Workforce guidelines, burnout, work engagement and the intention to leave: A cross-sectional study among Dutch emergency physicians

Annemieke E Boendermaker; Gideon H P Latten; Jelle T Prins; Kiki M J M H Lombarts; Paul L P Brand

doi:10.1371/journal.pone.0337882

. 2026 Oct 5;21(10):e0337882. doi: 10.1371/journal.pone.0337882

Workforce guidelines, burnout, work engagement and the intention to leave: A cross-sectional study among Dutch emergency physicians

Annemieke E Boendermaker ^1,^‡,^*, Gideon H P Latten ^2,^‡, Jelle T Prins ³, Kiki M J M H Lombarts ⁴, Paul L P Brand ⁵

Editor: Adrian Loerbroks⁶

PMCID: PMC13637872 PMID: 42832412

Abstract

Background and importance

Emergency medicine physicians (EMPs) work in a dynamic and challenging environment, with high risk of burnout. The prevalences of work engagement, burnout and the intention to leave among Dutch EMP have not been studied before. This study aims to evaluate the adherence to the Dutch Society of Emergency Physicians (DSEP/NVSHA) workforce recommendations, and the association between these recommendations and signs of burnout, work engagement and the intention to leave the profession.

Methods

Cross-sectional online survey based study among all Dutch EMPs in 2019. Two main outcomes, the prevalences of burnout and work engagement, were assessed using the Dutch version of the Maslach Burnout Inventory and the Utrecht Work Engagement Scale. A third main outcome, the intention to leave, was assessed by three self-developed questions. The correlations between the adherence to twelve workforce recommendations and these three main outcomes were assessed using SPSS.

Main results

295 EMPs participated (response rate 56%, 68% female, median age 39 years). Fifty-five respondents (18.5%) met the criteria for burnout. On work engagement, 29 (16.6%) respondents scored low to extremely low (i.e., the 25^th groups’ percentile) and 97 (32.9%) respondents scored high to extremely high (i.e., the groups’ 75^th percentile). Intention to leave the profession was high with 22–29%. Higher adherence to the workforce recommendations was significantly associated with all three main outcomes, as were five out of twelve separate recommendations.

Conclusions

To ensure a sustainable future in which EMPs are protected from burnout symptoms, supported in their work, and where disproportionate job turnover is minimized, it is crucial these results are met with decisive action. Hospital management must address the unique challenges and risks providing excellent 24/7 emergency care presents. Workforce guidelines are designed to proactively create a more sustainable work environment. This study underscores the necessity of its implementation and creates a foundation for future research.

Introduction

Emergency medicine physicians (EMPs) work on a 24/7 schedule with unpredictable caseloads and fast-paced decision-making with high impact and emotional strain. To maintain health, work engagement and a fulfilling career, it is important to invest in a sustainable work environment, aimed at preventing burnout and improving career longevity. In 2015, the Dutch Society of Emergency Physicians (DSEP/NVSHA) published its workforce guideline for durable employability and scheduling, stipulating a set of core recommendations and conditions to aspire to [1]. These recommendations are based upon extensive research and similar guidelines from the UK, USA and Australasia [2–4]. Nevertheless, international literature on the effects of adherence to workforce recommendations is lacking and the prevalence of burnout among Dutch EMPs is unknown.

Burnout is recognised worldwide as a syndrome related to a person’s profession. It consists of three domains, which are separately measured: emotional exhaustion, depersonalization and a sense of diminished personal accomplishment [5–8]. Burnout in healthcare providers is associated with diminished mental and physical health, but also with a reduced quality of work, a rise in patient related safety incidents, an increase in the intention to leave the profession and a lasting incapacity for work [9–11].

The opposite of burnout is considered to be work engagement; a positive, fulfilling, work-related state of mind in its own right that is characterised by three psychometrically distinct aspects: vigor, dedication, and absorption [12–14]. Where burnout is mainly predicted by job demands and a lack of job resources, work engagement is exclusively predicted by available job resources [11–14]. Work engagement fosters the intention to remain in the profession through a motivational process, stimulates extra-role behaviour, enhances overall wellbeing, and protects against patient related safety incidents [11–14].

The core recommendations for Dutch EMPs outlined in the workforce guideline address factors presumed to influence burnout and work engagement, such as scheduling and contract conditions. However, these recommendations have not yet been studied as a set. In this cross-sectional study, we aim to estimate the levels of burnout symptoms and work engagement experienced by Dutch EMPs prior to the COVID-19 pandemic, assess self-reported adherence to the different workforce recommendations and examine the association between compliance with these recommendations and the wellness parameters of burnout, work engagement, and intention to leave.

Methods

Design and setting

This cross-sectional survey-based study is a first wave of a larger cohort study and was conducted among all 526 Dutch EMPs registered with DSEP at the time. They represent more than 95% of all Dutch EMPs. In the Netherlands EMPs work primarily in the emergency department. From May 1^st to June 30^th 2019, all were invited via personal e-mail through DSEP to complete an online questionnaire developed by a multidisciplinary research team of EMPs, psychologists, epidemiologists, medical education researchers and human resource management specialists. The questionnaire included internationally validated questions to assess burnout, work engagement and intention to leave the profession, and demographic characteristics, and work situation (S1 Table). After two weeks, non-responders received a reminder to complete the questionnaire.

The study was approved by a regional Dutch ethics review board (RTPO-1046). All participants provided informed consent by checking the consent box at the start of the questionnaire. To further ensure data and privacy safety demographics were separated from the main dataset. Only the two main researchers had the key to link both data sets for analysis purposes.

Variables and definitions

Demographics – Respondents were asked to provide data on age, gender, relationship status and family composition, year of graduation from medical school, and year of completion of postgraduate EMP training.

Burnout – The Utrecht Burnout Scale (UBOS), the official validated Dutch adaptation of the Maslach Burnout Inventory, was used [15]. Respondents reported their agreement with statements on the three separate domains of burnout – emotional exhaustion (5 items), depersonalization (5 items) and sense of diminished personal accomplishment (7 items) – using a 7-point Likert scale, ranging from “never” (1) to “always” (7). To determine a threshold for ‘burn out’, we used the Brenninkmeijer EEplus1 definition, which requires the presence of emotional exhaustion and either high depersonalization or low personal accomplishment [16]. When emotional exhaustion, high depersonalization and low personal accomplishment were all present, respondents fulfilled the definition of ‘burnout syndrome’ and were also considered to have significant burn out symptomatology [17]. In line with the UBOS manual, the 75^th percentile of the distribution of the three composite variables was used as a cut-off for burnout. The scales were compared to the norm reference values of Dutch healthcare personnel presented in the UBOS manual [15]. To clarify its interpretation the UBOS score only indicates a burnout tendency or symptomatology cluster and does not constitute a formal diagnosis of burnout.

Work engagement – The 3-item version of the Utrecht Work Engagement Scale (UWES), which assesses vigor, dedication and absorption, was used [18]. Each item was scored on a 5-point Likert scale from “never” (1) to “always” (5). Overall work engagement was defined and analysed as a composite variable of all three items and compared to the norm reference values provided by the UWES manual of work engagement scores of Dutch healthcare professionals [19].

Work conditions – The work situation was assessed with a model derived from the Dutch Workforce Guideline for Durable Employability and Scheduling [1]. This workforce guideline offers 12 recommendations for working conditions, which were translated to dichotomous questions regarding EMPs’ working conditions. These included scheduled backward rotation, fixed cycle in rotation scheduling, fixed shift off, break time during shift, weekends per month, nightshift to team size, shift duration, contract size, additional scheduled time, presence of ED residents, team size to ED size, and contract type.

Intention to leave the profession [20,21] – Having ever considered to leave emergency medicine was assessed using a 4-point Likert scale, ranging from never (1) to multiple times (4). EMPs were asked, yes or no, whether, given the choice, they would choose the same career again ‘knowing what they know now’, and whether they saw themselves working as an EMP in 10 years’ time?” The choice for a 10-year time horizon was based on the expected young age of the respondent group, given the relative novelty of EMP as a profession in the Netherlands. The answers ‘no’ and ‘often/ multiple times’ were considered poor outcomes.

Analysis and statistics

To assess the sample’s representativeness of the EMP population, we compared respondents’ gender, age and hospital type to those of all registered EMP members of the DSEP (S2 Table). Descriptive statistics were used to describe the prevalence of the three outcome measures and adherence to the 12 workforce recommendations. We assessed differences in demographic and working conditions using variables between respondents with or without a positive value on the burnout composite score, work engagement and intention to leave using chi-square tests, Fisher exact tests or Mann-Whitney-U tests, as appropriate. Two sided p values <0.05 were considered statistically significant. Cronbach’s alpha was used to measure the internal consistency of construct variables. To assess correlation between the three main outcomes and the workforce recommendations, we computed Spearman rank (r_s), rank biserial (r_rb)and phi correlation (r_φ) coefficients. Binomial and ordinal logistic regressions were conducted to determine the effects of burnout and work engagement on the likelihood of the intention to leave.

If a respondent wanted to move forward with the online questionnaire all previous questions had to have been answered. So missing items were extremely rare. The entire questionnaire consisted of multiple preset research tools. If there was one item missing within a construct variable single imputation was used and sensitivity analysis was done to confirm robustness. If the entire preset, such as the UBOS or the work conditions, was missing the case was excluded for subsequent analyses. All analyses were performed using IBM SPSS Statistics for Windows, version 27 (IBM Corp., Armonk, N.Y., USA).

Results

Demographics

In total, 295 (56%) EMPs completed the questionnaire, of which 200 (67.8%) were female. Median age was 39 (IQR 35–44) years and respondents had been working as an EMP for a median of 6 (IQR 3–10) years. Age, sex and hospital type were comparable between respondents and the entire cohort of DSEP members (S2 Table).

Burnout symptoms and work engagement

The internal consistency of the construct variables were excellent, with Cronbach’s alpha for emotional exhaustion α = .91, for depersonalization α = .82, for personal accomplishment α = .81 and α = 0.70 for work engagement. Burnout, defined as emotional exhaustion plus high depersonalization and/or low personal accomplishment, was observed in 55 (18.6%) respondents (Table 1). High emotional exhaustion was present in 27.1%, and low personal accomplishment in 21.6%. Consistent with the UBOS manual, depersonalisation was reported as a male score at 25.0% and female score of 28.0%.

Table 1. Demographics and burnout. Numbers are median (IQR) or n (%). P value for categorical variables by X square test, and for comparison of means by independent samples t-test.

Demographics	Total (n = 295)	No burnout (n = 240)	Burnout (n = 55)	p
Sex – female	200 (67.8)	164 (68.3)	36 (65.5)	0.75
Sex – male	95 (32.2)	76 (31.6)	19 (34.5)
Age – years	39 (35-44)	40 (35-43)	41 (36-45)	0.22
Working as EMP– years	6 (3-10)	6 (3-10)	6 (3-9)	0.98
With partner	247 (83.7)	209 (87.1)	38 (69.1)	0.002
Without partner	48 (16.3)	31 (12.9)	17 (30.9)
With children	196 (66.4)	159 (66.3)	37 (67.3)	0.89
Without children	99 (33.6)	81 (33.8)	18 (32.7)

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On work engagement, 29 (16.6%) respondents scored low to extremely low (i.e., the 25^th groups’ percentile) and 97 (32.9%) respondents scored high to extremely high (i.e., the groups’ 75^th percentile).

When compared to the UBOS and UWES reference scores, the EMPs in this study did not score significantly different on emotional exhaustion scores (1.86 vs. 1.78, p = 0.31). The EMPs did score significantly lower on personal accomplishment (4.12 vs. 4.22, p = 0.03), but higher on overall work engagement (3.48 vs. 3.10, p < 0.01) (Table 2) [15–19].

Table 2. Burnout and work engagement scales compared to norm reference values of Dutch healthcare personnel. Burnout scales in reference to the validated norm reference values of Dutch healthcare personnel presented in the UBOS manual and Dutch physicians of the UWES manual [15–19]. * The UBOS manual applies gender-specific reference values to depersonalization scale due to consistently significant differences between male and female subjects, explained in terms of prevailing gender roles.

	Emergency physicians (n = 295)		Reference group (n = 10,552)
Burnout scales	Mean	SD	Mean	SD	p	95% CI
Emotional exhaustion	1.86	1.15	1.78	1.21	0.31	−0.07 - 0.23
Depersonalization
Women	1.21	0.78	1.14	0.78	0.12	−0.02 - 0.16
Men	1.45	1.11	1.27	0.84	<0.01	0.08 - 0.28
Diminished personal accomplishment	4.12	0.70	4.22	0.78	0.03	−0.19 - −0.01
	Emergency physicians (n = 295)		Reference group (n = 655)
Work engagement scales	Mean	SD	Mean	SD	p	95% CI
Overall work engagement	3.48	0.65	3.10	0.87	<0.01	−0.61 - −0.16
Subscales
Vigor	3.39	0.79	3.04	0.92	<0.01	−0.47 - −0.23
Dedication	3.78	0.81	3.29	1.04	<0.01	−0.62 - −0.36
Absorption	3.26	0.89	2.96	1.92	0.011	−0.53 - −0.07

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Intention to leave

Based on a Cronbach’s alpha of 0.62 – considered a weak internal consistency – the three questions were interpreted as assessing distinctly different aspects of the concept ofthe intention to leave and were assessed separately instead of taken together. Almost a third of respondents (29%) answered having considered leaving the profession several or multiple times. The consideration to leave the profession was significantly more common amongst respondents with burnout (n = 55, 36%) than those without (n = 240, 10%, p < 0.001). Sixty-eight respondents (23%) did not see themselves still working as EMP in 10 years’ time. This was also more common in physicians with burnout (49%) than those without (17%, p < 0.001). Physician age did not explain this difference (39.7 ± 5.7 vs 41.0 ± 5.8 years, 95% CI of difference −0.3 to 2.9 years, p = 0.103). Similarly, 23% of respondents reported not choosing EM as a career again (49% in burned out vs 18% in not burned out physicians, p < 0.001).

Table 3 shows the odds ratios from logistic regression analysis of burnout and work engagement on the intention to leave questions.

Table 3. Odds ratios (OR) of burnout and work engagement on the intention to leave questions.

	Positive future			Choosing EM again			Not considering to quit
	OR	95% CI	p	OR	95% CI	p	OR	95% CI	p
Burnout	0.2	0.1 - 0.4	<.001	0.2	0.1 - 0.4	<.001	0.2	0.1 - 0.3	<.001
Work engagement	3.3	2.1 - 5.2	<.001	4.2	2.6 - 6.6	<.001	3.5	2.3 - 5.4	<.001

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Working conditions

Table 4 shows the adherence of respondents’ EDs to the 12 dichotomized workforce recommendations and their association with burnout. There were differences in the adherence to the recommendations. The mean of followed recommendations was 6.6 with a range of 1–11. The most often followed recommendation (99.0%) was to work with designated ED residents, while the least commonly followed recommendation (8.3%) was the use of a fixed cycle in rotation scheduling.

Table 4. Adherence in the respondents’ ED to the 12 workforce recommendations and association with burnout. Numbers are n (%). Chi-square tests.

Recommendation	Answers	N (%)	Burnout	No burnout	p
Scheduled backwards rotation	0-1x/month	220 (76.9%)	40 (18.2%)	180 (81.8%)	0.78
Scheduled backwards rotation	>1/month	66 (23.1%)	13 (19.7%)	53 (80.3%)	0.78
Fixed cycle in rotation scheduling	Yes	24 (8.3%)	7 (29.2%)	17 (70.8%)	0.17
Fixed cycle in rotation scheduling	No	265 (91.7%)	47 (17.7%)	218 (82.3%)	0.17
Fixed shift off per week	Yes	165 (56.3%)	26 (15.8%)	139 (84.2%)	0.17
Fixed shift off per week	No	128 (43.7%)	29 (22.7%)	99 (77.3%)	0.17
No break during shift	Never/sometimes	298 (58.8%)	8 (9.5%)	76 (90.5%)	0.01
No break during shift	Often/always	209 (41.2%)	47 (20.9%)	162 (77.5%)	0.01
Working full weekends per month	1 in 3–5 weekends	68 (23.2%)	8 (11.8%)	60 (88.2%)	0.09
Working full weekends per month	1 in 1–2 weekends	225 (76.8%)	47 (20.9%)	178 (79.1%)	0.09
Appropriate team size for nightshifts	Yes	182 (66.2%)	29 (15.9%)	153 (84.1%)	0.25
Appropriate team size for nightshifts	No (too small)	93 (33.8%)	20 (21.5%)	73 (78.5%)	0.25
Shift duration 9 hours	Yes	180 (61.0%)	26 (14.4%)	154 (85.6%)	0.02
Shift duration 9 hours	No	115 (39.0%)	29 (25.2%)	86 (74.8%)	0.02
Contract size per week	32-38 hours	208 (70.3%)	36 (17.3%)	172 (82.7%)	0.36
Contract size per week	<32 or>38 hours	88 (29.7%)	19 (21.8%)	68 (78.2%)	0.36
Additional scheduled time	≥15%	63 (23.2%)	8 (12.7%)	55 (87.3%)	0.18
Additional scheduled time	<15%	209 (76.8%)	42 (20.1%)	167 (79.9%)	0.18
Working with designated ED residents	Yes	292 (99.0%)	54 (18.5%)	238 (81.5%)	0.51
Working with designated ED residents	No	3 (1.0%)	1 (33.3%)	2 (66.7%)	0.51
Team size in relation to ED size	Sufficient	32 (11.9%)	5 (15.6%)	27 (84.4%)	0.82
Team size in relation to ED size	Insufficient	238 (88.1%)	41 (17.2%)	197 (82.8%)	0.82
Contract type	Permanent	258 (87.5%)	43 (16.7%)	215 (83.3%)	0.02
Contract type	Temporary	37 (12.5%)	12 (32.4%)	25 (67.7%)	0.02

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Associations

The higher the number of recommendations a respondent’s ED adhered to correlated weak, yet significantly with burnout (Spearman ρ = −.2, p < 0.01), with a positive future (ρ = .2, p < 0.01), with choosing EM again (ρ = .1, p = .04) and considering to quit (ρ = .2, p = 0.02). Three workforce recommendations showed weak but significant correlation on their own with an increased risk of burnout when not adhered to: the presence of breaks during shifts (ρ = −.2, p = .01), a shift duration of 9 hours (ρ = −.14, p = .02), and a permanent contract (ρ = −.13, p = .02) (Table 4).

Work engagement was associated with working 1 in 3–4 weekends or less (ρ = .2, p < 0.03). Intention to leave the profession was associated with not adhering to the following recommendations: breaktime (ρ = .2, p < .001), working 1 in 3–4 weekends or less (ρ = .2, p < 0.01), shift length (ρ = .1, p = .04) and working in a team large enough to match the ED size (ρ = .1, p = 0.05).

Discussion

Main findings and interpretation

In this study, we examined adherence to Dutch workforce guidelines for EMPs and investigated the association between compliance with these recommendations and levels of burnout, work engagement and intention to leave the profession. Adherence to workforce recommendations varied with a mean of only 6.6 followed: the recommendation to work with designated ED residents was followed most frequently (99.0%), while the use of a fixed cycle in rotation scheduling was adhered to least (8.3%). Not adhering to three specific workforce recommendations was significantly associated with burnout: the absence of breaks during shifts, a shift duration of less or more than 9 hours, and a temporary contract. Work engagement was associated with working 1 in 3–4 weekends or less. Intention to leave the profession was associated with not adhering to the following recommendations: having breaktime, working 1 in 3–4 weekends or less, shift length of 9 hours and working in a team large enough to match the ED size. Although these relationships are weak and cannot be interpreted as causal, they do provide a basis for further investigation of the hypothesis that with better implementation, adherence to a workforce guideline aimed at durable employment may protect against burnout, job turnover and may enhance work engagement.

Comparing the prevalence of burnout symptoms in our population of Dutch EMPs (18.6%) with that reported in other studies using the Maslach burnout inventory proved less straightforward than expected, mainly due to the use of different cut-off values [22]. The study of Meynaar et al from 2015 showed a comparable way of calculating burnout, but reported a surprising low prevalence of 4.4% among 272 Dutch intensivists (41% response rate), which the authors hypothesised was due to the low workload in Dutch ICUs [23]. A previous meta-analysis, including over 1250 EMPs from 12 countries, showed high levels of emotional exhaustion and depersonalization (both around 40%) and low personal accomplishment in 35% of EMPs [24]. While these numbers are higher than those observed in our study, they are not directly comparable due to the use of various different cut-offs. Despite our relatively favourable results, we must recognize that 1 in 5 Dutch EMPs in our study displayed signs of burnout. Given the potential negative consequences for both physicians and patients, this prevalence is concerning and underscores the need for intervention [9–11]. Adhering to the workforce recommendations presents one avenue for improvement.

Work engagement (3.48, SD 0.65) was reported higher in Dutch EMPs compared to other Dutch medical specialists (3.10, SD 0.87) as reported by the UWES manual [19]. Also compared to the UWES-3 scores on work engagement of 5.023 direct care nurses from 6 European countries the Dutch EMPs scored higher [25]. This might be explained by emergency medicine in The Netherlands being a still relatively young medical specialty with lots to develop and proof, and a dynamic, exhilarating workload.

Since our study is the first to investigate the adherence to a workforce guideline, direct comparisons with other studies is challenging. Nevertheless, the workforce recommendations are based on previously published research and similar strategies for preventing burnout have been reported by others [2–4,13,26–28]. Time during a shift to take a break, recover and have designated time to eat are all proven to be beneficial for physician wellness [28–32]. Working 9 hours provides overlap between colleagues to safely transfer care of patients and to end the shift before concentration and energy levels diminish [32]. The job security that comes with a permanent contract besides the impact it has on team building might explain this recommendation to be associated with burnout. Having a sufficient team size helps to distribute workload.

Strengths and limitations

Our study is the first to investigate the prevalence of burnout, work engagement and intention to leave among Dutch EMPs. Also, a workforce guideline such as the DSEP guideline, even though based upon numerous studies, has not been analysed for its effects on these three outcomes as a set of recommendations. The response rate was 56% which we consider high in comparison with similar survey studies among physicians. The use of validated instruments, such as the Dutch version of the Maslach Burnout Inventory (UBOS) and the Utrecht Work Engagement Scales (UWES) allows for future comparisons.

The adherence to the workforce recommendations proved mediocre, variation was high, and only some recommendations showed (weak but significant) correlation. No adjustment for confounders at this point was made. Nevertheless, this study creates a foundation for future research and efforts to promote a sustainable EM workforce. This study did not account for the potential effects of the COVID-19 pandemic. Therefore, repeating this research in the current Dutch EM environment is recommended.

Conclusion

We found that almost 1 in 5 Dutch EMPs exhibited signs of burnout, just prior to the COVID-19 pandemic. On the opposite, levels of work engagement were higher compared to other Dutch medical specialists. Adherence to the DSEP workforce recommendations promises to be an effective strategy to prevent burnout and job turnover, and promote work engagement. Five recommendations in particular deserve to be addressed: the presence of recovery time during shifts, a shift duration of 9 hours, working less weekends, sufficient team size and the availability of a permanent contract. Repeating this study to obtain updated prevalence rates is planned, concurrent with the publication of the revised Workforce guideline. The results of this current study were used in its revision and provide the basis of a longitudinal analysis. It is crucial for a sustainable career in EM to create better work conditions and terms of employment for health care professionals.

Supporting information

S1 Table. Questionnaire workforce article English PLOS one.

(DOCX)

pone.0337882.s001.docx^{(49.5KB, docx)}

S2 Table. Dutch Society of Emergency Physicians table of members 2019.

(XLSX)

pone.0337882.s002.xlsx^{(11.9KB, xlsx)}

Data Availability

The data underlying the results of this study are available from Data Station Life Sciences (https://doi.org/10.17026/LS/BND3FR).

Funding Statement

This study was endorsed by the Dutch Society of Emergency Physicians (DSEP), and received funding from the Dutch Emergency Medicine Research Fund (Stichting Spoedeisende Geneeskunde Onderzoeksfonds. https://sgofonds.nl/). This contribution was only financial in nature and was awarded to main researcher AE Boendermaker, emergency physician and member of the taskforce physician wellness of DSEP. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0337882.r001

Decision Letter 0

Adrian Loerbroks

3 Feb 2026

Dear Dr. Boendermaker,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: The manuscript is well conducted, clearly written, and methodologically sound. The use of validated instruments (UBOS and UWES) is appropriate, and the statistical analyses are rigorous. The data support the authors’ conclusions and provide a meaningful contribution to understanding the well-being of emergency physicians in the Netherlands.

However, it is important to emphasize that the statistical correlations identified do not imply causality. They indicate significant associations between workforce recommendations and levels of burnout, work engagement, and intention to leave, but these relationships should not be interpreted as causal. Clarifying this point in the text would help prevent deterministic interpretations.

Additionally, while the questionnaires used are validated and reliable, the burnout measure does not constitute a formal clinical diagnosis. The results should be interpreted as an indicator of burnout tendency or risk, rather than confirmed burnout, which would require assessment by qualified medical or psychological professionals. A short clarification in the methods or discussion would strengthen the accuracy of interpretation.

Finally, as this study was conducted before the COVID-19 pandemic, its findings provide a valuable baseline but may not reflect current realities. Given the substantial changes in emergency care systems worldwide, a follow-up or pre-post study design would be highly relevant to assess potential shifts in burnout and work engagement after the pandemic.

Overall, this is a well-designed and valuable study that addresses an important topic. The manuscript would benefit from the clarifications above, which would enhance its methodological precision and interpretative transparency.

Reviewer #2: Dear authors,

generally, your manuscript is easily legible, well structured and straightforward in its aims, results and discussion. In my view, more elaborate statistical analyses would have been more interesting to the explanation of variance in your outcomes. However, I guess you might have wanted to save these more extensive analyses for the longitudinal data. This manuscript might be suitable for publication after addressing some points of (mostly) clarification and some more substantiation of empirical literature in the Introduction section. I wish you good luck with revising the manuscript.

Abstract

- Please add the following information to the abstract: year of study, mode of survey administration, statistical procedures for data analysis, statistical program for data analysis.

- Please write out abbreviations, e.g. DSEP.

- In your Conclusions section, you repeat the findings from your Results section. I wonder if it would be more interesting to readers to see suggestions how a “decisive action” might look like instead, i.e. ideas on who could address the study results and which strategies might be plausible.

- I would suggest to reconsider pointing out the repeat survey in the abstract. By the time this paper is published, readers might wonder why authors did not prefer to wait for the study data from this successive study to analyze longitudinal data instead of cross-sectional study results.

Background

- The Background section is rather short. Instead of or in addition the findings on the repercussions of burnout for healthcare providers in general, you might refer to empirical findings specifically for EM physicians to establish specific relevance for this professional group. This might also “complete the circle” with regard to the workforce guideline, i.e. why are certain recommendations included in this guideline. The same suggestion applies for work engagement.

- Please add that you measured self-reported adherence and compliance to recommendations. Otherwise, one might confuse it with objective assessments of adherence to recommendations.

Methods

- Please clearly state which part of the study was cross-sectional and which is the cohort study (since a study cannot be cross-sectional and a cohort at the same time). I guess that you analyzed cross-sectional data from one wave of a cohort study. Please explain how many waves were already conducted and how many waves are planned.

- Please shortly explain how you gained access to the email addresses. I guess that you obtained them from the Dutch Society of Emergency Physicians? It would be helpful for international readers to know if every single Dutch emergency physician has to register with the Dutch Society of Emergency Physicians. If not, how many EM physicians are there in the Netherlands in total and how do they compare with those who are not part of the society? Are only emergency physicians working in hospitals eligible to participate or also those working in pre-hospital settings?

- Did you apply any inclusion or exclusion criteria for participants? If yes, please explain.

- Please explain why you choose this specific set of demographic variables and not others from your comprehensive questionnaire, which might have also been suitable with regard to burnout (e.g. working hours (item 13), weekend work (item 28))?

- Please name the amount of items for each burnout domain since your participants answered these items and not the domains per se.

- Why did you use two operationalizations of burnout, i.e. Brenninkmeijer EEplus1 definition and the one provided by the UBOS manual?

- What was the time horizon given in the question on “intention to quit”? Please add this information to the text.

- Please report the Cronbach’s alpha for all of your scales. Please also consider that CA is not a simple measure of “correlation” (page 7) but one of internal consistency.

- I could not find Figure 1 referenced on page 5. Please clarify.

- Please add information on how you addressed missing data in analyses.

- Please explain why you refrained from multivariable logistic regression analyses to include all demographic factors in one analytical model to explain variance in your outcomes?

Results

- I could not find “Supplementary Table 1 – E_table_1.docx“ in my copy of the manuscript.

- I don’t think that the presentation of descriptive results in Table 1 is intuitive. Please consider a complete depiction by separately showing frequencies and percentages for all categorical categories in separate lines, e.g. female/male.

- Which statistical analyses did you use to compute odds rate for results in Table 3?

Discussion

- Please remove references to your tables in the Discussion section.

References

- Please check if the journal recommends to include an English translation in square brackets after foreign manuscript titles, e.g. in citations 1, 15.

- Please review all of your references and choose one continuous citation style.

**********

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Reviewer #1: Yes: Dr. Giovanni Leonardo Briganti

Reviewer #2: Yes: Anna Schneider

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Comments by the editor:

Abstract:

1) As the aim you state “to evaluate the adherence to the DSEP workforce recommendations, and the association between these recommendations and signs of burnout, work engagement and the intention to leave the profession”

- Please spell out DSEP (abbreviation cannot be understood)

- Neither data on the recommedations nor on the associaitons are presented in the Results section of the abstract. Please add this data.

- I suggest deleting your interpretation/discussion of your findings from the results section of the abstract. Copmarison with findings from the literature are usually not made in results section. Also, this reates the impression that you gathered the original data that allowed for such comparisons (e.g. in other health care prefofessions)

Methods in abstract/Methods seciton:

- Cross-sectional survey-based cohort study please change to cross-sectional study. Cohort is a misleading expression; even if you plan to collect prospective data you are not presenting it at this point.

- Would delete this from the abstract: "this study creates a foundation upon which future research can build and a repeating questionnaire is already planned for end 2025", please present broader implications

;- Methods in abstract: how was intention to leave measured?

“How this study might affect research, practice or policy” --> present broader implications please rather than adverstisement of your follow-up study

Methods section in the paper

- The Utrecht Burnout Scale (UBOS): I never heard of the approach to re-name the translation of an original scale (also due to copyright issues). I cannot access the referenced study. Please confirm that the UBOS items are fully identical to the MBI; thus that the UBOS really is close translation and that original MBI items were not removed, significantly revised or that new items were added. Otherwise valditiy of the UBOS should be documented.

- Work conditions were measured by a self-developed measure. Please show the questionnaire as online supplement to make sure wording of items is transparently shown

- In the methods section you state that you cacluated Cronbach’s alpha. Are these reported in the result section for burnout and work engagement?

- Results: you compared work engagements values to the norm reference values provided by the UWES manual of work engagement scores of Dutch healthcare professionals. Does this comparison account for gender and age differences between samples? If not: could such differences partly serve as explanations?

- In the results section you state that EM physicans score lower on overall work engagement than the reference sample (3.48 vs. 3.74). This seems insonsistent with the numbers in the table which are 3.48 and 3.10, respectively, which would mean EM physicans score higher. Please check.

- Table 3: It seems more intuitive to flip outcomes and exposure of the analyses, as one would implicitely assume that burnout and WE predict the professional outcomes. The logistic regression analyses should be metioned in the methods section. How did you define exposures and outcomes?

Discussion

- How do your finding related to WE compare to the literature?

- Limitations: confounding --> no adjustment

- Any recommendations for research and pracitce?

PLoS One. 2026 Oct 5;21(10):e0337882. doi: 10.1371/journal.pone.0337882.r002

Author response to Decision Letter 1

20 Apr 2026

The manuscript is well conducted, clearly written, and methodologically sound. The use of validated instruments (UBOS and UWES) is appropriate, and the statistical analyses are rigorous. The data support the authors’ conclusions and provide a meaningful contribution to understanding the well-being of emergency physicians in the Netherlands.

- We thank the reviewer for the compliments. We appreciate the acknowledgement of the quality of our work.

- Thank you. We fully agree with the reviewer’s comment. We reviewed the texts to see where we may have caused any confusion. We chose to make a specific statement in the Discussion – Main findings section.

- Page 10, line 285-288

- Valid point. The burnout tool does not measure burnout as a diagnosis on a personal level. We went through the text to ascertain if at any point the text may suggest burnout to be a diagnosis, and we added a clarification in the method section of our paper.

- Page 3 Line 67, Page 4 line 115, Page 5 Line 146, 150-151, 154-155, Page 10, line 289

- We have found this a valid point as well and are pleased to announce we are currently collecting data in the follow-up study.

In its first set-up, a follow-up study or longitudinal approach was envisioned, but aimed at the workforce guideline and its adherence. The guideline tested stems from 2015 and a revision was planned for 2020. Hence, the study from 2019 was set to be a baseline and a provider of data for the rewrite. The guideline revision was delayed due to a number of causes, including the COVID-19 pandemic and the recognition of Emergency Medicine as a medical specialty in the Netherlands. The revision has been published in December 2025 and the follow-up study is currently ongoing.

- We thank the reviewer for the opportunity to share our study and address the above mentioned clarifications. We hope to have addressed them to satisfaction.

Reviewer 2

Generally, your manuscript is easily legible, well structured and straightforward in its aims, results and discussion.

- We thank the reviewer for the compliments. We appreciate the acknowledgement of the quality of our work.

In my view, more elaborate statistical analyses would have been more interesting to the explanation of variance in your outcomes. However, I guess you might have wanted to save these more extensive analyses for the longitudinal data.

- Important remark and indeed, most of the focus on variance, and more sturdy predictors will be done in the follow-up study with the longitudinal data.

Abstract

Please add the following information to the abstract: year of study, mode of survey administration, statistical procedures for data analysis, statistical program for data analysis.

- Thank you for these practical tips on improving our abstract.

Abstract – methods line 48 now gives more information on mode of survey, and year. A new sentence is added about the statistical procedures.

- Page 3, line 48. Line 51-53

Please write out abbreviations, e.g. DSEP.

- The text now explains the DSEP abbreviation; a small omission on our part.

- Page 3 line 45

In your Conclusions section, you repeat the findings from your Results section. I wonder if it would be more interesting to readers to see suggestions how a “decisive action” might look like instead, i.e. ideas on who could address the study results and which strategies might be plausible.

- Abstract – conclusion. We removed the repeat of results, to make room for a more detailed recommendation.

- Page 3 Line 68-72

I would suggest to reconsider pointing out the repeat survey in the abstract. By the time this paper is published, readers might wonder why authors did not prefer to wait for the study data from this successive study to analyze longitudinal data instead of cross-sectional study results.

- The mention of the repeat study is removed from the abstract as suggested.

- Page 3

Line 72

The Background section is rather short. Instead of or in addition the findings on the repercussions of burnout for healthcare providers in general, you might refer to empirical findings specifically for EM physicians to establish specific relevance for this professional group. This might also “complete the circle” with regard to the workforce guideline, i.e. why are certain recommendations included in this guideline. The same suggestion applies for work engagement.

- The suggestion the reviewer gives is a valid one. However, there are no findings specific for EMPs on both burnout and work engagement, other than that EMPs overall almost ‘always’ score worst among peers. This is likely mainly due to the 24/7 schedule, in a fast-paced, unpredictable setting, where stressful situations are common. We rewrote the first sentence of the introduction to highlight these differences a bit more.

- Page 4, line 87-88

Please add that you measured self-reported adherence and compliance to recommendations. Otherwise, one might confuse it with objective assessments of adherence to recommendations.

- ‘Self -reported’ was added line 116, page 4

Please clearly state which part of the study was cross-sectional and which is the cohort study (since a study cannot be cross-sectional and a cohort at the same time). I guess that you analyzed cross-sectional data from one wave of a cohort study. Please explain how many waves were already conducted and how many waves are planned.

- This study was the first cross-sectional wave of a cohort study of which the second wave was planned for 5 years later. This has been explained more correctly now on page 5, line 123. Page 1 title page, Page 4 line 115

Please shortly explain how you gained access to the email addresses. I guess that you obtained them from the Dutch Society of Emergency Physicians? It would be helpful for international readers to know if every single Dutch emergency physician has to register with the Dutch Society of Emergency Physicians. If not, how many EM physicians are there in the Netherlands in total and how do they compare with those who are not part of the society? Are only emergency physicians working in hospitals eligible to participate or also those working in pre-hospital settings?

- The Dutch RGS, the registration commission for medical specialists, had 583 registered EMPs at 01-01-2019. At 01-06-2019 DSEP confirmed us to have 526 members. 526/583 equals 90.2% of all Dutch EMPs. Most residencies end in September with approximately 45 new EMPs finishing their training. At 01-01-2020 there were 611 registered EMPs at the RGS, and 603 EMP members of DSEP. 98,7%. We added this in the text.

In the Netherlands all EMP work in EDs as a main part of their job. Prehospital care is not part of our job description.

Both facts are now clarified in the text.

- Page 5, line 124-126

Did you apply any inclusion or exclusion criteria for participants? If yes, please explain.

- The study included all Dutch EMPs registered with the DSEP. We added as per your suggestion a sentence to clarify this in the Analysis and statistics section of the methods.

- Page 6, line 189-194

Please explain why you choose this specific set of demographic variables and not others from your comprehensive questionnaire, which might have also been suitable with regard to burnout (e.g. working hours (item 13), weekend work (item 28))?

- We are unsure which section of text is meant by this comment. We are happy to clarify our choices, but would like to know where specifically the reviewer’s question is applicable to.

Please name the amount of items for each burnout domain since your participants answered these items and not the domains per se.

- The amount of items per burnout domain were added to the text.

- Page 5, line 144-145

Why did you use two operationalizations of burnout, i.e. Brenninkmeijer EEplus1 definition and the one provided by the UBOS manual?

- In literature on burnout the use of the MBI / UBOS is standard. Yet the cut-off for how and when to call cases positive or negative for burn-out symptomatology is varying highly.

Some use only the emotional exhaustion scale (EE), and leave out the other two domains (DP and PA) completely, other use a combination of two out of three domains, and none use the exact same cut-off. In general, studies on burnout report burnout rates going from 20 percent to as high as 90 percent, using the same measurement tool, but different interpretation of the outcomes.

Brenninkmeijers’ proposed EEplus1 (high EE and either high DP ór low PA) and the proposed Burnout Syndrome (both high EE ánd high DP plús low PA) are examples of unifying the way we report on burnout. To determine ‘high EE and DP, and low PA’ the manual suggests to use the 75th percentile of the distribution of the composite variables.

We believe this way we report the most truthful representation of burnout symptoms in our sample.

- Page 5 Line 142-155

What was the time horizon given in the question on “intention to quit”? Please add this information to the text.

- We added this information to the text. In short: having ‘ever’ considered to leave the profession.

- Page 6 Line 169-170

Please report the Cronbach’s alpha for all of your scales. Please also consider that CA is not a simple measure of “correlation” (page 7) but one of internal consistency.

- We thank you for bringing it to our attention that we used the word correlation in the explanation of the Cronbach’s alpha, instead of internal consistency. The CAs were added.

- Page 7, line 206-208

I could not find Figure 1 referenced on page 5. Please clarify.

- The absence of figure 1 you so rightfully point out, is due to one of the final changes we had to make to our article to fit it within the set boundaries for submissions. So sorry, we forgot to remove the reference ‘figure one’.

- Page 6, line 175

Please add information on how you addressed missing data in analyses.

- We added transparency on how we dealt with missing data. The on line questionnaire worked in a way where respondents could only more forward after filling in all previous questions, so missing items was extremely rare.

- Page 6, line 189-194

Please explain why you refrained from multivariable logistic regression analyses to include all demographic factors in one analytical model to explain variance in your outcomes?

- A multivariate logistic regression analysis was performed correcting for age, sex, career length, and the most common work stressors and energy sources. These work stressors and energy sources were derived from the job demands and resources model (Schaufeli W, Bakker A, 2004). This model uses work pressure, role conflict and emotional burden as three well established job demands, and possibilities for personal growth, work fit, autonomy, peer support, team atmosphere and team effectiveness as six well known job resources.

For burnout as expected energy sources ( OR 0.8, with 0.7-0.9 CI 95% and p .003) and work stressors (OR 1.9 and 1.4-2.5 CI 95% at p <.0001) proved to be strong predictors. We tested the composite variable of the 12 workforce factors, which showed a calculated OR of 0.9 with 0.9-1.1 CI 95% for burnout.

Only the energy sources were of predictive value for work engagement (workforce came at OR 0.9, 0.8-1.1 CI 95% and p .901) and for the intention to leave work stressors had a OR of 0.7 with 0.6-0.9 CI 95% p .001 and Energy sources had a OR of 1.3, with 1.2-1.5 CI 95% and p <.001, with the workforce recommendations coming at 1.1 (0.9-1.4, p =.2550

The effects of the work stressors and energy sources from the JDR model have been proven extensively in prior research. The adherence to the workforce recommendations was mediocre, variation was high, and only three recommandations showed (weak but significant) correlation.

Since the workforce recommendations in this study came at no significant OR for the three primary outcomes, as was to be suspected, we decided to put the emphasis in this article on different aspects.

Results - I could not find „Supplementary Table 1 – E_table_1.docx“ in my copy of the manuscript.

- We thank the reviewer for the feedback on our results section. Supplementary Table 1 – E_table_1.docx has now been renamed S2. Table and was supposerd to be available with the first submission. We will make sure to add it again to the uploaded files as intended.

I don’t think that the presentation of descriptive results in Table 1 is intuitive. Please consider a complete depiction by separately showing frequencies and percentages for all categorical categories in separate lines, e.g. female/male.

- Table 1 has been completed with the comparative groups for readability. In the subscript we added clarification on the used statistical analysis.

- Page 7

Which statistical analyses did you use to compute odds rate for results in Table 3?

- The OR were calculated using a logistic regression analysis. This was clarified in the text.

- Page 8, line 239

Discussion - Please remove references to your tables in the Discussion section.

- It has been removed per the suggestion of the reviewer.

- Page 11, line 307

References - Please check if the journal recommends to include an English translation in square brackets after foreign manuscript titles, e.g. in citations 1, 15. Please review all of your references and choose one continuous citation style.

- The references were adjusted to the required Vancouver style, as per recommendations by the International Committee of Medical Journal Editors, and PLOS One

Editor

Abstract:

As the aim you state “to evaluate the adherence to the DSEP workforce recommendations, and the association between these recommendations and signs of burnout, work engagement and the intention to leave the profession”

- We thank the editor for the valuable commentary given.

Please spell out DSEP (abbreviation cannot be understood)

- Line 45 on page 3 now explains the DSEP abbreviation; a small omission on our part.

Neither data on the recommendations nor on the associations are presented in the Results section of the abstract. Please add this data.

- To improve readability burnout, work engagement and the intention to leave are now referred to as the three main outcomes. The workforce recommendations and their correlation to the three main outcomes were added in the result section of the Abstract.

- Page 3, line 48-52, 58-63

I suggest deleting your interpretation/discussion of your findings from the results section of the abstract. Comparison with findings from the literature are usually not made in results section. Also, this relates the impression that you gathered the original data that allowed for such comparisons (e.g. in other health care professions)

- We appreciate the advice to remove the interpretation of our findings within the scope of (inter)national literature from the abstract. This removal allowed space to add the results on workforce recommendations mentioned above.

- Page 3, line 55-58

Methods in abstract/Methods section: Cross-sectional survey-based cohort study please change to cross-sectional study. Cohort is a misleading expression; even if you plan to collect prospective data you are not presenting it at this point.

- We have amended the mention of this study being a cohort study. In its intent it is the first wave of a cohort study, but we fully agree that in this single paper it can be misleading.

- Page 3, line 48

Would delete this from the abstract: "this study creates a foundation upon which future research can build and a repeating questionnaire is already planned for end 2025", please present broader implications

- The follow-up study is no longer mentioned in the abstract. We rewrote the conclusion of the abstract with all recommendations from the reviewers in mind.

- Page 3, line 72, Line 68-72

Methods in abstract: how was intention to leave measured?

- In the Methods section of the Abstract it was added how the intention to leave was measured: “by three self-developed questions”

- Page 3, line 50-51

Methods section in the paper: The Utrecht Burnout Scale (UBOS): I never heard of the approach to re-name the translation of an original scale (also due to copyright issues). I cannot access the referenced study. Please confirm that the UBOS items are fully identical to the MBI; thus that the UBOS really is close translation and that original MBI items were not removed, significantly revised or that new items were added. Otherwise validity of the UBOS should be documented.

- The UBOS is the official Dutch adaptation of the MBI. The Dutch test publisher, Swets & Zeitlinger (now Pearson Test Services), obtained a formal license from the copyright holder, Consulting Psychologists Press (currently Mind Garden, Inc., Palo Alto, CA). The original MBI items were translated into Dutch and subsequently back-translated in accordance with the guidelines prescribed by the copyright holder, ensuring conceptual and linguistic equivalence with the original instrument. A comprehensive Dutch test manual was published in 2001. In our view, this manual provides more extensive documentation than the original MBI manual available at that time. Importantly, more recent editions of the American MBI manual have incorporated empirical data based on the UBOS. Finally, the widespread use of the UBOS is reflected in the scientific literature: a quick search in Google Scholar yields approximately 25,000 hits for “UBOS,” indicating its substantial impact and adoption in both research and practice.

- Page 5 line 142

Work conditions were measured by a self-developed measure. Please show the questionnaire as online supplement to make sure wording of items is transparently shown

- If we are not mistaken the entire questionnaire translated to English was provided. We will, with the submission of the reviewed article, make sure it is available to you.

In the methods section you state that you calculated Cronbach’s alpha. Are these reported in the result section for burnout and work engagement?

- The Cronbach’s Alphas were not mentioned, but were added.

- Page 7, line 206-208

Results: you compared work engagements values to the norm reference values provided by the UWES manual of work engagement scores of Dutch healthcare professionals. Does this comparison account for gender and age differences between samples? If not: could such differences partly serve as explanations?

- This question is absolutely interesting, whether gender and age might serve as an explanation for the differences in work engagement. The entire dataset used in the UWES manual consists of 9.679 participants with a 42.8% male to 57.2% female ratio and a mean age of 38.2.

Our study has a 32.2% male to 67.8% female ratio, and a mean age of 39. Since the entire group seems quite similar in sex and age, we did not further investigate into the demographics of the subgroup. The subgroup scores of 655 (6.8%) Dutch doctors were used as comparison. The demographics within this subgroup are not mentioned in the UWES manual.

In the results section you state that EM physicians score lower on overall work engagement than the reference sample (3.48 vs. 3.74). This seems inconsistent with the numbers in the table which are 3.48 and 3.10, respectively, which would mean EM physicians score higher. Please check.

- How sloppy of us. As a result of combining sentences to reduce word count we made a mistake. Thank you so much for pointing it out: EM physicians scored “higher on” overall work engagement.

- Page 7, line 222-223

Table 3: It seems more intuitive to flip outcomes and exposure of the analyses, as one would implicitly assume that burnout and WE predict the professional outcomes. The logistic regression analyses should be mentioned in the methods section. How did you define exposures and outcomes?

- Burnout and work engagement were seen as the exposures and the intention to leave as the outcomes. We flipped table 3. Page 9

Discussion - How do your finding related to WE compare to the literature?

- We added a recently published article as reference in which the same UWES-3 tool was used to measure work engagement in 5.023 direct care nurses from 6 European countries.

- Page 11, line 304-306

Limitations: confounding --> no adjustment

- We added this limitation in the discussion

- Page 11, line 331-332

Any recommendations for research and practice?

- We hope to have improved our recommendations throughout the text.

- Page 11 line 330-333

We thank the editor and reviewers for their thorough work and helpfull recommendations. We will be pleased to further elaborate, or adjust the manuscript if any of the comments were not sufficiently implemented or explained.

Attachment

Submitted filename: Response to reviewers PONE-D-25-60264.docx

pone.0337882.s004.docx^{(57.6KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0337882.r003

Decision Letter 1

Adrian Loerbroks

12 Jun 2026

Dear Dr. Boendermaker,

Please submit your revised manuscript by Jul 27 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Adrian Loerbroks

Academic Editor

PLOS One

Journal Requirements:

1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

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Additional Editor Comments:

The authors considerably revised the paper and improved its quality significantly. I have only a few final comments/requests:

1. Please carefully proof-read the paper to remove various existing spelling or grammar errors, for instance in the abstract:

- 2 errors: Cross-sectional on line survey-based study among all Dutch EMPs in 2019 --> Cross-sectional online survey based study among all Dutch EMPs in 2019

- Higher adherence to the workforce recommendations was significantly associated with all three main outcomes, as did five out of twelve separate recommendations” --> as were

2. Methods: The logistic regression analyses should be mentioned in the methods (“analysis and statistics”) section as an analytical strategy (along with exposures and outcomes used)

3. Methods: Please present the response options of all the intention to leave variables and explain how you defined “poor outcomes” based on those variables.

4. Table 3: please check the odds ratios for “considering to quit”. Without clarification readers may interpret you findings in terms of burnout being associated with considerably reduced intentions to quit and work engagement as linked to increased thoughts about quitting. This pattern would be counterintuitive when compared to the literature and when compared to the associations with the other 2 professional outcomes presented in Table 3. Please clarify.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: The authors have adequately addressed the majority of the reviewers' comments. The manuscript is recommended for acceptance with the following minor observations.

1. The 95% CI reported for burnout on "Considering to quit" is 0.1–0.2, which is implausible given an OR of 0.2. This appears to be a typographical error. The lower bound of the CI cannot equal the OR point estimate. This must be verified against the original output and corrected.

2. In the text (Results section) the authors state EMPs scored higher on overall work engagement (3.48 vs. 3.74, p<0.01). The value 3.74 does not match Table 2, which reports the reference group mean as 3.10. The text should read 3.48 vs. 3.10. Although this was flagged by the editor and acknowledged by the authors in the response letter, the error persists in the final clean manuscript and has not been corrected.

3. Reviewer 2 asked why specific demographic variables were chosen for analysis and not others available in the questionnaire (e.g. working hours, weekend work). The authors responded that they were unsure which section of the text the comment referred to, without providing a substantive methodological justification. A brief sentence in the Analysis and Statistics section explaining the rationale for variable selection would strengthen methodological transparency.

4. "job securiy" (paragraph 3, Discussion) should read "job security", and "assosiated" should read "associated". Similarly "recommandations" appears in the Strengths and Limitations section instead of "recommendations". These should be corrected before final production.

5. The alpha of 0.62 for the intention to leave scale is below the conventional threshold of 0.70. While the authors correctly decided to analyse the three items separately, no mention is made in the limitations of the implications this has for the construct validity of this measure. A single sentence acknowledging this as a limitation would be appropriate.

These minor corrections notwithstanding, this study provides a valuable baseline for the ongoing longitudinal research and is recommended for publication.

Reviewer #2: The authors have addressed the reviewer comments in a clear and comprehensible manner, and the revised version of the manuscript is well done. I would recommend a final check of punctuation and spelling, as I noticed a few minor errors. Overall, in my view, the manuscript is ready for publication.

**********

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Reviewer #1: Yes: Dr. Giovanni Leonardo Briganti

Reviewer #2: Yes: Anna Schneider

**********

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PLoS One. 2026 Oct 5;21(10):e0337882. doi: 10.1371/journal.pone.0337882.r004

Author response to Decision Letter 2

25 Jul 2026

Dear Editor,

We appreciate the reviewers' valuable comments on our paper ‘Workforce guidelines, burnout, work engagement and the intention to leave. A cross-sectional study among Dutch Emergency Physicians’. We have thoroughly studied the comments and are pleased to provide the following answers and corresponding changes to our paper. We will be happy to provide further elaborations or adjustments to the manuscript if required.

Reviewer #1

- The authors considerably revised the paper and improved its quality significantly.

We thank the reviewer for the compliments. We appreciate the acknowledgement of the quality of our work.

- Please carefully proof-read the paper to remove various existing spelling or grammar errors, for instance in the abstract:

- 2 errors: Cross-sectional on line survey-based study among all Dutch EMPs in 2019 --> Cross-sectional online survey based study among all Dutch EMPs in 2019

‘Online’ and ‘survey based’ have been corrected. And the paper has been combed through in its entirety for other spelling or grammar errors. Lines 32

152

- Higher adherence to the workforce recommendations was significantly associated with all three main outcomes, as did five out of twelve separate recommendations” --> as were

Thank you. Changed as suggested. Line 43

- Methods: The logistic regression analyses should be mentioned in the methods (“analysis and statistics”) section as an analytical strategy (along with exposures and outcomes used)

We have added the logistic regressions to the methods section. Lines 148-150

- Methods: Please present the response options of all the intention to leave variables and explain how you defined “poor outcomes” based on those variables.

Two of the three intention to leave questions were polar questions with only Yes / No options. This was added to the description of the questions in the Methods section. Lines 132, 135-136

- Table 3: please check the odds ratios for “considering to quit”. Without clarification readers may interpret you findings in terms of burnout being associated with considerably reduced intentions to quit and work engagement as linked to increased thoughts about quitting. This pattern would be counterintuitive when compared to the literature and when compared to the associations with the other 2 professional outcomes presented in Table 3. Please clarify.

To clarify this, we added “not” to table 3, as in: Not considering to quit. Table 3

Reviewer #1

- The authors have adequately addressed the majority of the reviewers' comments. The manuscript is recommended for acceptance with the following minor observations.

Thank you for your recommendation and your review.

- The 95% CI reported for burnout on "Considering to quit" is 0.1–0.2, which is implausible given an OR of 0.2. This appears to be a typographical error. The lower bound of the CI cannot equal the OR point estimate. This must be verified against the original output and corrected.

This was indeed a typographical error. It has been corrected based on our SPSS Syntax/Output and confirmed by repeated analysis. Table 3

- In the text (Results section) the authors state EMPs scored higher on overall work engagement (3.48 vs. 3.74, p<0.01). The value 3.74 does not match Table 2, which reports the reference group mean as 3.10. The text should read 3.48 vs. 3.10. Although this was flagged by the editor and acknowledged by the authors in the response letter, the error persists in the final clean manuscript and has not been corrected.

Thank you for bringing this to our attention. It has now been corrected. Line 185

- Reviewer 2 asked why specific demographic variables were chosen for analysis and not others available in the questionnaire (e.g. working hours, weekend work). The authors responded that they were unsure which section of the text the comment referred to, without providing a substantive methodological justification. A brief sentence in the Analysis and Statistics section explaining the rationale for variable selection would strengthen methodological transparency.

Reviewers’ remark referred to:

We apologise for still not fully understanding this question.

To clarify, in table 1 we examined the relationship of certain demographics (age, sex, career length, family setting) to our burnout outcome; Table 4 presents the relationship of burnout to the Workforce regulations recommendations (such as working hours, weekend work, shift duration et cetera). These variables (including items 13 and 28) were analysed as a set and were therefore reported separately.

- job securiy" (paragraph 3, Discussion) should read "job security", and "assosiated" should read "associated". Similarly "recommandations" appears in the Strengths and Limitations section instead of "recommendations". These should be corrected before final production.

These and some others have been corrected Lines 248, 252, 269, 270, 275, 281, 282, 293

- The alpha of 0.62 for the intention to leave scale is below the conventional threshold of 0.70. While the authors correctly decided to analyze the three items separately, no mention is made in the limitations of the implications this has for the construct validity of this measure. A single sentence acknowledging this as a limitation would be appropriate.

The respondent’s intention to leave was assessed by asking three questions covering what we assumed to be three different aspect of the intention to leave: considering to quit, seeing oneself still in this career in 10 years’ time and choosing the same profession in hindsight. The Cronbach’s alpha value < 0.70 showed that these three questions assessed different aspects of the intention to leave. Consequently, no construct variable was made or used. The three questions were therefore analysed separately throughout the paper. We added a sentence as clarification. Lines 192-193

- These minor corrections notwithstanding, this study provides a valuable baseline for the ongoing longitudinal research and is recommended for publication.

Thank you for your endorsement.

- Reviewer #2: The authors have addressed the reviewer comments in a clear and comprehensible manner, and the revised version of the manuscript is well done. I would recommend a final check of punctuation and spelling, as I noticed a few minor errors. Overall, in my view, the manuscript is ready for publication.

Punctuation and spelling was checked. Thank you for your recommendations.

Attachment

Submitted filename: Response to reviewers PONE-D-25-60264R2.docx

pone.0337882.s005.docx^{(37.8KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0337882.r005

Decision Letter 2

Adrian Loerbroks

30 Jul 2026

<p>Workforce guidelines, burnout, work engagement and the intention to leave. A cross sectional study among Dutch Emergency Physicians.

PONE-D-25-60264R2

Dear Dr. Boendermaker,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Adrian Loerbroks

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0337882.r006

Acceptance letter

Adrian Loerbroks

PONE-D-25-60264R2

PLOS One

Dear Dr. Boendermaker,

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Table. Questionnaire workforce article English PLOS one.

(DOCX)

pone.0337882.s001.docx^{(49.5KB, docx)}

S2 Table. Dutch Society of Emergency Physicians table of members 2019.

(XLSX)

pone.0337882.s002.xlsx^{(11.9KB, xlsx)}

Attachment

Submitted filename: Response to reviewers PONE-D-25-60264.docx

pone.0337882.s004.docx^{(57.6KB, docx)}

Attachment

Submitted filename: Response to reviewers PONE-D-25-60264R2.docx

pone.0337882.s005.docx^{(37.8KB, docx)}

Data Availability Statement

The data underlying the results of this study are available from Data Station Life Sciences (https://doi.org/10.17026/LS/BND3FR).

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PERMALINK

Workforce guidelines, burnout, work engagement and the intention to leave: A cross-sectional study among Dutch emergency physicians

Annemieke E Boendermaker

Gideon H P Latten

Jelle T Prins

Kiki M J M H Lombarts

Paul L P Brand

Roles

Abstract

Background and importance

Methods

Main results

Conclusions

Introduction

Methods

Design and setting

Variables and definitions

Analysis and statistics

Results

Demographics

Burnout symptoms and work engagement

Table 1. Demographics and burnout. Numbers are median (IQR) or n (%). P value for categorical variables by X square test, and for comparison of means by independent samples t-test.

Intention to leave

Table 3. Odds ratios (OR) of burnout and work engagement on the intention to leave questions.

Working conditions

Table 4. Adherence in the respondents’ ED to the 12 workforce recommendations and association with burnout. Numbers are n (%). Chi-square tests.

Associations

Discussion

Main findings and interpretation

Strengths and limitations

Conclusion

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Adrian Loerbroks

Roles

Author response to Decision Letter 1

Decision Letter 1

Adrian Loerbroks

Roles

Author response to Decision Letter 2

Decision Letter 2

Adrian Loerbroks

Roles

Acceptance letter

Adrian Loerbroks

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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