Job burnout in 159 anesthesiology trainees

Abstract

Background:

Anesthesiology may be stressful and most anesthesiologists develop mechanisms for coping. However, inexperienced trainee anesthesiologists seem to be vulnerable. We studied stress perception and job burnout in trainee anesthesiologists.

Methods:

Responses to perceived stress scale (PSS) and Maslach Burnout Inventory (MBI) were evaluated in 159 trainee anesthesiologists.

Results:

In our results, when perceived stress was increased, emotional exhaustion and depersonalization increased but personal accomplishment decreased, as expected. Perceived stress was very high in the early years of training. There was a negative correlation between age and emotional exhaustion and depersonalization, but positive correlation with personal accomplishment. Female anesthesiologists had higher personal accomplishment, but lower depersonalization points than male anesthesiologists in our study. There was no statistical association between marital status, PSS, and MBI; ≥2 children group had a significant high personal accomplishment but low depersonalization and emotional exhaustion scores. Line regression analysis showed a statistically significant relationship between PSS and emotional exhaustion and between age and depersonalization.

Conclusions:

Social factors such as gender and number of children affect the work life of our trainees.

INTRODUCTION

Job burnout defines a state of physical and mental exhaustion commonly observed in physicians, surgeons, nurses, and other health care workers. Jackson has identified potential stressors in the operating room, such as the noisy environment and poorly designed work spaces; added to the list may be long working hours, fatigue, demanding interpersonal relations, the need for sustained vigilance, work overload, fear of litigation, and unskilled leadership by superiors.[1,2] As a result, anesthesiology is a stressful field.[3] Today, we also know that some stress appears to be necessary and beneficial. However, if an individual is exposed to uncomfortably high levels, psychologic difficulties may result. Where should the line be drawn between beneficial stress and harmful stress? If an individual feels obligated to respond to a situation but feels unable to cope with the demands, burnout begins.[4] Nyssen et al. found that mean stress levels among anesthesiologists were not higher than the other working group populations studied.[5] This is consistent with the premise that, although anesthesia may well be stressful, anesthesiologists develop coping mechanisms over time. However, inexperienced trainee anesthesiologists seem to be vulnerable.[6,7]

The aim of this study was to identify and measure the stress perception and job burnout in trainee anesthesiologists.

METHODS

From October 2009 to June 2010, we conducted a study to measure the perceived stress and job burnout in trainee anesthesiologists. In Turkey, Istanbul is the biggest metropolitan city almost with 13 million population. For that reason most of the education and training hospitals are present in Istanbul. A majority of (almost 60%–70%) Turkish anesthesiologists receive residency training in Istanbul. The study was conducted as voluntary survey of 159 anesthesiology trainees who come from different parts of the country to Istanbul, in order to be an anesthesiology resident. Each participant answered the questions once during the study period. They were asked to fill out 3 pages of questionnaires consisting of 3 parts in which Part 1 included demographic data (age, gender, marital status, number of children, and years in training), Part 2 included the Perceived Stress Scale (PSS) for Turks (translated and validated to Turkish by Baltas et al. in 1998.)[8,9] consisting of 10 items, each of which is answered on a scale from 0 (never) to 4 (very often) and has an internal consistency of 0.76 (Cronbach alpha coefficient). Part 3 included Maslach Burnout Inventory Scale (MBI).[10] For many years the 22-item MBI has been used to measure burnout and is subdivided into 3 subscales: (a) Emotional exhaustion (9 items), (b) Lack of personal accomplishment (8 items), and (c) Depersonalization (3 items).

Emotional exhaustion subscale shows lack of emotional resources, in which the individual feels emotionally drained. Personal accomplishment subscale assesses feelings of doubt about one's ability to perform tasks and lack of successful achievement in working with people.

Depersonalization is a kind of defense mechanism and this subscale measures an unfeeling and impersonal response toward recipients of one's care. The subject is asked to answer each item on a scale from 0 (never) to 6 (every day). In Turkey, this scale was translated to Turkish and validated in 1992 by Ergin.[11] In the Turkish version of the scale each item is answered on a scale from 0 (never) to 4 (every day). The MBI has an internal consistency of 0.81 (Cronbach alpha co-efficient).

Statistical analysis

Statistical calculations were performed with NCSS 2007 program for Windows. Besides standard descriptive statistical calculations (mean and standard deviation), one-way ANOVA was used in the comparison of groups, post hoc Tukey multiple comparison test was utilized in the comparison of subgroups, unpaired t test was used to compare the two groups and Chi-square test was performed for the evaluation of qualitative data. Spearman correlation test was used to determine the relationship between variables. Statistical significance level was established at P<0.05.

RESULTS

A total of 159 trainee anesthesiologists participated in the study. One hundred and fifty-seven participants answered the questions. The response rate was 98.7%. Demographic data of the study are presented in Table 1.

Table 1.

Demographic data's of the study

In our results, when perceived stress was increased, emotional exhaustion and depersonalization increased but personal accomplishment decreased [Table 2]. Perceived stress was very high in the early years of training (P<0.05) [Table 3]. Comparing the first year of training with the second and third year, we found that there was a significant difference between groups (P<0.05) [Table 4].

Table 2.

Correlation between perceived stress scale and Maslach burnout inventory subscales

Table 3.

PSS according to social variables of the study population

Table 4.

Relation between the year of training perceived stress scale and Maslach burnout inventory subscales

Perceived stress was decreased in older ages. There was a negative correlation between age and emotional exhaustion and depersonalization but a positive correlation between age and personal accomplishment [Table 5].

Table 5.

Age, perceived stress scale and Maslach burnout inventory subscales

Female anesthesiologists showed higher personal accomplishment, but lower depersonalization scores than male anesthesiologists [Table 6]. There was no statistical association between marital status, PSS, and MBI in our study [Table 7]. There was no statistical difference (P=0.177) in PSS between groups of no child, single child, and ≥2 children. Comparing the MBI scores of the no child group with ≥2 children group, we observed that the ≥2 children group showed a statistically significant high personal accomplishment but low depersonalization and emotional exhaustion scores [Table 8].

Table 6.

Gender, perceived stress scale, and Maslach burnout inventory subscales Spearman correlation coefficient

Table 7.

Marital status, perceived stress scale and Maslach burnout inventory subscales

Table 8.

Number of child, perceived stress scale, and Maslach burnout inventory subscales

Linear regression analysis between PSS and emotional exhaustion, personal accomplishment and depersonalization gave an Adjusted R² value of 0.166.

While the relationship between PSS and Emotional Exhaustion remained significant (P=0.001), the relationship between personal accomplishment and depersonalization was not found to be significant (P=0.110, P=0.395) [Table 9].

Table 9.

Multivariate analyses of perceived stress scale with subscales of Maslach burnout inventory

Linear regression analysis between age and PSS, emotional exhaustion, personal accomplishment, and depersonalization gave an Adjusted R² value of 0.137 value. The relationship between age and depersonalization was found to be significant (P=0.006). The other values did not reveal any significant relationship with age [Table 10].

Table 10.

Multivariate analyses of age with perceived stress scale and subscales of Maslach burnout inventory

DISCUSSION

Characteristics of “burnout” are emotional exhaustion, depersonalization, and lack of a sense of personal accomplishment. People affected by the burnout syndrome may show early signs of stress arousal (irritability, forgetfulness, sleep disorders), may attempt to compensate for stress (social withdrawal, increased cynicism, persistent tiredness) and suffer from exhaustion (exhibit depression or anxiety symptoms, chronic pain syndromes, or functional disorders of the cardiovascular or gastrointestinal system). Suicide, drug addiction, and increased rates of early retirement are frequent in anesthesiologists. Burnout not only places the individual at great risk for physical and psychologic dependence including substance misuse, but it may also lead to compromised safety.[12–16] In the last 5 years more than 14 anesthesiology trainees and residents died from suicide in our country, so this study was conducted to understand the reason for this terrible social problem.

In our study, as expected, when perceived stress rose, emotional exhaustion and depersonalization increased, but personal accomplishment decreased.

In our country medical faculties and training and research hospitals play an important role in anesthesiology training. While training and research hospitals work trainees in with anesthesia technicians or experienced anesthesia nurses, young trainees in hospitals affiliated with medical schools work alone in the operating room. The number of specialist anesthesiologists or trainee/supervisor ratio may differ among hospitals. Trainees who work with experienced nurses or technicians and under the supervision of an anesthesiology staff may have less stress levels. The presence of skilled assistance of the anesthesia nurse technician may be the greatest factor in reducing stress in our training hospitals. As the number of anesthesiologists was well below the need, nurse anesthetists and anesthesia technicians were the main providers of anesthesia in our country and training was basically a relationship between trainer and apprentice. So we studied a group of trainees who work in training and research hospitals with the help of anesthesiology technician or nurse. Regardless of a medical school education , an experienced nurse or technician can usually handle most situations without the assistance from the resident. Lack of control of trainees in their own field may cause feelings of inadequacy and low scores for sense of personal accomplishment. This may explain the increase in perceived stress scale we observe in residents at the early stages of their residency training. Widening the scope of this study with residents from hospitals affiliated with medical school is among our goals for future studies.

In our study, perceived stress decreased with increasing age. There was a negative correlation between age and emotional exhaustion and depersonalization but, positive correlation with personal accomplishment.

Increased personal accomplishment may be explained with Turkish traditional respect for elders. More experienced trainees may have undertaken mentoring roles and have become able to give advice on coping strategies to younger colleagues.

Female anesthesiologists have higher personal accomplishment, but lower depersonalization scores than male anesthesiologists. This result may be explained by the fact that most of our female anesthesiology trainees (85%) were married. Bringing up children, a traditional role for women, is perceived as personal accomplishment in our country. Maternal feelings may prevent the development of depersonalization.

These data are correlated with the “number of children.” In our study, there was no statistical difference in PSS between groups of no child, single child, and ≥2 children. But we saw that there was a significant association with the number of child and MBI subscales.

Comparing the no child group with ≥2 children, we observed that in ≥2 children group has significant high personal accomplishment but low depersonalization and emotional exhaustion scores [Table 8]. In Turkey the term “personal accomplishment” includes children and family. Marriage and family responsibilities may represent social support. Similar results were observed with the study of Castelo-Branco et al., in which being single was shown to be a predisposing factor for the development of burnout.[17] But there was no statistical correlation between marital status, PSS, and MBI in our study. This result also explains with our trainees that never live alone. A majority of (almost 60%–70%) Turkish anesthesiologists receive residency training in Istanbul. They take a placement examination after graduating from medical school. We work with trainees from different parts of the country who mostly live with a relative. Many families move to the city for the education of their child. We think that the positive social support of the family plays an important role on perceived stress.

This study has highlighted the job burnout and level of stress of anesthesiology trainees in Turkey. Limitations of this study include the fact that the classic PSS and MBI couldn’t be used in Turkey, because of the language difference. This may be a shortcoming of our study.

In conclusion, as we look over the results, we discuss that we have to manage general tests or exams for our trainees (this is very rare in our country), or we can set a reward system for stimulating their personal accomplishment degrees in our country. Mannequin-based simulation systems may be a way to explore their capabilities as anesthesiologists and help them to be aware of what they know and don’t know. Social factors such as gender and number of children play an important role in the professional life of our trainees.