Depersonalization

Depression was evaluated using the PHQ-9, which is a selfreport scale of depressive symptoms. The PHQ-9 consists of nine items reflecting almost exactly the nine diagnostic criteria for MDD in the DSM-IV. The nine items in the PHQ-9 ask about the frequency of depressive symptoms over the previous two weeks, and each is scored as 0 points for “Not at all,” 1 point for “Several days,” 2 points for “More than half the days,” or 3 points for “Nearly every day.” Thus, the highest possible total score is 27 points. The Korean PHQ-9 was standardized in the general elderly population by Han et al. [19 (link)] and in a primary care setting by Choi et al. [20 ]
Item 9 in the PHQ-9 asks, “Over the last 2 weeks how often have you been bothered by this problem: thoughts that you would be better off dead or hurting yourself in some way?” The PHQ-8, which has been used in numerous previous studies [11 (link),13 (link),21 (link)], excludes Item 9 from the PHQ-9 but retains the other eight items unchanged.
The extent of depressive symptoms was evaluated by a clinical psychologist using the HAMD, which is a clinician-administered scale of depressive symptoms [22 (link)]. It was originally developed for measuring severity in patients already diagnosed with MDD, but its uses have since expanded, including in research to evaluate the effects of treatment, and it is currently considered the standard for observer rating scales for depression. The original scale consisted of 21 items, but the four items regarding diurnal variation, depersonalization-derealization, paranoid symptoms, and obsessive-compulsive symptoms, respectively, are not only rare in patients with depression but were also found to reduce internal consistency. Therefore, the 17-item version, which omits these items, is currently the most widely used version [23 (link)]. In this study, we used the Korean adaptation of the 17-item version of the HAMD, standardized by Yi et al. [24 ]

To assess changes in well-being, we used four validated scales (EE, depression symptoms, subjective happiness and work–life balance) at each assessment point (see table 1 for Cronbach’s alphas). These four metrics were selected a priori and they were the only metrics administered. Demographic questions were included at baseline and open-ended items were also included at the 1-month follow-up. In the 1-month assessment, we also asked for evaluation feedback on a 1–5 scale, (‘strongly agree’ to ‘strongly disagree’) through questions such as, ‘I would recommend the 3 Good Things exercise to a friend,’ ‘I have encouraged others to try 3 Good Things,’ ‘I would like to participate in 3 Good Things again next year,’ and with an open-ended comments text box.
In addition to using scale scores to examine change following 3GT, we also report the percentage of participants whose scores fell below well-being thresholds established by prior literature.
Burn-out EE Subscale: The Maslach Burnout Inventory, which is the gold-standard tool in the field of burn-out, has been used extensively with HCWs. A meta-analysis has revealed that of the three subscales (EE, depersonalisation and personal accomplishment), EE consistently produces the largest and most consistent coefficient alpha estimates, while depersonalisation and personal accomplishment were both lower and less consistent than EE.31 (link) In addition to being more psychometrically robust, EE can be used to discriminate between burned out and non-burned out outpatients suffering from work-related neurasthenia (according to criteria outlined in the International Statistical Classification of Diseases and Related Health Problems - 10th Revision).32 (link) We used a 5-item derivative33 (link) of the original 9-item EE scale.32 (link) Example items include ‘I feel frustrated by my job’ and ‘Events at work affect my life in an emotionally unhealthy way’. Participants respond using a 5-point Likert scale (1=disagree strongly; 5=agree strongly). Each participant’s mean of the five items was converted to a 0–100 point scale, with higher scores representative of more severe EE. A score of 50 or higher indicates that the respondent is not disagreeing with the EE statements, and is the first threshold for per cent concerning because it indicates at least mild EE.34 (link) These ‘per cent concerning’ thresholds should not be considered clinically diagnostic, but rather identify those whose scores represent more of a struggle on a given metric. The per cent concerning threshold can be grasped quickly, providing an anchor for interpretation and offering a way of communicating something about the distribution of the data within a single number. For EE, internal consistency in the current study was good (Cronbach’s alpha=0.85)
Depressive symptoms: The Center for Epidemiological Studies Depression Scale-10-item version is a psychometrically sound tool for screening respondents for clinical depression.35 (link) All items are prefaced with, ‘during the past week, how often did this occur’ and includes items such as ‘I could not ‘get going’ and ‘my sleep was restless’. Responses are answered on a 4-point scale (0=rarely or none; 3=all of the time). Each participant’s responses are summed together to achieve a 0–30 point scale. A score of 10 or higher is considered a positive screen, and was the threshold we used to group participants by depressive symptom severity as ‘per cent concerning’.36 (link) Internal consistency in the current study was good (Cronbach’s alpha=0.85)
Subjective Happiness: Lyubomirsky and Lepper’s Subjective Happiness Scale (SHS) is a valid, psychometrically sound and internationally used scale of global happiness.37 38 (link) Example items include ‘In general I consider myself (1=not a very happy person to 7=a very happy person)’ and ‘Compared to most of my peers I consider myself (1=less happy to 7=more happy)’. All four items of the SHS are answered using a 7-point scale, and each participant’s responses were averaged, with higher scores representative of higher subjective happiness. Benchmarking data in diverse populations demonstrate mean SHS scores consistently flank a value of 5 on therefore a threshold of below 5 was used to group participants as the ‘per cent concerning’.38 (link) Internal consistency in the current study was very good (Cronbach’s alpha=0.86).
Work–life balance: Work–life balance items are from the work–life climate scale, which has been shown to have good psychometrics when used on HCWs,39 Work–life balance items elicit behavioural work–life infractions by asking: During the past week, how often did this occur? Followed by phrases such as: Skipped a meal, arrived home late from work or slept less than 5 hours in a night. The response scale for the work–life climate items ranged from: rarely or none of the time (less than 1 day); some or a little of the time (1–2 days); occasionally or a moderate amount of time (3–4 days); all of the time (5–7 days) and not applicable. Work–life climate scale scores were computed by taking the mean of the items. Previous research has used 2 or fewer days as ‘per cent positive,’ referring to scores greater than 2 as work–life imbalance. We use the imbalance designation (per cent of respondents with a mean over 2) as the ‘per cent concerning’.39 Internal consistency in the current study was good (Cronbach’s alpha=0.81).

Data regarding burnout were collected using an English version of the original 22-item, 3-sub-scale Maslach Burnout Inventory (MBI) questionnaire.
The subscales are (a) emotional exhaustion (EE), measured using 9 items to address the feeling of being emotionally drained, (b) depersonalization (DP), measured using 5 items to address the tendency to view the others as objects rather than as feeling persons, and (c) personal achievement (PA), measured using 8 items to address the degree to which a person perceives doing well on worthwhile tasks.[10 ] A 7-point scoring (0 = never; 6 = every day) was used by the participants to answer each item in the questionnaire. The calculated scores for each domain were categorized as mild, moderate, and sever impairment using the following cut-off values: For EE, mild: 0–16, moderate: 17–26, and severe: ≥27. For DP, mild: 0–6, moderate: 7–12, and severe: ≥13. For low PA, mild: ≥39, moderate: 32–38, and severe: 0–31.
MBI has high reliability and validity, with reliability coefficient of 0.89, 0.74, 0,77 for EE, DP, and PA, respectively.[10 ] Moreover, the reported Cronbach's alpha of the questionnaire is 0.9, 0.76, 0.76 for EE, DP, and PA, respectively.[9 (link)]
A sociodemographic questionnaire was also used to determine potential risk factors associated with burnout. Demographic data collected included age, gender, current designation, and nationality. The social data collected included marital status, number of children, impact of critical care specialty on family life, and satisfaction with salary.
The questionnaire was distributed by the investigators in paper form and in English language only, with the estimated time for questionnaire completion being 6–8 min. The aim of the study and the questionnaire were explained to the participants. In addition, they were informed that participation is voluntary, and were assured of anonymity and data confidentiality. Verbal informed consent was obtained from all participants, and no incentives were offered for participation in the study. The study participants answered the questionnaire independently, and the questionnaire was distributed during the break time of the working shift and re-collected by the investigators at the same shift. Only responses with at least 80% of the questionnaire being completed were considered for the final analysis.

The JSPE-HP was specifically developed to measure empathy in health professionals. This questionnaire is a 20-item instrument that has been widely used and validated among health professionals. It uses a 7-point Likert scale that is anchored by ‘strongly disagree’ and ‘strongly agree’ (range: 20–140).32 33 (link) In this study, the Japanese version of the JSPE was used.34 (link) All the participants completed the JSPE-HP, and the scale was administered before and after their training.
To measure burnout, the MBI-HSS for medical personnel, which is the global standard for healthcare professionals, was used.35 (link) This validated instrument includes 22 items, each of which is scored from 0 to 6 based on the self-reported frequency of the feeling addressed by each item. In addition to providing an overall measure of burnout, the instrument enables the measurement of the three distinct domains of burnout using summated ratings. The emotional exhaustion domain consists of nine items, with a total score range of 0–54. The depersonalisation domain consists of five items, with a total score range of 0–30. The personal accomplishment domain consists of eight items, with a total score range of 0–48. Specifically, we defined the presence of physician burnout as any score over 26 on the emotional exhaustion subscale, any score over 9 on the depersonalisation subscale or any score under 34 on the personal accomplishment subscale.36 (link) All the participants completed the MBI-HSS before and after the training.
These analyses were performed using R statistical software (V.4.0.2). The data characteristics of the physicians were analysed using descriptive statistics. Analytical statistics were employed to address the outcomes. The normality of all the data was verified by the Shapiro-Wilk test. The Wilcoxon signed-rank test was also used to test for significant differences between the pretraining and post-training JSPE-HP and MBI-HSS scores. Statistical significance was defined as p<0.05.