Transcript
Page 1: Stress experienced by physicians and nurses in the cancer ward

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

INTRODWTION

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 patient’s suffer- ing increases, bringing added emotional burden [l]. Identification with the dying patient may come to represent a threat to one’s own existence [2]. 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 [3] 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. 15-17’J. 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 [20]. 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 individual’s 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 [25]. 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 [26].

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.

METHOD

Questionnaire development

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.

1013

Page 2: Stress experienced by physicians and nurses in the cancer ward

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 subject’s 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 [27]. 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.

Sample

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).

RESULTS*

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 [28]. 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 [29]. 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 nurse’s 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

Page 3: Stress experienced by physicians and nurses in the cancer ward

Stress in the cancer ward 1015

Table 1. Conflict situations

Doctors NUt%s

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.

1.9.

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 don’t 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. I’m disappointed by the limited power of medicine 60.7 5.4. I sometimes have to treat foul-smelling wounds 75.0 5.5. I’m 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 I’m so taken up by my work that I can’t 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 undisturbed with each

other 16.1 7.4. We don’t have enough single rooms for the dying 60.7

8. Workday (for common items, alpha = 0.74, 0.69) (including profession-specific items, olpbo = 0.73, 0.81) 8.1.

8.2. 8.3. 8.4. 8.5. 8.6. 8.1. 8.8.

It happens again and again that I’m suddenly called away during a personal conversation with a patient I spend too much time with office work I sometimes feel underchallenged by tasks that don’t correspond to my training The telephone rings too often I’m allowed too little liberty to strike my own decisions For the work I do I receive too little recognition from my superiors I have conflicts with colleagues N Much rushing about arises for me through some patients who call me for trivial reasons

8.9. N It annoys me when patients try to play nursing personnel off against each other 8.10. N The nursing directors give us too little support 8.11. N Sometimes I have to ‘carry the can’ for the mistakes of others 8.12. D The nursing personnel sometimes act too independently

80.7 3.0 91.0 3.3 73.7 3.2 72.4 3.4 42. I 3.0 30.7 2.7 15.4 2.8 81.4 3.4 14.0 2.1 29.8 3.0 28.1 3.1 32.1 2.1 26.3 2.5 26.5 3.0

- -

- 35.1

3.5 61.4 3.7 35 55.2 3.g 2.1 59.5 3.2 1.6 93.2 1.9 2.3 79.8 2.2 3.0 28.6 2.5 2.6 43.0 3.1 - 96.6 2.0 - 94.3 2.8

- 2.6

52.9 2.4 - -

2.8 67.8 3.2 3.5 62.5 3.2 3.3 45.2 3.5

2.9 52.3 2.8 2.3 22.7 3.1

2.9 32.2 3.1 3.5 81.2 3.7

- - - - 1.9

66.7 2.2 69.8 2.7 57.8 2.8 51.8 2.3 - -

[Table 1 continued overleaf

Page 4: Stress experienced by physicians and nurses in the cancer ward

1016

Tuhle I-conrimed]

ANDREAS ULLRICH and PETER FITZGERALD

Doctors NlUX.S

Rel. Sev. Rel. sev.

9. Con/&r wirh doctors (nurses only, alpha = 0.70)

9.1. My proposals for the care of individual patients receive loo little attention from doctors 9.2. AS I see it, some doctors bother too little about rhe personal problems of patients 9.3. I’m sometimes put in a tighr spot by questions from patients which the doctors should

anwer 9.4. It sometimes happens that doctors criticize me in Ihe presence of patients 9.5. I someGmes find that patients receive insutlicienc therapy for pain

10. Communicating the diagnosis (doctors only, alpha = 0.51)

IO. I. There are patients who, despite considerable etTort. do not understand my explanations

concerning their illness 10.2. I can’t judge, before revealing the diagnosis, whether the patient can cope with the truth 10.3. I have 10 explain to cancer patients the meaning of their diagnosis

Il. Thherap.~ decisions (docmrs only. alpha = 0.66)

I I. I. In isolated cases, and as a result of orders from higher up, I have lo carry out a particular therapy despite my personal scepticism

11.2. I sometimes ask myself if I’ve really helped the patient with the therapy or operation I ordered

11.3. I am forced lo See how badly patients suffer from the chemotherapy I prescribe 11.4. Sometimes a patient dies in my hands 11.5. Beween doctors and nursing personnel there are sometimes disagreements concerning

therapy concepts

- -

- - -

- 26.7 3.0 - 62.2 2.9

- 92.0 2.4 - 23.3 2.9 - 55.4 3.8

72.7 61.8 83.3

2.3 - - 2.6 - - 2.7 - -

57. I 2.8 - -

92.9 78.6 55.4

3.5 - - 3.2 - - 1.9 - -

80.0 3.3 - -

firms which hate nor been included in the abow scales

I sometimes realize that the suffering of my patients has little e&t on me I sometimes see how colleagues treat very ill patients unfeelingly

. . . . ^ . . 56. I 70.2 36.8

I.5 21.6 2.3 3.3 58.1 3.5

Amongst my colleagues It IS not usual to speak about personal 1eeilngS 2.2 18.2 1.6

The conflict-situation items, translated from German and listed under their final Scale headings. ‘Alpha’ after each heading is Cronbach‘s alpha, calculated in item analyses over the severity scores; the alpha values are in pairs, the first being for doctors, the Second for nurses. Relevance is expressed as a percentage. The severity values are mean ratings calculated over those subjects who marked the item as relevant.

‘The values of relevance > = 90% and of severity > = 3.2 are printed in bold typeface.

“Irems marked N were only administered to the nurses and those marked D only lo the doctors.

engender overcommitment and tiredness but not absent. Thus if reported symptom level, rather than more undesirable symptoms. reported stress level, is taken as an indicator of

There is another way of looking at these results. objective stress, then neither lack of satisfaction with With few exceptions, the correlations between symp- the job and the surroundings (job critique, space. toms and rejection by relatives, death and dying, job workday) nor proximity to the dying are linked to critique, space and workday are low or altogether health-related stress. Ident$cation with the patient’s

4. Death and dying i I -.:,/i, **

w* 3. Identification with the patient 1 . ,,“.,, 1

11. Therapy decisions k i : ‘.,,.-, ,’ 1

10. Communicating the diagnosis B-: . c :&

1. Dealing with patients ,,*,. M*

6. Private life u

5. Job critique

8. Workday

9. Conflict with doctors j 113 Nurses /

2. Rejection by relatives b-4

! I ! Ii/ I I I I I i I

0 0.5 1 1.5 2 2.5 3 3.5

Average Rating

Fig. 1. Average levels of stress for each of the stress scales. Where a difference between professions is significant by l-test this is marked: l P c 0.05, **P < 0.01.

Page 5: Stress experienced by physicians and nurses in the cancer ward

Stress in the cancer ward 1017

Upper/lower back pain

Tiredness

Irritabiliity

Heaviness/tiredness in legs

Headaches/pressure in head

Exaggerated need for sleep

Neck/shoulder pain

Joint/limb pain

Cold feet

Tendency to cry

Sudden exhaustibility

Visceral pain I

Sleeplessness by I I.

Dizziness b

h-regular heart beat ‘w

Pain/pulling in breast 3 Bob

Nausea Lh+

Loss of appetite

Discomfort in throat 4

Diarrhoea

Attacks of breathlessness :-

Y II

0 20 40

I Nurses

m *actors

II I

60 80 100

Percent Experiencing Problem

Fig. 2. Levels of physical complaints. The results represent percentage of subjects admitting to suffering from the problem to some degree. Significant differences between professions, judged according to a chi-squared test, are marked l P c 0.05, l *P < 0.01. The complaints are displayed according to the rank ordering for nurses. ‘Including stomach or abdominal pain. *Thumping, racing, faltering heart. ‘Shooting

pain/pain/contraction in the breast. ‘Lump/restriction/choking in the throat.

suffering is itself principally tiring. It is the effects of interpersonal difficulties (private life, dealing with patients) which are most worrying.

Doctors. The findings can be summarized in one over-simple phrase: stressed doctors are tired. The canonical-correlation results are summarized in Fig. 3.

Once again, almost all stress-complaints corre- lations were positive. Differences between stress and complaint items in the sign of a coefficient therefore point to low positive rather than negative correlation. Where signs are in the same direction (whether posi- rice or negutitle) the corresponding items are more likely to be strongly correlated.

Two factors were extracted. The first had a canon- ical correlation of 0.89 (Z = 3.42, P < O.Ol), the second one of 0.86 (Z = 1.96, P = 0.05). For Factor 1, stress predicted 8.5% of complaints variance, compared to 3.1% for Factor 2; the corresponding values for prediction of stress by complaints were 18.4% and 5.4%.

Whereas complaints for nurses relate to inter- personal stress, this relationship is much less strong amongst doctors. The three scales that stand out on

Factor 1 are space, dealing with patients and workday. The picture that emerges is of doctors working under sub-optimal conditions. Space stress correlates strongly (> 0.35) with sudden exhaustibility and cold feet, and workday with tiredness, tendency to cry, sudden exhaustibility (r = 0.56), visceral pain, cold feet, nausea, irritability (r = 0.51), exaggerated need for sleep, and dizziness. The factor can perhaps be summarized as ‘malaise’.

Factor 2 may represent a more somatized rejection of aspects of the job. Whereas the strongest corre- lations (>0.35) for job critique overlap many of those mentioned above (tiredness, exhaustibility, cold feet, back pain, exaggerated need for sleep), there is also a different physical aspect shown by the correlations with irregular heartbeat (r =0.35) and diarrhoea (r = 0.46). The workday correlations con- tinue this theme, as Factor 2 associates it to three symptoms-dizziness, discomfort in the throat, and attacks of breathlessness (r = 0.38, r = 0.34 and r = 0.29, respectively)- which distinctly relate to panic [30].

Identl$carion with the patient has strong negative loadings on both factors. Its principal correlations

Page 6: Stress experienced by physicians and nurses in the cancer ward

1018 ANDREAS ULLRICH and PETER FITZGERALD

NURSES DOCTORS

(- 107) Factor 2 Factor 1

upper/lower back pam -

tiredness -

irritabihty -

t

- heaviness/tiredness in legs -

- headaches/pressure in head -

6 -

‘i - - - - -

c - - - - - - % - - - - I I I I I I

-0.5 0 0.5

exaggerated need for sleep

neck/shoulder pain

joint/limb pain

cold feet

tendency to cry sudden exhaustibility

visceral pain

sleeplessness

dizziness

irregular heartbeat

pain/pulling in chest

nausea

loss of appetite dLscomfort in throat

diarrhoea

attacks of breathlessness

- - ..,.!s - - 45 ‘A - -... .:A

- n--.-- - c; 1 &::;:::.;.t / - --A.,, - -

- 5 .‘a

,....‘.T:::A - -

+k:::::::::

- A__.__w

I I I , I -0.5 0 0.5

standardized standardized canonical coefficient canonical coefficient

Fig. 3. Results for the canonical-correlation analysis relating stress scales (top) and physical complaints (bottom)

(>0.30) are with tendency to cry, loss of appetite, diarrhoea, irritability and dizziness. This is in marked contrast to the pattern found amongst nurses, where identification was associated with tiredness, rather than with these more somatized and emotional reactions.

Profession -specific items and scales. Canonical and Pearson-correlation statistics were recalculated to include profession-specific items and scales (see Table 1). At neither the item nor the scale level was there much that was new. Conjict with doctors (amongst nurses) related most highly to irritability (r = 0.35). Communicating the diagnosis and therapy decisions (both only amongst doctors) were essen- tially unrelated to physical symptoms.

Sex d@rences. The possibility existed that the relationships uncovered between stress and symp- toms were due to sex differences. We therefore calcu- lated partial correlations between the stress scales and the symptoms, with sex held constant. Neither amongst doctors nor amongst nurses was there more than a very slight and completely non-significant change in the values of the correlations, when com- pared with those reported above.

Summary. Interpersonal stress is the main link with physical complaints amongst nurses. Most im- portantly, the way in which work impinges upon private life relates to physical well-being. For doctors, there is stronger somatization. It is linked as much to dissatisfaction with aspects of the job and the working environment as to difficulty in dealing with patients.

Complaints and ‘life ’ variables

A number of the background and institutional variables-henceforward ‘life’ variables-were chosen for canonical correlation with physical com- plaints. Profession, it emerged, brings with it certain complaints: nurses suffer back pain and cold feet, young doctors get very tired. Sex, not profession, affects tendency to cry.

The number of variables employed was limited (see Fig. 4), in part because inclusion of more, less important variables reduced the analyses to non- significance. In the event, only the analysis with both professions combined proved significant (canonical correlation = 0.71, Z = 3.66, P < 0.01). The life- variable portion of the single factor accounted for

Page 7: Stress experienced by physicians and nurses in the cancer ward

Stress in the cancer ward

standardized canonical coeffim’ents

1019

upper-,/lower back pain tiredness

irritability heaviness/tiredness in legs

headaches/pressure in head exaggerated need for sleep

neck/shoulder pain joint/limb pain

cold feet tendency to cry

sudden exhaustibility visceral pain sleeplessness

dizziness irregular heartbeat

pain/pulling in chest nausea

loss of appetite discomfort in throat

diarrhoea attacks of breathlessness

profession (doctor...nurse)

age sex (female...male)

oncological experience beds in hospital/clinic

work with trainees (yes...no)

/ - - - 2 -

Fig. 4. Results for the canonical analysis relating physical complaints and selected life variables.

7.1% of the complaints variance. The coefficients are plotted in Fig. 4.

The relationship is defined largely on the basis of profession, sex and age. Back pain is related to (1) profession (see Fig. 2) and (2) age (r = -0.26 overall), but not to sex (sex/back-pain correlations within profession are completely non-significant). The greater physical demands upon nurses are the likely source of their greater incidence of back pain. The further correlations with age imply that it is younger (and thus less senior) nurses who strain their backs most. Back pain and tiredness are signifi- cantly related (r = 0.35 overall) but it is only for doctors that age and tiredness correlate (r = -0.31; r= - 0.06 for nurses). Tiredness is a greater problem amongst junior doctors, and a likely accompanying symptom is back pain.

Of the other relationships, tendency to cry is sex-related (r = -0.40 overall). incidence of cold feet correlates with profession (r = 0.34); nurses suffer more, though it is unclear why this is so. For the other three life variables, correlations with physi- cal complaints were generally of low magnitude, and none were of particular interest.

Stress and ‘life’ variables

The same six life variabtes were entered into canon- ical correlation with the stress scales. The picture that emerged was four-fold. (1) Hospital size is important. (2) Across a variety of scales, stress reduces with age. (3) The presence of trainees exacerbates work stress.

(4) There are other profession-related differences, most markedly for death and dying.

The results are displayed in Fig. 5. When both professions were treated together, two factors emerged. The first had a canonical correlation of 0.51 (Z = 4.58, P < O.Ol), the second one of 0.44 (Z = 2.86, P < 0.01). Life variables accounted for 9.9% of stress variance (3.1% and 6.8% for Factors 1 and 2 respectively). Taking the professions separ- ately, only nurses yielded significant results. The sole factor to emerge was very similar to Factor 1 of Fig. 5, and it is not therefore shown here.

A prime influence in Factor 1 is hospital size, as reflected in the bed count. Nurses in smaller hospitals are more stressed through identification with the patient (r = -0.23), but express less job critique (r = 0.24). Doctors show a different pattern: for them, small hospitals or clinics are associated with space difficulties (r = -0.27).

Age is also a significant modifier of stress. The young have greater difficulty dealing with patients, more workday stress and express more job critique; they are more stressed by death and dying. Young nurses complain more of rejection by relatives and of private-life stress. Significant correlations are too many to cite, but they range between -0.21 and -0.35. It seems likely that three processes are in operation: (1) with age comes experience and the ability to cope; (2) with age comes seniority and a distancing from many stressors: (3) the most dis- satisfied leave when young [29].

Page 8: Stress experienced by physicians and nurses in the cancer ward

1020 ANDREAS ULLRICH and PETER FITZGERALD

standardized canonical coe,f,%nmts -06 -01-02 0 O? 0-I 06

i i ,‘I “I

dealing with patients - n \ ”

rejection by relatives -

ldentlflcation with the patient -

death and dying -

job critique - I

private life -

space -

workday -

profession (doctor. .nurse) - ....

sex (female...male) -

oncological experience - ..n

hospital bed count -

<

a.“’

work with trainees (yes...no) - A

Factor 2 Factor I

Fig. 5. Results for the canonical analysis relating stress scales and selected life variables.

For nurses, the presence of trainees is associated with greater workday stress (r = 0.37), more conflicr with doctors (r = 0.30) and greater job critique (r = 0.25). Although the correlations for workday and job critique are similar amongst doctors, they are not significant.

A number of these relationships are borne on Factor 2, in particular the age/dealing with patients pattern. However, the canonical relationship between stress and life variables is not strong. This may account in particular for the high loadings achieved by identification with the patient, when inspection of the underlying correlations reveals that there is no such strong or simple relationship between identifi- cation and life variables.

Finally, there are stress-level differences between the professions. The strongest of these concerns death and dying, which nurses find more stressful than doctors (r = 0.32, P c 0.01). There are similar but less marked differences for identification with the patient, dealing with patients and space (see also Fig. 1).

Total stress/complaints

As very rough measures of stress and well-being, total-stress (for common items) and total-complaint scores were calculated by summing. Irregular shifts correlates amongst nurses with both stress and com- plaints (r = 0.25 and r = 0.27, respectively). For doctors there is a similar relationship, at least for stress: frequent stand-by duty is associated with higher values (r = 0.33).

CONCLUSIONS

The sample consisted of nurses and doctors who cared for cancer patients. Background and institutional information were gathered, along with measures of stress and reported incidence of 21 physical complaints. Potentially stressful situations were categorized under 11 headings, which reflected conflict areas both in the patient-helper relationship and in the helpers’ work and home environment. It was expected, following the conception of stress as misfit between demands and ability to cope, that work and background conditions would relate to amount of stress experienced, and that stress, through somatization, would be predictive of ill-health.

The link between stress and symptoms found ample confirmation in the present data. Through canonical- and Pearson-correlation analyses, stress- symptom patterns were identified. For nurses, many physical complaints relate to interpersonal difficulties, both in their private lives (as a result of the disruption their work causes) and in their dealings with patients. The type of complaint-irritability, headaches-contrasts with the effects of greater identification with the suffering of the patient. In the latter case, overcommitment on the part of the nurse may lead to undue tiredness, without other symp- toms. Certain stress areas, such as proximity to the dying, were unrelated to psychosomatic illness, although powerful stressors (Siegrist [31] came to a similar conclusion).

For doctors, there was malaise linked to dissatis- faction with the job or work environment. Although

Page 9: Stress experienced by physicians and nurses in the cancer ward

Stress in the cancer ward I021

the general picture was of tiredness, a sub-pattern of symptoms linked stress to loss of control, in the form of irregular heartbeat, diarrhoea, discomfort in the throat, dizziness and breathlessness. The doctors’ stress may derive in part from lack of confidence when faced with their limited ability to alter the course of the illness [32-341. Identification with the patients’ suffering, which was linked to tiredness amongst nurses, had effects amongst doctors which suggest an almost physical rejection of the patient.

It can be argued that the direction of causality is not necessarily or always from stress to physical symptoms. It could be that certain physical symp- toms predispose to stress in certain job situations. A rigorous test of the stress-symptoms link would require initial screening for symptomatology, and then a longitudinal study design, preferably with crossover between stressor conditions (as achieved, for example, by Parkes [8]). However, three points may be noted. (1) Inspection at the item level (Table 1) suggests that those stress scales which relate to physical complaints do not entail more physical demands on carers than do those stress scales which do not relate to physical complaints. (2) Some stress scales relate most strongly to certain physical- complaint patterns, and other stress scales to other physical-complaint patterns; that is, there is no general effect ascribable to ill health. (3) The stress-symptoms relationship is different for doctors and nurses. Taking these three points together, it seems unlikely that causality could run solely from the physical to the psychological.

Profession, age, sex, hospital size and presence of trainees emerged as ‘life-variable’ predictors of stress. Nurses reported more empathy-stress. With age, stress reduced for most stress areas. Working with trainees was associated with greater job dissatisfac- tion in general. Small hospitals engendered less job critique amongst nurses, but more stress through identification with the patients. Doctors found such hospitals cramped. A number of direct relationships between life variables and physical complaints also emerged. These were of a predictable kind: nurses suffered from exertion-related complaints, young doctors were very tired. Irregular working hours related to both total level of stress and total symptom level.

Our results agree with others in finding that caring for the ill and dying is a major stressor for carers [6,7,9,35]. However, any rank-ordering of stressors is open to the criticism that item wording can greatly influence mean values. We have concentrated on harmfuf stress, namely that which can be linked to (psycho)somatic complaints. Our results suggest that it is not necessarily those areas which receive the highest stress ratings which are most harmful.

The final picture if of nurses and doctors who bring certain socio-demographic characteristics with them to work, who are subjected to certain institutional constraints, who react variously to the stresses of caring for the sick and dying, and whose stress pattern relates to psychosomatic disorders. To reduce the likelihood of somatization, certain institutional variables can be modified. However, intervention in particular problem areas-interpersonal difficulties,

for example, for nurses; job dissatisfaction for doctors-may be more effective.

Acknowledgements-The authors are grateful to three anonymous reviewers for their comments on a previous version of this paper. They are also grateful to Jill Cross- land, Kathy Parkes and Maureen Parr.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

IS. 16.

17.

18.

19.

20.

21.

22.

REFERENCES

Artiss K. L. and Levine A. S. Doctor-patient relation in severe illness. New Engl. J. Med. 288, 1210-1214, 1973. Meenvein F. Bemerkungen zur Arzt-Patient-Beziehung bei Krebskranken. Z. Psychosom. Med. Psychoanal. 22, 278-300, 1976. Kasper A. M. The doctor and death. In The Meaning of Dearh (Edited by Feifel H.). McGraw-Hill, New York, 1959. Feifel H., Hanson S., Jones R and Edwards L. Physicians consider death. Proc. Ann. Meef. Am. Psychopatholog. Ass. 75th Annual Contention, p. 201. 1967. Bailar J. C. and Smith E. M. Progress against cancer? New Engl. J. Med. 341, 12261232, 1986. Birch J. The anxious learners. Nursing ‘Mirror 148, 17-22, 8 Febr., 1979. Gray-Tort P. and Anderson J. G. Stress amone hosuital nursing staff: its causes and effects. Sot. Sci. Med. iSA, 639-647, 1981. Parkes K. R. Occupational stress among student nurses: a natural experiment. J. appl. Psychol. 67, 784-196, 1982. Parkes K. R. Stressful episodes reported by first-year student nurses: a descriptive account. Sot. Sci. Med. 20, 945-952, 1985. Stewart B. E., Meyerowitz B. E., Jackson L. E.. Yarkin K. L. and Harvey J. H. Psychological stress associated with outpatient -oncology- nursing. Cancer Nurs. 5, 383-387, 1982. Yasko J. M. Variables which predict burnout experi- enced by oncology clinical nurse specialists. Cancer Nurs. 6, 109-116, 1983. Vachon M. L. S., Lyall W. A. L. and Freeman S. J. J. Measurement and management of stress in health professionals working with advanced cancer patients. Drh Educ. 1, 365-375, 1978. Reimer C. and Kurthen B. Zur Beziehungsproblematik zwischen Aerzten und Krebspatienten. Psychother. Psychosom. Med. Psychol. 35, 86-94, 1985. Wise T. N. Training oncology fellows in psychological aspects of their specialty. Cancer 39, 2584-2587, 1977. Cox T. Stress. Macmil&, London, 1978. Theorell T. Life events before and after onset of the premature myocardial infarction. In Stressful Life bents: Their-Nature and Eficts (Edited by bohren- wend D. S. and Dohrenwend B. P.). Wiley. New York, _ 1974. Gay J. E. Nursing a stressful occupation-prove it! J. R. Sot. Hllh 103, 78-81, 1983. Freudenberger H. J. Staff bum-out J. Sot. Issues.30, 159-165, 1974. Maslach C. and Pines A. The burn-out syndrome in the day care setting. Child Care Q. 6, 110-113, 1977. McElroy A. M. Burnout-a review of the literature with application to cancer nursing. Cancer Nurs. 5,21 l-217, 1982. Shinn M., Rosario M., March H. and Chestnut D. E. Coping with job stress and burn-out in the human services. J. Person. sot. Psychol. 46, 864-876, 1984. Hingley P. and Cooper C. L. Stress and rhe Nurse Manager. Wiley, Chichester, 1986.

Page 10: Stress experienced by physicians and nurses in the cancer ward

1022 ANDREAS ULLRICH and PETER FITZGERALD

23.

24.

25.

26.

27.

28.

Brengelmann J. C. Persoenliche Effektivitaet, Stress and Lebensqualitaet. Strukturen der positiven Lebensgestal- tung. In Psyche und Geist (Edited by Resch A.). pp. 395-423. Resch, Innsbruck, 1986. Lazarus R. S. Psychological Stress and the Coping Process. McGraw-Hill, New York, 1966. Glaser B. G. and Strauss A. L. Awareness of Dying. Aldine, Chicago, IL, 1965. Parkes K. R. Coping in stressful episodes: the role of individual differences, environmental factors, and situational characteristics. J. Person. sot. Psychol. 51. 1277-l 292, 1986. von Zerssen D. Klinische Selbstbeurteilungs-Skalen (KSb-S) aus dem hfuenchener Psychiatrischen Informa- ;ionssys;em. Die Beschwerdelis;e. Beltz, Wehheim, 1976. Proell U. and Streich W. Arbeirszeit und Arbeitsbedin- gungen im Krankenhaus. Bundesanstalt fuer Arbeitss- chutz, Dortmund, 1984.

29. Bailey J. T. Stress and stress management. An overview. J. Nurs. Educ. 19, 5-7, 1980.

30. Clark, D. M. A cognitive model of panic attacks. In Panic: Psychological Perspectives (Edited by Rachman S. and Maser J. D.). Erlbaum, Hillsdale, NJ, 1988.

3 1. Siegrist J. Arbeit und Inreraktion im Krankenhaus. Enke, Stuttgart, 1978.

32. Melvin J. and Krant M. D. Problems of the physician in facing the patient with the diagnosis. From. Radial. Ther. Gncol. 11, 59-67, 1976.

33. Schulz R. and Adermann D. How the medical staff copes with dying patients: a critical review. Omega 7, 1 l-21, 1976.

34. Vaillant G. E., Sobowale N. C. and McArthur C. Some psychologic vulnerabilities of physicians. New Engl. J. Med. 287, 372-375. 1973.

35. Caldwell T. and Weiner M. F. Stresses and coping in ICU nursing. Gen. Hosp. Psychiat. 3, 119-127, 1981.


Recommended