Content area
Background
Burnout is a global challenge and healthcare professionals are especially at risk. This paper outlines the development of a tailored, evidence-based, theory-driven intervention designed to prevent burnout among hospital-based healthcare professionals (LAGOM program). During development, particular attention was paid to cooperation and constant feedback loops with various stakeholders, especially with the participants of the intervention.
Methods
The LAGOM project has been taking place at Charité - Universitätsmedizin Berlin and the Immanuel Hospital, Berlin since 2022. To develop, implement and evaluate the burnout prevention program, we conducted two reviews, interviews, focus groups and workshops. Central to the development process was the application of an Intervention Mapping (IM) approach and the Precede/Proceed logic model, which provided a structured, stepwise framework for translating needs assessment findings into targeted intervention strategies by following its six iterative steps. In addition to the multi-professional project team, various advisory boards, including the management of the two hospitals, were involved in the project. The healthcare professionals for whom the intervention was developed were actively involved in every phase of program development.
Results
LAGOM (“Long-term Health-Related Organizational Concepts with Mind-Body Medicine”) includes 9-week in-person and online sessions covering stress patterns, communication, work culture reflection, self-care, and relaxation and exercise practices based on mind-body medicine. Participation in those sessions is working time. With endorsement from the management board of both hospitals, LAGOM also aims to enhance the work environment within the hospital structures, combining structural and behavioral prevention identified in the IM-guided development process.
Conclusions
This article details the scientific development process for a burnout prevention program guided by the IM approach, thereby illustrating how intervention development methods can be employed to improve the standards for reporting on intervention development. Employing best practice frameworks, evidence-based behavior change techniques and close collaboration with healthcare professionals enhances effectiveness of LAGOM.
Trial registration
The feasibility study and pragmatic controlled trial accompanied to LAGOM were prospectively registered with the German Clinical Trials Register (DRKS00032014, registered 17th October 2023 and DRKS00034060, registered 31st May 2024).
Background
Burnout poses a global challenge to society, particularly impacting healthcare professionals and compromising patient safety, care quality, professionalism, and workplace well-being [1,2,3,4,5,6,7,8,9]. Without effective burnout prevention embedded in corporate health management, the healthcare system is at risk. Evidence suggests interventions should be easily accessible at work, combining individual and structural aspects [10,11,12,13,14,15]. Establishing healthier work conditions as a standard practice should include implementing programs for preventing burnout, yet executing these remains a challenge (e.g. low adherence) and is still insufficiently researched [16,17,18,19,20]. Many interventions are effective only in ideal conditions and not in daily clinical routine [20]. To address this, interventions must be contextually relevant and developed based on a detailed needs assessment, considering the work environment. The cooperation of those who will participate in the program is also very important in the development of the intervention. Compared to externally developed approaches, interventions that involve employees in the local work environment in the design and implementation could increase their sense of control and engagement, which should lead to an effective reduction in burnout [8].
The intervention development presented in the present paper addresses these challenges. The overall goal of the project was to develop, implement, and evaluate a tailored, evidence-based, theory-driven intervention for burnout prevention among healthcare professionals working in a hospital. As the intervention developed here is intended to include structural prevention aspects in addition to individual prevention, the work environment played a major role during the IM process. The participation of healthcare professionals in the entire project process, including intervention development, also played a major role. For intervention development, we applied Bartholomew’s Intervention Mapping Approach [21, 22] and Green and Kreuter’s Precede logic model [23] as a framework.
The here developed intervention (LAGOM) has already undergone feasibility testing [24] and is currently undergoing effectiveness evaluation within a pragmatic randomized controlled clinical trial [25]. This paper describes the intervention and its development in detail following the six steps of IM. This is meant to help replicate and further develop the intervention.
Methods
LAGOM is a Swedish word that describes the “golden mean”: Something is just right, not too much and not too little, the ideal balance. It is also an acronym for “Long-term Approach and Guidelines for Occupational Mental Health with Mind-Body Medicine”. The development, implementation and evaluation of a custom tailored, evidence-based, theory-informed intervention inspired by mind-body-medicine (MBM) to prevent burnout was the overall project goal. Appropriate ethics votes were obtained for all steps of the project as needed (Ethics Committee of the Charité – Universitätsmedizin Berlin EA2/110/22, EA1/157/23, EA4/061/24). The feasibility study and pragmatic controlled trial accompanied to LAGOM were prospectively registered with the German Clinical Trials Register (DRKS00032014, registered 17th October 2023 and DRKS00034060, registered 31 st May 2024). We followed the six steps of the Intervention Mapping Approach to develop the intervention [21, 22], Fig. 1. The structure of this paper is based on the IM’s six-step approach.
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Project team
The core project team consisted of six people: A work- and occupational psychologist (AKK) with several years of expertise in study planning, biometrics and project design. Two PhD candidates: A psychologist (MS) with many years of study experience and MBM expertise in occupational prevention and a movement and mindfulness scientist (JB) with a qualitative focus. Further, a nutritionist (JS) with several years of expertise in MBM and guidance of MBM groups, an expert in electrophysiological measurements (MB) and an expert in strategic project management (MS) were part of the core project team. The core team worked closely together throughout the project with daily meetings. For the first three steps of the IM, the team worked together with the same tasks at the IM; from step 4 onwards, the tasks were then assigned with regard to the expertise (study design and planning; content conception of the LAGOM program; project management). The core team was supplemented by two physicians (one from the Immanuel Hospital (CSK), one from the Charité (GS)) who had both scientific expertise and actively worked at the respective sites with the professional groups for whom the course was to be developed and a psychologist (WS) with many years of experience in project implementation at the Charité. A one-hour project meeting was held once a week with the extended team to discuss the most important topics.
Additionally, various advisory boards were part of the project. Throughout the process, the individual steps were accompanied, supervised and critically reflected by those advisory boards. The expert advisory board consisted of up to 13 healthcare professionals, including nurses and medical doctors from various disciplines. An external research group comprising 25 researchers contributed additional scientific expertise to the program. A steering committee consisting of eight participants in key positions at executive level including the administrative director, hospital director, head of organizational development, chief executive officer, two nursing directors as well as a chief physician and the sustainability manager provided strategic oversight throughout the process. The expert advisory board as well as the steering committee included participants of each hospital sites. Two experts in the field of mind-body medicine were involved in the development process. Participants were recruited through stakeholder mapping and contacted via phone calls or emails based on their relevant institutional roles and expertise. The hospital staff for whom the intervention was developed was actively involved in all steps of the project, e.g. staff could engage in the development process without being in the expert advisory board through participation in focus groups. At any point in the intervention development, interested individuals had the opportunity to actively participate in one of these advisory boards, further supporting the intended user-centeredness. At regular meetings about every three months, all participants were informed about the current status of the project and their feedback was obtained.
Step 1: needs assessment and program goal
The first step of IM is to carry out a needs assessment to clarify the status quo regarding the health problem (in this case burnout) together with those affected (in this case healthcare professionals) and to define the program goal. This step identifies personal determinants and environmental as well as behavioral factors that contribute to burnout. This is based on the methodology of Green and Kreuter’s Precede logic model [23] to identify health outcomes and health problems for the intended program.
Our needs assessment is informed by five sources: [1] Six on-site work shadowings including five semi-structured interviews with healthcare professionals for whom the intervention was to be designed. The interview guide was developed for the study at hand (Supplement 5). Details of the interviews will be published in a subsequent manuscript [2]. An on-site think experiment (discussion workshop). This took place one afternoon on the hospital grounds of the Charité. Interested healthcare professionals could spontaneously drop by for a piece of cake and a cup of coffee and talk about questions in the context of the project and contribute their opinions and views (Manuscript in preparation) [3]. A scoping review summarizing current international workplace interventions aimed at reducing stress and/or preventing burnout among healthcare workers [27] [4]. A grey literature review with semi-structured interviews [12]. The integration and summarization of these five sources of information then results in the needs assessment and overall program goal.
Step 2: Preparing matrices of change objectives
Step 2 outlines the necessary changes to achieve the program goal defined in Step 1. All identified behavioral factors that contribute to burnout will be fully addressed in the program. Due to the large number of identified environmental factors and limited project resources, these must be prioritized and reduced to the most relevant ones. Hence, the relevance and changeability of the environmental factors is assessed by the project´s advisory boards (Supplement 1). On this basis, the environmental factors to be included in the program are selected through discussions within the project team. Then, each behavioral factor (e.g. healthcare professionals do not take regular breaks) is rewritten into desired behavioral outcomes (e.g. healthcare professionals take regular breaks). This is done by asking what needs to change so that certain behavioral risk factors lead to improved health outcomes. All behavior outcomes are then broken down into sub-goals, known as performance objectives (e.g. healthcare professional finds a suitable place without disruption to take a break). These were validated by the expert advisory board. Further, for each environmental performance objective, the environmental agents - i.e. the people who have the opportunity to initiate change due to their management position with regard to the relevant environmental condition - are identified. For the selected (changeable and relevant) environmental factors the team defines performance objectives. Those are later considered in the development of work environment strategies and further discussed with relevant stakeholders for implementation. The next step is to determine what people need in order to change their behavior, both on a personal level (personal determinants e.g. knowledge, attitude or skills) and on an external level (external determinants e.g. positive reinforcement, infrastructure or a certain leadership culture). To identify the personal and external determinants of the performance objectives, a working list of determinants was generated by brainstorming, reviewing the findings from the empirical literature using a comprehensive literature search, and testing the theories for additional constructs separate for each performance objective. The core project team then agreed on a list of the most relevant and changeable determinants (Supplement 2). By crossing performance objectives with determinants and writing change objectives, the final product of step 2 are the matrices of change with performance objective in the rows and determinants in the columns.
Step 3: selecting Theory-Informed intervention methods and practical strategies
In step 3, theory-informed methods that can influence change in personal or external determinants and conditions are identified (e.g. methods that increase the personal determinant “self-efficacy” or influence “attitude”). Based on this, theoretical methods (e.g. guided practice) and practical strategies (e.g. breathing exercise) for applying the methods to the intervention program are chosen. After generating evidence-based methods and strategies for all external and personal determinants the methods are rated regarding its fit within the population and clinical context as well as its relevance and changeability. Matrices of change, linking methods, strategies and possible program components with each identified change objective from step 2 are the final product of step 3. After that the project team generates program themes, components, scope, and sequence, order of component-delivery, setting and duration, messages, communication channels and finally selects or designs practical applications to deliver change methods (Supplement 3 and Supplement 4).
Step 4: producing program components and materials
The aim of step 4 is to develop program materials and pretest those program materials. All program materials are based on the identified methods and strategies from step 3. Here the project team consults with the healthcare professionals of the expert advisory board to determine their preferences for program design; here done via online-feedback form. The program materials are reviewed with inclusion of MBM materials, evidence-based contents and methods, books, and past courses. A pretest of the program materials supports the final production process.
Step 5: planning program adoption, implementation, and sustainability
A feasibility study evaluates the program’s feasibility during working hours, practicability and alignment with the healthcare professionals. Details can be found in the corresponding publication [24]. Parallel to the development of the program, efforts were also made during the entire funding period to implement it sustainably, independently of the project’s funding period:
*
The management of both participating hospitals (Charité and Immanuel hospital) was involved during the entire process.
*
The health insurance fund that financed this project was informed at least twice a year about the current status of the project and long-term implementation and sustainability were jointly considered.
*
The other members of the various advisory boards were also involved in these processes.
Step 6: planning for evaluation
The evaluation plan of the feasibility study for the here developed LAGOM program is published elsewhere [24]. Currently, LAGOM is undergoing effectiveness testing [25].
Results
Step 1: needs assessment and program goal
Figure 2 shows the logic model of the problem. Many factors that promote burnout were identified at the behavioral level. Environmental factors also play a major role in the development of burnout: on an interpersonal, organizational and on a societal level. Derived from the needs assessment the core project team defined the following overall program goal:
A reduction in burnout scores by the end of the LAGOM program among participants.
Step 2: program outcomes and objectives (logic model of change)
Tables 1, 2, 3, 4, 5, 6, 7 and 8 show the logic models of change for topic 1 to topic 8 that are based on the behavioral factors as identified in step 1. Based on changeability and relevance, the project team agreed on the following environmental topics (topic 9 to 13) to be included in LAGOM: (1) Missing appreciation by peers (team-level); (2) Lack of communication styles and methods (team-level); (3) Missing appreciation by leaders (leadership-level); (4) Lacking feedback routines (leadership-level); (5) Optimizable open ear policy (organisational-level). Those topics 9 to 13 were discussed in the steering committee and it was decided to create “stimuli” for the work environment in consultation with the board members and target group and test those within the pilot phase (step 5). Those included e.g. peer-feedback training and briefings on staff meeting (1 on 1) with focus on mental health or open-ear slots. The included environmental aspects are shown in Table 9 as offers and impulses for your working environment. This process was derived parallel to the IM process. At the same time the study team thoroughly elaborated external determinants (cues, reinforcement etc.) within the behavioral factors and included later methods, strategies and program components based on these learnings/prerequisites.
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Step 3: program design
Table 10 shows the linking of methods and strategies with each identified change objective from step 2.
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Step 4: producing program components and materials
The final LAGOM program consist of nine sessions that include structural and behavioral prevention. Table 9 shows the schedule of the 9-week LAGOM program revised after feasibility testing [24]. Each session will follow the same structure: [1] psychoeducational and interactive part on different topics with practical exercises and group exchange [2], a relaxation or movement exercise [3], session conclusion and invitations for individual deepening of subjects and a recipe of the week. The individual training components are accompanied by work field impulses. This takes place either directly on site during the sessions or externally, for example through emails. The weekly LAGOM sessions are led by qualified and experienced trainers with MBM background and specially trained for the course adaption. Figure 3 shows excerpts from the LAGOM desk calendar, Fig. 4 shows the LAGOM poster. More details on the intervention content can be found at Schröter, Berschick [24] and Koch, Schröter [25].
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Step 5: planning program adoption, implementation, and sustainability
Various steps have been undertaken to ensure the sustainable implementation and dissemination of LAGOM. A key prerequisite for workplace prevention is management-level support by the steering committee, which was secured in the LAGOM project through active involvement and support from top management. Workshops were held at the Charité and the Immanuel Hospital to introduce the program and the associated evaluations to the managers of the participating institutions. Collaboration with sustainability management and change management was established, and the LAGOM homepage was linked to the sustainability management website to ensure its continuity beyond project funding. Focus groups and expert advisory board as well as the steering committee were convened to gather insights, supervision and feedback during the content creation period. Interdisciplinarity was fostered to enhance the project’s robustness and relevance across various organizational functions and medical fields. Feasibility assessments were conducted to refine LAGOM [24], ensuring its practicality and effectiveness in real-world settings.
Step 6: planning for evaluation
The detailed evaluation plans for the feasibility study as well as for the effectiveness study are published elsewhere [24, 25].
Discussion
The LAGOM program aims to prevent burnout among healthcare professionals in hospitals by means of behavioral and structural prevention. The program was developed with the help of the addressees in a structured manner based on the six steps of the IM. This paper illustrates in detail the preparatory work and the individual steps of the IM in combination with the PRECEDE-PROCEED logic model that led to the development, testing and implementation of the LAGOM program. The program was co-developed with an expert advisory board including healthcare professionals and a steering committee with participants on executive level as well as tailored to the specific realities of two hospital settings. It addresses the critical gap, as shown in a systematic review, of limited availability of evidence-based interventions that explicitly target organizational and system level factors [28]. This is of particular importance as one of the main causes of burnout is poor working conditions [29], which is also reflected in the results of our needs assessment. Numerous methodological approaches have been developed to guide the design and evaluation process of interventions [30, 31]. Multiple ways of theorizing interventions have been suggested, such as RE-AIM model or Behavior Change Wheel, as well as theory-driven evaluations [32,33,34,35,36]. Grounding interventions in a theoretical framework has been strongly suggested as it enables the formulation of a program theory explaining how and why an intervention is expected to produce its intended outcomes [30, 37]. While Behavior Change Wheel and RE-AIM model focus more on either design or evaluation, IM provides a full-process guidance. Besides IM, one of the most widely adopted frameworks for theory-driven, full-process guidance interventions in nursing and healthcare research is the Medical Research Council (MRC) Framework. IM and MRC both have strengths and weaknesses and the MRC framework has been updated in recent years to address critiques, e.g. regarding contextual sensitivity [37]. While IM doesn’t allow for as much flexibility in theoretical guidance and the systematic development steps as MRC, it offers a highly structured, detailed and prescriptive development process. Despite potential lower flexibility, this rigor was considered as a strength in our context as it supports a theoretically coherent and contextually grounded process. To further enhance our chosen approach, we included the PRECEDE-PROCEED model as it extends understanding of what needs to be changed and why, which is then translated through the steps of IM by operationalizing diagnostic insights into actionable intervention content. Especially for healthcare interventions which are widely recognized as complex the combination of IM and PRECEDE-PROCEED Logic model ensures a robust implementation and evaluation strategy and has been suggested [21, 30, 36]. A notable strength of the LAGOM program is its participatory design. Collaboration between the addressees of the intervention, the management level and the project team is crucial for successful development and implementation. Engaging stakeholders from all levels not only ensures that the intervention is contextualized, but also fosters a sense of ownership and collective responsibility for burnout prevention within an organization. Iterative project design and adaptation provides the opportunity to refine interventions based on ongoing feedback and evolving needs. Continuous feedback and flexibility are also important to maintain relevance of the intervention over time, especially in a dynamic and high-pressure environment like hospital settings. This participatory approach aligns with findings that interventions co-developed with the population they are intended for are more likely to succeed due to higher relevance and perceived control [8]. Furthermore, the applied approach ensures transparency for various stakeholders such as health professionals, researchers, practitioners and policy makers who wish to understand, evaluate or replicate the program.
This study also has some limitations. As important as the integration of behavioral and structural prevention is: Effective structural prevention in hospitals requires the involvement of many different stakeholders and the acquisition of mostly non-existent financial resources. E.g. as the involvement of staff placed additional demands, participation of the expert advisory board fluctuated considerably despite welcoming opportunities to articulate their workplace challenges and needs. In the LAGOM project, many people from the management level worked on the steering committee, supporting the project and trying to make many things possible. For example, it was ensured that all interested employees were able to participate in the program during their working hours. However, within the needs analysis it becomes clear that there is a greater need to improve structures than can be covered by the resources of this program. Personnel shortage, increasing red tape as well as severe time constraints, which often prevent staff from taking adequate breaks, including time to eat or hydrate, reflect systemic challenges that necessitate not only organizational level changes but also broader structural and policy reforms. The LAGOM team had to focus on certain aspects in order to ensure feasibility. This, while important for immediate intervention, also highlights the challenge of addressing the full scope of burnout’s root causes in terms of available resources. However, the structures created by the project and the knowledge generated about the prevailing problems in the two hospitals will enable these additional topics to be addressed in the future.
Structured checklists for reporting the structured development of complex interventions would have great added value. Such checklists would improve transparency and replicability and furthermore allow other institutions to adapt and scale the intervention more effectively, leading to broader, system-wide improvements in healthcare professionals´ well-being.
The findings from this study underline the need for continued research on integrated burnout prevention strategies. IM guides the design of interventions at the behavioral and structural prevention levels by identifying barriers, selecting intervention components, applying theories, and effectively engaging end users. IM requires a significant amount of time, expertise and stakeholder engagement which poses challenges to implement this complex process in fast-paced healthcare environments. This is particularly critical when there is a notable gap between the resources allocated for intervention development and the practical feasibility of implementation due to constrains by structural or organizational limitations. This gap highlights the need for further research and practical applications focusing on structural interventions for healthcare professionals which have the potential to address burnout at a larger, systemic scale. Furthermore, future studies should explore how interventions like LAGOM can be adapted for different healthcare professions and contexts and evaluate long-term outcomes, including organizational metrics such as staff retention, patient satisfaction, and overall workplace well-being. The success of structural components may take longer to manifest and require sustained institutional commitment.
Policy implications should not be overlooked. Institutional support and policies promoting mental health and well-being must be prioritized to enable the successful implementation and sustainability of such interventions. That also includes addressing systemic barriers such as establishing adequate staffing levels. Further recommendations include the integration of co-design approaches, as they have been a valuable source to ensure success as well as establishing reporting standards that include structured checklists for transparency.
Conclusions
The IM framework proved effective in systematically addressing the complexity of burnout prevention. Its application in other healthcare settings could help develop interventions that balance individual and structural components, tailored to the unique needs of each organization.
The LAGOM program demonstrates the potential of a comprehensive, participatory approach to burnout prevention in the healthcare setting. By addressing both individual and structural factors, it offers a promising model for creating healthier work environments. However, its effectiveness depends on sustained engagement from both employees and leadership, highlighting the importance of a supportive organizational culture. Future research should focus on long-term implementation strategies and broader application across diverse healthcare professions and settings to further advance burnout prevention efforts.
The following key messages outline the central implications. Both individual and structural conditions should be targeted to enable effective burnout prevention. Co-developing interventions is essential to ensure contextual sensitivity and relevance. Institutional and policy support has shown to build a solid foundation for implementation and sustainability. Future research should focus on long-term outcomes while the development of robust implementation strategies is essential to ensure effective translation into everyday practice.
Data availability
The datasets generated and analysed during the current study are not publicly available to protect study participant privacy but are available from the corresponding author on reasonable request.
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