Sot. Sci. Med. Vol. 31. No. 9. pp. 1013-1022. 1990 Printed in Great Britain. All rights reserved
0277-9536190 53.00 + 0.00 Copyright C 1990 Pergamon Press plc
STRESS EXPERIENCED BY PHYSICIANS AND NURSES IN THE CANCER WARD
ANDREAS ULLRICH and PETER FITZGERALD?* Max Planck Institute of Psychiatry, Department of Psychology, Kraepelinstasse 2, Munich, F.R.G. and Department of Experimental Psychology, University of Oxford, Oxford OX1 3UD, England
Abstract-This study examined occupational stress amongst medical staff on cancer wards. The sample consisted of 91 nurses and 57 physicians from 13 institutions in Bavaria, F.R.G. Strong associations emerged between specific, situational stressors and reported psychosomatic complaints. In particular. interpersonal difficulties, whether on or off the job, related to physical distress amongst nurses. For doctors, dissatisfaction with the job and working conditions related to general malaise. Certain characteristics of the cater (sex. profession, age) and of the institutional environment (e.g. presence of trainees, size of institution) were also linked with stress and complaint levels.
Key words-stress, burnout, nursing, doctor-patient relationship, cancer nursing
Caring for cancer patients entails conflicts which are also evident with other chronic illnesses. There is a feeling of helplessness given the limited ability of medicine to alter the course of the illness. The fact that the illness is frequently very long draws the doctor or nurse into a deeper relationship with the patient. The empathic reaction to the patients suffer- ing increases, bringing added emotional burden [l]. Identification with the dying patient may come to represent a threat to ones own existence . Wide- spread, repressed fear of death amongst doctors has been claimed [3,4]. Within the field of medicine, moreover, oncology stands somewhat apart: neither in relation to cause nor to treatment has any decisive breakthrough been achieved [S].
Large-sample studies of stress amongst medical staff have mostly involved nurses [6-111. With few exceptions [12, 131, comparable studies do not exist for doctors. Instead, analytical  or anecdotal [I41 reports dominate. Furthermore, previous work has tended to regard the problems of doctors and nurses as separate. This pays little regard to the large overlap in demands upon the two professions.
The link between stress and physical distress is now well documented [e.g. 15-17J. The term burnout [18, 191 has become popular in describing a syndrome of physical and emotional exhaustion amongst health professionals. Symptoms are somatic, such as headache, backache and fatigue . The syndrome is now best seen as a subcategory of stress effects [21,22].
Stress is considered here to result from an im- balance between the demands of the workplace and the individuals ability to cope [ 15,23,24]. Within the framework of a cancer ward, such variables as work rota or presence of trainees may act as stressors: they may influence the amount of stress experienced.
*To whom correspondence should be addressed.
Interaction with the patient, in particular the need to deal with dying and death, is also a major stressor . Staff will suffer through, or cope with stressors in a manner that relates both to their own back- ground and personal qualities and to institutional variables .
The relationship between physical complaints and stress is central to this study. A strong relationship would point to somatization and burnout. Differen- tial contributions to the relationship by different stress or conflict areas would identify potentially harmful stressors. The inclusion of both doctors and nurses allows examination of any profession-specific differences in the relationship. Stress is measured here using (1) a questionnaire describing many conflict situations, and (2) a checklist of (psycho)somatic symptoms.
The protocols of thirty structured interviews with doctors and nurses were sifted for the most com- monly mentioned problems. This led to a pilot ques- tionnaire, which was administreed to a further 25 staff employed on cancer wards. Additional refine- ments were then undertaken. The final version of the questionnaire covered four areas:
Conflict situations. Items described typical conflict situations (see Table 1). Respondents indicated whether a problem arose for them (the releoance of an item, scored 0 or 1) and, if so, the degree of emotional burden it caused (the severity of an item, rated from 1 to 5).
Fifty items were identical for both professions. 12 were specific to nurses and 10 to doctors. As pre- sented to the subjects, the items were grouped under provisional scale headings. A series of correlation and item analyses led to a minor reassignment of items. The final scales appear to be both meaningful and reliable. They too are given in Table 1.
1014 ANDREAS ULLRICH and PETER FITZGERALD
Background. This section contained questions about age, sex, marital status, habitation and size of commune. It also covered the subjects professional status (years of medical practice, years of training, hierarchical position, months on present ward, full- or part-time employment).
Institutional variables. This was in three parts, with a large number of questions referring to the insti- tution and to employment and ward conditions.
Health. Subjects completed a standardized health questionnaire . They rated, on a five-point scale, the frequency with which they experienced 21 physical complaints (backache, tiredness and so on) which were liable to contain some psycho- somatic component. The complaints are listed in Fig. 2.
For the most part, it is in internal oncology and radiotherapy that special treatment centres have been created, and thus that cancer wards are to be found. They exist almost exclusively in larger hospitals (more than 400 beds). Thirteen such hospitals in the West German state of Bavaria agreed to participate. Nurses and physicians were selected so that approximately half came from wards having exclusively cancer patients; for the remaining subjects, the percentage of cancer patients on the ward ranged from 25 to 75 approximately. Ques- tionnaires were completed by 91 nurses and 57 doctors (questionnaire return rates of 5 1% and 68%, respectively).
In the following, the level of significance for statistical tests is set at 5%. For doctors, Pearson correlations greater than 0.34 are significant at the 1% level; the corresponding value for nurses is 0.27. Except where stated otherwise, results are for those items and scales common to both professions. For the conflict situations, results are based on stress severity ratings (a rating of zero was assigned when the subject marked the item as irrelevant).
Responses to the conflict-situations questionnaire are summarized in Table 1. As expected, almost all items addressed problems often encountered. The similarity between the professions is strong: 80% of the items showed no significant difference in relevance
*The socio-demographic patterns for both doctors and nurses corresponded largely with the West German norms for hospital staff . Most of the nurses were female (91%). most of the doctors male (74%). Nurses were younger, averaging 32 years of age; doctors aver- aged 37 years of age. This age difference has two obvious sources: the longer training for doctors, and the high drop-out rate amongst nurses . Of the nurses, 57% were not living with a partner. This was true of only 23% of doctors.
Doctors performed stand-by duty, requiring presence in the hospital, three to five times per month; or they were on call, with a frequency between three and ten times per month. Most nurses (90%) performed one period of night duty (five to seven consecutive nights) per month.
between the two groups. as judged by a chi-squared test.
Physical complaints and stress
Profiles at the scale level are given in Fig. 1. Nurses show greater stress levels. Perhaps because they are in closer contact with patients they are particularly vulnerable in those areas which suggest an empathic component (Scales 3 and 4). Doctors alone must make therapy decisions and communicate diagnoses, and they rate these activities as relatively stressful.
Figure 2 displays the frequency with which subjects reported (psycho)somatic complaints. Again, the pattern is similar in the two professions, although the physical requirements of the job lead to more exertion-related complaints amongst nurses.
Canonical-correlation analyses were performed, pitting complaints against stress-scale severity levels. An analysis combining the data from doctors and nurses was attempted. Although two factors were significant, they were impossible to interpret. It is clear from Fig. 3 why this was so: the stress- complaints relationship for doctors and nurses is quite different. The professions are therefore dealt with separately in what follows.
Nurses. One factor emerged. The canonical corre- lation was 0.77 (Z = 2.86, P < 0.01). Stress predicted 12.6% of complaints variance and complaints 17.2% of stress variance.
In order to corroborate the findings of the canon- ical-correlation analyses, product-moment corre- lation matrices were also computed. Almost all correlation coefficients between stress scales and complaint items were positive. Negative loadings in Fig. 3 (nurses) represent low rather than negative correlation between the data sets.
For nurses, it is primarily interpersonal stress that relates to physical distress. Private life is most strongly linked to complaints. The following had product-moment correlations greater than 0.3~ with pricate life : headaches/pressure in head, tiredness, tendency to cry, loss of appetite, irritability. and neck/shoulder pain. One major correlate of physical distress amongst nurses thus lies partially beyond the work situation, in the nurses private life. Somatiza- tion is likely if life outside work fails to relieve stress generated in the job.
Dealing with patients is another powerful stressor. The scale correlates significantly with most com- plaints, but most strongly with irritability (r = 0.52) and neck/shoulder pain (r = 0.40). There may be three partially distinct phenomena here, namely interpersonal conflict (leading to irritability and headaches), physical distaste for certain tasks (lead- ing to visceral pain and nausea), and physical strain, causing back pain, heaviness in legs, and neck/ shoulder pain (all correlations > 0.30).
Identification with the patient correlates most markedly with tiredness, in its various forms (tired- ness, heaviness/tiredness in the legs, exaggerated need for sleep, and sudden exhaustibility; all correlations >0.40). Compared to some of the symptoms related to private life and dealing with patients, this list is almost reassuring. Identification with suffering may
Stress in the cancer ward 1015
Table 1. Conflict situations
RCI. Sev. Rel. Sev.
1. De&w wirh wtients fcrlobo = 0.78. 0.75) 1.1. I .2. 1.3. 1.4.
1.5. I.6 I .7. 1.8.
1.10. 1.11. 1.12. 1.13. 1.14.
&ken commtt&tion is difficult in the case of some patients I have to deal with patients who have totally closed themselves otT Many patients cling emotionally very strongly to me Patients are sometimes reproachful towards me because their therapy shows no real signs of success Many patients do not keep to therapeutic agreements I sometimes have to cope with patients who are aggressive There are patients who want to check everything I do I have to deal with patients whose spontaneous contribution to the treatment is too small With some patients I have the feeling that they want to influence me through their crying I have too little time to go into the personal problems of individual patients The sight of crying patients upsets me I feel personally rejected by some patients Our work is sometimes hindered by too frequent visits from relatives &fore falling asleep or on waking up, I sometimes worry about the problems of individual patients
2. Rejection by relatives (alpha = 0.74, 0.46) 2.1. Some relatives dont trust us to care optimally for the patient 2.2. I feel personally rejected by some relatives
3. Identifcarion with rhe patient (alpha = 0.57, 0.67) 3.1. Some patients receive too little support from their relatives 3.2. The sight of patients who lose their hair during therapy upsets me 3.3. I have to deal with patients who are badly crippled/deformed 3.4. I sometimes have to deal with patients who remind me of persons close to me 3.5. I sometimes worry about the children of incurably ill patients
4. Dying and death (alpha = 0.58. 0.65) 4.1. I sometimes have to tell relatives of the death of a patient 4.2. 1 experience with some patients the long-drawn-out advance of the illness 4.3. Against my conviction, many patients are kept alive by al1 possible methods 4.4. Sometimes a patient whom I very much liked dies during my absence 4.5. In my section it sometimes happens that several patients lie dying at the same time
61.4 I.7 14.1 2.2 58.9 2.5 67.4 2.8 84.2 2.4 80.7 2.6
82. I 2.1 80.9 2.9 93.0 2.0 83.0 2.0 91.2 2.2 89.9 2.9 16.8 1.7 77.5 1.7
84.2 2.0 74.2 2.2
36.8 2.0 45r3 1.7 66.1 3.2 82.0 3.9 80.7 2.1 87.4 3.3 45.6 2.4 37.5 2.0 33.3 1.9 48.3 2.2
82.5 2.6 90.9 3.2
13.1 2.3 76.4 2.3 43.9 I.8 35.2 1.4
100.0 2.6 98.8 3.3 49. I 2.2 71.6 2.6 70.2 2.5 73.3 3.1 58.9 3.0 55.3 3.1 87.7 3.1 92.0 3.8
93.0 2.6 85.1 3.5 lOO.0 35 100.0 3.1 49.1 3.3 12.9 4.1 93.3 2.9 96.6 3.2 92.9 2.9 98.9 3.6
5 Job critique (for common items, alpha = 0.64, 0.66) (ineluding profession -spec:Jic items, alpha = 0.71, 0.75) 5.1. Sometimes I feel burnt out inside 55.4 5.2. 1 have phases in which I ask myself what purpose my work serves 62.5 5.3. Im disappointed by the limited power of medicine 60.7 5.4. I sometimes have to treat foul-smelling wounds 75.0 5.5. Im underpaid for what I do 33.3 5.6. I have weekend duty too often 38.2 5.7. An unpleasant aspect of my work are the night duties 40.0 5.8. N I sometimes have to lay out a corpse - 5.9. N My work is physically demanding - 5.10. N An unpleasant aspect of my work is the frequent seesaw hours of duty (switching
between late and early shifts) 5.1 I. D My work can lead to physical exhaustion 64.3
6. Pricaie life (alpha = 0.68, 0.76) 6. I. My contact to friends and acquaintances suffers again and again under the effects of
my irregular working hours 62.5 6.2. At times Im so taken up by my work that I cant devote myself enough to my family 71.2 6.3. Some crises with friends or family stem from my work situation 41.4
7. Space (alpha = 0.74, 0.73) 7.1. My work is made worse through space limitations in the sickrooms 33.9 7.2. Our work is made more difficult through lack of a day room for the patients 19.6 7.3. I feel the lack of a quiet room in which we colleagues could talk...