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1. Work-related Stress among
Physicians
Dr Faisal Al Haddad
Consultant of Family Medicine &
Occupational Health
Supervisor of Postgraduate Training Center
for Family & Community Medicine
CBAHI Surveyor

2. Work-related Stress
The adverse reaction people have to
excessive pressures or other types of
demand placed on them at work
UK’s HSE

3. What is Burnout?
 A syndrome of emotional exhaustion and cynicism
that occurs frequently among individuals who do
'people work' of some kind.
 It consists of three components:
– emotional exhaustion
– depersonalization
– feelings of low personal accomplishment.

4. Development of Stress
1. Environmental demands: demands in the working
environment
2. Primary appraisal: the person’s appraisal of whether these
demands seem to be a threat
3. Secondary appraisal: the person’s appraisal whether he can
cope with these demands successfully
4. Stress and illness: occur when the person can not cope with
the demands

5. Karasek’s Job Strain Model
LOW STRAIN ACTIVE
HIGH STRAINPASSIVE
Job Demands
Low High
Low
High
Job Decision
Latitude (Skill use +
Decision authority(
Active Learning,
Motivation to
Develop New
Behavior Patterns
Risk of A
Psychological
Strain and
Physical Illness
B
A

6. Effort-Reward Imbalance Model
An imbalance between perceived effort spent and
rewards received at work can lead to emotional
stress

7. Stress in Healthcare Professionals
Stress levels among HCP including doctors are high compared
with the general working population:
 Work is demanding and characterized by high degree of
responsibility
 Medical errors can have catastrophic effects on both the patient
and the medical professional
 HCP are exposed to both emotional and physical risk.

8. Risk Factors of Occupational Stress
 Type A personality
 Workload
 Organizational changes
 Poor management
 Insufficient resources to do work
 Dealing with patient’s suffering
 Medical mistakes
 Malpractice litigations and complaints
 Isolation
 Poor relationships with other doctors

9. Adverse Effects of Stress at Work
Physical effects:
 Coronary heart disease
 Musculoskeletal disorders
 Peptic ulcer disease
Psychosocial effects:
 Mental illness (depression, anxiety, suicidal thoughts)
 Social behaviour and interpersonal relations impairment
 Sexual behaviour impairment
 Maladaptive behaviours such as smoking and drinking.

10. Adverse Effects of Stress at Work
Organizational effects:
 High turnover among employees
 Absenteeism
 Poor time keeping
 Impaired work performance and productivity
 An increase in client complaints
 An increase in employee compensation claims

11. Objectives
 To examine whether PHC physicians have a higher
level of work related stress than hospital physicians
 To explore the work characteristics that may lead to
stress among physicians.

12. Methodology
Study design
Cross sectional study
Sample Size:
 The sample size needed to detect difference between PHC
physicians and hospital physicians in the proportion of
psychological stress was 77 in each arm, which was
increased to 92 to allow for a 20% dropout rate.
 The participants were selected randomly from the total staff
numbers in each group using a random number table

13. Questionnaire
 Socio-demographic data: age, gender, job title,
smoking status and marital status.
 4 items represent the Reeder Scale to investigate
the level of psychological stress
 35 items represent HSE’s Stress Indicator Tool to
identify causes of psychological stress

14. Reeder Scale
"In general, I am usually tense or nervous“
"There is a great deal of nervous strain connected to
my daily activities“
"My daily activities are extremely trying and stressful“
"At the end of the day I am completely exhausted"

15. HSE’s Stress Indicator Tool
1. Control: how much say the person has in the way he does the
work.
2. Demands: workload, work patterns and the work environment.
3. Role: whether people understand their role within the
organization and whether the organization ensures that they do
not have conflicting roles.
4. Change: how organizational change is managed and
communicated in the organization.

16. HSE’s Stress Indicator Tool
5. Peer Support: encouragement, sponsorship and resources
provided by colleagues.
6. Managers' Support: support provided by the organization and
line management.
7. Relationships: promoting positive working to avoid conflict and
dealing with unacceptable behaviour.

17. Questionnaire
 Pilot study was conducted to check the understandability and
clarity of questions.
 The survey was anonymous.
 Questionnaires were distributed manually to the study
participants who were informed through the questionnaire
about the purpose of the study, that their participation was
voluntary and that their responses will be kept confidential.
 Data collected were checked manually for completeness and
stored confidentially.

18. Scoring System
 Stress items were scored 1, 2, 3, 4, and 5 for the
responses never, rarely, sometimes, often, and always,
respectively.
 For each domain, the scores of the items were
summed and the total divided by the number of the
items, giving a mean score for each domain.

19. Statistical Analysis
 Data analysis was done using Epi-Info 6.04 and SPSS 14.0 statistical
software packages.
 Data are presented using descriptive statistics in the form of
frequencies and percentages for qualitative variables, and means and
standard deviations for quantitative variables.
 The reliability of the questionnaire was assessed by checking internal
consistency with Cronbach's Alpha coefficient.
 Quantitative continuous data were compared using Student t-test in
case of comparisons between two independent groups, and one-way
ANOVA test for multiple group comparisons.

20. Statistical Analysis
 When normal distribution of the data could not be assumed, the non-
parametric Mann-Whitney or Kruskal-Wallis tests were used instead.
 Qualitative variables were compared using chi-square test.
 Pearson correlation analysis was used for assessment of the inter-
relationships among scores of domains and age.
 To identify the independent predictors of stress, multiple stepwise
backward linear regression analysis was used.
 Statistical significance was considered at p-value <0.05.

21. Results
 173 physicians completed the questionnaires: 88 PHC physicians and 85
hospital physicians
 The response rate was 94%
 67.7% of the respondents physicians were male
 The overall mean age of the respondents was 41.5 years.
 64.2% of the respondents were specialists and 35.8% were consultants.
 The hospital group were significantly more likely to be male, unmarried and
current smokers.

22. Reeder scale scores
Question
Group (mean±SD(
p-value
PHC (n=88(
Hospital
(n=85(
"In general, I am usually tense or
nervous"
2.61±0.73 2.62±0.72 0.965
"There is a great deal of nervous strain
connected to my daily activities"
2.89±0.88 3.21±0.96 0.019
"My daily activities are extremely trying
and stressful"
2.88±0.87 3.48±0.98 >0.001
"At the end of the day I am completely
exhausted"
3.27±1.04 3.68±1.05 0.012
Total 2.94±0.41 3.28±0.49 0.001*

23. Domain
Group (mean±SD(
p-value
PHC
(n=88)
Hospital
(n=85)
Demands 2.98±0.55 3.14±0.55 0.081
Relationships 1.16±0.32 1.31±0.32 0.004
Control 3.08±0.76 3.09±0.74 0.901
Role 2.60±0.45 2.60±0.47 0.912
Change 1.10±0.33 1.17±0.36 0.189
Peers’ support 1.85±0.37 1.81±0.41 0.496
Managers' support 2.00±0.57 2.05±0.58 0.403
Stress Indicator Tool domains

24. Domain
Age
p-value>30
(n=28)
30-
(n=106)
50-
(n=39)
Mean±SD Mean±SD Mean±SD
Reeder 3.30±0.64 3.15±0.65 2.83±0.76 0.021
Control 2.94±0.78 2.94±0.69 3.58±0.66 >0.001
Demands 3.16±0.51 3.11±0.52 2.85±0.63 0.019
Role 2.47±0.50 2.55±0.46 2.82±0.32 >0.001
Change 1.13±0.29 1.10±0.35 1.24±0.35 0.060
Peers’ support 1.85±0.36 1.79±0.40 1.93±0.36 0.168
Relationships 1.30±0.19 1.24±0.35 1.16±0.33 0.132
Managers' support 2.11±0.53 1.95±0.58 2.15±0.57 0.150
Reeder Scale & Stress Indicator Tool domains VS
Age

25. Reeder Scale & Stress Indicator Tool domains VS
Marital Status
Domain
Marital status
Mann
Whitney
Test
p-value
Married
(n=154)
Unmarried
(n=19)
Mean±SD Mean±SD
Reeder 3.110±0.696 3.058±0.631 0.189 0.664
Control 3.077±0.742 3.142±0.800 0.001 0.981
Demands 3.054±0.561 3.105±0.488 0.247 0.619
Role 2.608±0.453 2.505±0.506 0.604 0.437
Change 1.127±0.342 1.200±0.354 0.619 0.432
Peers’ support 1.811±0.386 1.989±0.403 2.486 0.115
Relationships 1.230±0.3193 1.263±0.376 0.010 0.920
Managers' support 2.010±0.566 2.126±0.638 1.162 0.281

26. Reeder Scale & Stress Indicator Tool
domains VS gender
Domain
Gender
Mann
Whitney
Test
p-value
Male
(n=117)
Female
(n=56)
Mean±SD Mean±SD
Reeder 3.103±0.724 3.107±0.610 0.026 0.872
Control 3.160±0.764 2.925±0.689 2.546 0.111
Demands 3.026±0.556 3.130±0.543 0.988 0.320
Role 2.611±0.452 2.568±0.476 0.177 0.674
Change 1.166±0.354 1.070±0.313 3.824 0.051
Peers’ support 1.830±0.402 1.832±0.369 0.014 0.906
Relationships 1.234±0.324 1.232±0.330 0.022 0.882
Managers' support 2.054±0.593 1.957±0.530 1.524 0.217

27. Reeder Scale & Stress Indicator Tool domains VS
Job Title
Domain
Job title
Mann
Whitney
Test
p-value
Specialist
(n=111)
Consultant
(n=62)
Mean±SD Mean±SD
Reeder 3.12±0.698 3.076±0.673 0.424 0.515
Control 2.975±0.802 3.279±0.594 6.321 0.012*
Demands 3.086±0.558 3.011±0.544 0.807 0.369
Role 2.595±0.471 2.602±0.440 0.036 0.850
Change 1.121±0.359 1.160±0.313 0.570 0.450
Peers’ support 1.856±0.399 1.785±0.375 0.800 0.371
Relationships 1.232±0.345 1.237±0.288 0.106 0.745
Managers' support 2.041±0.593 1.989±0.540 0.199 0.656

28. Reeder Scale & Stress Indicator Tool domains VS
Smoking Status
Domain
Smoking Status
Mann
Whitney
Test
p-value
Non-Smokers
(n=135)
Current
(n=19)
Mean±SD Mean±SD
Reeder 3.069±0.673 3.463±0.635 5.665 0.017*
Control 3.084±0.764 2.900±0.663 2.084 0.149
Demands 3.058±0.540 3.295±0.422 4.227 0.040*
Role 2.573±0.482 2.616±0.385 0.008 0.930
Change 1.152±0.327 1.037±0.406 1.461 0.227
Peers’ support 1.816±0.394 1.774±0.391 0.201 0.654
Relationships 1.229±0.328 1.311±0.302 0.852 0.356
Managers' support 2.019±0.570 2.142±0.551 0.656 0.418

29. Dependant Factor Independent Factor B R2
P-value
Reeder Group (reference: PHC( 0.322 0.172 >0.001*
Smoking (reference: non( 0.153
Marital status (reference: married( -0.363
Control Age 0.027 0.232 >0.001*
Reeder -0.275
Demands Reeder 0.509 0.395 >0.001*
Change Sex (reference: male( -0.117 0.089
Age 0.007
Smoking (reference: non( -0.091
Marital status (reference: married( 0.157
Peer Support Marital status (reference: married( 0.159 0.156 >0.001*
Reeder -0.174
Relationships Reeder 0.201 0.225 >0.001*
Managers' Support Reeder -0.146 0.030 0.022*
Multiple linear regression

30. Results
Hospital physicians were more stressed at work than PHC
physicians
Organizational changes introduced in FCM Department which
reduced the workload among PHC physicians (e.g. short booking
system, recruitment of more staff)
Hospital physicians:
– have more on call duties and deal with more emergency cases
– are involved in ward rounds
– deal with more severely ill patients and their families

31. Results
 Hospital physicians had poorer relationships with their
managers and colleagues.
 Hospital physicians were subjected to more conflict and
unacceptable behavior from colleagues at work including
bulling and personal harassment.
 Hospital physicians reported greater levels of friction and
anger between colleagues
 It could be due to lack of policies promoting positive behavior
and preventing or resolving unacceptable behavior

32. Results
 Older physicians tended to have lower levels of work stress
than younger physicians
 Older physicians perceived their work as less demanding and
had higher levels of control over their work and a better
understanding of their roles and responsibilities.
 Consultants had higher control over their work which makes
sense since consultants generally have more experience and
higher professional competency than specialists

33. Results
 Current smokers reported higher levels of stress and work
demands than non-smokers
 Stressed physicians may smoke more to cope with stress at
work
 Gender, marital status and job title had no significant effect on
the level of work stress and the primary work stressors
 Being hospital doctor, of younger age, married or a smoker is
predictive of of higher levels of stress.

34. Recommendations
Work stress attributed to organizational changes should be
reduced by:
 Providing physicians with information to enable them to understand the
reasons for proposed changes
 Encouraging physicians to influence proposals
 Ensuring that physicians are aware of timetables of changes
 Providing them with access to relevant support during such changes.

35. Recommendations
 Engagement of senior managers to commit to managing work
related stress and the production of a stress policy.
 Physicians should be encouraged to support their colleagues,
to make themselves aware of what support is available and
how and when to access it.
 Stress management training should be recommended to foster
awareness and recognition of stressors and to teach
appropriate stress reduction skills.

36. Conclusion
 Work stress was higher among hospital physicians
compared with PHC physicians
 Hospital physicians were subjected to higher
workloads, conflicts and unacceptable behavior at
work.
 Actions to reduce work stress among hospital
physicians were indicated in this workplace

37. Thank you