2Ege University, Faculty of Medicine, Department of Psychiatry, Izmir - Turkey
3Dr. Berna Gokengin Psychodrama Organization Consulting, Izmir - Turkey
4Ege University, Faculty of Medicine, Department of Internal Medicine, Immunology Department, Izmir - Turkey
5Ege University, Faculty of Medicine, Department of Public Health, Izmir - Turkey
Objective: Aim of the present study is to evaluate the effectiveness of Basic Communication and Coping with Difficult Situations Skills Training, which includes two different therapy techniques, on the burnout level and job satisfaction of hospital office staff.
Method: Communication Skills Training was applied to hospital office staff (n=54). Psychodrama and cognitive-behavioral therapy techniques were used and practiced to evaluate basic communication skills, anger management, conflict management, and coping with stress issues. The participants filled in a Personal Information Form, Pre-Test/Post-Test Form, Maslach Burnout Inventory (MBI), Minnesota Satisfaction Questionnaire (MSQ), and Training Program Evaluation Form.
Results: On the MBI, depersonalization scores significantly decreased after training, and personal accomplishment scores increased significantly, whereas emotional exhaustion scores were not affected. However, the emotional exhaustion scores of staff members with a duration of employment of over ten years were significantly higher than those of staff members with a duration of employment of less than ten years. Participants with a job tenure of over ten years showed a decrease regarding the change in the scores of emotional exhaustion after the training, whereas participants with a tenure of less than ten years showed a slight increase. Pre- and post-training subscale scores of MSQ did not differ significantly. However, the participants with a duration of service of over ten years showed an increase after training in Overall Job Satisfaction and Intrinsic Job Satisfaction subscales. Participants declared overall satisfaction with the training and asked for continuation of the program.
Conclusion: We can say that communication skills training using therapy techniques can decrease burnout symptoms related to increasing length of employment and have a positive impact on job satisfaction.
In the health sector, most studies regarding burnout and job satisfaction are carried out with clinicians and nurses. We did not find any studies in the literature regarding the burnout and job satisfaction in office staff working in healthcare institutions (data register, data processing, test result room, public relations office). Office staff includes persons who are the first to make contact with the patients in various ways (face-to-face, telephone, e-mail). It is important that those employees are able to multi-task, employing a high level of communication skills, computer use, and intensive telephone conversation at the same time (1). Thus, these people are working under intense stress, having to communicate with patients, patient relatives, and healthcare professionals, completing their tasks under time pressure, and solving issues of relevance to health such as registration and documentation if needed. Workplace stress counts as one of the psychosocial risks negatively affecting the employees’ health and safety (2). The necessity to reduce burnout, which increases with growing stress, has led to the creation of short and effective rehabilitation programs (3).
Reviewing the literature on healthcare staff and burnout, we found among the effective psychosocial interventions against burnout techniques of cognitive behavioral therapy (CBT) (3-9). CBT is a type of psychotherapy focusing on problematic signs, teaching how to reexamine thought structures and to develop new coping mechanisms helping to solve the problem in question (10).
Psychodrama assumes that “both difficulties and healing can be influenced by the interpersonal field as much as individual psychodynamics” (11). The basic activity of psychodrama consists of the principles of creativity and spontaneity (12). Psychodrama techniques are frequently used educational methods (13). Commonly used techniques in psychodrama include icebreakers, role play, and sharing. Aim of the icebreakers is to familiarize the group members with one another, with the facilitators, and with the method, and to bind the group together. Thus icebreakers trigger action and spontaneity (14). For role play, it is not necessary to be an actor; what is important is the capability to work together (15). Sharing allows consolidating the achievements after each game (14). Role play, changing roles, and mirroring are psychodramatic processes that facilitate the examination of individual experiences of various conflicting situations within the group. Thus group members can more easily understand negative thoughts triggered by different situations and the nature of the impact of those thoughts on their emotion. In addition, the group environment offers a supportive surrounding for the application of new thoughts and behaviors (16).
Today, major psychotherapy techniques are put to use in different groups, undergoing changes, becoming more flexible, and new therapies are being developed by blending several psychotherapeutic techniques together (17). The advantage of using psychodrama and CBT techniques jointly lies in the fact that some participants will benefit more from the cognitive methods, while others may respond better to psychodrama approaches.
Aim of this study is to evaluate a program called Basic Communication Skills and Coping with Difficult Situations Skills Training, including two different therapeutic techniques, regarding its impact on burnout level and job satisfaction in hospital office staff.
Hypothesis 1: Using “Basic Communication Skills and Coping with Difficult Situations Skills Training,” the level of knowledge about communication skills among hospital office staff can be increased.
Hypothesis 2: Using “Basic Communication Skills and Coping with Difficult Situations Skills Training,” the awareness of communication skills among hospital office staff can be increased.
Hypothesis 3: Using “Basic Communication Skills and Coping with Difficult Situations Skills Training,” the level of burnout among hospital office staff can be reduced.
Hypothesis 4: The effect of “Basic Communication Skills and Coping with Difficult Situations Skills Training” on the burnout level of hospital office staff is correlated with age, duration of employment, educational degree, marital status, and/or state of communication training.
Hypothesis 5: “Basic Communication Skills and Coping with Difficult Situations Skills Training” can increase job satisfaction in hospital office staff.
Hypothesis 6: The effect of “Basic Communication Skills and Coping with Difficult Situations Skills Training” on the job satisfaction of hospital office staff is correlated with age, duration of employment, educational degree, marital status, and/or state of communication training.
The present study, using a Pre-Test/Post-Test design, examines the effect of a “Basic Communication Skills and Coping with Difficult Situations Skills Training” program on the burnout level and job satisfaction of office staff working in units such as the data register, data processing, test result room, or the public relations office in the hospital of the Medical School of Ege University, where they have face-to-face contact with patients or their relatives.
The training was planned during the academic year 2014-2015 by the Head Physician Office of the Hospital of Ege University School of Medicine in the context of activities undertaken towards the hospital’s accreditation and quality standards. No approval was taken from the ethics committee. However, the participants were informed orally at the beginning of the training and while administering the questionnaires, and written voluntary consent documents were received from all participants. The program consisted of three units and had a total of 85 participants, 54 of whom completed the entire training. Among the reasons for non-completion were annual leave, retirement, or work commitment in their department at the time of training. There were no participants excluded because of unwillingness and/or lack of motivation.
Development of the Training Program
Preparing the training program, “Kern’s six-step approach to curriculum development” was used (18).
1. Problem Identification and General, Needs Assessment: The Patient Relations Unit of Ege University’s Medical School Hospital evaluated the complaints filed by the Prime Ministiry Communication Center (BIMER) Provincial Health Directorate and patients or their relatives between June 1 and December 15, 2014. Of the total of 719 complaints, 19% (n=137) concerned communication problems that patients or their relatives had experienced with the first persons they encountered in the hospital, namely, staff working in data processing, patient reception, and results unit.
2. Needs Assessment for Targeted Learners: The evaluations from participants in previously provided standard communication skills training programs in the hospital were evaluated.
3. Goals and Objectives: Three doctors who had received psychodrama training and one psychiatrist with CBT training formed a program team; evaluating the literature, they formulated the goals, objectives, and educational strategies for the training program. The program goal was defined as “developing the basic communication skills and skills for coping with difficult situations” of Ege University School of Medicine Hospital staff. The training program’s cognitive (communication process, verbal and non-verbal communication skills, empathy, communication barriers, anger and anger management, identification of conflict and conflict management), attitudinal (awareness of the importance of effective communication, verbal and non-verbal communication skills, adequate empathetic approach, and individual factors in anger management), and skills objectives (application of verbal and non-verbal communication skills, the skill to show an empathetic approach, conflict solving skills, methods of coping with stress) were identified.
4. Educational Strategies: Power Point presentations with the theoretical information regarding the topics included in the training program and interactive applications (icebreakers and scenarios for psychodrama and CBT techniques) were prepared.
5. Implementation: The program lasted a total of 25 hours delivered in three units with intervals of one month each. The first program unit, which lasted for 2 full days, provided transfer of theoretical knowledge regarding communication skills, anger control, conflict management, and coping with stress as well as applications using psychodrama and CBT techniques. The CBT applications focused particularly on anger experience and problem-solving skills. For this purpose, participants were asked to score anger that they had experienced in personal examples and convey the word, sentence, or images that had gone through their mind at the moment when they felt the anger most acutely. Based on this information, it was tried to determine the person’s automatic thoughts. Having established the individual’s automatic thoughts, they were guided towards the development of alternative thoughts by examining the validity of their original thoughts. In addition, the person was supported in finding out about the basic work-related problem; alternative solutions were produced and problem-solving skills developed.
In the psychodrama practice, various icebreakers were played. These allowed the participants to become aware of their own and other people’s different needs for limit-distance, the importance of accepting the person in front of them, experience trust and using body language, realize the difficulties and intractability of situations caused by communication barriers, and understand the degree of adaptation and the attitudes involved in active/passive positions. In addition, role change aimed at reaching an understanding of the concept of empathy.
Work with topics related to conflict and anger enables people to express themselves, develop awareness about anger levels and come to terms with them, become aware of resistance in communication and situation of coping with anger, express the internal voice of anger, and to see themselves in the general situation. In working with awareness, it is tried to make participants aware of their stress levels and reduce them accordingly. Seeing that they are not alone in the group, they can accept negative emotions in a safe environment and thus relax. Participants could find parallels between the affects in the game and those in real life and thus had an opportunity to share and assess these memories.
In the second and third unit of four hours each, only psychodrama practice was used, where participants enacted scenarios related to communication that they had prepared. At the end of the plays inspired by work life or general life, the roles that they had played were dissected from the perspective of communication together with the group. They were encouraged to use the newly learned knowledge, the insights achieved, and the new perspectives of awareness to create a different pattern on stage. In the last session, meditation/imagination technique accompanied by music aimed at mental and physical relaxation. At the conclusion of the event, a “group tree” activity was played in order to increase the sense of belonging and everybody’s awareness of how valuable and necessary their personal contributions are for the continuity of the organization.
6. Evaluation and Feedback: A “Pre-Test/Post-Test Form” was used to assess the level of participants’ knowledge. The effect of the training course on the participants was evaluated using the “Maslach Burnout Inventory (MBI),” the “Minnesota Satisfaction Questionnaire (MSQ),” and the “Training Program Evaluation”.
Personal Information Form: Includes questions about participants’ age, gender, marital status, educational status, length of employment, department within the organization, and status of previous participation in communication skills training.
Pre-Test/Post-Test Form: Form with 20 items assessing the level of participants’ knowledge about basic communication skills at the beginning and at the end of the training.
Maslach Burnout Inventory (MBI): First designed by Maslach and Jackson in 1981 to measure burnout syndrome in various ways. The instrument consists of three subdimensions: “emotional exhaustion,” “depersonalization,” and “personal accomplishment”. For each person, three separate burnout scores are calculated. For individuals experiencing burnout, high “emotional exhaustion” and “depersonalization” scores and low “personal accomplishment” scores are expected (19).
For the Turkish adaptation of the scale by Ergin (20), a five-point Likert-type scale (1: never – 5: always) is used. For each of the subdimensions, the respective Cronbach’s alpha values were calculated as 0.83 for “emotional exhaustion,” 0.65 for “depersonalization,” and 0.72 for “personal accomplishment”. In our study, we found Cronbach’s alpha values of 0.90 for “emotional exhaustion,” 0.74 for “depersonalization,” and 0.79 for “personal accomplishment”.
Minnesota Satisfaction Questionnaire (MSQ): Developed by Weis et al. (21), consisting of 20 items assessed on a 5-point Likert-type scale (1: not satisfied – 5: very satisfied), showing intrinsic, extrinsic, and general satisfaction factors. There are no reversely scored questions in the scale. Baycan (22) translated the instrument into Turkish and carried out validity and reliability studies, finding a Cronbach’s alpha of 0.77. Studies made in various professional groups found the following Cronbach’s alpha values for each of the subdimensions: “intrinsic satisfaction” 0.86, “extrinsic satisfaction” 0.80, and “general satisfaction” 0.90 (23). In our study, we calculated the respective Cronbach’s alpha values as “intrinsic satisfaction”: 0.83, “extrinsic satisfaction”: 0.83, and “general satisfaction”: 0.84.
Training Program Evaluation: The form consists of 12 items concerning duration of training, content and appropriateness for need, training environment, teaching materials, and educational quality, scored on a five-point scale (1: don’t agree – 5: agree completely). In the evaluation, the results for 3: “agree,” 4: “strongly agree,” and 5: “completely agree” were grouped as “agree”. In addition, at the end of the form, there was a section “thoughts and recommendations”, requesting the participants’ views regarding the training program.
At the beginning of the program, the “Personal Information Form” was completed, at the end the “Training Program Evaluation”; both at the beginning and at the end, “Pre-Test/Post-Test Form”, MBI, and MSQ were administered.
The study used descriptive statistics for quantitative data. For the MBI and MSQ scores before and after training, dependent-groups t-test was applied. To compare the subdimension scores from both scales before and after training according to age, duration of employment, school type, marital status, and previous communication training, a two-way repeated measures variance analysis was used. With this analysis, difference between subgroups (group), difference before and after training regarding group points (time), and direction of change in the scores for both groups before and after training (group x time) were examined (24). Data were evaluated using the SPSS 21.00 package. Results of the analysis were considered statistically significant at the level of p<0.05.
Mean age was 37.57±6.86 years. Of the participants, 81.5% were female, 63% married, 55.6% high school graduate, and 50% had a duration of employment of 10 years or more. The mean duration of employment of the participants was 13.17±7.04 years. Previous participation in communication skills training was reported by 53.7% of the participants.
Skills-related knowledge of the participants scored an average of 13.7±2.2 points pre-test and 15.3±1.7 post-test. The difference between pre- and post-test scores was statistically significant (p=0.003).
In the “Training Program Evaluation,” all of the participants (n=54) stated that the instructors had sufficient knowledge of the topic, speed of explanation and tone of voice had facilitated following the training, understandable language had been used, and the educational material and examples provided had been sufficient. While 98.2% of the participants (n=53) stated that the program was well prepared, the topics presented comprehensively, the education environment appropriate, and the knowledge acquired in the training was applicable professionally, 96.3% (n=52) said that the content met their needs, 92.6% (n=50) found the audiovisual tools sufficient, and 68.6% (n=37) said that the training period was long enough. The participants stated that they were generally content with the program and wanted it to be repeated, but they did not find the training period sufficient.
In the “thoughts and recommendations” section of the “Training Program Evaluation” form, 52 persons gave responses, of whom 94.2% (n=49) reported that they were very content with the training. Only 2 participants gave their views in the “recommendation” section and 1 person in the “other” category.
“I think that this kind of training creates awareness in thought and action. From the perspective of seeing and evaluating not only my own life but experiences from other lives.”
“The example given in today’s training was useful because it was something that we may encounter at any time in our lives.”
“I cannot express myself better, it gave a better direction for me to act right in the right place.”
“This training was useful to repeat knowledge we’d known or forgotten, as a reminder and most importantly from the perspective of awareness.”
“Initially, I had thought that the training was a waste of time and at least an escape from work stress, but at the end I find quite the contrary, it was very useful and not about escaping from work or stress, but I saw that it had to do with being useful for becoming aware of oneself and of others, and I found the training very useful and educational.”
“I realized that there are a lot of things in our lives. I got to know my behavior, my reactions. I discovered that I can change my attitudes, at least to some degree.”
“I think my awareness in life has increased.”
“As someone between patients and a busy working group, I thought that I tried to apply what has been explained in this training. But I understood that it was insufficient. This kind of training should be given to all hospital staff, I think.”
Evaluating all participants, the MBI showed a statistically significant reduction of the mean score in the depersonalization subdimension after training (p=0.003), a significant increase in the personal accomplishment subdimension (p=0.005), but no change in the subdimension emotional exhaustion (Table 1).
The sample group of the study was compared for their pre- and post-training burnout level and job satisfaction according to age, duration of employment, educational status, marital status, and previous communication training (Tables 1 and 2). Before and after training, among those with a job tenure of more than 10 years the emotional exhaustion scores were statistically significantly higher than for persons who had been on the job for ten years or less. While participants with duration of employment of more than 10 years showed a decrease in their scores, there was no change in the people with 10 years or less of job tenure (Table 1, Figure 1). Participants with more than 10 years of work experience were affected positively.
Evaluating all participants, none of the MSQ subdimensions found any statistically significant change in the mean scores pre-/post-training (p>0.05). However, the MSQ subdimensions general satisfaction and intrinsic satisfaction scores after training showed an increase for participants with more than 10 years of job tenure, while for those with 10 years or less on the job, no change was found (Table 2).
This study evaluates a Basic Communication and Coping with Difficult Situations Skills Training program prepared for hospital office staff, which includes two different therapy techniques, from the perspective of its effect on burnout level and job satisfaction. We found that the program had a positive effect on persons with greater work experience regarding emotional exhaustion and depersonalization as well as general and intrinsic satisfaction.
Among the factors affecting people’s burnout levels and job satisfaction in the work life are physical environment conditions, working conditions, health policies, institutional opportunities, work environment, appropriateness of the work for the skills and experiences of the employee, workload, insufficient human resources, administrative support, privileges, appreciation, encouragement, supervision, training, career development, being permanently employed or on short contracts, low salary, work safety, patient relations and interpersonal relations (25,26).
This study has tried to decrease burnout levels and increase job satisfaction merely by strengthening the personal resources such as people’s experience of awareness, self-improvement, and gaining insight. Therefore, we were not to expect a distinct change in all subdimensions of burnout and job satisfaction scales. As we could not find any previous studies with the same group in our literature review, the discussion of the results from our study has its limitations.
In our study, which used different therapy techniques, we found an increase in the knowledge about communication skills after the training. The literature shows that psychodrama can be used with healthcare providers in order to increase their self-awareness, communication skills, and capability to establish empathy (27,28). Nurses participating in a study by Oflaz et al. (29) stated that psychodrama helped them to increase their level of self-awareness, understanding other people’s perspectives, increased their capability to express their feelings and thoughts, and helped them connecting with the feelings and thoughts of their patients.
Agarwal et al. (30) pointed out that the support workers’ (receptionist, director, laboratory assistants, room cleaning personnel etc.) communication skills were as important as the medical staff’s communication skills, given that the former were interacting with the patients from their arrival in the hospital until the moment of their discharge. Their study showed that patients were affected at an intermediate level by the support staff’s communication skills (30).
Not only among clinicians and nurses, but also for other clinical and office staff burnout has been reported to be common and highly correlated with working conditions (31). Kim et al. (32) found a burnout level of 49.25% among doctors, 41.5% among nurses responsible for care, and 35.7% among administrative officers.
Our results showing a decrease for the MBI subdimension depersonalization and an increase for personal accomplishment are consistent with the findings of a study by Ozbas and Tel (33). The researchers used psychodrama to increase oncology nurses’ psychological competencies. They found that psychodrama enhanced the nurses’ work-related sense of competence, and the MBI scores for emotional exhaustion and depersonalization decreased, while the personal accomplishment score increased (33). In our study, burnout decreased regarding emotional exhaustion and depersonalization for participants with a work experience of ten or more years. Study results examining the effect of work experience on burnout show differences. In a cross-sectional study among oncology nurses, those with longer work experience showed higher burnout and “compassion fatigue” compared to less experienced ones (34).
Study results show that in healthcare and non-healthcare staff the relation between learning and job satisfaction generally displays a similar trend. For hospital administrators, especially those working outside the healthcare field, individual, group, and organization-level activities to develop their learning capacities are recommended to provide support from all work categories for the employees’ job satisfaction. A concerted institutional learning culture affects staff job satisfaction and patients’ satisfaction with health services positively (35).
We found that communication skills training including CBT and psychodrama techniques increased the general and intrinsic satisfaction of hospital office staff with ten or more years of work experience. The partial confirmation of our hypotheses relating to burnout level and job satisfaction for the group with 10 or more years of work experience may be connected to a positive contribution of the experiences of participants with a longer duration of employment to insight acquisition and the learning process. It was seen that more experienced persons are more open in group games and sharing. Considering that in the more experienced group the pre-training “depersonalization” scores were higher and the “general and intrinsic satisfaction” scores lower, it is conceivable that this group felt a greater need for such a therapy-assisted training and hence derived a greater benefit.
A study with healthcare professionals found that in the higher age group job satisfaction was comparatively higher. This situation might be related to a reduction of negative reactions by paying less attention to things that are or are not liked and to an increasing internalization of the organization’s realities. No significant difference was found among healthcare professionals with regard to job satisfaction (25).
Some studies show that with increasing work experience, work satisfaction also increases. Higher satisfaction levels may be explained by the access to high-level positions with increasing age and with the fulfilment of higher-level needs. Better adaptation to work can be linked to experiencing less conflict between work life and personal life. Different education levels may cause significant differences in job satisfaction (25). A study evaluating job satisfaction and working life quality of receptionists and medical record unit staff established the areas affecting the level of work satisfaction. Of the participants, 78% formulated a medium level of job satisfaction by saying “I am very happy”. Significant relations were observed between job satisfaction and gender, collegial support, provision of health services to hospital staff, demands of the job interfering with family life, perceived need for support groups, and the availability of food and water in the workplace. Safety and working conditions in the hospital, superior-subordinate relationship, pay being comparable to staff in the same position in other institutions, use of skills and competencies, and supervisors’ interest in staff wellbeing are significantly positively related to job satisfaction (36).
A study on job satisfaction and work-related stress in medical, paramedical, and office staff reported that most participants worked in a good institution and knew their job well but were not satisfied with administration and pay. Of the office staff, 78.7% said that their job satisfaction was at an intermediate level; compared to the other participants, they knew their work less well. They thought to be working in a good institution, but said that the administration did not pay them attention and that the work was not good for their physical health. They were not happy with their salary, did not feel good about the issue of work and said that they did not have good relations with their supervisors. Most of the participants in the study (85.3%) were sufficiently devoted to their work, but they were exposed to work-related stress and felt the need for preventative measures (37).
A study by Yilmaz and Erkal (38) found that with increasing job satisfaction levels in hospital staff, burnout levels decreased. The “intrinsic satisfaction” dimension of job satisfaction affected family life positively, while the burnout dimensions “emotional exhaustion” and “depersonalization” affected family life negatively. In order to increase job satisfaction and reduce burnout and negative effects of work on family life, they recommended training and seminar programs particular on topics like coping with stress, problem solving, burnout, and job satisfaction (38).
The relevance of our study is that ours is a training model that, in addition to theoretical and practical activities used in commonly provided communication skills training, gives space to CBT as well as psychodrama techniques. Considering basic communication skills training as a psychosocial intervention, ours is the first study examining the effects of this training model on burnout level and job satisfaction.
The most important limitation of this study, whose short-term results have been presented, lies in the negative effect of its implementation during working hours on continuity of attendance. Thus a lower number of people completed all training sessions.
For a training program to reduce participants’ burnout level and increase their job satisfaction there is a necessity to use techniques addressing both the cognitive and the emotional dimension of communication skills. In this training model, we observed that participants showed development especially in the areas of awareness of their emotions, development of empathy skills, and gaining insight at problem-solving skills.
In the future, we think that more long-term studies with larger samples using measuring tools suitable for these parameters may be useful in the reduction of burnout and the increase of job satisfaction.
Conflict of Interest: Authors declared no conflict of interest.
Financial Disclosure: Authors declared no financial support.
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