A journey through roses and thorns: becoming a physician by learning from patients with life-threatening illnesses. A qualitative study with international medical students.

The medical students' well-being may be threatened by various stressors associated with providing care to different kinds of patients. This study aims to explore students' clinical experiences with patients who suffer from life-threatening illnesses, focusing on potential risk and protective factors. Audio-recorded and face-to-face interviews were conducted and transcribed verbatim. The "Interpretive Description" approach was used to analyse data. Overall, ten medical students with a mean age of 28 years old were interviewed. Well-being promoting factors were the following: therapeutic relationships, work-life balance, social support and communication, perception of improvement in knowledge and availability of advanced directives. Whilst factors that may reduce well-being included death exposure, managing emotions, communication difficulties, internal conflicts and disagreements, lack of knowledge and subjective concerns. These findings shed light on facets that are inherent parts of clinical experience with patients suffering from a life-threatening illness and that may turn in risk or protective factors for the medical students. Understanding the students' subjective experiences may aid in the improvement of the current educational programs, as well as in the development of tailored supportive and preventative interventions to promote well-being and professional competencies among this kind of students.

Healthcare professionals' perceptions about the Italian law on advance directives.

BACKGROUND: In the variegated legislative framework on advance directives, the first specific regulation in Italy on this issue came into force only in 2018. RESEARCH OBJECTIVE: This qualitative study aimed to investigate the implications of the new Italian law on advance directives in clinical practice from the perspective of those who deal with this delicate ethical issue on an everyday basis, that is, Italian healthcare professionals. RESEARCH DESIGN: A qualitative research design using semi-structured audio-recorded interviews was adopted. The data collection and analysis were performed according to the Grounded Theory approach. PARTICIPANTS: Nineteen healthcare professionals (16 nurses, 3 physicians) working in a palliative care unit of a research and clinical institute in Italy. ETHICAL CONSIDERATIONS: The study is part of the WeDistress HELL Project (WEllness and DISTRESS in HEalth care professionals dealing with end of Life and bioethicaL issues) approved by the Ethical Committee of ICS Maugeri - Institute of Pavia (Italy). FINDINGS: The authors identified a main overall category, 'Pros and Cons of the Italian law on advance directives', composed of six constituent categories: Positive welcome, Self-determination and protection, Prompts for future betterment, Uncertainties, Lack of knowledge, and Neutrality and no suggestions. DISCUSSION: The Italian law n. 219/2017 on advance directives was seen as a legal instrument possessing both strengths and weaknesses, but able to guarantee the patient's self-determination and support healthcare professionals in providing care according to patients' wishes. CONCLUSION: An understanding of the healthcare providers' perspective may support the discussion on advance directives and bridge the gaps that currently persist in handling ethical issues.

Measuring Moral Distress Among Critical Care Clinicians: Validation and Psychometric Properties of the Italian Moral Distress Scale-Revised.

OBJECTIVES: Moral distress is a common experience among critical care professionals, leading to frustration, withdrawal from patient care, and job abandonment. Most of the studies on moral distress have used the Moral Distress Scale or its revised version (Moral Distress Scale-Revised). However, these scales have never been validated through factor analysis. This article aims to explore the factorial structure of the Moral Distress Scale-Revised and develop a valid and reliable scale through factor analysis. DESIGN: Validation study using a survey design. SETTING: Eight medical-surgical ICUs in the north of Italy. SUBJECTS: A total of 184 clinicians (64 physicians, 94 nurses, and 14 residents). INTERVENTIONS: The Moral Distress Scale-Revised was translated into Italian and administered along with a measure of depression (Beck Depression Inventory-Second Edition) to establish convergent validity. Exploratory factor analysis was conducted to explore the Moral Distress Scale-Revised factorial structure. Items with low (less than or equal to 0.350) or multiple saturations were removed. The resulting model was tested through confirmatory factor analysis. MEASUREMENTS AND MAIN RESULTS: The Italian Moral Distress Scale-Revised is composed of 14 items referring to four factors: futile care, poor teamwork, deceptive communication, and ethical misconduct. This model accounts for 59% of the total variance and presents a good fit with the data (root mean square error of approximation = 0.06; comparative fit index = 0.95; Tucker-Lewis index = 0.94; weighted root mean square residual = 0.65). The Italian Moral Distress Scale-Revised evinces good reliability (α = 0.81) and moderately correlates with Beck Depression Inventory-Second Edition (r = 0.293; p < 0.001). No significant differences were found in the moral distress total score between physicians and nurses. However, nurses scored higher on futile care than physicians (t = 2.051; p = 0.042), whereas physicians scored higher on deceptive communication than nurses (t = 3.617; p < 0.001). Moral distress was higher for those clinicians considering to give up their position (t = 2.778; p = 0.006). CONCLUSIONS: The Italian Moral Distress Scale-Revised is a valid and reliable instrument to assess moral distress among critical care clinicians and develop tailored interventions addressing its different components. Further research could test the generalizability of its factorial structure in other cultures.

[Subjective and objective indicators of job stress and burnout in a residential home for the elderly]. / Indicatori soggettivi e oggettivi di rischio stress e burnout in una residenza sanitaria assistenziale.

INTRODUCTION: Elderly care workers have a higher risk than other professionals of developing burnout. Despite literature has highlighted the methodological advantage resulting from an integration of subjective and objective measures of stressors, only few studies have investigated job stress and burnout in the Italian elderly care context using this kind of assessment. The aims of this study were: (a) to investigate the level of stress and burnout and their organizational sources in a sample of eldercare workers by means of subjective and objective tools, and b) to compare the stress and burnout levels between health care staff and nursing aides employed in a residential home for the, elderly. METHODS: The sample of the study included the totality of the elderly workers employed in a residential home for the elderly (N=49; response rate: 100%). The Maslach Burnout Inventory-GS and the Areas of Worklife Scale were used for the subjective assessment of burnout and organizational riskfactors. A check list of objective indicators was used for the objective assessment of job stress. RESULTS: Results from the self-report questionnaires showed high levels of exhaustion and a perception of high workload and unfairness for, the total sample. Objective parameters ofjob stress risk were biomechanical overload, dealing with suffering people and the risk of work-related violence. Nursing aides had greater risk of burnout and reported a greater number of objective sources of stress, compared to health care workers. CONCLUSIONS: This exploratory study supports the use of both subjective and objective method for the assessment of job stress risk as the most comprehensive approach for the implementation of preventive and corrective interventions.

From the addiction rehabilitation program to the return to work: results of an employment and social intervention among young adults with substance dependence. / Dalla riabilitazione delle dipendenze alla reintegrazione al lavoro: risultati di in progetto di reinserimento sociale e lavorativo per giovani con dipendenza da sostanze.

INTRODUCTION: Substance dependence problems are considered to be a relevant issue for a large proportion of the working population and represent a huge health and occupational cost. However, few studies have examined the return to work after addiction problems. AIMS: This exploratory follow-up study aims to evaluate the return to work, in terms of employment outcomes, perceived work environment and physical and mental health of patients who have completed an addiction rehabilitation program and an employment and social intervention. METHODS: The sample includes 51 participants with a baseline diagnosis of substance abuse disorder who have completed a rehabilitation and a social-occupational intervention. Patients were assessed by means of self-report questionnaires referring to perceptions of the work environment, individual characteristics and mental and physical health. RESULTS: The results show that the majority of the sample (88.2%) is employed at follow-up and refers positive perceptions about the psychosocial work environment, the mental and physical health and the stabilization of the change. The factors that significantly influence job satisfaction are work ability (p=0.02), work engagement (p=0.04) and absence of desire (p=0.05). CONCLUSIONS: The present study shows that many patients some years after the rehabilitation program have kept their job with positive levels of individual and organizational well-being. Work is not perceived as a source of stress but it represents a protective factor for health, personal identity and social integration.

[Professional outcomes and psychological health after workplace bullying: an exploratory follow-up study]. / Esiti professionali e salute psicologica a seguito di vessazioni sul luogo di lavoro: uno studio esplorativo di follow-up.

BACKGROUND: The literature shows that workplace bullying can lead to negative consequences for both individuals' health and professional outcomes. Most of these studies used cross-sectional designs and self-report questionnaires and further research is needed in order to explore long-term effects of workplace bullying. OBJECTIVES: This follow-up study aimed to explore professional and psychological outcomes in a sample of subjects who required a specialized and multidisciplinary assessment for psychological problems related, in their opinion, to workplace bullying. METHODS: The sample includes 71 patients with a baseline diagnosis of work-related psychological disorder who were assessed at follow-up by means of a structured telephone interview. The interview included structured questions about professional career developments and psycho-somatic health, and administration of the General Health Questionnaire-12. RESULTS: 62.0% of the participants were currently working and, of these, 59.1% had changed workplace after experiencing mobbing. Patients who changed workplace scored significantly higher on job satisfaction levels (p<0.01) and showed lower levels of social dysfunction (p<0.01) compared to those who did not change their job. Patients with a baseline diagnosis of Adjustment disorder/Post-Traumatic Stress disorder had higher levels of general dysphoria (p<0.04) and social dysfunction (p<0.01) at follow-up than other patients. CONCLUSIONS: These findings  stress the importance of an accurate diagnostic assessment of mobbing-related psychopathological disorder. Victims of workplace bullying require early and continuous psychological support in order to promote their psychological well-being and work reinstatement.

Does job satisfaction predict early return to work after coronary angioplasty or cardiac surgery?

PURPOSE: Few studies have analyzed the relationship between job satisfaction and return to work (RTW) in cardiac patients. The aim of this paper was to investigate whether job satisfaction predicted early RTW in patients sick listed after cardiac invasive procedures. METHODS: A 6-month prospective study was carried out in a sample of 83 patients in working age who had recently been treated with angioplasty or cardiac surgery. Job satisfaction was measured using the scale from the Occupational Stress Indicator during cardiac rehabilitation. Time to RTW was assessed at the 6-month occupational physician examination. Logistic regression analyses were used to study the association between job satisfaction at baseline and early RTW at follow-up, adjusted for socio-demographic, medical (type of cardiac intervention, ejection fraction) and psychological (depression, locus of control, illness perception) factors. RESULTS: Participants with high job satisfaction were more likely to return early to work, with an odds ratio (OR) of 5.92 (95 % CI, 1.69-20.73) in the most-adjusted model, compared to participants with low job satisfaction. Satisfaction with organizational processes was the job satisfaction component most strongly associated with early RTW (OR, 4.30; 95 % CI, 1.21-15.03). CONCLUSIONS: To the best of our knowledge, this is the first prospective study that investigated whether job satisfaction predicts time to RTW after cardiac interventions. The results suggested that when patients are satisfied with their job and positively perceived their work environment, they will be more likely to early RTW, independently of socio-demographic, medical and psychological factors.

Work engagement and occupational stress in nurses and other healthcare workers: the role of organisational and personal factors.

AIMS AND OBJECTIVES: The aims of this study were to: (1) identify the role of organisational and personal factors in predicting work engagement in healthcare workers and (2) compare work engagement and occupational stress perceptions of healthcare professional categories. BACKGROUND: Healthcare professionals, with particular regard to nurses, are exposed to several job stressors that can adversely affect both their mental and physical health and also decrease work engagement. Work engagement can be considered as the positive opposite of burnout, and it is characterised by energy, involvement and professional efficacy. DESIGN: A cross-sectional survey research was conducted with self-report questionnaires. METHODS: The Maslach Burnout Inventory-General Survey, the Areas of Worklife Scale and four scales from the Occupational Stress Indicator were administered to a sample of 198 hospital staff (registered nurses, nurse aides, physicians and physiotherapists), of which 110 participated in the study. RESULTS: The most significant predictors of energy were workload, mental health and job satisfaction; the best predictors of involvement were community, workload, mental health and job satisfaction; professional efficacy was best predicted by values and job satisfaction. In relation to the second aim, physiotherapists had the highest levels of occupational stress and disengagement from their work, while nurse aides were the most work-engaged and job-satisfied professional category, with positive perceptions of the work environment. CONCLUSIONS: Both organisational and personal factors were found to be significantly associated with work engagement. In this study, physiotherapists were the category with the highest risk of work-related psychological problems, whereas nurse aides had the lowest risk. RELEVANCE TO CLINICAL PRACTICE: Interventions aimed at improving clinical practice and psychological health of nurses and hospital staff should focus on workload, workers' personal expectations and job satisfaction.

[Occupational stress in municipal police officers: contribution to the Italian adaptation of a questionnaire for the assessment of the operational and organizational stressors]. / Lo stress negli operatori di polizia locale: contributo all'adattamento italiano di uno strumento per la misura di stressor operativi e organizzativi.

INTRODUCTION: The study of occupational stress in police has received growing interest because of the potential negative effects that it may produce both on an individual and on an organizational level. The aim of the present research is to give a first contribution to the Italian adaptation of two questionnaires used in order to assess operational and organizational stressors in police: the Operational Police Stress Questionnaire (PSQ-Op) and the Organizational Police Stress Questionnaire (PSQ-Org). METHODS; The PSQ-Op-It and the PSQ-Org-It have been administered to all the municipal police officers serving the population of a small town in Northern Italy (N = 88). An explorative factor analysis has been carried out to verify the internal structure; in order to assess the concurrent validity, correlations with psycho-physical malaise (GHQ-12) and burnout (MBI-GS) have been calculated. RESULTS: The factor analysis (rotation method oblimin) confirmed the original structure of the two questionnaires: two factors, corresponding to organizational and operational stressors, have been extracted. The Cronbach's alphas of the two questionnaires, 0.95 and 0.94 respectively, have pointed out good internal consistency. The two instruments are related to the subscales of the GHQ-12 and the MBI-GS, with the exception of the professional inefficacy dimension. CONCLUSIONS: The PSQ-Org-It and the PSQ-Op-It have shown good psychometric properties, so they could be used in order to assess police-specific stressors. Nevertheless we suggest to deepen the obtained results by confirmative factor analyses to carry out through the administration of the instrument to more numerous samples, in different and more structured urban contexts.

Engagement and Vicarious Traumatization in rescue workers.

PURPOSE: The aims of this study are (1) to investigate the incidence of the symptoms of Vicarious Traumatization in a group of rescue workers; (2) to explore some of the main predictors of Engagement and Vicarious Traumatization; and (3) to identify the individual and organizational factors able to improve the state of well-being of those working in the helping professions. METHODS: A total of 782 rescue workers, involved in critical operations of various kinds in constant contact with traumatized subjects, were investigated applying the Maslach Burnout Inventory-General Scale (MBI-GS) and the Secondary Traumatic Stress Scale (STSS). RESULTS: The post-traumatic symptoms most frequently reported were those of an intrusive nature. A partial overlap emerged between the predictors of Vicarious Traumatization and Engagement: if compared with social and demographic characteristics and with the degree of commitment required by the work, organizational variables would appear to have the greatest influence over the two constructs. A supportive working environment in particular favors Engagement, reducing the probability of developing Burnout. CONCLUSIONS: The results confirm the hypotheses that Engagement and Vicarious Traumatization are primarily determined by organizational variables, and, particularly, by the level of job support.

Organizational features of workplace and job engagement among Swiss healthcare workers.

The aim of this study was to determine the engagement level among healthcare workers in a Swiss hospital, identifying organizational predictors that could affect it. A four-part survey (a demographic questionnaire, Maslach Burnout Inventory-General Survey, Areas of Worklife Scale, and the General Health Questionnaire) was completed by 206 nurses and physicians. With regards to organizational predictors of job engagement, energy was primarily influenced by workload, involvement by values, and efficacy by reward. Moreover, we found that engagement might affect psychophysical health conditions: better health generally corresponds to higher levels of engagement. These results confirm that engagement is influenced by organizational variables and that engaged employees are generally more healthy and efficient. Therefore, interventions to minimize the impact of work stressors and to improve engagement are needed. Effective management of excessive workload, higher levels of autonomy, and greater job support are vital to limit psychological problems of healthcare workers.

[Stress risk evaluation in health personnel: framework and applicative experiences]. / La valutazione del rischio stress negli operatori sanitari: inquadramento del problema ed esperienze applicative.

The Italian legislative decree 81/08 requires stress risk evaluation for all the workers, including health personnel. The present paper compares two different occupational stress evaluation procedures, tested in two North Italy sanitary structures: a) the first through subjective methods, based on self report questionnaires and focus groups; b) the second through an objective approach, utilizing the OSFA (Objective Stress Factors Analysis) method. The comparison of the two experiences indicates that the subjective approach may present several limitations, since it gives a measure of the "felt" stress, not directly related to the nature of the job. On the other hand, the objective approach, and particularly the OSFA method, allows an analysis of the work conditions and the identification of single and specific aspects that can be ameliorated in order to eliminate or reduce the occupational stress sources.

Underneath the White Coat: Risk and Protective Factors for Palliative Care Providers in Their Daily Work.

Palliative care practice is associated with risk factors linked to end-of-life, chronicity, personal, interpersonal, and work characteristics, as well as with protective factors, but how these are perceived by the health care providers themselves is not clear. This article aims to elaborate a theoretical framework explaining the risk and protective factors for palliative care providers in their daily practice. Nineteen providers (16 nurses, 3 physicians) working in a palliative care unit of a clinical-research institute in Northern Italy were interviewed. A Grounded Theory qualitative approach guided the data collection and analysis. From the interviews, 28 codes, subsequently organized into 11 interconnected categories, emerged. They described both stressors (emotion management regarding death/dying, conflicts, communication and relationship with patients/caregivers, discrepancies between patients' and caregivers' needs, communication of poor diagnosis/prognosis, decision making about treatment, and real-life and work interference) and protective factors (social support, positive approach and value of past experience, recognized value of/passion toward professional work, work-family balance). Experiencing these elements as positive or negative depends on the professionals' point of view, as well as their past and present experience.Understanding what dealing with life-limiting illnesses means may suggest tailored interventions to improve professionals' well-being by fostering the protective elements and combatting the risk factors.

Clinicians' moral distress and family satisfaction in the intensive care unit.

This study explored the relationship between clinicians' moral distress and family satisfaction with care in five intensive care units in Italy. A total of 122 clinicians (45 physicians and 77 nurses) and 59 family members completed the Italian Moral Distress Scale-Revised and the Family Satisfaction in the ICU questionnaire, respectively. Clinicians' moral distress inversely correlated with family satisfaction related to the inclusion in the decision-making process. Specifically, physicians' moral distress inversely correlated with satisfaction regarding the respect shown toward the patient. Nurses' moral distress inversely correlated with satisfaction regarding breathlessness and agitation management, provision of emotional support, understanding of information, and inclusion in the decision-making process.

The moderating effect of exposure to robbery on the relationship between post-traumatic stress and job satisfaction.

Research has disregarded the boundary conditions of the effects of post-traumatic stress symptoms (PTSS) at work. Addressing this issue, the present study examines the moderating impact of the (shared vs. isolated) exposure to robbery on the relationship between PTSS and employee job satisfaction. Drawing on the conservation of resources theory, we argue that PTSS would positively affect employee job satisfaction when the robbery is experienced collectively. To test our predictions, we conducted a two-wave study-with a lag of two months between measurements-on 140 employees from a national bank in Italy. Results from hierarchical regression analyses supported our prediction: the exposure to robbery moderated the relationship between PTSS and job satisfaction. While within the "isolated exposure" group the job satisfaction score was higher among less symptomatic victims, within the "shared exposure" group those with high PTSS reported higher job satisfaction levels than those with low PTSS. We discuss the implications of these findings for theory and practice.

Occupational risk perception, safety training, and injury prevention: testing a model in the Italian printing industry.

This study examined occupational risk perception in relation to safety training and injuries. In a printing industry, 350 workers from 6 departments completed a survey. Data analysis showed significant differences in risk perceptions among departments. Differences in risk perception reflected the type of work and the injury incidents in the departments. A structural equation analysis confirmed a model of risk perception on the basis of employees' evaluation of the prevalence and lethalness of hazards as well as the control over hazards they gain from training. The number of injuries sustained was positively related to the perception of risk exposure and negatively related to evaluations about the safety training. The results highlight the importance of training interventions in increasing workers' adoption of safety procedures and prevention of injuries.

The impact of customer incivility and verbal aggression on service providers: A systematic review.

BACKGROUND: Working in direct contact with the public may involve psycho-social hazards for employees who are frequently exposed to rude or verbally aggressive customers. Negative encounters may undermine employees' well-being and job performance, impairing the quality of the service provided with tangible costs for organizations. OBJECTIVE: The paper provides a systematic review of research on customer incivility and verbal aggression in service settings using the following framework 1) antecedents of customer misbehavior as reflected in worker perceptions, customer reasons and environmental factors; 2) maladaptive and adaptive coping strategies used by service providers in response to customer incivility and verbal aggression; 3) effects of customer incivility and verbal aggression on service providers' well-being and work-related outcomes; and 4) practical implications for the management. We present a model of the relationships between these four areas. METHODS: A systematic review was conducted using PsychINFO and Scopus. RESULTS: Fifty-three papers (20 pertaining to customer incivility and 33 pertaining to customer verbal aggression) were included. CONCLUSION: Both customer incivility and verbal aggression may impair employees' well-being and job outcomes. Current gaps, practical implications, and directions for future research are discussed.

Healthcare professionals' moral distress in adult palliative care: a systematic review.

OBJECTIVES: Palliative care providers may be exposed to numerous detrimental psychological and existential challenges. Ethical issues in the healthcare arena are subject to continual debate, being fuelled with ongoing medical, technological and legal advancements. This work aims to systematically review studies addressing the moral distress experienced by healthcare professionals who provide adult palliative care. METHODS: A literature search was performed on PubMed, Scopus, Web of Science and PsycINFO databases, searching for the terms 'moral distress' AND 'palliative care'. The review process has followed the international PRISMA statement guidelines. RESULTS: The initial search identified 248 papers and 10 of them were considered eligible. Four main areas were identified: (1) personal factors, (2) patients and caregivers, (3) colleagues and superiors and (4) environment and organisation. Managing emotions of self and others, witnessing sufferance and disability, caring for highly demanding patients and caregivers, as well as poor communication were identified as distressing. Moreover, the relationship with colleagues and superiors, and organisational constraints often led to actions which contravened personal values invoking moral distress. The authors also summarised some supportive and preventive recommendations including self-empowerment, communication improvement, management of emotions and specific educational programmes for palliative care providers. A holistic model of moral distress in adult palliative care (integrating emotional, cognitive, behavioural and organisational factors) was also proposed. CONCLUSIONS: Cognisance of risk and protective factors associated with the moral distress phenomenon may help reframe palliative healthcare systems, enabling effective and tailored actions that safeguard the well-being of providers, and consequently enhance patient care.

Emotional dissonance and exhaustion among healthcare professionals: the role of the perceived quality of care.

OBJECTIVES: The aim of this exploratory study was to analyze the association between emotional dissonance and emotional exhaustion among healthcare professionals, and the mediating role of the perceived quality of care in this relationship. MATERIAL AND METHODS: Self-report questionnaires were administered to 724 healthcare workers. The measurement model was tested and the mediation hypothesis was verified through hierarchical multiple regression analyses. Bootstrapping was used to construct confidence intervals to evaluate the mediation effects. RESULTS: Emotional dissonance was significantly related to emotional exhaustion, and the perceived quality of care was negatively related to emotional exhaustion. The perceived quality of care had a partial mediating effect on the relationship between emotional dissonance and emotional exhaustion. Emotional dissonance had a significant effect on emotional exhaustion, and the perceived quality of care was a mediating factor in this relationship among healthcare professionals. CONCLUSIONS: The management of the perceived quality of care may be helpful in the prevention of burnout and distress in the workplace. Int J Occup Med Environ Health. 2019;32(6):841-51.

Staff burnout and patient satisfaction with the quality of dialysis care.

BACKGROUND: Although there has been increasing interest in assessing patient satisfaction with health care during the past year, relatively few studies investigated hemodialyzed patient satisfaction. STUDY DESIGN: Cross-sectional study of the relationship between burnout in nephrologists and nurses and patient satisfaction with their care. SETTING & PARTICIPANTS: Nephrologists (n = 68), nurses (n = 334), and hemodialyzed patients (n = 695) from 10 dialysis centers across northern Italy. PREDICTOR: Staff burnout was assessed using the Maslach Burnout Inventory. Three staff burnout subscales were developed by using factor analysis: Emotional Exhaustion, Depersonalization, and Personal Accomplishment. OUTCOMES: Patient satisfaction was assessed by means of a multichoice questionnaire that incorporated 4 patient satisfaction dimensions: (1) completeness of medical information, (2) emotional relationship with health care staff, (3) performance of dialysis center staff, and (4) organizational aspects of health care service. Each item was scored on a 4-point scale ranging from 1 (very dissatisfied) to 4 (very satisfied). Spearman rank-order correlation was used to examine relationships between patient satisfaction and each of the 3 staff burnout subscales for each dialysis center. RESULTS: Overall, burnout scores were lower than the Italian normative sample, with no significant differences between physicians and nurses. However, considering each dialysis center separately, in 2 centers, nurses registered higher emotional exhaustion levels compared with physicians, with statistically significant differences (P = 0.004 and P = 0.003, respectively). Analysis of patient overall satisfaction assessments showed general appreciation for the "courtesy" and "kindness" of staff, but evidence of problems regarding organizational aspects and structural factors. However, the most critical dimension was for "information." There was a significant positive correlation between staff personal accomplishment and client satisfaction (P < 0.01) and a significant negative correlation between staff emotional exhaustion and patient satisfaction (P < 0.01). No significant correlation was found between staff depersonalization and patient satisfaction level. LIMITATIONS: Factor analysis should be considered exploratory and confirmed in future use of the questionnaire. CONCLUSION: Our results suggest that high levels of burnout in physicians and nurses are associated with poor patient satisfaction in dialysis units. Identifying and preventing staff burnout may increase patient satisfaction with health care.