not complete the Patient-Reported Outcomes Measurement Information System (PROMIS) items. The mean (SD) FT score toward black people was 77.9 (21.0) and toward white people was 81.1 (20.1), and the mean (SD) racial IAT score was 0.4 (0.4). Burnout at the R2 Questionnaire time point was associated with greater explicit and implicit racial biases. In multivariable analyses adjusting for demographics, specialty, depression, and FT scores toward white people, resident physicians with burnout had greater explicit racial bias (difference in FT score, -2.40; 95% CI, -3.42 to -1.37; P < .001) and implicit racial bias (difference in IAT score, 0.05; 95% CI, 0.02-0.08; P = .002). A dose-response association was found between change in depersonalization from R2 to R3 Questionnaire and R3 Questionnaire explicit bias (for each 1-point increase the difference in R3 FT score decreased, -0.73; 95% CI, -1.23 to -0.23; P = .004) and change in explicit bias. Conclusions and Relevance: Among resident physicians, symptoms of burnout appeared to be associated with greater explicit and implicit racial biases; given the high prevalence of burnout and the negative implications of bias for medical care, symptoms of burnout may be factors in racial disparities in health care.

Race, ethnicity, and medical student well-being in the United States.

BACKGROUND: Little is known about the training experience of minority medical students. We explore differences in the prevalence of burnout, depressive symptoms, and quality of life (QOL) among minority and nonminority medical students as well as the role race/ethnicity plays in students' experiences. METHODS: Medical students (N = 3080) at 5 medical schools were surveyed in 2006 using validated instruments to assess burnout, depression, and QOL. Students were also asked about the impact of race/ethnicity on their training experience. RESULTS: The response rate was 55%. Nearly half of students reported burnout (47%) and depressive symptoms (49%). Mental QOL scores were lower among students than among the age-matched general population (43.1 vs 47.2; P < .001). Prevalence of depressive symptoms was similar regardless of minority status, but more nonminority students had burnout (39% vs 33%; P < .03). Minority students were more likely to report that their race/ethnicity had adversely affected their medical school experience (11% vs 2%; P < .001) and cited racial discrimination, racial prejudice, feelings of isolation, and different cultural expectations as causes. Minority students reporting such experiences were more likely to have burnout, depressive symptoms, and low mental QOL scores than were minority students without such experiences (all P < .05). CONCLUSIONS: Symptoms of distress are prevalent among medical students. While minorities appear to be at lower risk for burnout than nonminority students, race does contribute to the distress minority students do experience. Additional studies are needed to define the causes of these perceptions and to improve the learning climate for all students.

The Women's Role Strain Inventory: a Chinese translation and psychometric analyses for Taiwanese women.

BACKGROUND: To date, there is no instrument that measures role strain experienced by Chinese speaking women engaged in multiple roles of working professionals, and wife/mother. OBJECTIVES: The objectives of this study were to: (1) translate the women's role strain inventory (WRSI) into Chinese; (2) compare the translated version (WRSI-C) to the original English version of the instrument to measure role strain of women who are engaged in multiple roles; and (3) complete a psychometric evaluation of the (WRSI-C) Chinese version of the WRSI in this different culture. PARTICIPANTS: Taiwanese women (N=448) working as professional nurses, attending classes, and maintaining family responsibilities provided the data. METHOD: Reliability of the WRSI-C was compared to the English version by comparing Cronbach's alpha coefficients. Test-retest reliability was assessed using intra-class and Spearman correlations. Validity of the WRSI-C (long form) was assessed using exploratory factor analyses. RESULTS: The WRSI-C was found to be both reliable and valid. CONCLUSIONS: The reliability and validity of the WRSI-C appeared to be consistent across English and Taiwanese samples.

Reliability and validity of Turkish version of clinical stress questionnaire.

This study was conducted for the purpose of testing the validity and reliability of the Turkish version of the Clinical Stress Questionnaire, which was developed to examine the stress that nursing students experience in their first clinical experiences that are threatening or challenging. The study sample was comprised of 80 first-year nursing students who had their first clinical practice experience. Internal consistency of the total questionnaire was Cronbach's alpha=0.70 and the factor analysis supported the original construct. Based on these results the Turkish version of the Clinical Stress Questionnaire can be used as a valid and reliable instrument.