European Journal of Anaesthesiology:
Job satisfaction, stress and burnout in anaesthesia: relevant topics for anaesthesiologists and healthcare managers?
Rama-Maceiras, Pablo; Parente, Suzana; Kranke, Peter
From the Department of Anaesthesia and Perioperative Medicine, Complejo Hospitalario Universitario A Coruña, Spain (PRM), Department of Anaesthesia, Centro Hospitalar Lisboa Occidental, Alges, Lisboa, Portugal (SP) and Department of Anaesthesia and Critical Care, University Hospital of Würzburg, Oberdürrbacher, Germany (PK)
Correspondence to Pablo Rama-Maceiras, Department of Anaesthesia and Perioperative Medicine, Complejo Hospitalario Universitario A Coruña, C/Xubias de Arriba n° 84, CP 15006, A Coruña, SpainTel: +34 981 178152; e-mail: firstname.lastname@example.org;email@example.com
Published online 2 April 2012
Job satisfaction is defined as an employee's positive reaction towards his/her work. Changes in health policies, which are seen as a threat to the autonomy of health workers, are associated with a decrease in satisfaction levels, increase burnout among physicians, and may impair the quality and safety of care. The work environment of anaesthesiologists include stressful areas such as the operating theatre, the ICU, and the emergency setting, and this has been linked to higher levels of stress and lower satisfaction. We frequently lack feedback from patients and even our colleagues despite usually working within a team. Nevertheless, job satisfaction and burnout rates in anaesthesia are similar to other specialties. The most relevant factors in job satisfaction are worker autonomy, control of the working environment, recognition of our value, professional relationships, leadership and organisational justice. Although these can be manipulated for good or otherwise, there are additional, less malleable factors such as personality, expectations and motivation of the employee, that play a part. Within organisations there needs to be the will to evaluate employees’ satisfaction, to improve their work environment and to develop strategies and coping mechanisms for professional stress. Personal wellness should also be nurtured, as a satisfactory work-life balance and an adequate social support network might act as a buffer for dissatisfaction and burnout. Improvement in satisfaction might create a positive work climate that would benefit both the safety of our patients and our profession.
This article is accompanied by the following Invited Commentary:
Lindfors P. Reducing stress and enhancing well-being at work: are we looking at the right indicators? Eur J Anaesthesiol 2012; 29:309–310.
‘I am working too hard’
‘I don’t get enough time with my family’
‘I spend too much time on paperwork’
Recent surveys indicate that these are common complaints of physicians.1,2 They all reveal a decrease in job satisfaction. We may find a reason for these comments in recent changes to health systems.3 In particular, the role of the physician has moved from a ‘central position’, in which the autonomy of each individual doctor is not questioned, to a point wherein we are under pressure to deliver results.4 Pressures from cost-containment policies and the demands of patients and society have led to a decrease in the time spent with our patients, a loss of influence in the decision-making process, and a reduction in our permitted margin of error.5 These factors may well have contributed to an increase in stress and a decrease in satisfaction among physicians.1,3,6–8
The current review offers a conceptual framework for job satisfaction and the factors that affect it, and suggests practical measures on how it might be improved, not simply for the sake of the physician[Combining Acute Accent]s well being but also for the safety of our health systems.
Stress at work, dissatisfaction and their consequences
Stress – according to contemporary definitions – is a nonspecific adaptive response intended to maintain the status quo in the face of any challenge or trauma.7 It is not inherently bad when it can be managed with both proper cognitive evaluation (using psychological filters and appraisal of the stress factors, based on our memory and past experiences) and with coping strategies.7 But in the absence of these supports, stress can lead to a decrease in satisfaction and impair our mental and physical health.9 The result may be burnout,10 a syndrome that combines emotional exhaustion (overextended by work), depersonalisation (treating people in an impersonal way), and a sense of low personal accomplishment (feeling of incompetence and lack of achievement at work; Fig. 1).11
Burnout plays a key role in the impairment of physicians’ relationships with other members of the health team, disrupting collaboration and setting the scene for depression or substance abuse.12,13 There is an associated trend to quit or decrease work activity,6 further impairing the quality of teamwork and the care delivered.14–16 The final consequence is likely to be an increase in expenditure for the health system17 fuelling in turn greater cost-containment policies and further stress generation, tightening this vicious circle.6
This link, between stress, satisfaction and burnout, and their consequences, has been confirmed. Studies indicate that for the same level of stress, good job satisfaction offers some protection against burnout and maintains mental health, compared with poor satisfaction.18–22 Dissatisfied health employees are the most vulnerable to burnout, leading to a reduction in safety23,24 and even in the level to which patients adhere to their treatment.17,25 Conversely, satisfied physicians tend to be more committed to the work of their organisation,26 increase productivity – because job satisfaction is a prerequisite for a good work process27 – and decrease treatment costs as well. Satisfied employees promote satisfied patients.26,28,29 Accordingly, employees’ satisfaction should be a strategic goal of health organisations.3,30
Defining and evaluating job satisfaction and burnout
If ‘job satisfaction’ is defined as an employee's positive affective reaction,9,31 there are immediate problems related to its assessment by quantitative methods. There is no strong evidence as to how such a subjective outcome should be measured and expressed. Studies of stress at work and job satisfaction mainly use questionnaires and scales,14,20,32–34 making adequate comparisons difficult.20 Surveys and questionnaires are usually cross-sectional, which limits the development of causal inferences. Because they are usually designed to assess a priori theories and models of job satisfaction, they are often based on low sample populations, and subjective perceptions are exposed to sampling or participation bias and low response rates, and sometimes exclude relevant factors that affect the final outcome.
The Maslach Burnout Inventory is probably the most widely accepted test of burnout.11 It includes 22 questions relating to the three domains of burnout, and every item is rated on a 7 point Likert-type scale. The total score for each domain is evaluated according to predetermined cutoff scores.14 Scores are considered high if they are in the upper third of the normal distribution. High scores on the emotional exhaustion and depersonalisation domains and low scores on the personal accomplishment scale indicate a high degree of burnout.
Job satisfaction models and theories
A helpful way to consider satisfaction is the Maslow hierarchy of needs (Fig. 2).35 This theory views our needs as a pyramid with the most basic needs at the bottom; as soon as one need has been met, we move to the next level, searching for safety, social acceptance, self-esteem and self-actualisation in the development of our full potential. The Maslow model has been slightly modified for the work setting,3,36 making wages the basic need, and seeing training as reinforcing a feeling of safety. Further up the pyramid, we head towards sense of belonging, recognition and finally new challenges at work.
However, Maslow's hierarchy is not the only model for job satisfaction (Fig. 3). The ‘Affect theory’ suggests that job satisfaction is the balance between employee expectations and their achievements,37 the ‘Dispositional theory’ gives a relevant role to the innate characteristics of the employee (that is personality),38 the ‘Two factor theory’ links satisfaction to motivation,39 and the ‘Job characteristics model’ correlates job satisfaction to the tasks, skill variety, autonomy and feedback received.40 Last but not least, the ‘Reciprocal influence theory’ emphasises the relationship between the team members and between managers and employees.41 Similarly for stress, the ‘Job-Demand Control Model’ tells us that stress at work is the balance between workload and the resources available to manage that workload,42 and finally, the ‘Effort-Reward Imbalance Model’ suggests that stress is related to the lack of Organisational Justice, that is, the imbalance between demands and rewards in the work place.43
Some of the factors in these theories are employee or physician-related (intrinsic), as seen in Fig. 3, whereas others are related to job characteristics (extrinsic). The latter are considered more malleable when developing organisational strategies to improve satisfaction, but intrinsic factors should also be taken into account. Positively disposed employees develop more realistic expectations about their job and about life in general, and they are usually more satisfied,10,44 whereas negatively disposed individuals who dwell on negative aspects are often less satisfied with their jobs.9,18,44–46 These are arguments for promoting coping strategies tailored to the personality of each employee. 25
Am I at risk for job dissatisfaction or burnout?
Given that stress factors, job characteristics and personality affect satisfaction, it is easy to imagine that physicians working in inadequate environments (demanding jobs, steep hierarchical organisations, larger sized teams and jobs with few opportunities for reward) are more prone to job dissatisfaction. To this we can add overcommitted employees with high expectations, and lack of social support networks.21,22,44,47–49 Other important risk factors are interference with the homework balance,50 poor control over workload,31 lack of resources and lower levels of experience.6,47,51,52 The development of coping mechanisms or a better financial position can explain the lower rate of dissatisfaction among experienced physicians,33 although a ‘survival bias’ after early retirement of dissatisfied physicians leaving a core of more satisfied employees, could also explain the link between satisfaction and experience showed in some surveys.1 Poor health status can also be considered a risk factor because it has been shown to influence work ability, and to be related to burnout.31,53
Satisfaction appears to be independent of the nature of practice, whether public or private.54 The latter seems to offer higher incomes, greater control over job and organisational justice,55 but public service offers better opportunities for teaching and research,56,57 all sources of greater satisfaction. It is possible that personalities of physicians and the profiles of patients, together with the nature of stress factors, might differ between private and public practice, biasing the results.55
Physicians in leading positions are usually more satisfied in their job, but dysfunctional workplaces show a different pattern, wherein employee satisfaction does not increase as a function of job level.58 The main reasons for higher satisfaction levels seen in managers are achievement of better working conditions, promotional opportunities and autonomy.58 On the contrary, an excess of administrative duties, and involvement in strategic plans, disciplinary actions and budgetary issues, have a negative impact on managers’ satisfaction.49,59
Finally, the role of sex in satisfaction is confused. Some studies have shown lower satisfaction and a higher level of stress among women,14,52 related to greater responsibility in the home or to discrimination in the workplace,31,60 whereas others found no differences between men and women.20,48 The continuing increase in physicians who are women, and in the fraction of part-time workers will merit special attention in the future.14,31
Some of the factors described above will be recognised by anaesthesiologists, and about one quarter of us are at risk of burn-out,47,59 although the figures vary depending on the country and the cutoff being considered.20,33 Satisfaction rates among anaesthesiologists are about 71–75%,31,32 which are similar to other medical specialties56,61 and greater than other hospital staff.62
Job satisfaction in anaesthesia
The main determinants of dissatisfaction for anaesthesiologists are professional stress, the nature of our jobs, and our personalities.
Sources of stress
Through our activities in the operating theatre, the ICU, preoperative assessment, the management of acute and chronic pain, the emergency area and even in quality assurance and management,14 anaesthesiologists provide a service to 50–60% of hospital patients.63,64 All of these areas place high demands on safety, quality of care and efficiency,27,63,65 but they also have obvious and well known sources of stress (Table 1).14,52,66,67 These have been classified into four different domains, difficult medical situations; moments of work overload; decision-making in difficult areas – especially ethical and critical decisions – and problems with lack of respect and recognition.32,68
Moral distress, which occurs when a caregiver knows the ethically appropriate course of action to take but is unable to act upon it, is common for nurses and anaesthesiologists providing treatment or surgical procedures of little or no benefit.66,69 Typical reactions to moral distress include withdrawal for nurses and anger for physicians, both negatively affecting collaboration in the workplace. Finally, the absence of a well defined and organised department has also been associated with stress.14
The factors that can improve or impair job satisfaction in anaesthesia are similar to those suggested for other specialties. Improvement requires good relationships with patients and colleagues, recognition at work, autonomy and control over your job, intellectual stimulation and providing good quality care,18,31,32,47 whereas heavy workload, lack of justice, poor recognition or interference with social life are all linked to dissatisfaction.70 Because anaesthesia usually provides the means to achieve a medical outcome rather than being an end itself,14 we are left with the feeling of immediacy and without positive feedback from our patients and colleagues. This is another source of dissatisfaction.14,18 Being well regarded by surgical colleagues and patients, and being provided with adequate assistance contributes to job satisfaction.14,32 Shortage of anaesthesiologists and financial pressures of the health system can make it difficult to get this assistance.71 Also, our role as a support specialty requires team working, wherein conflict72,73 and disruptive behaviour can occur, interfering not only with quality and patient safety, but also with performance and satisfaction of team members.73,74
One interesting Swedish qualitative investigation reveals four nonexclusive ‘types’ of anaesthesiologists, all with different needs in terms of job satisfaction.75 The first group is the so-called ‘professional artists’. They see the patient as a physiological object and find satisfaction solving immediate difficult problems. ‘The Samaritans’ compose the second group; they see the patient as an individual, and their reward is relieving suffering. The third group is ‘the servants’, as they are like helpers for the helpers, and find satisfaction in servicing other actors (mainly the surgeons) in their roles. Finally, last but not least are ‘the coordinators’, those with an innate tendency to organise, to make the system work better.75
A similar survey of residents revealed two additional categories: those ‘following the protocol’, probably the most basic, who found satisfaction seeing the expected results at completion of the procedure or treatment, and those ‘learning from every new patient’, concentrating on their own competence development.76
Job satisfaction: finding solutions
When all the pieces of the puzzle are assembled it would seem that there are at least three main groups of strategies for managing job satisfaction: institutional policies, teaching and learning how to handle the stress factors of our profession, and finally personal and ‘different’ solutions.1,77
With regard to institutional policies, we could put into practice measures to enhance organisational support (Fig. 4). Promoting the participation of the employee in the decision-making process, and increasing their autonomy and control over the job is considered the ‘big motivator’, and is also the most effective way to improve job satisfaction.3,5,10,18,27,28,78,79 Because individuals dislike being manipulated, unappreciated and disrespected, decisions made by their organisations should be less autocratic and more consultative or even delegative,80,81 encouraging employees to identify problems and suggest solutions.3,20 This creates a challenging environment, wherein employees are more involved and have the chance to train, learn and develop new skills.80
Two examples of how this stimulating environment works are seen in job rotation and the role of seniors. Job rotation can promote ‘recycling’ or professional development78 and can increase variety at work, avoiding monotony.18,82 Seniors can act as mentors,51 teaching younger employees to cope with difficult situations,83 and this effort must be rewarded.78 Nonsalary incentives are important in increasing motivation78,84 and employee self-esteem28,80 through both job recognition and professional development, but they must be managed with a great sense of organisational justice (people perception of fairness in the organisation)85 and always with patient benefit in mind.17,86 Economic rewards must be competitive to avoid dissatisfaction, but their role is often secondary because satisfaction solely based on money is often temporary.28
Leaders play a key role in promoting professional wellbeing,87 developing beneficial policies, enhancing team spirit, and acting as role models.28,69,86 They should help the employee to maintain a satisfactory work-life balance, and promote effective communication,14 listening rather than dictating, and flattening the hierarchy.85,88 Communication should be bidirectional to foster trust, mutual understanding and good relationships,69 and should attempt to align both the goals of the workers and the organisation,27,29,89 and encourage the employees to move from ‘expressing constraints’ to ‘constructive problem solving’.90 Managers are usually appointed for their personal medical skills and/or qualifications, but they often lack training in leadership,91 so training programs for managers should also be developed to help with communication and decision-making styles.85
Finally, organisations should learn nontechnical skills (situation awareness, resource management, communication, decision-making, teamwork and leadership92,93) to help employees resolve conflicts and crises.72,94 Incidents in anaesthesia are often related to nontechnical skills,95 and only 45% of physicians considered themselves to have adequate training in these skills.18 Briefings,96 periods of reflection after crises,97 and counselling98 can improve team performance.
Fundamental to any organisation's strategy is periodic assessment of patients’ perceptions, performance and job satisfaction.9,25 They should be assessed every 12–18 months and not longer than 2 years.26,28 Following evaluation, institutions should be prepared to act on the results because exercises of this nature generate a feeling of change that seems less threatening because it originates from colleagues rather than managers.90 Lastly, we must be patient because results are not immediate.9
The second group of strategies involves teaching and learning about stress management for anaesthesiologists, as overload impedes career development and can even impair safety.51 There are two main strategies, either solving problems or converting threats into positive challenges.68,99 Difficult technical and medical situations can be made easier by sharing with helpful colleagues,66 but at times there needs to be an understanding of the limitations of our own profession, and even the limits of our own competence. We must sometimes be prepared for failure. Overload can be managed by prioritising or delegating work and getting help from colleagues, but also learning to say ‘No’ in some circumstances.77 Unfortunately, difficult ethical decisions, conflict and lack of respect are difficult to cope with and must be managed mainly through proper communication and discussion with colleagues.68,73
The last group of solutions are more ‘personal’, but are nevertheless relevant because our lives serve as a buffer for stress.1 If we understand satisfaction to be a subjective reaction, we must learn to increase this feeling through our ‘small daily triumphs’,6 like a patient waking up with a smile on his face or giving you thanks after her complicated postoperative care. Some strategies that can also help to increase personal wellness – a definition that goes beyond the absence of distress and includes achieving success in various aspects of personal and professional life100 – are cultivating your relationships, sharing personal reflections (shared reflective writing), practising meditation, nurturing self-care and developing hobbies.6,101,102 Not surprisingly, these solutions are rarely promoted by health organisations, but they should be put into practice in our personal lives. A change to another specialty or even to other fields of medicine (management, pharmaceutical industry) is still an option,6,103 but it is not always feasible or desirable. Choosing a positive attitude towards our job may sometimes be difficult, but it is usually rewarding, and improves our work environment.104
In this review, we have depicted stress at work, dissatisfaction and burnout as dysfunction within health systems, and shown how the promotion of job satisfaction could help our organisations. Because anaesthesia is not very different from other specialties, we should try to achieve job satisfaction by attention to three areas: improving job characteristics, managing stress and developing personal wellness.
If you are a manager, try to develop policies in your institution or department to promote the ‘big four’: to create an adequate environment that fosters communication, to increase participation and autonomy of the employees, to promote control over work to avoid overload, and try to recognise the achievements of the workers, making them feel secure, needed and appreciated.
If you are an employee, do not moan continually about every shortcoming, and even if you believe that the system is never going to change, try to make change yourself. You can improve your sense of wellbeing by learning how to manage stress better, how to balance personal and professional goals, how to develop personal wellness strategies or simply find reward in the gratitude of those patients who think that their outcome was better because you were there. Finally, remember that although medicine needs a scientific and rationale basis, its physicians are human beings, with passions and emotions,105 which can be harnessed to help us get job and life satisfaction, even in this current time of crisis.
We would like to thank Gordon Lyons, Nieves Molíns and Rebecca Ramanathan for their assistance with the manuscript.
There are no financial support or sponsorship declared.
There are no conflicts of interest declared.
The present review article is based on a talk given at the Euroanaesthesia 2011 in Amsterdam organised by Subcommittee No. 1 ‘Evidence-based practice and quality improvement’ (Scientific Committee of the European Society of Anaesthesiology) with the title: ‘How to run a successful anaesthesia department’.
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