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Current Psychology
Emotion Granularity: Basically ok day to day in the desert of burnout?
--Manuscript Draft--
Manuscript Number: CUPS-D-19-01687
Full Title: Emotion Granularity: Basically ok day to day in the desert of burnout?
Article Type: Original Article
Funding Information: National Center for Complementary and
Integrative Health
(10.13039/100008460)
Dr. Eve Ekman
Abstract: This aim of this study is to use an ecological momentary assessment, EMA, explicitly
designed for healthcare providers, to investigate a granular level of daily emotion
experiences with a population of burnout health care providers. Three pilot studies,
(total n=100), examined the feasibility for this EMA and descriptive differences
between psychometrically validated measures of stress and burnout to ESM reported
emotions experienced over ten days. Key findings include demonstrated feasibility for
this EMA and a high incidence, 50% of all 1881 reported emotions, as some form of
enjoyable emotions. Fear-based emotions accounted for 17%, and anger based
emotions accounted for 15% of all emotion responses. This co-occurrence of daily
enjoyment and burnout is discussed in the context of meaning-based coping,
mindfulness of emotion, and related positive emotion constructs. Future directions
include using emotion-focused interventions to reduce daily stress and burnout.
Corresponding Author: Eve Ekman, PhD MSW
University of California Berkeley
Berkeley, CA UNITED STATES
Corresponding Author Secondary
Information:
Corresponding Author's Institution: University of California Berkeley
Corresponding Author's Secondary
Institution:
First Author: Eve Ekman, PhD MSW
First Author Secondary Information:
Order of Authors: Eve Ekman, PhD MSW
Elizabeth Goodman Gurfein, PsyD
Michael Cohn, PhD
Rhianon Liu, MD
Benjamin Emeret-Aronson, PhD
Order of Authors Secondary Information:
Author Comments: Thank you for the opportunity to submit.
Suggested Reviewers: Wolf Mehling, MD
University of California San Francisco
Wolf.Mehling@ucsf.edu
understanding of emotion and stress in medicine and ecological momentary
assessment
Michael Krasner, MD
University of Rochester
Michael_Krasner@URMC.Rochester.edu
research on stress in healthcare
Helen Riess
Massachusetts General Hospital
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Abstract
This aim of this study is to use an ecological momentary assessment, EMA, explicitly designed for
healthcare providers, to investigate a granular level of daily emotion experiences with a population
of burnout health care providers. Three pilot studies, (total n=100), examined the feasibility for
this EMA and descriptive differences between psychometrically validated measures of stress and
burnout to ESM reported emotions experienced over ten days. Key findings include demonstrated
feasibility for this EMA and a high incidence, 50% of all 1881 reported emotions, as some form of
enjoyable emotions. Fear-based emotions accounted for 17%, and anger based emotions accounted
for 15% of all emotion responses. This co-occurrence of daily enjoyment and burnout is discussed
in the context of meaning-based coping, mindfulness of emotion, and related positive emotion
constructs. Future directions include using emotion-focused interventions to reduce daily stress
and burnout.
Keywords: emotion regulation, emotion awareness, ecological momentary assessment, burnout,
Manuscript (Must NOT Contain Author Information) Click here to view linked References
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Introduction
…We should abandon the measurement of stress, which tends to be too unidimensional, in favor of
measuring the degree and quality of the emotions of daily living. Information derived from such
measures could greatly expand our understanding of how individuals handle both positive and
negative experiences.’ Richard Lazaurs
Research studies conducted in thousands of hospitals across the country have revealed an
‘epidemic of burnout among trainees and health care providers (Shanafelt, Dyrbye, & West, 2017;
West, Dyrbye, Erwin, & Shanafelt, 2016).’ The repercussions include personal and professional
consequences which range from depression and suicidality to poorer patient care and high job
turnover(Dyrbye et al., 2008; Fahrenkopf et al., 2008; West et al., 2006). Research efforts to
address this epidemic have primarily focused on institutional and organizational factors and,
accordingly, solutions have aimed at the macro, organizational level(Krasner et al., 2009; Vachon,
2016). However, while institutional efforts are incredibly important, there remains a need to train
providers at the individual level. To create practical individual level trainings for providers, a more
detailed understanding of stress is needed. Macro-level observations of clinician burnout miss the
granularity of what kind of daily events trigger stress and how healthcare workers experience and
responded to these triggers. Thus, interventions based on the most commonly used psychometric
measures of burnout may not address the day to day emotional experience or existent coping
strategies of healthcare professionals. The studies presented here assess the feasibility of using
ecological momentary assessment of emotion to collect data with healthcare workers and present
results of this method of data collection.
Background Study
In 2016 The Accreditation Council for Graduate Medical Education (ACGME), responsible for
designing educational competencies for residency programs nationally, added a “Well Being”
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competency which stated: “In the current healthcare environment, residents and faculty members
are at increased risk for burnout and depression Psychological, emotional, and physical well-
being are critical in the development of the competent, caring, and resilient physicians. . .
Programs have the same responsibility to address well-being as they do to evaluate other aspects
of resident competence.” (ACGME Common Program Requirements, n.d. ) This new ACGME
competency has increased interest in identifying well-being related needs that can inform the
development and delivery of effective resilience curriculum.
One author, EE, adapted a Mindfulness and Compassion-Based Intervention, MBCI, for
physicians in training at an urban training hospital and trauma center from 2015-2017. The
intervention, Supporting Provider Resilience By Upping Compassion and Empathy, SPRUCE
(Ekman, 2016), teaches emotion regulation skills through a reflective exercise of mapping daily
emotion, structured sharing, and secular guided meditations.
Participants in the SPRUCE curriculum expressed clear interest and engagement in the program;
however, the resident's schedules posed constraints on expanding delivery and assessment of the
intervention. In the face of those challenges, the self-reflective group sessions, qualitative
interviews, and validated survey instruments provided clear pictures of resident stress and well-
being. In addition to high burnout scores among residents, there were specific descriptions of
what kinds of events lead to painful emotions and how these emotions were coped with both
skillfully and unskillfully. These sessions and interviews also highlighted the enjoyable
experiences within daily work.
Conceptual Framework
Emotions include a bundle of physiological responses that unfold from a trigger (start) to an
experience (middle) and response (end)(Ekman & Davidson, 1994; Gross, 1998b). Triggers of
emotion can vary significantly between and within individuals, and the experience of emotion can
range in intensity. Once an individual experiences an emotion, they may respond with one or more
of many internal and external behavioral reactions or strategies(Davidson, Jackson, & Kalin, 2000;
Gross, 2002). Emotions fluctuate throughout a day and influence perception. Knowing that an
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individual, or group, is “stressed” or “burnt out” does not provide information on how their
negative emotions were triggered, how they felt, or how they responded.
Similarly, uni-dimensional measures of emotion can obscure information about positive emotions
that occur within the daily life of someone experiencing burnout and stress(Lazarus, 1990). In their
foundational work on the daily experience of stress and emotions (Folkman & Moskowitz, 2000)
found that positive emotions occurred in participants who reported stress. The broaden and build
theory of emotional well being shaped by EMA data posits that positive emotions provide
opportunities to broaden and build psychological resources, in contrast to negative emotions which
shut down and narrow one’s focus (Barrett, Gross, Christensen, & Benvenuto, 2001; Tugade,
Fredrickson, & Barrett, 2004). The daily experience of positive emotions is a strong predictor of
overall well being, even in the presence of difficult emotional experiences (Barrett, 2004;
Fredrickson, 2003).
Additionally, the present mood can influence how previous emotions are reported. For example,
Ebner-Priemer & Trull, 2009, showed participants reported more past frustration related emotions
during an angry moment than when asked later after the emotion or mood passed. The predictions
of future feelings, affective forecasting, or past feelings, retrospective recollection, have both been
proven to be highly inaccurate (Gilbert, Pinel, Wilson, Blumberg, & Wheatley, 1998; Wilson &
Gilbert, 2005). Memory is most reliable for the most recent and challenging emotion, or the peak
and end emotion, instead of accurately recalling the entire picture of the day or week (Miron-Shatz,
Stone, & Kahneman, 2009; Redelmeier & Kahneman, 1996). Given the complexity of emotion and
the subjectivity of emotional recall, to better understand stress and burnout a more nuanced and
timely assessment is needed.
Ecological Momentary Assessment for Emotion
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Ecological momentary assessment (EMA) was developed by psychologists to improve self-report
measures by increasing ecological validity and reducing heuristic biases (Ebner-Priemer & Trull,
2009; Shiffman, Stone, & Hufford, 2008). EMA can ask brief questions across more time points in
comparison to a standard survey battery for a laboratory experiment which may include a set of
150-400 questions. Not only is the volume of these questions strenuous, these questionnaires ask
about a time scale that is not relevant to daily emotion experience (Kashdan & Steger, 2006).
Instead, they ask participants to provide the best estimation of type and intensity of emotion
experienced in the last week or series of months. This ‘averaging’ loses the ecological and
longitudinal validity of daily questioning. Even using the daily reconstruction model, DRM, a
structured evening diary questionnaire which asks participants to recall with detail their daily
emotion episodes at the end day, has differential capabilities for understanding daily emotion than
a single point in time survey(Kahneman, Krueger, Schkade, Schwarz, & Stone, 2004). With DRM
and EMA, the daily questions not only gather meaningful granular data, but they also train
participants to become more effective observers of their experience. This development of increased
self-awareness through data collection is demonstrated with EMA based behavioral health
interventions (Ebner-Priemer & Trull, 2009; Heron & Smyth, 2010; Stone & Shiffman, 1994). One
challenge of single point in time surveys of emotion and stress is that the participant may not be
skilled at emotional self-reflection.
Figure 1. Emotion Timeline
Trigger
Interaction, thought, experience
Experience
Type and intensity of emotional
feelings
Response
Internal or external behavior or
response
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As seen in the figure above, an emotion timeline describes the unfolding process of emotion from
the trigger to experience and response. The daily questions in this EMA focus on the trigger (the
stimulus of the emotion), experience (psychological feeling, type of emotion, intensity, and
embodiment) and response (coping strategy) to emotion.
Conceptual Framework
Prior EMA studies of emotion have drawn on psychometrically validated emotion scales such as the
PANAS and DERS to collect data on the experience of positive or negative (valence), with high or
low intensity (arousal)(Barrett, 2004; Barrett et al., 2001; Ebner-Priemer & Trull, 2009). These
questions have provided meaningful experience data but do not give information on the emotion’s
trigger, response, or embodiment of emotion. Understanding the process of how daily emotion is
triggered is especially vital for high-stress populations who have both more triggers to difficult
emotions and nominal time to recover. This paper discusses triggers and experience in detail, but
only briefly examines embodiment and response.
Triggers. The trigger is made up of an important event which precipitates the emotion, and the
appraisal of the emotion. The appraisal process is automatic and constantly sorts through and
filters how we experience the world. Debate on whether the body, mind, or other construct is
‘pulling’ the emotion trigger can remain unresolved for this paper. Prior EMA research has
shown that mind-wandering may trigger negative emotions(Killingsworth & Gilbert, 2010).
Laboratory-based research on emotion triggers have examined myriad facets of what contributes
to the saliency of a trigger (LeDoux, 2003)and the physiology that occurs with high arousal
triggers (Blascovich & Mendes, 2010)
Experience. The experience of emotion includes the subjective psychological felt experience; the
felt physiological arousal of emotion, and intensity(Bradley & Lang, 2000; Davidson, 2003;
Levenson, 1992). The intensity of psychological and physiological arousal of emotions can be wide-
ranging. One can feel a little or a lot of joy, anxiety, or grief. The difference between a bit annoyed
and very annoyed is a significant experienced variance, one that likely has differential impacts on
embodiment and behavior. Capturing intensity of felt emotion could be as important as the type of
emotion felt.
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Response. Response to emotion has been studied through observation and self-report,
physiological and neurological measurement(de Wied, van Boxtel, Zaalberg, Goudena, & Matthys,
2006; Sahdra et al., 2011). Forms of measurement include macro and micro facial expression,
thermadermic facial behavior, and other externalized behaviors such as vocal tone, body language,
and activity (e.g., yelling, hugging, dancing with joy). There are automatic and more considered
emotion responses. Automatic responses include yelling, physically avoiding or succumbing to
tears, and cognitive reappraisals ( e.g., ‘I am going to wait until I am less angry to respond,’ or ‘this is
hard but meaningful’)(Barrett et al., 2001; Gross, 2002).
For this study, a mobile program called EmoTrak was developed and used to collect daily emotional
data from participants via text message. The goals of the study were to 1) Determine feasibility for
this EMA within a high-stress population of medical professionals 2) Investigate descriptive EMA
data and compare with psychometrically validated surveys of burnout, positive and negative
emotion, and perceived stress. These goals inform an overarching aim of developing an emotion-
focused mobile assessment for residents and other high-stress populations prone to burnout.
Methods
This paper presents findings from three smaller studies conducted with health care professionals
and residents at the University of California, San Francisco (UCSF), total n=100. Study one took
place in Spring 2015, n=20, updates and improvements were made to the app for the second study
in Fall 2015, n=31, and further updates and improvements for the third study in Fall 2016, n=49.
Studies one and two were descriptive studies and study three was a control wait list design.
Participants and recruitment: PI Ekman described the study and gave study info sheets for
voluntary participation in Pediatrics, Family Community Medicine and Psychiatry. Faculty from
these departments also forwarded information about the study to resident listserves. Additionally,
an email was sent from a well respected faculty member across several departments to recruit
healthcare professionals in addition to residents. Interested participants contacted the PI by email,
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and were sent a link which directed them to online content, a baseline survey, instructions to
generate an anonymous study ID, and provided their phone number which would receive the text
message prompts and begin the EMA.
Setting: The hospital and clinics where the study participants work is an urban level I trauma
center that provides comprehensive health care service across specialties. The hospital also
functions as the safety net county hospital providing healthcare for underserved populations.
Measurements
EMA: EmoTrak, was made up of a series of questions (see table 1). These were asked twice a day
for 10 days. Half of the study used a pilot SMS version of the daily tracking the other half used a
mobile application built for the study. Participants received reminders to fill out the survey twice
daily by text and were sent follow up emails if they missed more than 4 responses in a row.
Prompts to fill out the survey were delivered via text message (SMS) to the participant’s phone.
Participants were instructed to respond to the text message as soon as possible after receipt, as
long as it was safe to do so and would not interfere with patient care activities. Participants could
choose the timing of the texts within their work shift for the week. The goal was to reach
participants during work hours. If the participant did not respond, a reminder was sent 2 hours
later. The text message consisted of a brief greeting and a link to a mobile-optimized web
questionnaire.
Table One
EmoTrak Questions
Questions
Response
Choose an emotion you are most recently feeling?
List of Emotion Words From PANAS ( choose one)
What is the Intensity?
Very Slightly- Extremely 5 point likert
Did you feel it in the body?
Very Slightly- Extremely 5 point likert
Where i n the body?
Drop Down for Body Locations ( multiple)
Do you know the trigger?
Free Response
Which best fits the trigger?
Categories developed from study 1 &2 responses
What was your response?
Drop Down Emotion Responses : Avoid, Changed, Enjoyed,
Observed, Responded, Stayed, Suppressed, Other
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For the mobile app instructions for downloading from the iTunes app store onto an iPhone were
provided by email to participants. Once open, the app provided a brief user guide and participants
were given options to set timing of their daily alerts. Feedback from study one and two were
incorporated to improve usability in the app.
Table Two
EmoTrak emotion states
Emotion Type and range
Fear: afraid, anxious, timid, nervous, jittery, shaky worried, apprehensive
Sadness: sad, blue, downhearted, alone, lonely, discouraged, hopeless
Happy: joyful, delighted, cheerful, excited, enthusiastic, lively, energetic, peaceful
Angry, hostile, irritated, scornful, loathing, resentful, indignant, furious, annoyed
Surprise: amazed, surprised, astonished
Disgust: offended, feelings of repulsion with myself or others, morally offended
Contempt: deserving of blame, scorn, feeling better then another, disdain, ashamed
Surveys: Before using the EMA participants filled out psychometrically validated surveys on stress,
burnout, well being, and emotion. The following scales were included.
Burnout was measured with the Maslach Burnout Inventory (MBI) (Maslach & Jackson, 1981).
Respondents indicated how often they felt emotional exhaustion, personal accomplishment, and
cynicism in the workplace
Wellbeing was measured with the Flourishing Scale (FS). (Diener et al., 2010)Respondents indicated
the level of meaning and purpose they felt in life and at work.
Perceived stress was measured with the 4-item perceived stress scale (PSS) (Cohen, Kamarck, &
Mermelstein, 1983). Respondents indicated how often in the past month, they found their lives
unpredictable, uncontrollable, and overloaded.
Qualitative Interviews
Brief structured user experience interviews were completed with a sample of participants, n=13,
after the final group of participants. At the end of the final survey participants were asked if they
would participate in a brief phone interview about using the app. These interviews were recorded
How Long did it last?
Under a minute, a couple of minutes, a half hour, and hour, more than
an hour
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and transcribed. These interviews asked the same questions listed below. The questions were
generated by discussion among the study team about how to learn more about the app, how people
used it and what more they might want from their experience.
Results
There were 1881 responses from 100 total respondents across all three studies, in studies one and
two there were 751 responses from 51 respondents. Analysis of daily emotion data included every
recorded response. N=9 participants responded less than once per day; the average of all
respondents was 1.4 per day out of a total of 2 possible responses per day.
The daily emotion data from both pilots were combined, in pilot one there were 20 participants in
pilot two there were 31 . There were no significant differences in the two pilot groups emotion
tracking. Participants chose one most recent emotion from drop down lists of emotion from main
categories of fear, sadness, happy, angry, surprise, disgust and contempt, and then rated intensity.
Content Analysis of Trigger
To capture data on the trigger participants were asked if they knew the trigger and then asked to
write in the trigger through free text entry. Participants reported knowing the trigger of their
emotion 83% percent of the time. In the first two studies there were 450 free text responses out of
a total 715 responses. Entering in text was the most time consuming part of the app. When
participants knew the trigger they entered it 75% of the time.
Table Three
Emotion Trigger Categories
Main Category
Sub Categories
Wellbeing
Exercise, Enjoyable Activity/Play, Spiritual Practice, Relaxation
Work Stress
Too many things to do/deadlines, Challenging Patient Situation, Challenging Co-Worker Sit uation,
Paperwork, Health Care System Limitations, Feeling lack of motivation,
Work Satisfaction
Achieving Goals/Productivity, Enjoyable Patient Situation, Enjoyable Colleague Situation,
Satisfaction and Success
Social
Support/Connection
Spending time w/ friends, Spending time w/ family, Spending time w/ Significant Other,
Social Stress
Challenging situation w/ friends, Challenging situation w/ family, Challenging situation w/
Significant Other, Feeling Lonely/Isolated,
Personal/ Physical
Concerns
Lack of Sleep, Physical Health Concerns, Body Image Concerns, Financial Stress
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Simple content analysis was applied to the qualitative entries from the first two studies. Each entry
was assigned a descriptive tag. These tags were then reviewed and redundant themes were
collapsed. Free responses were assigned basic themes. These themes were then reduced and
grouped together into the following six main groups for ease of analysis. Under each of the six main
groups there are up to four sub themes which fall under the umbrella of the theme. We then
compared which primary trigger groups were associated with feeling which emotion categories.
Illustrative qualitative responses are included in the table below to show the type of free responses
entered for these triggers.
Table Five and Table Six
In study three participants selected a trigger from the six categories above and provided fill in
responses for the trigger. In this third study the frequency and intensity of the emotion categories
(e.g. anger, fear etc.) remained the same as in study one and two, however the triggers to these
emotions shifted. In this study work stress increased from 41% to 50% in triggering anger,
personal concern dropped from 29% to 12% and social stress dropped from 20% to 12% as a
trigger. Despite more anger at work, enjoyment triggered by work satisfaction increased from 23%
to 31%.
Emotion frequency and intensity: The felt intensity of these emotions was evenly distributed
across the main emotion categories. Intensity was measured on a 1-5 likert scale from extremely to
very slightly. Participant’s reported intensity of emotion was an average of .5 within the range of 0
to 1 across all emotions.
Emotions were first analyzed individually. The most commonly experienced emotion was peaceful,
which accounted for 19% of all reported emotions over ten days. The next most commonly
reported emotions were annoyed and anxious, which both accounted for 11% of the total
responses. For ease of analysis the list of emotions was broken down into main categories, or
families of emotions: Anger, Fear, Sadness, Enjoyment, Contempt Surprised and Other. Peaceful,
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joyful, lively and cheerful were the most common emotions in the happy or enjoyment family.
Irritable, annoyed and frustrated were the most common emotions in the anger family. Anxious,
apprehensive and worried were the most common emotions in the fear family. Sad, discouraged
and lonely were the most common emotions in the sadness family.
Overall 48% of all reported emotions were in the happy/enjoyable, 17% fear, 15% anger, 10% sad
and in 7% Other disgust, contempt, guilty and embarrassed were all just under 2%. In studies one
and two all emotion experiences were reported as lasting more than 30 minutes 65% of the time.
Table Seven
Embodied Emotions
Participants indicated where they experienced emotions in the body as well as intensity of the felt
sensation. Most emotions were experienced above the waist, and every emotion was felt
somewhere in the chest and face. These sensations were evenly distributed within the emotion
families except for enjoyment. For enjoyment, sensation in the chest was reported twice as much as
the eyes and jaw. Reported sensation of anger and fear were similar except that anger included
feelings in the eyes. Anger was also commonly reported to be felt in the forehead and shoulders.
Surprise, contempt and guilty were infrequently chosen among all emotion choices, but there is an
informative nuance of sensation among these emotions with surprise in the eyes and chest,
contempt having a profile similar to anger, and guilty felt in the legs.
Table Eight Bodily Sensations of Emotion
Although it is not within the scope of this paper to cover in-depth analysis of response to emotion, it
is notable that there were patterns of suppression and avoidance for both anger and fear 30% of
the time, while they were enacted externally 30% of the time. Sadness was suppressed less often
than anger and fear, under 15% and enacted 30% of the time.
Enjoyment was never suppressed or avoided and was split between observed/experienced and
enactment. Looking at responses to more intense emotions, or individual and group level habits of
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response by emotion were not fully explored in the current analysis. In study three, we added a
question about whether the response was helpful on a 5 point likert scale, from very helpful to
regrettable. Rumination was described as being unhelpful or regretful over 75% of the time;
avoidance was unhelpful or regrettable 45% of the time.
Standardized assessment data
The descriptive data from the pilots show a high stress group of care providers. The average score
on the PSS was 27 while the national average is 14 and high stress care providers in other studies
range from 17-20. On the burnout scale, the subscale of emotional exhaustion was high, 28,
personal accomplishment was medium at 37, and depersonalization or cynicism was low at 7.
In study 3 all MBI rates were higher, including depersonalization. National physicians in training
median for emotional exhausion is 24, personal accomplishment is 39, and depersonalization is 10.
Table Nine
Acceptability
Participants used the app to record an emotional experience an average of 1.4 times per day,
demonstrating that this method is feasible in the context of a medical provider’s schedule. In
combining all three studies 46% of participants would recommend EmoTrak to others. Another
27% of participants were neutral about whether they would recommend the app, (n=92
respondents).
Feasibility Data
Data collected within the app as well as follow up survey and interview questions provided
information about how participants used the app. Primary attrition in the study was between filling
out the pre-survey and downloading the app. Approximately 70% who filled out the survey
downloaded or started the app. The average time to response after the reminder ping was sent was
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1 hour 43 minutes, and it took an average of 1.9 pings to elicit a response. Average time to
complete a response was 2 minutes, 3 seconds. The average number of responses per day was 1.4.
The follow up interviews were completed with 13 participants from the third study. Each interview
was an average of fifteen minutes, done by phone by a research assistant. The transcribed
interviews were analyzed with content analysis to identify basic themes by two members of the
study team.
Table Nine
User Experience Interview
I would recommend EmoTrak to Others:
Percent
Strongly agree
13
Somewhat agree
33
Neither agree nor disagree
27
Somewhat disagree
21
Strongly disagree
7
Total N
92
Qualitative Feasibility Data
The content analysis provided information about the reported benefits, difficulties, and
suggestions for future interventions. Three themes emerged regarding participants' perceived
benefits of using the app: awareness of embodied emotion, savoring enjoyable/emotion, and
creating the habit of noticing emotion. Participants commented that the app helped them develop
an awareness of where emotions were felt in the body and the connection between emotion and
physical sensations. For example, one participant said, "I don't tend to dwell on difficult
emotions for a long time, but I do think I remember one time I was feeling really upset, (I) really
was able to focus on my body sensations and I think that was helpful and was able to get some
distance and also just notice what the natural physiological process was." Another participant
said, "I could kind of focus on that tension I was feeling and work on it to go away, or if I was
feeling something that was fun, then I could focus on the pleasant feeling as well."
Participants also reported that through using the app, they became aware of how often they
experienced positive emotion. They experienced positive emotions more often than they
expected.
One participant said that using the app "shared something with me that I wouldn't have thought
was true, and it showed me that I have a positive emotion more frequently and I thought that was
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really nice." Another participant stated, "When I did start to map out my emotions and see the
trends over time, I actually found that I enjoyed my work more consistently than I had realized."
The third theme regarding the benefits of using the app was that the app helped participants
develop the habit of noticing their emotions. For example, one participant said, "to be more
reflective on emotions I had during the day was really helpful, and it definitely made me more
aware and think about, 'I'm feeling angry right now. Why do I feel angry?' So then I'd remember
to put it into the app. So, I found that helpful."
Another participant noted, "It just made me more aware of how many times a day I would have
an emotional reaction to something that was either good or bad. I just wasn't previously used to
being kind of attuned to how I was feeling at different times of the day, and the app just general
brought to my awareness of that." A third participant said, "I would say that my biggest
revelation in the whole two weeks participating with the app was that, in general, when I was
feeling an emotion, I would stop and then just notice what the emotion is. And for me, that was
like the hugest impact or difference that I noticed from the app. It was just literally the
identification of the emotion, whether or not I recorded it in the app."
Two themes emerged related to participants' challenges using the app: inability to locate physical
sensations associated with emotions and inability to respond to the app's prompts. Regarding the
challenge of finding physical correlates of emotion in the body, one participant said, "I think that
was a harder part for me, was the body response. Like where are you feeling your emotion. That
part, I had a little bit of a harder time with, but identifying what emotion I was feeling was very
helpful."
Another commonly cited challenge was difficulty finding time to respond to the app's prompts:
"I think, in general, even though it's fairly brief, I just found it pretty impractical to be able to go
through it multiple times in a day. It has to be something, obviously, that you are trying to
prioritize, but there are days where I don't get to the bathroom, so, being able to do the app, even
though it seems like something really simple... was more challenging." Participants provided
divergent suggestions about how to resolve this issue. Some suggested the app trial length be
reduced from two weeks to one week, whereas others suggested the trial length be extended from
two weeks to one month, with less frequent prompting each week.
Lastly, the participant's recommendations for future use of the app had two common themes.
Participants would like the app to provide suggestions about how to respond to emotions. One
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participant suggested that the app could offer mindfulness exercises: "You know, if you choose a
negative emotion, there would be like a, you know, at the end of that little bit, "Would you like a
three-minute mindfulness exercise?" Or something to help you sort of break those patterns. That
could be really cool. "Lastly, a common theme in participants feedback is that they would
recommend the app to others: "I think it's generally helpful to have a better awareness of the
emotions that you're experiencing and what the triggers are. More kind of to be mindful. I think
that can help everyone, doctors and patients and everyone alike."
Discussion
The daily emotion data collected from this population paints a compelling and intriguing
story about stress and emotion among residents. There were 1881 responses from 100 total
respondents across all three studies. Analysis of daily emotion data included every recorded
response. Nine participants responded less than once per day; the average of all respondents was
1.4 per day out of a total of 2 per day.
Looking on the bright side
The striking finding of the overall emotion data is the frequency of enjoyable emotions amid
high burnout. Given the high-stress profile of these participants, expected emotions might
include irritation, discouragement, and anxiety. However, feelings of enjoyment (peaceful,
excitement, joy) made up over 50% of responses across all three studies. Notably, these feelings
of enjoyment were felt with the same intensity as other reported negative emotions such as worry
and irritation. Fear and then anger, followed enjoyment at 12-15% and 15-18% percent,
respectively, across all three studies, the combination of which are still less than total
experienced enjoyment. Positive psychology researchers would not be surprised by this ratio of
50%-50% positive to negative emotions. Positive psychology theory posits that 75% enjoyable
to 25% negative is indicative of mental health. The broaden and build theory of positive
emotional experiences suggests that positive emotions are a necessary part of homeostasis
promoting new growth, learning, and overall flourishing.
Data from the third study shows that higher burnout does not predict higher levels of negative
emotion, nor vice versa. What accounts for the difference in what is shown by daily emotion and
burnout? Is one form of self report more 'real' than another? The contrast of this data presents an
essential opportunity for investigating measurement: the moment to moment experience can be
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quite distinct from one's 'global' assessment of wellbeing. These findings highlight the
boundaries of the burnout scale. The burnout scale asks about a person's experience of stress in
their overall work environment, measuring how the outside conditions make them feel. Residents
face a great deal of professional responsibility, very little free time and have an intense patient
workload that shifts rotation to rotation. In such a work environment, it is easy to imagine that
residents would assess the past and future as overwhelming in a survey probing recent
experiences.
Looking at daily experienced emotions provides more nuance about the moment to moment
experience that can co-occur amid stress. Despite the high levels of reported emotional
exhaustion, especially in study 3 and relatively high levels of cynicism the subscale of personal
accomplishment maintained average levels. The feeling of accomplishment in work was not lost
event when individuals felt extremely emotionally exhausted and depersonalized from their
work. This finding fits within the theory of meaning-based coping. Meaning based coping
applies a positive reappraisal about the purpose or value of the work being done, helping
participants feel that the difficulty they are experiencing has some greater purpose or
significance.
Minding emotions
The design of the daily emotion data collection also provided participants an opportunity to
practice everyday mindfulness of emotion. Each day they took a couple of moments to check in with
their emotion and perform some introspection as to what was the trigger, experience, and response
to this emotion. Understanding emotions at this granular level can help improve attention to
enjoyable emotions(Barrett, Gross, Christensen, & Benvenuto, 2001; Garland et al., 2010). There
may also be some benefits of merely being present in the moment. Bringing daily awareness
through tracking may both help participants see the impermanence of difficult emotional
experiences and the present moment of enjoyable emotional experiences. Positive reappraisal and
savoring or taking in the good, especially when coping with difficult experiences, can be a very
effective strategy for coping with stress (Folkman, 2008; Hurley & Kwon, 2013).
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Triggered
The qualitative description of triggers to emotion presented a precious opportunity to hear the
voices of study participants. The most frequent triggers for anger and enjoyment come from
recalling life outside of work, even though these participants spend around 80 hours per week at
work. Their work impacts personal relationships, time for self-maintenance, and self-care. Work
played the most substantial role in fear where half of all triggers were about deadlines, overwhelm,
and rumination about something at work. 95% of reported emotion experiences lasted more than
15 minutes in study three, and 30 minutes or more for 65% in study one and two. The emotion a
physician is experiencing can influence the entire time they have to be with a patient.
Future trainings can target skills to manage work-related anxiety, and still focus on managing
difficult emotional experiences at work and how they relate to home life. The main categories of
these triggers (work stress and satisfaction, social support and social stress, wellbeing, and
personal concerns) would most likely have relevance for a general public audience.
Limitations
Several of this paper’s limitations are a byproduct of the developmental nature of the EMA
tool, EmoTrak, that was used and assessed for feasibility across the three samples described in this
paper. Participants in each of the three studies responded to different iterations of EmoTrak,
possibly influencing response styles and feasibility data. Secondly, to enhance existing assessment
tools of moment-to-moment emotional experience, the user prompts, and questions that made up
the EMA were not psychometrically validated. Instead, they were based on expert opinion and
empirically-derived models of emotion. Now that feasibility has been established across these three
studies; one future research direction will be to test the reliability and validity of this tool. Another
limitation of this paper is that the samples of participants in studies one and two were more
heterogeneous in terms of occupation than was the example in study three. Participants in studies
one and two represented various levels of training and specialization within healthcare, whereas
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100% of participants in study three were residents. This may limit generalizability to specific
populations, such as medical residents. The data from study three, however, have been analyzed
and presented separately in this paper in addition to being aggregated with data from the first two
studies.
Lastly, the nature of the assessment tool described in this paper may have taught and enhanced
participant’s mindfulness of emotion by asking them to reflect on their current emotional state, and
by providing the framework of trigger, emotion, embodiment, intensity, and response. Learning to
monitor present moment experience of emotion may have provided some participants with a tool
that enhanced their ability to regulate emotion and thus their responses.
Future Directions
Results of the studies presented in this article suggest that training in the following domains may
strengthen the natural emotional resilience of health care providers:
· Support and encourage the enjoyable at work
· Identify anger and frustration coping strategies to reduce the leakage at home
· Training skills to support the management of anxiety at work
· Meaning matters- how can the work environment bolster affirmation and support of meaning at
work.
Future studies of healthcare professionals are needed to strengthen the findings from these
studies. It is critical to know more about how the daily emotion profiles of individuals relates to
their specific stress profile. For example, are people who suppress anger more or less likely to
feel burnout? Does stress with a significant other relate to satisfaction at work or feelings of
support from colleagues?
There is room to expand current research on emotions. The same is true for developing
understanding of what triggers and felt emotions elicit what responses, including avoiding or
suppressing or acting out with words or actions. The potential actions associated with certain
emotions are deeply contextualized. For example, the physician in training is unlikely to respond
with verbal anger towards a patient who is falsely accusing the doctor of not caring, but may
respond with verbal anger to their spouse who claims they haven't done the dishes. Also, triggers
can be common and universal or learned and specific to the individual. There are circumstances
might influence triggers such as culture, age, gender and other variables. Within a group of high
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stressed physicians in training, are there common triggers? Do these triggers elicit common
emotional responses?
The EMA approach described in this paper offers unique self-assessment training and supports
the development of self-regulation skills. Using EMA of emotion can act as a needs assessment,
a diagnostic tool to assess the daily emotional experience of distressing, and enjoyable emotion.
Using this assessment to evaluate the impact of training programs could be additive on top of
standardized burnout assessment. The current state of intervention development for burnout is
quite nascent. Limited training opportunities may not impact the scores on burnout and systemic
feelings of overwhelm, but may impact daily emotion experience. This EMA approach could
also provide a platform for teaching mindfulness of daily emotions. EMA approaches could
include the teaching of reappraisal strategies for difficult emotion episodes, brief guided
meditations targeted for working with specific emotions, or a platform to share and support other
colleagues and team members.
Conclusion
The basic feasibility of this form of measurement was demonstrated among a group of highly
stressed medical professionals in an exceptionally time-limited work/training setting. The app
completion rates and qualitative feedback from residents show that using the app was possible
during the busy workday, though sometimes it took an hour or two to respond. Participants who
started using the app completed at least one response per day. The daily emotion data provided
unique insights in comparison to the data that was collected by a standardized single point in
time measures.
The takeaways from this study are that EMA is feasible, and offers a unique way to capture data
about daily emotions. Teaching residents to apply the timeline emotion illuminates within-person
variability and patterns of what triggers them to what emotion, where and how they feel it, and
their response to the emotion. Lastly, although the levels of perceived stress and burnout were
quite high in this population, participants reported experiencing high levels of positive emotion.
This ability to feel positive emotions may be a critical factor in their ability to successfully cope.
Funding: The research was supported by awards from Eve Ekman from National Center for
Complementary and Integrative Health, 10.13039/100008460 [T32]. The funders had no role in
study design, data collection and analysis, decision to publish or preparation of the manuscript.
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Disclosure: The authors declare no conflict of interest.
References
Accreditation Council for Graduate Medical Education, (n.d.), Common Program Requirements.
Retrieved from https://www.acgme.org/What-We-Do/Accreditation/Common-Program-
Requirements Barrett, L. F., Gross, J., Christensen, T. C., & Benvenuto, M. (2001). Knowing
what you’re feeling and knowing what to do about it: Mapping the relation between
emotion differentiation and emotion regulation. Cognition & Emotion, 15(6), 713–724.
Bradley, M. M., & Lang, P. J. (2000). Measuring emotion: Behavior, feeling, and physiology. Cognitive
Neuroscience of Emotion, 25, 49–59.
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of
Health and Social Behavior, 385–396.
Davidson, R. J. (2003). Affective neuroscience and psychophysiology: Toward a synthesis.
Psychophysiology, 40(5), 655–665.
Diener, E., Wirtz, D., Tov, W., Kim-Prieto, C., Choi, D., Oishi, S., & Biswas-Diener, R. (2010). New well-
being measures: Short scales to assess flourishing and positive and negative feelings. Social
Indicators Research, 97(2), 143–156.
Folkman, S. (2008). The case for positive emotions in the stress process. Anxiety, Stress, and Coping,
21(1), 3–14.
Garland, E. L., Fredrickson, B., Kring, A. M., Johnson, D. P., Meyer, P. S., & Penn, D. L. (2010). Upward
spirals of positive emotions counter downward spirals of negativity: Insights from the
broaden-and-build theory and affective neuroscience on the treatment of emotion
dysfunctions and deficits in psychopathology. Clinical Psychology Review, 30(7), 849–864.
1
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13
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17
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19
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Hurley, D. B., & Kwon, P. (2013). Savoring Helps Most When You Have Little: Interaction Between
Savoring the Moment and Uplifts on Positive Affect and Satisfaction with Life. Journal of
Happiness Studies, 14(4), 1261–1271. https://doi.org/10.1007/s10902-012-9377-8
Levenson, R. W. (1992). Autonomic nervous system differences among emotions. Psychological
Science, 3(1), 23–27.
Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal of
Organizational Behavior, 2(2), 99–113.
Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of
positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology,
54(6), 1063.
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Table Four
Emotion Category and Triggers Free Text Examples
Emotion
Trigger and Response
Trigger and Response
Trigger and Response
Anger
Personal Concern:
Work Stress:
Social Stress:
Lost my sunglasses. I had a
meltdown.
Figuring out insurance
Lack of sleep
I find one of my attending’s obnoxious
Thrown under bus by co-intern ;)
Getting paged to deal with a pt who refused
to be helped and kept yelling
Boyfriend Drunk
Not feeling appreciated by husband
Fear
Personal Concern:
Work Stress:
Social Stress:
Speaking to a large group
Worries about moving apartments
Too much to do today
Pressure to see a lot of pts, write notes, and
discharge pts
Learning my aunt was in the hospital
Continued issues with my child.
Sadness
Personal Concern:
Work Stress:
Social Stress:
Anniversary of father's death
Just feeling overwhelmed,
unmotivated, lonely, hopeless about
romantic prospects
Working night float and not having time to
socialize with anyone.
Tough social situation with a family seen in
acute care
Fight with boyfriend
Missing my significant other
Enjoyment
Social Support:
Work Satisfaction:
Wellbeing:
Girlfriend and I talked about the
future and we are on the same page.
Hanging out with friends, dancing
Starting my night shift, helping my co-
intern finish up some work, and having to
think about different research projects to get
involved with.
Worked out, cooked lunch, and put on
an outfit that made me feel good. And
listening to Bob Marley
Sleeping after a 24 hour shift and
knowing I still have the day off
Note: The text included are examples from the free text entry of the trigger. Each emotion has a sample of trigger
types.
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Table Five
Emotion and Trigger Studies 1&2
Emotion
Wellbeing
Work
Stress
Work
Satisfaction
Social
Support/Connect
Social
Stress
Personal/Physical
Concerns
Commute
Other
Total
Anger
0
24
0
0
12
17
2
5
60
Enjoyment
98
1
51
65
0
1
0
9
225
Fear
2
58
0
1
16
20
0
11
108
Sadness
0
12
0
0
15
2
0
1
30
Other
2
8
0
0
2
10
2
6
30
Total
102
103
51
66
45
50
4
32
453
Note: The numbers are the raw count for each trigger recorded by all participants.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
24
Table Six
Emotion and Trigger Study 3
Emption
Wellbeing
Work
Stress
Work
Satisfaction
Social
Support/Connection
Social
Stress
Personal/Physical
Concerns
Other
Total
Anger
17
99
2
4
29
25
26
202
Enjoyment
183
6
163
146
0
5
16
519
Fear
4
92
5
5
29
13
44
192
Sadness
4
50
3
9
29
8
23
126
Other
12
39
14
3
5
14
10
97
Total
220
286
187
167
92
65
119
1136
Note: The numbers are the raw count for each trigger recorded by all participants.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
25
Table Seven
Emotion Category and Intensity All Studies
Emotion
Total Count
% of all emotions
Average Intensity
Anger
291
15.42%
0.50
Fear
329
17.44%
0.57
Sadness
183
9.70%
0.52
Enjoyment
924
48.97%
0.53
Other
132
7.00%
0.56
Blank
28
1.48%
0.64
Total
1887
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
26
Table Eight
Embodied Emotion Intensity and Location All Studies
Emotion
Avg. Intensity Study 1&2
Avg Intensity Study 3
Areas of the body
Anger
2.37
2.15
Eyes Jaw Neck Chest Stomach
Fear
2.34
2.50
Jaw Neck Chest Stomach
Sadness
2.49
2.26
Forehead Eyes Shoulder Chest Stomach
Enjoyment
2.22
1.83
Eyes Jaw Shoulders Chest –(twice as much in Chest than Jaw)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
27
Table Nine
Burnout, PANAS and Perceived Stress Scales All Studies
Scale
Mean (SD) Study 1&2
Mean (SD) Study 3
MBI Emotional Exhaustion
35.26 (11.39)
40.30 (9.57)
MBI Personal Achievement
45.46 (7.30)
46.25 (6.13)
MBI Depersonalization
12.95 (6.71)
17.05 (6.10)
PANAS Positive
32.05 (6.37)
28.43 (5.93)
PANAS Negative
22.15 (5.87)
23.24 (6.07)
PSS
27.25 (4.7)
51.67 (7.95)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
Emotion Granularity: Basically ok day to day in the desert of burnout?
Eve Ekman PhDa, Elizabeth Goodman Gurfein PhD b, Michael Cohn PhDc,Rhianon Liu MDd &
Benjamin Emeret-Aronson PhDe,
a University of California Berkeley Greater Good Science Center,
b Native American Health Clinic,
cUniversity of California San Francisco Osher Center for Integrative Medicine,
d Sutter Santa Rosa Health Center,
e Open Source Wellness
Main Auuthor Contact: Eve Ekman evee@berkeley.edu
2425 Atherton Street Berkeley CA 94704
Title Page w/ALL Author Contact Info
