Experiences of Workplace Violence Among Healthcare Providers in Myanmar: A Cross-sectional Survey Study.

Background Healthcare providers face enormous threats to personal safety from workplace violence (WPV). Prior investigations estimate a highly varied prevalence of WPV in the United States and around the world, including both verbal and physical assault. Little is known about WPV in Myanmar. Only a single prior study has evaluated WPV experiences among physicians in Myanmar, reporting an unusually low prevalence of verbal (8.7%) and physical (1.0%) assault. Given this much lower prevalence compared with similar studies in other low- and middle-income countries (LMICs), we embarked on a study to identify the prevalence of WPV in a separate cohort of healthcare providers in Myanmar. Methods This was a cross-sectional analysis of WPV prevalence among healthcare providers who attended a national emergency medicine conference in Myanmar in November 2018. The survey instrument was adapted from a validated survey from the Joint Program on Workplace Violence in the Healthcare Sector (International Labour Office, International Council of Nurses, World Health Organization, and Public Services International), which had been used in other global settings. Results Sixty-three participants completed the survey questionnaire, including 35 women (55.6%) and 26 men (41.3%). Among them, 25 (39.7%) were primary care providers. Overall, the combined prevalence of WPV in the previous 12 months was found to be 47.6% (n = 30; 95% CI: 34.9-60.6%). The prevalence of verbal assault was 47.6% (n = 30; 95% CI: 34.9-60.6%), and that of physical assault was 4.8% (n = 3; 95% CI: 1.0-13.3%). Twenty-four participants (42.4%) reported that they were encouraged to report violence in the workplace, and five (8.1%) reported they had received training on how to manage WPV. Respondents who were 30-34 years in age and those working in private facilities were significantly less likely to report WPV on univariate analysis. Conclusion Although our cohort comprised a limited sample of a select group of providers, we found a dramatically higher prevalence of WPV experiences among healthcare providers attending an emergency medicine conference in Myanmar when compared with a prior investigation. Very few participants had received training on WPV, and less than half reported a work culture where WPV reporting is encouraged. To combat healthcare provider shortages, more investigation is required into WPV to understand its impact and identify amelioration strategies.

Continuing Education for Prehospital Healthcare Providers in India - A Novel Course and Concept.

BACKGROUND: Emergency medical services (EMS) in India face enormous challenges in providing care to a geographically expansive and diverse patient population. Over the last decade, the public-private-partnership GVK EMRI (Emergency Management and Research Institute) has trained over 100,000 emergency medical technicians (EMTs), with greater than 21,000 currently practicing, to address this critical gap in the healthcare workforce. With the rapid development and expansion of EMS, certain aspects of specialty development have lagged behind, including continuing education requirements. To date, there have been no substantial continuing education EMT skills and training efforts. We report lessons learned during development and implementation of a continuing education course (CEC) for EMTs in India. METHODS: From 2014 to 2017, we employed an iterative process to design and launch a novel CEC focused on five core emergency competency areas (medicine and cardiology, obstetrics, trauma, pediatrics, and leadership and communication). Indian EMT instructors and providers partnered in design and content, and instructors were trained to independently deliver the CEC. Many challenges had to be overcome: scale (>21,000 EMTs), standardization (highly variable skill levels among providers and instructors), culture (educational emphasis on rote memorization rather than practical application), and translation (22 major languages and a few hundred local dialects spoken nationwide). LESSONS LEARNED: During the assessment and development phases, we identified five key strategies for success: (1) use icon-based video instruction to ensure consistent quality and allow voice-over for easy translation; (2) incorporate workbooks during didactic videos and (3) employ low-cost simulation and case discussions to emphasize active learning; (4) focus on non-technical skills; (5) integrate a formal training-of-trainers prior to delivery of materials. CONCLUSION: These key strategies can be combined with innovation and flexibility to address unique challenges of language, system resources, and cultural differences when developing impactful continuing educational initiatives in bourgeoning prehospital care systems in low- and middle-income countries.

First look at emergency medical technician wellness in India: Application of the Maslach Burnout Inventory in an unstudied population.

INTRODUCTION: Professional wellness is critical to developing and maintaining a health care workforce. Previous work has identified burnout as a significant challenge to professional wellness facing emergency medical technicians (EMTs) in many countries worldwide. Our study fills a critical gap by assessing the prevalence of burnout among emergency medical technicians (EMTs) in India. METHODS: This was a cross-sectional survey of EMTs within the largest prehospital care organization in India. We used the Maslach Burnout Inventory (MBI) to measure wellness. All EMTs presenting for continuing medical education between July-November 2017 from the states of Gujarat, Karnataka, and Telangana were eligible. Trained, independent staff administered anonymous MBI-Medical Personnel Surveys in local languages. RESULTS: Of the 327 EMTs eligible, 314 (96%) consented to participate, and 296 (94%) surveys were scorable. The prevalence of burnout was 28.7%. Compared to EMTs in other countries, Indian EMTs had higher levels of personal accomplishment but also higher levels of emotional exhaustion and moderate levels of depersonalization. In multivariate regression, determinants of burnout included younger age, perceived lack of respect from colleagues and administrators, and a sense of physical risk. EMTs who experienced burnout were four times as likely to plan to quit their jobs within one year. CONCLUSION: This is the first assessment of burnout in EMTs in India and adds to the limited body of literature among low- and middle-income country (LMIC) prehospital providers worldwide. Burnout was strongly associated with an EMT's intention to quit within a year, with potential implications for employee turnover and healthcare workforce shortages. Burnout should be a key focus of further study and possible intervention to achieve internationally recognized targets, including Sustainable Development Goal 3C and WHO's 2030 Milestone for Human Resources.

Increased preoperative white blood cell count predicts postoperative atrial fibrillation after coronary artery bypass surgery.

OBJECTIVE: To better understand the relationship between humoral and cellular markers of inflammation and postoperative atrial fibrillation (AF). DESIGN: A prospective and descriptive study. SETTING: Academic institution. PARTICIPANTS: Sixty adult patients > or = 60 years of age presenting for elective coronary artery bypass surgery with cardiopulmonary bypass (CPB). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: With institutional review board approval, serial measurements for high sensitivity C-reactive protein (CRP) and white blood cell count (WBC) were performed before the induction of anesthesia, on arrival in the intensive care unit, and on the mornings of postoperative days 1 and 2. Continuous telemetry and daily 12-lead electrocardiographs were used to confirm new-onset AF. AF occurred in 17 of 60 (28%; 95% confidence interval, 17%-41%) patients. A history of preoperative myocardial infarction was more frequent among patients who developed AF (p = 0.049). Patients with or without AF did not differ in CRP values at any of the 4 study time points (p = 0.61 to p = 0.81). Preoperative WBC values were higher for patients who developed AF, and, according to stepwise logistic regression, it was the sole independent predictor of postoperative AF (odds ratio = 6.7; 95% confidence interval, 1.6-29.0; p = 0.01). A 2-fold higher preoperative WBC was associated with a nearly 7-fold higher risk of developing AF, and WBC >7 x 10(9)/L was associated with a nearly 4-fold higher risk of AF (odds ratio = 3.8, p = 0.03). CONCLUSION: In this cohort of patients undergoing CABG surgery, preoperative leukocytosis was a significant predictor of AF independent of CRP.

Workplace violence among prehospital care providers in India: a cross-sectional study.

OBJECTIVES: The purpose of this study was twofold: (1) establish the prevalence of safety threats and workplace violence (WPV) experienced by emergency medical technicians (EMTs) in a low/middle-income country with a new prehospital care system, India and (2) understand which EMTs are at particularly high risk for these experiences. SETTING: EMTs from four Indian states (Gujarat, Karnataka, Tamil Nadu and Telangana) were eligible to participate during the study period from July through November 2017. METHODS: Cross-sectional survey study. PARTICIPANTS: 386 practicing EMTs from four Indian states. RESULTS: The overall prevalence of any WPV was 67.9% (95% CI 63.0% to 72.5%). The prevalence of physical assault was 58% (95% CI 52.5% to 63.4%) and verbal assault was 59.8% (95% CI 54.5% to 65%). Of physical assault victims, 21.7% were injured and 30.2% sought medical attention after the incident. Further, 57.3% (n=216) of respondents reported they were 'somewhat worried' and 28.4% (n=107) reported they were 'very worried' about their safety at work. CONCLUSION: WPV and safety fears were found to be common among EMTs in India. Focused initiatives to counter WPV in countries developing prehospital care systems are necessary to build a healthy and sustainable prehospital healthcare workforce.

Higher high-density lipoprotein cholesterol in African-American women with polycystic ovary syndrome compared with Caucasian counterparts.

CONTEXT: Studies have demonstrated lipid differences among African-Americans and Caucasians and between women with polycystic ovary syndrome (PCOS) and normally ovulating women. However, few studies have examined racial differences in lipoprotein levels in women with PCOS. OBJECTIVE: This study compared lipoprotein levels in African-American and Caucasian women with PCOS. DESIGN AND SETTING: We performed a retrospective chart review of 398 subjects seen as new patients for PCOS at the Duke University Medical Center Endocrinology Clinic in Durham, NC. PATIENTS: We identified 126 charts appropriate for review, based on a diagnosis of PCOS (using the 1990 National Institutes of Health criteria), a self-reported race of either Caucasian or African-American, and a body mass index (BMI) higher than 25. We excluded patients taking glucophage, oral contraceptives, or lipid-lowering medications. MAIN OUTCOME MEASURE: Age, BMI, total cholesterol, high-density lipoprotein (HDL) cholesterol, non-HDL cholesterol, random triglycerides (TG), and oral glucose tolerance test measurements were collected and included in the analysis. RESULTS: African-American women with PCOS had higher HDL cholesterol levels (52.6 vs. 47.5 mg/dl, P = 0.019), lower non-HDL cholesterol (134.1 vs. 154.6 mg/dl, P = 0.046), and lower TG levels (97.5 vs. 168.2 mg/dl, P < 0.001) than Caucasian women. These differences could not be attributed to age, BMI, or differences in insulin resistance as determined by homeostasis model assessment of insulin resistance. CONCLUSION: African-American women with PCOS appear to have a more favorable lipid profile than Caucasian women with PCOS having higher HDL cholesterol, lower non-HDL cholesterol, and lower TG when BMI and insulin resistance are equal.