Burnout, psychological morbidity and use of coping mechanisms among palliative care practitioners: A multi-centre cross-sectional study

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1 575850PMJ / Palliative Medicine X(X)Koh et al. research-article2015 Original Article Burnout, psychological morbidity and use of coping mechanisms among palliative care practitioners: A multi-centre cross-sectional study Palliative Medicine 2015, Vol. 29(7) The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalspermissions.nav DOI: / pmj.sagepub.com Mervyn Yong Hwang Koh 1, Poh Heng Chong 2, Patricia Soek Hui Neo 3, Yew Jin Ong 4, Woon Chai Yong 5, Wah Ying Ong 6, Mira Li Juan Shen 1 and Allyn Yin Mei Hum 1 Abstract Background: The prevalence of burnout, psychological morbidity and the use of coping mechanisms among palliative care practitioners in Singapore have not been studied. Aim: We aimed to study the prevalence of burnout and psychological morbidity among palliative care practitioners in Singapore and its associations with demographic and workplace factors as well as the use of coping mechanisms. Design: This was a multi-centre, cross-sectional study of all the palliative care providers within the public healthcare sector in Singapore. Setting/participants: The study was conducted in hospital palliative care services, home hospice and inpatient hospices in Singapore. The participants were doctors, nurses and social workers. Results: The prevalence of burnout among respondents in our study was 91 of 273 (33.3%) and psychological morbidity was 77 (28.2%). Working >60 h per week was significantly associated with burnout (odds ratio: 9.02, 95% confidence interval: , p = 0.002) and psychological morbidity (odds ratio: 7.21, 95% confidence interval: , p = 0.005). Home hospice care practitioners (41.5%) were more at risk of developing psychological morbidity compared to hospital-based palliative care (17.5%) or hospice inpatient care (26.0%) (p = 0.007). Coping mechanisms like physical well-being, clinical variety, setting boundaries, transcendental (meditation and quiet reflection), passion for one s work, realistic expectations, remembering patients and organisational activities were associated with less burnout. Conclusion: Our results reveal that burnout and psychological morbidity are significant in the palliative care community and demonstrate a need to look at managing long working hours and promoting the use of coping mechanisms to reduce burnout and psychological morbidity. Keywords Burnout, psychological morbidity and use of coping mechanisms among palliative care practitioners: A multi-centre cross-sectional study What is already known about the topic? Burnout and psychological morbidity affects the palliative care practitioner and can lead to poorer general health, psychological well-being, reduced job satisfaction and may adversely affect patient care. Little is known about the demographic factors that may influence burnout and psychological morbidity among palliative care practitioners. The type of coping mechanisms used and the particular mechanisms that are associated with lower burnout and psychological morbidity is also not known. 1 Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore 2 HCA Hospice Care, Singapore 3 Department of Palliative Medicine, National Cancer Centre Singapore, Singapore 4 Assisi Hospice, Singapore 5 National University Cancer Institute, Singapore, Singapore 6 Dover Park Hospice, Singapore Corresponding author: Mervyn Yong Hwang Koh, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, Singapore mervyn_koh@ttsh.com.sg

2 634 Palliative Medicine 29(7) What this paper adds? This study demonstrates that longer working hours and working in multiple settings within the same month significantly increases the risk of burnout and psychological morbidity. We also showed that those who did home hospice care were more at risk of psychological morbidity. Spirituality (describing self as a spiritual person) may be protective against depersonalisation and low personal accomplishment. Women reported lower personal accomplishment as compared to men. Being married is also associated with less emotional exhaustion. Those who used these coping mechanisms - physical well-being, clinical variety, setting boundaries, transcendental (meditation and quiet reflection), passion for one s work, having realistic expectations, remembering patients and had organisational activities that were found to be protective against burnout, appeared to cope better against burnout. Implications for practice, theory or policy? We propose that national health ministries and palliative care administrators look into managing and reducing the long working hours of palliative care practitioners to prevent burnout and psychological morbidity. We hope this paper can increase self-awareness among palliative care practitioners worldwide that they be aware of these demographic factors associated with burnout and psychological morbidity as well for them to make use of some of the coping mechanisms that may help prevent burnout. Introduction Palliative care practitioners (PCPs) are exposed daily to death and dying as part of their work. This coupled with a background of often being highly motivated individuals with high loci of control, having to juggle an expanding patient load, inadequate staffing, unpredictable timings and lack of self-care often present significant stress. 1 3 It may not only lead to burnout but also results in poorer general health, psychological well-being, lower job satisfaction and even ultimately affect the care of patients. 4 6 Burnout is defined as a state of mental and/or physical exhaustion caused by prolonged exposure to excessive and prolonged stress. 7 Burnout has been well-described among palliative care physicians and nurses According to Maslach et al., 11 this phenomenon leads to emotional exhaustion (EE), cynicism, detachment, a lack of effectiveness and having a poor sense of accomplishment. It is also associated with compassion fatigue which is defined as the emotional cost of caring and a stress response that occurs suddenly leading to helplessness, isolation and confusion whereby emotionally weary or traumatised healthcare workers have considered or even left the profession. 12,13 Given the morbidity and the long-term implications, there is a strong need for PCP to exercise self-care and selfawareness to prevent burnout and compassion fatigue. 4 Coping mechanisms like focusing on personal and professional relationships, setting personal boundaries and ensuring clinical variety have been quoted as being helpful in establishing longevity in this demanding profession. 14 Palliative care has been increasingly embedded in the Singapore healthcare fabric over the past 30 years with hospice home care, inpatient hospices, hospice day-care centres and palliative care services in all its acute hospitals. 15 These services have grown exponentially to serve an ageing population (10% of 5.4 million aged above 65 years) 16 with rising trends in cancer and end-stage organ diseases. The prevalence of burnout and psychological morbidity and its associated demographic factors among PCP in Singapore is not known. Swetz et al. 14 studied the use of coping strategies in preventing burnout among PCP in Virginia. However, whether these methods (or which specific strategy) actually prevent burnout has not been studied. Methods This article aimed to evaluate the prevalence of burnout and its impact upon the psychological health among PCP (physicians, nurses and social workers) within the public healthcare sector in Singapore. It also aims to study the demographic factors which may be associated with burnout and psychological morbidity. The use of coping mechanisms among them was also chartered. Measures Maslach Burnout Inventory. We chose the Maslach Burnout Inventory Human Services Survey (MBI-HSS) to ascertain the prevalence of burnout in our local palliative care population. It is a universally validated tool that characterises the Burnout Syndrome. Its 22 items looks at three individual components of (1) Emotional Exhaustion (EE) (9 items) measuring feelings of emotional overextension and exhaustion from work, (2) depersonalisation (DP 5 items) measures an impersonal and unfeeling response towards patients and finally (3) lack of personal accomplishment (PA 8 items) that concerns feelings of competence and successful achievements at work. Each item is rated on a 7-point Likert scale grading the extent these feelings are experienced ranging from 0 = Never to 6 = Every Day). It has also been used extensively in healthcare and palliative care research. 17 We defined burnout in

3 Koh et al. 635 our study as high scores on EE >26 (maximum: 54) and/ or high scores on DP >9 (maximum: 30). This is in line with other similar studies in palliative care that have adopted this method of measuring burnout based on high EE and/or DP scores. 8,18 General Health Questionnaire. We also screened our respondents for the risk of developing psychological morbidity. The 12-item General Health Questionnaire (GHQ- 12) is another validated instrument that looks at the risk of individuals developing psychological sequelae like anxiety and depression. Items are scored 0 ( not at all or the same as usual ) or 1 ( rather more than usual or much more than usual ), giving a maximum score of 12. Those scoring 4 or more are considered to have a high probability of psychiatric morbidity. 19 Study design Study participants. This was a multi-centre, prospective, cross-sectional study of all the palliative care providers within the public healthcare sector in Singapore. It includes seven acute hospital palliative care units, six palliative home care services and four inpatient hospices. Other than one 30-bed hospice that declined, all had agreed to participate in this study. Questionnaire. We collected respondent characteristics like age, sex, marital status, number of children, type of PCP (doctor, nurse or social worker) including seniority, years of experience in palliative care, location of practice, level of spirituality (single question asking whether participants considered themselves to be spiritual) and presence if any of recent bereavement (in the past 2 years). These were factors which we felt may influence the development of burnout. The second part of the questionnaire included the MBI- HSS and the GHQ-12. The last section examined the use of coping mechanisms that were postulated by Swetz et al. 14 that promoted longevity in palliative care. This included domains like physical well-being, personal relationships, professional relationships, clinical variety, personal boundaries, hobbies, transcendental (meditation and quiet reflection), time away, talking with others, having passion for one s work, having realistic expectations, remembering patients, using humour and laughter and organisational activities (any activity that the organisation holds to help prevent burnout). We received permission and purchased the licences to administer both these questionnaires in English. The study was approved by the institutional review board of the primary sponsoring institutions involved. Survey methodology. Individual institutional leaders among the authors coordinated the survey in their own centres. The questionnaires were distributed during department meetings at each centre. Staff who were absent or working shifts were handed questionnaires at a separate time. To foster and protect confidentiality, participants were informed that this was an anonymous survey where their immediate supervisors would not be able to identify nor have access to their responses. Participants were also given the choice to decline participation during the prior briefing by opting not to fill up the questionnaire. Consent was implied when participants completed the survey. The survey was conducted between March and April 2013 and the forms were collected in May Statistical analysis Summary measures on participants demographics and job characteristics were obtained. Continuous variables are presented as mean (standard deviation) for normally distributed data or median (interquartile range) for skewed distribution while categorical variables are summarised using frequency (percentages). Univariate analysis was first performed to investigate the relationship between various factors and the GHQ-12 and MBI scales. Multivariate analyses based on multiple linear regression or logistic regression models were then constructed. All statistical analyses were carried out using stata v10.1 (StataCorp, College Station, TX, USA) and a of <0.05 is considered statistically significant. Results Demographics synopsis We invited 293 PCPs to participate and 273 completed the questionnaire (response rate of 93.2%). There was incomplete data for three subjects (Table 1). There were more females (83.4%) than males (16.6%) and half of our respondents (50%) were married. The majority of those surveyed were palliative care nurses (58.3%), followed by doctors (28.1%) and social workers (13.6%). Around 81 (30.7%) PCPs have been in the palliative medicine field for less than a year. Prevalence of burnout The prevalence of burnout in our study according to common criteria for healthcare professionals was 91 out of 273 (33.3%) these respondents scored >26 for EE and/or >9 for DP. In all, 72 (26.4%) had high scores for EE, 43 (15.8%) had DP and 111 (40.7%) had low sense of PA. In all, 77 (28.2%) scored significantly on the GHQ-12 to be at significant risk of psychological morbidity (Table 2). We present the following factors that we found on multivariate analysis to be statistically significant. Working hours Those who worked >60 h per week were significantly more at risk of EE on both univariate and multivariate analyses (odds ratio (OR): 8.54: 95% confidence interval (CI): , p = 0.002) and burnout (OR: 9.02, 95%

4 636 Palliative Medicine 29(7) Table 1. Demographics of respondents. Demographic data N = 273 a Gender Male 45 (16.5%) Female 226 (82.8%) Marital status Single 134 (49.1%) Married 134 (49.1%) Age (years) (21.6%) (36.3%) (24.5%) (16.1%) With children No 135 (49.5%) Yes 106 (38.8%) Spirituality Yes 214(78.4%) No 56 (20.5%) Recent bereavement Yes 112 (41.0%) No 159 (58.2%) Profession Doctor 74 (27.1%) Nurse 156 (57.1%) Social worker 37 (13.6%) Doctor Junior (house officer, medical officer, 20 (27.0%) resident) Senior (consultant, registrar, resident 50 (67.6%) physician) Others 3 (4.1%) Nurse Assistant nurse, healthcare assistant 42 (27.3%) Staff nurse 76 (49.4%) Advanced practice nurse, nursing 24 (15.6%) officer/manager Others 14 (9.1%) Social worker Medical social worker, social worker 14 (38.9%) assistant Principal social worker, senior medical 13 (36.1%) social worker Others 10 (27.8%) Clinical work coverage (%) < (54.2%) (39.9%) Working hours per week <40 46 (16.8%) (53.1%) (19.0%) >60 24 ((8.8%) Overnight calls Yes 86 (31.5%) No 181 (66.3%) Weekend overnight calls Yes 85 (31.1%) No 174 (63.7 %) Table 1. (Continued) Demographic data N = 273 a Workplace Hospital 80 (29.3%) Home care 65 (23.8%) Inpatient hospice 100 (36.6%) Multiple places 22 (8.1%) Years in palliative care 1 81 (29.7%) (15.0%) (11.4%) (15.0%) (14.7%) >10 30 (11.0%) a Total number of respondents is 273. CI: , p = 0.002) compared to those who worked <40 h a week. We also found that those who worked >60 h per week (OR: 7.21, 95% CI: , p = 0.005) were more at risk of psychological morbidity again on both univariate and multivariate analyses (Table 3). Spirituality Those who described themselves as being less spiritual actually reported higher DP scores (OR: 2.83: 95% CI: , p = 0.014) as well as low PA (OR: 2.85, 95% CI: , p = 0.005) and were at higher risk of psychological morbidity (OR: 2.66, 95% CI: , p = 0.014) compared to those who described themselves as being spiritual (Table 5). Gender and marital status The female gender was associated with lower PA despite correcting for occupation, working hours and number of years in palliative care (OR: 3.65, 95% CI: , p = 0.003) (Table 5). We also found that men (40.0%) were more at risk of psychological morbidity compared to women (25.2%); however, this was not found to be significant on multivariate analysis. Those who were single also experienced higher EE (OR: 2.02, 95% CI: p = 0.04) compared to their married counterparts. The number of children the respondents had did not have a significant bearing on burnout or psychological morbidity. Workplace and occupation Those who worked in multiple different settings in the past month as compared to only one setting (hospice, home care or hospital) were significantly more at risk of burnout (OR: 3.75, 95% CI: p = 0.046) and psychological morbidity (OR: 7.79, 95% CI: , p = 0.003).

5 Koh et al. 637 Table 2. Prevalence of burnout and psychological morbidity. Burnout EE DP Low PA Psychological morbidity (GHQ-12) Respondents a 91 (33.3%) 72 (26.4%) 43 (15.8%) 111 (40.7%) 77 (28.2%) Doctors b 31 (41.9%) 23 (31.1%) 15 (20.3%) 22 (29.7%) 25 (33.8%) Nurses b 48 (31.2%) 40 (26.0%) 22 (14.3%) 69 (44.8%) 40 (26.0%) Social workers b 10 (27.8%) 8 (22.2%) 5 (13.9%) 16 (44.4%) 10 (27.8%) EE: emotional exhaustion; DP: depersonalisation; PA: personal accomplishment; GHQ-12: 12-item General Health Questionnaire. a The total number of respondents was 273. b There were 74 doctors, 156 nurses and 37 social workers in the study. Table 3. Working hours burnout and psychological morbidity (GHQ-12). Work hours Burnout Emotional exhaustion Depersonalisation Low personal accomplishment Psychological morbidity N (%) N (%) N (%) N (%) N (%) <40 11 (24.4) (17.8) (8.9) (40.0) (17.4) (25.9) 26 (18.2) 23 (16.1) 69 (48.3) 36 (24.8) (46.2) 21 (40.4) 11 (21.2) 12 (23.08) 20 (38.5) >60 15 (62.5) 14 (58.3) 3 (12.5) 8 (33.3) 12 (50.0) versus < ( ) versus <40 ( ) >60 versus <40 a ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) GHQ-12: 12-item General Health Questionnaire; CI: confidence interval. Table 4. Comparison of differences in work settings for psychological morbidity and burnout. Work settings Psychological morbidity Burnout Yes (N (%)) No (N (%)) Yes (N (%)) No (N (%)) Hospital 14 (17.5%) 66 (82.5%) (31.3%) 55 (68.8%) Home care 27 (41.5%) 38 (58.5%) 24 (36.9%) 41 (63.1%) Hospice 26 (26.0%) 74 (74.0%) 27 (27.8%) 70 (72.2%) Multiple places 9 (40.9%) 13 (59.1%) 12 (54.6%) 10 (45.5%) Home care versus hospital 3.87 ( ) ( ) Hospice versus hospital 2.69 ( ) ( ) Multiple places versus hospital 7.79 ( ) ( ) CI: confidence interval. We also found that those who worked in home hospice care (41.5%) were more at risk of developing psychological morbidity compared to counterparts doing hospital-based palliative care (17.5%) or hospice inpatient care (26.0%) (p = 0.007) (Table 4). Senior nurses (advanced practice nurses, nursing officers or nurse managers) appeared to be more at risk of burnout (50.0% vs 14.6%, p = 0.02) and EE (45.8% vs 12.2%, p = 0.03) as compared to junior nurses. However, this was found to be not significant on multivariate analysis.

6 638 Palliative Medicine 29(7) Table 5. Multivariate analysis on other demographic factors. Burnout Emotional exhaustion Depersonalisation Low personal accomplishment Psychological morbidity Gender 3.65 ( ) ( ) Marital status 1.69 ( ) ( ) ( ) Spirituality 1.80 ( ) ( ) ( ) ( ) ( ) Profession 2.39 ( ) Percent of clinical work 60% 80% versus 0% 60% 1.80 ( ) ( ) ( ) ( ) % 100% versus 0% 60% 1.99 ( ) ( ) ( ) ( ) Years in palliative care 1 2 years versus 1 year 0.34 ( ) ( ) ( ) ( ) years versus 1 year 1.09 ( ) ( ) ( ) ( ) years versus 1 year 1.45 ( ) ( ) ( ) ( ) years versus 1 year 0.62 ( ) ( ) ( ) ( ) years versus 1 year 0.62 ( ) ( ) ( ) ( ) No. of coping mechanisms 0.81 ( ) ( ) ( ) ( ) < ( ) This table does not include Work hours and different Work settings which were shown in Tables 3 and 4, respectively. CI: confidence interval.

7 Koh et al. 639 Table 6. Coping mechanisms protective against burnout. Coping mechanisms Coping mechanisms Those who had more coping mechanisms (mean: 12.3) appeared to have less burnout (OR: 0.81, 95% CI: , p = 0.001) and psychological morbidity (OR: 0.83, 95% CI: , p = 0.002) compared to those with burnout (mean: 11.0). Of the 14 coping mechanisms surveyed, the following were found to be protective against burnout physical well-being, clinical variety, having hobbies, transcendental (meditation and quiet reflection), passion for one s work, having realistic expectations, remembering patients and organisational activities were found to be protective against burnout. These factors were significantly associated with lower burnout compared with those who did not use these coping strategies (Table 6). Other factors There were no significant differences in burnout and psychological morbidity when we compared between the different occupations (doctor, nurse and social worker). We found other factors like having a recent bereavement in the past 2 years, having to do overnight or weekend duties, percentage of clinical versus nonclinical work as not having a significant bearing on burnout and psychological morbidity (Table 5). Discussion Frequency (N = 273) (%) Physical well-being 252 (92.3%) 0.043* Personal relationships 254 (93.0%) Professional relationships 250 (91.6%) Clinical variety 168 (61.5%) 0.005* Personal boundaries 219 (82.2%) Hobbies 234 (85.7%) 0.011* Transcendental (meditation 226 (82.8%) 0.003* and quiet reflection) Time away 236 (86.5%) Talking with others 220 (80.6%) Having passion for one s work 248 (90.8%) 0.029* Having realistic expectations 243 (89.0%) <0.001* Remembering patients 188 (68.9%) <0.001* Using humour and laughter 252 (92.3%) Organisational activities 151 (55.3%) 0.007* *p< 0.05 is considered statistically significant and associated with less burnout. Based on this study, the prevalence of burnout among palliative care professionals in Singapore is 33% compared to 24% among Australian PCPs. 8 This is also higher than 14% reported among US hospice workers in Minnesota even though their study did not include physicians and used a different burnout scale. 20 A Canadian study of Hospice and Palliative Care workers estimated a burnout prevalence of 21% again using a different burnout scale. 13 As compared to Japanese PCPs, our scores for EE (26% vs 15%) and DP were higher (16% vs 8%) though our study participants had better scores for low PA (28% vs 53%). 21 A shortage of PCPs and nurses could explain the higher rate of burnout in Singapore. 22 There were 17 palliative care specialists in Singapore in 2010 (Population 4.8 million) compared to Australia 92 specialists (population: 22.3 million) in Studies on Singaporean nurses also show that they are exposed to higher levels of stress. 24 Working hours We found in our study that those who worked for >60 h per week were 8.54 times more at risk of EE and 9.02 times more at risk of burnout compared to those working 40 h per week. They were also 7.21 times more at risk of psychological morbidity. This finding is similar to other studies that surveyed oncologists and physicians. 25,26 Dunwoodie and Auret s 8 study also revealed high scores for DP and burnout for those who worked longer hours. Another study found that prolonged shifts of 12 h increased the risk of workplace accidents by at least twice compared with those working 8 h shifts. 27 PCPs are at a very real and significant risk of burnout should they be made to work for >60 h a week. Spirituality Spirituality was found to be an important protector against burnout 28,29 those who were less spiritual reported higher DP scores (OR: 2.83: 95% CI: , p = 0.014) and low PA (OR: 2.85, 95% CI: , p = 0.005) and were also at higher risk of psychological morbidity (OR: 2.66, 95% CI: , p = 0.014). This is comparable to other studies on the importance of spirituality in helping with coping in internal medicine residents 30 and nursing aides. 31 We postulate that spirituality may help tide a weary PCP through the hard times as their spiritual beliefs may help them to cope against DP and guide them internally to believe in a sense of personal mission and accomplishment. Gender and marital status Women in our study also reported lower PA scores compared to their male counterparts (OR: 3.65, 95% CI: , p = 0.003). This was consistent despite correcting for other factors like occupation, years of experience and other factors. This was similar to other studies on female surgeons 32 and The Physician Worklife Study which described female physicians as being 1.6 times more prone to burnout than men with this increasing 12 15% with every 5 h after 40 h per week worked. 33 Female physicians in that

8 640 Palliative Medicine 29(7) study also reported needing more time for outpatient consults compared to men. The lack of control and autonomy over their workplace was also associated with higher burnout than men. While we cannot fully explain the reason for lower PA among women in our study, one possibility could be the fact that women often have to fulfil multiple roles both at work and home. Those who were not married were also twice (OR: 2.02, 95% CI: p = 0.04) as likely to report high scores of EE and burnout than those who were married. This was again supported by data from The Physician Work Life Study which showed that support from a spouse was protective against burnout. 33 Being married may offer the support network that is important to those practising in this field. Workplace and occupation Those who worked in multiple settings simultaneously within the same month were found to be more prone to developing psychological morbidity. This could possibly be because of a carry-over effect where the clinician still has concerns about the patients they have seen in a different setting although they have moved on to another area of care. We also discovered that those who were doing home hospice care (41.5%) were also more prone to psychological morbidity (26%) than those who were in acute hospital (17.5%) or inpatient hospice. It may be because those in community home care have responsibility for more patients, less support, control and acute care resources in patient care as compared to an inpatient hospice or hospital setting. This finding is different from the Australian study which revealed a higher degree of psychological morbidity in those doing acute hospital palliative care. 8 The lower rates of burnout in home care in Australia may be explained by greater general practitioner involvement 34 compared to Singapore where there is much less primary care involvement in palliative care. We also found that in terms of working experience, senior and staff nurses were more at risk of burnout and EE compared to their junior counterparts. The difference could be explained by senior and staff nurses working longer hours compared to junior nurses. Other studies in oncology have also shown older nurses to be more prone to burnout. 35 Coping mechanisms Even though we found that having more coping mechanisms (mean: 12.3 vs 11.0) appeared to be protective against burnout and psychological morbidity with the result being statistically significant, we do not think this was clinically significant as there appears to be little difference between the burnout and non-burnout groups. This perhaps illustrates that it may not be the total number of coping mechanisms that may be protective against burnout, but other factors which we did not include in our study which could be contributory as well. Interestingly, we found eight specific coping mechanisms to be related to lower burnout in those who used them compared to those who did not use these coping skills. These were physical well-being, clinical variety, having hobbies, transcendental (meditation and quiet reflection), passion for one s work, having realistic expectations, remembering patients and organisational activities. This is consistent with other studies supporting the importance of PCPs developing coping mechanisms 36 and institutions taking the lead to create an environment that helps staff to reflect and develop coping mechanisms. 37 Limitations There are some limitations to our study which may include under-reporting due to fear of social or workplace discrimination should respondents report themselves as burnt out. There are also some smaller organisations where there may be concerns about confidentiality despite the survey being anonymous. Survival bias may also influence the results as those who may be burnt out may have already left palliative care. 8 While our study did show associations between certain demographic factors with burnout and psychological morbidity, this study was not designed to establish a causal link between them. We also recognise that there are many facets that may lead to workplace burnout and psychological morbidity which we did not study. Workplace stressors like managing challenging patients and family members, 38 committing a medical error, 39 strength of workplace leadership, 24 control over work schedules, being transferred to other units, lack of resources and quality of care 40 all of which can predispose individuals to burnout. It would have been interesting to also know the effort: reward ratios mentioned in other studies 41 as this impacts burnout as well. Other areas like challenging social and family circumstances may also impact the PCP adversely. While we were able to describe the prevalence of use of coping mechanism, these different mechanisms may have a different impact on burnout and psychological morbidity. Conclusion Our study showed a relatively high prevalence of burnout among PCPs in Singapore compared to those in other countries. We also found that those who worked longer hours and in different settings simultaneously were more at risk of burnout and psychological morbidity. Similarly, those who did home care were more at risk of psychological morbidity. Spirituality and being married appeared to be protective against burnout. Women also had a lower sense of personal accomplishment, whereas men had a significantly higher chance of psychological morbidity. Senior nurses and staff nurses were also more prone to burnout than junior nurses.

9 Koh et al. 641 Also, those who had certain coping mechanisms appeared to cope better against burnout. We propose that palliative care and healthcare administrators look at these factors carefully in the planning and distribution of their staff and resources especially in the areas of long working hours. These results provide valuable insight into the important issues of burnout and psychological morbidity and use of coping mechanisms in palliative care and serve as a platform for future resource planning in order to minimise burnout in the palliative care profession. Declaration of conflicting interests The authors have no conflict of interest to declare. Funding This study was funded by the National Healthcare Group Health Outcomes and Medical Education Research NHG-HOMER Grant (FY13/A04). References 1. Meier D and Beresford L. Preventing burnout. J Palliat Med 2006; 9(5): Graham J, Ramirez AJ, Cull A, et al. Job stress and satisfaction among palliative physicians. Palliat Med 1996; 10: Shanafelt TD, Bradley KA, Wipf JE, et al. Burnout and selfreported patient care in an internal medicine residency program. Ann Intern Med 2002; 136: Kearney MK, Weininger RB and Vachon MLS. Self-care of physicians caring for patients at the end of life. JAMA 2009; 301(11): West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA 2006; 296(9): Wallace JE, Lemaire JB and Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009; 374(9702): Girdin DA, Everly GS and Dusek DE. Controlling stress and tension. Needham, MA: Allyn & Bacon, Dunwoodie DA and Auret K. Psychological morbidity and burnout in palliative care doctors in Western Australia. Intern Med J 2007; 37: Vachon MLS. Staff stress in hospice/palliative care: a review. Palliat Med 1995; 9: Pereira SM, Fonseca AM and Carvalho AS. Burnout in palliative care: a systematic review. Nurs Ethics 2011; 18(3): Maslach C, Schaufeli W and Leiter M. Job burnout. Annu Rev Psychol 2001; 52: Abendroth M and Flannery J. Predicting the risk of compassion fatigue. J Hosp Palliat Nurs 2006; 8(6): Slocum-Gori S, Hemsworth D, Chan WW, et al. Understanding compassion satisfaction, compassion fatigue and burnout: a survey of the hospice palliative care workforce. Palliat Med 2013; 27(2): Swetz KM, Harrington SE and Matsuyama RK. Strategies for avoiding burnout in hospice and palliative medicine: peer advice for physicians on achieving longevity and fulfillment. J Palliat Med 2009; 12(9): Koh M, Lee A and Hum A. Palliative care in Singapore: impacting a Nation. Eur J Palliat Care 2014; 21(5): Demographics of Singapore population. Singapore: Department of Statistics, Maslach C, Jackson SE and Leiter MP. Maslach Burnout Inventory manual. Palo Alto, CA: Consulting Psychologists Press, Embraico N, Papazian L and Kentish-Barnes N. Burnout syndrome among critical care workers. Curr Opin Crit Care 2007; 13: Goldberg DP. Manual of the general health questionnaire. Windsor: NFER Publishing, Whitebird RR, Asche SE, Thompson GL, et al. Stress, burnout, compassion fatigue and mental health in hospice workers in Minnesota. J Palliat Med 2013; 16: Asai M, Morita T, Akechi T, et al. Burnout and psychiatric morbidity among physicians engaged in end-of-life care for cancer patients: a cross-sectional nationwide survey in Japan. Psychooncology 2007; 16: Song KB. Living with the end in mind. A study of how to increase the quality of death in Singapore. Singapore: Lien Foundation, Palliative Care Services in Australia. Australian Institute of Health and Welfare, 2013, WorkArea/DownloadAsset.aspx?id= Lim J, Bogossian F and Ahem K. Stress and coping in Singaporean nurses: a literature review. Nurs Health Sci 2010; 12(2): Whippen DA and Canellos GP. Burnout syndrome in the practice of oncology: results of a random survey of 1000 oncologists. J Clin Oncol 1991; 9: Tomioka K, Morita N, Saeki K, et al. Working hours, occupational stress and depression among physicians. Occup Med 2011; 61: Wagstaff AS and Sigstad Lie JA. Shift and night work and long working hours a systematic review of safety implications. Scand J Work Environ Health 2011; 37(3): Vachon ML. Burnout and symptoms of stress in staff working in palliative care. In: Chochinov HM and Breitbart W (eds) Handbook of psychiatry in palliative medicine. New York: Oxford University Press, 2000, pp Kash KM, Holland JC, Breitbart W, et al. Stress and burnout in oncology. Oncology 2000; 4: Doolittle BR, Windish DM and Seelig CB. Burnout, coping, and spirituality among internal medicine resident physicians. J Grad Med Educ 2013; 5(2): Lucchetti G, Lucchetti AL and Oliveira GR. Nursing home care: exploring the role of religiousness in the mental health, quality of life and stress of formal caregivers. J Psychiatr Ment Health Nurs. Epub ahead of print 23 May DOI: /jpm Dyrbye LN, Freischlag J, Krista LK, et al. Work-home conflicts have a substantial impact on career decisions that affect the adequacy of the surgical workforce. Arch Surg 2012; 147(10):

10 642 Palliative Medicine 29(7) 33. Julia E, McMurray MD, Mark Linzer MD, et al. The work lives of women physicians results from the physician work life study. J Gen Intern Med 2000; 15: Mitchell K. Palliative care in Australia. Ochsner J 2011; 11: Quattrin R, Zanini A and Nascig E. Level of burnout among nurses working in oncology in an Italian region. Oncol Nurs Forum 2006; 33(4): Uren SA and Grahamm TM. Subjective experiences of coping among caregivers in palliative care. Online J Issues Nurs 2013; 18(2): Timmermann M, Naziri D and Etienne AM. Defence mechanisms and coping strategies among caregivers in palliative care units. J Palliat Care 2009; 25(3): Meier DE, Back AL and Morrison RS. The inner life of physicians and care of the seriously ill. JAMA 2001; 286(23): Sirriyeh R, Lawton R and Gardner P. Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals psychological well-being. Qual Saf Health Care 2010; 19(6): e Lambert VA and Lambert CE. Nurses workplace stressors and coping strategies. Indian J Palliat Care 2008; 14: Wu H, Liu L, Wang Y, et al. Factors associated with burnout among Chinese hospital doctors: a cross-sectional study. BMC Public Health 2013; 13: