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Abstract
Objectives To evaluate the feasibility of the Bali Yoga Programme for Residents (PYB-R), an 8-week virtual yoga-based intervention and determine its impact on the mental health of resident physicians.
Design Single-group repeated measures study.
Setting Associations from the four postgraduate medical education programmes in Québec, Canada.
Participants Overall, 55 resident physicians were recruited to participate of which 53 (96.4%) completed the assessment pre-PYB-R. The postintervention assessment was completed by 43 residents (78.2%) and 39 (70.9%) completed all phases (including 3-month follow-up). Most were in their first year (43.4%) or second year (32.1%) of residency. The majority were female (81.1%) with a mean age of 28±3.6 years.
Primary and secondary outcome measures The primary outcome measure was feasibility as measured by participation in the PYB-R. Secondary outcome measures were psychological variables (anxiety, depression, burn-out, emotional exhaustion, compassion fatigue and compassion satisfaction) and satisfaction with the PYB-R. Residents were further subgrouped based on the quality of work life and a number of PYB-R sessions attended.
Results The attrition rate for programme completion was 19%. Of the 43 residents who completed the PYB-R, 90.6% attended between 6 and 8 sessions. Repeated-measures analysis of variances (ANOVAs) at three time points (baseline, PYB-R completion and 3-month follow-up) confirmed a decrease in scores for depression and anxiety, and an increase in scores for compassion satisfaction. No changes were observed in the other psychological variables evaluated. ANOVAs also confirmed that a better quality of life at work helps develop compassion satisfaction, a protective factor to compassion fatigue. Most participants (92.9%) indicated they were satisfied or very satisfied with the quality of the programme.
Conclusions A virtual yoga-based programme is feasible and has lasting positive effects for up to 3 months on the mental health of resident physicians. Further research is warranted to validate these findings using a larger sample of residents with a control group.
- burnout
- physicians
- mental health
- quality of life
- anxiety disorders
- psychosocial intervention
Data availability statement
Data are available on reasonable request. We welcome our peers to ask for data or any other relevant information. Data will be available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
A yoga-based mind-body intervention was designed for resident physicians and led by a certified yoga instructor.
The programme was designed to be flexible regarding scheduling and modalities used in order to maximise participation.
Data collected from residents were self-reported and thus susceptible to social desirability and expectancy bias.
It was not possible to verify that residents viewed each video to completion.
Lack of a control group limits our ability to draw a causal link between participation in the programme and the observed effects on mental health.
Introduction
There are growing concerns regarding the mental health of physicians and their quality of work life (QWL) due to heightened levels of stress and burn-out in the wake of the COVID-19 pandemic.1 According to data from the Canadian Medical Association (CMA), the number of physicians experiencing burn-out increased from 25% in 2018 to 53% in 2021.2 3 Prepandemic burn-out rates were even higher among resident physicians (52%) and depression was common (18%)2; these levels increased moderately by 2021.3 4 The systematic review and meta-analysis by Erschens et al highlight that burn-out rates among medical students are subject to substantial variation, influenced by the stage of their medical education and the nature of their work.5 Factors associated with burn-out include an increase in patient care responsibilities that come with the beginning of their resident role, the high pressure of acadmemic competition, long work hours, lack of autonomy, abuse of power, difficulty maintaining healthy social life and development of professional cynicism.5–9 The repercussions of physician burn-out extend across three primary realms: the health and QWL of physicians, the quality of patient care and broader implications for the healthcare system and society. Burnt-out physicians are at a higher risk for depression, anxiety and suicide.10 Furthermore, burn-out compromises patient care, as evidenced by increased medical errors and diminished care quality.11 12 Patients tended by burnt-out physicians often perceive a lack of compassion, leading to poorer symptom management, higher incidence of unexpected medical events and more frequent complaints.13 In Canada, the financial toll of physician burn-out, manifested through reduced work hours, absenteeism, turnover and early retirement, is estimated at US$213 million annually.14 Similarly, in the USA, burn-out incurs an estimated cost of US$4.6 billion each year to the healthcare system.15 These statistics underscore the multifaceted impact of burn-out, emphasising the need for comprehensive strategies to address its effects not only on individual physicians but also on the overall quality of healthcare delivery and societal well-being.
In addition to burn-out and depression, resident physicians are also at risk for compassion fatigue (CF), which is characterised by emotional and physical exhaustion leading to a decreased ability to empathise or feel compassion for others. Given the caring aspect of their role, reliance on empathy and compassion is primordial to effective patient care.16
Despite the challenges linked to the profession, there is also the concept of compassion satisfaction (CS) to take into consideration, which refers to the positive feelings derived from helping others. While CF can have detrimental effects on healthcare provider’s mental health and the quality of patient care, fostering CS can serve as a protective factor.16 17 Reducing triggers (eg, poor working conditions, long shifts, stressful on-call duties, lack of appreciation, workplace bullying) and implementing adequate stress management programmes including activities such as mindfulness based interventions (MBIs) can help the enhancement of CS, self-compassion and sens of accomplishment, all of which directly impact physician well-being and performance.18–23 Compared with meditation-based approaches, yoga adds a bodily aspect which promotes mind–body balance using three primordial elements: breathing exercises, postures and mindfulness exercises.23 Empirical evidence supports yoga’s regulatory effects on the autonomic nervous system; it dampens the hyperactivity of the sympathetic nervous system, linked to both mental and physical problems and promotes parasympathetic activity, thereby pre-empting stress-related health issues24–26
Few studies have investigated the effect of practising yoga on the mental health of resident physicians27–29; these studies found yoga has beneficial effects on their burn-out symptoms, anxiety, CS and blood pressure. Evidence from systematic reviews of MBIs to improve physician well-being suggests more work is needed to determine the ideal context for implementing and evaluating these interventions.30–33 Recent studies have underscored the necessity of virtual methods in delivering interventions, particularly for healthcare professionals like resident physicians, who often face barriers in accessing traditional in-person programmes due to their demanding schedules.28 30 While there is few evidence supporting the effectiveness of virtual reality and online mindfulness programmes for physicians,34 35 the specific application of such virtual interventions for resident physicians remains unexplored to our knowledge. This gap highlights an opportunity to leverage technology in developing tailored, flexible and accessible wellness programmes for resident physicians, catering to their unique needs and constraints, as well as offering a viable solution for future natural events that would impose strict social distancing. The aim of this study was to evaluate the feasibility of the first virtual yoga programme for residents physicians and to determine the impact of this programme on the mental health and well-being of participants. We hypothesised that a virtual yoga programme would be feasible in terms of attendance, home practice and overall satisfaction. Furthermore, we hypothesised that programme completion would reduce the intensity of symptoms related to CF, burn-out, anxiety and depression, that it would increase levels of CS, and that this effect would be maintained for up to 3 months. As secondary analyses, first, we evaluated if resident physicians with better QWL preintervention showed greater improvement in psychological variables after completing the virtual yoga programme. Second, we evaluated whether regular yoga practice following programme completion was associated with improvements in psychological variables at 3 months.
Methods
Study design, population and setting
A single-group repeated measures study was conducted between 10 January 2021 and 20 June 2021. We recruited 55 participants. Anticipating an approximate drop-out rate of 25%, this allows us to anticipate a final sample of around 40 participants. This number allows a power of 80% to detect a f of 0.20 (near medium which is 0.25; G*Power, assuming a correlation of 0.5 between moments of measurement) at an alpha level of 0.05.36 37
Participants were recruited from associations from the four postgraduate medical education programmes in the Canadian province of Québec (University of Montreal, McGill University, Laval University, University of Sherbrooke), through their association’s Facebook page and through emails sent by these associations. The inclusion criteria were to be a resident physician working at a healthcare facility in Québec, to be able to understand French and write in French and to be physically able to do yoga postures. The sole exclusion criterion was enrolment in another psychotherapeutic intervention, whether individual or group, concurrent with the programme. Each participant received an individual email that included an anonymised Qualtrics link to complete the questionnaires and sign the consent form.
Patient and public involvement
Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Survey instruments
Participants completed each of the following questionnaires: the Oldenburg Burnout Inventory (internal consistency of 0.70 and a test–retest reliability of 0.81), the revised 21-item Professional Quality of Life scale measuring CS and CF (The CS subscale has an internal consistency of 0.92 and CF has 0.90),38 the General Anxiety Disorder 7-Item Assessment measuring anxiety (internal consistency of 0.92 and a test–retest reliability of 0.83),39 the Patient Health Questionnaire-9 measuring depression (internal consistency of 0.89 and a test–retest reliability of 0.84)40 and the Quality of Work Life Systemic Inventory (QWLSI) (The internal consistency (Cronbach’s alpha) of its eight subscales ranges from 0.60 to 0.82.5 The overall internal consistency is 0.88 and the test–retest reliability is 0.85).41 The QWLSI is a tool for assessing QWL based on the perceived gap between the situation experienced in the present moment and the personal goals set in 34 different areas of professional life. Low QWL scores on the QWLSI have been associated with burn-out.42 Finally, participants also completed two questionnaires developed in-house: a 16-question sociodemographic questionnaire and a satisfaction questionnaire with open questions that permitted to gather of qualitative data (see online supplemental material).
Supplemental material
Supplemental material
Intervention
We developed a virtual yoga programme based on the Bali Method of Yoga with the assistance of a certified yoga instructor (Aura Wellness Center, yoga academy registered with the Yoga Alliance and the International Yoga Federation) who previously taught the Bali Method as part of two studies on attention-deficit/hyperactivity disorder in children.43 The Bali yoga consists of gentle Hatha asanas (yoga postures).44 Its distinctive features include the importance given to the relaxation response during and between yoga poses, staying longer in each postures, the importance given to the visualisation, and the psychoeducational content on the psychophysiological aspects of, in this case, yoga and stress linked to the resident physicians reality. Bali Yoga Programme for Residents (PYB-R) was offered as an 8-week programme with 1 hour of group practice per week, called synchronous practice. Participants had the option of performing the programme offline (asynchronous practice) if their work schedule precluded real-time attendance, using the recording of the weekly session that was sent to them at their request. A 15 min yoga session had also been provided to them so they could do an extra practice on their own if they wanted to. It was a suggestion to do so and there were no minimum or maximum number of extra practices that were required. The PYB-R was adapted from a programme that has been used repeatedly for nearly a decade in different populations.44–47 Each PYB-R session included a period of psychoeducation on mental health, instruction on yoga poses (see online supplemental table 1), and a meditation session. Psychoeducation topics covered included the impact of everyday thoughts, pressure to perform, breathing as a tool, burn-out, CF, setting limits, learning self-benevolence, learning self-care and focusing on the present moment (see online supplemental figure 1). Each session began with a 5 min psychoeducational segment that introduced the session’s theme and provided key insights to enhance understanding and relevance. These concepts were then woven into the yoga practice, allowing participants to explore and apply them in a practical, experiential manner.
Statistical analysis
Descriptive statistics were used to provide a sociodemographic portrait of participants. The analysis included residents who participated in at least 50% of PYB-R sessions. T-tests were used to compare characteristics of participants retained for analysis with those excluded, and to compare participants who attended 6–8 sessions vs those who attended 5 or fewer. To determine feasibility, we evaluated session attendance, individual practices and programme satisfaction using descriptive statistics. The effect of participation in the PYB-R on the mental health and well-being of resident physicians was assessed by performing repeated measures analysis of variances (ANOVAs) across three time points (T1=baseline survey; T2=completion of PYB-R at 8 weeks; T3=3-month follow-up assessment) for each psychological variable. We used post hoc tests to explore pairwise differences between levels of the repeated measures and corrected for multiple comparisons using the Bonferroni-Holm procedure.
To test whether residents with better QWL scores at baseline showed greater improvement in psychological variables after completing the programme, a mixed-group ANOVA (low QWL (<25th percentile) vs average-to-good QWL (≥25th percentile)) by time (T1, T2) was performed.42 A significant interaction led to the analysis of simple effects according to specific differences between the two groups at each time point and between groups over time. We also compared participant scores on the questionnaires between residents who practised yoga regularly (≥30 min/week) from T2 and T3 versus those that practised yoga less frequently (<30 min/week) using repeated measures ANOVAs. We tested for an association between resident age and session attendance (≥6 sessions vs <6 sessions) using the Mann-Whitney test, and we tested the association of age with medical specialty and residency level using χ2 analysis. We also compared the characteristics of those who did or did not complete the programme to assess for potential bias. All analyses were performed by using JASP (V.0.18.0).
Results
Of 55 resident physicians recruited to participate, 53 (96.4%) completed the baseline questionnaire (see online supplemental figure 1). The postintervention questionnaire was filled out by 43 residents (81.2%; 43/53), and 39 residents (from 11 different specialties) completed all three phases of the study including the 3-month follow-up assessment (73.6%; 39/53).
Table 1 compares the characteristics of residents completing the baseline and postintervention questionnaires (N=39) vs those only completing the baseline questionnaire (N=14). These groups were similar in age, gender, ethnicity and years of residency. Residents completing the baseline and postintervention questionnaires had a mean age of 28±3.1 years, the majority were female (84.6%; 33/39), and most were in their first year (38.5%; 15/39) or second year (30.8%; 12/39) of residency.
Comparison of characteristics between residents who completed the preintervention and postintervention questionnaires versus those completing only the baseline questionnaire
No differences in mental health were observed between residents who completed the preintervention and post-intervention questionnaires (N=39) versus those completing only the baseline questionnaire (N=14) (see online supplemental table 2). When we compared psychological variables between residents who participated in 6–8 yoga sessions (N=48) vs ≤5 sessions (N=5), no differences were observed (see online supplemental table 3). All variables were normally distributed; however, large effect sizes were observed when comparing residents completing 6–8 sessions vs ≤5 sessions.
Regarding the feasibility of the PYB-R in terms of participation, the attrition rate for programme completion was 19% and the total attrition rate (including 3-month follow-up) was 26%. Among residents who completed the PYB-R, 91% attended 6–8 sessions; the average attendance was 6.9 sessions (median=8, SD=1.7). Over the course of the programme, the mean synchronous attendance was 4.9 sessions (median=5, SD=2.4) and the mean asynchronous attendance was two sessions (median=1.0, SD=1.8), underlining that most participants attended more sessions synchronously than asynchronously. Nine participants attended all 8 sessions synchronously and 17 participants attended all 8 sessions via the hybrid option (mix of synchronous and asynchronous attendances). Weekly individual practice (excluding group sessions) was achieved on average by 60% of residents. Mean weekly individual practice time over the programme duration was 70.8 min (SD=7.6, median=71.0). Resident satisfaction with the PYB-R was high with 85.7% of participants responding that the PYB-R met their needs and 81% indicating they were satisfied or very satisfied with the quality of the programme (table 2). 7% of participants felt the PYB-R was not the right programme for them. The majority of residents reported being extremely or very satisfied with the components of the PYB-R including psychoeducation, postures, meditation and group practice (see online supplemental table 4).
Satisfaction of resident physicians with the Bali Yoga Programme (PYB)
The repeated-measures ANOVAs (T1-T2-T3) did show a decrease in scores for depression (F2,76=14.08, p<0.001, ηp2=0.33) and anxiety (F2,76=14.14, p<0.001, ηp2=0.27), and an increase in the scores for CS (F2,75=185.44, p<0.001, ηp2=0.83). No significant changes were observed across the three time points with respect to disengagement (F2,76=1.39, p=0.28, ηp2=0.03), emotional exhaustion (F2,76=0.72, p=0.49, ηp2=0.02), total burn-out (F2,76=1.39, p=0.26, ηp2=0.04) or CF (F2,76=1.27, p=0.85, ηp2=0.03). Between T1 and T2, we observed a significant decrease in mean scores for depression, which improved from low depressive symptoms to the absence of symptoms (7.1±5.3 vs 0.3.3±4.0; p<0.001), and anxiety, improved significantly but remained in the same category of low anxious symptoms (7.0±4.2 vs 0.4.6±3.0; p<0.001), and an increase in mean scores for CS, improved from low CS to the upper limit of the moderate level of CS (19.1±3.1 vs 28.5±5.2; p<0.001). There was no significant change in any psychological variables between T2 and T3 (see table 3).
Mean scores for variables related to mental health at baseline, following programme completion and at 3-month follow-up
We tested whether initial QWL was associated with improvement in psychological variables at T2 and observed significant changes in depression, anxiety and CS. Group analysis (low QWL (<25th percentile) vs good QWL (≥25th percentile)) by time (T1–T2) revealed a significant interaction (F1,41=8.25, p=0.006, ηp2 = 0.03) (see online supplemental figure 2). At T1, scores for depression were significantly lower in the good QWL group (mean 6.0±4.4 vs mean 12.0±6.4). Following the completion of the PYB-R, the scores for depression were similar between the two groups. Regarding anxiety, the group-by-time interaction was significant (F1,41=11.39, p=0.001, ηp2=0.06). At T1, anxiety levels were significantly lower in the good QWL group (mean 6.0±3.1 vs 0.12±5.5), but there was no difference observed at T2. Finally, the group-by-time interaction for CS was significant (F1,40=4.90, p=0.03, ηp2=0.02). The good and low QWL groups showed similar levels of CS at T1. Although these levels increased in both groups after programme completion, the mean score at T2 was significantly higher in the good QWL group (t(40)= 3.48, p (Holm)=0.003, d=−1.54). No interactions were observed between time (T2–T3) and practice (≥30 min/week vs <30 min/week in the 3 months following PYB-R completion) on symptoms of depression, anxiety or CS.
Discussion
Overall, our results demonstrate that implementing a virtual yoga intervention to enhance the mental health and well-being of resident physicians is both feasible and effective. We observed high participation rates with 90.6% of residents attending at least six of the eight sessions. Furthermore, an average of 70 min of yoga practice was achieved weekly which is noteworthy considering their busy work schedules and their other occupations. With the availability of a hybrid option, it was possible for 60% of residents to attend all eight sessions. Lasting improvements in CS and reductions in symptoms of anxiety and depression were observed for up to 3 months, which could indicate that the participants continue benefiting from their learnings overtime. The fact that burn-out, disengagement and FC scores remained the same may suggest that the PYB-R protected them from a worsening of their condition on these three variables despite the impact that the pandemic may have had on their work conditions. The vast majority of residents reported they were satisfied with the quality of the PYB-R and that the programme met their needs.
Strengths and limitations
This study has several strengths and limitations to highlight. The first strength of the PYB-R is that it was conducted virtually and was designed to be flexible with respect to scheduling and modalities to maximise participation among medical residents. These features make it possible to reach large numbers of individuals across different regions with minimal costs involved. Second, PYB-R was led by a certified yoga instructor and it was manualised, ensuring the yoga teacher to follow a structured intervention protocol. Third, a 3-month follow-up was included in the study design, which provides beneficial information to the understanding of the programme’s effects while it remains an irregular component in studies in the field.32 48 Fourth, even though the sample size of this study appears small, it was reaching our pilot project feasibility objectives. It is important to highlight that the 55 participants were recruited within a month, which is promising for the implementation of large-scale projects. Despite these strengths, this study has limitations. First, while the findings of this study are encouraging, the sample size and the lack of a control group limits our ability to draw a causal link between the programme and the observed effects on the mental health of residents. Second, we acknowledge that participation in a yoga programme may inherently attract individuals with a pre-existing interest in such practices, giving rise to selection bias. However, evidence shows that receiving a preferred psychosocial mental health treatment is associated with a lower dropout rate, underscoring that this selection bias might not be detrimental in this case.49 Third, another limitation is that it was not possible to verify if the videos were viewed to completion. The use of software to confirm viewership would have strengthened our results regarding PYB-R feasibility. Fourth, our findings are based on self-reported measures which are known to be potentially biased, notably through social desirability and expectancy bias.50 There is evidence, however, that social desirability is not always correlated with self-reported well-being questionnaires, and that when it is, it has a limited effect on variance (3%–10%).51 Evidence also suggests the psychological changes observed during MBIs are not associated with the initial expectations of individuals.52 Thus, it is unlikely that social desirability and expectation bias had a large effect on the results of this study.
Strengths in relation to other studies
Participation in the PYB-R programme was considerably higher than rates reported in other studies investigating MBIs which range from 33% to 68%.27–29 In a recent randomised trial examining the feasibility of a yoga called RISE (resilience, integration, self-awareness, engagement), Loewenthal et al observed improvements in multiple measures of psychological health in resident physicians including reduced levels of stress and burn-out.28 However, 6-weekly in-person sessions with suggested home practice was not feasible and participants suggested having the programme online to increase feasibility, which is supported by the results of our study. Considering the complexity of their schedule and potential future pandemics or other natural events that may provoke important social distancing rules, the ability to engage virtually, as our initiative proposes, is a notable strength that enhances the feasibility of such a programme. Unlike our study, Loewenthal et al included a control group; this group showed no improvement in psychological health measures from baseline to postprogramme, suggesting that the effect of time had minimal impact on the sample.28
Comparison with the wider literature
There is growing evidence that MBIs can improve the well-being of physicians and other healthcare professionals at all levels of experience and training.49 Our findings that participation in the PYB-R reduced symptoms of anxiety and improved CS for up to 3 months following programme completion is consistent with the literature on MBIs in healthcare.27 53–57 While we also observed improvements in symptoms of depression among PYB-R participants, previous studies of MBIs have reported no changes in depression postintervention.27 28 Although self-reported levels of burn-out did not change following completion of the PYB-R, others have demonstrated yoga-based interventions can effectively reduce symptoms of burn-out.29 55–58 The lack of effect on burn-out and CF we observed among PYB-R participants could be due to the fact that these variables are largely related to the work environment which was particularly disrupted and unstable during the winter of 2021 during the height of the COVID-19 pandemic. Although the PYB-R provides tools to help improve emotional regulation, these techniques may not be sufficient in a stressful context.59
Resident physicians who completed the PYB-R showed significant improvements in CS. Similar results were observed among healthcare professionals in Japan who participated in an MBI during the COVID-19 pandemic.60 CS is a protective element of burn-out and CF and is directly linked to self-compassion.61 62 During the course of the pandemic, fear of infection likely increased stress levels and may have contributed to lower levels of CS among healthcare professionals.63 Since resident physicians generally work in competitive environments under difficult conditions, they are often trained to strive for self-improvement rather than CS and self-compassion.64 As demonstrated in a recent study by Wang et al,65 self-compassion is essential to the development of CS. The PYB-R aims to teach self-compassion through a better understanding of its limits and an awareness of its psychological symptoms.
Discussing important differences in results
We found residents with better QWL had fewer symptoms of depression and anxiety at baseline compared with those with poor QWL. After completion of the PYB-R, these symptoms were reduced in both groups but to a much greater degree in the group with poor QWL, suggesting that participation in the programme alleviated some of the difficulties experienced in the work environment. Similarly, we observed improvements in CS in both groups, but to a greater degree in the group with better QWL. A work environment that meets the physical and psychological needs of the professional facilitates the development and maintenance of self-compassion and CS.66–68 Ultimately, it is the responsibility of the institution to provide this conducive working environment.
Implications of the study
Changes to the Canadian healthcare system during the COVID-19 pandemic have had and will continue to have, serious consequences for the workforce.1 A 2021 report from the CMA highlighted the need to raise awareness and destigmatise mental health among physicians, to enhance and expand the availability of specialised support services, and to better evaluate the effectiveness of these services.3 Healthcare institutions must provide employees with the necessary tools to manage their emotions and cognitive flexibility in order to minimise anxiety, depression, CF and burn-out. The findings of this study highlight the value of the PYB-R as a preventive tool, not only for the psychological health of individual residents but also for the performance of the healthcare system and the quality of care provided.
Unanswered questions and future research
Further research is required to determine how long the beneficial effects observed in PYB-R participants are maintained (6 months, 1 year, etc) and to optimise how and when the programme is offered to maximise participation. Additional research is also needed to investigate the impact of MBIs on the quality of care in terms of patient outcomes and satisfaction.
Conclusions
It has been shown that the current generation of resident physicians values their psychological well-being and is actively seeking solutions to address their challenges.3 It is time to offer them accessible solutions that meet their diverse needs. Our results demonstrate that a virtual yoga for resident physicians is feasible and can have lasting positive effects on their depressive and anxious symptoms, as well as enhancing their CS which is a protective factor to FC and burn-out. Further research using a more robust study design and a larger sample size is required to validate these findings. Research is also needed on the impact of such results on the quality of care and the health system. Generally speaking, well-being is a reflection of corporate culture; institutions that evaluate the QWL of their physicians and provide tangible mental health resources have observed improvements in the quality of care delivered.69 Recognising that an intervention may have a greater effect on health professionals when it is conducted directly by institutions, it would be interesting to make a global assessment of such an initiative as part of an organisational strategy.33
Data availability statement
Data are available on reasonable request. We welcome our peers to ask for data or any other relevant information. Data will be available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Le Comité d’éthique de la recherche pour les projets étudiants impliquant des êtres humains—UQAM.#2021-3451. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors acknowledge Percipient Research and Consulting for assistance with language editing.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors The guarantor of the study is M-PB; she accepted full responsibility for the finished work and the conduct of the study, had access to the data and controlled the decision to publish. M-PB was involved in conceptualisation, protocol development, data analysis and drafted the manuscript. GD was involved in conceptualisation, protocol development and manuscript editing. RF was involved in conceptualisation and manuscript editing. All authors approved of the final version of the manuscript and agreed to be accountable for all aspects of the work. AI was used to translate some sentences from French to English.
Funding This work was supported by the Canadian Medical Association (CMA) and the Fond de Recherche du Québec (#N/A)—Volet Société Culture (FRQSC). #289651.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.