Practice assistants´ perceived mental workload: A cross-sectional study with 550 German participants addressing work content, stressors, resources, and organizational structure

Introduction Practice assistants represent a highly relevant occupational group in Germany and one of the most popular training professions in Germany. Despite this, most research in the health care sector has focused on secondary care settings, but has not addressed practice assistants in primary care. Knowledge about practice assistants’ workplace-related stressors and resources is particularly scarce. This cross-sectional study addresses the mental workload of practice assistants working in primary care practices. Methods Practice assistants from a network of 185 German primary care practices were invited to participate in this cross-sectional study. The standardized `Short Questionnaire for Workplace Analysis’ (German: Kurzfragebogen zur Arbeitsanalyse) was used to assess practice assistants´ mental workload. It addresses eleven workplace factors in 26 items: versatility, completeness of task, scope of action, social support, cooperation, qualitative work demands, quantitative work demands, work disruptions, workplace environment, information and participation, and benefits. Sociodemographic and work characteristics were also obtained. A descriptive analysis was performed for sociodemographic data and “Short Questionnaire for Workplace Analysis” factors. The one-sided t-test and Cohen´s d were calculated for a comparison with data from 23 professional groups (n = 8,121). Results A total of 550 practice assistants from 130 practices participated. The majority of practice assistants was female (99.3%) and worked full-time (66.5%) in group practices (50.6%). Compared to the other professional groups, practice assistants reported higher values for the factor social support (4.0 versus 3.7 [d 0.44; p<0.001]), information and participation (3.6 versus 3.3 [d 0.38; p<0.001] as well as work disruptions (2.7 vs. 2.4 [d 0.42; p<0.001]), while practice assistants showed lower values regarding scope of action (3.4 versus 3.8 [d 0.43; p<0.001]). Conclusions Our study identified social support and participation within primary care practices as protective factors for mental workload, while work disruptions and scope of action were perceived as stressors.


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• If neither of these applies but you are able to provide details of access elsewhere, with or without limitations, please do so. For example: Data cannot be shared publicly because of [XXX]. Data are available from the XXX Institutional Data Access / Ethics Committee (contact via XXX) for researchers who meet the criteria for access to confidential data. The aims of this cross-sectional study are threefold: i) to assess the mental workload of PrAs working 83 in German primary care practices, ii) to identify resources and stressors, and iii) to compare results 84 with aggregated data from 23 different professions. 85

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The psychosocial assessment of PrAs reported in this paper was obtained as part of a larger cross-88 sectional study investigating multiple aspects of stress in primary care practices. Details of the study 89 are reported elsewhere [21,22]. Briefly, general practitioners (GPs) and PrAs of the 185 general 90 medicine practices of the practice network of the Institute for General Medicine, University Hospital 91 Essen, Essen, Germany, were asked to participate in the study. The practices were located in urban 92 and rural regions of North Rhine-Westphalia (Western Germany) with an average distance of 30 km 93 (range: 2±180 km) to the Institute. In a prior study it was shown that the practices affiliated with the 94 network are representative for German primary care practices [23]. Practices had been invited by mail 95 and contacted by phone for further recruitment. Those refusing to participate were asked to answer a 96 short questionnaire on practice characteristics and to provide reasons for non-participation. Data were 97 collected between April and September 2014 during on-site visits. Within each practice, all GPs 98 (practice owners and employed physicians) and PrAs including medical secretaries and PrA trainees 99 were eligible for participation and received the study documents. The study documents comprised a 100 study information sheet, an informed consent form to be completed by all participants, and a set of 101 questionnaires which included sociodemographic questions and the KFZA analyzed in this paper. To 102 ensure data protection, participants were asked to seal the completed questionnaire in an envelope. 103 As an incentive, practice teams received a department store chain voucher of 5 euros per person, 104 irrespective of the participation of individual team members. In addition, the dataset contained 105 information about the practices´ location from the practice network´s database and matched with 106 public regional data for the population size in 2012 (www.it.nrw.de). This paper follows the STROBE 107 recommendations for reporting cross-sectional studies [24]. individual's perception of the work environment. According to DIN EN ISO 10075 "Ergonomic principles 116 related to mental workload", the instrument is categorized as a "precision level 2 process for overview 117 purposes" [26]. The instrument is listed in the toolbox for "Instruments for recording mental loads" of 118 the Federal Institute for Occupational Safety and Health and covers multiple aspects of the work 119 environment [27]. It includes four dimensions: work content, resources, stressors, and organizational 120 culture. Dimensions consist of 11 factors which are derived from 26 single items with answer options 121 on a Likert scale ranging from 1 (does not apply at all) to 5 (is completely true). Work content contains 122 two factors (versatility, completeness of task) and five single items (learning new skills, use of 123 knowledge, skills and ability, variety of tasks, visibility of task accomplishment, completeness of 124 product). Resources contains three factors (scope of action, social support, cooperation) and nine 125 single items (influence on sequence of activities, influence on work content, influence on workload 126 and procedures, social support by co-workers, social support by supervisors, social cohesion within the 127 department, necessity of cooperation, opportunity for social exchange with co-workers, feedback from 128 supervisors and co-workers). Given the time constraints in primary care practices, the KFZA was deemed suitable as it takes only 139 10 minutes to complete. Also, data from more than 8,000 participants from 23 other professional 140 groups are available for comparison [25]. The questionnaire can be applied throughout all professions 141 and workspaces and is readily available for academic use [28]. 142 with data from other professional groups or from the same professional group provides information 172 on how to set a benchmark against other results [29]. Differences between the means of our 173 population and the comparative population were analyzed using a one-sided t-test (95% significance 174 level; 0.05 = alpha). Additionally, Cohen´s d was calculated to estimate the effect size.

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Our study identified social support within primary care practices as a resource and a protective factor 242 for mental workload among PrAs, while the lack of benefits at work was perceived as a stressor. 243 When comparing data on PrAs with the aggregated data of other professional groups, we were able to 244 perform a more informative analysis yielding slightly different results. Scope of action and work 245 disruptions showed the largest negative difference and the strongest effect size, whereas social 246 support and benefits showed the largest positive difference and the strongest effect size. Interestingly, 247 when comparing with other professional groups, the factor benefits that was identified as a stressor 248 in the single evaluation turned out to be a resource. Since the scores are rather low in both samples, 249 lack of benefits at work might be a general problem, while PrAs might experience more benefits at 250 work than other professional groups. PrAs in general practices tend to be responsible for a wide range In our study we were only able to assess the current situation and not the state desired by PrAs, which 285 could have provided even more insights. The comparison with data from 23 professional groups was 286 limited as only aggregated mean results were available without standard deviations. Due to this, we 287 were unable to calculate confidence intervals for both populations. A strength of our study is the 288 comparison of the results of the 2000 with the 2014 study from the same professional group. However, 289 the PrA populations were not identical, and caution is advised when interpreting the results. 290

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Mental well-being has a tremendous impact on preserving a healthy and productive workforce. 292 Therefore, our goal must be to first identify risk factors for mental well-being at work and put them 293 into perspective with other occupations, which we aimed to do in this study. Second, we need to 294 develop measures to tackle risk factors for psychological strain at work and enhance protective factors 295 such as social support, scope of action, benefits at work, and cooperation. Last, measures need to be 296 evaluated and implemented in the everyday working life of PrAs. 297 The load stress modelstress-strain model developed by Rohmert and Rutenfranz in 1975 differentiates 70 between the terms 'psychological stress' as defined above and 'psychological strain'. The term 71 'Ppsychological stress' describes all external factors that influence one's psychological well-being. 72

List of abbreviations
When connecting referring to psychological stress to in a work environment, the term `mental work 73 load´ refers to employees´ expositions exposure to individual work demands and the environment at Given the time-constraints in primary care practices, the KFZA was deemed chosen as a suitable tool 158 as it takes only 10 minutes time to complete. Also, data from more than 8,000 participants from 23 159 other professional groups are available for comparison [25]. The questionnaire can be applied 160 throughout all professions and workspaces and is freely readily available for academic use [28].

287
Our study identified social support within primary care practices as a resource and a protective factor 288 for mental work load among PrAs, while the lack of benefits at work was perceived as a stressor. 289 When comparing data on PrAs with the aggregated data of other professional groups, we were able to 290 perform a more informative analysis was possible yielding slightly different results. Scope of action 291 and work disruptions showed the largest negative difference and the strongest effect size, whereas 292 social support and benefits showed the largest positive difference and the strongest effect size. 293 Interestingly, when comparing with other professional groups, the factor benefits that was interpreted 294 identified as a stressor in the single evaluation turned out to be a resource when comparing with other 295 professional groups. Since values the scores are rather low in both samples, lack of benefits at work 296 might be a general problem, whereas while PrAs might experience more benefits at work compared 297 to than other professional groups. PrAs in general practices tend to be responsible for a wide range of 298 tasks in different workplaces throughout the practices, as they while arepresenting the first point of 299 contact for patients with unexpected events occurring on a regular basis [1]. This job profile may 300 explain the high values scores for work disruptions. Although PrAs are responsible for a wide range of 301 tasks, GPs remain the decision makers, resulting in leading to a setting-immanent limited scope of 302 action for PrAs. 303 The cComparison between the professional groups of PrA groups from 2000 to 2014 showed revealed 304 significant differences forin most factors, but small effect sizes. The factor benefits showed a moderate Additionally, they are rewarded with a better salary. Both may be signs for a of professionalization. 313 PAs iIn a recent study from by Vu-Eickmann et al., PrAs reported a high patient volume, which in 314 addition to handling many tasks at once may explain the be the reason for high score for work 315 disruptions [1]. 316 Social support is an important resource and can positively influence job satisfaction, as shown in a 317 recent study with Portuguese nursing staff [30]. Job satisfaction was again has been shown to positively 318 correlate with patient satisfaction [31]. A systematic review yielded a similar result connecting linking 319 social support with staff well-being in emergency departments [32]. In contrast, studies have shown 320 that negative work aspect (i.e.: lack of benefits, limited scope of action) cause psychological strain and 321 can lead to a higher turnover rate and depressive symptoms [10,33]. 322 In agreement with three other studies available on the this topic, we showed that PrAs in primary care 323 practices receive high social support and have a rather limited scope of action and still insufficient 324 benefits at work [1,7,8]. 325 326

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It is a strength of our study that it was based on a data set with a large number of participants (550 328 PrAs). Also, prior analyses had shown that the practice network from which this sample was taken is 329 representative for German primary care practices With 550 participating PAs, our study comprised 330 had a high large number of participants and a high response rate of 70.3%. Additionally, it was shown 331 that the practice network from which this sample was taken is representative for German primary care 332 practices [23]. Each participant received an incentive in the form of a 5 5-Euro voucher to avoid a 333 selection bias by only selecting only highly motivated PrAs. As the network is located in a rather densely 334 populated area, our results may over represent PrAs working in urban areas. The KFZA proved to be 335 an implementation-economica cost-effective screening tool to gain first insights into employees' 336 In this our study we were it was only possible able to measure assess the current situation and not the 339 state desired by PrAs, which could have given provided even further more insights. The cComparison 340 with data from 23 23 professional groups was limited as only aggregated mean results were available 341 without standard deviations. Due to this, we were unable to calculate a calculation of confidence 342 intervals for both populations was not possible. A strength of our study is the comparison of the results 343 of the 2000 with the 2014 results study from the same professional group. YetHowever, the PrA these 344 were two different populations of PAs were not identical, and caution is advised when interpreting the 345 results. 346 347

348
Mental well-being has a tremendous impact on preserving a healthy and productive workforce. 349 Therefore, our it has to be the goal must be to first identify risk factors for mental well-being at work 350 and put them into perspective with other occupations, which we aimed to do in as were the aims of 351 this study. Second, we need to develop measures need to be developed to tackle risk factors for 352 psychological strain at work and enhance protective factors such as social support, scope of action, 353 benefits at work, and cooperation. Lastly, measures need to be evaluated and implemented in the 354 everyday working life of PrAs.