Iranian Journal of Ergonomics

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Introduction: One of the major problems in hospitals leading to high prevalence of musculoskeletal disorders among the health staff is associated with patients handling. This study was aimed to reduce musculoskeletal disorders using ergonomic intervention among Nahavand Alimoradian hospital staff.

Material and Methods: This study was conducted in four wards of 160-bed Nahavand Alimoradian hospital. The data collecting tool was Nordic Musculoskeletal Questionnaire. SPSS software was used for data analysis. The questionnaire was completed, before and after educational intervention, for 46 employees of the four wards which had the most complaints about musculoskeletal disorders. Training classes were held for the target group covering prevention of work-related musculoskeletal disorders, proper techniques for patient handling and stretching exercises for low back pain prevention.

Results: The main results tended to be the high prevalence of musculoskeletal disorders especially in low back, shoulders and wrists of the employees. Low back pain was the most prevalent disorder among the personnel. The educational intervention had not significant effect on lessening the musculoskeletal disorders in hospital staff (p > 0.05).

Conclusion: At present, regarding enhancements in healthcare procedures, there is an urgent need to ergonomic intervention in the design of environment, tools and equipment concurrent with educational intervention. Normal 0 false false false EN-US X-NONE FA

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Introduction: Job stress can influence job turnover in organizations. Little data is available on job stress dimensions and their relationship to job turnover among Iranian nurses. The aims of this study were investigating job stress dimensions and examining their relationship to job change intention among nurses. 

Materials and Methods: In this cross-sectional study, 385 randomly selected nurses from hospitals of Shiraz University of Medical Sciences participated. The Persian version of Job Content Questionnaire (P-JCQ) and demographic questionnaires were used for data collection. Using SPSS (version 11.5) software, descriptive statistics and Mann-Whitney U test were applied for data analysis.

Results: The means (SD) of decision latitude, psychological job demands, social support, physical job demands and job insecurity were found to be 58.15 (6.50), 38.19 (5.14), 22.67 (3.67), 16.03 (2.58) and 7.74 (3.85), respectively. The results revealed that decision latitude and social support dimensions had low levels, but psychological and physical job demands as well as job insecurity dimensions had high levels among the study subjects. The findings showed that 56.4% of the subjects intended to change their jobs. The mean score of all job stress dimensions had significant relationship with job turnover.

Conclusion: The majority of subjects were exposed to high levels of job stress and most of nurses intended to change their jobs. Based on the results, any interventional program for minimizing job turnover should focus on reducing job insecurity and physical job demands as well as increasing decision latitudes and social support among nurses Normal 0 false false false EN-US X-NONE FA

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Introduction: Musculoskeletal disorders are amongst dominant occupational injuries and disabilities in developed and developing countries. The RULA technique is one of the best methods for assessing upper limbs postures. The purpose of this study was to investigate the working postures using RULA and ergonomic interventions in the quality control unit of a glass manufacturing company.

Material and Methods: This interventional study was conducted in the mirror control workstations of a glass manufacturing company. To assess workers’ postures, the RULA technique was applied before and after the intervention. After data analysis, corrective engineering measures were recommended and implemented in all workstations.

Results: The findings showed that 40% of workers had a grand score of 7, 40% with a grand score of 6 and 20% with a grand score of 5. Accordingly, 60% of workstations were in action level of 3 (i.e. investigation and changes are required soon) and 40% of workstations were in action level of 4 (i. e. investigation and changes are required immediately). After intervention, 20% of workstations were in action level of 3 and 80% were in action level of 2.

Conclusion: To prevent musculoskeletal disorders, increase work efficiency and improve workforce health, with positive interaction of research team and remarkable cooperation of company management, engineering interventions were designed and implemented at all workstations   and the risk level was reduced efficiently. Normal 0 false false false EN-US X-NONE FA

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Introduction: Regarding the increasing growth in jobs dealing with computers and the development of musculoskeletal disorders (MSDs) among VDT users, the assessment and identification of ergonomic risk factors are of greater importance. This study aimed to evaluate MSDs among office VDT users.

Materials and Methods: This cross-sectional study was conducted on 71 participants (37 females and 34 males) selected randomly among administrative staff of Isfahan Art University. CMD questionnaire was used to assess the prevalence of MSDs and for measuring ergonomic risk factors ROSA method was employed in VDT stations.

Results: According to ROSA risk levels, 21% (15 participants) were at low risk (score of less than 3), 48% (34 participants) were in the notification area (score 3 to 5) and 31% (22 participants) were in the need area for ergonomic intervention (score of more than 5). Sex, body mass index, educational level and work experience had significant impacts on ROSA final score (p<0.001). There was a positive significant correlation between ROSA final score and MSDs in the participants (p<0.001, r=0.828).

Conclusion: With regard to the purpose of ROSA method for evaluating risk factors of working with computer in administrative and office settings and the finding of this study, it can be employed as a useful tool in identifying and ranking ergonomic risks in today office environments. Normal 0 false false false EN-US X-NONE AR-SA

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Introduction: Musculoskeletal disorders (MSDs) are common consequences of poor working conditions associated with computer use. Regarding the lack of information about MSDs and the extensive use of computer among the university students in our country, this study aimed to explore the awareness level of ergonomic considerations in computer use and the prevalence of MSDs among university students.

Materials and Methods: This cross-sectional study was conducted on 450 students of three faculties of medicine, dentistry and paramedical of Babol University of Medical Sciences in 2012. The subjects were selected by simple sampling method. The data were gathered by the researcher-made questionnaire consisting of 6 open and 10 closed questions. Data processing was performed by using descriptive statistics and chi-square test.  

 Results: The mean (SD) age of students was 21.7 (2.5) years, 64% were females and 67% were undergraduate students. Ninety percent of the students had personal computer and 48% had spent 1 hour or more on their computer daily. It has been reported that approximately 55% of students had suffered from MSDs and less than 10% of them had been familiar with ergonomic considerations in computer use. Chi-square test indicated a significant difference in the incidence of MSDs in terms of the duration of working with computer (p<0.05).

 Conclusion: The complaints of MSDs in about half of the students and the lack of awareness of ergonomic considerations in most of them suggest the possibility of increasing future problems. Therefore, regarding the inclination of most students in receiving information and their influential role in the dissemination of knowledge, performing interventional programs including education in computer ergonomic principles is recommended.   Normal 0 false false false EN-US X-NONE AR-SA

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Match between school furniture dimensions and children’s anthropometric dimentions in male elementary schools. Rashid Heidari Moghaddam1, Rasoul Ahmadi2 , Majid Motamedzade3, Ghodratollah Roshanaie4 stract: Introduction: Given the important role of appropriate furniture in the posture of the students and that non ergonomic furniture can produce uncomfortable posture, low ‌‌‌back pain, neck pain, lack of concentration and discomfort, therefore, this study examine match between school furniture dimensions and children’s anthropometric dimensions in male elementary schools in Hamadan city. Materials and Methods: In this study 600 children have been studied. Their weight and height and their anthropometric dimensions included shoulder height, elbow height, knee height, popliteal height, popliteal-bottock length and hip breadth have been measured. Then, the fitness between current furniture's dimensions and calculated ergonomic dimensions have compared. Results: : Findings showed that dimensions of available furniture included seat height, seat depth, seat width, back rest height, desk height, underneath desk height and anthropometric dimensions of students was not matched. This study has shown that by increasing the seat depth and decreasing the seat height in new designs, they have relatively improved in compare with the old designs. Conclusion: Available school furniture dimensions in Hamadan elementary schools are not appropriate for most students and induce postural discomfort and musculoskeletal disorders. Key words: Ergonomics, Anthropometrics, Design, Furniture 1- Department of Ergonomics, Faculty of Health and Medical Sciences Research Center, School of Public Health. Hamadan University of Medical Science, Hamedan, Iran. 2- Corresponding author, Ergonomics graduate student, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran. 3- Professor, Department of Occupational Hygiene, School of Health and Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran. 4- Roshanaei, Ghodratollah, Department of Biostatistics and Epidemiology. Modeling of Noncommunicable diseases Research center, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran.

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Introduction: Musculoskeletal disorders are the most common occupational diseases and injuries. The importance of control and reduction the discomfort to the extent that in many countries, Prevention of work-related musculoskeletal disorders among workers has been considered as one of the national priorities. Methods: the cross-sectional study was carried out as an intervention in a chicken slaughterhouse. In order to determine the prevalence of musculoskeletal disorders, Cornell questionnaire was used. By identifying the tasks that are very high in musculoskeletal disorders posture evaluate was conducted and then the proportional to risk level tasks, engineering and management measures was performed. Given that most tasks are the kind of manual handling and carrying, were used the KIM methods for evaluating posture before and after of intervention. Results: The results of the Cornell questionnaire showed that the highest risk level Belongs to the neck, shoulders, back, arms and waist. Also evaluate by the KIM method the highest level of risk was estimated, the task of throwing the box and pick up the ice with the risk level 4 score, that after the intervention, decreased to the 2 score. Improvement obtained for all interventions on the average about 46.37 percent. The McNemar test was also significant difference between the results obtained before and after intervention. Conclusion: ergonomic problems have undesirable effects on employee health and productivity. This study, engineering and management interventions could significantly reduce the amount of corrective measures to improve working conditions in different parts of the company.

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Introduction: The prevalence of work-related musculoskeletal disorders in computer users is high. The purpose of this study was to evaluate ergonomic assessment musculoskeletal disorders risk in computer users determine the effect of an eight-week corrective exercises program on reduction of musculoskeletal pain.

Material and Methods: In the first phase of the study, RULA technique and Nordic questionnaires were used to evaluate postures and musculoskeletal disorders of 84 computer users of Tuyserkan administrations. In the next phase, 30 individuals for participating in a corrective exercises program intervention divided into two groups namely, experimental (n=15) and the controls (n=15). Subjects were re-evaluated after period of eight weeks. Data was analyzed using independent and dependent t-tests.

Results: The overall prevalence of pain was seen in neck, lumbar, shoulders, back, carpal and hand, elbow respectively. In posture analysis, 61.3 and 53.6 percent of subjects were in action level of 2 in left and right limbs respectively, 32.2 and 44.1 percent of subjects were in action level of 3 and 2.4 percent in level of 4 in right side. After the corrective exercise intervention, there was 38.3% significantly reduction pain for upper limbs (p=0.001) and 38.7% for lower limbs (p=0.006).

Conclusion: This study showed that frequency of musculoskeletal problems in neck, lumbar, shoulders, back, wrist was generally high among our subjects, and selected corrective exercises could reduce the risk level and pain.

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Introduction: As the traffic is one of the most common social troubles in big cities, widen the roads culture and using the intelligent methods are using to control the traffic. Therefore, the traffic control systems are innovated. These system operators have to do many cognitive jobs to manage these systems. CWA as a framework to improve the design of these systems has introduced in this paper to analyze them.

Material and Methods: CTA recognizes the restrictions of system throughout the 5 phases that begin with work domain analysis and ends in necessary personal qualification. Task analysis, strategy analysis and investigating the cooperation and organizations are between paces, respect.

Results: the results of this investigation consist of outline of the technique CWA, work domain analysis, decision ladders, details of relevant indicators, strategies, Information Flow Map (IFM), to frame the social organization and cooperation, and worker qualification analysis.

Conclusion: The results of this study may used in selection and training the mentioned systems operators. The main reason is to use the experienced staff with high cognitive abilities in working with these systems. Otherwise, it can result in waste the organization money and energy. The operator decision making is more dependent on the information process, the operator also needs to have higher cognitive abilities. Strong visual search, timing and problem solving are perquisites of this job opportunity.

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Introduction: Job satisfaction and productivity among industrial workforce depend on multiple factors. Among these factors, designing the workstation based on bodily characteristics and dimensions of the workers is of critical significance. Since industrial chairs have direct impacts on biomechanical and anthropometric compatibility, they play a major role in enhancing workers’ interaction with their workplace. The current study approached the redesign of such a product with a focus on ergonomics. Materials and Methods: The present research was a typical combined design project. In the quantitative phase, 90 participants underwent 12 anthropometric measurements (which were important in designing industrial chairs). The underlying cognitive aspects of the question were evaluated via qualitative methodologies. Results: Since normal distribution of the data was confirmed, raw anthropometric data were descriptively processed and reported. Cognitive assessments revealed correlations between correct form and softness of the backrest, and appropriate slope of the seat-pan, being a main factor determining the level of comfort while interacting with industrial chairs. Conclusion: Diverse physical constraints and conditions caused by the variety of duties and workstations have made it somehow difficult for specialists to design a universal industrial chair functioning in all different contexts. Nevertheless, the current study confirmed the effectiveness of involving personnel in redesigning the workplace and easing the challenges.

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Introduction: Job involvement is defined as one’s psychological dependence on his/her job. Employees with high job involvement pay more attention to their job. The present study aimed to determine the relationship between teachers’ job involvement and demographic characteristics in Kermanshah (Iran) secondary schools during 2013.

Materials and Methods: This cross-sectional study was performed on 211 teachers (161 male and 50 female). Data were collected using the Job Involvement Scale. The collected data were analyzed using Spearman’s correlation coefficient, independent t-test, and analysis of variance (ANOVA). P values less than 0.05 were considered significant.

Results: The teachers’ mean age and work experience were 32.21 and 8.49 years, respectively. Low, moderate, and high levels of job involvement were detected in 22.3%, 54.5%, and 23.2% of the teachers, respectively. Job involvement was significantly higher in married teachers than single subjects (p = 0.027). Moreover, teachers without a second job had higher job involvement than those with a second job (p = 0.006). There were no statistical correlations between job involvement and age, sex, work experience, or level of education.

Conclusion: The participating teachers generally had low-moderate levels of job involvement. Low salary, working multiple jobs, and low social prestige were mostly responsible for such low levels of job involvement. Therefore, increasing teachers’ salary, providing teachers with special facilities (e.g. low-interest loans), and developing a system for teachers’ promotion (similar to that existing for faculty members) can be effective in increasing job involvement among teachers

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Introduction: The introduction of a thematic framework is necessary for the field of ergonomics and human factors. Content analysis is a useful tool for the trend analysis and distribution of published articles however, reports on the content analysis of ergonomics journals are rare. The present study was conducted to identify research trends in the journal of Human Factors through a content analysis of its recent articles published over the past ten years (2005-2014).

Materials and Methods: The present study used the directed content analysis method. Two analysis experts classified 741 articles based on their thematic codes. A conceptual framework was used to perform the content analysis. EXCEL 2007 and SPSS-19 were used for the data preparation, theme distribution and trend analysis of the published themes.

Results: From the total of 21 themes extracted, six themes defined over 50% of the variance in the published articles, including “Biomechanics, Anthropometry and Work Physiology", "Display and Control Design", "Surface Transportation Systems", "Cognitive Processes", "Attentional Processes" and "Sensory, Perceptual and Psychomotor Processes". The journal had a special focus on "Biomechanics, Anthropometry and Work Physiology" (about 12%). 

Conclusion: The thematic framework and distribution pattern noticed in this study can be used for planning education and research on human factors and ergonomics in universities, research centers and related organizations.

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Introduction: Musculoskeletal disorders are major concerns of the modern world due to their effect on the physical health and productivity of the workforce. More extensive research is therefore required to identify and prevent these injuries and control the risk factors causing their development.

 Materials and Methods: The present study uses a theoretical model of ergonomic interventions to examine and improve ergonomic conditions in an automobile spare part manufacturing plant. A total of 44 employees were selected through simple random sampling and according to the Morgan table from the 50 personnel working at the plant. The Nordic Musculoskeletal questionnaire and the review of ergonomics tips inventory were used to identify the ergonomic risk factors. Based on the theoretical model used in the research, the ergonomic intervention was performed in two stages.

Findings: In the macro stage of the ergonomic intervention, 7 goals were set and 13 ergonomic recommendations were made in the form of several workshops and task forces. In the micro stage of the ergonomic intervention, 20 ergonomic risk factors were identified and 13 strategies and plans were suggested. With the senior manager's approval, 11 strategies entered the implementation stage with the aim of improving ergonomic conditions and increasing productivity at the workplace.

Conclusion: The main outcome of the comprehensive ergonomic interventions performed in the present study was a modified organizational culture, entailing both direct and indirect benefits, such as providing low-cost or no-cost solutions to the problems, creating an active environment of continuous improvement, increasing employees' motivation for participation and being innovative in solving the problems, increasing the inclination among the employees to be an innovative thinker, improving communication between the authorities and the personnel and increasing the employees' general knowledge and capabilities.

 

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Introduction: Using human data and observing local manufacturers of domestic products for imported furniture seems necessary to design and manufacture sofas with ergonomic indices. This paper uses data from the study of human population. The design process from the perspective of ergonomic furniture and product design consists of ergonomic principles such as shape and posture in the correct state and consideration of parts of body that need cushion for protection.

Methods: In this research, anthropometric data of 150 males and 110 females between the ages of 25 to 35 were measured. The calculations were based on a sample size sofa to gather user evaluation.

Results: After analyzing the measured results of a similar internal investigation using SPSS software and combining them with ergonomic principles, the optimal size sofa measurements with all angles for Iranians adults was calculated and the results were compared with the dimensions of the furniture.

Conclusions: Seat height and backrest height and width, respectively 37, 57 and 62 cm, the angle of 105 degrees between the seat and the back, and the slope of 5 degrees for the seat surface are suggested as the standard.

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Introduction: Introduction: Inappropriate sizes of school furniture and the deformation of children’s bodies is one of the issues of concern in the world. The aim of this study was the evaluation of anthropometry of primary students aged 6-12 years in Mazandaran, Iran and the design of school furniture based on the anthropometric criteria of the students.

Methods: In this cross-sectional study, 18 anthropometric dimensions of 2336 boys and girls aged 6-12 years in 2014-2015 were measured. To collect data, anthropometric chair, camera and camera stand, and Anthropometric photo graphical software were used. After determining the anthropometric dimensions, ergonomic school furniture was designed.

Results: Average, minimum, maximum, standard deviation, median and percentile value of 2.5 to 97.5 of the anthropometric dimensions of students were calculated. The results showed that gender had no effect on the popliteal height in the age groups of 6 to 7 and 7 to 8, but age had effects on popliteal height (P < 0.001). In the age groups of 8 to 9 and 9 to 10 years and also the age groups of 10 to 11 and 11 to 12 years both gender and age had effects on popliteal height (P < 0.001).

Conclusions: The results showed that by eliminating the effects of gender, 16.2 mm popliteal height increased per year. It was also found that after eliminating the effects of age, popliteal height increased 20.39 mm more in girls than in boys. Until the age of puberty, the anthropometric dimensions in girls increased more than in boys. The dimensions of ergonomics tables and chairs for students were designed in three sizes.

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Introduction: Many employees in different professions including nurses work with shifts. On the other hand, different and long shift work  can endanger physical and mental health of nurses. This study, according to ergonomic standards, aimed to design a model for shift working in order to minimize the problems caused by shift work.

Methods: In this study, all 35 nurses working in the emergency ward of Imam Sajjad (AS) Hospital of Ramsar city, Iran, were considered. Then, the information gathered from answering the Morningness-Eveningness questionnaire (MEQ) (Circadian rhythm) and Survey Sampling International (SSI) (personal and social charactristics) questionnaire were changed to a model and then reconstruct after comparing it again with circadian rhythm principals. The final model was implemented with GAMS (gamma-glutamylaminomethylsulfonic acid) and at the end, shift working with ergonomic criteria were proposed.

Results: Shift working were designed for each nurse. Also, the obtained objective function value (Z=1.110223e-16) showed that the designed model was really close to ideal model. According to hospital rules and policies, if five more nurses get added to the currently employed ones, the proposed working program on one hand will improve satisfaction and efficiency of nurses and on the other hand it can decrease the effects of disorders on shift work.

Conclusions: Hospitals can have healthy and motivated workforce by applying the scientific approach to adjust a suitable working plan for their nurses and decrease the number of disabilities and also the rate of early retirement.

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Introduction: The importance of product design has been dramatically increased in recent years due to economic considerations as well as changes in user preferences, policy making and legal needs. In response to this, and as one of the most influential branches in the field of product design (in terms of the fit between product and user), ergonomics has also been developed proportionally. The aim of this study was to review the most important considerations and different traditional and new approaches in product design as well as challenges and limitations in this regard.

Methods: A review was made of the relevant electronic databases including Ergonomics Abstracts, PubMed/Medline, Web of Science, Science Direct, Scopus and Google Scholar using the following keywords: product, design, ergonomic, design procedures and design approach. The search was limited to full text articles in the English language, published in peer reviewed journals between 1990 and 2015.

Results: Comparison of the traditional and new approaches in product design indicated that the new approaches helped designers to choose the best product model based on various aspects and a more detailed interaction between user and product. Ergonomic considerations in product design also include engineering and psychological aspects as well as taking into account abilities and limitations of both products and users, to find a good fit between user and product.

Conclusions: The findings suggest that the traditional approaches in product design alone may not anymore guarantee the success of a product in the market, particularly in universal scale and for a wide range of users. In other words, consideration of various technical (in terms of user-product interaction) and legal (environment, sustainability, cost benefit, etc.) aspects in new ergonomic approaches may be taken into account to improve the quality and success of the products in the global market. Ergonomists may encounter with some challenges to achieve this goal, but high-quality ergonomics services can be considered as an effective solution in this regard.

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Introduction: In the recent decades, owing to the advancement of technology, most jobs and occupations require the use of computers. Lack of information about ergonomic conditions has resulted in various occupational injuries. Break time between work and doing exercise, help in reduction of musculoskeletal symptoms. The present study aimed to use a new ergo-feedback software and to assess its usability in office staff.

Methods: Thirty office staff participated in this study. In the first step, muscle-skeletal symptoms were checked by a body map checklist. Then, the Borg score was determined by the participants, initially and after one work day. The software was then run in their systems and they worked with it for about two weeks. After two weeks, the Borg scale was completed again and efficacy of the software was evaluated by the system usability scale (SUS). Data analysis was performed using descriptive statistics (mean and standard deviation) and Wilcoxon test. Statistical analysis was done by the SPSS software version 19.

Results: The results showed that there was a significant difference between the Borg score pre and post intervention (P > .05). The majority of the users were satisfied with the software with the SUS score showing about 82.25% satisfaction.

Conclusions: According to this study, office workers were satisfied with using this software and it can help reduce musculoskeletal symptoms during a prolonged time period.

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Introduction: Musculoskeletal disorders (MSDs) are inevitable consequences of ergonomic principles neglect. The increasing use of computer by students may result in these disorders. Therefore, the present study was conducted to determine the prevalence of MSDs and evaluate the effectiveness of ergonomics training intervention among university students.

Methods: This interventional and cross-sectional study was performed on a group of medical and paramedical students. Samples were chosen by simple sampling method. In the first stage, data were gathered by means of a self-made measurement and Nordic Musculoskeletal Questionnaire (NMQ). Furthermore, an educational booklet regarding the principles of ergonomics in computer use (educational intervention) was offered to the subjects. In the second stage of the study, the effectiveness of intervention was evaluated using a written exam and a quasi-objective structured clinical examination (quasi-OSCE) test. Data were analyzed by SPSS 15, as well as descriptive and analytical statistical indexes.

Results: From 205 students participated in the first round of the study, the results showed that 62.44% of them (128 persons) reported at least one complain or limitation in their musculoskeletal systems during the past year. Less than 10% of the participants were aware about the considerations of ergonomics principals during computer use. After submission of the educational materials, their awareness about the ergonomics considerations in computer use significantly improved(P<0.001) and more than 95% of them had good or medium performance after the intervention.

Conclusions: The training program was effective on the awareness of ergonomics principles in computer use. However, prevention of musculoskeletal disorders requires complementary measures such as elimination of risk factors and administrative controls.

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Introduction: A significant number of employees of any organization experience burnout, in many different countries. It is obvious that burnout prevention and mental health promotion play an important role in the improvement of the quality of services. One of the strategies that could be useful in reducing premature aging is deployment of a total ergonomics (ergonomics micro and macro). The main objective of this study was to investigate the relationship between variables considered in the context of total ergonomics and burnout.

Methods: The sample was selected from one of the hospitals in Yazd, including various departments with 506 employees. The sample size of 216 was determined according to Morgan. The data were collected through questionnaires and samples were selected through a stratified random sampling method.

Results: The results showed that moderate job burnout and perceived organizational support by the employees was lower than average, and there was a significant negative relationship between burnout and variables involved in comprehensive ergonomics. The study showed that demographic variables of burnout were effective on employees.

Conclusions: This study investigated burnout level, organizational support, organizational justice and physical environment. The reduction of Burnout was assessed by improved total ergonomic (macro and micro ergonomic) conditions. The results obtained in this study correspond with the results of various research studies. At the end of the study, based on the results, suggestions were made to reduce burnout.