Abstract
Background
Healthcare providers working with victims of physical trauma are exposed to significant human suffering at work. This may place them at risk of burnout, secondary traumatic stress (STS), and other psychological disturbances. This study aimed to evaluate the professional quality of life and psychological well-being among trauma professionals.
Methodology
This was a cross-sectional study conducted among 153 staff members (nursing officers, resident doctors, and faculty) of a Level 1 trauma center in North India. The Professional Quality of Life (ProQoL-5) and Depression, Anxiety, and Stress (DASS-21) Scales were used.
Results
More than 50% of the participants had a moderate risk of burnout and STS. In addition, 54% of participants reported having anxiety, 40% stress, and 36% depressive symptoms. Depression, anxiety, and stress were all strongly predicted by burnout and STS.
Conclusion
Psychological distress symptoms were seen in a significant portion of professionals working in the trauma center. Workplace interventions for the promotion of psychological well-being among trauma professionals are recommended.
How to cite this article
Gupta S, Bhatia G, Sagar R, Sagar S. Assessment of Psychological Well-being Among Medical Professionals Working with Patients Who Suffer from Physical Trauma: An Observational Study from India. Indian J Crit Care Med 2023;27(7):493–502.
Keywords: Burnout, Healthcare professionals, Professional quality of life, Secondary traumatic stress, Trauma
Highlights
Healthcare providers caring for victims of physical trauma are exposed to challenging working conditions which may affect their mental health.
This study indicates the risk of psychological disturbances in a large number of trauma professionals.
Workplace-based interventions for improving the professional quality of life of trauma professionals are recommended.
Introduction
The practice of medicine, while purposeful and fulfilling, is a demanding and challenging profession. Particularly, for surgical and emergency-related fields, which are almost synonymous with long and often unpredictable working hours, highly stressful working conditions, limited opportunities for recreation, and exposure to grave human suffering and misery for prolonged periods.1,2 Direct exposure to stressful events for extended periods, as seen in first responders to a traumatic event (such as Firemen, Policemen, and Emergency Medical Staff), has garnered research interest for 30 years or so and has often been associated with anxiety disorders, depressive disorders, post-traumatic stress disorders among other psychiatric illnesses.3,4 However, recent literature also reports the effects of exposure to second-hand trauma on the quality of life of healthcare providers.5,6
Secondary traumatic stress (STS) describes the adverse impact of repeated empathic engagement with trauma survivors and associated cognitive, schematic, and other psychological effects.6 Secondary traumatic stress may present as emotional exhaustion, emotional detachment, irritability, sleeplessness, anxiety, depressive and suicidal ideas, a diminished sense of purpose or enjoyment in work, and an increase in self-destructive behaviors.5 Burnout has been well-documented in healthcare professionals, mostly among emergency and critical care specialties, as a state of physical, emotional, and mental exhaustion caused by long-term involvement in emotionally demanding situations.2,7,8 Common symptoms of burnout include headache, fatigue, insomnia, diminished satisfaction with work, and emotional instability.9,10
These factors, along with compassion satisfaction (pleasure derived from the alleviation of patient suffering and positive work experience) are often measures to estimate the professional quality of life, which refers to total positive and negative emotions, in that a professional comes across in the context of work as a helper.11,12 It is composed of two opposing constructs, compassion satisfaction, and compassion fatigue, which in turn comprised STS and burnout.10,13,14 Professional quality of life affects and is affected by professional well-being and performance, and yet remains neglected in the stressful working conditions of most medical specialties.12,14,15 In the climate of increasing suicidal deaths among physicians, along with the well-researched psychological impact of COVID-19 pandemic on the mental health of medical professionals, a paradigm shift is necessary for medical educators and policy-makers to understand that the professional well-being of medical trainees and professionals plays a significant role in their education and future career.8,16,17
Trauma surgery and critical care is an upcoming surgical specialty in India, with super-specialty (Master of Chirurgiae) programs currently running in three medical institutes under the Central Government. Training in this specialty is made additionally challenging in India due to the tremendous caseload, limited resources, and a small force of skilled care providers.18,19 It is essential that at this nascent stage in the development of the field, measures are taken to promote physical as well as psychological well-being in the healthcare providers because personal well-being is strongly associated with empathy, which is associated with a healthy doctor–patient relation and ethical medical practice in future.18,20,21
This study aimed to evaluate the professional quality of life among medical professionals (doctors and nurses) working at a Level 1 trauma center at an apex medical institute in India and to examine its association with their psychological health.
Methodology
This was a cross-sectional observational study conducted among the staff and trainees of a Level 1 trauma center at an apex medical institute located in North India. The sample collection commenced after written approval from Institutional Ethics Committee was obtained (Ref. no. IECPG-740/27/10/2022 The sample size was calculated using a study conducted on similar lines among 282 nursing professionals and medical social service officers working in a trauma center in Baltimore that reported at least one symptom of STS in 70.2% of the participants. At a 95% confidence interval and a 5% margin of error, using Kelsey's formula for sample size calculation, a sample size of 153 was obtained. A convenience sampling method was used. Both male and female healthcare providers, aged more than 18 years and working in the trauma center for at least 1 month were included in the study. After obtaining informed consent, the participants were required to respond to the study questionnaire, whose responses were collected and analyzed using SPSS v26.0. Since the data followed a normal distribution (p-values on Kolmogorov–Smirnoff test ranged from 0.014 to 0.005), Pearson's correlation coefficient (r) was used to determine correlations, and p-value of less than 0.05 was considered significant.
The questionnaire consisted of:
Semi-structured Proforma: It is composed of sociodemographic details, professional details, and questions pertaining to workplace satisfaction.
Professional Quality of Life Scale-5 (ProQoL): This is a validated, 30-item measure of the positive effects of working with those who have experienced traumatic stress in the last 1 month. The ProQOL has subscales for compassion satisfaction, burnout, and compassion fatigue. Responses are measured on a 5-point Likert scale, where a higher score on each subscale indicates greater perceived compassion satisfaction, burnout, and compassion fatigue, respectively. The scale has been widely used among medical professionals in various countries including India to assess the quality of life with respect to the professional environment.22,23
Depression, Anxiety, and Stress Scale (DASS-21): It is a set of three self-report scales designed to measure the negative emotional states of depression, anxiety, and stress in the last 1 month. It has been widely used for research among the Indian population, with good internal consistency and criterion validity for the identification of depression, anxiety, and stress.24,25
Results
Sociodemographic Profile
A total of 153 trauma professionals were included in the study, out of which 70 (45.8%) were males and 83 (54.2%) were females. Among them, 77 (50.3%) were unmarried and 76 (49.7%) were married. The majority of professionals belonged to nuclear families (n = 117, 76.5%). More than half of the respondents lived with their family members (n = 88, 57.5%). The mean age of the sample was 32.3 (±7.0) years. Sociodemographic and work profiles have been presented in Tables 1 and 2, respectively.
Table 1.
Sociodemographic details
| Parameter | Category | Frequency (%)/mean (±SD) |
|---|---|---|
| Gender | Male | 70 (45.8) |
| Female | 83 (54.2) | |
| Age (years) | 32.3 (±7.0) | |
| Marital status | Unmarried | 76 (49.7) |
| Married | 77 (50.3) | |
| Separated/divorced/widowed | 0 | |
| Family structure | Nuclear | 117 (76.5) |
| Joint | 36 (23.5) | |
| Living arrangement | Alone | 43 (28.1) |
| With friend/roommate | 22 (14.4) | |
| With family | 88 (57.5) |
Table 2.
Work profile
| Parameter | Category | Frequency (%)/mean (±SD) |
|---|---|---|
| Designation | Nursing officers | 78 (50.9) |
| Junior resident doctors | 35 (22.9) | |
| Senior resident doctors | 35 (22.9) | |
| Faculty | 5 (3.3) | |
| Years of experience at trauma center | 5.2 (±2.9) | |
| Hours spent at work per day in the last month | 10.5 (±4.0) | |
| Number of night duties in the last month | 6.5 (±2.2) | |
| Mortalities witnessed at work in the last month | 5.5 (±2.6) | |
| Incidences of violence at work in last month | 7.8 (±3.4) | |
| Mass casualties witnessed at work in the last month | 3.1 (±1.7) | |
| Number of holidays availed in the last month | 4.0 (±3.6) | |
| Sleep deprivation (lack of adequate sleep: 5–7 hours/day) | Never | 14 (9.2) |
| Sometimes | 32 (20.9) | |
| Often | 70 (45.8) | |
| All the time | 37 (24.1) | |
| Food deprivation (lack of time or opportunity to have at least 3 meals/day) | Never | 31 (20.3) |
| Sometimes | 41 (26.8) | |
| Often | 60 (39.2) | |
| All the time | 21 (13.7) | |
| Deprivation of family time (lack of adequate time with family- at least 1 hour/day excluding bedtime) | Never | 16 (10.5) |
| Sometimes | 33 (21.6) | |
| Often | 63 (41.2) | |
| All the time | 41 (26.8) | |
| Deprivation of personal time (lack to time or opportunity for personal activities) | Never | 14 (9.2) |
| Sometimes | 32 (20.9) | |
| Often | 73 (47.7) | |
| All the time | 34 (22.2) |
In terms of designation, 78 (51.0%) of the respondents were nursing officers, 35 (22.9%) respondents were senior and junior residents each and 5 (3.3%) were faculty members. The mean duration of experience at the trauma center was 5.2 (±2.9) years. Trainees reported spending a mean of 10.5 (±4.0) hours per day at work and did a mean 6.5 (±2.2) 24-hour duties in the past month. They also reported witnessing a mean 5.5 (±2.6) mortalities, 3.1 (±1.7) mass casualties, and 7.8 (±3.4) incidences of physical violence at work in the past month. The staff took a mean 4.0 (±3.6) days off work in the last 30 days. A large number of the staff members often felt deprived of sleep personal time and time with their families.
Workplace Satisfaction
While assessing workplace satisfaction, most of the participants appeared somewhat satisfied with the general workplace environment (n = 63, 41.2%), their interpersonal relations with other staff members (n = 78, 41.2%), conflict resolution approach (n = 47, 30.7%), infrastructure and facilities provided (n = 53, 34.6%), time granted off work (n = 61, 39.9%) and time for recreational activities (n = 57, 37.3%). Most of the participants were quite satisfied with the standard of academic activities in the department (n = 63, 41.2%) and expressed low satisfaction over superiors’ concern over staff's psychological well-being (n = 52, 20.9%). The findings are presented in Table 3.
Table 3.
Workplace satisfaction
| Parameter | Category | Frequency (%) |
|---|---|---|
| General environment | Not at all satisfied | 2 (1.3) |
| Little satisfied | 27 (17.6) | |
| Somewhat satisfied | 63 (41.2) | |
| Quite satisfied | 56 (36.6) | |
| Interpersonal relations | Not at all satisfied | 2 (1.3) |
| Little satisfied | 11 (7.1) | |
| Somewhat satisfied | 78 (50.9) | |
| Quite satisfied | 62 (40.5) | |
| Conflict resolution | Not at all satisfied | 32 (20.9) |
| Little satisfied | 46 (30.1) | |
| Somewhat satisfied | 47 (30.7) | |
| Quite satisfied | 28 (18.3) | |
| Departmental infrastructure and facilities | Not at all satisfied | 25 (16.3) |
| Little satisfied | 52 (33.9) | |
| Somewhat satisfied | 53 (34.6) | |
| Quite satisfied | 23 (15.0) | |
| Time granted off work | Not at all satisfied | 16 (10.5) |
| Little satisfied | 48 (31.4) | |
| Somewhat satisfied | 61 (39.9) | |
| Quite satisfied | 28 (18.3) | |
| Time for recreational activities | Not at all satisfied | 1 (0.7) |
| Little satisfied | 27 (17.6) | |
| Somewhat satisfied | 57 (37.3) | |
| Quite satisfied | 22 (14.4) | |
| Academic standards | Not at all satisfied | 16 (10.5) |
| Little satisfied | 43 (28.1) | |
| Somewhat satisfied | 46 (30.1) | |
| Quite satisfied | 48 (31.4) | |
| Concern for staff's psychological well-being | Not at all satisfied | 45 (29.4) |
| Little satisfied | 52 (33.9) | |
| Somewhat satisfied | 32 (20.9) | |
| Quite satisfied | 24 (15.7) |
In terms of designation, one-way ANOVA indicated no difference among nursing officers, junior residents, senior residents, and faculty members in terms of number of daily working hours in the past month [F(3, 149) = 2.41, p = 0.06]. Junior residents had a significantly greater number of night duties in a month [F(3, 149) = 5.09, p = 0.002] as compared with senior residents, faculty, and nursing officers. Senior residents took a significantly lesser number of days off work [F(3, 149) = 39.61, p = 0.001] in comparison with junior residents, faculty members, and nursing officers. In the assessment of workplace satisfaction, a significantly greater number of nursing officers expressed little satisfaction with academic standards [χ2(df) = 34.98(9), p = 0.001] and departmental concern for staff's psychological well-being [χ2(df) = 25.11(9), p = 0.003] as compared with residents and faculty. There were no significant differences among nursing officers, residents, and faculty in other domains of workplace satisfaction (Table 4).
Table 4.
Group differences in work profile and workplace satisfaction
| Parameter | Category | Frequency (%) | F(df)/χ2(df) | p-value | |||
|---|---|---|---|---|---|---|---|
| Nursing officers(n = 78) | Junior resident(n = 35) | Senior resident(n = 35) | Faculty(n = 5) | ||||
| Daily working hours | 9.2 (±2.7) | 8.4 (±1.9) | 16.1 (±8.5) | 9.0 (±0.7) | 2.41 (3,149) | 0.069 | |
| Duties per month | 5.9 (±1.4) | 7.6 (±2.3) | 6.9 (±2.8) | 6.2 (±1.6) | 5.09 (3,149) | 0.002* | |
| Holidays per month | 6.3 (±3.1) | 0.9 (±1.6) | 0.7 (±1.1) | 3.2 (±0.9) | 39.61 (3,149) | 0.001** | |
| Workplace satisfaction | |||||||
| General environment | Not at all satisfied | 2 (2.6) | 0 | 0 | 0 | 11.71 (9) | 0.230 |
| Little satisfied | 17 (21.7) | 6 (17.1) | 4 (11.4) | 0 | |||
| Somewhat satisfied | 36 (46.1) | 12 (34.3) | 19 (54.3) | 1 (20) | |||
| Quite satisfied | 23 (29.4) | 17 (48.6) | 12 (34.3) | 4 (80) | |||
| Interpersonal relations | Not at all satisfied | 1 (1.3) | 1 (2.9) | 0 | 0 | 13.67 (9) | 0.135 |
| Little satisfied | 7 (8.8) | 0 | 4 (11.4) | 0 | |||
| Somewhat satisfied | 42 (53.8) | 14 (40) | 21 (60) | 1 (20) | |||
| Quite satisfied | 28 (35.9) | 20 (57.1) | 10 (28.6) | 4 (80) | |||
| Conflict resolution | Not at all satisfied | 21 (26.9) | 5 (14.3) | 6 (17.1) | 0 | 6.34 (9) | 0.706 |
| Little satisfied | 24 (30.7) | 10 (28.6) | 11 (31.4) | 1 (20) | |||
| Somewhat satisfied | 21 (26.9) | 13 (37.1) | 11 (31.4) | 2 (40) | |||
| Quite satisfied | 12 (15.4) | 7 (20) | 7 (20) | 2 (40) | |||
| Departmental infrastructure facilities | Not at all satisfied | 18 (23.1) | 6 (17.1) | 1 (2.9) | 0 | 16.13 (9) | 0.064 |
| Little satisfied | 27 (34.6) | 11 (31.4) | 13 (37.1) | 1 (20) | |||
| Somewhat satisfied | 26 (33.3) | 9 (25.7) | 16 (45.7) | 2 (40) | |||
| Quite satisfied | 7 (8.9) | 9 (25.7) | 5 (14.3) | 2 (40) | |||
| Time granted off work | Not at all satisfied | 6 (7.7) | 4 (11.4) | 6 (17.1) | 0 | 16.71 (9) | 0.058 |
| Little satisfied | 20 (25.6) | 13 (37.1) | 14 (40) | 1 (20) | |||
| Somewhat satisfied | 33 (42.3) | 13 (37.1) | 14 (40) | 1 (20) | |||
| Quite satisfied | 19 (24.4) | 5 (14.3) | 1 (2.9) | 3 (60) | |||
| Time for recreational activities | Not at all satisfied | 9 (11.5) | 1 (2.9) | 1 (2.9) | 1 (20) | 7.53 (9) | 0.582 |
| Little satisfied | 26 (33.3) | 15 (42.9) | 15 (42.9) | 1 (20) | |||
| Somewhat satisfied | 30 (38.5) | 13 (37.1) | 16 (45.7) | 2 (40) | |||
| Quite satisfied | 13 (16.7) | 6 (17.1) | 3 (8.6) | 1 (20) | |||
| Academic standards | Not at all satisfied | 15 (19.2) | 1 (2.9) | 0 | 0 | 34.98 (9) | 0.001* |
| Little satisfied | 30 (38.5) | 4 (11.4) | 9 (25.7) | 0 | |||
| Somewhat satisfied | 19 (24.4) | 12 (34.3) | 14 (40) | 1 (20) | |||
| Quite satisfied | 14 (17.9) | 18 (51.4) | 12 (34.3) | 4 (80) | |||
| Concern for staff's psychological well-being | Not at all satisfied | 31 (39.7) | 2 (5.7) | 11 (31.4) | 1 (20) | 25.11 (9) | 0.003* |
| Little satisfied | 26 (33.3) | 10 (28.6) | 14 (40) | 2 (40) | |||
| Somewhat satisfied | 14 (17.9) | 12 (34.3) | 6 (17.1) | 0 | |||
| Quite satisfied | 7 (8.9) | 11 (31.4) | 4 (11.4) | 2 (40) | |||
*Indicates p-value of less than 0.05 (statistically significant)
Psychological Profile
The psychological profile was assessed using the DASS-21 and the ProQoL-5 scales. Depression, anxiety, and stress scores obtained on the DASS-21 scale were classified into severity categories as per the scale's standard interpretation system and have been presented in Table 5. Majority of the participants had scores within the normal range for depression, anxiety, and stress. However, 21 (13.7%) participants showed signs of mild, 19 (12.4%) of moderate, 10 (6.5%) of severe, and 5 (3.3%) of extremely severe depression. The most common psychological symptoms reported were of anxiety. Eighteen (11.8%) participants each reported mild and severe levels of anxiety, 30 (19.6%) reported moderate anxiety, and 17 (11.1%) reported extremely severe anxiety symptoms. Symptoms of mild stress were reported by 36 (23.5%), moderate stress by 16 (10.5%), severe stress by 5 (3.3%), and extremely severe stress was reported by 3 (1.9%) participants.
Table 5.
DASS-21 and ProQol-5 score categories
| Scale | Parameter | Category | Total | Frequency (%) | χ2 (df) | p-value | |||
|---|---|---|---|---|---|---|---|---|---|
| Nursing officer (n = 78) | Junior resident(n = 35) | Senior resident (n = 35) | Faculty (n = 5) | ||||||
| DASS-21 | Depression | Normal | 98 (64.1) | 53 | 25 | 17 | 3 | 15.28 (12) | 0.226 |
| Mild | 21 (13.7) | 8 | 4 | 7 | 2 | ||||
| Moderate | 19 (12.4) | 6 | 5 | 8 | 0 | ||||
| Severe | 10 (6.5) | 7 | 1 | 2 | 0 | ||||
| Extremely severe | 5 (3.3) | 4 | 0 | 1 | 0 | ||||
| Anxiety | Normal | 70 (45.8) | 36 | 18 | 14 | 2 | 9.73 (12) | 0.639 | |
| Mild | 18 (11.8) | 11 | 3 | 3 | 1 | ||||
| Moderate | 30 (19.6) | 12 | 6 | 11 | 1 | ||||
| Severe | 18 (11.8) | 7 | 6 | 4 | 1 | ||||
| Extremely severe | 17 (11.1) | 12 | 2 | 3 | 0 | ||||
| Stress | Normal | 93 (60.8) | 51 | 21 | 18 | 3 | 9.64 (12) | 0.657 | |
| Mild | 36 (23.5) | 14 | 8 | 12 | 2 | ||||
| Moderate | 16 (10.5) | 7 | 6 | 3 | 0 | ||||
| Severe | 5 (3.3) | 4 | 0 | 1 | 0 | ||||
| Extremely severe | 3 (1.9) | 2 | 0 | 1 | 0 | ||||
| ProQoL-5 | Compassion satisfaction | Low | 3 (1.9) | 2 | 1 | 0 | 0 | 3.48 (6) | 0.746 |
| Average | 100 (65.4) | 49 | 21 | 27 | 3 | ||||
| High | 50 (32.7) | 27 | 13 | 8 | 2 | ||||
| Burnout | Low | 69 (45.1) | 37 | 19 | 11 | 2 | 4.06 (3) | 0.255 | |
| Average | 84 (54.9) | 41 | 16 | 24 | 3 | ||||
| High | 0 | 0 | 0 | 0 | 0 | ||||
| Secondary traumatic stress | Low | 69 (45.1) | 27 | 18 | 23 | 1 | 13.30 (6) | 0.039* | |
| Average | 81 (52.9) | 48 | 17 | 12 | 4 | ||||
| High | 3 (1.9) | 3 | 0 | 0 | 0 | ||||
*Indicates p-value of less than 0.05 (statistically significant)
Using the ProQol-5 scale, scores in the three domains of compassion satisfaction, burnout, and STS were obtained, and categorized into low, average, and high as per the scale's scoring instructions. A total of 50 (32.7%) participants scored high on compassion satisfaction, 100 (65.4%) scored average, and only 3 (1.9%) had low scores. Sixty-nine (45.1%) scored low on the burnout subscale and 84 (54.9) had average scores. On scores of the STS subscale, 69 (45.1) scored low, 81 (52.9%) scored average, and only 3 (1.9%) had high scores.
While comparing the risk of depression, anxiety stress, burnout, and STS between nursing officers, junior and senior residents, and faculty, it was observed that the only domain showing a significant difference was STS, where a significantly greater number of nursing officers were at a higher risk as compared with junior residents, senior residents and faculty members [χ2(df) = 13.30(6), p = 0.039]. No other domains showed statistically significant differences in distribution between various groups.
Correlations
Correlations of psychological symptoms and determinants of professional quality of life were examined with the sociodemographic and work profiles of the participants, as presented in Table 6.
Table 6.
Correlations
| Parameter | Depression | Anxiety | Stress | Compassionsatisfaction | Burnout | Secondary traumatic stress |
|---|---|---|---|---|---|---|
| Age | –0.152 | –0.194* | –0.235** | 0.251** | –0.286** | –0.095 |
| Experience | –0.061 | 0.016 | 0.003 | 0.202** | –0.221** | 0.051 |
| Hours at work | –0.063 | –0.069 | 0.571* | 0.054 | –0.113 | 0.479** |
| Night duties | –0.093 | –0.088 | 0.104 | –0.087 | 0.131 | 0.110 |
| Mortalities | 0.068 | 0.107 | 0.121 | 0.029 | 0.005 | 0.114 |
| Violence | 0.080 | 0.676 | 0.727 | 0.826 | 0.701 | 0.545 |
| Mass casualty | 0.021 | –0.020 | –0.025 | 0.142 | 0.034 | 0.328* |
| Holidays | 0.074 | 0.055 | 0.080 | 0.012 | 0.025 | –0.197* |
| Sleep deprivation | 0.197 | 0.215** | 0.266** | –0.108 | 0.251** | 0.052 |
| Food deprivation | 0.280** | 0.274** | 0.301** | –0.117 | 0.317** | 0.202* |
| Family time deprivation | 0.197* | 0.230** | 0.273** | –0.173* | 0.353** | 0.024 |
| Personal time deprivation | 0.209** | 0.197* | 0.232** | 0.138 | 0.396** | 0.165 |
| Recreation frequency | –0.218* | –0.312* | –0.471** | 0.019 | –0.424* | 0.172 |
| General environment | –0.236** | –0.230** | –0.248** | 0.423** | –0.382** | –0.152 |
| Interpersonal relations | –0.322** | –0.272** | –0.257** | 0.420** | –0.436** | –0.212** |
| Conflict resolution | –0.220** | –0.182* | –0.200* | 0.238** | –0.268** | –0.77 |
| Department facilities | –0.245** | –0.198* | –0.267** | 0.193** | –0.301** | –0.114 |
| Time off work | –0.162* | –0.189* | –0.073 | 0.071 | –0.086 | –0.116 |
| Academic standards | –0.269** | –0.193* | –0.142 | 0.062 | –0.119 | –0.101 |
| Concern | 0.153 | –0.364** | –0.714** | 0.381* | –0.415** | –0.406** |
*Indicates p-value of less than 0.05 (statistically significant);
**Indicates p-value of less 0.001 (Statistically highly significant)
Depression score had a significant positive correlation with food deprivation (r = 0.280, p < 0.001), deprivation of time with family (r = 0.197, p = 0.031), and deprivation of personal time (r = 0.209, p = 0.042). Significant negative correlations of depression scores were observed with frequency of engagement in recreational activities (r = −0.218, p = 0.023) and several domains of workplace satisfaction, including general environment of the department (r = −0.236, p < 0.001), interpersonal relations with colleagues (r = −0.322, p < 0.001), conflict resolution system in the department (r = −0.220, p < 0.001), infrastructural facilities provided (r = −0.245, p < 0.001), time granted off work (r = −0.162, p = 0.004) and academic standards (r = −0.269, p < 0.001) maintained in the department.
Scores on anxiety subscale had significant positive correlations with sleep deprivation (r = 0.215, p < 0.001), food deprivation (r = 0.274, p < 0.001), deprivation of family time (r = 0.230, p < 0.001) and deprivation of personal time (r = 0.197, p = 0.031). Significant negative correlations of anxiety scores were observed with age (r = −0.235, p < 0.001) frequency of engagement in recreational activities (r = −0.312, p = 0.027), and several domains of workplace satisfaction, including the general environment of the department (r = −0.230, p < 0.001), interpersonal relations with colleagues (r = −0.272, p < 0.001), conflict resolution system in the department (r = −0.182, p = 0.021), infrastructural facilities provided (r = −0.198, p = 0.038), time granted off work (r = −0.189, p = 0.007) academic standards (r = −0.193, p = 0.016) and departmental concern for staff's psychological well-being (r = −0.364, p < 0.001).
Stress scores had significant positive correlations with number of hours at work (r = 0.571, p = 0.026), sleep deprivation (r = 0.266, p < 0.001). food deprivation (r = 0.301, p < 0.001), deprivation of family time (r = 0.237, p < 0.001) and deprivation of personal time (r = 0.232, p < 0.001). Significant negative correlations of stress scores were observed with age (r = −0.235, p < 0.001) frequency of engagement in recreational activities (r = −0.471, p < 0.001) and several domains of workplace satisfaction, including general environment of the department (r = −0.248, p < 0.001), interpersonal relations with colleagues (r = −0.272, p < 0.001), conflict resolution system in the department (r = −0.200, p = 0.021), infrastructural facilities provided (r = −0.267, p = 0.038), time granted off work (r = −0.189, p < 0.001), and departmental concern for staff's psychological well-being (r = −0.714, p < 0.001).
Compassion satisfaction had significant positive correlations with age (r = 0.251, p < 0.001), years of experience in working in the field of trauma and critical care (r = 0.202, p < 0.001), satisfaction with general environment of the department (r = 0.432, p < 0.001), interpersonal relations (r = 0.420, p < 0.001), conflict resolution (r = 0.238, p < 0.001), infrastructural facilities provided (r = 0.193, p < 0.001) and departmental concern for staff's psychological well-being (v–0.381, p < 0.001). Deprivation of time with family had a significant negative correlation with compassion satisfaction (r =–0.173, p = 0.042).
Burnout had significant positive correlations with sleep deprivation (r = 0.251, p < 0.001). food deprivation (r = 0.317, p < 0.001), deprivation of family time (r = 0.353, p < 0.001) and deprivation of personal time (r = 0.396, p < 0.001). Significant negative correlations were observed with age (r = −0.286, p < 0.001), years of experience (r = −0.211, p < 0.001), frequency of recreational activities (r = −0.424, p = 0.017) general workplace environment (r = −0.382, p < 0.001), interpersonal relations (r = −0.436, p < 0.001), infrastructural facilities provided (r = −0.301, p < 0.001) and departmental concern for staff's psychological well-being (r = −0.415, p < 0.001).
Secondary traumatic stress had positive correlations with the number of hours spent at work in a month (r = 0.479, p < 0.001), mass casualties witnessed in a month (r = 0.328, p = 0.004) and food deprivation (r = 0.202, p = 0.024). Negative correlations were observed between STS and interpersonal relations (r = −0.212, p < 0.001) and departmental concern for staff's psychological well-being (r = −0.406, p < 0.001).
Correlations were also drawn between psychological symptoms and determinants of workplace satisfaction. Depression, anxiety, and stress scores had significant positive correlations with burnout as well as STS and significant negative correlations with compassion satisfaction, as shown in Table 7.
Table 7.
Correlations between psychological symptoms and professional quality of life
| Compassion satisfaction | Burnout | Secondary traumatic stress | |
|---|---|---|---|
| Depression | –0.380** | 0.587** | 0.507** |
| Anxiety | –0.415** | 0.599** | 0.503* |
| Stress | –0.406* | 0.612** | 0.486** |
*Indicates p-value of less than 0.05 (statistically significant);
**Indicates p-value of less than 0.001 (statistically highly significant)
Regression Analysis
After the preliminary assumptions were met, multiple linear regression was performed to predict the levels of different determinants of professional quality of life (compassion satisfaction, burnout and STS) using sociodemographic details and workplace satisfaction (Table 8). Compassion satisfaction had an R-value of 0.690, indicating a good level of prediction and coefficient of determination, and R2 indicated that the variables of age, marital status, incidences of violence witnessed at work, satisfaction with the general workplace environment, and satisfaction with interpersonal relations with colleagues, predicted about 47.7% of the variability in compassion satisfaction. F (113.42) and p-value (< 0.001) indicated an extremely good fit for the data. Burnout had an R-value of 0.738, indicating a good level of prediction and coefficient of determination. R2-value indicated that the variables of age, deprivation of personal time, and satisfaction with interpersonal relations with colleagues, predicted about 61.3% of the variability in compassion satisfaction. F (108.22) and p-value (< 0.001) indicated an extremely good fit for the data. Secondary traumatic stress had an R-value of 0.640, indicating a good level of prediction and coefficient of determination. R2 value indicated that the variables of hours spent at work per day in the last 1 month and sleep deprivation could predict 41% of the variability. F (93.64) and p-value (< 0.001) indicated a good fit for the model.
Table 8.
Multiple linear regression analysis
| Outcome variable | Predictor variables | Unstandardized coefficient (Std. error) | Standardized coefficient | 95% Confidence interval | t | p-value |
|---|---|---|---|---|---|---|
| Compassion satisfaction | Constant | 20.87 (5.70) | 9.57–32.16 | 3.65 | 0.001 | |
| Age | 0.31 (0.15) | 0.33 | 0.18–0.61 | 2.10 | 0.013 | |
| Marital status | 3.97 (1.45) | 0.29 | 1.08–6.85 | 2.72 | 0.007 | |
| Violence | 0.23 (0.09) | 0.19 | 0.05–0.42 | 2.53 | 0.013 | |
| Generalenvironment | 2.28 (0.82) | 0.25 | 0.65–3.88 | 2.78 | 0.006 | |
| Interpersonal relations | 2.23 (0.91) | 0.22 | 0.42–4.40 | 2.44 | 0.016 | |
| Burnout | Constant | 20.30 (4.23) | 21.92–38.66 | 7.17 | 0.001 | |
| Age | –0.26 (0.11) | –0.31 | 0.38–0.47 | 0.31 | 0.022 | |
| Personal time Deprivation | 1.55 (0.54) | 0.23 | 0.48–2.62 | 2.87 | 0.005 | |
| Interpersonal relations | –1.48 (0.68) | –0.15 | 0.14–2.82 | 2.18 | 0.031 | |
| Secondary traumatic stress (STS) | Constant | 22.10 (5.93) | 10.35–33.85 | 3.72 | 0.001 | |
| Hours/day | 1.05 (0.45) | 0.29 | 1.38–3.48 | 1.07 | 0.005 | |
| Sleep deprivation | 1.49 (0.40) | 0.23 | 0.11–2.88 | 2.14 | 0.034 | |
| Depression | Constant | 7.64 (3.61) | 0.49–14.80 | 2.12 | 0.036 | |
| Food deprivation | 0.81 (0.38) | 0.21 | 0.04–1.58 | 2.08 | 0.039 | |
| Sleep deprivation | 1.40 (0.38) | 0.18 | 1.05–1.85 | 1.49 | 0.044 | |
| Burnout | 0.21 (0.09) | 0.32 | 0.03–0.39 | 2.27 | 0.025 | |
| STS | 0.18 (0.05) | 0.31 | 0.06–0.28 | 3.22 | 0.002 | |
| Anxiety | Constant | –2.31 (1.77) | –11.72–7.31 | 0.48 | 0.029 | |
| General environment | –0.47 (0.04) | –0.01 | –1.02–0.91 | –1.16 | 0.005 | |
| Burnout | 0.23 (0.09) | 0.36 | 0.04–0.24 | 2.48 | 0.014 | |
| STS | 0.15 (0.05) | 0.26 | 0.04–0.26 | 2.69 | 0.008 | |
| Stress | Constant | –4.96 (2.95) | –4.35–5.51 | –0.94 | 0.017 | |
| Hours/day | 0.21 (0.02) | 0.04 | –0.03–0.06 | 0.54 | 0.024 | |
| Burnout | 0.28 (0.10) | 0.37 | 0.07–0.49 | 2.67 | 0.009 | |
| STS | 0.16 (0.06) | 0.24 | 0.04–0.28 | 2.59 | 0.011 |
Multiple linear regression was also performed to predict the occurrence of psychological disturbances in the participants using sociodemographic variables, workplace satisfaction, and determinants of professional quality of life (Table 7). Depression had an R-value of 0.676 and R2-value of 0.457 indicating that food deprivation, sleep deprivation, burnout, and STS could predict 45.7% variability in depression scores. F (63.64) and p-value (< 0.001) indicated the average fit of the model. Anxiety had an R-value of 0.660 and an R2-value of 0.435 indicating that general workplace environment, burnout, and stress could predict 43.5% variability in anxiety scores. F (82.46) and p-value (< 0.001) indicated a good fit for the model. Stress had an R-value of 0.691 and an R2-value of 0.478 indicating that general workplace environment, burnout, and stress could predict 47.8% variability in anxiety scores. F (97.42) and p-value (< 0.001) indicated a good fit for the model.
Model Summary
Compassion satisfaction: R = 0.690, R2 = 0.477, F (29, 3.861) = 113.42, p-value < 0.001.
Burnout: R = 0.783, R2 = 0.613, F (29, 6.710) = 108.22, p-value < 0.001.
Secondary traumatic stress: R = 0.640, R2 = 0.410, F (29, 2.944) = 93.646, p-value < 0.001.
Depression: R = 0.676, R2 = 0.457, F (29, 3.575) = 63.641, p-value < 0.001.
Anxiety: R = 0.660, R2 = 0.435, F (29, 3.150) = 82.464, p-value < 0.001.
Stress: R = 0.691, R2 = 0.478, F (29, 3.886) = 97.429, p-value < 0.001.
Discussion
This was a cross-sectional study conducted among the employees of a level 1 Trauma Center in an apex medical institution located in North India. A majority of the participants were in their 30s, married, lived with their families in a nuclear setup, working in the field of trauma for a mean of 5 years, and spent a mean of 10.5 hours at work every day, witnessing and managing patient mortality, mass casualties, and incidences of violence as part of their profession. A large percentage of participants experienced frequent sleep deprivation, food deprivation, and deprived of personal and family time. Most of the participants were somewhat satisfied with their working conditions but expressed dissatisfaction with the general concern shown by the department over the mental well-being of the staff members. Most of the participants had good levels of compassion satisfaction, indicating a sense of reward and fulfilment in their role as healthcare providers to victims of physical trauma. However, more than 50% of the participants were at moderate risk of suffering from burnout and STS. Also, about 54% of the participants had symptoms of anxiety, 40% had symptoms indicative of stress, and 36% had depressive symptoms. Correlations and multiple linear regression findings indicated that determinants of professional quality of life, such as burnout and STS, which were affected by strenuous working conditions and lack of personal time, in turn, affected the psychological health of the participants. Findings also suggest that higher compassion satisfaction, engagement in recreational activities, and greater workplace satisfaction were associated with lower depression, anxiety, and stress scores, thus acting as protective factors against psychological distress.
A recent systematic review of 14 studies on STS and burnout among Indian mental health professionals indicated moderate to severe levels of burnout and STS in a large majority of mental healthcare providers.26 Studies conducted on healthcare workers during COVID-19 pandemic using similar study instruments, also reported a high prevalence of burnout and STS, which were also associated with depression and anxiety.12,27 In this context, a greater number of studies have focussed on mental health care workers while professionals working with victims of physical trauma have not been given due importance.6,28,29 In one of the few studies that exclusively examined the emotionally disturbing incidences experienced by 38 trauma professionals, mass casualties, burns, injury to children, injuries sustained in sexual assault, suicidal attempts, and grievous physical assault were reported to exert adverse psychological effects on vicariously exposed medical staff.3 Another study from Arizona, conducted among 22 attending surgery consultants and trainees, also presented high levels of stress experienced during their rotational posting in Trauma sub-specialty.1 However, these studies had a small sample size and did not use standardized study instruments, indicating a need for larger scale, in-depth studies focussing on trauma professionals.
This was the first study conducted on these lines among trauma professionals in India, a small workforce of professionals providing healthcare to victims of physical trauma in resource-limited settings, long and difficult working hours, and often without frequent breaks.9 Prolonged exposure to human suffering and misery with added perceived stress of building personal and professional accomplishments is associated with psychological distress and decrease in empathy among medical students as well as professionals.18,20,30 This finding is important not only for those in training but also for those who have advanced in their medical career and for whom working through personal distress may have become the normal way of life, as this may lead to expecting others (patients, colleagues, and subordinates) to deal with distress in the same manner.19,20 This may have adverse outcomes on their relationship with their patients and their social and familial relationships.30
Our study also reported a significant impact of professional quality of life on symptoms of psychological distress, including stress, anxiety and depression. These observations stand in agreement with an earlier study conducted among 331 trauma professionals in Iran, which reported a significant relationship between professional quality of life with general as well as psychological health, measured using the General Health Questionnaire-28. Another study conducted among 282 nursing professionals working with physical trauma victims reported significantly greater use of unhealthy coping strategies among those with high STS scores, a relationship mediated by environmental and personal stressors.31
It is thus recommended that due consideration be given to the psychological well-being of medical professionals and trainees working with victims of physical trauma.32 It may be desirable to institute hospital-based employee mental health programs designed specifically to the different needs of different specialties. A suitable example is the Worksite Wellness Education Program at a medical university in Egypt, aimed at improving employees’ knowledge of workplace stress, addressing various stress factors, such as sleep disruption, substance use, fear of malpractice litigation, and healthy coping strategies through presentations, posters, role play, group discussion, and video films. A study conducted among 108 Emergency Department staff who were enrolled in this program reported improved post-interventional professional quality of life.15 Other measures aimed at not only the reduction of work-related stress but also at improving resilience and healthy coping among trauma professionals are also warranted. Improving division of departmental duties, providing suitable on-duty facilities, such as comfortable duty rooms, 24-hour working cafeterias with nutritious food, scheduling regular breaks for personal and family time, faculty with an empathic and understanding approach toward issues faced by the trainees and junior staff and periodic mental health promotional activities in the department may help toward creating a mental health friendly environment at the workplace. Initiation of a student/employee wellness program aimed at providing psychological support to employees in need with the provision of referral to specialized professional help as required may prove instrumental in the promotion of mental well-being as well as the prevention of psychological crises and untoward events.
This study suffered from a few limitations, such as being a single-center study, with a cross-sectional design, relying solely on self-report, and no comparisons made with other medical/surgical specialties. This limits the generalizability of our findings. The study instruments were self-administered and the study offered no incentive, thus there was no way to vouch for the reliability and truthfulness of the responses.
However, this study provides an insight into the psychological state of medical professionals working with victims of physical trauma and some probable modifiable and non-modifiable factors that these conditions may be attributed to. This study may pave the way for further in-depth research on specific factors that may affect the mental health of trauma professionals. This study also builds a case for workplace interventions, such as resident wellness programs, tailored to the institutional infrastructure, work environment, and needs of healthcare providers.
Conclusion
This study indicated that while working with victims of physical trauma is fulfilling for healthcare providers, but they are at a significant risk of burnout and STS. The presence of psychological distress was observed in a large percentage of trauma professionals, which was affected by professional quality of life. Workplace-based interventions for the improvement of professional quality of life and promotion of psychological well-being among trauma professionals are recommended.
Orcid
Sahil Gupta https://orcid.org/0009-0001-6450-9821
Gayatri Bhatia https://orcid.org/0000-0001-9500-7798
Rajesh Sagar https://orcid.org/0000-0003-4563-7841
Sushma Sagar https://orcid.org/0000-0002-4700-9868
Footnotes
Source of support: Nil
Conflict of interest: None
References
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