International Bulletin of Business Administration ISSN: 1451-243X Issue 11 (2011) EuroJournals, Inc. 2011 http://www.eurojournals.

com

A Review of the Causes and Effects of Organisational Role Stress in Doctors

Pia Muriel Cardoso Professor of Obstetrics and Gynaecology, Goa Medical College Research Scholar, Department of Management Studies, Goa University, Goa, India E-mail: pmcardoso30@yahoo.co.uk Tel: +91-9823169350 Christo F.V.Fernandes Faculty of Human Resources and Organizational Behavior Goa Institute of Management, Sanquelim, Goa E-mail: christofvfernandes@gmail.com or christo@gim.ac.in Tel: +91-9823088484 Abstract

Background
Work stress is increasingly recognized as one of the most serious occupational health hazards reducing workers satisfaction and productivity, and increasing absenteeism and turnover (Gianakos,2001).Stress at the workplace manifests itself in the form of disease, burnout and even precipitates death, if left untreated.

Aims and Objectives

An extensive review was aimed at, not only of the causes and effects of stress in doctors, but of different studies done in differing regions of the world. Excessive stress has costs to both the employer and the employees. If therefore, the causes can be correctly identified, coping strategies can be implemented to resolve stress related problems at the workplace and beyond.

Methodology
Authors used search criteria and found 367 articles published between 1980 and 2011.Inclusion/exclusion criteria were applied to screen and select articles, and articles were kept and reviewed. Authors combined and reconciled their data, and created a database of findings.

Findings
The top stressors in doctors are emergency calls , night calls, time pressure, working after a sleepless night, dealing with problem patients, worrying about patient complaints and litigation, interruption of family life, and unrealistically high expectations by others as well as bureaucratic red tape.

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Introduction
The Modern World, which is a world of achievement , is also a world of stress.(Pestonjee 1992). Stress is a subject which is hard to avoid. Right from the time of birth till the last breath drawn, every individual is subjected to various stressful situations. Present thinking is that each individual needs a moderate amount of stress to be alert and capable of functioning effectively in an organization. It is, in fact, an asset as long as it is tolerable and helps in creating healthy competition.(Kets de Vries 1979,Pestonjee 1987,Mathew 1985). Concept Definition Role stress is defined in medical literature as Physical, emotional and mental strain resulting from the mismatch between an individual and his/her environment.(Richards C. 1989). Bynoe (1994) further described it as a three way relationship between demands on a person, that persons feelings about those demands, and their ability to cope with those demands. Stress, can further be defined as a process which causes or precipitates individuals to believe they are unable to cope with the situation facing them, and the feelings of anxiety, tension, frustration and anger which result from the recognition that they are failing in some way and the situation is getting out of their control. (Payne R 1999). Methods Article collection was performed in 2010 by search engine and database searches of EBSCO, Medline/Pubmed,MEDSCAPE, and Google.The initial search yielded 367 articles related to occupational role stress.Each article was read and kept if it met inclusion criteria.There were articles at the end of the inclusion/exclusion process.

Findings
Stress and Its Effects in Doctors The Magnitude of the Problem It is a known fact that stress among physicians, nurses and other health professionals is high. (Caplan, 1994; Graham et al, 1996; Al-Aameri and Al-Fawzan, 1998). The proportion of doctors in U.K. showing an above threshold level of stress is around 28% compared to 18% in the general working population. (Firth-Cozens J 2003). Caplan (1994), using the GHQ-28 or General Health Questionnaire, in a study of stress, anxiety and depression in hospital consultants, general practitioners and senior health service managers revealed that 48% of general practitioners scored as stressed. In another study , using the GHQ-30, 27% of men and 28% of women in the general population scored as being stressed. (Edwards, Kornacki and Silversin 2002.) The British Medical Association (2001) in United Kingdom conducted a national survey of GPs (general practitioners) to which 23521 doctors responded. 21% experienced excessive and unmanageable levels of stress, 61% found it excessive but manageable. In a study of 300 Lithuanian general practitioners, one half of respondents were found to be suffering from work related psychosocial stress. (Vanagas and Bihari-Axelsson 2005). Surprisingly, in a study of doctors and dentists in North India, Bhugra, Bhui and Gupta (2008) showed that in comparison with previous studies in the West, when assessed on all three subscales of the Maslach Inventory the burnout rates were very low. Key symptoms of depersonalisation and emotional exhaustion each were present in less than half the respondents.

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The Reflection of Doctors Role Stress on Patient Care The Working Party Report (1997) of the Association of Anaesthetics of Great Britain and Ireland stated that a stressed doctor is not necessarily a bad doctor but difficulties may occur when the stress gets out of control. It is possible that doctors may feel overworked and unsupported when politicians make commitments that health services sometimes cannot deliver. (Smith 2001) Disturbingly,, the quality of health care administered can be extremely influenced by the stress of the health staff (Firth-Cozens, 1998) , there exists a positive association between work stress and the number of errors committed by doctors. (Perry et al, 2000). In a study of over 2000 Canadian physicians it was found that doctors under stress had more problems with patients, obtained less satisfaction from medical practice, and rated their quality of care lower. (Burke and Richardsen 1990, Richardsen and Burke 1991). Stress Related Morbidity Many studies have shown high levels of stress in doctors, with psychological morbidity ranging from 19% to 47%. (Wall TD et al 1997, Hsu K, Marshall V 1987,Kapur N, Borrill C, Stride C 1998,FirthCozens J 1987) compared with a rate of around 18% for the general employed population.(FirthCozens J 2000). Such mental problems make health staff in general and doctors in particular susceptible to more physical and emotional morbidity (Gautam, 2001) which in turn needs careful consideration. Research into morbidity has predominately measured levels of stress, anxiety, and depression (Chambers & Campbell, 1996; Firth-Cozens,1995). The trend emerging is that general practitioners and senior hospital doctors have high levels of stress, anxiety, and depression. They take very little time off work for illness, but when they are absent from work for physical or emotional reasons, they tend to be off for long periods. Symptoms like fatigue, emotional burnout, marital and family discord, and even clinical depression regularly afflict more than half of doctors. The problems are so pervasive that 60% of doctors report having considered leaving the medical profession.(Grenmy J 2006) Stress and Burnout Stress may pose a risk to mental and physical wellbeing resulting in burnout (Burke and Desczca, 1986). Burnout consists of a set of symptoms associated with chronic stress in a variety of occupations (Farber, 1983; Kushnir et al., 1997).These symptoms include emotional exhaustion, physical fatigue, and cognitive weariness (Shirom, 1989). Burnout has been consistently related to work performance, job satisfaction, quality of life, and psychological well-being, and it is positively related to withdrawal behavior. It may precipitate health professionals leaving the profession completely. Here, caring and job satisfaction are replaced by anger and frustration.(Sweet, 2003). Other consequences of burnout include lowered productivity, increased absenteeism, increased healthcare costs, role and professional conflicts, and difficulty making decisions in a changing health system (Felton, 1998; Johnson et al., 1995). It may further affect patient satisfaction and treatment compliance (Maslach,Jackson and Leiter 1996 ; Williams et al 2001.) In a study of stress and job burnout in junior doctors, Schweitzer B. showed that 77.8% of doctors had experienced symptoms consistent with burnout since graduating. A study of British GPs showed that a significant number are affected by burnout. (Kirwan and Armstrong 1995). Stress as a Contributor to Death in Doctors A systematic review of suicides in European and North American doctors described the relative risk of suicide among doctors as being between 1.1 to 3.4 times for male doctors and 2.5 to 5.7 times for female doctors.(Lindeman, Laara, Hakko and Lonnqvist 1996). 58

The suicide rate among doctors has been reported to be higher than other professionals with comparable education and the general population in UK (Sonneck and Wagner 1996), Rimpelae (1989) A subsequent study reported a heartening low suicide rate among male doctors, as compared to the general population, although female doctors had a higher rate of suicide.(Hawton, Clements, Sakarovitch, Simkin and Deeks 2001.) Deaths among doctors as a result of such causes as suicide, external injury, and poisoning have been found to be high (Hawton, Clements, Sakarovitch, Simkin,& Deeks, 2001; Juel, Mosbech & Hansen,1999; Office of Population Censuses & Surveys,1986). Evidence has also shown that male doctors (ages 2074 years) have a significantly higher proportional mortality ratio for viral hepatitis, liver cancer, and cirrhosis and that female doctors (ages 2074 years) have a higher ratio for cancer of the pancreas (Office of Population Censuses & Surveys, 1995). The Stressors Role Overload; the Most Common Stressor at Work One of the first studies to look at the causes of stress in general practice, undertaken by Branthwaite and Ross (1988) found that insecurity about work, isolation, poor relationships with other doctors, disillusion with the role of GPs and changing demands were all sources of perceived stress. In the late 1980s, Cooper, Rout and Farragher found that the four most important predictors of job stress were: work-home interface, demands of the job, patients' expectations and practice administration. Their stressors are often caused by a variety of factors, including the heavy demands of direct patient care, information overload, the overemphasis placed on curing disease rather than relieving pain (Maoz, Rabinowitz, Herz, & Katz, 1992), doctorpatient and doctorcolleague or doctorboss interactions as well as homework conflict. (Maslach, 1982; Maslach & Leiter,1997). Are Patient Demands Unrealistic? There are often demands on physicians for perfection, as reflected in the present model of medicine, which aims for the absolute killing of disease. This can lead to emotional strain and is unrealistic, unmanageable, and overdemanding (Kushnir et al., 1997). Demands are seen by cognitive theorists as indicating unrealistic and absolute expectations of events or individuals, and are often recognizable by cue words such as must, ought, should.(Walen, Di Guiseppe, & Dryden, 1992). Ramirez (1996) associated stress with work overload, resource inadequacy, dealing with patients suffering, keeping up to date, being responsible for the quality of work of other staff, and having to deal with relatives. Most other studies conducted on doctors also emphasised on role overload, manifest as patients demands, unrealistic expectations, lack of autonomy and interference with family life. (Allen.I, Hale R, Herzberg J, Paice E 1999, Bonn D,Bonn J 2000,Falkum E, Gjerberg E, Hofoss D, Aasland O.G .1997,Caplan R.P. 1994.) Being on Call Workload was the most important source of perceived stress in a study done on American doctors. It showed that they put in an average of 58.03 hours a week. This average was not any higher than that of other professionals such as business executives, public accountants, technology professionals and attorneys. However, being on-call may be contributing to the feeling of being overloaded. Not being able to schedule any non-work activity during on call days may be frustrating. (Aziz A. 2004) The sources of stress among doctors include number of hours worked (Fielden and Peckar,1999;Tattersall,Bennett and Pugh,1999;Deary,Blenkin,Raymond,Endler,Zealley,and Wood,1995). 59

Studies of the relationship of sleep loss and sleep disruption represent a major source of stress for doctors. (Spurgeon and Harrington ,1989.). Stress and the General Practitioner In 1990, GPs reported most stress from night calls (Howie, Porter, Heaney and Hopton 1991),(Sutherland and Cooper 1992),(French, McKinley and Hastings 2001),emergencies during surgery hours, and interruption of family life. A Medical Audit Advisory Group surveyed its constituent GPs in 1993 and found that the top ten stressors in descending order of frequency were emergency calls during surgery hours, night calls, time pressure, working after a sleepless night, dealing with problem patients, worrying about patient complaints, interruption of family life, 24 hour responsibility for patients' lives and unrealistically high expectations by others of the doctor's role and partner on holiday. (French, Mckinley and Hastings 2001). Worrying about patients' complaints was an important stressor as was a feeling that the media is becoming more hostile and creating a blame culture. GPs also frequently cited both imposed changes from the management and perceived loss of autonomy (greater accountability) as having a negative impact on morale.(Edwards, Kornacki, Silversin 2002), (Hayter, Peckam and Robinson 1996) The 2006 Physician Morale Survey by the American College of Physician Executives reported that three fourths of doctors reported having experienced stress-related problems. These included patient overload, loss of autonomy, loss of respect, lower reimbursements, and bureaucratic red tape. Another survey reported by Hayter, Peckam and Robinson (1996) has noted that a changing trend is the rise of inappropriate patient demands coupled with increasing expectations of what doctors can provide as a cause of stress, rather than simply an increase in numbers of patient demands. Patients are increasingly active consumers and they demand, and have been encouraged to expect, enhanced services, including extended hours and rapid access while showing less respect and deference to health professionals (Edwards, Kornacki, Silversin2002) A recent study by Sibbald, Enzer, Cooper, Rout and Sutherland (2000) showed that by 1998 GPs were reporting less stress than in 1990 caused by disturbance of home life, interruptions by emergency calls and night visits. However there was an increase in stress due to high expectations of others; adverse publicity by the media; the working environment; dealing with problem patients; worrying about complaints; finding a locum; arranging hospital admissions and dealing with terminal illness. Sources of stress in general practitioners include increasing demands and constraints. (Simmoens S, Scott A, Sibbald B 2002; Vanagas G,Bihari-Axelsson S 2004;Norman P,Fitter M, Wall T 1991;Peters B 1995;Schieman S, Van Gundy K,Taylor J 2001;ShanleyB, Schulte KM, Chant D, Jasper A 2002;Sturmberg J 1999;Wilhemsson S,Faresjo T,Foldevi M,Akerlind I 1998.). Important sources of stress in general practitioners which have been enumerated are excessive paperwork, health reforms, bureaucratic interference (Simmoens S, Scott A, Sibbald B 2002),job demands, decision lattitude (Vanagas G,Bihari-Axelsson S 2004).workplace location(Sexton R 2003), job pressure, patient load(Simmoens S, Scott A, Sibbald B 2002),(Scattner P,ComanG 1998)CharlesJones H,Houlker M 1999),(Scott A, Wordsworth S 1999) lack of organizational support (Branthwaite A,Ross A 1988),de Jonge J,MulderM,Nijhuis F1999),Young G, Spencer J 1996),Rout U 1996, Sutherland V,Cooper CL 1993),dealing with difficult patients (Calnan M,Wainwright D,Forsythe M,Wall B, Almond S 2001).McGlone S,Chenoweth I 2001). Rout (1999) found in his study of general practitioners that time pressure/interruption, working environment/communication, and career and goal achievement were identified as three main stressors. Myerson (1991) found that among general practitioners 90% of the respondents felt that inadequate time was the most important problem. Other problem areas discussed include confrontational situations, the stress of uncertainty, being on call, night work and treatment of and care of patients. Other stressors are team conflicts, insecurity, lack of autonomy, large workload, increasing criticism, expectations and demands from public (Sonneck and Wagner 1996). For young 60

physicians, the sources of stress were: patient relationships, business/financial issues, time pressure, and competence concerns. (Simpson and Grant,1991). Stress in Doctors around the World The major source of stress for Australian doctors were found to be shortage of time, responsibility for peoples welfare, and the omnipresence of illness and death (Bates, 1982). The Working Party Report (1997) of the Association of Anaethetists of Great Britain and Ireland listed factors including frustration, conflict and hassle, disruption of the circadian rhythms, lack of control and unpredictability at work or a feeling of being over-extended or pressed beyond real or perceived limits at work. Other factors were fear of litigation and pressure on time, pressure to pass examinations. Wu,Zhu, Li, Wang Z and Wang M (2008) in China, found that the main significant predictors of exhaustion were role overload, responsibility, physical environment and self-care. A study conducted on 1133 consultants working in the UK, reported that work overload; poor administration and resources; administrative responsibilities assumed; and dealing with patients pain were perceived as sources of stress. In addition, lack of clear direction concerning the organizational goals was found to be among the significant causes of work stress (Murphy, 1987). Role ambiguity, role conflict and clarity of organizational roles were also found to be of significant relationship with work stress among 433 employees of seven Kuwaiti governmental sectors (Al-Fadli, 1999). Responsibility for others and lack of career development were found to be of significant relationship with work stress among doctors practicing emergency medicine in the Northern Governorates of Jordan. The main stressors were found to be, in order of occurrence: lack of career development, qualitative job overload, responsibility towards patients, quantitative role overload, role conflict, and role ambiguity. (Nusair and Deibageh 1997). Ahmady, Changiz, Masiello and Brommels(2007) ,in a study done in Iran,using the ORSS concluded that role stress was experienced by the faculty at all three medical schools studied by them. The main stressors were role overload, role expectation conflicts, inter-role distance, resource inadequacy, role stagnation and resource inadequacy. Implications and Conclusion of this Literature Review Howie, Hopton, Porter and Heaney (1991, 1992) carried out extensive research studies into occupational stress in general practice, particularly with respect to the timing of consultations and doctors' working styles. Many of the main stressors for GPs appear to be created or perpetuated by doctors' own policies: overbooking patients, starting surgeries late, accepting commitments too soon after surgeries are due to finish, making insufficient allowances for extra emergency patients, and allowing inappropriate telephone or other interruptions. This review of the various causes and effects of stress in doctors must bring to light the magnitude of this problem, inorder that methods can be designed by doctors themselves, as well as the management systems in place, to streamline work policies, and ensure that stress levels in doctors are maintained at acceptable levels, so that they may be coped with adequately, and that productivity is maintained at an optimum level.

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