In human health care, advantages of teamwork include reduced hospitalization time and costs, enhanced service provision, improved patient satisfaction, increased staff motivation, and greater team innovation.1 Studies in human health care also reveal that positive team environments enhance job satisfaction, improve well-being, and provide better role clarity for employees.2,3 Conversely, negative team environments have been associated with team members becoming stressed, frustrated, and dissatisfied.4,5 Research has identified dissatisfaction and stress at the individual level to be associated with substance abuse, burnout, turnover, and reduced psychologic well-being in numerous health professions,6–11 including veterinary medicine.6,7,12–14 Occupational and psychological stresses are associated with a high rate of suicide among veterinarians.6,7 A recent study found veterinarians have a disproportionately high risk of suicide, at 4 times the proportional mortality ratio of the general population and twice that of other health professions.6,7 Similar studies have not yet been done with other members of the veterinary team.
Although several studies have explored job stress, job satisfaction, and burnout among veterinarians,6,12–15 to date, empirical studies have not examined the effect of team effectiveness on the outcomes of job satisfaction and burnout in the entire veterinary team.
Although a broadly accepted definition of team effectiveness has not been developed, it is generally thought to consist of inputs, processes, and outputs.2,3,16 Inputs include organizational-level factors such as specified tasks, distinct roles, and relevant members2,17–19 and individual-level factors such as self-knowledge, commitment, and flexibility.2,17,18,20,21Team processes usually include leadership, communication, coordination, and conflict resolution,4,22–24 and outcomes include turnover, profitability, patient care, and client satisfaction.2,3,16
Job satisfaction is one of the most researched variables in organizational behavior.25 It has an effect on the organization in terms of performance26,27 and outcome quality measures,28 and it also influences an individual's physical health (eg, cardiovascular disease and musculoskeletal disorders)29 and psychological well-being (eg, anxiety and depression).25,29,30 Furthermore, studies have found job satisfaction to be positively associated with organizational commitment31–35 and negatively associated with job turnover.32–34,36,37
Burnout is defined as a syndrome of emotional exhaustion, cynicism, and decreased professional efficacy and leads to decreased effectiveness at work.38 Emotional exhaustion (hereafter referred to as exhaustion), a key component of the burnout syndrome, is characterized by decreased emotional energy as a result of excessive personal or work demands.38 Cynicism represents a dysfunctional, self-protective coping mechanism for chronic work stress and exhaustion, with workers withdrawing from various aspects of the job as well as from coworkers and clients.38–40 In contrast, professional efficacy describes feeling personally capable of completely fulfilling expectations of the job or occupation.38 High exhaustion and cynicism scores and low professional efficacy scores have been associated with higher levels of negative physical and mental health outcomes in a number of professions.38 Previous studies indicate exhaustion usually precedes cynicism,39,40 and cynicism can result in decreased professional efficacy,41 although burnout is said to be present with extreme scores in even just 1 domain. The objective of the study presented here was to evaluate the effect of veterinary team effectiveness on the outcomes of job satisfaction and burnout in companion animal veterinary practice. It was hypothesized a priori that higher ratings of veterinary team effectiveness would result in higher individual job satisfaction and less individual burnout in a veterinary practice setting.
Materials and Methods
Study participants—This study protocol was approved by the University of Guelph Research Ethics Board. A list of all small animal clinics located within a 1-hour drive of Guelph, ON, Canada, or Ridgetown, ON, Canada, was obtained from the publicly accessible College of Veterinarians of Ontario data base. A random number generator was used to select clinics to be contacted. Clinics were contacted sequentially until approximately 50 clinics were enrolled. Clinics were initially contacted through a letter of introduction and were subsequently telephoned to discuss the project and obtain clinic-level consent to invite staff participation. The primary author traveled to each consenting clinic to explain the purpose of the research project to the practice team and to distribute access codes to the online surveya to potential participants.
As part of the online survey, participants were asked to provide demographic information, including age, gender (male or female), job status (full-time or part-time), employee group (owner-partner veterinarian, associate veterinarian, office manager, veterinary technician, veterinary assistant, receptionist, kennel attendant, or other), number of years in veterinary medicine, and number of years of tenure at the clinic. Full-time versus part-time status was self-identified by the participants. Tenure was defined as the number of years a participant had worked at their current clinic of employment.
Team effectiveness instrument—Team effectiveness was assessed by means of a 41-item questionnaire specifically developed for use with veterinary teams (Appendix). The questionnaire was developed in 4 phases. Phase I involved 8 focus groups, with 4 independent veterinarian and 4 independent RVT focus groups used to explore participants’ perceptions about characteristics of effective veterinary teams, including the benefits and challenges to working as part of a veterinary team.b In the jurisdiction in which the focus group study was conducted, RVTs are graduates of an accredited college program who have passed a credentialing examination and are required to obtain regular continuing education to maintain their designation.
Phase II used the themes and wording identified during thematic analysis of the focus group transcripts to develop an initial pool of 216 items for consideration in development of the questionnaire. The items were then each assessed for face validity,42 relevance, and clarity by a veterinarian, an RVT, a receptionist, and a kennel attendant representing 4 employee groups within a veterinary practice. The items were scored on a 4-point scale (1= not relevant, 2 = unable to assess relevance without item revision, 3 = relevant but needs minor alterations, and 4 = very relevant and succinct). Two of the authors (ICM and JBC) then reviewed the questions and rankings, eliminating items not receiving a ranking of 4 by at least 3 of the 4 raters43 and eliminating redundant questions, reducing the questionnaire to 51 items. A 7-point Likert-type scale was used for responses (1 = totally disagree, 2 = strongly disagree, 3 = somewhat disagree, 4 = neither agree nor disagree, 5 = somewhat agree, 6 = strongly agree, 7 = totally agree).
Phase III involved a pilot study of 22 employees from a convenience sample of 3 companion animal practices to pretest the questionnaire. On the basis of the pilot study results, inter-item correlations of > 0.8 were reviewed and items identified as redundant were removed.42 After reverse coding negatively worded items, a total team effectiveness score was developed by summing the scores of all items. Items with correlations of < 0.4 with total team effectiveness score were also eliminated.42 The final team effectiveness instrument contained 41 items, producing a measure with possible total team effectiveness scores ranging from 41 to 287.
Phase IV included psychometric evaluation of the instrument by use of data from the current study. In addition to the MBI-GS and job satisfaction measures, a validated measure of relational coordination44,45 and 2 global questions were included with the final online survey to further assess the construct validity42 of the team effectiveness survey in measuring team effectiveness. Relational coordination has been positively correlated with desirable team outcomes,44,45 providing a good comparison measure for evaluating the construct validity of the team effectiveness survey. The global questions were “How likely are you to leave your job in the next year?” (responses were extremely likely, very likely, likely, neither likely nor unlikely, unlikely, very unlikely, and extremely unlikely) and “Overall, I feel we have an effective team” (responses were totally disagree, strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree, strongly agree, and totally agree). Exploratory factor analysis was used to explore the underlying structure of the 41-item team effectiveness survey. Four latent variables were identified and used in the subsequent regression analysis: coordinated team environment, toxic team environment, team engagement, and individual engagement. The variables were named to reflect the underlying construct expressed by the items in each factor. Cronbach alpha coefficients were calculated for the team effectiveness instrument as well as for each of the latent variables developed during factor analysis to evaluate the internal consistency of the instrument.42
Measurement of job satisfaction—A single-item measure, “On the whole, how satisfied are you with your job?” assessed job satisfaction. The item was scored on a 7-point Likert scale (1 = extremely dissatisfied, 2 = very dissatisfied, 3 = dissatisfied, 4 = neither dissatisfied nor satisfied, 5 = satisfied, 6 = very satisfied, and 7 = extremely satisfied). Single-item, overall job satisfaction measures are a valid and reliable means of assessing global job satisfaction.45–49 Job satisfaction was also categorized into satisfied, neutral, and dissatisfied categories, with the satisfied category including participants who were satisfied to extremely satisfied, and the dissatisfied category including those dissatisfied to extremely dissatisfied.
Measurement of burnout—All 3 dimensions (termed subscales) of burnout (exhaustion, cynicism, and professional efficacy) were assessed with the MBI-GS,38 an instrument considered the gold standard for measuring the construct of burnout.50–53 The MBI-GS consists of 16 items with response options ranging from 0 (never), 1 (a few times a year or less), 2 (once a month or less), 3 (a few times a month), 4 (once a week), 5 (a few times a week), to 6 (every day). The exhaustion subscale was assessed with 5 items, cynicism with 5 items, and professional efficacy with 6 items. A mean score for each subscale was calculated by adding responses for each question and dividing by the number of items.38 To facilitate comparisons with other studies as well as to calculate mean scores for each of the 3 subscales of the MBI-GS, data scores were also categorized to reflect high-, medium-, and low-risk categories of burnout, on the basis of established normative ranges developed for the instrument.38 These were subsequently referred to as burnout risk categories. Burnout is said to be present if an individual is in the high-risk category for any burnout dimension38; thus the number of participants with high scores in 1, 2, or 3 dimensions was also examined.
Statistical analysis—The influence of survey order on scores for the MBI-GS, relational coordination, and total team effectiveness score was assessed by use of ANOVA and Kruskall-Wallis tests. There were 3 orders of presentation: team effectiveness, relational coordination, and MBI-GS; relational coordination, MBI-GS, and team effectiveness; and MBI-GS, team effectiveness, and relational coordination. Each survey began with demographic questions and ended with global questions and a comment section. Construct validity of the developed team effectiveness instrument was assessed by determination of a positive relationship between the total team effectiveness score and both the relational coordination score and each of the 2 global questions by use of Spearman rank order correlation.42
Descriptive statistics were determined for independent variables, by use of frequencies for categorical variables (gender, employee group, and job status [full-time vs part-time]), and by use of the mean, SD, minimum, maximum, skewness, and kurtosis for continuous variables (age, years in veterinary medicine, tenure at clinic, and the 4 latent variables identified during exploratory factor analysis of the team effectiveness). Quadratic terms for the continuous variables were also created to address potential nonnormality in the data. Descriptive statistics were similarly determined for the mean scores for job satisfaction, the 3 domains of the MBI-GS, and the summary score for total team effectiveness. The number of participants could potentially vary for each outcome because they were based on the number of respondents who provided information for each question. Means, SDs, and medians for job satisfaction and burnout were also assessed by employee group.
All scales were tested for normal distribution by use of the Shapiro-Wilk test statistic and the Kolmogorov-Smirinov test statistic with Lilliefors significance correction. All independent variables considered for model building were explored, by use of both parametric and nonparametric techniques, for unconditional associations with the outcome measures of job satisfaction, exhaustion, cynicism, and professional efficacy. Univariable linear regression was used to explore this relationship for continuous variables (age, years in veterinary medicine, tenure, and the 4 team effectiveness latent variables identified by factor analysis). Dichotomous variables (male vs female and full-time vs part-time status) were evaluated with t tests and Mann-Whitney tests. Categorical variables (employee group and clinic) were evaluated with ANOVA and Kruskall-Wallis tests.
Because a nonparametric equivalent does not exist for regression models with random effects, mixed linear regression models were developed to investigate the associations between the team effectiveness latent variables and the outcomes of job satisfaction, exhaustion, cynicism, and professional efficacy while controlling for other factors. Clinic was included as a random effect at all stages of the model-building process to address potential clustering of responses within clinic. The 4 team effectiveness latent variables were entered into all models as predictor variables. For the toxic team environment latent variable, the items were reverse coded to calculate the total team effectiveness score. For the regression models, the original coding was used. In addition, during construction of the multivariable mixed linear regression models, gender, employee group, job status, age, years in veterinary medicine, tenure at clinic, and all 2-way interactions were initially included. Quadratic terms for age, years in veterinary medicine, and tenure were also tested in all models.
Model building was performed by manual backward elimination of interaction terms by use of a P value < 0.05. Once all nonsignificant interaction terms were removed, manual sequential backward removal of nonsignificant main effects was performed, beginning with the least significant. If interaction terms were significant, the corresponding main effects were left in the model. In the final model, all previously removed main effect variables were independently reintroduced individually in the order they were initially removed to do a final check for significance.
The models were assessed for outliers and high leverage observations by graphical visualization of standardized residuals. Outlier and high leverage observations were evaluated for common factors. The effect on regression parameters of rerunning the model in the absence of outliers or high leverage values was evaluated. To illustrate the percentage of variation explained by each random effects model, the approximate R2 value was estimated by squaring the Pearson correlation coefficient between the dependent variable and the fitted values. All analyses were performed with standard software.c,d For all final comparisons, a P value < 0.05 was considered significant.
Results
Study participants—Fifty-three of 77 (69%) clinics contacted initially agreed to participate in the study; however, a suitable date could not be arranged for 2 clinics and 3 additional clinics contributed no data to the study. Thus, the overall clinic response was 62% (48/77).
Codes to access the online questionnaire (1/potential respondent) were distributed to the participating clinics; the number of questionnaires was based on the reported number of employees. Participating clinics had from 3 to 25 employees (mean, 9.4; median, 8). Of 457 potential respondents, 274 (60%) from 48 clinics participated in the online surveys. Of the 273 participants contributing demographic information, 31 (11.3%) were owner-partner veterinarians, 39 (14.3%) were associate veterinarians, 25 (9.1%) were managers, 90 (33.0%) were veterinary technicians, 15 (5.5%) were veterinary assistants, 55 (20.1%) were receptionists, and 11 (4.0%) were kennel attendants. An additional 7 (2.6%) participants reported other employment responsibilities. The median age of participants was 35 years (mean ± SD, 38 ± 11.87 years), and the median duration of employment in veterinary medicine was 9 years (mean ± SD, 12 ± 9.57 years). The median duration of tenure at their current practice of employment was 4 years (mean ± SD, 7 ± 8.60 years). In the study population, 243 (89%) were female and 30 (11%) were male. Additional demographic information broken down by employee group was determined (Table 1).
Demographics of survey participants by employee group in 48 companion animal veterinary practices in Ontario, Canada.
| Employee group | No. | Age (y [mean {SD}]) | Years in veterinary medicine (mean[SD]) | Years tenure at clinic (mean [SD]) | Full-time vs part-time status* | Gender (No. [%]) |
|---|---|---|---|---|---|---|
| Owners-partners | 31 | 49 (9.15) | 23 (9.80) | 17 (10.57) | 25 FT | Female (13 [41.9]) |
| 6 PT | Male (18 [58.1]) | |||||
| Associate veterinarians | 39 | 39 (11.02) | 13 (11.24) | 6 (6.63) | 25 FT | Female (25 [82.0]) |
| 14 PT | Male (7 [18]) | |||||
| Managers | 25 | 43 (8.74) | 17 (9.18) | 12 (9.67) | 21 FT | Female (21 [84]) |
| 4 PT | Male (4 [16]) | |||||
| Veterinary technicians | 90 | 31 (7.13) | 9 (6.21) | 5 (4.97) | 78 FT | Female (90 [100]) |
| 4 PT | Male (0 [0]) | |||||
| Veterinary assistants | 15 | 33 (14.06) | 8 (9.57) | 5 (6.84) | 4 FT | Female (15 [100]) |
| 11 PT | Male (0 [0]) | |||||
| Receptionists | 55 | 41 (12.13) | 10 (8.09) | 8 (7.99) | 35 FT | Female (55 [100]) |
| 19 PT | Male (0 [0]) | |||||
| Kennel attendants | 11 | 32 (16.94) | 5 (3.91) | 5 (4.00) | 2 FT | Female (11 [100]) |
| 9 PT | Male (0 [0]) | |||||
| Other | 7 | 37 (15.74) | 11.5 (12.88) | 7 (8.60) | 2 FT | Female (6 [85.7]) |
| 5 PT | Male (1 [14.3]) |
Participants self-reported part-time (PT) and full-time (FT) status.
Team effectiveness—The overall mean ± SD score for total team effectiveness was 191.92 ± 39.27 (n = 230; median, 193.00), and the Cronbach alpha value was 0.964. Means, SDs, medians, and Cronbach alpha values for the team effectiveness subscales were determined (Table 2). In testing the validity of the team effectiveness instrument, positive relationships between the total team effectiveness score and relational coordination (r = 0.64; P < 0.001) and the 2 global questions (“How likely are you to leave your job in the next year?” [r = 0.47; P < 0.001] and “Overall, I feel we have an effective team” [r = 0.78; P < 0.001]) were found, which supported the construct validity of the team effectiveness instrument. The 2 tests of normality for the total team effectiveness scale and toxic team environment latent variable (subscale 2) differed. The coordinated environment (subscale 1), team engagement (subscale 3), and individual engagement (subscale 4) latent variables were not normally distributed. The outcome of both parametric and nonparametric tests used to explore relationships among the independent variables and outcomes was determined (Tables 3 and 4). No difference was detected for the potential effect of survey order on scores for the MBI-GS, relational coordination, or team effectiveness surveys.
Descriptive statistics for overall team effectiveness and team effectiveness subscale scores, including Cronbach alpha values and results of normality tests in 48 companion animal veterinary practices in Ontario, Canada.
| Variable | N | Mean ± SD | Median (range) | Cronbach alpha | Kolmogorov-Smirnov | Shapiro-Wilk |
|---|---|---|---|---|---|---|
| Subscale 1: Coordinated team environment | 260 | 43.52 ± 11.42 | 46.00 (9–63) | 0.920 | < 0.001 | < 0.001 |
| Subscale 2: Toxic team environment* | 251 | 48.36 ± 15.38 | 48.00 (16–84) | 0.916 | 0.082 | 0.012 |
| Subscale 3: Team engagement | 254 | 60.44 ± 9.99 | 61.00 (17–77) | 0.890 | 0.006 | < 0.001 |
| Subscale 4: Individual engagement | 261 | 45.82 ± 10.37 | 48.00 (9–63) | 0.896 | < 0.001 | < 0.001 |
| Total team effectiveness score | 230 | 191.92 ± 39.27 | 193.00 (65–269) | 0.964 | 0.200 | 0.026 |
Most items in this subscale had reversed wording.
N = Number of participants.
Results of parametric and nonparametric tests for individual-level variables and the outcome of job satisfaction in 48 companion animal veterinary practices in Ontario, Canada.
| Job satisfaction | |||||
|---|---|---|---|---|---|
| Variable | Predictor variable format | Median | Mean ± SD | P value (parametric) | P value (nonparametric) |
| Age (y) | Continuous | 35 | 37.58 ± 11.87 | 0.016* | — |
| Years in veterinary medicine | Continuous | 9 | 12.02 ± 9.63 | 0.224* | — |
| Tenure at clinic (y) | Continuous | 4 | 7.55 ± 8.37 | 0.035* | — |
| Gender | Dichotomous | — | — | 0.116† | 0.180‡ |
| 0 = Male (11.3%) | |||||
| 1 = Female (88.7%) | |||||
| FT versus PT (h/wk)§ | Dichotomous | — | FT = 39.2 ± 5.76 | 0.132† | 0.195‡ |
| 0 = FT (71.2%) | PT = 20.9 ± 8.92 | ||||
| 1 = PT (28.8%) | |||||
| Employee group (8 employee groups) | Categorical | — | — | 0.003| | < 0.001¶ |
| Clinic (48 clinics) | Categorical | — | — | < 0.001| | < 0.001¶ |
| Coordinated team environment scores | Continuous | 46 | 43.52 ± 11.42 | < 0.001* | — |
| Toxic team environment scores | Continuous | 48 | 48.36 ± 15.39 | < 0.001* | — |
| Team engagement scores | Continuous | 61 | 60.44 ± 10.00 | < 0.001* | — |
| Individual engagement scores | Continuous | 48 | 45.82 ± 10.37 | < 0.001* | — |
Univariable linear regression.
t test.
Mann-Whitney test.
Participants self-reported part-time and full-time status.
ANOVA.
Kruskall Wallis test.
— = Not applicable.
See Table 1 for remainder of key.
Results of parametric and nonparametric tests for individual-level variables and the outcomes of exhaustion, cynicism, and professional efficacy in 48 companion animal veterinary practices in Ontario, Canada.
| Exhaustion | Cynicism | Professional efficacy | |||||
|---|---|---|---|---|---|---|---|
| Variable | Predictor variable format | P value in parametric test | P value in nonparametric test | P value in parametric test | P value in nonparametric test | P value in parametric test | P value in nonparametric test |
| Age | Continuous | 0.117* | — | 0.139* | — | 0.066* | — |
| Years in veterinary medicine | Continuous | 0.139* | — | 0.696* | — | 0.342* | — |
| Tenure at clinic | Continuous | 0.443* | — | 0.742* | — | 0.098* | — |
| Gender | Dichotomous | 0.915† | 0.675‡ | 0.848† | 0.937‡ | 0.039† | 0.053‡ |
| 0 = Male (11.3%) | |||||||
| 1 = Female (88.7%) | |||||||
| FT | Dichotomous | < 0.001† | < 0.001‡ | 0.007† | 0.015‡ | 0.825† | 0.857‡ |
| versus part-time status§ | 0 = FT (71.2%) | ||||||
| 1 = PT (28.8%) | |||||||
| Employee group (8 employee groups) | Categorical | < 0.001|| | < 0.001¶ | < 0.001|| | < 0.001¶ | 0.044| | 0.066¶ |
| Clinic (48 clinics) | Categorical | 0.008| | 0.014¶ | 0.002| | 0.007¶ | 0.050| | 0.090¶ |
| Coordinated team environment | Continuous | < 0.001* | — | < 0.001* | — | < 0.001* | — |
| Toxic team environment | Continuous | < 0.001* | — | < 0.001* | — | < 0.001* | — |
| Team engagement | Continuous | < 0.001* | — | < 0.001* | — | < 0.001* | — |
| Individual engagement | Continuous | < 0.001* | — | < 0.001* | — | < 0.001* | — |
See Tables 1 and 3 for key.
Job satisfaction—The overall mean ± SD score for job satisfaction was 5.46 ± 1.36 (n = 265; median, 6.00), with a maximum score of 7.b Because job satisfaction was not normally distributed (P < 0.001 for Kolmogorov-Smirnov and Shapiro-Wilk normality tests), parametric and nonparametric tests were conducted to examine the relationship between job satisfaction and each independent variable (Table 3). The results were similar for each independent variable by use of parametric and nonparametric tests. Job satisfaction scores by employee group were summarized (Table 5). When job satisfaction was categorized into satisfied, neutral, and dissatisfied categories, 83.1% of participants were satisfied, whereas 13.5% were dissatisfied.
Descriptive statistics for job satisfaction, exhaustion, cynicism, and professional efficacy scores by employee group in 48 companion animal practices in Ontario, Canada.
| Job satisfaction | Exhaustion | Cynicism | Professional efficacy | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Employee group | N | Mean ± SD | Median | N | Mean ± SD | Median | N | Mean ± SD | Median | N | Mean ± SD | Median |
| Owner-partner | 29 | 6.14 ± 0.69 | 6.00 | 31 | 2.00 ± 1.17 | 2.00 | 31 | 1.35 ± 1.27 | 1.00 | 31 | 5.50 ± 0.41 | 5.67 |
| Associate veterinarian | 39 | 5.44 ± 1.25 | 6.00 | 39 | 2.33 ± 1.22 | 2.40 | 39 | 1.39 ± 1.04 | 1.00 | 39 | 5.21 ± 0.70 | 5.50 |
| Manager | 24 | 5.58 ± 1.38 | 6.00 | 24 | 2.20 ± 1.41 | 2.00 | 24 | 1.21 ± 1.09 | 0.90 | 24 | 5.24 ± 0.80 | 5.50 |
| Veterinary technician | 89 | 5.06 ± 1.48 | 5.00 | 89 | 2.44 ± 1.46 | 2.40 | 89 | 1.77 ± 1.61 | 1.20 | 89 | 5.06 ± 0.76 | 5.33 |
| Veterinary assistant | 13 | 5.62 ± 1.56 | 6.00 | 15 | 1.25 ± 1.43 | 0.80 | 15 | 0.51 ± 0.70 | 0.20 | 15 | 5.31 ± 0.82 | 5.67 |
| Receptionist | 54 | 5.74 ± 1.25 | 6.00 | 54 | 1.56 ± 1.30 | 1.20 | 53 | 0.75 ± 1.02 | 0.40 | 53 | 5.27 ± 0.79 | 5.50 |
| Kennel attendant | 10 | 4.80 ± 1.48 | 5.00 | 10 | 1.96 ± 1.35 | 1.80 | 10 | 1.20 ± 1.10 | 0.80 | 10 | 4.72 ± 1.05 | 4.67 |
| Other | 7 | 6.00 ± 1.41 | 6.00 | 7 | 1.14 ± 1.04 | 0.80 | 7 | 0.94 ± 1.11 | 0.20 | 7 | 5.48 ± 0.39 | 5.33 |
| Total | 265 | 5.46 ± 1.36 | 6.00 | 269 | 2.06 ± 1.39 | 1.80 | 268 | 1.30 ± 1.33 | 0.80 | 268 | 5.20 ± 0.75 | 5.42 |
N = Number of participants.
Burnout—The overall mean ± SD mean score for exhaustion was 2.06 ± 1.39 (n = 269; median, = 1.80), mean ± SD score for cynicism was 1.30 ± 1.33 (n = 268; median, = 0.80) and for professional efficacy, mean ± SD score was 5.20 ± 0.75 (n = 268; median, = 5.42). Because none of the burnout domains were normally distributed (P < 0.001 by use of Kolmogorov-Smirnov and Shapiro-Wilk normality tests), parametric and nonparametric tests were used to explore relationships among the independent variables and outcomes (Table 4). As with job satisfaction, results were similar for the 2 tests. Burnout scores by employee group were summarized (Table 5).
When exhaustion was categorized into high-, medium-, and low-risk categories, 22.4% (n = 61) of participants were in the high risk category of burnout from exhaustion. When cynicism was similarly categorized, 23.2% (n = 63) of participants were in the high-risk category. For professional efficacy, 70.6% of participants (n = 192) were in the low-risk category, with 9.3% (25) in the high-risk category. The percentages of participants in high-, moderate-, and low-risk categories for each domain of burnout were determined (Table 6). In total, 35.3% of respondents were in the high-risk category of at least 1 domain. Of these, 18% were at high risk in 1 domain, 15.1% were at high risk in 2 domains, and 2.2% were at high risk in 3 domains.
Distribution of participants (number [%]) in high-, moderate-, and low-risk categories of burnout in 48 companion animal veterinary practices in Ontario, Canada.
| Variable | Emotional exhaustion | Cynicism | Professional efficacy |
|---|---|---|---|
| High burnout | 61 (22.4) | 63 (23.2) | 25 (9.2) |
| Moderate burnout | 61 (22.4) | 54 (19.9) | 55 (20.2) |
| Low burnout | 150 (55.1) | 155 (57.0) | 192 (70.6) |
Mixed linear regression models—Few differences were detected between parametric and nonparametric tests for independent variables and outcomes, supporting the decision to use mixed linear regression for evaluating associations. After controlling for random effects, the final model for job satisfaction included years in veterinary medicine, tenure, full-time versus part-time status, toxic team environment, and individual engagement (Table 7). The model's approximate R2 was 55.3%. The pattern of residuals plotted against the predicted values for each of the models visually approached normality, although results of the Shapiro-Wilk and Kolmogorov-Smirinov tests were significant. When the single identified outlier was excluded from the model, years in veterinary medicine became nonsignificant. However, because upon evaluation there appeared to be no justifiable reason to exclude the observation, the outlier was left in the model.
Mixed linear regression models for job satisfaction, exhaustion, cynicism, and professional efficacy scores in 48 companion animal practices in Ontario, Canada.
| Job satisfaction | Exhaustion | Cynicism | Professional efficacy | |||||
|---|---|---|---|---|---|---|---|---|
| Variable | Estimate | SE | Estimate | SE | Estimate | SE | Estimate | SE |
| Years in veterinary medicine | –0.018* | 0.009 | — | — | 0.008 | 0.015 | — | — |
| Tenure | 0.032† | 0.011 | — | — | 0.054 | 0.049 | –0.007 | 0.008 |
| Full-time vs part-time | ||||||||
| Full-time | –0.340* | 0.137 | 0.597‡ | 0.151 | –0.289 | 0.242 | –0.804* | 0.332 |
| Part-time | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Employee group | ||||||||
| Owner-partner | — | — | — | — | 0.491 | 0.479 | — | — |
| Associate veterinarian | — | — | — | — | 0.217 | 0.449 | — | — |
| Manager | — | — | — | — | 0.055 | 0.497 | — | — |
| Veterinary technician | — | — | — | — | 0.378 | 0.436 | — | — |
| Veterinary assistant | — | — | — | — | –0.602 | 0.507 | — | — |
| Kennel attendant | — | — | — | — | –0.487 | 0.441 | — | — |
| Other | — | — | — | — | 0 | 0 | — | — |
| Coordinated team environment | — | — | — | — | –0.024* | 0.010 | 0.011* | 0.006 |
| Toxic team environment | -0.026‡ | 0.005 | 0.047‡ | 0.006 | 0.024† | 0.007 | — | — |
| Individual engagement | 0.068‡ | 0.008 | –0.184* | 0.008 | –0.027* | 0.011 | 0.015* | 0.006 |
| Age | — | — | — | — | –0.022* | 0.011 | 0.016* | 0.007 |
| Age × Tenure | — | — | — | — | 0.004* | 0.001 | — | — |
| Age × Full-time | — | — | — | — | — | — | –0.024* | 0.009 |
| Tenure × YrsVetMed | — | — | — | — | –0.004* | 0.002 | — | — |
| Tenure × Full-time | — | — | — | — | -0.081† | 0.024 | 0.028* | 0.014 |
P ≤ 0.05.
P ≤ 0.01.
P ≤ 0.001.
YrsVetMed = Years in veterinary medicine. — = Not applicable.
Controlling for random effects, the final model for exhaustion included full-time versus part-time status, toxic team environment, and individual engagement, with an approximate R2 of 50.4% (Table 7). Both graphing the residuals and tests of normality indicated the model fit the data well. No outliers were identified.
After controlling for the random effect of clinic, the final model for cynicism included full-time versus part-time status, employee group, age, tenure, years in veterinary medicine; the interaction terms tenure by age, tenure by years in veterinary medicine, and tenure by full-time versus part-time status; and the coordinated team environment, toxic team environment, and individual engagement subscales. The approximate R2 for this model was 42.4% (Table 7). Results of the Shapiro-Wilk and Kolmogorov-Smirinov tests were significant; however, the scatterplots of residuals and predicted values visually approached normality. One high leverage observation was identified but was left in the model because its removal did not change the significance of the variables.
Finally, when controlling for random effects, the final model for professional efficacy included age, tenure, full-time versus part-time status, age by full-time versus part-time status, tenure by full-time versus part-time status, and the coordinated team environment and individual engagement subscales. The approximate R2 for this model was 20.6% (Table 7). Results of the Shapiro-Wilk and Kolmogorov-Smirinov tests were significant; however, the scatterplots of residuals and predicted values visually approached normality. No outliers or high leverage observations were identified.
Discussion
The findings of the present study suggested that team effectiveness is a multidimensional concept. Domains of team effectiveness previously identified in health-care teams include leadership, conflict management, communication, and coordination,4,22–24 which are consistent with the findings of the present study.
Recommendations arising from studies on improving job satisfaction and reducing burnout advocate a 2-pronged approach: examining areas where there is a gap between job demands and key resources and increasing work engagement.10,54–56 Job demands include workload and personal conflict, whereas resources include control coping, social support, use of skills, autonomy, and the opportunity to participate in decision making.54 Gaps can be identified through the use of surveys and consultations with staff.10,55 Work engagement describes a positive, fulfilling, affective-motivational state of work-related well-being that is considered to be at the opposite end of the burnout spectrum.56 Increasing work engagement may prevent and alleviate burnout by enhancing an individual employee's energy, vigor, and resilience.40,55
Of the 4 subscales identified through factor analysis of the team effectiveness survey, 3 had a significant effect on job satisfaction and burnout. A coordinated team environment was associated with decreased cynicism and increased professional efficacy. A toxic team environment was associated with decreased job satisfaction as well as increased cynicism and exhaustion. Individual engagement was significantly associated with increased job satisfaction and professional efficacy and decreased exhaustion and cynicism. Team engagement was not significant in the final models. Thus, the a priori hypothesis that higher veterinary team effectiveness would have a positive effect on the outcomes of individual job satisfaction and burnout was largely supported.
In the present study, a coordinated team environment was inversely associated with cynicism. Because many items making up this subscale involved structured communication and recognition of input from the team, it appears cynicism may result when clinics lack effective communication strategies. Under these circumstances, employees may disengage from the work environment because they may feel they are not being listened to. Research reveals that changing the format in which information is shared, providing timely information, and involving staff in dissemination of information have positive effects on burnout and work engagement.10 Veterinary practices should regularly evaluate their internal communications (eg, staff meetings, internal newsletters, clinical policies, and procedures) to ensure all team members are kept abreast of changes in the clinic and given the opportunity to provide suggestions to improve patient and client service.
In contrast, a coordinated team environment was positively associated with professional efficacy. Items related to professional efficacy in the coordinated team subscale included people working toward the same goals, a team effort working with clients, and recognition of individual contributions to the team. Research indicates professional efficacy may be reduced when there is a lack of social support in the work environment54,57 or there is a lack of opportunity for staff to engage in professional development.54 This results in people feeling inadequately prepared to help clients and less competent.54 By actively encouraging professional development of all staff and ensuring all team members are recognized for their contributions, veterinary clinics can enhance an individual's professional efficacy. In addition, colleagues and supervisors can be encouraged to provide guidance and social support to help team members develop coping skills and enhance self-efficacy54,56 because these interventions have a buffering effect on burnout.40,57
The present study found that a more toxic team environment was associated with lower job satisfaction. Although the mean job satisfaction among participants in the present study was comparable to that in a recent US study of 7,905 team members in 216 human primary health-care workgroups,28 it was slightly lower than in a comparable study of 626 practice staff in 96 human primary health-care teams in Australia.58 In the Australian study, a good team climate, determined on the basis of the level and quality of teamwork, was associated with higher job satisfaction. This suggests that veterinary practices may benefit from addressing factors contributing to a toxic team environment. Findings from other studies55,59,60 suggest that veterinary practices should consider identifying and resolving conflicts efficiently, ensuring all employees are treated equally and fairly, and developing zero-tolerance policies for incivility.
Items from the team effectiveness survey that comprised the toxic team environment subscale included frustrations with coworker relationships and the job itself. Job satisfaction was higher among participants who had had positive relationships with their coworkers. These findings were congruent with results from studies involving other health professionals. A systematic literature review of job satisfaction in general practice physicians found relationships and contact with colleagues to be associated with higher job satisfaction.61 Similarly, a literature review of job satisfaction in nurses found predictors of job satisfaction included relationships with fellow workers and managers as well as recognition from managers.62 A study15 of Ontario veterinarians found relationships with colleagues (both veterinarians and nonveterinarians) was the second strongest of 6 primary determinants of veterinarian job or career satisfaction. In that study, veterinarians who indicated their coworkers worked well together, were good at their jobs, and treated them with respect had higher job and career satisfaction than other respondents.15 Findings of the present study indicated that taking steps to create and maintain a positive work environment contributed to employee satisfaction. Steps that may be taken to ensure a positive work environment include not tolerating incivility,59,60 facilitating information sharing to build respect and trust,44,45,63 and improving human resource management practices to recruit and retain qualified workers.64,65 These studies suggest that improving relationships in the clinic should improve job satisfaction for all team members.
In the present study, the presence of a toxic team environment was positively associated with higher exhaustion and cynicism. The toxic team environment scale included items related to conflict among coworkers. Conflict with coworkers and supervisors has been commonly associated with burnout.40,54,66,67 Several studies66–68 with nurses and physicians in intensive care units have found that positive coworker relationships offer protection against burnout. Veterinary teams experiencing a toxic team environment could consider interventions targeted at improving collegiality in the clinic as 1 approach to managing such an environment. For instance, a study69 with health-care workers found that a structured intervention to improve civility and collegiality also reduced burnout and turnover intent, while improving respect, management trust, and job satisfaction. The structured intervention involved facilitated sessions over a 6-month period to build community and provide focused training in conflict resolution, leadership, and improving relationships with colleagues.69
Items in the toxic team environment subscale were also related to feeling overloaded and frustrated by the job. In the literature on burnout, workload has been identified as one of the main factors in creating stress, which in turn leads to burnout.40,54,70 In human physicians, burnout is associated with excessive workload, chronic work-related stress, and reduced autonomy.9,71 Similarly, studies have identified the strongest predictors of burnout for nurses in human medicine include workload,54,66,72 lack of decision latitude, and social capital (defined as common values and perceived mutual trust in an organization).72 These results suggest that monitoring work hours, increasing decision-making latitude, and improving relationships in the clinic may reduce burnout. In veterinary clinics where a toxic team environment exists, practices may need to consider their current staffing levels and individual workloads to ensure work overload is not a factor contributing to the current environmental state. Because a lack of autonomy has also been identified as a contributor to burnout, owners and managers could ensure all team members have clearly defined roles and are given freedom to make decisions consistent with their position in the practice.
The present study identified that the more engaged an individual felt with their position, the higher their job satisfaction. In the individual engagement subscale, many items described acknowledgment for an individual's contributions to the functioning of the clinic such as feeling recognized, appreciated, and capable of performing as an integral team member. Moreover, participants with higher individual engagement felt they were encouraged to further develop their skills and knowledge. Previous studies56,73 reveal that job engagement positively affects job satisfaction. Organizational literature also indicates that high work engagement may help individuals cope with stressful situations.74 This suggests that enhancing individual engagement in the clinic not only improves job satisfaction but also reduces the likelihood of stress and burnout.
Higher individual engagement resulting in reduced burnout is consistent with the findings of the present study, in that individual engagement was also negatively associated with exhaustion and cynicism and positively associated with professional efficacy. The individual engagement subscale was consistent with psychological empowerment, which was associated with reduced burnout75–77 and improved job satisfaction75,78 in a number of nursing studies. To minimize burnout, leaders in veterinary clinics should ensure that they empower their team members. This may include providing them with support and guidance, access to information about organizational activities and decisions, adequate resources to complete their jobs in a meaningful fashion, and opportunities to grow and develop.76,78–80
Other variables significant in some of the multivariate regression models included full-time versus part-time status, tenure, years in veterinary medicine, age, and employee group. Full-time workers were significantly less satisfied than part-time workers. This result is interesting because a meta-analysis examining job attitudes of full-time and part-time employees found full-time and part-time employees had similar job satisfaction, organizational commitment, and intent to leave the position.81 In the present study, full-time workers were not only less satisfied, but also more likely to suffer from exhaustion. Several studies66,82 have linked increased weekly work hours with a higher likelihood of burnout. Studies13,83,84 with veterinarians also linked longer work hours, particularly being on call, with increased stress and burnout. These findings suggest that the veterinary profession should remain aware of associations between work hours, job dissatisfaction, and burnout.
The present study found that job satisfaction increased with tenure at the practice. This supported the hypothesis that a satisfied individual is more likely to remain in the current position. Interestingly, in this study, job satisfaction decreased with years in veterinary medicine. This contrasted with other studiese,f in veterinary medicine that have found greater job satisfaction in older veterinarians and individuals who have been in the profession longer. Understanding the relationship between years in practice and job satisfaction is important for sustaining a viable and healthy veterinary profession; therefore, further research is warranted to understand these differences in findings.
Although the present study found that years in veterinary medicine significantly influenced job satisfaction, a 1993 meta-analysis of nurse satisfaction found that years of experience and age had weak correlations with job satisfaction.33 A 2007 meta-analysis of job satisfaction in nurses85 found that job stress, autonomy, and nurse-physician collaboration were strongly correlated with job satisfaction. Autonomy and collaboration were reflected in the individual engagement subscale by individuals feeling they had the opportunity to contribute their knowledge and expertise to major changes at the clinic. Similarly, a recent United Kingdom study published in 2 reports86,87 found that veterinary team engagement was reduced when employees were not given the autonomy to address client needs. Thus, veterinary practices should consider encouraging an environment of autonomy to increase staff members’ feelings of individual engagement.
In the present study, age was negatively associated with cynicism and positively associated with professional efficacy. This may be attributed to healthy worker bias because older employees may develop coping mechanisms to address stressors.83 Some studies14,84 have suggested that targeting interventions at students during their education or employees in early stages of their careers may reduce the incidence of burnout. For instance, Hatch and Winefield84 advised that providing communication skills training, teaching coping skills, and improving cognitive skills for young professionals may decrease depression, anxiety, stress, and burnout.
In the present study, employee group was a predictor of cynicism. Veterinary assistants and those in the “other” employment category had the lowest cynicism scores and were also most likely to be working part-time. In contrast, veterinary technicians had significantly higher cynicism scores than others on the veterinary team. This could explain why the annual turnover ratee for veterinary technicians in the United States is 35%, whereas the mean for all jobs is only 12%.88 Turnover rate is expressed as a percentage calculated by dividing the number of employees who have left employment by the total number of employees, and multiplying by 100. It usually refers to an annual turnover rate, although it can be calculated for different time periods. In contrast, the turnover rate for associate veterinarians in the same report was 20%, and for managers, 13%.89 Further studies to determine potential antecedents of cynicism in various employee groups in veterinary clinics are warranted, particularly in veterinary technicians.
The percentage of veterinary team members at high risk of burnout in the present study is of concern: 35.3% of veterinary team members were classified at high risk in at least 1 domain. Research with human health-care teams indicates that 15% to 45% of hospital nurses experience burnout.72 Burnout is also common in physicians, affecting an estimated 25% to 75% of this population.90–95 Several studies12,83,84 have examined burnout in veterinarians. A 1992 study reported 67% of female and 53% of male US veterinarians were considered at high risk of burnout by use of a self-diagnosis burnout scale96; other veterinary studies have found that burnout ranged from 15% to 40%.12,83,84 The present study found that all veterinary team members, not only veterinarians, were at risk of burnout and that elements relating to team effectiveness contributed to or detracted from an individual's level of burnout. The serious organizational and individual repercussions of burnout suggest a need for the veterinary profession to consider and address contributing factors. Individual practices can begin by evaluating the overall function of their veterinary team.
In the present study, a potential response bias may have been introduced by having clinics and team members choose whether or not they wished to participate. Thus, participants at the clinic level as well as the individual level may be more or less interested in team effectiveness than other veterinary teams, which could bias the results in either direction. Second, at the clinic level, several clinics did not want to participate because they felt their teams were in a stressful period. This may have skewed the results because job satisfaction may have been higher and burnout lower in the study clinics. Third, although participants were assured their responses were confidential, some may still have hesitated to provide negative information about their clinic. A fourth limitation was the use of cross-sectional data. Causal relationships, between team effectiveness and outcomes of job satisfaction and burnout thus could not be assessed. The use of longitudinal studies would more fully explore these relationships and such studies could assess the effect of various interventions. Finally, because the study was performed with companion animal hospitals from a specific geographic area, it may not be possible to extrapolate the results to other types of veterinary practice or to practices in other geographic areas.
The findings of the present study indicated that team effectiveness had a strong effect on psychosocial health and work contentment in veterinary practices. Overall job satisfaction was generally good in the study population; however, the number of individuals at high risk of exhaustion and cynicism is of concern. In addition to the effect these outcomes can have on an individual and the team in which they work, research in human medicine indicates that burnout and job dissatisfaction can also have a negative effect on the quality of care patients receive and ultimately patient outcomes90,91,95,97; to date, similar studies have not been done in veterinary medicine. There is a need for further research to determine whether clinic level and individual factors can be modified to improve team effectiveness, which in turn should positively influence job satisfaction and reduce the risk of burnout in veterinary practice. It may also positively improve quality of care for veterinary patients. Knowing what contributes to or detracts from an effective veterinary team will assist in developing strategies to improve veterinary team function and in turn the health and well-being of those working in the veterinary profession.
LimeSurvey, version 1.92, Carsten Schmitz, Hamburg, Germany. Available at: www.limesurvey.org. Accessed Dec 17, 2010.
Moore IC. Exploring and evaluating veterinary team effectiveness in companion animal practice. MSc thesis, Department of Population Medicine, University of Guelph, Guelph, ON, Canada, 2013.
PASW SPSS 19.0, SPSS Inc, Chicago, Ill.
SAS, version 9.2, SAS Institute Inc, Cary, NC.
Welsch BB. Gender differences in job stress, burnout and job satisfaction as mediated by coping style of veterinarians in private equine practice. PhD dissertation, University of Florida, Gainsville, Fla, 2005.
Fairnie HM. Occupational injury, disease and stress in the veterinary profession. PhD thesis, Curtin University of Technology, Bentley, WA, Australia, 2005.
ABBREVIATIONS
| MBI-GS | Maslach Burnout Inventory-General Survey |
| RVT | Registered veterinary technician |
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Appendix
Team effectiveness instrument items in each of 4 subscales in a study of team effectiveness in companion animal veterinary practice.
Subscale 1 (9 items): Coordinated team environment
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Subscale 2 (12 items): Toxic environment
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Subscale 3 (11 items): Team engagement
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Subscale 4 (9 items): Individual engagement
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Indicates reverse coded item.
