Well-being in healthcare providers is a popular topic because the mental health of physicians, physician assistants (PAs), and NPs directly affects patient care.1,2 Among the concepts represented within the realm of well-being are job satisfaction and work stress. Job satisfaction is multifaceted, with intrinsic factors (responsibility, nature of work) and extrinsic factors (pay and benefits, coworker and supervisor relationships).3,4 Poor job satisfaction is associated with burnout, self-esteem, depression, anxiety, staff turnover, and suboptimal patient care.5-8 A study by Jackson and colleagues showed reduced job satisfaction in female surgeons, those under age 60 years, and those working more than 60 hours per week.9 Neither clinical specialty nor profession has been shown to have a significant effect on job satisfaction.10
Even providers with high levels of professional satisfaction face some level of work stress and burnout in clinical practice.11 Job stress (also known as work stress) is defined by the National Institute for Occupational Safety and Health as “harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker.”12 Workplace stressors faced by clinicians may include long hours, emotionally charged situations, bureaucracy, and increased patient care demands.13 As workload and work stress increase, physicians report an increased incidence of medical mistakes and reduced standards of patient care.14 In addition, work stress is significantly associated with burnout, which has many negative consequences, including decreased empathy, poor medical care, depression, suicidal ideation, and absenteeism.15,16
Job satisfaction, work stress, and burnout are separate but related concepts.13,17,18 Although few demographic characteristics have been shown to affect job satisfaction, recent literature has suggested that there may be a difference in perceived workplace stressors based on professional group (that is, physicians versus PAs).19,20 Surgical departments are staffed with a diverse population of surgical providers, with a recent expansion of PAs and NPs. Given this diversity, how do demographic variables such as age, sex, and profession influence work stress and job satisfaction in the field of surgery? By reducing work stress and increasing job satisfaction, a facility can improve patient care and avoid the financial costs associated with provider turnover, which can exceed $500,000 per position.5-8,14,21
The purpose of this study was to measure job satisfaction and workplace stressors in the surgery department at a tertiary care hospital. Researchers hoped to determine whether job satisfaction or workplace stressors differed by demographic group (age, sex, profession, years in practice, hours working per week). Discovery of any differences would let the facility more effectively deliver targeted strategies to improve provider wellness and ultimately patient care.
In spring 2017, an electronic survey was distributed to all surgeons, PAs, and NPs in the department of surgery at a tertiary care hospital. Survey recipients included those practicing in general surgery, otorhinolaryngology (ENT), neurosurgery, plastic surgery, and vascular surgery. The survey collected information on demographic factors (age, sex, job role, number of years practicing, and hours spent working in an inpatient and outpatient setting per week), perceived workplace stressors, and job satisfaction. Job satisfaction was assessed using a single item, five-point Likert-type scale from very dissatisfied to very satisfied. Participants were asked to select up to three (but were not required to select any) of their most significant workplace stressors from the following list: workload, electronic medical record (EMR), OR efficiency, job security, supervisory support, work-life balance, compensation/finances, or other. The listed workplace stressors were based on results from an internal qualitative study in 2016 in which surgical providers and residents described (in free text) their perceived causes of burnout. In that study, the free text responses were coded by two independent reviewers using guided content analysis. Burnout was not assessed in our study because it had been assessed during the 2016 internal study and because our study focused on work stress and job satisfaction.
Mean and median job satisfaction were calculated for the entire sample, as well as by profession (surgeon, PA, or NP), age, sex, years in practice, and hours working each week (in both inpatient and outpatient settings). Job satisfaction was compared between groups using t-tests and ANOVA. Welch ANOVA was used for comparing job satisfaction by age group as the data violated the assumption of homogeneity of variance. Because participants could indicate up to three workplace stressors, the proportion of total responses was calculated for each stressor. A two-sample z-test of proportions was used to compare the most notable workplace stressors by profession, sex, age group, years in practice, and hours per week spent in inpatient and outpatient settings. To preserve anonymity, all individuals who indicated an age greater than 60 years were condensed into one group and all individuals who indicated spending more than 70 inpatient hours per week were condensed into one group.
Fifty-one PAs and NPs and 75 surgeons received the survey, and 21 PAs and NPs and 45 surgeons completed it (Table 1). The response rate was 52.4% (41.2% for PAs and NPs and 60% for surgeons).
The mean job satisfaction in the overall sample was 3.86 (SD 0.875), corresponding with a satisfaction between “neither satisfied nor dissatisfied” (3) and “satisfied” (4). Seventy-seven percent of participants indicated that they were satisfied or very satisfied (Table 2). Mean job satisfaction did not differ by professional degree [t(64) = 0.946, P = .347], age [F(4,11.14) = 1.203, P = .363], sex [t(64) = -0.730, P = .468], inpatient hours per week [F(4,61) = 0.585, P = .675], or outpatient hours per week [F(4,59) = 1.106, P = .362].
Sixty-six participants selected up to three of their top workplace stressors, resulting in 185 responses (up to three responses per individual). As a whole, the top three stressors cited by all survey participants were workload (n = 33, 17.8% of responses), work-life balance (n = 33, 17.8% of responses), and EMR (n = 28, 15.1% of responses). The top three workplace stressors cited by PAs and NPs were supervisory support, compensation/finances, and workload. In comparison, the top three workplace stressors cited by surgeons were OR efficiency, work-life balance, and workload (Table 3). Surgeons were more likely than PAs and NPs to cite OR efficiency (z = 3.42, P < .001) as a major work stressor. PAs and NPs were more likely than surgeons to cite supervisory support (z = 3.66, P < .001) or compensation/finances (z = 2.23, P = .03). Women were more likely than men to cite supervisory support (z = 3.22, P = .001). Compensation/finances was cited as a work stressor more frequently by providers practicing for 16 to 20 years compared with those who had been in practice for 11 to 15 years (z = 2.20, P = .03) or those in practice for more than 20 years (z = 2.26, P = .02). Individuals spending 51 to 60 hours per week providing inpatient care were more likely to cite OR efficiency as a major stressor than those spending less than 40 hours in the hospital per week (z = 2.39, P = .02). No significant differences in workplace stressors were found by age group or by hours spent in an outpatient setting per week.
In summary, most participants indicated that they were satisfied with their jobs. Job satisfaction was greater in providers who had been practicing for 11 to 15 years compared with those who had been in practice for more than 20 years. No other significant differences in job satisfaction were found based on demographic group (age, sex, profession, or hours spent in an inpatient or outpatient setting). Surgeons were more likely than PAs and NPs to cite OR efficiency as a major job stressor, and PAs and NPs were more likely than surgeons to cite compensation/finances. Both PAs and NPs and female providers of all types were more likely to cite supervisory support as a major job stressor compared with surgeons and male providers, respectively. This result is likely confounded as most female surgical providers in the study were PAs or NPs, and most PAs and NPs in the study were women (Table 1). Participants who had been practicing for 16 to 20 years were more likely to cite compensation/finances as a major stressor compared with those who had been in practice for 11 to 15 years or more than 20 years. OR efficiency was noted as a stressor more frequently by participants spending 51 to 60 hours providing inpatient care per week compared with those spending fewer than 40 hours per week at the hospital. This finding also is confounded because the only clinicians who reported spending 51 to 60 hours providing inpatient care per week were surgeons.
Though our sample was relatively small due to involvement of a single department, our response rate was good. Surgeon response rate was higher than PA and NP response rate. Job satisfaction in our study cohort was similar to or slightly higher than that described in other studies in the literature. Studies on job satisfaction of PAs and NPs in surgery are lacking compared with that of surgeons. In a recent study of PAs across the United States, most indicated that they were happy at work.19 Similarly, in a study of NPs in the state of Arizona, mean job satisfaction was 4.69 out of 6.22 In a study of young surgeons in Europe and North America, median job satisfaction as measured by an extended version of the Global Job Satisfaction Instrument (range, -87 to 87) was 33.23 These results are similar to the mean job satisfaction in our sample of PAs and NPs and surgeons (“satisfied,” with median score 4 out of 5). Although PAs and NPs and surgeons cited different workplace stressors as primary stressors, no difference in job satisfaction was found between the two groups. This may suggest that job satisfaction is driven more strongly by components of the job such as interest in the field, positive patient interactions, or strong relationships with coworkers rather than work stress.
In this study, job satisfaction was greater in providers who had been practicing for 11 to 15 years compared with those who had been in practice for more than 20 years. In addition, there was a trend toward increasing job satisfaction until ages 41 to 50 years, after which the job satisfaction declined. This trend may have reached significance in a larger sample. These results can be compared with findings from a longitudinal study of US citizens by Dobrow and colleagues, which found an increase in job satisfaction with age, but a decrease in job satisfaction with longer tenure in a position.24 The current study did not assess length of tenure in a single position, precluding further investigation of this concept in this sample. Efforts to describe the relationship between job satisfaction, years in practice, and tenure in a position within the medical community are warranted.
PAs and NPs cited different workplace stressors than did surgeons at this institution. PAs and NPs were significantly more likely to cite supervisory support or compensation/finances as major workplace stressors than were their surgeon colleagues, and surgeons were more likely to cite OR efficiency. Although supervisory support was noted more frequently as a stressor by PAs and NPs, this likely is a confounded result, because most PAs and NPs in the study were women (women in the study also were more likely to cite supervisory support compared with men). Notably, while completing the survey, PAs and NPs may have perceived supervisory support differently than surgeons (for example, as the supervising surgeon versus the department chair or hospital administrators). PAs and NPs work daily with supervising surgeons, but surgeons may only interact directly with the department chair or other administrator on a weekly or monthly basis. Because PAs and NPs have significantly more interaction with supervisors than do surgeons, they may be more likely to perceive lack of supervisory support as a major stressor. Differences in the perceived stressors of compensation/finances and OR efficiency can likely be explained by the gap in salary between PAs and NPs and surgeons and variance in job requirements between the two professional groups. Previous studies have noted differences in the factors that surgeons and PAs or NPs feel contribute most to their stress.19,20 In one study, “income not high enough” and “spending too many hours at work” were the top two factors that PAs felt were contributing to their stress.19 Another study found that physicians (in surgical and nonsurgical fields) considered “too many bureaucratic tasks” as the top factor contributing to their stress, followed by “too many work hours” and “increasing computerization.”20 Although these studies cannot be directly compared, they describe similarities and differences between professional groups. Our findings corroborate the results of these studies and support the need for a multidisciplinary well-being leadership team in surgery departments, such that the needs of each group are adequately represented and addressed.
Participants who had been practicing for 16 to 20 years were more likely to cite compensation/finances as a major stressor compared with those in practice for 11 to 15 years or more than 20 years. This may be influenced by other variables such as surgical specialty or subspecialty, variability in pay based on salary negotiation, or percentage of time spent doing nonclinical tasks such as research or teaching. Alternatively, those practicing for 16 to 20 years are more likely to be between ages 45 and 60 years and may have additional household expenses (such as college tuition for children) that cause additional financial stress. Larger studies with multivariate analyses or group discussion in the institution may shed more light on this finding.
As with any survey-based research, our study was limited by response bias and selection bias. Although our response rate was good, a larger sample size would have given a more accurate depiction of job satisfaction and major workplace stressors within the department. In addition, a larger sample size would have provided greater power to the study, allowing for more robust (multivariate) statistical analyses and conclusions. The study was limited to a single department in a single hospital system, which restricts generalizability to other institutions and fields such as orthopedic or cardiothoracic surgery. In addition, to reduce survey time and increase response rate, we asked a single question about job satisfaction rather than using a longer standardized or validated measure of job satisfaction. There was likely some variability in how respondents interpreted the choices for work stressors (that is, surgeons, PAs, and NPs could perceive supervisory support in different ways), which might have introduced heterogeneity into the study. In addition, we did not measure burnout in this cohort, which may have provided more context for our findings.
Healthcare provider well-being continues to be a topic of interest nationwide, with implications for the physical and emotional health of both provider and patient.15,16 In a cross-sectional study of surgeons and PAs and NPs at a tertiary care hospital, we found notable differences in job satisfaction as well as workplace stressors based on demographic factors including age, sex, job role, years in practice, and hours spent per week in inpatient and outpatient settings. Healthcare organizations should be aware of similar differences within their institutions and should be wary of adopting a “one size fits all” approach to reducing stress and improving job satisfaction and well-being at their institutions. More research is indicated to determine how time in practice, tenure, and related characteristics affect job satisfaction in surgical providers.
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