Behavioral consequences of job-related stress among resident physicians: the mediating role of psychological strain

Factors Associated With Burnout and Stress in Trainee Physicians: A Systematic Review and Meta-analysis

Importance

Evidence suggests that physicians experience high levels of burnout and stress and that trainee physicians are a particularly high-risk group. Multiple workplace- and non-workplace-related factors have been identified in trainee physicians, but it is unclear which factors are most important in association with burnout and stress. Better understanding of the most critical factors could help inform the development of targeted interventions to reduce burnout and stress.

Objective

To estimate the association between different stressors and burnout/stress among physicians engaged in standard postgraduate training (ie, trainee physicians).

Data Sources

Medline, Embase, PsycINFO, and Cochrane Database of Systematic reviews from inception until April 30, 2019. Search terms included trainee, foundation year, registrar, resident, and intern.

Study Selection

Studies that reported associations between stressors and burnout/stress in trainee physicians.

Data Extraction and Synthesis

Two independent reviewers extracted the data and assessed the quality of the evidence. The main meta-analysis was followed by sensitivity analyses. All analyses were performed using random-effects models, and heterogeneity was quantified using the I2 statistic.

Main Outcome and Measures

The main outcome was the association between burnout/stress and workplace- or non-workplace-related factors reported as odds ratios (ORs) and their 95% CIs.

Results

Forty-eight studies were included in the meta-analysis (n = 36 266, median age, 29 years [range, 24.6-35.7 years]). One study did not specify participants' sex; of the total population, 18 781 participants (52%) were men. In particular, work demands of a trainee physician were associated with a nearly 3-fold increased odds for burnout/stress (OR, 2.84; 95% CI, 2.26-3.59), followed by concerns about patient care (OR, 2.35; 95% CI, 1.58-3.50), poor work environment (OR, 2.06; 95% CI, 1.57-2.70), and poor work-life balance (OR, 1.93; 95% CI, 1.53-2.44). Perceived/reported poor mental or physical health (OR, 2.41; 95% CI, 1.76-3.31), female sex (OR, 1.34; 95% CI, 1.20-1.50), financial worries (OR, 1.35; 95% CI, 1.07-1.72), and low self-efficacy (OR, 2.13; 95% CI, 1.31-3.46) were associated with increased odds for burnout/stress, whereas younger age and a more junior grade were not significantly associated.

Conclusions and Relevance

The findings of this study suggest that the odds ratios for burnout and stress in trainee physicians are higher than those for work-related factors compared with nonmodifiable and non-work-related factors, such as age and grade. These findings support the need for organizational interventions to mitigate burnout in trainee physicians.

A Recommendation for Expanding the Definition of Moral Distress Experienced in the Workplace

Despite the importance of moral distress in the nursing scholarship, little attention is paid to the phenomena in the psychological literature as an important occupational stressor. A factor limiting the application of moral distress to other occupational settings is its definitional features. First, a necessary condition of moral distress is the acknowledgment prior to behaviour initiation that behaviour will contravene personal moral ideals. Second, the definition of moral distress specifies that the inability to act in accordance with one's moral framework is driven by institutional constraints (non-autonomous behaviour). This article proposes that moral distress not be limited in these ways, and makes two central contributions to resolve this core problem. We offer a critique and extension of the conceptual definition of moral distress. Fourteen Australian medical doctors participated in a semi-structured interview regarding occupational morally distressing events. Medical doctors were chosen for our interviews because they are an occupational population with considerable decision-making autonomy. Based on the findings, two recommendations are made: (1) that the definition of moral distress is not limited to events where decision-making and behaviour is non-autonomous, and (2) moral distress should not be limited to occasions where the moral conflict is identified prior to decision-making or behaviour. An alternative definition of moral distress is proposed. We conclude that while organisational limitations are an important precipitate of moral distress, they are not a necessary condition for its emergence.

Using pediatric advanced life support in pediatric residency training: does the curriculum need resuscitation?

OBJECTIVE

The Pediatric Advanced Life Support (PALS) course is used throughout North American pediatric residency programs to provide a core pediatric resuscitation curriculum. Despite this widespread use, its effectiveness has not been formally assessed in pediatric residents. This study aimed to evaluate the PALS curriculum's effectiveness in providing pediatric residents with knowledge, skill and confidence in pediatric resuscitation.

DESIGN

Course evaluation.

SETTING

Tertiary care pediatric hospital.

SUBJECTS

Pediatric residents.

INTERVENTIONS

Subjects were followed prospectively for 1 yr following completion of an annual PALS course. Multiple choice and short answer questionnaires were used to evaluate residents' knowledge immediately before and after completion of the course and throughout the following year. Confidence in ten aspects of pediatric resuscitation was assessed. Scores were compared before and after the PALS course to evaluate acquisition of knowledge and confidence. Scores at 12 months were compared with the immediate post-PALS course scores to evaluate maintenance of knowledge and confidence over time. Technical skills were evaluated by staff anesthetists using a 3-point scale.

MEASUREMENTS AND MAIN RESULTS

Knowledge questionnaire scores were significantly higher post-PALS compared with pre-PALS, but knowledge of the details of PALS algorithms decreased significantly over the following 12 months. Confidence ratings improved post-PALS on only two of ten measures and remained very low overall. Residents could complete the four core technical skills but required assistance or multiple attempts.

CONCLUSIONS

PALS is successful in providing basic resuscitation knowledge to pediatric residents, but knowledge of critical algorithm details is not sustained. The course does not provide for the expected level of competency in relevant technical skills. Residents do not achieve the confidence to feel well prepared to provide comprehensive care to pediatric patients in cardiopulmonary arrest. These findings support the hypothesis that the PALS course alone is insufficient to provide pediatric residents with competency in cardiopulmonary resuscitation.

Factors affecting resident performance: development of a theoretical model and a focused literature review

PURPOSE

The clinical performances of physicians have come under scrutiny as greater public attention is paid to the quality of health care. However, determinants of physician performance have not been well elucidated. The authors sought to develop a theoretical model of physician performance, and explored the literature about factors affecting resident performance.

METHOD

Using expert consensus panel, in 2002-03 the authors developed a hypothesis-generating model of resident performance. The developed model had three input factors (individual resident factors, health care infrastructure, and medical education infrastructure), intermediate process measures (knowledge, skills, attitudes, habits), and final health outcomes (affecting patient, community and population). The authors used factors from the model to focus a PubMed search (1967-2002) for all original articles related to the factors of individual resident performance.

RESULTS

The authors found 52 original studies that examined factors of an individual resident's performance. They describe each study's measurement instrument, study design, major findings, and limitations. Studies were categorized into five domains: learning styles/personality, social/financial factors, practice preferences, personal health, and response to job environment. Few studies examined intermediate or final performance outcomes. Most were single-institution, cross-sectional, and survey-based studies.

CONCLUSIONS

Attempting to understand resident performance without understanding factors that influence performance is analogous to examining patient adherence to medication regimens without understanding the individual patient and his or her environment. Based on a systematic review of the literature, the authors found few discrete associations between the factors of individual resident and the resident's actual job performance. Additionally, they identify and discuss major gaps in the educational literature.

Measurement of Organizational Culture and Climate in Healthcare

Although there is increasing interest in the relationship between organizational constructs and health services outcomes, information on the reliability and validity of the instruments measuring these constructs is sparse. Twelve instruments were identified that may have applicability in measuring organizational constructs in the healthcare setting. The authors describe and characterize these instruments and discuss the implications for nurse administrators.

Impaired residents: identification and intervention

PURPOSE

To describe the effect of a psychologist on faculty staff supporting impaired residents to successful program completion in general surgery.

METHODS

Since 1996, the Department of Surgery has had a staff psychologist on faculty who works closely with the Trauma service. Duties include provision of patient and family therapies (representing a revenue-generating activity for the department), in-services for staff stress management, research, and community education activities. As resident performance issues have arisen, the psychologist has been instrumental in early identification of and referral for underlying issues affecting resident behavior.

RESULTS

From 1996 to October 2001, 12 residents (2 with multiple referrals) have been identified with significant psychological issues impairing performance. The various psychological problems include depression, anger control issues, and addictions; required interventions have included referrals for therapeutic counseling, recommendations for career change, and therapeutic counseling combined with pharmacotherapy. Fellow residents referred 4 of the 12 residents to the psychologist for possible evaluation, and the remaining 8 had referral initiated by performance concerns.

CONCLUSIONS

Significant psychological problems can impair resident performance and possible training program completion. Early identification and intervention by a professional psychologist on faculty can provide support for increased opportunity to complete residency training.

Stress and psychiatric disorder in healthcare professionals and hospital staff

BACKGROUND

Previous studies of stress in healthcare staff have indicated a probable high prevalence of distress. Whether this distress can be attributed to the stressful nature of the work situation is not clear. No previous study has used a detailed interview method to ascertain the link between stress in and outside of work and anxiety and depressive disorders.

METHODS

Doctors, nurses, and administrative and ancillary staff were screened using the general health questionnaire (GHQ). High scorers (GHQ>4) and matched individuals with low GHQ scores were interviewed by means of the clinical interview schedule to ascertain definite anxiety and depressive disorders (cases). Cases and controls, matched for age, sex, and occupational group were interviewed with the life events and difficulties schedule classification and an objective measure of work stress to find out the amount of stress at work and outside of work. Sociodemographic and stress variables were entered into a logistic-regression analysis to find out the variables associated with anxiety and depressive disorders.

FINDINGS

64 cases and 64 controls were matched. Cases and controls did not differ on demographic variables but cases were less likely to have a confidant (odds ratio 0.09 [95% CI 0.01-0.79]) and more likely to have had a previous episode of psychiatric disorder (3.07 [1.10-8.57]). Cases and controls worked similar hours and had similar responsibility but cases had a greater number of objective stressful situations both in and out of work (severe event or substantial difficulty in and out of work-45 cases vs 18 controls 6.05 [2.81-13.00], p<0.001; severe chronic difficulty outside of work-27 vs 8, 5.12 [2.09-12.46], p<0.001). Cases had significantly more objective work problems than controls (median 6 vs 4, z=3.81, p<0.001). The logistic-regression analyses indicated that even after the effects of personal vulnerability to psychiatric disorder and ongoing social stress outside of work had been taken into account, stressful situations at work contributed to anxiety and depressive disorders.

INTERPRETATION

Both stress at work and outside of work contribute to the anxiety and depressive disorders experienced by healthcare staff. Our findings suggest that the best way to decrease the prevalence of these disorders is individual treatment, which may focus on personal difficulties outside of work, combined with organisational attempts to reduce work stress. The latter may involve more assistance for staff who have a conflict between their managerial role and clinical role.

Personality profiles of male and female positive role models in medicine

This study was designed to investigate the personality profile of positive role models in medicine. Participants were a national sample of 188 physicians (164 men, 24 women) who had been nominated by the chief executive officers of their institutions as positive role models and who completed the Revised NEO Personality Inventory. Compared to the general population, these 188 male and female positive role models in medicine scored higher on Conscientious factor, and on Achievement Striving, Activity, Competence, Dutifulness, Trust, Assertiveness, and Altruism facets, but they scored lower on the Vulnerability facet than the general population. In addition, the male role models scored significantly higher than men in the general population on the Agreeableness factor, and the female role models obtained significantly higher scores than the population norms on Extraversion and Openness factors, and on Feelings, Ideas, Positive Emotions, Values, Warmth, Aesthetics, and Fantasy facets. The female role models scored far below their sex-related norms on Neuroticism factor and on Angry Hostility facet. Comparisons between the male and female role models showed that the female role models scored higher on the Openness factor, and on the Feelings, Positive Emotions, Aesthetics, and Fantasy facets of personality. Implications in medical education and in explaining, assessing, and improving the qualities that contribute to professional success and in promoting the concept of "positive medicine" are discussed.

Survey of perceived stress and work demands of consultant doctors

OBJECTIVES

The objectives of this study were to assess the work demands as potential stressors of health service consultants, and to describe the development of tools for measuring stress experiences of consultants.

METHODS

A stratified random sample of 500 NHS consultants in Scotland was targeted by a postal questionnaire and 375 (75%) returned a valid response. They completed questionnaires, including information on demographic factors, work demands, occupational stressors, and burnout.

RESULTS

Principal components analysis showed that professional work demands of consultants fell into three categories: clinical, academic, and administrative. Their perceived stressors separated into four main factors: clinical responsibility, demands on time, organisational constraints, and personal confidence. These were assessed by 25 questions in the specialist doctors' stress inventory. Specific questions about perceived stressors which resulted in a high positive response included questions about demands on time, and organisational change in the NHS.

CONCLUSION

These self reported data characterise and measure the consultants' work demands and their role as potential stressors. These measurements could form the basis for strategies to reduce occupational stress in these workers.