This Invited Commentary accompanies the following article:
Rama-Maceiras P, Parente S, Kranke P. Job satisfaction, stress and burnout in anaesthesia: relevant topics for anaesthesiologists and healthcare managers? Eur J Anaesthesiol 2012; 29:311–319.
In an article published in the present issue of the European Journal of Anaesthesiology, Rama-Maceiras et al. draw attention to the importance of well-being of anaesthetists and discuss both personal and organisational development and specific intervention plans.1 One issue which emerges from that article is that, when studying occupational health including bio-physical, psychological, social and cultural problems, it becomes necessary to co-operate with experts of each area such as occupational health physicians, psychiatrists, psychologists and social scientists.
Individuals react very differently to stressful stimuli. Many factors may at the same time act negatively or positively depending on the situation and the personal background. Well-being is a systemic phenomenon in which it is difficult to separate causes from effects. This is why I would like to emphasise the following definitions regarding well-being.
The human mind and body can be understood holistically, and the well-being of an individual may be seen as the net effect of positive and negative bio-psycho-socio-cultural factors. ‘Sense of coherence’ proposed by Antonovsky2 can widen our understanding of health. According to this hypothesis, an individual's health is determined to a great extent by how they experience the world as meaningful, comprehensible and manageable. It encourages an individual to strengthen the healthy aspects of their organism even when suffering symptoms of illness. It also emphasises the importance of culture – especially one's own value system – for well-being and health. Health can also be seen as a person's ability to fulfil their roles in society.3 Health may be considered as a multidimensional concept including positive body feeling, absence of excessive complaints or signs of disease, joy, happiness, job and life satisfaction, performance, self-realisation and sense of meaningfulness. Health depends on the existence and on the perception of stress and strain, and on the means of dealing with it.4
The concept of ‘stress’ is complicated, with differing definitions based on stimulus, response, interaction or transaction. Most studies on work stress have considered the presence of stressors, the evaluation process and the response. However, there is still no consensus as to the definition of stress or as to the work stress process. In the transactional approach by Lazarus and Folkman,5 stress can be understood as a process: ‘Stress is a misfit between an individual and his particular environment’. Individuals, according to this theory, make a cognitive evaluation of threats vs. strengths that come from the environment. The degree to which people evaluate stress as a serious threat while activating their coping methods reveals the level of their perceived stress. When modelling our stress process, it is important to take into account the whole environment of the anaesthetist including organisation, patients, family, social life, life events and personal demands.6
Adaptation in stressful situations involves activation of neuro-immuno-endocrinological mechanisms. This adaptation is called ‘allostasis’, meaning that an organism has regained a new stability through change.7 When these adaptive systems are turned on and off efficiently and not too frequently, the body is able to cope effectively with stressors that it might not otherwise manage. However, in excessively high and longstanding stressful situations causing strain, allostatic systems may become overstimulated and fail to function normally. This disturbance is called ‘allostatic load’.8 Allostatic load leads to disturbances in the defence system of the organism, causing changes in neuro-immuno-endocrinological and pain pathways, which over time may lead to disease.9 However, the deleterious effects of chronic stress can be counteracted by supporting the coping acts of the individual, allowing them to function according to their own value system enhancing positive expectations, increasing social support, promoting healthy behaviours (psychotherapy, mindfulness, physical exercise, stretching, pause gymnastics, optimal nutrition, sleep and rest, moderate drinking, no smoking), optimising ergonomics and reducing strain related to psycho-socio-cultural aspects in the workplace.6
Burnout refers to a negative consequence of chronic work-related stress.10 Theoretical models of burnout range from individual to interpersonal, organisational and societal. Many share the assumption of a chronic discrepancy between the expectations of a motivated employee and the reality of unfavourable working conditions. Neuroticism (enduring tendency to experience negative emotional states), alexithymia (a state of deficiency in understanding, processing or describing emotions), fragility and low sense of coherence are related to vulnerability to burnout.11 Physicians with a demanding personality appear to be more prone to burnout. Kalimo et al.11 have further developed the three-dimensional Maslach burnout index and formed a ‘Finnish burnout index’ which makes it possible to assess burnout with one measure. Lately, the focus has been also on engagement, the positive antithesis of burnout, which gives new perspectives on interventions to alleviate effects of stress.
Working conditions can be characterised as physical and mental conditions relating to the work environment. They are known to be potential sources of stress, health hazards and disease, but they may also enhance well-being, work ability and job and life satisfaction. Furthermore, they can shape health behaviours. However, individual differences – linked to sex, genetics, life environment, life events, learned models to cope with stress and actual life situation – are crucial in the aetiological chain between working conditions and well-being and health. Moreover, individual factors can either make a person prone to strain or can protect them from it.
Three models defining stressful psycho-social factors affecting health appear to be promising: the job strain (demand–control),12 the social support13 and the organisational justice14 models. The job strain model focuses on situational factors of work and arrangements, the social support model on the quality of co-operation and social interaction at work and the organisational justice model on decision-making procedures, managerial practices and distribution of resources. The widely tested effort–reward imbalance model refers to the latter dimensions of organisational justice.
Our studies showed that job control and organisational justice together with workplace relationships were the most important correlates of work-related well-being among anaesthetists.6,15,16 Job control involves employees’ authority to make decisions concerning their jobs and the use of skills regarding task variety and options to develop and learn new things. Organisational justice refers to the extent to which employees are treated in a just way at their workplace. It includes a procedural component (the extents to which decision-making procedures include input from the affected parties, are consistently applied, suppress bias and are accurate, correctable and ethical) and a relational component (polite, considerate and fair treatment of individuals).
Interventions for improving the well-being of anaesthetists can be focused on professional issues, occupational health, organisational factors and at an individual level.6 In the future, the focus should be on the effectiveness of the different types of interventions.
The author wants to thank Professors Kari Nurmi, Marko Elovainio and Raija Kalimo for their useful comments. There are no conflicts of interest and there was no financial support.
This article was checked and accepted by the Editors, but was not sent for external peer-review.
1. Rama-Maceiras P, Parente S, Kranke P. Job satisfaction, stress and burnout in anaesthesia: relevant topics for anaesthesiologists and healthcare managers? Eur J Anaesthesiol
2. Antonovsky A. Health, stress and coping: new perspectives on mental and physical well being. San Francisco, California: Jossey-Bass; 1979.
3. Erben R, Franzkowiak P, Wenzel E. Konzeptuelle überlegungen zur gesundheitsförderung. Conceptual considerations on the requirements of health. In: Wenzel E, editor. Die ökologie des körpers. The ecology of the body. Suhrkamp, Frankfurt, 1989, 13–120.
4. Bengel J, Strittmatter R, Willmann H. What keeps people healthy? The current state of discussion and the relevance of Antonovsky's salutogenic model of health. Cologne, Germany: Federal Centre for Health Education (FCHE); 1999.
5. Lazarus R, Folkman S. Stress, appraisal and coping. New York, New York:Springer; 1984.
6. Lindfors P. Work-related well being of Finnish anesthesiologists. People and work. Research reports 88. Helsinki, Finland: Finnish Institute of Occupational Health; 2010.
7. Sterling P, Eyer J. Allostasis: a new paradigm to explain arousal pathology. In: Fisher S, Reason J, editors. Handbook of life stress, cognition and health. New York, New York: J Wiley Ltd; 1988. p. 631.
8. McEwen BS, Stellar E. Stress and the individual. Mechanisms leading to disease. Arch Intern Med
9. McEwen BS. Stress, adaptation, and disease. Allostasis and allostatic load. Ann N Y Acad Sci
10. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Ann Rev Psychol
11. Kalimo R, Pahkin K, Mutanen P, Toppinen-Tanner S. Staying well or burning out at work: work characteristics and personal resources as long-term predictors. Work Stress
12. Karasek RA. Job demands, job decision latitude, and mental strain: implications for job redesign. Adm Sci Q
13. Theorell T, Orth-Gomer K, Eneroth P. Slow-reacting immunoglobulin in relation to social support and changes in job strain: a preliminary note. Psychosom Med
14. Elovainio M, Kivimäki M, Vahtera J. Organizational justice: evidence of a new psychosocial predictor of health. Am J Public Health
15. Lindfors PM, Meretoja OA, Töyry SM, et al. Job satisfaction, work ability and life satisfaction among Finnish anaesthesiologists. Acta Anaesthesiol Scand
16. Lindfors PM, Heponiemi T, Meretoja OA, et al. Mitigating on-call symptoms through organizational justice and job control: a cross-sectional questionnaire study among Finnish anesthesiologists. Acta Anaesthesiol Scand