Background
Physician wellness is frequently discussed, though it is not sufficiently prioritized. Variations in health care policies, increasing patient admissions, increasing responsibilities, and environmental stressors can affect physician wellness [
1]. A physician’s performance is also partially related to health economics, in the sense that his/her income may depend on ordering and prescribing preferences, and decisions to admit or operate a patient. These decisions may be evaluated by a variety of entities and this may also cause stress. The psychosocial aspects of work have been increasingly discussed in the medical literature in recent years [
2‐
5]. Majority of physicians admit that patient care is affected negatively by their stress at work [
3‐
5]. A physician’s workload involves both cognitive and emotional burdens leading to an increase in job stress (JS) [
1,
4,
6,
7]. Implementations with a view to reduce the physicians’ JS should lead to an increase in physicians’ performance and consequently serve for a more satisfactory patient care [
1‐
3,
7‐
9].
Stress and psychosocial risk factors are considered critical issues in the field of occupational health [
1,
2,
10]. Workload and JS are stated as predictors of workers’ health, productivity, and motivation [
10]. The most frequently used models to measure JS are those examining the worker’s psychosocial workload (demand) and sense of job control[
11‐
16]. Demand is higher in those working night shifts, especially among emergency physicians [
4,
7,
17]. Abnormal stress levels are reached earlier in emergency physicians compared to those of other medical specialties [
7,
17]. JS is higher in female physicians, medical students, and residents compared to the general population [
16,
17]. Stress is higher in physicians who are dissatisfied with their job, causing 30-50 % of such physicians to change or leave their occupation [
4,
7,
17]. The level of JS and sense of job control may differ from one healthcare system to another, and also display variations in different populations. However, social support and time may change the status of the job satisfaction, too. These reasons led us to perform this study where physicians are seperated as residents and faculty physicians from different specialties working night shifts in order to evaluate the problem from workload management perspective by scores of demand, job control, social support, and JS.
Discussion
In most healthcare environments, professionals in the health sector suffer heavy workload. Overall, work was found to be the biggest (74 %) stressor in the lives of employees [
22]. Occupational environment and the nature of the work of the physicians is physically demanding. Long-term occupational stress has been shown to lead to burnout and the term ‘burnout’ is often used by the health care personel synonymously with job stress [
4‐
9,
16]. In conclusion, the aim of this study was to assess occupational stress among residents and faculty physicians in different medical specialties working night shifts. We determined that job control and social support scores were lower but job strain scores were higher among the residents compared to the faculty physicians. This is an expected result and it may be related with the working conditions of the residents. In residence, professional knowledge and skills are imperfect and job-control is low, because the required specialization period is not completed yet. In this sense, residents require assistance that will guide them and support them to improve their knowledge and skills. Previous investigations have determined that seniority, working with consultants in emergency medicine, and feeling appreciated in work place are factors in resident’s satisfaction or burnout status [
7,
8,
16,
23]. These are the notions that are synonymous with JS and support the results of our research.
Emergency physicians (EP), who already might have suffered from some degree of sleep deprivation, experience stress from both noncritical and critical patients who demand intense focus and rapid decision-making [
1,
4,
7,
24,
25]. They may have cognitive and emotional burdens and even more unrelaxed night shifts than other specialists. For these reasons, the perceived workload and JS of emergency physicians are expected to be higher than other physicians. However, in this study, no difference was detected in demand, job control, social support and JS scores between residents and faculty physicians working in emergency, internal medicine, and surgical branches. JS was not found to be greater in emergency physicians, perhaps due to their increased job-control (they did not reach statistical significance though). Another factor may have been the shorter shift length of the EPs (16 vs. 32 h). However, an EP is far more likely to take care of more than 60 patients in a night shift with minimal relaxing time. This is totally half the length than their colleague’s. Therefore, we consider that JS experienced by EPs may be at least the same as the physicians of the other specialties. Overall, in an environment with high psychological and physiological demands, night shift work can be stressful for the physicians in all specialties and JS displayed no differences between specialities [
15,
22]. Our results too, showed that physicians of different specialties who work night shifts frequently face stress factors like JS. It is stated in the literature that if a simple defect in a health unit is not healed timely then it may have an impact on the other units and eventually turn into a general fatigue and dissatisfaction [
4,
26‐
28]. Hence it should be considered that there might be a similar and general JS in all the physicians working night shifts.
Demands reflects work speed, work intensity, and workload [
11,
15]. Interestingly, we determined that the demand score of faculty physicians was affected only by the small number of night shifts per month. Demand scores may be so high because of the difficulty of adaptation in case night shifts are rare. Thus, the physicians who are not used to night works may perceive working hours relatively prolonged and this may adversely influence their decision making abilities, hence increase their JS. Faculty physicians included in this study might have perceived higher demand despite they were favored and given very few night shifts, possibly because of a chronic disease or sleep problem or advanced age. So, these faculty physicians may be in the position of increasing their job controls. Nonetheless, we can state that, this demand in the faculty physicians was less with respect to the residents, in our study. As for the residents, however, we found no factors influencing demand; which suggests that it should be a consequence of compulsory submission which is a normally expected of residents.
Job-control reflects the employee’s opportunities to make decisions and how to use his/her skills in the workplace. In jobs with heavy demand and low job-control, stress levels are very high [
10,
12,
18]. In situations where JC is high, workers are more creative, more motivated and feel less stressed when faced with heavy workloads [
10,
12,
18]. Passive work situations are those in which both demand and job-control are low. In such cases, the time needed for learning skills is reduced, and with low job-control, learned helplessness may occur [
10,
12]. Job-control is higher in a work that requires frequent repetition [
10,
12,
13,
29,
30]. Occupations characterized by low demand and high job-control are considered low-stress jobs [
12,
31]. In the studies using demand, job-control and social support models, white-collar workers were found to have much more job-control than blue-collar workers [
12,
31,
32]. In this study, job-control scores were significantly higher in faculty physicians who had a chronic disease. This may be thought as a compensatory mechanism, where a specialist physician feeling inadequate may act highly controlled among residents and their colleagues with a view to become influential or to come into prominence. A positive correlation between age and job-control is an expected result among faculty physicians, due to confidence as a result of professional experience. In residents, however, job-control is normally low due to lack of professional knowledge and skills.
The social environment in a workplace is an independent variable for occupational stress – the worst situations are those where social support is lacking, workload is high, and job-control is low [
12,
14,
20,
21]. Many studies have shown that more and more physicians wish to change their specialty and don’t intend to continue their occupation [
3,
4,
7,
14,
32‐
34]. In this study, we couldn’t determine any factor influencing social support score of the faculty physicians, whereas we determined widespread lack of social support among residents. The social support score of the residents who typically see too many patients were found to decrease. Because satisfaction from work and work environment may decrease as a result of automatisation at work and having probably no concerns other than completing the work timely and consequently, this may alienate residents from their profession. This result highlights the urgent need to improve conditions in the work environment of the residents. Nonetheless, we found no relation between the decision to continue in the profession and social support for the physicians, in general.
Some studies reported a relationship between JS and chronic diseases (e.g. sleep disorders, myocardial infarction, cancer, burnout). [
14,
20,
22,
28,
33‐
35] When physician wellness is compromised, increased job stress, burnout, depression, relationship issues, substance abuse, and suicide may occur [
1,
4]. Interleukin-8 was measured as a stress biomarker in emergency physicians after working a 24-h shift, and increased levels were found, indicating an increase in inflammatory processes [
28]. Emergency physicians working in shifts, along with older physician age, were found to have an increased risk of cardiovascular diseases [
35].
Contrary to these findings, we found no relationship between the chronic diseases and the calculated level of JS of residents as well as faculty physicians. Nonetheless, as it is discussed above, having a chronic disease in residents may independently affect JS in advanced stages, due to the reduced social support or is it because chronic diseases (including sleep disorder) occur as a result of having limited social support; this issue deserves/requires further discussion.
A previous study demonstrated that 84.3 % of the night shift physicians did not state any complaints of sleeping problem but 83.3 % of them have poor sleep quality [
21]. Still, this study found no relationship between job-stress and poor sleep quality. Perhaps physicians deny their health problems and/or have become completely accustomed to the stressful work environment in which they find themselves. Relationship between sleep problem and job stress needs further investigation.
Limitations
Because this study was conducted in a single tertiary care teaching hospital, our results may not be generalized. Since there is no cut-off value defined in DCSQ measurements, each institution must make its own assessment of the repeated measurements. Reassessment of the duty physician’s job-stress with DSCQ is recommended after a while for measuring the improvements of subsequent developments after wellness activities, especially by social supports in work place. Administering the questionnaire to those working day shifts may also reveal different results, and might separate out other stress factors from the stress of night shift work.
Conclusions
As a result, job stress is higher in residents than in faculty physicians. We suggest that, the problems of the work environments of the residents should be identified and concrete actions should be taken in order to improve their working conditions and include them in the decision making mechanisms. Also, it is advisable to pay attention to social support of the residents in the work environment who have a chronic disease or too many patients routinely, in order to reduce their JS.
JS level was similar among emergency physicians and physicians in different specialities working night shifts. In fact, similarity suggest that JS is not high indeed. Reassessment should be done to determine the effects of JS on physician wellness, longevity of career, and patient care outcomes.
Competing interest
The authors have no commercial association or source of support that might pose a conflict of interest.
Authors’ contributions
FCT conceived the study, FCT and IT designed the research, and obtained research funding that was shaped between all authors. FCT and IT supervised the conduct of the research and data collection. FCT and IT undertook recruitment of participating centers and patients and managed the data, including quality control. FCT, IT, SH and BT provided collection of datas on statistical program from the study forms and FCT and CTS analyzed the data; chaired the data oversight committee. FCT drafted the manuscript, and all authors contributed substantially to its revision. FCT takes responsibility for the paper as a whole. All authors read and approved the final manuscript.