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Background Many chronic diseases increase the risk of depressive symptoms, but few studies have examined whether these diseases also affect the composition of symptoms a person is likely to experience. As the risk and progression of depression may vary between chronic diseases, we used network analysis to examine how depression symptoms are connected before and after the diagnosis of diabetes, heart disease, stroke, and cancer. Methods Participants (N = 7779) were from the longitudinal survey of the Health and Retirement Study. Participants were eligible if they had information on depression symptoms two and/or four years before and after the diagnosis of either diabetes, heart disease, cancer or stroke. We formed a control group with no chronic disease that was matched on age, sex and ethnic background to those with a disease. We constructed depression symptom networks and compared the overall connectivity of those networks, and depression symptom sum scores, for before and after the diagnosis of each disease. Results Depression symptom sum scores increased with the diagnosis of each disease. The connectivity of depression symptoms remained unchanged for all the diseases, except for stroke, for which the connectivity decreased with the diagnosis. Limitations Comorbidity with other chronic diseases was not controlled for as we focused on the onset of specific diseases. Conclusions Our results suggest that although the mean level of depression symptoms increases after the diagnosis of chronic disease, with most chronic diseases, these changes are not reflected in the network structure of depression symptoms.

Background Identifying the most significant risk factors for physician burnout can help to define the priority areas for burnout prevention. However, not much is known about the relative importance of these risk factors. Aims This study was aimed to examine the relative importance of multiple work-related psychosocial factors in predicting burnout dimensions among physicians. Methods In a cross-sectional sample of 2423 Finnish physicians, dominance analysis was used to estimate the proportionate contribution of psychosocial factors to emotional exhaustion, depersonalization and reduced personal accomplishment. The psychosocial factors included job demands (time pressure, patient-related stress, lack of support, stress related to information systems, work–family conflict) and job resources (job control, team climate, organizational justice). Results Together, psychosocial factors explained 50% of the variance in emotional exhaustion, 24% in depersonalization and 11% in reduced professional efficacy. Time pressure was the most important predictor of emotional exhaustion (change in total variance explained ΔR2 = 45%), and patient-related stress was the most important predictor of both depersonalization (ΔR2 = 52%) and reduced professional accomplishment (ΔR2 = 23%). Stress related to information systems was the least important predictor of the burnout dimensions (ΔR2 = 1–2%). Conclusions Psychosocial factors in physicians’ work are differently associated with the dimensions of burnout. Among the factors, the most significant correlates of burnout are job demands in the form of time pressure and patient-related stress.

Online symptom checkers (SCs) are eHealth solutions that offer healthcare organizations the possibility to empower their patients to independently assess their symptoms. The successful implementation of eHealth solutions, such as SCs, requires a supportive organizational culture and leadership. However, there is limited knowledge about the factors associated with leaders’ support for the use of SCs. The aim of the study was to identify the factors associated to primary care leaders’ support for SCs in triage and their experiences of the benefits and challenges related to the use of SCs. An online survey was used to collect data from 84 Finnish primary care leaders. The data were analyzed using statistical analysis methods and content analysis. Vision clarity, perceiving efficiency improvements, and considering the service to be beneficial for patients were associated with leaders’ support for the service (β ranging from 0.41 to 0.44, p < 0.001). Leaders’ support for the service was also associated with how well the leaders provided information about the service to their subordinates (β =0.22, p < 0.048). SCs present slightly more challenges than benefits regarding health professionals’ work. The developers of SCs should focus more on features that decrease health professionals’ workload as well as how the solution can benefit patients.

Cross-cultural competence is an essential component of the nursing profession, but little is known about the specific psychosocial work characteristics that potentially promote or hinder such competence. In the present study, psychosocial work characteristics were based on Karasek's Job Demand-Control Model. The researchers examined whether Karasek's psychosocial work characteristics, such as high-strain jobs, high-strain isolated jobs, active jobs, and active collective jobs, are associated with cross-cultural competence (empathy, skills, positive attitudes, and motivation), and whether there are differences between native and foreign-born registered nurses (RN) in these potential associations. A random sample of 744 native RNs (91.0% women) and a total sample (n = 212) of foreign-born RNs (94.3% women) working in Finland were used. Data were collected using a questionnaire and analyzed with a series of multiple linear regression analyses. High-strain and high-strain isolated jobs were negatively associated with all four dimensions of cross-cultural competence. Active collective jobs, but not active jobs, were positively associated with cross-cultural skills. There were no differences between native and migrant nurses in these associations. The psychosocial work environment is associated with cross-cultural competence in both native and migrant nurses. Improvements in psychosocial working conditions, especially minimizing negative factors in the work environment, such as high-strain and high-strain isolated jobs, may need to be considered as a part of the efforts aimed to enhance cross-cultural competence among nursing personnel.

Background Mobile devices such as tablets and smartphones are increasingly being used in health care in many developed countries. Nurses form the largest group in health care that uses electronic health records (EHRs) and their mobile versions. Mobile devices are suggested to promote nurses’ workflow, constant updating of patient information, and improve the communication within the health care team. However, little is known about their effect on nurses’ well-being. Objective This study aimed to examine the association between using a mobile version of the EHR and nurses’ perceived time pressure, stress related to information systems, and self-rated stress. Moreover, we examined whether mobile device use modifies the associations of EHR usability (ease of use and technical quality), experience in using EHRs, and number of systems in daily use with these well-being indicators. Methods This was a cross-sectional population-based survey study among 3610 Finnish registered nurses gathered in 2020. The aforesaid associations were examined using analyses of covariance and logistic regression adjusted for age, gender, and employment sector (hospital, primary care, social service, and other). Results Nurses who used the mobile version of their EHR had higher levels of time pressure (F1,3537=14.96, P Conclusions According to our results, it seems that at present mobile device use is not beneficial for the nurses’ well-being. In addition, mobile device use seems to intensify the negative effects of usability issues related to EHRs. In particular, inexperienced users of EHRs seem to be at a disadvantage when using mobile devices. Thus, we suggest that EHRs and their mobile versions should be improved such that they would be easier to use and would better support the nurses’ workflow (eg, improvements to problems related to small display, user interface, and data entry). Moreover, additional training on EHRs, their mobile versions, and workflow related to these should be provided to nurses.

Psykiatrisia avohoidon palveluita on digitalisoitu aktiivisesti jo ennen koronavirusepidemiaa, mutta varsinkin epidemian käynnistymisen jälkeen etäasioinnin merkitys on kasvanut. Tämän poikkileikkaustutkimuksen tavoitteena oli selvittää, kuinka koronaepidemia on vaikuttanut psykiatristen avohoitokäyntien toteutusmuotoon ja kuvailla psykiatristen erikoissairaanhoidon palveluiden johtajien kokemuksia etäasioimisesta. Tutkimuksen tuloksia voidaan hyödyntää psykiatristen avohoitopalveluiden arvioinnissa sekä kehittämisessä sekä jatkotutkimuksessa. Kyselyaineisto kerättiin osana COVID-19 tilannekuvaseurantaa sähköisellä kyselylomakkeella koronaepidemian käynnistymisen jälkeen toukokuussa 2020. Kyselyssä oli sekä strukturoituja että avoimia kysymyksiä. Kyselyyn vastasi 39 aikuispsykiatrian, nuorisopsykiatrian ja lasten psykiatrian toimialojen esimiestä ja johtajaa 19 eri sairaanhoitopiiristä. Kvantitatiiviset kysymykset avohoitokäyntien toteutusmuotojen määrästä raportoitiin prosenttiosuuksina ja avointen kysymysten vastaukset analysointiin induktiivisella sisällönanalyysillä. Tulosten perusteella etäasioinnin suhteellinen osuus kaikista asiointitavoista kasvoi voimakkaasti koronaepidemian käynnistymisen jälkeen. Psykiatrisista avohoitokäynneistä toteutettiin puhelimitse tai etäyhteydellä tammikuussa 9% ja toukokuussa 48% (39 prosenttiyksikön kasvu). Etäasiointia haastoivat välineiden riittämättömyys ja toimimattomat ohjelmat, asiakkaiden puuttuvat laitteet, yhteydet ja tilat, etäasioinnin soveltumattomuus kaikkeen toimintaan, ammattihenkilöiden ja asiakkaiden negatiivinen asennoituminen, riittämätön osaaminen etäasioinnin käyttöön ja organisatoriset ongelmat. Etäasiointia edistivät asiakkaiden ja ammattihenkilöiden myönteinen asenne ja ilmapiiri, koronaepidemian aiheuttama tarve etäasioinnille, etäasioinnin soveltuvuus ja tuttuus psykiatrisissa avohoitopalveluissa, asiakkaiden aikaisempi tuntemus, pitkät välimatkat, toimivat etäverkostot ja ajansäästö, toimiva tekniikka, ohjelmistot ja välineet sekä riittävä tuki. Etäasiointi on mahdollistanut epidemiatilanteessa psykiatristen avohoitopalveluiden tarjoamisen niille asiakkaille, joille etäasiointi soveltuu ja jotka kykenevät etäasiointiin. Etäasioinnin merkitys koronaepidemian aikana on ollut tärkeä, mutta etäasioinnin lisäksi on tärkeää innovoida ratkaisuja, kuinka psykiatrisia avohoitopalveluita voitaisiin toteuttaa niille asiakkaille, joille etäasiointi ei syystä tai toisesta sovellu., Psychiatric outpatient care has been actively digitalized even before the COVID-19 outbreak. However, COVID-19 has increased the adoption of digital and remote health services. The aim of this cross-sectional study was to examine whether COVID-19 has impacted on the form of psychiatric outpatient services and describe psychiatric healthcare leaders’ experiences of digital and remote services. The results of this study can be used to evaluate and develop psychiatric outpatient services and to facilitate further research. The data was collected through an online survey after the COVID-19 outbreak in May 2020. The questionnaire contained structured and open-ended questions. A total of 39 adult psychiatric, youth psychiatric and pediatric psychiatric service leaders answered the survey from 19 different health care districts. Quantitative questions about the forms of psychiatric outpatient services were reported using percentages, whereas open-ended questions were analyzed using inductive content analysis. The results showed that the relative amount of digital and remote services increased after the COVID-19 outbreak. Of the psychiatric outpatient visits, 9 % were conducted using phone or remote access in January and 48 % in May (rose by 39 percentage units). The challenges for using remote services were related to the lack of IT equipment and inoperative programs, customers’ lack of devices, connections and room, remote services’ unsuitability for all operations, negative attitude of professionals and customers, insufficient IT knowledge, and organizational problems. The supporters of remote service usage were related to customers’ and professionals’ positive attitude and atmosphere, the necessity for the remote services caused by the COVID-19, suitability and familiarity of remote services in psychiatry, familiarity of the customers, long distances, well-functioning remote networks and time savings, functional technology, programs and devices, and sufficient support. Digital and remote services have enabled psychiatric outpatient services to those patients for whom they are suitable and who can use them. The importance of digital and remote services in the era of COVID-19 epidemic has been important, but it is important to innovate other solutions to those patients who are not able to use digital or remote services for any reason.

Introduction The use of eHealth is rapidly -->increasing; however, many healthcare professionals have insufficient eHealth competency. Consequently, interventions addressing eHealth competency might be useful in fostering the effective use of eHealth. Objective Our systematic review aimed to identify and evaluate the behavior change techniques applied in interventions to promote healthcare professionals’ eHealth competency. Methods We conducted a systematic literature review following the Joanna Briggs Institute’s Manual for Evidence Synthesis. Published quantitative studies were identified through screening PubMed, Embase, and CINAHL. Two reviewers independently performed full-text and quality assessment. Eligible interventions were targeted to any healthcare professional and aimed at promoting eHealth capability or motivation. We synthesized the interventions narratively using the Behavior Change Technique Taxonomy v1 and the COM-B model. Results This review included 32 studies reporting 34 heterogeneous interventions that incorporated 29 different behavior change techniques. The interventions were most likely to improve the capability to use eHealth and less likely to enhance motivation toward using eHealth. The promising techniques to promote both capability and motivation were action planning and participatory approach. Information about colleagues’ approval, emotional social support, monitoring emotions, restructuring or adding objects to the environment, and credible source are techniques worth further investigation. Conclusions We found that interventions tended to focus on promoting capability, although motivation would be as crucial for competent eHealth performance. Our findings indicated that empathy, encouragement, and user-centered changes in the work environment could improve eHealth competency as a whole. Evidence-based techniques should be favored in the development of interventions, and further intervention research should focus on nurses and multifaceted competency required for using different eHealth systems and devices.

Background Electronic health records (EHRs) are expected to provide many clinical and organizational benefits. Simultaneously, the end users may face unintended consequences, such as stress and increased cognitive workload, due to poor EHR usability. However, whether the effects of usability depend on end user characteristics, such as career stage or age, remains poorly understood. Objective The objective of this study was to examine the associations of EHR usability and user age with stress related to information systems and cognitive failures among registered nurses. Methods A cross-sectional survey design was employed in Finland in 2017. A total of 3383 registered nurses responded to the nationwide electronic survey. Multiple linear regression was used to examine the associations of EHR usability (eg, how easily information can be found and a patient’s care can be documented) and user age with stress related to information systems and cognitive failures. Interaction effects of EHR usability and age were also tested. Models were adjusted for gender and employment sector. Results Poor EHR usability was associated with higher levels of stress related to information systems (β=.38; P Conclusions Information system stress due to poor EHR usability afflicts younger and older nurses alike. However, younger nurses starting their careers may be more cognitively burdened if they find EHR systems difficult to use compared to older nurses. Adequate support in using the EHRs may be particularly important to young registered nurses, who have a lot to learn and adopt in their early years of practice.

Background Health information systems (HIS) have been widely adopted in nursing to increase the efficiency and safety of patient care. Previous studies have shown that low HIS quality is a barrier to obtaining such benefits from HIS use. The association between HIS quality and HIS benefits has not, however, been studied taking into account the characteristics of the work environment, such as job strain. This study examined the joint associations of HIS quality and job strain with the perceived patient care-related benefits of HIS use in nursing. Methods Cross-sectional survey data of 2707 Finnish registered nurses were used to examine the associations of two indicators of HIS quality (ease of use and technical quality) and job strain with the benefits of HIS use. Missing data were addressed with multiple imputation and linear regression was used to examine the associations. All analyses were adjusted for age, gender, and employment sector. Results Together with the covariates, HIS quality explained 14% to 20% of the variance in the perceived benefits of HIS use. The additional variance explained by job strain was only 1%. HIS quality in terms of ease of use interacted with job strain in predicting HIS benefits. Nurses who found HIS difficult to use and experienced high job strain reported the lowest benefits from HIS use. By contrast, nurses who found HIS easy to use considered HIS beneficial for improving patient care even if they experienced high job strain. Conclusions The results suggest that healthcare organizations should focus on ensuring good HIS quality to improve patient care through HIS use in nursing. Exposure to job strain may intensify the association between low HIS quality and lower patient care-related benefits from HIS use. HIS with good quality seem to improve patient care even in a high-strain work environment. Key messages Nurses who work with low-quality health information systems and experience job strain perceive the systems least beneficial for improving patient care. High-quality information systems, by contrast, are perceived to improve patient care even in a high-strain work environment.

Objectives Smoking rates have declined with a slower pace among those with psychological distress compared to those without. We examined whether other health behaviors (heavy alcohol consumption, physical inactivity, short sleep duration) showed similar trends associated with sychological distress. We also examined differences by age and birth cohort. Methods Data were from the annually repeated cross-sectional U.S. National Health Interview Surveys (NHIS) of 1997-2016 (total n = 603,518). Psychological distress was assessed with the 6-item Kessler Psychological Distress Scale (K6). Results Psychological distress became more strongly associated with smoking (OR 1.09 per 10 years; 95% CI 1.07, 1.12), physical inactivity (OR 1.08; 1.05, 1.11), and short sleep (OR 1.12; 1.06, 1.18), but less strongly associated with heavy alcohol consumption (OR 0.93; 0.89, 0.98). The associations of smoking and alcohol consumption attenuated with age, whereas the association with physical inactivity strengthened with age. Compared to older birth cohorts, smoking became more strongly associated with psychological distress among younger birth cohorts up to those born in the 1980s. Conclusions The strength of associations between psychological distress and health behaviors may vary by time period, age, and birth cohort.

Background Nursing informatics competences (ie. knowledge and skills in electronic and structured documentation) have become a necessary prerequisite for nurses to carry out their professional roles. Therefore, there is a global need to integrate nursing informatics into nursing curricula. In Finland, the requirements to increase nursing informatics education were noted in eHealth strategies in 2015. However, it is not known whether these educational initiatives have succeeded in increasing nursing informatics competences of recent nursing graduates. Objectives To examine whether nurses who graduated after the Finnish educational initiatives have higher nursing informatics competences than nurses who graduated before the initiatives. Additionally, the associations of age, gender, work setting and geographical area with the nurses' informatics competences were examined. Design Cross-sectional study. Settings The study was carried out between October–December 2018 in Finland. Participants Registered nurses who graduated before (n = 931) and after (n = 712) the 2015 educational initiatives. Methods Nursing informatics competences were measured by four items: (1) terminology-based documentation, (2) patient-related digital work, (3) general IT competency and (4) electronic documentation according to structured national headings. The associations of the year of the graduation and demographic background variables with nurses' overall nursing informatics competence and also separately with four specific competence items were examined with analysis of covariance. Results Nurses' graduation year was associated with their overall nursing informatics competence and the specific competence related to terminology-based documentation. Nurses who had graduated after the initiatives had higher competence than nurses with earlier graduation years. Associations were also found between age and work setting with the nursing informatics competences. Younger nurses and nurses working in specialised healthcare and elderly care had the highest competence. Conclusions The national eHealth strategies with educational initiatives seem to have affected favorably on nursing informatics education in Finnish nursing programs and have potentially led to increased nursing informatics competences of recent nursing graduates. The results of this study highlight the importance of educational policies stating the directions and objectives of education programs.

Factors influencing the reporting of patient safety incidents that result from health information technology (HIT) failure are poorly understood. We examined whether organizational justice is associated with the non-reporting of HIT system-related safety incidents among registered nurses. Cross-sectional survey data were collected from nurses (N = 1399) who reported encountering a HIT system-related patient safety incident within the past 12 months. Selecting one or more reasons for not filing an incident report from a predefined list of potential reasons was used as an indicator for non-reporting. Logistic regression models were fit to predict the reason-specific likelihood of non-reporting with organizational justice. High organizational justice was associated with a reduced likelihood of non-reporting if non-reporting occurred because reporting was too hard or took too much time (OR = 0.81, 95% CI 0.67 to 0.96), because the reporting had no impact on the organization's processes (OR = 0.63, 95% CI 0.53 to 0.76), because the respondent was worried about the consequences (OR = 0.61, 95% CI 0.43 to 0.87), or because the respondent was not required to file a report (OR = 0.67, 95% CI 0.51 to 0.89). Justice was not associated with non-reporting if it occurred due to the lack of access to a reporting system, because no actual harm was caused to the patient, or some other, non-specified reason. The associations were robust to adjustment for several nurse and work characteristics. The results suggest that non-reporting of HIT system-related safety incidents is less common in a high-justice work environment. Fair treatment of nurses may encourage their reporting of safety incidents.

Objectives Taking precautions against COVID-19 is important among older adults who have a greater risk for severe illness if infected. We examined whether Big Five personality traits are associated with COVID-19 precautionary behaviors among older adults in Europe. Method We used data from the Survey of Health, Aging, and Retirement in Europe (N = 34 629). Personality was self-reported in 2017 using the BFI-10 inventory. COVID-19 precautionary behaviors – wearing a mask, limiting in-person contacts, keeping a distance to others, washing hands, and using a disinfectant – were assessed in the summer of 2020 through self-reports. Associations between personality and precautionary behaviors were examined with multilevel random-intercept logistic regression models. The models were adjusted for age, gender, and educational attainment. Results Personality traits were differentially associated with precautionary behaviors, with higher openness, conscientiousness, and neuroticism showing the most consistent associations. The pattern of associations between personality traits and precautionary behaviors varied depending on the specific behavior. The associations were relatively weak in comparison to those between sociodemographic factors and precautionary behaviors. Conclusions Among older adults, taking COVID-19 precautionary behaviors was most consistently related to higher openness, conscientiousness, and neuroticism, suggesting that precautionary behaviors may be motivated by multiple psychological differences.

Background Despite the documented importance of dispositional compassions for a range of health-related outcomes, its role in predicting health behaviors remains unclear. Purpose This study examined the associations between dispositional compassion and three domains of health behavior, including physical activity, alcohol use, and smoking. Methods The participants (N = 1,279–1,913) were from the Finnish population-based Young Finns study. We collected self-reports of compassion in 1997 and 2011 and health behaviors in 2001, 2007, and 2011. In addition, an objective pedometer measure of physical activity was collected in 2011. Linear and logistic regression models were fitted to estimate the cross-sectional and longitudinal associations between compassion and the health behavior outcomes. Results In a cross-sectional analysis, compassion was associated with having never smoked and a reduced likelihood of at-risk alcohol use and binge drinking. There was no robust association between compassion and physical activity. In longitudinal analyses over a 14-year period, the associations remained for at-risk alcohol use and binge drinking. Conclusions Dispositional compassion may have a protective effect against unhealthy behaviors, especially excessive alcohol consumption. peerReviewed

Background The popularity of web-based patient-professional communication over patient portals is constantly increasing. Good patient-professional communication is a prerequisite for high-quality care and patient centeredness. Understanding health care professionals’ experiences of web-based patient-professional communication is important as they play a key role in engaging patients to use portals. More information is needed on how patient-professional communication could be supported by patient portals in health care. Objective This systematic review of qualitative studies aims to identify how health care professionals experience web-based patient-professional communication over the patient portals. Methods Abstract and full-text reviews were conducted by 2 reviewers independently. A total of 4 databases were used for the study: CINAHL (EBSCO), ProQuest (ABI/INFORM), Scopus, and PubMed. The inclusion criteria for the reviewed studies were as follows: the examination of health care professionals’ experiences, reciprocal communication between patients and health care professionals, peer-reviewed scientific articles, and studies published between 2010 and 2019. The Joanna Briggs Institute’s quality assessment criteria were used in the review process. A total of 13 included studies were analyzed using a thematic synthesis, which was conducted by 3 reviewers. Results A total of 6 analytical themes concerning health care professionals’ experiences of web-based patient-professional communication were identified. The themes were related to health care professionals’ work, change in communication over patient portals, patients’ use of patient portals, the suitability of patient portals for communication, the convenience of patient portals for communication, and change in roles. Conclusions Health care professionals’ experiences contain both positive and negative insights into web-based patient-professional communication over patient portals. Most commonly, the positive experiences seem to be related to the patients and patient outcomes, such as having better patient engagement. Health care professionals also have negative experiences, for example, web-based patient-professional communication sometimes has deficiencies and has a negative impact on their workload. These negative experiences may be explained by the poor functionality of the patient portals and insufficient training and resources. To reduce health care professionals’ negative experiences of web-based patient-professional communication, their experiences should be taken into account by policy makers, health care organizations, and information technology enterprises when developing patient portals. In addition, more training regarding web-based patient-professional communication and patient portals should be provided to health care professionals.

Objectives This study aimed to examine the longitudinal association of workplace violence with disturbed sleep and the moderating role of organisational justice (ie, the extent to which employees are treated with fairness) in teaching. Methods We identified 4988 teachers participating in the Finnish Public Sector study who reported encountering violence at work. Disturbed sleep was measured in three waves with 2-year intervals: the wave preceding exposure to violence, the wave of exposure and the wave following the exposure. Data on procedural and interactional justice were obtained from the wave of exposure to violence. The associations were examined using repeated measures log-binomial regression analysis with the generalised estimating equations method, adjusting for gender and age. Results Exposure to violence was associated with an increase in disturbed sleep (RR 1.32 (95% CI 1.15 to 1.52)) that also persisted after the exposure (RR 1.26 (95% CI 1.07 to 1.48)). The increase was higher among teachers perceiving the managerial practices as relatively unfair (RR 1.46 (95% CI 1.01 to 2.09) and RR 1.59 (95% CI 1.04 to 2.42) for interactional and procedural justice, respectively). By contrast, working in high-justice conditions seemed to protect teachers from the negative effect of violence on sleep. Conclusion Our findings show an increase in sleep disturbances due to exposure to workplace violence in teaching. However, the extent to which teachers are treated with justice moderates this association. Although preventive measures for violence should be prioritised, resources aimed at promoting justice at schools can mitigate sleep problems associated with workplace violence.

BACKGROUND: Both work stress and poor recovery have been shown to contribute to the development of burnout. However, the role of recovery as a mediating mechanism that links work stress to burnout has not been sufficiently addressed in research. AIMS: To examine recovery as a mediator in the relationship between work stress and burnout among teachers. METHODS: A cross-sectional study of Finnish primary school teachers, in whom burnout was measured with the Maslach Burnout Inventory-General Survey and work stress was conceptualized using the effort-reward imbalance (ERI) model. Recovery was measured with the Recovery Experience Questionnaire and the Jenkins Sleep Problems Scale. Multiple linear regression analyses and bootstrap mediation analyses adjusted for age, gender and total working hours were performed. RESULTS: Among the 76 study subjects, high ERI was associated with burnout and its dimensions of exhaustion, cynicism and reduced professional efficacy. Poor recovery experiences, in terms of low relaxation during leisure time, partially mediated the relationship between ERI and reduced professional efficacy. Sleep problems, in the form of non-restorative sleep, partially mediated the relationship between ERI and both burnout and exhaustion. CONCLUSIONS: Supporting a balance between effort and reward at work may enhance leisure time recovery and improve sleep quality, as well as help to reduce burnout rates.© The Author 2016. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: [email protected]/* */ Language: en