Home health aides’ experiences of their occupational health: a qualitative meta-synthesis

Figures & data

Table 1. Keywords and combinations

Database and date for search	Keywords and combinations
CINAHL 01.11.19	(MH “Home Health Aides”) OR TI home N3 (nurse* OR aide*) OR AB home N3 (nurse* OR aide*) AND (MH “Occupational Health+”) OR (MH “Occupational Hazards+”) OR (MH “Stress, Occupational+”) OR (MH “Impairment, Health Professional”) OR (MH “Health Personnel, Infected”) OR (MH “Stress, Occupational+”) OR TI [(work OR workplace OR occupational) N3 (stress OR health OR environment OR condition* OR exposure)] OR AB [(work OR workplace OR occupational) N3 (stress OR health OR environment OR condition* OR exposure)]
MEDLINE 05.11.19	exp Home Health Aides/OR [home adj3 (aide* or nurse*)] TI, AB AND exp Occupational Health/, OR exp occupational diseases/OR exp occupational stress/ OR [(work or workplace or occupational) adj3 (stress or health or environment or condition* or exposure)] TI, AB
PsycINFO 06.11.19	exp Home Care Personnel/OR [home adj3 (aide* or nurse*)] TI, AB AND exp Occupational Health/OR exp occupational stress/ OR [(work or workplace or occupational) adj3 (stress or health or environment or condition* or exposure)] TI, AB

Table 2. Overview of qualitative studies included in in the meta synthesis (N = 27)

Study	Study design	Sample	Main theme	Main findings
Author and date: Agbonif, Hittle, Suarez & Davis (2017) (Denton et al., 2015)	One-on-one interviews conducted in person and by phone	N= 58	Understand the health and safety risk factors for home care workers when they visit patients’ homes to provide care	Performing multiple physical activities: walking, lifting, carrying medical equipment, furniture, moving patients on and off chairs, wheelchairs toilets Exposed to patients’ saliva, sweat, respiratory mucus and urine, environmental exposures, violence, household infestations, such as bedbugs, lice and cockroaches, tobacco
Title: Occupational exposures of home healthcare workers		Female N= 52
Journal: Home Healthcare now		Male N= 6
Country: Ohio, USA
Author and date: Andersen & Westgaard (2013) (Andersen & Westgaard, 2015)	Semi-structured interviews	N= 17	Identify critical factors in the interaction between work environment interventions and independent rationalization	Tight budgets and restricted hiring induced work overload and delays. Work overload, physical, mental and emotional strenuous work situations, time pressure, busy, hectic and stressful work days; constant fight against time; activities related to patient care were described as increasing source of exhaustion, tension in neck and shoulders, headaches, back pain, reduced job performance
Title: Understanding significant processes during work environment interventions to alleviate time pressure and associated sick leave of home care workers–a case study		Female; 89%
Journal: BMC Health Services Research		Female N= unknown
Country: Norway		Male N= unknown
Author and date: Andersen & Westgaard (2015) (Karlsson et al., 2009)	Semi-structured interviews	N= 17	Explore potential organizational discrepancies in the appraisals of factors relating to home care workers’ working conditions	Poor economy affected work conditions, time pressure, busy and stressful work situations, constant fight against time
Title: Discrepancies in assessing home care workers’ working conditions in a Norwegian home care service: differing views of stakeholders at three organizational levels		Female N= unknown		Increase in indirect tasks: documentation, writing reports, and transferring over large geographical area
Journal: BMC Health Services Research		Male N= unknown		Increased demands of efficiency were perceived to be prioritized at the expense of compassionate care, had to be downgraded due to lack of time Sufficient time is important for job satisfactions and is a prerequisite in order to do a good job.
Country: Norway
Author and date: Barken, Denton, Plenderleith, Zeytinoglu & Brookman (2015) (Zoeckler, 2018)	Semi-structured telephone interviews	N= 46	Explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers	Transfer and moving clients, simple wound care, exercises, medication management, catheterization, colostomies, compression stockings, G‐tube feeding, continence care, blood sugar monitoring, eye drops and injections. Feelings of greater sense of control over work, increased sense of autonomy and mastery as gained responsibility for transferred tasks. Although more skills gained as individuals, home care work were still regarded as a low skilled job
Title: Home care workers’ skills in the context of task shifting: complexities in care work		Female N= 46
Journal: Canadian Review of Sociology		Male N= 0
Country: Ontario, Canada
Author and date: Butler, Simpson, Brennan & Turner (2010) (Barken et al., 2015)	Telephone interviews	N= 69	Explore the influence of turnover among home care workers	Experiences of lack of compensation, low pay, not enough hours, not being reimbursed for mileage and not feeling appreciated enough
Title: Why do they leave? Factors associated with job termination among personal assistant workers in home care		Female = 92%		The job created a sense of burnout, stress, death of clients was emotionally draining, issues with the agency, such as misunderstandings regarding training requirements, lack of decision-making, miscommunication, and unclear expectations
Journal: Journal of Gerontological Social Work		Female N= unknown
Country: Maine, USA		Male N= unknown
Author and date: Butler, Wardamasky & Brennan-Ing (2012) (Butler, 2018)	In-depth telephone interview	N= 88	Explore why home care aides leave their jobs and how they perceive their work experiences	Low pay and inconsistent hours, drive home, health aides seek other employment, even though they find the work rewarding and satisfying Emotionally or physically burned out from the work
Title: Older women caring for older women: the rewards and challenges of the home care aide job		Female = 92.3%
Journal: Women Caring for Older Women		Female N= unknown
Country: Maine, USA		Male N= unknown
Author and date: Butler (2018) (Butler et al., 2010)	In-depth telephone interview	N= 252	Examine factors related to turnover among home care aides in Maine to gain an understanding of how home care aides experience their work	Need to be careful and take care of one’s health and safety at work Home care work had no impact on health and safety, in contrast to those who had sustained an occupational injury. Staying in shape was important in this type of work to avoid injuries. Home care work was good for their health’ as it kept them active and engaged. Physical hazards; heavy lifting, strains in the back, clients with dangerous behaviors affected physical health and safety. Exposure to client’s sickness, difficulties in the winter, driving conditions and falls, becoming attached to clients who were ill, sad or died.
Title: Exploring relationships among occupational safety, job turnover, and age among home care aides in Maine		Female = 94.6%
Journal: New Solutions		Female N= unknown
Country: Maine, USA		Male N= unknown
Author and date: Denton, Brookman, Zeytinoglu, Plenderleith, & Barken (2015) (Butler et al., 2012)	Semi-structured telephone interviews	N= 20	Explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers	Develop trusting relationships and close bonds with clients, including assisting them with personal care and activities of daily living. safety issues, lack of time and Sraining, inconsistent scheduling and increase in client acuity
Title: Task shifting in the provision of home and social care in Ontario, Canada: implications for quality of care		Female N= 20
Journal: Health & Social Care in the Community		Male N= 0
Country: Canada
Author and date Franzosa, Tsui & Baron (2018) (Critical Appraisal Skills Programme)	Focus groups interview	N= 27	Explore aides perceptions of high-quality home care delivery and what barriers aides face in providing high-quality care	Regularly go above and beyond their assigned tasks, working unpaid hours, performing extra tasks to fill care gaps. Extra cooking and cleaning, supported clients’ emotional, cognitive and social health. Lack of respect and support from agency supervisors, little to no contact with other members of the clinical care team, feeling isolated on the job and having no appropriate channels to report these issues
Title: Home health aides’ perceptions of quality care: goals, challenges, and implications for a rapidly changing industry		Female N= unknown
Journal: New Solutions		Male N= unknown
Country: USA
Author and date: Hittle, Agbonifo, Suarez, Davis & Ballard (2016) (Tourangeau et al., 2014)	One-on-one interviews	N= 54	Identify occupational exposures for home healthcare nurses and aides	Physical activity exposures like walking, lifting or carrying medical equipment or furniture
Title: Complexity of occupational exposures for home health‐care workers: nurses vs. home health aides		Female N= 48		Transfer clients in/out of beds, baths, chairs, wheelchairs and toilets, dressing clients, changing bedding and mopping/cleaning client’s floors
Journal: Journal of Nursing Management		Male N= 6		Experiences of violence from patient’s, exposure to blood, urine, salvia, cleaning chemicals, drug residue, smoking, house-hold infestations, such as bedbugs, lice and cockroaches
Country: USA
Author and date: Hoppe,Heaney, Fujishiro, Gong & Baron (2015) (Franzosa et al., 2018)	Focus groups interviews	N= 58	Identify psychosocial work characteristics of home care workers that may affect their occupational safety and health	Workload and time pressures, too many tasks in too little time; working longer than the assigned hours without receiving any financial compensation Aides and clients negotiate and share control over environment. Accept the lack of control in the job as inherent to the role as a caregiver, especially for elderly clients. Experiences of receiving care, concern, emotional support and appreciation from their client as a strong job resource
Title: Psychosocial work characteristics of personal care and service occupations: a process for developing meaningful measures for a multiethnic workforce		Female; 85%
Journal: Ethnicity & Health		Female N= unknown
Country: USA		Male N= unknown
Author and date: Love, Tendick-Matesanz, Thomason, Carter, Glassman & Zanoni (2017) (Hoppe et al., 2015)	Focus group interview	N= 37	Examine how home care workers describe workplace musculoskeletal disorder factors and identify problem- solving strategies to improve ergonomic conditions	Psychosocial stressors, physical challenges and musculoskeletal pain when assisting the client with ADL activities. Emotionally demanding and fears of clients or themselves falling. Identified the need of education and training in how to catch their client or break a client’s fall in emergent situations. Equipment may be broken, missing parts, or inappropriately sized.
Title: “Then They Trust You …”: managing ergonomics in home care		86% females
Journal: New Solutions		Female N= unknown
Country: Chicago, USA		Male N= unknown
Author and date: Markkanen, Quinn, Galligan, Sama, Brouillette & Okyere (2014) (Agbonifo et al., 2017)	Focus groups interviews	N= 99	Characterize the context of home care aides work and occupational safety health hazards	Musculoskeletal disorders, back and and shoulder injuries and musculoskeletal strain hazards.
Title: Characterizing the nature of home care work and occupational hazards: a developmental intervention study	Individual In‐depth interviews	Female N= 93		Satisfaction when makes a difference in clients’ lives, enabling them to stay at home. Job flexibility and autonomy were reported as rewarding factors. Exposure to slips, trips, and falls either inside or outside of the home, car accidents, bed bugs, infectious diseases, indoor air quality concerns, clutter/hoarding, harsh cleaning chemicals, clients’ pets, bloodborne pathogens via exposure to blood or by getting stuck by a used sharp medical device
Journal: American Journal of Industrial Medicine		Male N= 6
Country: Massachusetts, USA
Author and date: Markkanen, Galligan & Quinn (2017) (Love et al., 2017)	Focus groups interview	N= unknown	Summarize the major occupational safety and health risks in home health care	Occupational and musculoskeletal strain hazards and contributing factors to injuries. Working in isolation, threat of violence and awkward work postures. Limited workspace, clutter/hoarding,pet s, distractions. Clients moves suddenly during a sharp procedure, non- cooperation, aggression, limited mobility and overweight
Title: Safety risks among home infusion nurses and other home health care providers		(8 focus groups)
Journal: Journal of Infusion Nursing		Female N= unknown
Country: Massachusetts, USA		Male N= unknown
Author and date: Muramatsu, Sokas, Lukyanova & Zanoni (2019) (Markkanen et al., 2017)	Focus groups interview	N= 45	Explore home health aides health in their work contexts	Feeling stressed, attachment to clients, depression, hypertension, asthma, arthritis, diabetes, musculoskeletal problems (knee and back injuries)
Title: Perceived stress and health among home care aides: caring for older clients in a Medicaid-funded home care program		Female = 97.8%		Lack of prior information, hazardous work environments: pets/clutter, cleaning supplies, safety protection/gear, low pay/lack of benefits (no health insurance, no paid sick leave) and lack of support from supervisors
Journal: Journal of Health Care for the Poor and Underserved.		Female N= unknown
Country: Chicago, USA		Male N= unknown
Author and date: Muramatsu, Sokas, Chakraborty, Zanoni & Lipscomb (2018) (Muramatsu et al., 2019)	Focus group interview	N= 44	Address the gap of knowledge about slips, trips and falls among home care aides who work in clients’ homes.	Workplace environmental hazards; rugs, steps, stairs, wheel- chair, medical equipment, clutter, ice, dark lights, objects on and slippery floor. Home care tasks, rushing or multitasking, carrying loads (laundry, groceries or garbage) cleaning or helping clients move and bathing contributed to falls.
Title: Slips, trips, and falls among home care aides: a mixed-methods study		Female, 95.5%
Journal: Journal of Occupational and Environmental Medicine		Female N= unknown
Country: Chicago, USA		Male N= unknown
Author and date: Nielsen & Jørgensen (2016) (Samia et al., 2012)	Observation, individually semi- structured interview	N= 16	Contribute to an understanding on how home health caregivers experience engagement in their work	Engaged and happy with the jobs, enjoyed most aspects of the work and looked forward to going to work. Low pay, increased time pressures impacted their levels of work engagement. Some made an extra effort to get to know the patients closely, displayed emotions, spending extra time attending to the patients’ social and needs and acting like the patients was their own family.
Title: Meaning creation and employee engagement in home health caregivers		Female N= 16
Journal: Scandinavian journal of Caring Sciences		Male N= 0
Country: Denmark
Author and date: Samia, Ellenbecker, Friedman & Dick (2012) (Wills et al., 2016)	Interview and observation	N= 29	Describe home care nurses’ experience of job stress and the potential moderating characteristics of the work environment	Stress and frustration were expressed in scheduling and patient visits. Lack of control over own practice and the environment, decisions made by administration. Excessive documentation requirements, heavy patient caseloads excessive hours of overtime, was sources of burn out. Valued relationships with patients, control of own practice and the environment, organizational support, leadership who are respectful of their professional role and collegial relationships
Title: Home care nurses’ experience of job stress and considerations for the work environment		Female N= unknown
Journal: Home Health Care Services Quarterly		Male N= unknown
Country: USA		(mean age, unknown)
Author and date: Schoenfisch, Lipscomb &Phillips (2017) (Muramatsu et al., 2018)	Focus groups interview	N= 18	Gather qualitative information about the context of home care work, worker safety and health	Lifting, transferring, repositioning and turning clients were physically demanding and risk factors for back injuries. Challenges in using assistive devices, in the home environment or devices were not available Physical and verbal abuse by clients, being under-valued by other professionals and worked additional (unpaid) hours to meet clients ‘needs and did tasks outside their role.
Title: Safety of union home care aides in Washington State		Female = 83%		Social isolation, feelings of being alone, lonely and not knowing any other caregivers when workers lacked regular interaction with others.
Journal: American Journal of Industrial Medicine		Female N= unknown
Country: North Carolina, USA		Male N= unknown
Author and date: Sims-Gould, Byrne, Beck & Martin- Matthews (2013) (Andersen & Westgaard, 2013)	Semi structured interviews	N= 118	Examine how home care workers respond to and manage crises in their work	Physical and verbal abuse from patients, hazardous situations and safety issues, weather, cluttered spaces, ergonomics, inadequate equipment or furniture, pest infestations and dangerous pets
Title: Workers experiences of crises in the delivery of home support services to older clients: a qualitative study.		Female N= 111
Journal: Journal of Applied Gerontology		Male N= 7
Country: Canada
Author and date: Tourangeau, Patterson, Rowe, Saari, Thomson, MacDonald & Squires (2014) (Smith et al., 2019)	Focus groups interview	N= 50	Identify factors that affect Canadian home care nurse intention to remain employed	Patient variety necessitated a wide variety of nursing knowledge and skills in their practice. The influence of autonomy, flexibility in scheduling, opportunities for orientation and education, relationships with clients, families, colleagues and supervisors were described as factors that influenced the work.
Title: Factors influencing home care nurse intention to remain employed		Female N= 47
Journal: Journal of Nursing Management		Male N= 3
Country: Canada
Author and date: Wills, Polivka, Darragh, Lavender, Sommerich & Stredn ey (2016) (Polivka et al., 2015)	Semi-structured interviews, focus groups	N= 68	Describe the decision-making processes home healthcare personnel use to manage their personal health and safety when managing hazards in client homes	Musculoskeletal risks when lifting with insufficient assistance or lack of operative lifting equipment Environmental exposures hazards like aggressive pets, inadequate protection from biohazards, client tobacco smoke, slip and trip hazards like snow, ice, rugs and clutter
Title: “Making Do” decisions: How home healthcare personnel manage their exposure to home hazards		Female N= 59
Journal: Western Journal of Nursing Research		Male N= 3
Country: Ohio, USA
Author and date: Zoeckler (2018) (Sims-Gould et al., 2013)	In-depth, semi structured interviews	N= 25	Examine occupational stressors among paid home care workers by analyzing home healthcare agency characteristics and individual home healthcare workers’ experiences	Characterized work as physically and emotionally hazardous Pay/benefits, underpaid in the low-skilled jobs, injured on job, extensive time in traffic Hazardous homes: bedbugs, lifting, air quality and violence, pressures from family and friends, expectations
Title: Occupational stress among home healthcare workers: integrating worker and agency-level factors		Female N= 24		Little respect as a member of the healthcare team, client death and personal bonds where stressors that impacted occupational health
Journal: New Solutions		Male N= 1		Left because of a better job, experience of frustration, failure to meet care needs of patients, take care of grandkids or emotional burnout
Country: New York, USA

Figure 1. Flow chart depicting the process of selecting and exclusion of studies

Table 3. Critical appraisal skills program (CASP) checklist for the studies

Questions in CASP	Yes	No	Can´t tell
1. Was there a clear statement of the aims of the research?	All included studies
2. Is a qualitative methodology appropriate?	All included studies
3.Was the research design appropriate to address the aims of the research?	All included studies
4. Was the recruitment strategy appropriate to the aims of the research?	All included studies
5. Was the data collected in a way that addressed the research issue?	All included studies
6. Has the relationship between researcher and participants been adequately considered?	(Agbonifo et al., 2017, Sims-Gould et al., 2013)		(Schoenfisch et al., 2017, Andersen & Westgaard, 2013, Smith et al., 2019, Tourangeau et al., 2014, Driessen et al., 2010, Nielsen & Jørgensen, 2016, Delp et al., 2010, Hittle et al., 2016, Butler et al., 2010, Mabry et al., 2018, Karlsson et al., 2009, Hanson et al., 2015, Butler, 2018, Wills et al., 2016, Barken et al., 2015, Holtermann et al., 2012, Butler et al., 2012, Denton et al., 2015, Markkanen et al., 2014, Polivka et al., 2015, Markkanen et al., 2017, Andersen & Westgaard, 2015, Muramatsu et al., 2019, Muramatsu et al., 2018, Samia et al., 2012)
7.Have ethical issues been taken into consideration?	All included studies
8. Was the data analysis sufficiently rigorous?	All included studies
9. Is there a clear statement of findings?	All included studies

Question 10 in CASP is “How valuable is the research?” All included studies were deemed as very valuable.

Table 4. Translation of second-order concepts and their arrangement in third-order key concepts

THIRD-ORDER KEY CONCEPTS USED TO ORGANIZE SECOND-ORDER CONCEPTS	SECOND-ORDER CONCEPTS	SUMMARY DEFINITION (TRANSLATION) OF THE SECOND-ORDER CONCEPT	PAPERS THAT INCLUDE THE SECOND-sORDER CONCEPT
PHYSICAL STRENUOUS WORK TASK DEMANDS	Assisting clients at their homes	Physically demanding tasks while helping clients with ADL activities and medical procedures at different home settings (e.g. feeding, bathing, cooking, cleaning, wound care, exercises).	(Critical Appraisal Skills Programme, Muramatsu et al., 2018, Tourangeau et al., 2014, Hittle et al., 2016, Zoeckler, 2018, Denton et al., 2015)
	Heavy lifting	Strenuous manual labor with high mechanical strain, awkward postures and repetitive movements (e.g. transferring clients on/off chairs, wheelchairs and toilets, repositioning patients).	(Hoppe et al., 2015,Love et al., 2017,Markkanen et al., 2017,Muramatsu et al., 2019,Muramatsu et al., 2018, Tourangeau et al., 2014, Hittle et al., 2016, Andersen & Westgaard, 2015, Sims-Gould et al., 2013, Butler et al., 2010, Denton et al., 2015,Agbonifo et al., 2017,Markkanen et al., 2014,Polivka et al., 2015)
	Strain and musculoskeletal injuries/disorders	Physical work task demands as a source of hectic workdays, exhaustion and musculoskeletal pain (e.g. pain in neck, shoulders and back, headaches).	(Hoppe et al., 2015,Love et al., 2017,Markkanen et al., 2017,Muramatsu et al., 2019,Muramatsu et al., 2018, Schoenfisch et al., 2017, Tourangeau et al., 2014, Hittle et al., 2016, Andersen & Westgaard, 2015, Andersen & Westgaard, 2013, Sims-Gould et al., 2013, Barken et al., 2015, Butler et al., 2010, Butler, 2018, Denton et al., 2015,Agbonifo et al., 2017,Markkanen et al., 2014,Polivka et al., 2015)
PHYSICAL WORKING ENVIRONMENT	Environmental hazards	Exposed to risk factors in an uncontrolled and ever-changing working environment (e.g. poor walking/driving conditions, limited workplace, stairs, poor working light, pets, smoking, drug residues, biological exposures, infections).	(Critical Appraisal Skills Programme, Love et al., 2017, Markkanen et al., 2017, Muramatsu et al., 2019, Muramatsu et al., 2018, Smith et al., 2019, Tourangeau et al., 2014, Andersen & Westgaard, 2013, Butler et al., 2010, Agbonifo et al., 2017,Markkanen et al., 2014)
	Lack of equipment	Musculoskeletal risk and pain when lifting with insufficient assistance from or lack of equipment (e.g. broken/missing walker or mechanical lifts, inappropriately sized wheelchair).	(Critical Appraisal Skills Programme, Hoppe et al., 2015, Schoenfisch et al., 2017, Smith et al., 2019, Hittle et al., 2016, Andersen & Westgaard, 2015, Andersen & Westgaard, 2013, Agbonifo et al., 2017, Markkanen et al., 2014)
PSYCHOSOCIAL WORKING ENVIRONMENT	Lack of support from supervisors	To little or no appreciation and support from agency supervisors (e.g. lack of positive feedback, respect, staff meetings, supervisors never available).	(Critical Appraisal Skills Programme, Markkanen et al., 2017, Smith et al., 2019, Mabry et al., 2018, Barken et al., 2015,Butler et al., 2010,Butler, 2018)
	Meaningful relationships	Appreciated trusting relationships, close bonds and friendships with clients and their families.	(Critical Appraisal Skills Programme, Smith et al., 2019, Hittle et al., 2016, Mabry et al., 2018, Butler et al., 2012, Agbonifo et al., 2017)
	Meaningful relationships as a burden	Close relationships with clients contributed to emotional strain and grief due to their serious health condition or death.	(Markkanen et al., 2017, Schoenfisch et al., 2017, Hittle et al., 2016, Sims-Gould et al., 2013, Barken et al., 2015,Butler et al., 2010,Butler, 2018)
	The work is satisfying	Positive presence factors promoted job satisfaction (e.g. appreciation and support, making a difference, enabling clients to stay at home, autonomy, responsibility, flexibility, use of diversity of skills).	(Critical Appraisal Skills Programme, Markkanen et al., 2017, Schoenfisch et al., 2017, Smith et al., 2019, Hittle et al., 2016, Mabry et al., 2018, Andersen & Westgaard, 2015, Sims-Gould et al., 2013, Butler, 2018, Butler et al., 2012, Agbonifo et al., 2017, Samia et al., 2012)
	Verbal violence	Psychological distress due to unpleasant behavior’s and rude comments from some clients.	(Markkanen et al., 2017, Muramatsu et al., 2018, Schoenfisch et al., 2017, Tourangeau et al., 2014, Hittle et al., 2016, Andersen & Westgaard, 2013, Barken et al., 2015,Butler et al., 2010,Butler, 2018)
ORGANIZATIONAL CONDITIONS	Low pay	Experiences of lack of/inconsistent compensation and/or not being reimbursed for mileage. Exhaustion and strain because they had to work more.	(Markkanen et al., 2017, Sims-Gould et al., 2013, Barken et al., 2015, Butler, 2018, Samia et al., 2012)
	Working alone	Emotional strain due to little/no contact with colleagues. Individual responsibility for appraisal and initiative for facilitation of working environment.	(Critical Appraisal Skills Programme, Muramatsu et al., 2018, Smith et al., 2019, Hittle et al., 2016, Mabry et al., 2018, Sims-Gould et al., 2013, Wills et al., 2016)
	Lack of training and unclear expectations	Lack of control over own practice and environment, as well as participation in decision-making (e.g. misunderstandings, miscommunication, lack of prior information, decisions made by administration).	(Hoppe et al., 2015, Muramatsu et al., 2019, Andersen & Westgaard, 2015, Barken et al., 2015, Butler et al., 2012)
	Time pressure	Work overload due to poor economy, increased demands of efficiency and paperwork created strain and burnout (e.g. restricted hiring, heavy patient caseloads, performing extra tasks)	(Critical Appraisal Skills Programme, Franzosa et al., 2018, Hoppe et al., 2015 Muramatsu et al., 2018, Schoenfisch et al., 2017, Muramatsu et al., 2019, Muramatsu et al., 2018, Smith et al., 2019, Mabry et al., 2018,Karlsson et al., 2009,Andersen & Westgaard, 2015, Denton et al., 2015, Wills et al., 2016, Samia et al., 2012)
	Sick leave effect	Sick leave creates a need for the re-allocation of resources, which in turn creates more pressure and stress for the remaining employees who are still at work.	(Critical Appraisal Skills Programme, Franzosa et al., 2018, Muramatsu et al., 2018, Andersen & Westgaard, 2015)

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