Anaesthesiology is a stressful occupation due to long working hours, fatigue, demanding interpersonal relations, the need for sustained vigilance, unpredictability of work, fear of litigation, competence and production pressure [1–4]. Chronic exposure to these factors can lead to stress disorders. Stress is a mental, emotional and physical strain or tension which is due to an interaction between personal traits (perceived stress) and professional traits . Why some individuals exposed to the same stressors during the same period are more susceptible to stress than others who depend on their personality traits and the way they perceive stress [6–8].
Exposure to stress conditions for a long period of time can lead to the syndrome of burnout . The symptoms and signs of burnout include emotional exhaustion, lack of personal accomplishment and a sense of depersonalization with co-workers and patients. Burnout has been associated with impaired job-performance putting in danger the quality of patient care [10–12] and may contribute to drug addiction [13–16] and suicide [4,17], as previously demonstrated in anaesthesiologists. In spite of the increasing importance of this subject, there are yet no studies focusing on stress in Portuguese anaesthesiologists. While most previous studies conducted in other countries measured stress mainly through physical and mental indicators , in the present study we intended to determine stress, by measuring perceived stress, job and organization satisfaction (an indirect indicator of professional stress), and the burnout among Portuguese anaesthesiologists.
From January to June 2005, we conducted a cross-sectional study in which all Portuguese physicians registered as anaesthesiologists in the Portuguese Medical Association were invited to participate. Due to the legal obligation of all physicians to register with the medical association, we approached all anaesthesiologists working in Portugal for our study. Anaesthesiologists working exclusively in intensive care were excluded due to the specific nature of their work.
Data were collected using anonymous self-administered questionnaires that were sent by mail to the home address of 850 anaesthesiologists together with a prepaid stamped envelope for reply. A letter had previously been sent to the Head of all Departments of Anaesthesiology, announcing the study and its objectives. Two months after the questionnaires were first mailed to the physicians’ personal addresses, a reminder to return the questionnaires was sent to all departments. Two hundred and seventy questionnaires (31.8% of the 850 that were sent) were returned. Since the questionnaire concerned current professional situations, we excluded physicians who had not worked in the profession for at least 1 yr before receiving the questionnaire. We excluded seven questionnaires because they did not meet this inclusion criterion. Thus, 263 (30.9%) questionnaires were left for analysis.
The social and patient characteristics assessed included gender, age, marital status and number of children. Profession-related variables were type of hospital and location, type of working regime (working exclusively in the National Health Service (NHS) or both in the NHS and private hospitals), board certification status, years of practice, subspeciality training and average hours of work per week.
In order to measure the level of stress and the psychological consequences of stress we used three scales: Portuguese versions  of the Perceived Stress Scale (PSS) to directly measure the level of stress, the subscale of work satisfaction of the Pressure Management Indicator scale (PMI) to indirectly measure the amount of professional stress and the Maslach Burnout Inventory (MBI) to assess the consequences of stress.
The PSS [5,19] directly measures perceived stress. It consists of 14 items and was conceived to assess how much life situations are appraised as stressful; that is, how unpredictable and overloaded respondents find their lives. It measures level of stress as a function of objective stressful events, coping resources and personality factors. Each item is answered on a scale from 0 (never) to 4 (very often); PSS scores are obtained by reversing the scores on the 7 positive items and then adding across all 14 items. Higher scores indicate higher levels of perceived stress and there is no previously defined cut-off point to dichotomize the results (having stress/not having stress).
The work satisfaction component of the PMI [5,20] includes 12 items that directly measure satisfaction with one’s job (tasks and duties) (6 items) and organization of the institution (structure and functionality) (6 items) and indirectly measuring professional stress. Each item is answered on a scale from 1 (extremely unsatisfied) to 6 (extremely satisfied). In each subscale the score can vary from 6 to 36, with higher values representing higher satisfaction. Similar to other studies conducted in the Portuguese population, we did not assume cut-off points .
The 22-item MBI [5,21] is a measure of burnout and is subdivided in three subscales:
- Emotional exhaustion (9 items): This subscale refers to lack of emotional resources; that is, the feeling of having given everything and having nothing left to give.
- Lack of personal accomplishment (8 items): This subscale assesses feelings of doubt about one’s ability to perform tasks and lack of successful achievement in one’s work with people.
- Depersonalization (5 items): This subscale measures an unfeeling and impersonal response towards recipients of one’s service, care, treatment or instruction.
The subject is asked to answer each item on a scale from 0 (never) to 6 (every day). The authors of MBI have defined a cut-off value indicating the presence of disturbance based on an arbitrary statistical definition (mean of the population plus half SD). This definition results in different cut-off points between populations, thus impairing comparisons, and the same arbitrarily predefined prevalence of disturbance of around 31% assuming a normal distribution. Given that there is no natural criterion resulting in two clinically distinct groups of individuals, we opted for defining a cut-off value for each subscale of the MBI, as has been described for other scales (SCL-90)  based on the product of the number of items by the mid-point of the score (i.e. 3). Thus, in the subscale of ‘emotional exhaustion’, values ≥27 (9 × 3) are considered to indicate burnout; in the subscale of ‘lack of personal accomplishment’, values ≥24 (8 × 3) are considered to indicate burnout; and in the ‘depersonalization’ subscale, values ≥15 (5 × 3) are considered to indicate burnout.
At the end of the questionnaire, an open question was included for responders to identify the main stress factors encountered in their daily lives. The six most frequently referred factors were identified.
Data were stored and analysed using SPSS (SPSS Inc., Chicago, Illinois). Descriptive data are presented as mean and SD for continuous variables, after confirming that they are normally distributed, and counts and proportions for categorical variables. Mean of PSS and PMI scores were compared using the t-test for independent samples or analysis of variance, respectively between two groups or among three or more groups. The prevalence of burnout in our sample across categories of independent variables was compared using the χ2-test. A significance level of 5% was used and all tests were two-tailed. The independent association between perceived stress (PSS) and work satisfaction (PMI) with burnout scores was assessed using multiple linear regression models. Separate models were built for emotional-exhaustion score, lack of personal-accomplishment score and depersonalization score. In each model, PSS score, PMI score on job satisfaction and PMI score on satisfaction with organization were simultaneously included as independent variables and maintained in the final model only if independently associated with the outcome at the 5% significance level. Coefficients of determination (R2) are presented for the final models and express the proportion of variance in burnout explained by the independent variables included in the final model.
Two hundred and sixty-three questionnaires were included in our analysis. The mean age of the responders was 47 yr (range: 31–67 yr) and most were women (68.1%). Approximately, two-thirds worked in academic hospitals, mostly exclusively so (62.4%). Over 70% worked between 42 and 60 h/week (Table 1).
The mean value of the perceived stress as assessed by PSS was 24 (range: 8–40). There was no significant association between perceived stress level and any of the social-related patient characteristic and job-related variables, although there was a trend towards higher level of stress among specialists working exclusively in the NHS (Table 2).
Overall, the mean score on ‘satisfaction with job’ was 20.1 (range: 6–34) and the mean score on ‘satisfaction with organization’ was 21.3 (range: 9–36). Satisfaction with job and organization were both higher among anaesthesiologists working in community hospitals than in academic hospitals, although this difference was significant only for satisfaction with organization (Table 3). Both scores were also higher among anaesthesiologists working in the North of the country, but the difference was statistically significant only for satisfaction with job (Table 3). There was a J-shaped association between professional degree and both PMI scores, with physicians with leadership responsibilities having significantly less professional stress (Table 3). Weekly working hours was not associated with the amount of professional stress (Table 3).
When analysing the consequences of stress in Portuguese anaesthesiologists, we observed that 151 (57.9%) experienced emotional exhaustion, 116 (44.8%) showed lack of personal accomplishment and 239 (90.9%) depersonalization. The prevalence of emotional exhaustion was significantly lower among anaesthesiologists with more than 20 yr of working experience (P = 0.008); the prevalence of lack of personal accomplishment increased progressively with the number of children among women (30.6% for no children, 39.4% for 1 child, 43.8% for 2 children and 50.0% for 3 or more children, P = 0.09 for linear trend) but not among men (45.5% for no children, 58.3% for 1 child, 51.4% for 2 children and 54.5% for 3 or more children, P = 0.77 for linear trend) and anaesthesiologists working in community hospitals showed depersonalization significantly more often (P = 0.03) (Table 4). Most anaesthesiologists worked in several areas of practice simultaneously, and this probably explains that no significant association was found between parameters of burnout and different areas of practice.
When assessing how strongly burnout depends on job-related stress and perceived stress, we observed that there was an independent significant linear association between the score on emotional exhaustion on MBI and perceived stress (positive) and the score on ‘satisfaction with organisation’ of the PMI (inverse). This means that higher perceived stress and lower satisfaction with organization are each independently associated with higher emotional-exhaustion (Table 5). Approximately a quarter of the variability in emotional-exhaustion score was explained by these two factors. Job satisfaction was not associated with emotional exhaustion. The score on lack of personal accomplishment and depersonalization were significantly associated only with perceived stress, but the score on PSS explained only 7.1% and 3.1% of the variability in lack of personal accomplishment and depersonalization, respectively (Table 5).
In the open question where the anaesthesiologists were asked to spontaneously indicate the factors that generated stress, 101 (38.4% of the participants) named strained professional relationships, 101 (38.4%) unskilled leadership by their superiors, 101 (38.4%) work overload, 66 (25.1%) indiscipline of surgeons, 54 (20.5%) lack of working conditions (e.g. inappropriate working resources, lack of nursing staff) and 34 (12.9%) technically difficult situations (e.g. airway management).
In this study, the prevalence of depersonalization was high among Portuguese anaesthesiologists (90.9%), emotional exhaustion was found in 57.9% and lack of personal accomplishment in 44.8%.
Burnout represents a deterioration of values, dignity, spirit and will, spreading gradually over time . Indeed it is a cumulative process that leads to the loss of physical and mental energy. Burnout has serious and dangerous implications to the individuals as well as to patients and the institutions where they work .
Years of experience was the only variable that was associated with emotional exhaustion – the anaesthesiologists with more years of practice experienced less emotional fatigue compared to the younger ones, even though they were exposed to stress for a longer period. This can possibly be explained by the development of coping mechanisms throughout the years. This may be a determining factor in reducing the consequences of stress.
Lack of personal accomplishment, representing the negative self-evaluation regarding performance abilities, was higher in physicians with larger families. Conflicts between home and work responsibilities have previously been pointed out in other studies concerning anaesthetists  as a major source of stress. The difficulty in articulating professional and personal demands may clearly enhance job insecurity and feelings of negative self-evaluation. In our society, this association seems to be observed only among women, reflecting a traditional distribution of tasks and roles in families, according to which women are more deeply involved in responsibilities towards children.
Due to the characteristics of the speciality, anaesthesiologists are involved in a non-reciprocal relationship with the patients, with little contact or follow up after leaving the operating theatre, which can culminate in a loss of empathy and depersonalization . The alarmingly high frequency of depersonalization observed overall in our sample possibly reflects this. However our sample may not be representative of all Portuguese anaesthesiologists due to participation bias. It is likely that the ones with some kind of stress disorders were most motivated to answer our questionnaire. This is the most important limitation of our study. Anaesthesiologists working in community hospitals have more depersonalization than those working in academic hospitals (97.5% vs. 90.3%). Smaller hospitals usually comprise fewer anaesthesiologists, leading to increased isolation and lack of communication with colleagues, which may contribute to these results.
When compared to another working population, Portuguese teachers , we verified that emotional exhaustion and depersonalization are more prevalent among anaesthesiologists.
Anaesthesiologists that worked exclusively in the NHS had more perceived stress than those working in several institutions. This can be due to the routine of having to deal daily with the same personalities, problems inherent to the institution and the pressure to achieve the desired objectives and targets set by the institution. The fact that there is no economic reward in response to assessment of one’s work quality or quantity may also contribute to increasing stress.
Regarding the overall satisfaction with job and organization, we found that anaesthesiologists with leading functions experienced less professional stress. This means that they are more satisfied with their job and organization. The achievement of the desired graduation in their career is obviously a motive of great satisfaction or less stress. In general, the satisfaction with job and organization among Portuguese anaesthesiologists is no higher than in Portuguese teachers .
When trying to explain burnout we concluded that the perceived stress and organization satisfaction both were predictors of emotional exhaustion, one of the three dimensions of burnout. That is, when perceived stress is high and organization satisfaction is low, emotional exhaustion is more likely. A similar correlation was also described among Dutch and UK physicians . Perceived stress had a much lower contribution to personal accomplishment and depersonalization, thus there must be other factors that are responsible for these two dimensions of burnout.
The results of the open question of the questionnaire point to important stress factors in anaesthesiologists. Strained professional relationships, work overload and unskilled leadership by the superiors are pointed as major sources of stress. The first two stressors have previously been documented as major causes of stress . However, the perception of anaesthesiologists of their superiors’ lack of skills for leadership as a stress factor is a new finding and may be due to lack of communication with superiors. This stressor can possibly be modified by promoting meetings in which the staff and the superiors can bring to discussion their daily difficulties, problems and frustrations, eventually reinforcing relations and mutual understanding.
Unmanaged stress is a worldwide source of suffering and illness for anaesthesiologists reinforcing the increasing importance of this issue. In this study, we concluded that stress conditions and burnout were prevalent amongst Portuguese anaesthesiologists. We also identified some of the main stress factors. This opens a pathway for the resolution of this problem, since some stressors, although impossible to eliminate, can be attenuated by the development of coping mechanisms.
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