Anaesthesiologists deal with extreme working hours, high-risk patients and situations and an increasingly complex working environment.1–6 Although the practice of anaesthesia can be very stressful, this does not necessarily mean that an anaesthesiologist experiences psychological or physiological symptoms of stress.7,8 However, it is known from psychological research that stress reactions do occur when demands exceed resources. Stress reactions manifest as not only behavioural changes but also physical or psychological illness, such as burnout.9 Burnout poses a threat to the mental and physical health of the anaesthesiologist and therefore also to patient safety. Burnout has been defined as a syndrome with dimensions of emotional exhaustion, depersonalisation and feelings of reduced personal accomplishment.10 In psychiatry, the term depersonalisation is used to describe an anomaly in self-awareness. In the context of burnout, however, depersonalisation refers to an increased emotional distance between workers and their clients or patients. This attitude may be the result of emotional exhaustion and may lead to feelings of reduced personal accomplishment.11
The transactional model of stress, developed by Lazarus and Folkman,12 emphasises the active psychological interaction between the stressor and the individual. During the primary appraisal, an individual identifies, based on perceived demands, whether the stressor is a threat or a neutral or a positive challenge. In the secondary appraisal, the individual then chooses how to use his resources to cope. Threat appraisal and coping mechanisms may differ widely among individuals. When individuals have personality traits that make them resilient and they are equipped with adequate resources to address work-related demands, they are unlikely to manifest symptoms of burnout.13 Literature suggests a relationship between personality traits and coping strategies that moderate the development of stress into burnout.14 Therefore, personality traits are an important element in the process of developing burnout.15,16
The ‘Big Five’ model of personality traits is the most established and validated system used in the literature.17 The ‘Big Five’ traits describing personality are neuroticism, extroversion, openness to experience, conscientiousness and agreeableness. These personality traits are considered to be relatively stable in an individual over time and across situations.18
Until now, the relationships between personality traits, stress and burnout have never been studied in anaesthesiologists. The only studies on personality traits in anaesthesiologists used tests which are now considered obsolete.19–21 For that reason, the role of the ‘Big Five’ personality traits in anaesthesiologists’ psychological distress and burnout is unknown.
The objectives of this study were to examine the prevalence of psychological distress and burnout in Dutch anaesthesiologists and explore the relationships between psychological distress, burnout and personality traits.
This survey study was approved on 2 April 2012 by the local ethical committee (Commissie Mensgebonden Onderzoek regio Arnhem-Nijmegen, the Netherlands, Chairman Dr F.Th.M. Huysmans, Ethical Committee nr 2012/148).
In July 2012, questionnaires were sent to all 1955 consultant and resident members of the Dutch Society of Anaesthesia using the web-based program RadQuest. Anonymity was guaranteed. RadQuest was developed by the Department of Medical Psychology and the Department of Instrumental Services of the Radboud University Medical Centre, Nijmegen, the Netherlands. Nonrespondents received an electronic reminder after 3 months. Data was collected until December 2012.
The questionnaire consisted of 206 items, including general sociodemographic questions concerning sex, age, number of children under 18, marital status, years practising as an anaesthesiologist, subspecialty and whether the respondent worked in an academic or community hospital, and as a resident or a consultant. The questionnaire also contained several psychological instruments validated in Dutch samples.
Psychological distress was assessed by the General Health Questionnaire 12 (GHQ-12).22 The GHQ-12 consists of 12 questions referring to unpleasant and unusual mental phenomena and impairment of normal functioning. Examples of questions asked are ‘Have you been able to cope with your problems lately?’ and ‘Did you have difficulty sleeping because of worrying lately?’ A 4-point Likert scale was used, ranging from never to much more than usual. For each question, one point was scored if one of the two least favourable options was chosen. A sum of scores of two or more was considered indicative of psychological distress, which is in line with recommendations for use in the general population.22–25
Burnout was measured with the Dutch version of the Maslach Burnout Inventory, the Utrechtse Burnout Schaal (UBOS-C).26 The UBOS-C consists of 20 items, such as ‘At the end of the day I feel empty’ and ‘I do not care what happens to my patients’. Each item is scored using a 7-point Likert scale, ranging from never (0) to daily (6). The average score per dimension is calculated (emotional exhaustion, eight items; depersonalisation, five items; personal accomplishment, seven items). Burnout has been defined as a combination of a high score on emotional exhaustion ‘and’ a high score on depersonalisation, a low score on personal accomplishment or both. High or low scores in one of the dimensions have been defined as scores above the 75th percentile or below the 25th percentile. These values are extensively described in the accompanying manual of the UBOS-C. For this study, we used the table for healthcare workers.26 The Cronbach's α of the dimensions of the UBOS-C (emotional exhaustion, depersonalisation and personal accomplishment) in our sample were 0.90, 0.70 and 0.75, respectively, confirming good internal consistency of these dimensions.
We used a Dutch translation of the Big Five Inventory (BFI) questionnaire, examining the five traits in 44 items on a 5-point Likert scale. The scores are averaged, so the minimum score per trait is 1 point and the maximum score is 5 points.27 The five traits are bipolar and cover a high-to-low continuum. Extroversion (as opposed to introversion, eight items) is associated with terms such as playfulness, spontaneity, assertiveness and dominance. Neuroticism (as opposed to emotional stability, eight items) is associated with terms such as nervousness, anxiety, moodiness and hostility. Openness to experience (as opposed to conventional or conservative, 10 items) is associated with terms such as originality, creativity, nonreligiousness, independence and having broad interests. Conscientiousness (nine items) encompasses a variety of descriptors concerning a person's attitude to work and achievement. The last trait is agreeableness, also known as altruism (as opposed to hostility, nine items). This trait is associated with qualities such as love, empathy, friendliness and cooperation.18 The Cronbach's α values of the dimensions of the BFI (neuroticism, extroversion, openness to experience, conscientiousness and agreeableness) in our sample were 0.83, 0.81, 0.80, 0.76 and 0.74, respectively, also confirming good internal consistency of the BFI.
The Mann–Whitney U test was used to test for differences between the function groups (consultants, residents) for continuous variables. The χ2 test was used for nominal variables and the Fisher exact test for two-by-two tables. Univariable logistic regression was used to study the differences in sociodemographic variables and the personality traits between anaesthesiologists with and without burnout or psychological distress as measured with the GHQ-12, separately. Categories of a specific variable were grouped if there were small numbers. The (crude) odds ratios (ORs) with 95% confidence intervals (CIs) are presented.
Multivariable logistic regression with forward selection procedures was used to identify the variables that contributed independently to the risk of burnout and psychological distress as measured with the GHQ-12. Reference values were chosen arbitrarily; this statistical method compares groups (within the variable) with each other and it does not matter which group is chosen as the reference group. Owing to the fact that forward selection procedures do not identify other important variables, probability values for entry into the model were considered to find close alternatives to the variables selected. All sociodemographic variables and all personality trait variables were valid for selection. The adjusted ORs with 95% CI of the final burnout model and of the final psychological distress model are presented. The adjusted R2 is presented to indicate the total percentage explained variance in the outcome and the area under the receiver-operating characteristic (ROC) curve is presented as a measure of predictive discrimination.
In this study, we also aimed to identify the demographic variables and the personality trait variables that are related to each of the three dimensions of burnout, separately. Univariable linear regression was used to study the influence of the demographic variables and the personality trait variables on each of the three dimensions of burnout, separately. The dependent variable was the specific dimension of burnout. The (crude) regression coefficients with 95% CI are presented.
Analogous to the methods described earlier, multivariable linear regression with forward selection procedures was used to identify the variables that independently influence a specific dimension of burnout. Reference values were chosen arbitrarily. The adjusted regression coefficients with 95% CI of the final models are presented. The R2 value is presented to indicate the total percentage explained variance. Again, close alternatives to the final models are considered.
A P value of less than 0.05 was considered statistically significant. Statistical analyses were performed using SAS 9.2 for Windows (SAS Institute Inc., Cary, North Carolina, USA) and SPSS Statistics for Windows (Version 20.0, IBM Corp., Armonk, New York, USA).
A total of 1955 anaesthesiologists were asked to participate; 655 (33.5%) questionnaires were returned and could be used for analysis. Response rates of consultants and residents were in the same range (35 and 27%, respectively). Consultant anaesthesiologists returned 514 questionnaires and resident anaesthesiologists returned 141 questionnaires. Sociodemographic details are presented in Table 1. The male : female ratio was 388 (59.2%) : 267 (40.8%). Most of the respondents (577, 86.6%) were in a relationship, 63 (9.6%) were single and 25 (3.8%) were divorced or widowed. Approximately half of the respondents (345, 54%) had children younger than 18 years of age. The mean age of the respondents was 43.7 (26 to 64) years.
Analysis of the respondents and nonrespondents for sex ratio, consultant : resident ratio and the percentage working in an academic centre or a community hospital showed that these ratios were close, indicating that as far as these variables are concerned we have a representative sample.
Table 2 summarises psychological distress, burnout and personality traits in consultants and residents. Of all respondents, 39.4% indicated that they had experienced psychological distress (40.1% of consultants and 36.9% of residents). No significant differences were found between consultants and residents nor were differences found between anaesthesiologists working in academic centres and those working in community hospitals.
In total, 18% of respondents met the predefined criteria for burnout. The respective values for consultants and residents were 19.8 and 11.3%. This difference was significantly different (χ2 5.4; P < 0.02). No significant differences were found between men and women, consultant or resident, or between anaesthesiologists working in an academic centre or in a community hospital. The small differences in personality traits between consultants and residents did not reach statistical significance.
Table 3 shows the crude and the adjusted ORs with 95% CI for the sociodemographic variables and the personality traits influencing psychological distress and burnout. In a univariable (crude) analysis, variables are analysed in isolation and the reference values chosen are arbitrary (divorced, having no children and being a resident). In a multivariable analysis, all variables are analysed together.
The personality trait neuroticism was the most important factor positively influencing the presence of psychological distress, so neuroticism is a risk factor. Other relevant, but less important, factors are having children and the personality trait openness. Multivariable logistic regression with selection procedure was used. The adjusted R2 of the multivariable model was 0.27, indicating that 27% of the observed variability could be explained by this model. The area under the ROC curve was 0.76, indicating a good discriminatory power of the final model.
Neuroticism was again the most important factor positively influencing the presence of burnout, so neuroticism is a risk factor. Protective personality traits are extroversion and agreeableness. Sociodemographic variables did not have an effect. Multivariable logistic regression with selection procedure was used. The adjusted R2 of the multivariable model was 0.34, indicating that 34% of the observed variability could be explained by this model. The area under the ROC curve was 0.83, indicating a good discriminatory power of the final model.
Table 4 presents the crude and the adjusted regression coefficients with 95% CI of the demographic variables and the personality traits influencing the three dimensions of burnout. Emotional exhaustion was independently related to neuroticism, extroversion and openness. Sociodemographic variables had no effect. All five personality traits and also three sociodemographic variables (sex, age and being a consultant) were independently related to depersonalisation. Personal accomplishment was related to all five personality traits and one sociodemographic variable (having a relationship). Of the five personality traits, neuroticism was the most important risk factor for the three dimensions of burnout. Logistic regression with selection procedure was used.
The observed variability (R2) values explained by these three multivariable models were 36, 28 and 31%, respectively.
The problem of psychological distress and burnout has been acknowledged in our literature for over 15 years and the present study proves that the problem still needs attention. To our knowledge, this is the first study relating both psychological distress and burnout to personality traits in anaesthesiologists.
Our results indicate that there is a high prevalence of psychological distress in our sample of Dutch consultant and resident anaesthesiologists (39.4%). This means that a significant proportion experience unpleasant and unusual mental phenomena and impairment of normal functioning. This percentage is almost double that of the general population (22.8%) but compares with the percentage in other first-line healthcare workers in the Netherlands.24
The prevalence of burnout in the total study group was 18%, which is on the low side of the range of 20 to 40% burnout in anaesthesiologists reported in previous European publications.1,2,5,28,29
When interpreting this result, it is important to realise that the prevalence of burnout in the general Dutch population is 13%. This is amongst the lowest in Europe according to a Dutch report from 2013 which compared Dutch general occupational burnout with European figures.30 Another interesting aspect of these studies is that they reported an increased prevalence of burnout in residents.28,31–34 This is in contrast to the result of the present study, in which burnout was less prevalent in residents (11.3%) than in consultants (19.8%).
From a study performed by a Dutch insurance company among Dutch general practitioners, it is known that not all doctors with burnout symptoms seek help or stop working.35 If these findings are also applicable to the Dutch anaesthesiologist population, it may be that colleagues experiencing symptoms of burnout keep on working and potentially pose a threat to their own mental and physical health as well as to patient safety.
When all variables (sociodemographic and personality) are taken into consideration, our multivariable analysis showed neuroticism to be the most important factor increasing the risk for presence of psychological distress (OR 6.22) and presence of burnout (OR 6.40). Extroversion was the most important protective factor for burnout (OR 0.44). Separation of results from residents and consultants did not improve the final model.
This compares with studies in the general population. People who score high on neuroticism tend to have an increased susceptibility to their environment, a tendency to be anxious and insecure and a high performance drive. This predisposes them towards developing burnout. People who score highly on extroversion tend to seek interactions with other people, and this may help counteract the process of depersonalisation. They also tend to appraise problems in a positive way, which reduces stress and therefore risk of burnout.
Individuals with certain personality types may choose high-stress occupations, so doctors who choose to pursue a career in anaesthesia might have personality traits that make them fit for the specific stressful demands of the job and hence reduce the chance of developing burnout. However, stress will be experienced more intensely by individuals with some personality traits and hence will predispose them to developing burnout. Some studies suggest that certain personalities tend to choose specific medical specialties.36,37 For example, anaesthesiologists have been reported as more intelligent, self-sufficient, dominant, tense and introverted than general practitioners.38
Personality traits are important in burnout and psychological distress, and they are considered to be stable in time and hard to change. Therefore, strategies to address these problems can be focused on reinforcing the coping strategies of the individual. Educational programmes should be directed at personal competence and staying resilient, as well as professional knowledge and skills. For example, it has been suggested that trainee anaesthesiologists should be taught beneficial coping styles.6 Personality testing may be used in selection of residents to reduce burnout in future anaesthesiologists. Furthermore, it is recommended that colleagues should be educated about recognising symptoms indicating burnout, such as a detached and cynical attitude towards patients and coworkers.
A cause for concern in our study is the low response rate of 33.5%. Similar studies3,8,31,34,39–41 have reported response rates of 27 to 76%. In these studies, response rates were inversely related to the number of participants addressed. Our response rate of 33.5% is similar to the mean response rate of 34.6% found in a meta-analysis of 56 internet-based surveys.42 The authors of this meta-analysis also emphasise that the representativeness of a sample is much more important than the response rate obtained. Our data proved to be representative for sociodemographic variables, which argues in favour of the premise that no responder bias has occurred. It can be argued that anaesthesiologists who have burnout may tend not to react to professional e-mails or fill out work-related questionnaires. However, the reverse may also be true; such anaesthesiologists may be eager to share data to call attention to their situation. Even if selection bias had occurred, the high prevalence of psychological distress is still very disturbing.
In future longitudinal studies, the question of how personal and situational factors interact in the complex process of the development of burnout should be addressed. Considering coping strategies would be interesting in this regard. In addition, the relationship between burnout and sick leave, suicide rate, critical incidents and substance abuse should be studied further. This knowledge could then be used to develop specific strategies to reduce anaesthesiologist burnout. Furthermore, future research aimed at defining which specific personality traits are desired in aspiring anaesthesiologists is needed because the BFI tool is an instrument which assesses general personality traits.
We conclude that personality traits of anaesthesiologists are strongly related to the presence or absence of psychological distress and burnout, with neuroticism as the most important trait influencing the presence of both psychological distress and burnout, making it an important risk factor.
Acknowledgements relating to this article
Assistance with the study: we would like to thank Ria te Winkel for assistance in compiling the questionnaires, Michiel Vogelaar for assistance in data collection and database building and Mark van Ooijen for assistance in data collection.
Financial support and funding: this work was supported by internal funding of the Department of Anaesthesiology, Pain and Palliative Medicine of the Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands.
Declaration of interests: none.
Presentation: preliminary data from this study were presented orally at the annual meeting of the Dutch Anaesthesia Society in May 2013, Maastricht, the Netherlands.
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