Developing an Intervention Program Based on a Cohort of Sonographers’ Occupational Burnout Experience and Mitigating Associated Factors to Improve Worker Well-Being

Participant Interviews

The interview questions were created by the researcher, a registered sonographer with years of experience in private and hospital settings, who was also a trained mental health counselor from New York University. Following Morrow’s ¹⁸ conceptual foundation of qualitative research in counseling psychology, the semistructured interview was designed to explore the lived experience of sonographers’ occupational burnout and used language as a tool to capture the depths, nuances, and the insights of sonographers regarding potential solutions. It also identified some protective factors that could be used when designing program interventions or preventions. The researcher conducted the interviews with an attitude of warmth and empathy. Summarizing was used as a technique to reflect the main points and let the participant correct and clarify, if the summary felt inaccurate.

The qualitative data, gathered from semistructured interview, was inductively analyzed using a well-established six-stage approach. ¹⁹ The six-stage process included: becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, define themes, and write-up. ¹⁹ An analytic memo was written after each interview. Participants were involved in reviewing the qualitative data to get feedback about the accuracy of the researchers’ interpretation and findings. Both data sets were analyzed separately using descriptive statistics for quantitative data and thematic analysis for qualitative data. Findings were then integrated by comparing themes from qualitative data with patterns identified in the quantitative data, allowing for a richer understanding of sonographers’ occupational burnout and development of a curriculum, tailored to their needs.

Participant Interviews

Eight sonographers responded to the initial recruiting e-mail expressing their interest in participating in the interview portion of the study. From these participants, three were male sonographers and five were female sonographers. Based on their responses, the data were coded. A sample of thematic analysis coding is provided in Table 5. A summary of the qualitative themes that emerged through the thematic analysis and subcategories are provided.

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Table 5.

A Sample of the Coding Applied to a Participant’s Interviews, Using Thematic Analysis.

Quote	Codes	Categories	Themes
That’s a lot to be done in such little time. Now they can ask questions. You know, you can’t show them the screen if you want to show them like a little bit of the baby, or you know, it’s just it just makes it hard. There’s less human interaction.	Little time Hard Less human interaction	-Limited time of scanning does not allow for patient interactions. -Pressure to do a lot in little time -Not being able to share the screen with patients	Source of burnout
And it’s a lot it causes like a physical burnout, your body. your muscles, your arms, your neck, or whatever. And then it’s just like that stress of keeping up on time. like exhaustion, you know, like, physically, yeah, physical exhaustion. Mentally, also, because you know, sometimes you get emotionally attached to patients, especially in a hospital setting. People that are in patients you see them more often.	-Physical burnout, arms, and neck -Physical and mental exhaustion -Emotional attachment to patients especially in a hospital setting	-Physical and mental exhaustion -Emotional attachment to patients	Manifestation of burnout Source of burnout
It’s harder when you’re actually telling them. Then knowing and letting them walk away, Eventually, you’re just like, all right. Well, you forget about it. But when they react in front of you it’s it stays with you	-Harder -Forget about it -React in front of you	-Patient reactions (encounter) to bad news	Source of burnout
-Yeah, yeah, you’re part of a team. And you know, yeah -like, yeah, like detectives.	-Team -Detectives	-Being part of a team -The investigative part of the profession	Protective factors
If we can agree on what true emergencies are, what your stats are. That would be great. And if we can agree on what ultrasound is capable of, it’s a great tool. But there are some limitations.	Emergency Limitations	-Having clear guidelines regarding what STAT constitutes -Educate the whole team about ultrasound limitations.	Solutions

Participant Generated Solutions

Some solutions suggested by participants were clear guidelines on what an urgent (i.e. stat) sonogram is and how to manage this during overnight shifts, especially when there is only one sonographer working. They also mentioned educating the whole team on the limitations of sonography, as well as having a support group with other sonographers. They also wanted free massage therapy at work and also being able to voice struggles without retaliation. Other suggestions were an increased pay rate, educate administration about sonography, and no mandatory exam time slots for exams, as patient situations can be very unpredictable. They also wanted to educate students and help them develop more nonclinical (“soft”) skills, being more patient with new sonographers by giving them more time and support and setting a limitation on how many exams a sonographer does per shift.

Qualitative Analysis

An interesting finding of the qualitative data was a difference in perception and reaction to conflict and supervisors’ support between males and females. Among the eight interview participants, only three were male. While female sonographers were more likely to empathize with their supervisors and try to understand their challenges, male sonographers were more critical and placing blame on their supervisors. They also described their behavior as “bullies,” pointing out “they give preferential treatment” and blaming their supervisors for the new sonographers quitting. The language was also more direct when it came to patient interactions, especially when one male participant was able to recognize and label it, when patients were being abusive. Conversely, the female sonographers tended to justify patient’s reactions even if they were abusive or combative toward them. Male sonographers were more likely to stand up for themselves and say “no” to supervisors, whereas female sonographers tended to avoid such confrontations with authority figures. There was no difference whether the authority figure was a male or female. No female participants reported confronting their supervisor, despite problems, and challenges. One sonographer reported feelings of being “stuck” in a toxic environment and staying there for many years, which came with big consequences on her physical and mental health. Among female sonographers, there was a tendency to avoid conflicts, which probably is the root of the feelings of resentment, a repeated code that was subcategorized with the phrase: Manifestation of Burnout. Regarding awareness of work-related burnout, male sonographers reported not being burned out or at least not being aware of it. It is difficult to study how gender might influence differences in occupational burnout among male- and female-identified sonographers, as many sonographers tend to be females. However, when developing program interventions and/or preventions, such differences may need to be taken into consideration.

The source of occupational burnout themes, identified in the interviews, was supported by multiple studies,^{3 –9} which identified lack of supervisor/management as having a consistent impact on the sonographer’s sense of burnout. These findings also overlap with the quantitative data from the survey where high number of sonographic examination and feeling underappreciated were reported as the most important factors contributing their occupational burnout. While the interview participants were aware that practicing good ergonomics was important, some reported that maintaining good ergonomics was very difficult, due to the pressure of doing a lot of exams and having a limited rest between patients. In terms of solutions, having a support group was an important finding. This was also supported by the quantitative data where 46.1% said they would be interested in participating in a program intervention. During the interview, when asked what was helpful when going through difficult times at work, they mentioned the need to talk to other sonographers. One participant shared that it is hard to talk about work challenges with someone who does not understand or know anything about sonography and the taxing duties. This insight is important because it further suggested that a program intervention, implemented in a group setting, could be effective in supporting sonographers and helping them mitigate occupational burnout.

Leveraging the Research to Develop a Sonographer Support Group Curriculum

Group therapy is a form of psychotherapy where one or two trained therapists work with a group of people, which has been shown to be effective in improving each members’ symptoms and self-awareness. ²⁶ This proposed curriculum was based on a cognitive behavioral group therapy (CBGT) approach, as a way to help sonographers learn new coping skills, in a supportive setting.^{26 –28} This evidence-based approach was highly structured, and it included cognitive restructuring, exposure therapy, problem-solving skills, role playing, and relaxation techniques. This combination has been shown to be effective in treating many mental health problems such as anxiety, phobias, posttraumatic stress disorder, and so on.^{26 –29} These techniques were adapted into the support group curriculum to specifically address sonographers’ needs and help them mitigate work-related burnout. Problem-solving skills, cognitive restructuring, and role playing are tools used in conflict resolution. Cognitive restructuring and relaxation techniques are used to address both the physiological and cognitive aspect of anxiety, when dealing with conflict at work. Self-compassion techniques were also incorporated into the support group curriculum, as such practice has been shown to help reduce anxiety, lower stress, and burnout.^15,17,30,31 Considering the participants’ feelings of being “stuck” in their career and given the studies that pointed to sonographers who were thinking of changing careers or retiring,^4,7 this factor was added in two group sessions to specifically address these challenges. The intended goal of those session is to help sonographers explore the feeling of being “stuck” in their career and getting more clarity regarding their decision to leave the profession.

The main objectives of the support group curriculum are to: Increase awareness of burnout and how it affects the body, brain, and the overall well-being. Increase self-compassion and incorporate such practices into daily work/personal activities. Provide conflict resolution skills. Foster skills to reduce stress and anxiety and regulate emotions. Please use the QR code to access an outline of the curriculum that was developed (See Appendix B—Insert QR).

Limitations

The main limitation to this study was the research design and the threats to internal and external validity. The cohort of sonographers who responded were formed by convenience and therefore the responses are specific to them. In addition, the survey instrument was developed for this study and was not validated. The cohort’s expressions of anxiety and stress, as they related to conflict, were self-reported data and a validated tools was not available to measure anxiety or conflict. The survey tool that was used to assess occupational burnout was also not validated. Another limitation was the small sample size, which only included sonographers who worked in New York City.

Future research should be done using the developed support group curriculum, as part of an intervention program, to evaluate its effectiveness in mitigating burnout. It may also be helpful in reducing feelings of stress and anxiety during conflict at work and increased overall well-being. Also, further exploration of conflict at work in the sonography can help to better understand the challenges that sonographers face and the possible links of conflict to occupational burnout. With these new insights, it may be possible to implement conflict resolution skills training, as part of sonography education. The goal would be to provide preventative measures, so that future sonographers are better equipped with tools to deal with conflicts at work. Using validated tools to measure conflict, anxiety, and objective measures of stress such as cortisol levels or physiological monitoring can be an added dimension to future research.