Abstract
Background
Medical assistants (MA) constitute one of the largest professions in outpatient health care in Germany. The psychosocial working conditions of health care staff are generally believed to be challenging and to thereby increase the risk of poor mental health. A review of MA’s psychosocial working conditions and mental health is lacking, however. We aimed to systematically identify and summarize existing research on psychosocial working conditions and mental health of MA by addressing (1) Which methods, concepts, and instruments have been used to capture the psychosocial working conditions and mental health among MA in Germany? (2) What findings are available? and (3) What are the research gaps?
Methods
We systematically searched Medline, Scopus, CCMed and Google Scholar. Using the Population Concept Context (PCC)-framework, we applied the following eligibility criteria: (a) Language: English or German, (b) publication between 2002-2022, (c) original study, (d) study population: mainly MA (i.e., ≥ 50% of the study population), (e) concept: psychosocial working conditions and/or mental health, and (f) context: Germany. Two reviewers extracted data independently, results were compared for accuracy and completeness.
Results
Eight hundred twenty-seven sources were identified. We included 30 publications (19 quantitative, 10 qualitative, and one mixed methods study). Quantitative studies consistently reported high job satisfaction among MA. Quantitative and mixed methods studies frequently reported aspects related to job control as favorable working conditions, and aspects related to job rewards as moderate to unfavorable. Qualitative studies reported low job control in specific work areas, high demands in terms of workload, time pressure and job intensity, and a desire for greater recognition. Social interactions seemed to be important resources for MA. Few studies (n = 8) captured mental health, these reported inconspicuous mean values but high prevalences of anxiety, burnout, depression, and stress among MA. Studies suggested poorer psychosocial working conditions and mental health among MA during the COVID-19 pandemic.
Conclusions
Quantitative studies tend to suggest more favorable psychosocial working conditions among MA than qualitative studies. We suggest mixed methods to reconcile this alleged inconsistency. Future research should examine discrepancies between job satisfaction and unfavorable working conditions and if psychosocial working conditions and mental health remain changed after the COVID-19 pandemic.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12889-024-17798-2.
Keywords: Medical assistants, Psychosocial working conditions, Mental health, Germany
Background
In Germany’s decentralized primary health care system, medical assistants (MA) are the first point of contact for patients in primary care practices [1]. MA constitute one of the largest occupational groups in outpatient care in Germany [2]. With less than 4% men employed as MA in Germany, the profession is mainly female [2]. Although a popular choice for vocational training, the drop-out rates are very high both before and after completing the MA qualification [3]. For instance, a study reported that roughly a quarter of the non-physician healthcare workers who completed vocational training in 2019 and 2020 left the primary care practices even though they were offered a contract [4]. Among those, 18,7% declared to have switched to inpatient settings and 19,6% to a different profession [4]. Another study reported that around a third of surveyed primary care practices claimed to have been affected by the drop-out of MA from vocational training between 2017 and 2021 [5]. The primary care practices reported mainly personal reasons, followed by a lack of social skills and not fitting to the team as explanations for the drop-out from vocational training [5].
The range of MA’s professional activities include assisting physicians in diagnostic procedures and treatments (e.g. x-ray imaging, wound care, blood collection), carrying out administrative tasks such as the documentation and management of patients’ files, billing, scheduling appointments, organizing work processes in the practice, and keeping an overview of the available consumables [6]. The versatility of the job profile requires various team-related, organizational, and medical skills while demanding a high degree of responsibility and diligence towards the health care and safety of patients [7]. The MA profession can further be regarded as a customer/patient oriented profession involving interactional and emotional work demands [8–10].
Available evidence indicates that unfavorable psychosocial working conditions are, in general, associated with poorer (mental) health outcomes [11, 12]. In the case of the health care workforce, psychosocial working conditions and experienced stress have been further linked with diminished quality of care and poorer outcomes in patients’ health [13–16]. Specifically among MA, work stress has been associated with frequent self-reported slips and lapses and poorer interaction with patients [17]. Additionally, it has been suggested that unfavorable psychosocial working conditions such as leadership, job strain and job control, as well as poor mental health, can predict intended and actual turnover in health care professions [18, 19].
The consequences of particular psychosocial job characteristics, i.e. their possible impact on mental health, patient care as well as intended or actual turnover are relevant for the MA profession in the context of the German health care system, especially in view of the current shortage of skilled workers [20]. Thus, the examination of psychosocial working conditions and mental health among MA constitutes a research endeavor of utmost importance. In contrast to other large occupational groups in health care (e.g., nurses and physicians), the psychosocial working conditions and mental health among MA in Germany have only become the focus of research in recent years. A comprehensive review of this research is lacking to date, however.
Objectives
We aimed to systematically identify and summarize existing original data on the psychosocial working conditions and mental health among MA in Germany. We have focused on Germany due to the regional specificity of the profession. To achieve our objective, we addressed the following research questions: 1) Which methods, concepts, and instruments have been used to capture the psychosocial working conditions and mental health among MA in Germany? 2) What findings are available with regard to the psychosocial working conditions and mental health among MA in Germany? and 3) What are the research gaps pertaining to the psychosocial working conditions and mental health among MA in Germany? We applied the PCC-Framework (Population: MA, Concept of interest: psychosocial working conditions or/and mental health among MA, Context: Germany) recommended for scoping reviews [21] to conceptualize our research questions. We decided to conduct a scoping review, as it is a better suited method to identify available evidence and knowledge gaps when the body of literature is heterogeneous and thus not apt for a more precise, comprehensive systematic review [21, 22].
Methods
As recommended [21], we developed a scoping review protocol a priori and registered it with the Open Science Framework (https://osf.io/8sev4). Following the protocol, the review was carried out based on the following steps: (1) the identification of research questions, a framework to address them, and the selection of criteria for inclusion and exclusion, (2) the identification of relevant databases and additional sources, (3) the development of the search strategies, (4) the systematic search of the selected databases and additional sources, (5) the selection of eligible sources, (6) data extraction (charting), and (7) data synthesis and summary. The review was conducted by a multidisciplinary team including members with broad experience in epidemiological research on working conditions among MA (VM, AD, AL) using the Preferred Reporting Items for Systematic Reviews and Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines [23].
Eligibility criteria
We sought to include all types of original studies published between 2002-2022 either in English or German. Grey literature was included to consider possible reports and/or theses or dissertations that have not been published or peer-reviewed, but present original data. We included only studies with at least 50% of MA among the investigated study population (see Annex 1 with review protocol amendments).
Our review includes studies capturing either psychosocial working conditions and/or mental health among MA, regardless of whether these concepts constituted the primary focus of the respective studies. Our search strategy employed terms that capture theoretical constructs seeking to assess psychosocial working conditions (e.g., job-demands-control) and terminology related to them (e.g. stressor or resource) in order to increase sensitivity. Our search also included the term job satisfaction, because instruments used to capture it usually assess various domains pertaining to psychosocial working conditions. As for mental health, we were interested in common mental health disorders associated with psychosocial working conditions, e.g. anxiety disorder, burnout, and depression [24–27].
Due to the regional specificity of the profession, we only included studies conducted among MA in Germany. The identification of these studies is complicated due to the inconsistent translation of the term MA into English, hence for our population we used terms that have been commonly used in translations, but do not necessarily address the MA profession only (e.g., “medical assistant”).
Information sources and search
We selected four databases after consultation with an information specialist (see acknowledgements), those were Medline (via PubMed), CCMed (a database for German sources, consulted via LIVIVO), Scopus and Google Scholar. All database searches were executed on October 10, 2022. We additionally conducted manual reference checking of the sources included after full text screening, and consulted with experts in the field (see acknowledgements) in order to find further sources not identified through our search strategy.
We designed the search strategies for the different databases in consultation with an information specialist. We tested different combinations of search terms, keywords, operators and wildcards reflecting our PCC-Framework and applied the combinations yielding the most relevant results. Annex 2 presents the full electronic search strategy used for PubMed (Medline). The remaining full text search strategies are shown in the review protocol (https://osf.io/8sev4).
We searched Google Scholar using German-language search terms in order to increase the likelihood to identify grey literature (e.g., theses from German universities or reports from German organizations). For Google Scholar, we followed the recommendation to only consider the first 200 references [28]. The Google Scholar search was conducted from a computer located in the city of Düsseldorf, Germany.
Selection of sources of evidence and data charting process
After removal of duplicates in the citation management software, the remaining references were exported into the online software Rayyan.ai, where a second automatic duplicate search was performed. The screening of the remaining titles and abstracts was conducted simultaneously by KS and by a team composed of VM, AD and AL. Disagreements were solved through discussion. Full-text screening was conducted in parallel by two reviewers (KS and VM). Disagreements were solved through discussion and the involvement of a third reviewer (either AD or AL). In cases where more than one exclusion criteria applied, we recorded only the first criterion, following the order of exclusion criteria from the review protocol (https://osf.io/8sev4). Literature suggestions by experts and titles found through manual search underwent the same screening process.
We developed a data extraction sheet based on our research questions and established recommendations [21]. Two reviewers (KS and VM) piloted the extraction sheet making minor adjustments (see annex 1). We charted the following data: Reviewer, date, title, author(s) of publication, year of publication, name of journal/publication type (if not a journal article), aims/purpose, sample size, defining characteristics of study participants/setting and context related information, type of study (e.g. qualitative, quantitative, mixed methods), concepts used to capture psychosocial working conditions and/or mental health (if applicable), instruments used to capture psychosocial working conditions and/or mental health (if applicable), outcomes of significance to our concepts of interest, further findings of interest, authors’ conclusion/key findings (if applicable), and reviewer’s comments. After extraction of information from all sources, the charted results of both reviewers (KS and VM) were compared for accuracy and completeness.
As common in scoping reviews, we did not conduct a critical appraisal of individual sources due to the heterogeneity of the sources included.
Synthesis of results
For quantitative studies presenting outcomes with mean values, we defined the mid-point of each scale as a cut-off for critical psychosocial working conditions or critical mental health outcomes. Depending on the direction of the respective scales (i.e., a lower value indicating unfavorable psychosocial working conditions or mental health, or vice-versa), mean values were rated as critical if these exceeded the cut-off or if they fell below the cut-off. This approach allowed us to compare studies reporting results with mean values on the same constructs. Studies presenting outcomes without mean values (all qualitative and n = 6 quantitative studies) were only summarized narratively.
For the narrative summary of psychosocial working conditions, we employed a deductive structure for patterns found based on several established theories aiming at capturing psychosocial working conditions: the Job-Demands-Control [29], the Job-Demands-Resources [30], and the Effort-Reward Imbalance [31] models. Job demands are broadly defined as sources of stress present in the work environment [29], and more specifically as “[…] aspects of the job that require sustained physical and/or psychological effort and are therefore associated with certain physiological and/or psychological costs” [30]. Job control includes aspects related to decision latitude [29] and predictability, entailing the objective and subjective evaluation of an individual’s control of the work situation as well as beliefs about it [32]. Job resources have been defined as aspects of the job that are either functional in achieving work goals, reduce job demands and the costs associated with them, or stimulate personal growth, learning, and development [33], whereas the theoretical framework of the Effort-Reward-Imbalance model recognizes three basic forms of job rewards: financial, status-related, and socioemotional [31]. We also included the category job satisfaction, as it may be viewed as a summary measure of psychosocial working conditions that are relevant to a given individual.
Results
Our systematic search of databases generated n = 805 hits (n = 54 for CCMed, n = 2,170 for Google Scholar, of which we only considered the first 200 hits, n = 475 for Medline, and n = 76 for Scopus). Additionally, we assessed n = 8 records found through manual reference checking and n = 14 identified through consultation with experts in the field. The detailed results of the search and screening process, including the reasons for exclusion at each stage, are illustrated in Fig. 1. After full-text screening, n = 30 sources were included in our scoping review, consisting of ten qualitative, 19 quantitative and one mixed methods study (see Table 1 for study characteristics).
Fig. 1.
Flow diagram of excluded and included studies
Table 1.
Overview of the characteristics of the included studies (n = 30)
| Characteristics | N | % |
|---|---|---|
| Study type | ||
| Qualitative | 10 | 30.00 |
| Quantitative | 19 | 63.33 |
| Mixed methods | 1 | 3.33 |
| Year of publication | ||
| 2002–2006 | 1 | 3.33 |
| 2007–2011 | 5 | 16.66 |
| 2012–2016 | 6 | 20.00 |
| 2017–2021 | 15 | 50.00 |
| 2022 | 3 | 10.00 |
| Publication type | ||
| Journal article, peer reviewed | 26 | 86.66 |
| Thesis or dissertation | 3 | 10.00 |
| Study report | 1 | 3.33 |
| Relevant concepts captured in studya | ||
| Psychosocial working conditions | 28 | 93.33 |
| Mental health | 8 | 26.66 |
| MA population in study | ||
| Only MA | 19 | 63.33 |
| At least 50% of study population MA | 11 | 36.66 |
aCapturing both concepts is possible
The main characteristics of the selected sources are presented in Tables 1, 2, 3 and 4. Tables 2, 3 and 4 summarize the relevant results (concepts, instruments and outcomes) charted for each source of reference. Data such as defining characteristics of study participants/setting and context-related information were presented very heterogeneously or were not available in the different studies, making comparisons difficult. For example, some studies specified setting and context by mentioning if MA worked in general or specialized clinics [34, 35], whereas others studies reported the percentage of surveyed clinics located in rural or urban areas [36, 37] or if they were located in small towns, small or big cities [38]. Thus, we did not include these data in the summary tables. Our results suggest that studies reporting psychosocial working conditions and/or mental health among MA have increased substantially in the past years: the earliest study examining mental health among MA was published in 2014, and more than half of the examined studies were published within the last six years.
Table 2.
Quantitative and mixed methods studies capturing psychosocial working conditions among medical assistants in Germany (2002–2022)
| Reference nr | Authors | Publi- cation year | n MAa | Study design | Aim/purpose of the study | Concepts used to capture psychosocial working conditions | Instruments used to capture psychosocial working conditions | Main results reported with potential score range (if relevant) and observed value | Critical cut-offb |
|---|---|---|---|---|---|---|---|---|---|
| [39] | Degen et al. | 2021 | 254 | Quantitative, cross-sectional | To report the baseline characteristics of participants of an intervention study, focusing on job satisfaction and perceived chronic stress | Scale transformed by authors to a score from 0 (“not satisfied at all”) to 100 (“fully satisfied”); mean (SDd) | |||
| Job satisfaction | COPSOQ B11cc | 72.58 (14.42) | No | ||||||
| [10] | Dormann et al. | 2003 | 351 | Quantitative, cross-sectional | To examine concepts of organizational and personal customer orientation and their (extended) customer service foundations as well as associations between them and customer-oriented control | Scale range from 0 (“does not apply”) to 5 (“applies completely”); mean (SD) | |||
| Decision latitude | ISTA6.0e | 3.76 (0.70) | No | ||||||
| Customer-oriented decision latitude | Self-developed instrument | 3.63 (0.78) Scale transformed by authors to a score from 0 (“not satisfied at all”) to 100 (“fully satisfied”); mean (SDd) | No | ||||||
| Work satisfaction | Kunin-item | 5.52 (0.95) | No | ||||||
| [40] | Dreher et al. | 2021 | 2150 | Quantitative, cross-sectional | To investigate the prevalence of attitudes, stressors and work-related outcomes related to 2020 SARS-CoV-2 outbreak among MA working in inpatient and outpatient settings and to identify potential determinants of those outcomes | Agree, n (%) | Not calculated for any of the values (no mean value reported) | ||
| SARS-CoV-2 attitudes | Self-developed instrument | a) The risk of contracting SARS-CoV-2 is higher for me than for a person of same age and sex from the general population: 1770 (82.3%) | |||||||
| b) I feel sufficiently informed about dealing with SARS-CoV-2 patients by my employer: 1428 (66.4%) | |||||||||
| c) I feel sufficiently prepared for dealing with SARS-CoV-2 patients by my employer: 1301 (60.5%) | |||||||||
| d) My workload has increased due to the SARS-CoV-2 pandemic: 1076 (50.0%) | |||||||||
| e) I can use materials for personal protection at my work so that I feel sufficiently protected from contracting SARS-CoV-2: 702 (32.7%) | |||||||||
| SARS-CoV-2 stressors | a) I am burdened by a feeling of not being able to let patients down during the crisis: 1630 (75.8%) | ||||||||
| b) I am burdened by uncertainty about my financial situation during the crisis: 1448 (67.3%) | |||||||||
| c) I am burdened with thoughts of a possible infection with SARS-CoV-2 during work hours: 1413 (65.7%) | |||||||||
| d) I am burdened by the crisis-related shortfall of colleagues/staff at work: 1153 (53.6%) | |||||||||
| SARS-CoV-2 work outcomes | a) At my work all necessary materials for personal protection from SARS-CoV-2 are sufficiently available for me: 516 (24.0%) | ||||||||
| [41] | Erler et al. | 2012 | 15 | Quantitative, experimental | To describe the effects of an intervention on work satisfaction and burnout risk in the explorative evaluation of that intervention | Scale range apparently transformed by authors to a score from 0 (“fully satisfied”) to 100 (“not satisfied at all”); meanf | |||
| Job demands | COPSOQ | a) Quantitative demands: 62.05 | Yes | ||||||
| b) Emotional demands: 44.05 | No | ||||||||
| c) Demands for hiding emotions: 49.11 | No | ||||||||
| d) Work-privacy conflict: 38.21 | No | ||||||||
| Scale range apparently transformed by authors tor a score from 0 (“not satisfied at all”) to 100 (“fully satisfied”); mean | |||||||||
| Influence and development opportunities | a) Influence at work: 32.14 | Yes | |||||||
| b) Degree of freedom at work: 23.66 | Yes | ||||||||
| c) Possibilities for development: 72.32 | No | ||||||||
| d) Meaning of work: 87.5 | No | ||||||||
| e) Commitment to workplace: 71.43 | No | ||||||||
| Interpersonal relations and leadership | a) Predictability: 68.75 | No | |||||||
| b) Role clarity: 86.61 | No | ||||||||
| c) Quality of leadership: 65,63 | No | ||||||||
| d) Social support: 73.66 | No | ||||||||
| e) Feedback: 41.07 | Yes | ||||||||
| f) Social relations: 61.61 | No | ||||||||
| g) Sense of community: 80.36 | No | ||||||||
| Scale range apparently transformed by authors to a score from 0 (“fully satisfied”) to 100 (“not satisfied at all”); mean | |||||||||
| h) Role conflicts: 34.82 | No | ||||||||
| i) Bullying: 19.64 | No | ||||||||
| Job insecurity | a) Job insecurity: 26.34 | No | |||||||
| Scale range apparently transformed by authors to a score from 0 (“not satisfied at all”) to 100 (“fully satisfied”); mean | |||||||||
| Job satisfaction | a) Job satisfaction: 73.03 | No | |||||||
| [42] | Fauser et al. | 2020 | 1438 | Quantitative, cross-sectional | To determine the predictive value of the dimensions of the ERIg model for the construct burnout in a sample of MA in Germany | Score range: 3–12, higher scores indicating higher effort; mean (SD) | |||
| Effort-reward imbalance | ERI (short version) | a) Effort: 10.4 (1.38) | Yes | ||||||
| Score range: 6–27, higher scores indicating higher rewards; mean (SD) | |||||||||
| b) Reward: 14.3 (2.91) | Yes | ||||||||
| Score > 1 indicates effort-reward imbalance; mean (SD) | |||||||||
| c) ERI-Ratio: 1.54 (0.43) | Yesh | ||||||||
| Score range: 4–16, higher scores indicating higher overcommitment; mean (SD) | |||||||||
| Over-commitment | a) Overcommitment: 10.8 (2.83) | Yes | |||||||
| [36] | Feindel et al. | 2019 | 12 | Mixed-methods, cross-sectional | To develop and pilot test a questionnaire evaluating MA attitudes towards task shifting and their perceptions of its challenges, and to assess the psychometric properties of that questionnaire | Scale range from 1 to 7, higher value indicating higher satisfaction; median (IQRj): | Not calculated for any of the values (no mean value reported) | ||
| Working conditions and job satisfaction | Self-developed instrument and WCWi | a) Freedom of working method: 5 (3–6) | |||||||
| b) Colleagues and fellow workers: 6 (5–6) | |||||||||
| c) Recognition for work: 4 (2–6) | |||||||||
| d) Amount of responsibility: 5 (4–6) | |||||||||
| e) Income: 3 (1–3) | |||||||||
| f) Opportunity to use abilities: 5 (4–6) | |||||||||
| g) Hours of work: 5 (3–6) | |||||||||
| h) Amount of variety in job: 5 (4–6) | |||||||||
| i) Mental working conditions: 4 (3–5) | |||||||||
| j) Overall satisfaction: 5 (4–6) | |||||||||
| Concerns regarding delegation | Self-developed instrument | a) Did not see any financial incentive from the additional qualification: n = 98 (35.8%) | |||||||
| b) Felt tasks were not sufficiently defined: n = 95 (34.7%) | |||||||||
| c) Feared a lack of acceptance by patients: n = 79 (28.8%) | |||||||||
| d) Reported that it was unclear who bore responsibility and was therefore liable: n = 74 (27%) | |||||||||
| e) Feared that competition with other practice assistants could arise: n = 52 (19%) | |||||||||
| f) Stated that their remuneration had increased because of an additional qualification: n = 68 (24.8%) | |||||||||
| [43] | Gavartina et al. | 2013 | 586 | Quantitative, cross-sectional | To evaluate the job satisfaction and organizational attributes of practice assistants in general practices in Germany and to explore associations between them | Scale range from 1 = “extreme dissatisfaction” to 7 = “extreme satisfaction”; mean (SD) | |||
| Job satisfaction | WCW | a) Physical working condition: 5.18 (1.32) | No | ||||||
| b) Freedom of working method: 5.20 (1.35) | No | ||||||||
| c) Colleagues and fellow workers: 5.87 (1.28) | No | ||||||||
| d) Recognition for work: 5.07 (1.47) | No | ||||||||
| e) Amount of responsibility 5.38 (1.33) | No | ||||||||
| f) Income 3.89 (1.79) | Yes | ||||||||
| g) Opportunity to use abilities 5.26 (1.26) | No | ||||||||
| h) Hours of work 5.34 (1.49) | No | ||||||||
| i) Amount of variety in job 5.49 (1.22) | No | ||||||||
| j) Overall job satisfaction 5.74 (1.19) | No | ||||||||
| Scale range from 1 = “fully disagree” to 5 = “fully agree”, according to the number of items in the respective scales, the potential score range cannot be determined. We assume that the score was divided by the number of items, with a higher value indicating better organizational attributes; mean (SD) | |||||||||
| Organizational attributes for primary care | SOAPCk | a) Communication: 3.92 (0.48) | No | ||||||
| b) Decision making: 3.95 (0.64) | No | ||||||||
| c) Stress: 3.53 (0.73) | Yes | ||||||||
| d) Change [changes in the work organization and teamwork]: 3.13 (0.79) | No | ||||||||
| e) Overall score: 3.70 (0.48) | No | ||||||||
| [44] | Göbel et al. | 2022 | 254l | Quantitative, cross-sectional | To analyze the relationship between work-privacy-conflict and job satisfaction among German general practitioners and MA | Scale range transformed by authors to a numerical scale from 0 to 100, higher score indicating a stronger work-privacy conflict; mean (SD) | |||
| Work-privacy conflict | COPSOQ | a) Work-privacy-conflict: 32.67 (28.35) | No | ||||||
| [45] | Goetz et al. | 2011 | 2332m | Quantitative, cross-sectional | To evaluate the job satisfaction of German general practitioners and their non-physician staff | Scale range from 1 = “extreme dissatisfaction” to 7 = “extreme satisfaction”; mean (SD)n | |||
| Job satisfaction | WCW | a) Freedom of working method: 5.82 (1.23) | No | ||||||
| b) Colleagues and fellow workers: 6.18 (1.02) | No | ||||||||
| c) Recognition for work: 5.41 (1.49) | No | ||||||||
| d) Amount of responsibility: 5.92 (1.34) | No | ||||||||
| e) Income: 4.79 (1.65) | No | ||||||||
| f) Opportunity to use abilities: 5.82 (1.17) | No | ||||||||
| g) Hours of work: 5.75 (1.32) | No | ||||||||
| h) Amount of variety in job: 5.94 (1.15) | No | ||||||||
| i) Physical working condition: 5.63 (1.25) | No | ||||||||
| j) Overall job satisfaction: 5.95 (1.05) | No | ||||||||
| [37] | Goetz et al. | 2013 | 1158 | Quantitative, cross-sectional | To evaluate the job satisfaction of MA in German general practice and explore the associations between job satisfaction, staff characteristics and organizational culture within the practice | Scale range from 1 = “extreme dissatisfaction” to 7 = “extreme satisfaction”; mean (SD) | |||
| Job satisfaction | WCW | a) Freedom of working method: 5.71 (1.22) | No | ||||||
| b) Colleagues and fellow workers: 6.13 (1.03) | No | ||||||||
| c) Recognition for work: 5.33 (1.52) | No | ||||||||
| d) Amount of responsibility: 5.84 (1.11) | No | ||||||||
| e) Income: 4.62 (1.68) | No | ||||||||
| f) Opportunity to use abilities: 5.77 (1.17) | No | ||||||||
| g) Hours of work: 5.72 (1.39) | No | ||||||||
| h) Amount of variety in job: 5.94 (1.10) | No | ||||||||
| i) Physical working condition: 5.51 (1.28) | No | ||||||||
| j) Overall job satisfaction: 5.84 (1.09) | No | ||||||||
| Scale range from 1 (“fully disagree”) to 5 (“fully agree”), higher score indicating better organizational culture; mean (SD) | |||||||||
| Organizational culture | EPAo | a) Responsibilities within the practice team are clear: 4.26 (0.88) | No | ||||||
| b) Offering suggestions for improvement: 4.09 (1.06) | No | ||||||||
| c) Suggestions for improvement are taken seriously: 3.91 (1.10) | No | ||||||||
| d) Working atmosphere in the practice team is good: 4.19 (0.97) | No | ||||||||
| [46] | Hoffmann et al. | 2020 | 550 | Quantitative, cross-sectional | To assess the mental workload of MA working in German primary care practices, to identify resources and stressors and to compare the results with aggregate data from 23 professions | Scale range from 1 (“does not apply at all”) to 5 (“is completely true”), high scores (> 3) are considered positive; mean (95% CIq) | |||
| Job content | KFZAp | a) Versatility: 3.6 (3.58–3.70) | No | ||||||
| b) Completeness of task: 3.5 (3.41–3.57) | No | ||||||||
| Scale range from 1 = “does not apply at all” to 5 = “is completely true”, high scores (> 3) are considered positive; mean (95% CI) | |||||||||
| Resources | KZFA | a) Scope of action: 3.4 (3.37–3.49) | No | ||||||
| b) Social support: 4.0 (3.98–4.12) | No | ||||||||
| c) Cooperation: 3.6 (3.53–3.66) | No | ||||||||
| Scale range from 1 = “does not apply at all” to 5 = “is completely true”, high scores (> 3) are considered negative; mean (95% CIq) | |||||||||
| Stressors | KZFA | a) Qualitative work demands: 2.2 (2.14–2.29) | No | ||||||
| b) Quantitative work demands: 2.9 (2.83–3.01) | No | ||||||||
| c) Work disruption: 2.7 (2.67–2.81) | No | ||||||||
| d) Workplace environment: 2.2 (2.13–2.30) | No | ||||||||
| Scale range from 1 = “does not apply at all” to 5 = “is completely true”, high scores (> 3) are considered positive; mean (95% CI) | |||||||||
| Organizational culture | KZFA | a) Information and participation: 3.6 ( 3.57–3.73) | No | ||||||
| b) Benefits: 2.9 (2.77–2.94) | Yes | ||||||||
| [47] | Mahler et al. | 2007 | 89 | Quantitative, cross-sectional | To assess the frequency of participation in training courses as well as the reasons and obstacles for participation, and to find out which topics MA consider interesting and what effects they expect a training course to have on their work situation | Assessment of the own work situation | Self-developed instrument | Results provided through a bar-chart, exact values missing | Not calculated for any of the values (no mean value reported) |
| Further training | Only main answers reported here: | ||||||||
| a) Job-related training measures were taken by 62.5% of the physician assistants one to three times a year, more than 3 training courses a year even by about a quarter of the respondents (26.1%) | |||||||||
| b) Reasons to participate in a training course based on reported frequency (main reasons mentioned): 1) To broaden expertise (n = 88; 100%); 2) To obtain suggestions for changes in the daily work environment (n = 71; 80.7%) | |||||||||
| c) Obstacles to participation in training courses: 1) Training is too expensive (n = 26; 42.6%); 2) not compatible with the family situation (n = 24; 39.3%); 3) a lack of career opportunities (24.6%) | |||||||||
| d) Offer on training courses for MA is sufficient or very good (n = 29; 33,3%) | |||||||||
| e) Complained about the clarity of the continuing education programs (42.5%) | |||||||||
| f) n = 77 (87.5%) MA receive support from their supervisor in attending continuing education courses (e.g. cover of participation costs and/or travel costs, payment of overtime and/or time off) | |||||||||
| [3] | Mergenthal et al. | 2021 | 2371 | Quantitative, cross-sectional | To answer how satisfied are MAa with various aspects of their work, and which socio-demographic factors influence job satisfaction | Scale range from 1 = “extreme dissatisfaction” to 7 = “extreme satisfaction”; mean (SD) | |||
| Job satisfaction | WCWi | a) Psychological workload: 4.61 (1.7) | No | ||||||
| b) Freedom of working method: 4.98 (1.7) | No | ||||||||
| c) Colleagues and fellow workers: 5.50 (1.7) | No | ||||||||
| d) Recognition for work: 4.76 (1.8) | No | ||||||||
| e) Amount of responsibility: 5.53 (1.4) | No | ||||||||
| f) Income: 3.73 (1.9) | Yes | ||||||||
| g) Opportunity to use abilities: 4.91 (1.6) | No | ||||||||
| h) Hours of work: 5.01 (1.8) | No | ||||||||
| i) Amount of variety in job: 5.01 (1.7) | No | ||||||||
| j) Overall job satisfaction: 5.20 (1.6) | No | ||||||||
| [34] | Oelschlegel, H. | 2007 | 77 | Quantitative, cross-sectional | To research the role of MA in methadone substitution in GPrpractices in a southern German region in order to make suggestions to improve their training | Work motivation | Self-developed instrument | Reasons for working motivation: | Not calculated for any of the values (no mean value reported) |
| a) Earn money (n = 69): 31,9% (n = 22): very important, 33,3% (n = 23): important; 26,2% (n = 18): moderately important; 7,2% (n = 5): little important; n = 0: unimportant; 1,4% (n = 1): completely unimportant | |||||||||
| b) Helping other people (n = 71): 53,5% (n = 38): very important; 35,2% (n = 25): important; 5,6% (n = 4): moderately important; 1,4% (n = 1): little important; 1,4% (n = 1): unimportant; 2,8% (n = 2): completely unimportant | |||||||||
| c) Working in a team (n = 69): 31,9% (n = 22): very important; 50,7% (n = 35): important; 10,1% (n = 7): moderately important; 4,3%(n = 3): little important; 1,4%(n = 1): unimportant; 1,4% (n = 1): completely unimportant | |||||||||
| d) Recognition by the boss (n = 69): 21,7% (n = 15): very important; 31,9% (n = 22): important; 20,3% (n = 14): moderately important; 14,5%(n = 10): little important; 5,8%(n = 4): unimportant; 5,8% (n = 4): completely unimportant | |||||||||
| e) Recognition through patients or relatives (n = 70): 24,6% (n = 17): very important; 27,5% (n = 19): important; 20,3% (n = 14): moderately important; 15,9% (n = 11): little important; 4,3% (n = 3): unimportant; 8,7% (n = 2) completely unimportant | |||||||||
| f) Social recognition (n = 69): 2,9% (n = 2): very important; 22,8% (n = 16): important; 12,8% (n = 9): moderately important; 17,1% (n = 12): little important; 20% (n = 14): unimportant; 22,9% (n = 16): completely unimportant | |||||||||
| g) Personal experience (n = 67): 4,5% (n = 3): very important; 7,5% (n = 5): important; 16,4% (n = 11): moderately important; 10,4% (n = 7): little important; 4,5% (n = 3): unimportant; 56,7% (n = 38): completely unimportant | |||||||||
| Job satisfaction | a) Overall job satisfaction (n = 77): 94% mostly satisfied vs. 6% mostly unsatisfied | ||||||||
| Being afraid | a) Being afraid in the context of their work with substitution patients: 67,5% (n = 52): reported not to be afraid; 28,6% (n = 22): reported to be seldom afraid; 3,9% (n = 3): reported to be often afraid | ||||||||
| [35] | Scharf et al. | 2019 | 887 | Quantitative, cross-sectional | To quantify needs and desired improvements from a previous qualitative study as a starting point for the development, implementation and evaluation of interventions | n (%): | |||
| Needs regarding: Working conditions, work organization; rewards from supervisor, task-related independence, working climate, leadership | Self-developed instrument | a) I would like to have more responsibility in my job: 230 (26.3) | Not calculated for any of the values (no mean value reported) | ||||||
| b) I would like to have greater scope of action and freedom of choice: 356 (40.9) | |||||||||
| c) I would like to independently advise patients about their disease: 236 (27.1) | |||||||||
| d) I would like to make home visits: 112 (12.9) | |||||||||
| e) I would like to have more educational opportunities: 478 (54.9) | |||||||||
| f) I would like to have additional breaks: 346 (39.9) | |||||||||
| g) I would like to have different opening hours of the practice/clinic: 368 (42.3) | |||||||||
| h) I would like to have more staff at my workplace: 488 (55.7) | |||||||||
| i) I would like to work less hours: 466 (53.9) | |||||||||
| j) I wish for more understanding from my supervisor: 528 (60.3) | |||||||||
| k) I would like to have a better working climate: 400 (45.9) | |||||||||
| l) I wished from improved interactions between colleagues: 330 (37.9) | |||||||||
| m) I wish for more appreciation for my work from my supervisor: 531 (60.8) | |||||||||
| n) I wish for more recognition for my work from the society: 654 (75.4) | |||||||||
| o) I would like to have a higher salary: 759 (87.0) | |||||||||
| p) I would like the physicians to have educational opportunities related to organizational leadership: 653 (75.1) | |||||||||
| q) I would like to have less documentation in my day-to-day work: 659 (76.0) | |||||||||
| r) I wish for a better organization of the practice/clinical procedures: 479 (54.7) | |||||||||
| s) I would like to include the internet /new media in my daily work: 277 (31.8) | |||||||||
| t) I would like to have less multitasking: 585 (67.5) | |||||||||
| [48] | Szecsenyi et al. | 2011 | 3011s | Quantitative, cross-sectional | To evaluate whether there is an association between patient satisfaction and job satisfaction of the members of patient care teams | Scale range from 1 = “extreme dissatisfaction” to 7 = “extreme satisfaction”; mean (95% CIq)t | |||
| Job satisfaction | WCWi | a) Freedom of working method: 5.82 (5.77–5.86) | No | ||||||
| b) Colleagues and fellow workers: 6.17 (6.14–6.21) | No | ||||||||
| c) Recognition of work: 5.42 (5.37–5.48) | No | ||||||||
| d) Amount of responsibility: 5.92 (5.87–5.96) | No | ||||||||
| e) Income: 4.77 (4.71–4.83) | No | ||||||||
| f) Opportunity to use abilities: 5.82 (5.77–5.86) | No | ||||||||
| g) Hours of work: 5.73 (5.68–5.78) | No | ||||||||
| h) Amount of variety in job: 5.93 (5.98–5.97) | No | ||||||||
| i) Physical working condition: 5.62 (5.57–5.67) | No | ||||||||
| j) Overall job satisfaction: 5.94 (5.90–5.98) | No | ||||||||
| In summary, non-physician staff rated the job satisfaction with mean = 5.71 (SD = 0.91) | No | ||||||||
| Mean (SD) | |||||||||
| Estimation of the practice organization | Instrument of unspecified origin | Evaluation of the organization of the practice team: 4.09 (0.27) | No | ||||||
| [49] | Vu-Eickmann et al. | 2018 | 887 | Quantitative, cross-sectional | To examine the psychosocial working conditions of MA and possible associations with health outcomes, quality of care indicators and the intention to leave | Value range 6–24; mean (SD) | |||
| Effort-Reward imbalance | ERIg | a) Effort (cut-off ≥ 21): 18.56 (3.19) | Yes | ||||||
| Value range (11–44); mean (SD) | |||||||||
| b) Reward (cut-off ≥ 31): 28.25 (5.98) | No | ||||||||
| Score > 1 indicates effort-reward imbalance; mean (SD) | |||||||||
| Work stress | c) ERI ratio (Effort*11/Reward*6): 1.28 (0.42) | Yesu | |||||||
| d) Prevalence of work stress (according to ERI ratio): n = 616 (73.77%) | Not calculated | ||||||||
| Mean (SD) | |||||||||
| MA-specific working conditions: Workload, job control, collaboration, gratification, practice organization, resources | Self-developed instrument | a) Workload (value range 6–24): 17.36 (4.19) | Yes | ||||||
| b) Job control (value range 6–24): 21.11 (2.71) | Yes | ||||||||
| c) Collaboration (value range 4–16): 8.41 (2.85) | No | ||||||||
| d) Gratification crisis (value range 4–16): 11.52 (2.66) | Yes | ||||||||
| e) Practice organization (value range 3–12): 6.56 (2.08) | No | ||||||||
| f) Resources (value range 3–12): 4.63 (1.71) | No | ||||||||
| g) Supervisor (value range 3–12): 8.01 (2.35) | Yes | ||||||||
| [50] | Zaroti, S. | 2015 | 586 | Quantitative, cross-sectional | To explore what psychosocial work stress general practitioners and MA are exposed to, the differences between GP and MA regarding their psychosocial working environment in terms of form of employment and gender, and associations between psychosocial stress and burnout | Job demands | COPSOQc | Scales were transformed to a range from 0 (“fully satisfied”) to 100 (“not satisfied at all”); mean (SD) | |
| a) Quantitative demands: 49.19 (16.78) | No | ||||||||
| b) Emotional demands: 47.87 (19.12) | No | ||||||||
| c) Demand to hide emotions: 44.88 (23.10) | No | ||||||||
| d) Work family privacy conflict: 25.41 (24.44) | No | ||||||||
| Scales were transformed to a range from 0 (“not satisfied at all”) to 100 (“fully satisfied”); mean (SD) | |||||||||
| Influence and development opportunities | COPSOQ | a) Influence at work: 41.16 (21.41) | Yes | ||||||
| b) Decision latitude: 42.67 (20.03) | Yes | ||||||||
| c) Possibilities for development: 69.05 (14.47) | No | ||||||||
| d) Meaning of work: 83.75 (15.18) | No | ||||||||
| e) Commitment to workplace: 63.89 (17.60) | No | ||||||||
| Social relations and leadership | COPSOQ | a) Predictability: 67.03 (20.82) | No | ||||||
| b) Role clarity: 81.55 (13.69) | No | ||||||||
| c) Quality of leadership: 65.85 (20.90) | No | ||||||||
| d) Social support: 78.23 (18.50) | No | ||||||||
| e) Feedback: 51.39 (23.10) | No | ||||||||
| f) Social relations: 42.29 (16.88) | Yes | ||||||||
| g) Sense of community: 85.92 (15.90) | No | ||||||||
| Scales were transformed to a range from 0 (“fully satisfied”) to 100 (“not satisfied at all”); mean (SD) | |||||||||
| Insecurity at workplace | COPSOQc | h) Bullying: 17.64 (22.18) | No | ||||||
| a) Job insecurity: 20.20 (17.97) | No | ||||||||
| Scale was transformed to a range from 0 (“fully satisfied”) to 100 (“not satisfied at all”); mean (SD) | |||||||||
| Job satisfaction | COPSOQ | a) Job satisfaction: 73.61 (14.10) | No |
aMedical assistants
bFor studies presenting mean values, we defined the mid-point of each scale as a cut-off for critical psychosocial working conditions outcomes. Depending on the direction of the respective scales (i.e., a lower value indicating unfavorable psychosocial working conditions, or vice-versa), mean values were rated as critical if these exceeded the cut-off
cCopenhagen Psychosocial Questionnaire
dStandard deviation
eInstrument for the stress-related task analysis
fAll mean values from this study were derived from pre-intervention assessment
gEffort-reward imbalance
hBased on own cut-off value for the scale, not on our calculations
iWarr-Cook-Wall job satisfaction scale
jInterquartile range
kSurvey of Organizational Attributes for Primary Care
lN = 254 MA from a total sample of n = 366 including also n = 84 practice owners and n = 28 employed physicians
mN = 2,332 (81.0%) MA out of n = 2,878 non-physician staff members included in the study
nAll values for non-physician staff
oEuropean Practice Assessment
pShort Questionnaire for Job Analysis (German: Kurz-Fragebogen zur Arbeitsanalyse
qConfidence interval
rGeneral practitioners
sN = 3011 non-physician staff in primary practices (most probably medical assistants)
tAll results for non-physician staff
uAccording to the scale’s own cut-off value
Table 3.
Qualitative studies capturing psychosocial working conditions among medical assistants in Germany (2002–2022)
| Reference nr | Authors | Publication year | n MAa | Study design; data collection method | Aim/purpose of the study | Concepts capturing psychosocial working conditions | Main outcomes/Key findings |
|---|---|---|---|---|---|---|---|
| [51] | Ehlers-Mondorf et al. | 2021 | 34 | Qualitative, cross-sectional; semi-structured interviews | To present the experience of MA with the SARS-CoV-2 pandemic and address their suggestions for improvement of pandemic preparation | Teamwork | More workload and stressors for MA due to the SARS-CoV-2 pandemic. MA felt that their role as first contact persons for patients during the pandemic did not receive sufficient recognition |
| Billing issues | |||||||
| Unstructured information flow | |||||||
| Lack of appreciation | |||||||
| [52] | Gensinchen et al. | 2009 | 26 | Qualitative, cross-sectional; semi-structured interviews | To describe the perceptions and experiences of MA who provided case management to patients with depression in small primary care practices | Role perception | MA’s role as case managers was perceived as personally and professionally enriching. Integrating case management in daily work was difficult for many MA because of insufficient time, unexpected patient-related factors, and lack of understanding by colleagues and supervisors. Relationships with patients were especially important for MA and could be both a burdening and a relieving factor. The interaction with depressive patients was described as difficult and demanding. General practitioners support or lack thereof influenced the perceived stress. Incomplete knowledge on depression increased strain |
| Burdening and relieving factors | |||||||
| Interaction with depressed patients | |||||||
| Collaboration with doctor | |||||||
| Disease conception | |||||||
| [53] | Hoffmann et al. | 2022 | 12v | Qualitative, cross-sectional; semi-structured interviews | To present the qualitative results from the process evaluation of an intervention for COVID-19 surveillance and care for COVID-19 patients with increased risk used by VERAHs (specially qualified MA) and general practitioners | Sense of security | The implementation of the intervention gave MA a sense of security and support. MA emphasized additional workload as particularly negative because the intervention added additional tasks and strain in the already tightly organized daily practice. Fear for additional workload and overtime was uttered before the intervention was implemented. Some MA were overwhelmed by the workload during the pandemic, the time required to implement the intervention was considered a major problem |
| Workload and overtime | |||||||
| Job satisfaction | |||||||
| [54] | Kathmann et al. | 2013 | 10 | Qualitative, cross-sectional; semi-structured interviews with MAa, expert interviews | To explore the degree of precarity of the MA job through an examination of working conditions | Precarious work | Low salary most central aspect in the precarity of the MA profession. MA dissatisfied with their low salary (main reason to quit the profession). Comparison with other professions (doctors, nurses) in terms of salary and social standing/ recognition leads to disappointment and dissatisfaction, also with their supervisors/employers. Overtime is considered to have a strong impact on private life, restricting MA’s social sphere and leisure time and leading to desire to have flexible working hours. MA reported a limited scope of action regarding negotiation of working hours and salary. Further qualifications considered to barely have an impact on salary or career prospects |
| [38] | Mergenthal et al. | 2012 | 6 | Qualitative, cross-sectional; semi-structured interviews | To explore the role of MA with a migration background in the general practices | Setting GPrpractice (e.g. work and role distribution) | MA with migration background experience ad-hoc interruptions to take over unplanned activities such as translating. They assume the role of translators and cultural mediators. Help or translation is often requested by patients or physicians. The interviewed MA felt integrated into the family practice setting and reported no additional stress or resources emerging from the additional tasks they were assigned due to their migration background |
| Communication and interaction with patients | |||||||
| Language connection | |||||||
| [55] | Preiser et al. | 2021 | 19w | Qualitative, cross-sectional; participant observation, semi-structured interviews and focus group discussions | To answer how GP fulfill their role as entrepreneurs and leaders responsible for the occupational safety of their employees regarding the organization of working time, and what psychosocial demands and resources result from the way how working time for practice teams is organized | Work content and task | “Unplannable” events considered part of the daily routine during consultation hours and lead to perceived psychological stress for GP and the practice team. MA expressed satisfaction with the flexibility of different working time models and the GP’s overall willingness to adjust working time models and hours to their needs. The immediate treatment of patients was favored over predictable working times for MA and GP, as a result taking lunch breaks or finishing work on time was raised as challenging by MA. MA rarely took mini-breaks, the authors associated this observation not with a high workload, but with the design of the workplace. The practice staff described mutual social support when planning individual vacations |
| Organization of work | |||||||
| Working environment | |||||||
| New forms of work | |||||||
| [56] | Rothe, M. | 2019 | Qualitative (partly quantified), cross-sectional; semi-structured interviews | To examine the role understanding, perceptions, feelings and scope of action of MA dealing with “difficult” and psychosomatic ill patients in general practices | Stressors and facilitators | MA reported stress due to high workload, high time pressure, a high amount of administrative work and confidentiality. The behavior of colleagues, human resources planning complicating work (e.g. sick leave) and behavior of some patients were also considered stressors. A lower workload, structured work, support from supervisor, collegiality and nice patients were considered facilitators. High satisfaction (quantified) was reported for support from colleagues and support from supervisor. The latter was considered to be very important | |
| Perceived support by supervisor and team | |||||||
| [57] | Tasrouha et al. | 2020 | 1920 | Qualitative, cross-sectional; participant observation and focus group discussions | To gain an in-depth understanding of psychosocial demands and resources in the primary care setting | Work content and tasks | The key psychological demands observed were incomplete execution of tasks, frequent interruptions, high levels of work intensity, simultaneous processing of several tasks, and tightly coupled work processes. Also noise, missing/ unsuitable/unused/incorrectly used equipment/software and the feeling of being under constant observation were important demands. Key resources mentioned were an appropriate scope of action though influence on the sequence of activities and sufficient patient-related information. The possibility to take mini-breaks and efficient communication and cooperation within the team (e.g. clearly defined responsibility areas in the laboratory) were important resources. A positively perceived teamwork and a supportive working environment (e.g. access to suitable workstations, equipment and software) were further reported as important resources |
| Organization of work | |||||||
| Working environment | |||||||
| New forms of work | |||||||
| [58] | Vu-Eickmann et al. | 2017 | 26 | Qualitative, cross-sectional; semi-structured interviews | To gain in-depth insights into MAa work stress and resources, as well as prevention options for intervention needs | Key stressors | The perceived job-related stress is overall very high. Very quiet periods at work alternate with work-intensive periods. Factors contributing to (high) workload: high patient volume with a simultaneous shortage of staff, increased documentation effort, inefficient practice organization, inability to take breaks (leading to physical and mental strain), considerable overtime, which is not compensated. Unforeseeable events lead to low job control. These arise from frequent interruptions of work processes and the requirement of multi-tasking (e.g. through phone calls, physicians concerns or emergency patients, technical problems and missing materials). Collaboration can be a stressor (e.g. supervisor who interrupts work process of MA, unpredictable or emotionally short-tempered employer, lack of support within the team, negative change in patient attitudes and expectations) or a resource (positive patient interaction, interaction with colleagues and social support, a supporting supervisor). Everyday work (broad and varied range of activities, a certain scope of action in the own core areas) is considered a key resource. Desired improvement needs include: higher salary, greater recognition (by society, patients and supervisors), improvement of the staff: patient ratio, more regulated working hours, reduced documentation, lower hierarchical structure (with supervisor), continuing education and training opportunities for physicians (organizational leadership) |
| Key resources | |||||||
| Desired improvement needs | |||||||
| [59] | Werdecker et al. | 2022 | 15 | Qualitative, cross-sectional; semi-structured interviews and observations | To explore what contributes to the feeling of happiness among general practitioners’and their staff in the work context | Teamwork | Teamwork was observed to be important for physicians and staff in terms of work satisfaction, collegial support, broad scope of action to complete tasks are considered important for teamwork. Laughing together, trust shown for the design of one’s own working area in the non-physician team (e.g. laboratory, registration desk) was perceived as appreciative and contributed to a feeling of happiness. Team meetings were perceived as valuable instruments for strengthening collegial cooperation, as well as exchange within the team to handle difficult and stressful situations. Long-lasting intensive relations with patients and fitting between patient and team seemed to contribute to harmony in daily work. Feedback from patients on the effectiveness or the observation of a positive development as well as gratitude from patients also considered to contribute to the happiness and satisfaction of MAaat work |
| Relationship with patients | |||||||
| Patient fit | |||||||
| Effectiveness of one’s own actions, success and recognition |
aMedical assistants
rGeneral practitioners
vN = 12 VERAHs (MA with special training as care assistants in the family practice)
wOnly information from practice teams (n = 19 MA) was included in this summary
Table 4.
Characteristics and findings of studies capturing mental health among medical assistants in Germany (2002–2022)
| Refe-rence nr | Authors | Publi-cation year | n MAa | Study design | Aim/purpose of the study | Concepts used to capture mental health | Instru-ments used to capture mental health | Main results reported with potential score (if relevant) and value | Critical cut-offx |
|---|---|---|---|---|---|---|---|---|---|
| [39] | Degen et al. | 2021 | 250 | Quantitative, cross-sectional | To report the baseline characteristics of participants of an intervention study, focusing on job satisfaction and perceived chronic stress | Value range 0–48, with higher scores indicating higher levels of perceived stress in the past 3 months; mean (SDd) | |||
| Chronic stress | TICS-SSCSy | 19.62 (9.07) | No | ||||||
| [40] | Dreher et al. | 2021 | 2150 | Quantitative, cross-sectional | To investigate the prevalence of attitudes, stressors and work-related outcomes related to 2020 SARS-CoV-2 outbreak among MA working in inpatient and outpatient settings and to identify potential determinants of those outcomes | Reported as prevalence of a positive screening | |||
| Depression | PHQ-2z | 29.9% | Not calculated for prevalences | ||||||
| Generalized anxiety disorder | GAD-2aa | 42.6% | |||||||
| [41] | Erler et al. | 2012 | 15 | Quantitative, longitudinal | To describe the effects of an intervention on work satisfaction and burnout risk in the explorative evaluation of that intervention | Value range 0–100, with higher scores indicating higher exhaustionac; mean | |||
| Burnout | CBIab | 44.64 | No | ||||||
| Cognitive stress symptoms | COPSOQc | 27.68 | No | ||||||
| [42] | Fauser et al. | 2020 | 1438 | Quantitative, cross-sectional | To determine the predictive value of the dimensions of the ERI model for the construct burnout in a sample of MA in Germany | Value transformed into range 0–100, with higher scores indicating higher exhaustion; mean (SDd) | |||
| Burnout | CBI | 57.2 (20.05) | Yes | ||||||
| [60] | Karlsen et al. | 2021 | 40 | Quantitative, cross-sectional | To evaluate the differential stress inventory (DSI) by evaluating the objective and subjective stress differences in the five DSI types in the occupational setting | Reported as n, MA categorized into DSI types | |||
| Stress | DSIad | 1) Normal: 21 | Not calculated for any of the values | ||||||
| 2) Overstressed: 4 | |||||||||
| 3) Stress resistant: 8 | |||||||||
| 4) Low stress/high coping: 4 | |||||||||
| 5) High stress/high coping: 3 | |||||||||
| [61] | Viehmann et al. | 2017 | 550 | Quantitative, cross-sectional | To analyze the prevalence of chronic stress for general practitioners and MA | Reported as median (IQRj) | |||
| Chronic stress | TICS-SSCSy | 16 (12.25) | Not calculated for any of the values | ||||||
| Applying DEGS1ae cut-off for high stress (TICS-SSCS ≥ 23), n (%) | |||||||||
| Prevalence of high strain among MA due to chronic stress | 550 (26.4) | ||||||||
| [49] | Vu-Eickmann et al. | 2018 | 887 | Quantitative, cross-sectional | To examine the psychosocial working conditions of MA and possible associations with health outcomes, quality of care indicators and the intention to leave | Mean (SD) | |||
| Depressiveness | PHQ-2 | 1.56 (1.46) | No | ||||||
| Anxiety | GAD-2 | 1.47 (1.66) | No | ||||||
| n (%) | |||||||||
| Prevalence of depressiveness | PHQ-2 | 153 (17.45) | Not calculated for prevalences | ||||||
| Prevalence of anxiety | GAD-2aa | 177 (20.14) | |||||||
| [50] | Zaroti, S. | 2015 | 586 | Quantitative, cross-sectional | To explore what psychosocial work stress are GP and MA exposed to, the differences between GP and MA regarding their psychosocial working environment in terms of form of employment and gender, and associations between psychosocial stress and burnout | Mean (SDd)af | |||
| Burnout | COPSOQc | 38.02 (19.81) | No | ||||||
| Cognitive stress symptoms | COPSOQ | 26.36 (18.18) | No |
aMedical assistants
cCopenhagen Psychosocial Questionnaire
dStandard deviation
jInterquartile range
xFor studies presenting mean values, we defined the mid-point of each scale as a cut-off for mental health outcomes. Depending on the direction of the respective scales (i.e., a lower value indicating unfavorable mental health, or vice-versa), mean values were rated as critical if these exceeded the cut-off
yTrier Inventory for Chronic Stress
zPatient Health Questionnaire (short version)
aaGeneralized Anxiety Disorder questionnaire
abCopenhagen Burnout Inventory
acAll mean values from this study are derived from pre-intervention assessments
adDifferential Stress Inventory
aeGerman Health Interview and Examination Survey for Adults (German: Studie zur Gesundheit Erwachsener in Deutschland
afAll values for the MA group (n = 586) only
Synthesis of results
Psychosocial working conditions of medical assistants in quantitative and mixed methods studies
Table 2 presents a summary of quantitative and mixed methods studies capturing psychosocial working conditions with the respective concepts, instruments and outcomes of interest.
Job satisfaction
Job satisfaction was the most commonly captured concept related to psychosocial working conditions among MA (n = 10 quantitative and mixed methods studies). These studies either focused on evaluating job satisfaction among MA in general [3, 36, 37, 39, 43], among MA working in methadone substitution clinics [34], among patient care teams [48], in comparison with general practitioners (GP) [50], as part of an intervention evaluation [41] or theoretically as a service-oriented profession [10]. The consistency of the results regarding overall job satisfaction, captured with instruments such as the Copenhagen Psychosocial Questionnaire (COPSOQ) and the Warr-Cook-Wall job satisfaction scale (WCW), was high: all studies capturing job satisfaction reported that MA are overall satisfied with their job. The specific working conditions assessed with job satisfaction scales are presented in the narrative summary below.
Job demands
We summarized under this category concepts related to workload, time pressure (e.g. “quantitative demands”, “stress”, and “workload", “amount of responsibility”), emotions (e.g. “demands for hiding emotions”, “emotional demands”), role ambiguity (e.g. “role clarity”, “role conflict”, “responsibilities within the practice team are clear”, “tasks are not sufficiently defined”, “competencies of MA are clearly defined”), and work-privacy conflict [3, 41, 43, 44, 46, 49, 50]. Applying mid-point cut-offs, we identified potential critical outcomes among MA regarding “stress” [43] and “workload” [62], and conflicting outcomes for “quantitative demands” [41, 50]. Studies capturing role ambiguity [36, 37, 41, 47] suggested that most MA did not perceive their role or responsibilities as ambiguous. Similarly, studies capturing emotional demands [41, 50] and work-privacy conflict [41, 44, 50] reported values that can be interpreted as uncritical.
One quantitative study examined, amongst other things, demands during the COVID-19 pandemic [40] and found that 50.0% of the participating MA reported an increase in workload due to the pandemic and 53.6% felt burdened by staff shortages. As for emotional demands, these presented the highest burden for MA during the pandemic, with e.g. 75.8% of MA reporting feeling burdened by a feeling of not being able to let patients down during the crisis [40].
Job control
We conceptualized “job control” as an umbrella term for concepts related to decision latitude (e.g. “degree of freedom at work”, “scope of action”, “freedom of working method”, “decision latitude”, “decision making”, “job control” [3, 37, 41, 43, 45, 46, 48–50, 62]), as well as for the constructs “predictability”, “work disruption”, and “job insecurity” [41, 46, 49, 50]. Most quantitative and mixed method studies reported, if available, an un-critical value (e.g. below the mid-point cut-off) among MA for the concepts “degree of freedom at work”, “freedom of working method”, “decision making”, and “scope of action” [3, 36, 37, 43, 45, 46, 48]. Two studies presented potentially critical values for “influence at work” and “decision latitude” [41, 50]. A further study on the needs of MA reported that 40.9% (n = 356) of the sample would like to have a greater scope of action and freedom of choice [35], whereas another one [62] presented a potentially critical outcome for job control according to our calculations. The latter study further stated that occupational stressors related to poor job control were particularly problematic (prevalence of ≥ 85.1%) [62].
Job resources
We conceptualized “job resources” as aspects related to social relations at work (e.g. “social support”, “social relations”, “sense of community”, “bullying”, “working atmosphere in the practice team”, “cooperation”), training (e.g. “offer for training”, “support by supervisor for training”), feedback and leadership (e.g. “feedback”, “leadership quality”, “supervisor”), and other job aspects that can have a positive impact on work (e.g. “workplace environment”, “meaning of work”, “amount of variety in job” and “possibilities for development”) [3, 35–37, 41, 43, 45–50].
In general, the concepts related to social relations received the most positive values among the psychosocial working conditions captured in the scrutinized studies [3, 36, 37, 41, 43, 45, 47, 50, 62]. According to our calculations, only one study presented a value below the critical cut-off for “social relations” [50].
The evidence regarding leadership can be considered mixed. While most studies reported favorably about leadership [37, 47, 49, 50], others [35, 37] presented, according to our calculations, a critical value for the categories “feedback” and “supervisor”. Another study reported that the majority of MA expressed the need for more understanding from their supervisor and the wish for the physicians (their supervisors) to have educational opportunities related to organizational leadership [35].
“Meaning of work”, i.e. the feeling that the work done is important [41, 50], was consistently rated as very high. “Amount of variety in job” [3, 36, 37, 43, 45, 48] was also consistently reported as positive, and another study [49] reported that 89.5% (n = 790) in their sample agreed that their work is varied.
One study examining further training reported that a third of MA found the available offer of training courses for MA to be sufficient or very good and the majority of MA expressed to receive support from their supervisor to attend continuing education courses [47]. Another study examined “benefits”, which covered continuous education and opportunities for career advancement [46], and reported a value which, according to our calculations, can be considered as potentially critical. Scharf et al. [35] reported that more than half of the MA participating in their study expressed the need to have more educational opportunities. The concept “possibilities for development” was captured by two studies [41, 50], both reporting satisfaction in this area.
Job rewards
Status-related rewards entail career opportunities, which we analyzed as resources, and job security, which we analyzed as part of job control. Financial rewards of MA have been captured using the concept “income” [3, 36, 37, 43, 45, 48]. These studies consistently reported low satisfaction levels for this category, with two studies [3, 43] reporting potentially critical values according to our calculations. Further, one study captured the relationship between additional qualifications and financial incentives, reporting that 35.8% (n = 98) of the participating MA saw a financial incentive from additional qualification, but only 24.8% (n = 68) MA expressed to have received a remuneration increase due to an additional qualification [36]. Another study reported that 87.0% (n = 759) of the participating MA expressed their wish to have a higher salary [35].
Socioemotional rewards include esteem or recognition [31]. Studies capturing the concept “recognition for work” consistently reported moderate satisfaction with this form of reward [3, 36, 37, 43, 45, 48].
The imbalance between effort and rewards, captured with the ERI-ratio, has been associated with stress at work [32]. The ERI-ratio was captured by two quantitative studies [42, 49], which consistently reported mean ERI-ratios above 1, indicating the presence of work stress among MA. Vu-Eickmann et al. [49] reported that the prevalence of work stress according to the ERI ratio was high among MA (73.77%). Fauser et al. [42] also reported overcommitment as a further dimension of the ERI-model, which following our calculations also falled under the critical cut-off category among MA.
Psychosocial working conditions of medical assistants in qualitative studies
A total of n = 10 studies examined psychosocial working conditions among MA using qualitative methods. Table 3 presents the concepts identified in each study, as well as a summary of their main findings. Most studies used an inductive approach (i.e., categories emanating from the data) for the analysis of the collected data, whereas two studies [55, 57] structured the categories deductively (i.e., following a pre-established theoretical framework), adding inductive concepts into a pre-established category system. We present a brief narrative summary of the key findings structured by occurring themes under the categories job demands, job control, job resources and job rewards.
Job demands
The workload of MA was consistently reported as high [56–58]. High workload was said to be promoted by a high patient volume combined with a shortage of staff [58]. MA further expressed to be subjected to stress due to a high workload, high time pressure, great amount of administrative work and confidentiality requirements [52, 56]. Increased documentation requirements were perceived to raise the time needed to complete administrative tasks and, as a consequence, MA felt to have less time for patients [58]. According to the researchers’ observations, a high work load and work intensity further prevented MA from taking appropriate breaks [55, 58]. It was reported that in one practice MA completed administrative tasks during lunch breaks [55] and, more generally, that MA tended to work extra hours which often remained uncompensated [58], having a negative impact on their private lives [54].
Qualitative studies that examined psychosocial working conditions of MA during the COVID-19 pandemic reported an increased workload [51, 53], with one study reporting MA being overwhelmed by the situation [53]. Studies examining the implementation of interventions reported barriers in MA taking up new tasks and/or responsibilities in the context of these interventions due to an already existing lack of time [52, 53].
In general, the behavior of some patients, colleagues and supervisors was considered to be stressful [52, 56, 58]. These behaviors were reported to include a lack of understanding or support by colleagues or superiors [52, 58], emotionally short-tempered employers, and negative changes in patient’s attitudes [58]. The combination of a personally difficult employer combined with a lack of social support in the team was considered to be particularly stressful [58].
MA with a migration background reported that they were often asked to assume the role of translators and cultural mediators by patients, superiors, or colleagues, adding to their already existing workload [38]. However, those MA did not perceive these additional demands as stressful [38].
Job control
Tsarouha et al. [57] reported that high work intensity lead to frequent interruptions and incomplete execution of tasks. Interruptions by colleagues and patients were consistently reported as frequent [55, 57, 58]. “Unplannable” events and carrying out different tasks and roles simultaneously were considered as stressful by MA in one study [55]. Interruptions were caused by phone calls, emergency patients, and by supervisors’ behavior [58]. Multi-tasking was reported as common, especially among MA working at the reception desk [57]. Work design was considered to influence the ability to decide when to take breaks, e.g. the visibility of MA across the reception desk hindered them from taking mini-breaks [55] and led to the feeling of being constantly under observation [57]. However, MA reported to have a certain degree of decision latitude in some sets of assigned tasks, which they considered to be a key resource [58].
Job resources
Appropriate decision latitude regarding the sequence of job-related activities was mentioned as an important resource by MA [57–59]. MA managed interruptions through prioritization, e.g. by asking patients to cue or by not answering phone calls while doing something else [57]. Flexibility of working hours and the supervisor’s support in these regards were reported as positive by MA [55].
Good relationships with co-workers and superiors were consistently reported as a key resource of MA [52, 55–59], they facilitated teamwork and planning [55, 58] and helped MA deal with difficult and stressful situations, overall contributing to happiness at the workplace [59]. A study reported that team meetings helped MA strengthen cooperation with colleagues [59].
Good relationships with patients, including positive interactions with them, were consistently reported as an overarching job-related resource for MA [52, 56, 58, 59].
Further resources included access to suitable work stations, equipment and software [57], the broad variety of activities that characterize the profession [58], and trust shown in the organization of the own set of assigned tasks [59].
Job rewards
One study reported that MA’s low salary constitutes the central aspect of the precarity of the MA profession, and that MA are dissatisfied with their income, especially when they compare themselves to other professions in the health care sector [54]. Obtaining further qualifications was considered to hardly have an impact on salary or career prospects [54]. Besides desire for a higher salary, it was reported that MA desire greater recognition by society, patients, and supervisors [58]. A study conducted during the COVID-19 pandemic reported that MA felt that their role as frontline workers did not receive adequate recognition [51]. Positive feedback and gratitude from patients contributed to MA’s satisfaction with their work [53, 59].
Mental health among medical assistants
Among the reviewed studies, n = 8 captured mental health among MA. We present an overview of these studies, all of which used quantitative methods, in Table 4.
Burnout was captured by three studies using the Copenhagen Burnout Inventory (CBI) [41, 42] and the COPSOQ [50, 63]. Out of these, only one study [42] reported a potentially critical value for burnout according to our cut-off calculation.
Stress was captured by five studies with the concepts “cognitive stress symptoms” using the COPSOQ [41, 50, 63], “chronic stress” using the Trier Inventory for the assessment of Chronic Stress (TICS-SSCS) [39, 61], and “stress” using the Differential Stress Inventory (DSI) [60]. These studies reported consistently uncritical values when we applied a mid-point as cut-off. However, the prevalence of high strain among MA due to chronic stress was reported to be at 26.4% [61].
Two studies captured depressive symptoms using the short version of the Patient Health Questionnaire (PHQ-2) and generalized anxiety disorder symptoms using the Generalized Anxiety Disorder questionnaire (GAD-2) [40, 49]. The first study [49] reported no critical values according to our calculations for the sample average, but the prevalence of depressiveness among MA was 17.45% and for anxiety 20.14%. Similarly, a study conducted during the COVID-19 pandemic reported a prevalence of depressive symptoms of 29.9% and of generalized anxiety disorder symptoms of 42.6% among MA [40].
Discussion
Summary of evidence
This is to our knowledge the first scoping review on psychosocial working conditions and mental health among MA in Germany. Studies on this topic used to be sparse but have increased in numbers in the past years. The 30 reviewed studies used heterogeneous concepts and instruments. Compared to studies on psychosocial working conditions, studies on mental health among MA were rather scarce.
Quantitative and mixed methods studies consistently indicated that MA in Germany were satisfied with their job and considered their role and responsibilities to be clear. Studies examining work-privacy conflict, meaning of work, job insecurity, predictability, and amount of variety in job reported these consistently as unproblematic. We found a favorable tendency in reports on decision latitude as well as social relations at work. Findings were mixed regarding emotional demands, leadership, training and benefits, as well as on job demands. In quantitative and mixed methods studies, recognition for work was consistently reported as moderate, while satisfaction with income was consistently reported as low. Quantitative demands, stress and workload were partially reported as problematic, especially during the COVID-19 pandemic.
With the exception of the study by Hoffmann et al. [53], which reported that the examined intervention positively affected the job satisfaction among MA, “job satisfaction” was not directly referred to as a term in qualitative studies. Qualitative studies indicated more consistently that MA face job demands in terms of a high workload, high intensity, and time pressure, leading them to take few breaks or work overtime. The interaction with some patients and co-workers was also reported as demanding. Further, qualitative studies indicated that the everyday work of MA, especially during consultation hours, was characterized by interruptions, unplanned events, and the need for multi-tasking. Following qualitative studies, decision latitude regarding the sequence of job-related activities, support from colleagues and supervisors and positive relationships with patients constituted important job resources for MA.
Regarding mental health, most studies presented overall uncritical values, whereas the prevalence of mental health symptoms or high strain due to chronic stress, when measured, can be considered high when compared with the general female population in Germany before [64] and during the COVID-19 pandemic [65]. No prevalences were reported for burnout symptoms among MA.
Quantitative versus qualitative studies
Our results on psychosocial working conditions among MA revealed some discrepancies between quantitative and mixed methods studies on the one hand, and qualitative studies on the other. The latter consistently emphasized that high workload, a lack of time to complete tasks, and interruptions lead MA to prioritize tasks, multitask, skip breaks, or work longer in order to fulfill their tasks. Quantitative and mixed methods studies, in contrast, were less consistent regarding negative psychosocial working conditions pertaining to job demands and job control, or even reported favorably about them. A possible explanation for the observed discrepancies may be that the COPSOQ [66] and WCW instruments [67], which were most commonly used to examine psychosocial working conditions among MA in Germany, do not capture some of the specific aspects identified in qualitative studies, that is, interruptions, multitasking, long working hours, breaks, and rewards (except for income). Further, according to qualitative studies, the relationship with patients was an important resource or stressor among MA, whereas quantitative or mixed method studies rarely examined this concept, often limiting social relations at work to those with colleagues and supervisors. Hence, while the job satisfaction scales commonly used in the research of MA in Germany may provide important initial insights on their working conditions, it seems that they are not sufficient to capture the whole spectrum of psychosocial working conditions among MA.
Similar discrepancies between negative working conditions reported in qualitative studies and high levels of job satisfaction reported in surveys have been previously observed among healthcare workers in Germany [68]. It has been suggested that the global approach of the instruments capturing job satisfaction causes a reporting bias towards positive results, as they tend to produce answers that are assumed to be socially desirable and fail to capture more nuanced perceptions of the working conditions [68]. This could also be a possible explanation in the case of MA.
Low income versus job satisfaction
Although MA are generally satisfied with their job, low income represents the aspect they seemed to be the least satisfied with. This result was consistent throughout the various types of studies. To date, different collective agreements regulate MA’s salary and working hours but are not legally binding. As a consequence, MA’s salary often depends on their negotiation skills [54]. It has been suggested that because MA are already under enormous strain balancing their job and private life, they fail to participate in unions and organize themselves to claim better employment rights [54]. The overall job satisfaction and the higher satisfaction with other psychosocial working conditions such as social relations among MA could be interpreted as a possible reason for MA to accept their salary. It is also possible that MA not satisfied with their job have already left the profession and are not reflected in the results of this review, thus resulting in a possible selection bias. Such resignation or turnover have been described as possible explanations for the discrepancy between negatively perceived working conditions and high levels of job satisfaction among hospital staff in Germany [68]. A meta-analysis among nurses indicated that turnover was highly associated with supportive and communicative leadership, network centrality (i.e., being surrounded by meaningful social connections to peers), and organizational commitment, whereas salary had no significant effect [19]. To our knowledge, there is to date no study on actual turnover among MA.
Working conditions during the COVID-19 pandemic
Outpatient practices had a key role during the COVID-19 pandemic in Germany, e.g. by contributing to a great extent to the national immunization campaign and by assuming other tasks, such as the information of patients regarding the pandemic, which were not adequately or completely covered by the responsible health authorities [69]. Three studies indicated a subjective increase in workload for MA in this setting due to the pandemic [40, 46, 51], whereas the only included study examining mental health among MA during this period [40] reported a very high prevalence of depressive symptoms (29.9%) and of generalized anxiety disorder symptoms (42.6%) among MA compared with the general female population in Germany during the pandemic [65]. A qualitative study from our working group published after our retrieval of sources and thus not included in this review highlighted the workload increase and unfavorable changes in the social interaction with colleagues and patients among MA during the COVID-19 pandemic [70]. These forms of negative impact on psychosocial working conditions and mental health have also been observed among other health care workers during the pandemic [71–75]. However, it has been suggested that physicians’ practices in Germany were less well prepared for the pandemic situation than hospitals [69] and that female health care workers were at higher risk of negative mental health outcomes during the pandemic [76]. This may place MA among the most vulnerable health care workers during the crisis and could explain why the prevalence of anxiety and depressive symptoms among MA during the pandemic was, unlike that of other health care professions in Germany, higher than among the general population [74, 77, 78]. However, the prevalence of depressiveness (17.45%) and anxiety (20.14%) among MA was already high before the pandemic compared with the general female population in the country, which corresponded to 11.3% for any mood disorder and 3.0% for generalized anxiety disorder [64]. During the pandemic, MA further resented that their profession did not receive the same attention and recognition from society and the government for their contribution during the pandemic as nurses did [51, 70], and expressed a decrease of job satisfaction [70].
Recommendations for future research
Apart from highlighting gaps in the literature, our results emphasize the importance of combining qualitative research and quantitative studies into a single study (i.e., mixed methods). The selection of instruments or concepts to measure psychosocial working conditions should be adapted to the particularities of the profession under examination and can be derived from qualitative studies. For instance, as a patient-oriented profession, the relationship with patients should also be part of future quantitative assessments of psychosocial working conditions among the MA profession [9].
To better understand the discrepancy between the overall job satisfaction among MA and unfavorable psychosocial working conditions, such as a low salary, further studies should engage with MA turnover, as unsatisfied MA may have already left the profession and are potentially underrepresented in studies addressing job satisfaction. This could be done by surveying MA who are about to leave or already left the profession. Alternatively, a study following a cohort of newly trained MA over time could provide insights on the psychosocial working conditions and mental health statuses leading to turnover in the profession.
Our results suggest that the psychosocial working conditions and mental health among MA worsened during the COVID-19 pandemic. It is vital to keep in mind that these results reflect the situation during a crisis and may not apply to normal operations. Thus, further studies should examine if the deteriorated psychosocial working conditions and mental health of MA persist in the post-pandemic era.
Limitations
Due to the heterogeneity of the concepts and instruments used in the reviewed studies, concepts are not very clear-cut, and the comparison of different studies was difficult. We used a self-defined critical cut-off based on the mid-point of the reported scales as a pragmatic way to address this limitation. Through this approach, we aimed to facilitate the identification of prominent stressors in relation to other stressors, not in absolute terms. However, the choice of the cut-off was arbitrary, and this self-developed approach could not be applied to studies not reporting mean values. Also, the approach is only statistical and does not consider that mid-points can carry different meanings. For example, whereas an “amount of variety of job” value on the WCW scale of job satisfaction above the mid-point cut-off indicates satisfaction with this aspect of the job, a “versatility” value from the KFZA-scale above the mid-point cut-off indicates agreement with the statement that the job is versatile, but not necessarily satisfaction with this job aspect. Further, as common in scoping reviews, we did not conduct a critical appraisal of the individual sources of evidence, nor did we extract details about the recruitment of study participants, e.g., response rates. This is because, unlike systematic reviews, scoping reviews are not intended to provide evidence to guide policies [21], but aim to provide an overview of available evidence regardless of its quality [79]. Further, the replicability of Google Scholar searches has been criticized [80]. We have addressed this limitation by uploading the results of our database retrieval on OSF (https://osf.io/2837w/?view_only=37d260e1618e4556891819fd6e054f61), as recommended [80].
Conclusions
The psychosocial working conditions among MA in Germany have been captured with heterogeneous concepts and instruments, whereby the job satisfaction scales of the WCW and COPSOQ instruments were used most commonly. Mental health among this population was captured in only eight out of 30 studies which addressed anxiety symptoms, burnout, depressive symptoms, and stress using established instruments. The scrutinized studies indicate that MA in Germany were overall satisfied with their job, but reported mixed results regarding job demands, control, resources, and rewards. The studies reported consistently that MA were unsatisfied with their income and suggested that MA are subjected to stress due to an effort-reward imbalance. As for MA’s mental health, averages can be considered unproblematic, but prevalences appear to be high when compared with the German female population. Additionally, it will be interesting to see if the current staff shortages of MA will lead to positive changes of their working conditions in the future, such as higher salaries.
Our results indicate that quantitative studies have so far not adequately assessed the relationship with patients and the job control aspects related to interruptions and multitasking as part of the psychosocial working conditions of MA in Germany, both aspects that are characteristic of the MA profession and have been mentioned in qualitative studies. The discrepancy between overall job satisfaction, a low salary and stressful working conditions requires further examination, as job satisfaction appears to be too general a concept to capture the whole spectrum of the MA profession. Additionally, further research is required to assess if the psychosocial working conditions and mental health of MA in Germany remained changed after the COVID-19 pandemic, and to better understand the psychosocial working conditions and the mental health status among MA in Germany.
Supplementary Information
Additional file 1: Annex 1. Protocol amendments and their justification.
Additional file 2: Annex 2. Full electronic search strategy used for PubMed (Medline).
Acknowledgements
We thank Maria-Inti Metzendorf from the Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany for her advice on the selection of databases and on the development of the search strings, Dr. Sabrina Schlesinger from the German Diabetes Center in Düsseldorf, Germany, for discussion on methods for analyzing same outcomes measured with different instruments, and Dr. Julia Salandi from the Institute of Occupational, Social and Environmental Medicine, Centre for Health and Society, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany for commenting an early draft. We would also like to thank Prof. Dr. Katja Goetz from the Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany and Dr. Karola Mergenthal from the Institute of General Practice, Goethe University, Frankfurt am Main, Germany, two experts in the field who suggested further sources not found through our database search.
Authors’ contributions
Conceptualization of the review: KS, AL. Development of search strategies: KS. Conduction of (preliminary) searches: KS. Title and abstract screening: KS, AD, AL, VM. Full-text screening: KS, VM. Data extraction: KS, VM. Analysis of data: KS, VM. Drafting of the original manuscript: KS. Visualization: KS. Review of the manuscript: AL, AD, VM, KS.
Funding
Open Access funding enabled and organized by Projekt DEAL. This scoping review was funded by the German Employer's Liability Insurance Association for Health Services and Welfare Care (Berufsgenossenschaft Gesundheitsdienst und Wohlfahrtspflege, BGW), project ID = Ext FF_1344.
Availability of data and materials
Not applicable.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
AL has presented findings related to the health and working conditions of MA at meetings or workshops of professional associations or companies (i.e., ABF-Synergie GmbH) and has received honoraria. Our review has included the following studies authored by AD and AL, constituting a potential non-financial competing interest:
• [40] Dreher A, Pietrowsky R, Loerbroks A. Pandemic-related attitudes, stressors and work outcomes among medical assistants during the SARS-CoV-2 ("Coronavirus") pandemic in Germany: A cross-sectional Study. PLoS One 2021; 16(1): e0245473
• [35] Scharf, J; Vu-Eickmann, P; Li, J; Müller, A; Wilm, S; Angerer, P; Loerbroks, A. Desired improvements of working conditions among medical assistants in Germany: a cross-sectional study. J Occup Med Toxicol 2019; 14: 18 [10.1186/s12995-019-0237-x] [PMID: 31168312]
• [58] Vu-Eickmann P, Loerbroks A. Psychosoziale Arbeitsbedingungen Medizinischer Fachangestellter: Ergebnisse einer qualitativen Studie zu den berufsspezifischen Belastungen, Ressourcen, Präventionsmöglichkeiten und Interventionsbedürfnissen. Z Evid Fortbild Qual Gesundhwes 2017; 126: 43–51
• [62] Vu-Eickmann P, Loerbroks A. Psychosoziale Arbeitsbedingungen und Versorgungsqualität: Ergebnisse einer qualitativen Studie unter Medizinischen Fachangestellten (MFAs). Gesundheitswesen 2018; 80: 1084–7.
• [49] Vu-Eickmann P, Li J, Müller A, Angerer P, Loerbroks A. Associations of psychosocial working conditions with health outcomes, quality of care and intentions to leave the profession: results from a cross-sectional study among physician assistants in Germany. Int Arch Occup Environ Health 2018; 91(5): 643–54
KS and VM declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Association of Medical Professions. Career aspiration: Medical assistant (MFA): Requirements, training, prospects. Association of Medical Professions; 2020. Cited 12th July 2023. Available from: https://www.vmf-online.de/download/berufsbild-berufswunsch-mfa-medizinische-fachangestellte.
- 2.German Federal Office of Statistics (Destatis), Genesis-Online. Healthcare workforce: Germany, years, employment, facilities, gender, healthcare professions, 2021: 23621–0004: German Federal Office of Statistics; 2021. Cited 2023 July 25. Available from: https://www-genesis.destatis.de/genesis/online?operation=previous&levelindex=2&step=2&titel=Ergebnis&levelid=1690270645891&acceptscookies=false#abreadcrumb.
- 3.Mergenthal K, Güthlin C. Einflussgrößen auf die Arbeitszufriedenheit von Medizinischen Fachangestellten. Z Evid Fortbild Qual Gesundhwes. 2021;167:78–85. doi: 10.1016/j.zefq.2021.09.006. [DOI] [PubMed] [Google Scholar]
- 4.Central Institute of the Statutory Medical Care in the Federal Republic of Germany. Staffing situation in clinics of statutory health care and psychotherapeutic health care. Berlin: Central Institute of the Statutory Medical Care in the Federal Republic of Germany; 2021.
- 5.Oettel J, Zschille M, Leibner M. Training of medical assistants (MA) in practices and facilities of statutory health insurance physicians Berlin: Central Institute of the Statutory Medical Care in the Federal Republic of Germany; 2023.
- 6.National Association of Statutory Health Insurance Physicians, National Association of Statutory Health Insurance Fonds. Agreement on the delegation of medical services to non-physician staff in outpatient contract medical care pursuant to § 28 para. 1 sentence 3 SGB V]; 2015.
- 7.Vu-Eickmann P, Loerbroks A. Medizinisch Fachangestellte: ein Überblick über die psychosozialen Arbeitsbedingungen dieser Berufsgruppe sowie mögliche Implikationen. In: Angerer P, Gündel H, Brandenburg S, Nienhaus A, Letzel S, Nowak D, editors. Arbeiten im Gesundheitswesen: Psychosoziale Arbeitsbedingungen – Gesundheit der Beschäftigten – Qualität der Patientenversorgung. Landsberg: Ecomed Medizin; 2019. pp. 52–63. [Google Scholar]
- 8.Lampert B, Hornung S, Glaser J. Interkationsarbeit, Emotionsregulation und Detached Concern in gesundheitsbezogenen Dienstleistungen. In: Angerer P, Gündel H, Brandenburg S, Nienhaus A, Letzel S, Nowak D, editors. Arbeiten im Gesundheitswesen: Psychosoziale Arbeitsbedingungen – Gesundheit der Beschäftigten – Qualität der Patientenversorgung. ecomed Medizin: Landsberg; 2019. pp. 29–41. [Google Scholar]
- 9.Seubert C, Strecker C, Glaser J. Psychologische Arbeitsanalysen im Gesundheitswesen. In: Angerer P, Gündel H, Brandenburg S, Nienhaus A, Letzel S, Nowak D, editors. Arbeiten im Gesundheitswesen: Psychosoziale Arbeitsbedingungen – Gesundheit der Beschäftigten – Qualität der Patientenversorgung. ecomed Medizin: Landsberg; 2019. pp. 3–28. [Google Scholar]
- 10.Dormann C, Spethmann K, Weser D, Zapf D. Organisationale und persönliche Dienstleistungsorientierung und das Konzept des kundenorientierten Handlungsspielraums. Zeitschrift für Arbeits Organisationspsychol. 2003;47(4):194–207. doi: 10.1026//0932-4089.47.4.194. [DOI] [Google Scholar]
- 11.Niedhammer I, Bertrais S, Witt K. Psychosocial work exposures and health outcomes: a meta-review of 72 literature reviews with meta-analysis. Scand J Work Environ Health. 2021;47(7):489–508. doi: 10.5271/sjweh.3968. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Stansfeld S, Candy B. Psychosocial work environment and mental health–a meta-analytic review. Scand J Work Environ Health. 2006;32(6):443–462. doi: 10.5271/sjweh.1050.MID:17173201. [DOI] [PubMed] [Google Scholar]
- 13.Klein J, Grosse Frie K, Blum K, von dem Knesebeck O. Psychosocial stress at work and perceived quality of care among clinicians in surgery. BMC Health Serv Res. 2011;11:109. doi: 10.1186/1472-6963-11-109. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Paquet M, Courcy F, Lavoie-Tremblay M, Gagnon S, Maillet S. Psychosocial work environment and prediction of care indicators in one canadian health center. Worldviews on Evid Based Nurs. 2011;102:82–94. doi: 10.5281/zenodo.1178103. [DOI] [PubMed] [Google Scholar]
- 15.Virtanen M, Kurvinen T, Terho K, et al. Work hours, work stress, and collaboration among ward staff in relation to risk of hospital-associated infection among patients. Med Care. 2009;47(3):310–318. doi: 10.1097/MLR.0b013e3181893c64. [DOI] [PubMed] [Google Scholar]
- 16.Weigl M, Schneider A, Hoffmann F, Angerer P. Work stress, burnout, and perceived quality of care: a cross-sectional study among hospital pediatricians. Eur J Pediatr. 2015;174:1237–1246. doi: 10.1007/s00431-015-2529-1. [DOI] [PubMed] [Google Scholar]
- 17.Mambrey V, Vu-Eickmann P, Angerer P, Loerbroks A. Associations between Psychosocial Working Conditions and Quality of Care (i.e., Slips and Lapses, and Perceived Social Interactions with Patients)-A Cross-Sectional Study among Medical Assistants. Int J Environ Res Public Health 2021; 18(18). 10.3390/ijerph18189693. PMID: 34574618. [DOI] [PMC free article] [PubMed]
- 18.Chen H-C, Wang J-Y, Lee Y-C, Yang S-Y. Examining the predictors of turnover behavior in newly employed certified nurse aides: a prospective cohort study. Saf Health Work. 2023;14(2):185–192. doi: 10.1016/j.shaw.2023.04.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Nei D, Snyder LA, Litwiller BJ. Promoting retention of nurses: a meta-analytic examination of causes of nurse turnover. Health Care Manage Rev. 2015;40(3):237–253. doi: 10.1097/HMR.0000000000000025. [DOI] [PubMed] [Google Scholar]
- 20.Spielberg P. Mangel an MFA bei Niedergelassenen. Rechtzeitig den Schwund trotzen. Deutsches Ärzteblatt. 2022;119(12):A-540/B-444.
- 21.Peters MDJ, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015;13(3):141–146. doi: 10.1097/XEB.0000000000000050. [DOI] [PubMed] [Google Scholar]
- 22.Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(143):1–10. doi: 10.1186/s12874-018-0611-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–473. doi: 10.7326/M18-0850. [DOI] [PubMed] [Google Scholar]
- 24.Madsen IEH, Nyberg ST, Magnusson Hanson LL, et al. Job strain as a risk factor for clinical depression: systematic review and meta-analysis with additional individual participant data. Psychol Med. 2017;47(8):1342–1356. doi: 10.1017/S003329171600355X. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Virtanen M, Nyberg ST, Batty GD, et al. Perceived job insecurity as a risk factor for incident coronary heart disease: systematic review and meta-analysis. BMJ. 2013;347:f4746–f4746. doi: 10.1136/bmj.f4746. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Seidler A, Thinschmidt M, Deckert S, Then F, Hegewald J, Nieuwenhuijsen K, et al. The role of psychosocial working conditions on burnout and its core component emotional exhaustion - a systematic review. J Occup Med Toxicol. 2014;9(10):1–13. doi: 10.1186/1745-6673-9-10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Andrea H, Bültmann U, Beurskens AJHM, Swaen GMH, van Schayck CP, Kant IJ. Anxiety and depression in the working population using the HAD Scale–psychometrics, prevalence and relationships with psychosocial work characteristics. Soc Psychiatry Psychiatr Epidemiol. 2004;39(8):637–646. doi: 10.1007/s00127-004-0797-6. [DOI] [PubMed] [Google Scholar]
- 28.Bramer WM, Rethlefsen ML, Kleijnen J, Franco OH. Optimal database combinations for literature searches in systematic reviews: a prospective exploratory study. Syst Rev. 2017;6(1):245. doi: 10.1186/s13643-017-0644-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Karasek R. Job demands, job decision latitude, and mental strain: Implications for job redesign. Administrative science quarterly. 1979: 285–308.
- 30.Bakker A, Demerouti E. Job demands-resources theory: taking stock and looking forward. J Occup Health Psychol. 2017;22(3):273–285. doi: 10.1037/ocp0000056. [DOI] [PubMed] [Google Scholar]
- 31.Siegrist J. The Effort-Reward Imbalance Model. In: Cooper CL, Quick JC, editors. The Handbook of Stress and Health. John Wiley & Sons, Ltd: Chichester, UK; 2017. pp. 24–35. [Google Scholar]
- 32.Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occup Health Psychol. 1996;1(1):27–41. doi: 10.1037/1076-8998.1.1.27. [DOI] [PubMed] [Google Scholar]
- 33.Bakker AB, Demerouti E. The job demands-resources model: State of the art. J Manage Psych. 2007;22(3):309–328. doi: 10.1108/02683940710733115. [DOI] [Google Scholar]
- 34.Oelschlegel HM. Erfassung der Aufgaben der Arzthelferin bei der Methadonsubstitution in der allgemeinmedizinischen Praxis im Bereich Süd-Württemberg: Spezifische Probleme und Problemlösungen. Medizinische Fakultät: Erberhard-Karls-Universität zu Tübingen; 2007. [Google Scholar]
- 35.Scharf J, Vu-Eickmann P, Li J, et al. Desired improvements of working conditions among medical assistants in Germany: a cross-sectional study. J Occup Med Toxicol. 2019;14:18. doi: 10.1186/s12995-019-0237-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Feindel A, Rosenberg G, Steinhäuser J, Mozr C, Goetz K. Primary care practice assistants' attitudes towards tasking shifting and their perceptions of the challenges of task shifting - Development of a questionnaire. Health Soc Care Community. 2019;27(4):e323–e333. doi: 10.1111/hsc.12736. [DOI] [PubMed] [Google Scholar]
- 37.Goetz K, Campbell S, Broge B, et al. Job satisfaction of practice assistants in general practice in Germany: an observational study. Fam Pract. 2013;30(4):411–417. doi: 10.1093/fampra/cmt015. [DOI] [PubMed] [Google Scholar]
- 38.Mergenthal K, Gerlach FM, Güthlin C. Vorhandene Ressourcen effektiv nutzen – Medizinische Fachangestellte mit Migrationshintergrund in der Hausarztpraxis. Z Allg Med. 2012;88(11):466–474. [Google Scholar]
- 39.Degen L, Linden K, Seifried-Dübon T, et al. Job Satisfaction and Chronic Stress of General Practitioners and Their Teams: Baseline Data of a Cluster-Randomised Trial (IMPROVEjob). Int J Environ Res Public Health 2021; 18(18). 10.3390/ijerph18189458. PMID: 34574383. [DOI] [PMC free article] [PubMed]
- 40.Dreher A, Pietrowsky R, Loerbroks A. Pandemic-related attitudes, stressors and work outcomes among medical assistants during the SARS-CoV-2 ("Coronavirus") pandemic in Germany: a cross-sectional Study. PLoS One. 2021;16(1):e0245473. doi: 10.1371/journal.pone.0245473. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Erler A, Beyer M, Welbers G, Gerlach FM. Zusammenschluss von Hausarztpraxen zum SCHAATZ – Auswirkungen auf Arbeitszufriedenheit und Burnout-Risiko. Z Allg Med. 2012;88(7/8):303–312. [Google Scholar]
- 42.Fauser D, Scholz M, Wirtz MA. Assessment und Vorhersage von Burnout gemäß des Effort-Reward Imbalance-Modells bei Medizinischen Fachangestellten. Diagnostica. 2020;66(3):190–199. doi: 10.1026/0012-1924/a000247. [DOI] [Google Scholar]
- 43.Gavartina A, Zaroti S, Szecsenyi J, et al. Practice assistants in primary care in Germany - associations with organizational attributes on job satisfaction. BMC Fam Pract. 2013;14(110):1–6. doi: 10.1186/1471-2296-14-110. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Göbel J, Schmidt M, Seifried-Dübon T, et al. Higher work-privacy conflict and lower job satisfaction in gp leaders and practice assistants working full-time compared to part-time: results of the IMPROVEjob study. Int J Environ Res Public Health 2022; 19(5). 10.3390/ijerph19052618. PMID: 35270317. [DOI] [PMC free article] [PubMed]
- 45.Goetz K, Campbell SM, Steinhaeuser J, Broge B, Willms S, Szecsenyi J. Evaluation of job satisfaction of practice staff and general practitioners: an exploratory study. BMC Fam Pract. 2011;12:137. doi: 10.1186/1471-2296-12-137. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Hoffmann J, Kersting C, Weltermann B. Practice assistants´ perceived mental workload: A cross-sectional study with 550 German participants addressing work content, stressors, resources, and organizational structure. PLoS One. 2020;15(10):e0240052. doi: 10.1371/journal.pone.0240052. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.Mahler C, Trieschmann J, Szecsenyi J, Rosemann T. Fortbildungsmotivation von Arzthelferinnen - Ergebnisse einer Befragung. Z Allg Med. 2007;83(5):191–196. doi: 10.1055/s-2007-977708. [DOI] [Google Scholar]
- 48.Szecsenyi J, Goetz K, Campbell S, Broge B, Reuschenbach B, Wensing M. Is the job satisfaction of primary care team members associated with patient satisfaction? BMJ Qual Saf. 2011;20(6):508–514. doi: 10.1136/bmjqs.2009.038166. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Vu-Eickmann P, Li J, Müller A, Angerer P, Loerbroks A. Associations of psychosocial working conditions with health outcomes, quality of care and intentions to leave the profession: results from a cross-sectional study among physician assistants in Germany. Int Arch Occup Environ Health. 2018;91(5):643–654. doi: 10.1007/s00420-018-1309-4. [DOI] [PubMed] [Google Scholar]
- 50.Zaroti S. Psychosoziale Arbeitsbelastungen und Beanspruchungen von Hausärzten und Medizinischen Fachangestellten aus Baden-Württemberg-Eine quantitative Studie. Dissertation, Medizinische Fakultät, Universität Heidelberg 2015.
- 51.Ehlers-Mondorf J, Schrader H, Makowski L, Gágyor I, Joos S, Kaduszkiewicz H. SARS-CoV-2-Pandemie: Erfahrungen von Medizinischen Fachangestellten in hausärztlichen Praxen. Z Allg Med. 2021;97(12):502–507. [Google Scholar]
- 52.Gensichen J, Jaeger C, Peitz M, et al. Health care assistants in primary care depression management: role perception, burdening factors, and disease conception. Ann Fam Med. 2009;7(6):513–519. doi: 10.1370/afm.1037. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.Hoffmann M, Stengel S, Szecsenyi J, Peters-Klimm F. Health care professionals' perspectives on the utilisation of a remote surveillance and care tool for patients with COVID-19 in general practice: a qualitative study. BMC Prim Care. 2022;23(1):254. doi: 10.1186/s12875-022-01863-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 54.Kathmann T, Dingeldey I. Prekarisierung berufsfachlich qualifizierter Beschäftigung? Eine Analyse der Arbeitsbedingungen von medizinischen Fachangestellten. Reihe Arbeit und Wirtschaft in Bremen 4; 2013.
- 55.Preiser C, Tsarouha E, Weltermann B, et al. Psychosocial demands and resources for working time organization in GP practices. Results from a team-based ethnographic study in Germany. J Occup Med Toxicol. 2021;16(1):47. doi: 10.1186/s12995-021-00336-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 56.Rothe M, Benedikt G, Schäfert R, et al. Die Arzthelferin und der schwierige Patient. Eine qualitative Studie zu mentalen Konstrukten bei Arzthelferinnen über schwierige Patienten in der Hausarztpraxis. PPmP-Psychotherapie·Psychosomatik Medizinische Psychologie. 2006. 10.1055/s-2006-934299
- 57.Tsarouha E, Preiser C, Weltermann B, et al. Work-Related Psychosocial Demands and Resources in General Practice Teams in Germany. A Team-Based Ethnography. Int J Environ Res Public Health 2020; 17(19). 10.3390/ijerph17197114. PMID: 32998397. [DOI] [PMC free article] [PubMed]
- 58.Vu-Eickmann P, Loerbroks A. Psychosoziale Arbeitsbedingungen Medizinischer Fachangestellter: Ergebnisse einer qualitativen Studie zu den berufsspezifischen Belastungen, Ressourcen, Präventionsmöglichkeiten und Interventionsbedürfnissen. Z Evid Fortbild Qual Gesundhwes. 2017;126:43–51. doi: 10.1016/j.zefq.2017.06.005. [DOI] [PubMed] [Google Scholar]
- 59.Werdecker L, Esch T. Glück in der Hausarztpraxis. Ergebnisse einer qualitativen Studie unter Praxisteams. Z Allg Med. 2022;98(1):24–9. [Google Scholar]
- 60.Karlsen HR, Böckelmann I, Thielmann B. Subjective and objective demands on different types of differential stress inventory. Int Arch Occup Environ Health. 2021;94(5):855–866. doi: 10.1007/s00420-020-01632-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 61.Viehmann A, Kersting C, Thielmann A, Weltermann B. Prevalence of chronic stress in general practitioners and practice assistants: personal, practice and regional characteristics. PLoS One. 2017;12(5):e0176658. doi: 10.1371/journal.pone.0176658. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 62.Vu-Eickmann P, Loerbroks A. Psychosoziale Arbeitsbedingungen und Versorgungsqualität: ergebnisse einer qualitativen Studie unter Medizinischen Fachangestellten (MFAs) Gesundheitswesen. 2018;80:1084–1087. doi: 10.1055/s-0043-111232. [DOI] [PubMed] [Google Scholar]
- 63.Goetz K, Berger S, Gavartina A, Zaroti S, Szecsenyi J. How psychosocial factors affect well-being of practice assistants at work in general medical care?–a questionnaire survey. BMC Fam Pract. 2015;16:166. doi: 10.1186/s12875-015-0366-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 64.Jacobi F, Höfler M, Strehle J, et al. Twelve-months prevalence of mental disorders in the German Health Interview and Examination Survey for Adults - Mental Health Module (DEGS1-MH): a methodological addendum and correction. Int J Methods Psychiatr Res. 2015;24(4):305–313. doi: 10.1002/mpr.1479. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 65.Mauz E, Walther L, Junker S, et al. Time trends in mental health indicators in Germany’s adult population before and during the COVID-19 pandemic. Front Public Health. 2023;11:1065938. doi: 10.3389/fpubh.2023.1065938. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 66.Kristensen TS, Borritz M, Villadsen E, Christensen KB. The copenhagen burnout inventory: a new tool for the assessment of burnout. Work Stress. 2005;19(3):192–207. doi: 10.1080/02678370500297720. [DOI] [Google Scholar]
- 67.Warr P, Cook J, Wall T. Scales for the measurement of some work attitudes and aspects of psychological well-being. J Occup Psychol. 1979;52(2):129–148. doi: 10.1111/j.2044-8325.1979.tb00448.x. [DOI] [Google Scholar]
- 68.Hiemisch A, Stöbel-Richter Y, Grande G, Brähler E, Kiess W. Sind wir wirklich so glücklich, wie wir es glauben? Eine kritische Untersuchung der Arbeitszufriedenheit an einer Universitätskinderklinik. Gesundheitswesen. 2019;81(4):309–318. doi: 10.1055/s-0043-121873. [DOI] [PubMed] [Google Scholar]
- 69.Herrmann M. Herausforderung der COVID-19-Pandemie für die hausärztliche Versorgung. Ärztliche Psychotherapie. 2022;17(3):174–179. doi: 10.21706/aep-17-3-174. [DOI] [Google Scholar]
- 70.Dreher A, Mambrey V, Loerbroks A. Changes of working conditions and job-related challenges due to the SARS-CoV-2 pandemic for medical assistants in general practices in Germany: a qualitative study. BMC Prim Care. 2022;23(1):273. doi: 10.1186/s12875-022-01880-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 71.Frajerman A, Colle R, Hozer F, et al. Psychological distress among outpatient physicians in private practice linked to COVID-19 and related mental health during the second lockdown. J Psychiatr Res. 2022;151:50–56. doi: 10.1016/j.jpsychires.2022.04.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 72.Kramer V, Papazova I, Thoma A, et al. Subjective burden and perspectives of German healthcare workers during the COVID-19 pandemic. Eur Arch Psychiatry Clin Neurosci. 2021;271(2):271–281. doi: 10.1007/s00406-020-01183-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 73.Mojtahedzadeh N, Wirth T, Nienhaus A, Harth V, Mache S. Job demands, resources and strains of outpatient caregivers during the COVID-19 pandemic in germany: a qualitative study. Int J Environ Res Public Health. 2021;18(3684):1–26. doi: 10.3390/ijerph18073684. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 74.Morawa E, Schug C, Geiser F, et al. Psychosocial burden and working conditions during the COVID-19 pandemic in Germany: The VOICE survey among 3678 health care workers in hospitals. J Psychosom Res. 2021;144:110415. doi: 10.1016/j.jpsychores.2021.110415. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 75.Jerg-Bretzke L, Kempf M, Jarczok MN, et al. Psychosocial Impact of the COVID-19 Pandemic on Healthcare Workers and Initial Areas of Action for Intervention and Prevention-The egePan/VOICE Study. Int J Environ Res Public Health 2021; 18(19). 10.3390/ijerph181910531. PMID: 34639831 [DOI] [PMC free article] [PubMed]
- 76.Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun. 2020;88:901–907. doi: 10.1016/j.bbi.2020.05.026. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 77.Dragano N, Reuter M, Peters A, et al. Increase in mental disorders during the COVID-19 pandemic-the role of occupational and financial strains. Dtsch Arztebl Int. 2022;119(11):179–187. doi: 10.3238/arztebl.m2022.0133. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 78.Röthke N, Wollschläger D, Kunzler AM, et al. Psychische Belastung, Resilienz und Absentismusneigung bei Gesundheitspersonal in Deutschland während der ersten COVID-19-Pandemiewelle im Frühjahr 2020: Eine Ad-hoc-Befragung. Nervenarzt. 2021;92(6):579–590. doi: 10.1007/s00115-021-01132-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 79.von Elm E, Schreiber G, Haupt CC. Methodische anleitung für scoping reviews (JBI-Methodologie) Z Evid Fortbild Qual Gesundhwes. 2019;143:1–7. doi: 10.1016/j.zefq.2019.05.004. [DOI] [PubMed] [Google Scholar]
- 80.Pozsgai G, Lövei GL, Vasseur L, et al. Irreproducibility in searches of scientific literature: a comparative analysis. Ecol Evol. 2021;11(21):14658–14668. doi: 10.1002/ece3.8154. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Additional file 1: Annex 1. Protocol amendments and their justification.
Additional file 2: Annex 2. Full electronic search strategy used for PubMed (Medline).
Data Availability Statement
Not applicable.