1 Department of Work Psychology, Bat B-32 FAPSE, University of Liège, B-4000 Liège, Belgium. 2 Department of Anaesthesia and Intensive Care Medicine, Cliniques Universitaires St Luc, Av. Hippocrate, B-1200 Bruxelles, Belgium. 3 Department of Anaesthesia and Intensive Care Medicine, Bat B-35, University Hospital of Liege, B-4000 Liège, Belgium
Corresponding author. E-mail: asnyssen@ulg.ac.be
Accepted for publication: October 23, 2002
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Methods. We measured the effects of stress together with the sources of stress and job characteristics, using self-reported questionnaires rather than physiological indicators in order to better diagnose stress in anaesthetists.
Results. The mean stress level in anaesthetists was 50.6 which is no higher than we found in other working populations. The three main sources of stress reported were a lack of control over time management, work planning and risks. Anaesthetists reported high empowerment, high work commitment, high job challenge and high satisfaction. However, 40.4% of the group were suffering from high emotional exhaustion (burnout); the highest rate was in young trainees under 30 years of age.
Conclusions. Remedial actions are discussed at the end of the paper.
Br J Anaesth 2003; 90: 3337
Keywords: anaesthetists, stress
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Materials and methods |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The PSSM-A15 provides a measure of stress and consists of 25 items that refer to a stress reaction (e.g. I am strained or nervous; I feel pressed for time; I tend to miss out meals or forget to eat...). The response format is an eight-point Likert scale. Normative scores are available. A moderate level of stress can vary from 40 to 60, with a mean of 50. Values higher than 60 characterize severe stress.
The subscale of emotional exhaustion provides a measure of burnout.16 Burnout is a concept that consists of three dimensions: emotional exhaustion, depersonalization and lack of personal accomplishment.17 Practically, the use of the subscale of emotional exhaustion alone (nine items) appears to be a valid measure of professional burnout.18 19 The subject is asked to answer each item on a scale from 1 (never) to 7 (every day). The level of burnout can vary between 9 and 63, a score of 918 representing a low level, 1829 a moderate level and values higher than 29 characterizing severe burnout.
The self-reported physical health scale (adapted from Etienne20) lists the negative health consequences of stress. The subject is asked to give the extent to which he/she has been subject to 25 described health problems such as headache, stomach ache, ulcer, allergy and myocardial infarction. These problems were listed in collaboration with one senior anaesthetist. The response format is a five-point Likert scale from not at all to extremely.
The WOCCQ is a multidimensional scale to measure the control that a worker has in his/her work situation. It was developed in our Work Psychology Department to qualify control at work and has been validated on different populations.21 It has the advantage of encompassing six dimensions of control, allowing a more precise diagnosis about the job demands at work: control of resources, task management control, risk control, planning control, time management control and future control. Each item refers to a job characteristic phrased in the first person, such as I see my work piling up without being able to resolve latencies, I believe in the future of my job, I can say something about the way work should be done, I can adapt my work pace as I want. The questionnaire response format is: 1=rarely or never applicable to my job; 2=sometimes applicable to my job; 3=regularly applicable to my job; 4=almost always or always applicable to my job. The formulation of the items could easily be interpreted in terms of control. The valence of the items was balanced. Scores for all scales used in the analyses were composed by calculating the mean score of the items on each scale. Higher scores reflect better job control.
The problematic job situations questionnaire was developed to complete the WOCCQ by a qualitative analysis of the more problematic situations encountered by the anaesthetists. This was done by asking one open question: As part of your work, please cite three "major problematic situations" you meet. For each described situation, the anaesthetist also had to indicate, on Likert scales, to what extent the situation was either stressful or frequent.
The job characteristics questionnaire was adapted from Stordeur and colleagues22 to provide a measure of empowerment (eight items), work commitment (two items), job challenge (two items) and job satisfaction (one item) among anaesthetists with a five-point Likert scale response format from agree not at all to agree completely.
After institutional ethical approval was obtained, the questionnaires were sent to 318 French-speaking anaesthetists working in the Belgium University Network. A reminder was sent to those who had not returned their questionnaires 1 month later.
Statistical analysis
For the stress, burnout and job characteristics variables, a median score and range were calculated. Comparisons of these variables between training level groups were performed using the KruskalWallis test. All paired comparisons were evaluated using the MannWhitney U-test. Comparisons in categorized burnout between age groups were performed using the 2-test. A Friedman test (with separated measures) was used to compare control dimensions, to reduce type I error. The MannWhitney U-test was used to compare anaesthetists with Belgian workers previously studied by our department (n=2452 including policemen, office workers and hospital staff). Spearmans
correlation coefficient was performed between stress and job control dimensions. Significance was assumed for a P-value <0.05. A multiple linear regression was also used to explain stress by job control dimensions.
![]() |
Results |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The median stress level in anaesthetists measured with the PSSM-A was 50.6 (range 34.574.0), which is no higher than we found in other working populations (50.6 in policemen, 51.3 in office workers). The interindividual variability of scores was high: 17.9% of the anaesthetists were in the high-level group and 72.8% and 9.3%, respectively, in the medium- and low-level groups. The third-year anaesthetists showed the highest scores (Table 1) but the difference in stress scores between the six training level groups was not significant (H(5,151)=5.45; NS). However, there was a difference in physical health score between the third-year group and the fourth-year and senior training level groups (H(5,151)=13.07, P<0.05). The most frequently reported health problems were headache (15%), stomach ache (12.5%), intestinal ache (7%) and ulcers (6%).
|
|
|
|
The median scores for each variable were calculated separately for men and women as well as for the total group. The sexes differed significantly in only two variables: men indicated a higher level of empowerment (Adj.Z=3.94, P=0.05) and control risks (Adj.Z=3.69, P=0.0002).
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Nevertheless, results of the current study showed that 40.4% of the anaesthetists were suffering from high emotional exhaustion; the highest rate was in young residents under 30 years of age. These results are particularly alarming. Moreover, first-year residents did not feel as empowered as the others. Surprisingly, fourth-year anaesthetists also showed a low score for empowerment. It is well recognized among Belgian anaesthetist supervisors that the third year of training is particularly critical because this is when the trainees start to work on their own in the operating room, calling for help when problems occur. In fact, the third-year anaesthetists showed the highest stress scores in our study, but there were no significant differences between the six training levels. The lower self-confidence score found in fourth-year residents may come from this critical year. Results also indicated that 23% of trainees felt under-supervised (cf. problematic situations) and some authors have demonstrated that support can alleviate job stress.23 Together, the lack of empowerment and the lack of support, by decreasing the individuals ability to cope with stressful situations, could explain the high score for emotional exhaustion found in the young anaesthetist group.
What can be done to alleviate job stress and burnout? The results of the WOCCQ and problematic situation questionnaire indicate major job stressors in anaesthesia. The work organization, more specifically the lack of control over work, time planning and risks, the lack of supervision, and communication within the team, especially with the surgeons, are perceived as the major sources of stress. These results agree with the major stressors listed by the Association of Anaesthetists Stress Seminars Study reported in Dicksons editorial.24 These sources of stress also refer to the factors associated with human error most frequently reported in the literature.25 26 These stressors are things that the hospital and department administration can do something about in their managerial role since the major perceived demands are on work management and time management. Formal work organization can support trainees by providing advice and specialist counsellors when problems occur in their work environment. They can provide time to acquire knowledge, to manage research and to take a break during the day for eating and rest. Accident and incident conferences, in which anaesthetists present the critical situations they encountered, could also play a role in the social and emotional support in the case of major misadventures. Organized in a positive social climate, these conferences give the opportunity to discharge overload and emotional stress. The simulator, which is increasingly used for crisis-management training, can be of some help in improving communication and problem-solving strategies. Improving social support in the professional setting is vital if the individual is to better manage the effects of stress and, in doing this, organizations often reduce the constraints on the workers. However, although social support is a way for individuals to control or modify their capacity to cope with stressful situations, it does not directly decrease the sources of stress. Changing the work environment to eliminate or minimize the sources of stress would be a more useful strategy.
The present study has its limitations. The study sample size is relatively small and is focused on French-speaking anaesthetists working in the Belgian University Network. Some results, such as the high level of empowerment, may reflect the academic nature of the sample. They may also reflect the country of origin. We were not able to compare the anaesthetic groups with other doctors at the time of the present study. The question also arises as to whether the proposed strategies for alleviating stress would enable the trainees to better cope with stressful situations and recover from a high level of burnout. Further work should address these issues in order to better cope with stress at work.
![]() |
Acknowledgements |
---|
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
2 Neil H, Fairer JG, Coleman MP, Thurston A, Vessey MP. Mortality among male anaesthetists in the United Kingdom, 195783. Br Med J 1987; 295: 3602[ISI][Medline]
3 Spiegelman WG, Saunders L, Mazze RI. Addiction and anesthesiology. Anesthesiology 1984; 60: 33541[ISI][Medline]
4 Lutsky I. Psychoactive substance use among American anesthesiologists: a 30 year retrospective study. Can J Anaesth 1993; 40: 91521[Abstract]
5 Weeks AM, Buckland MR, Morgan EB, Myles PS. Chemical dependance in Anaesthetic Registrars in Australia and New Zealand. Anaesth Intens Care 1993; 21: 1515[ISI][Medline]
6 Klein GT. The effects of acute stressors on decision making. In: Driskell JE, Salas E, eds. Stress and Human Performance. USA: New Jersey, 1996; 4988
7 Lazarus RS. Psychological stress in the workplace. In: Crandall R, Perrewé PL, eds. Occupational Stress: a Handbook. Bristol: Taylor & Francis, 1995; 314
8 Mackay CJ, Cooper CL. Occupational stress and health: some current issues. In: Cooper CL, Robertson IT, eds. International Review of Industrial and Organizational Psychology. Chichester: John Wiley & Sons, 1987; 16799
9 DeKeyser V, Hansez I. Vers une perspective transactionnelle du stress au travail: Pistes dévaluations méthodologiques. Cahiers Med Travail 1996; 33: 13344
10 Karasek RA. Job demands, job decision latitude and mental strain: Implication for job redesign. Adm Sci Q 1979; 24: 285308[ISI]
11 Payne R. Stress in surgeons. In: Payne R, Cozens LF, eds. Stress in Health Professionals. UK: John Wiley & Sons, 1987; 89106
12 Thomas KW, Velthouse BA. Cognitive elements of empowerment. Acad Manage Rev 1990; 15: 66681[ISI]
13 Spreitzer GM. Psychological empowerment in the workplace: dimensions, measurement and validation. Acad Manage J 1995; 38: 144265[ISI]
14 Meyer JP, Allen NJ. Commitment in the Workplace. Thousand Oaks, CA: Sage Publications, 1997
15 Lemyre L, Tessier R, Fillion M. Mesure de Stress Psychologique (MSP): Manuel dUtilisation. S.1. Laval, Canada: Université de Laval, 1990
16 Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory, 3rd Edn. Palo Alto, CA: Consulting Psychologists Press, 1996
17 Maslach C. Burnout: the Cost of Caring. Englewoods Cliffs, NJ: Prentice-Hall, 1982
18 Cordes CJ, Dougherty TW. A review and an integration of research on job burnout. Acad Manage Rev 1993; 18: 62156[ISI]
19 Lee RT, Ashforth BE. A meta-analytic examination of the correlates of the three dimensions of job burnout. J Appl Psychol 1996; 81: 12333[CrossRef][ISI][Medline]
20 Etienne A-M. Impact de la réadaption cardiaque sur les patients ayant subi un pontage aorto-coronarien. Thèse de doctorat. Manuscrit non publié. Université de Liège, Belgique, 1997
21 Hansez I, De Keyser V. El WOCCQ: una nueva herramienta en el estuche de instrumentos contra los estresores laborales. El caso de los trabajadores de servicios publicos en Bélgica. Numéro Monografico Factores psicosociales de la prevencion de riesgos laborales: Perspectivas internacionales. Rev Psicol Trabajo Y de las Organizaciones 1999; 15: 17398
22 Stordeur S, Vandenberghe C, Dhoore W. On examining moderators of leader behaviors in nursing: An investigation of substitutes for, and enhancers and neutralizers of, leadership. In: de Jonge J, Vlerick P, Büssing A, Schaufeli W, eds. Organizational Psychology in Health Care at the Start of the New Millennium. Munich, Germany: Rainer Hampp Verlag, 2001; 85104
23 Cohen S, Wills TA. Stress, social support and the buffering hypothesis. Psychol Bull 1985; 98: 31057[CrossRef][ISI][Medline]
24 Dickson DE. Stress. Anaesthesia 1996; 51: 5234[ISI][Medline]
25 Cooper B, Newbower RS, Long CD. Preventable anesthesia mishaps: a study of human factors. Anesthesiology 1978; 49: 399406[ISI][Medline]
26 Chopra V, Bovill JG, Spierdiyk J, Koornneef F. Reported significant observation during anaesthesia: a prospective analysis over an 18-month period. Br J Anaesth 1992; 68: 1317[Abstract]