Psychological distress, burnout level and job satisfaction in emergency medicine: A cross-sectional study of physicians in China

bs_bs_banner Emergency Medicine Australasia (2014) 26, 538 542 doi: 10.1111/1742-6723.12315 ORIGINAL RESEARCH Psychological distress, burnout level and job satisfaction in emergency medicine: A cross-sectional study of physicians in China Yunbei XIAO, 1 Jinguo WANG, 1 Si CHEN, 2 Zhigang WU, 1 Jian CAI, 1 Zhiliang WENG, 1 Chengdi LI 1 and Xiaowei ZHANG 3 1 Department of Urology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China, 2 Department of Infectious Disease, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China, and 3 Department of Urology, Peking University People s Hospital, Beijing, China Abstract Background: Chinese physicians are not only facing heavy work overloads, but also abuse and injury because of patient mistrust of physicians. The primary objective of the present study was to measure psychological distress, burnout levels and job satisfaction among Chinese emergency physicians. Methods: All the physicians from the EDs of three large general hospitals were recruited to undertake a questionnaire-based survey from March to April 2012. The Hospital Anxiety and Depression Scale (HADS), Maslach Burnout Inventory-General Survey and Minnesota Satisfaction Questionnaire were used. Correlations between job satisfaction and psychological distress and burnout were calculated using the Pearson correlation. An outcome was considered statistically significant if P < 0.05. Results: Completed questionnaires were received from 205 (82.0%) physicians. The mean HADS anxiety subscale scores for the ED physicians and general population were 7.8 ± 3.4 and 4.7 ± 3.5, respectively (t = 1.526, P < 0.05). Additionally, the mean HADS depression subscale scores were 7.9 ± 3.6 and 4.7 ± 3.9, respectively (t = 1.567, P < 0.05). Fifty-two (25.4%) exhibited high levels of career burnout. All aspects of job satisfaction were significantly lower in the ED physicians compared with a previous report (P < 0.05). Burnout was significantly negatively correlated with intrinsic and extrinsic job satisfaction in the sampled population. Conclusion: Psychological distress is prevalent in this group of ED physicians, and it deserves attention from the whole society. Burnout and job satisfaction among ED physicians are at a moderate level. Burnout is negatively associated with higher job satisfaction. Key words: burnout level, China, emergency medicine, job satisfaction, psychological distress. Introduction The practise of emergency medicine involves dealing with multiple sources of uncertainty, combined with a very Correspondence: Dr Xiaowei Zhang, Department of Urology, Peking University People s Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing 100044, China. Email: docachang@126.com Yunbei Xiao, MD, Urology Clinicist; Jinguo Wang, MD, Urology Clinicist; Si Chen, MD, Infectious Physician; Zhigang Wu, MD, Urology Clinicist; Jian Cai, BSc, Professor; Zhiliang Weng, BSc, Professor; Chengdi Li, BSc, Professor; Xiaowei Zhang, MD, Clinical Instructor, Doctor-in-Charge. Yunbei Xiao and Jinguo Wang contributed equally to this work. Accepted 7 September 2014 Key findings Psychological distress is prevalent in Chinese emergency medicine physicians. Their burnout and job satisfaction are at moderate level. Burnout is negatively associated with higher job satisfaction. stressful environment, a combination of circumstances that appears to be frequently associated with stress, burnout and loss of career satisfaction. 1,2 Previous research demonstrates that ED physicians experience high levels of stress. Between 26.8% and 51% of ED doctors have been found to experience significant clinical distress. 3,4 This compares with 17.8% within the general population 5 and 19 29% for doctors in other specialties. 6 The data indicate that ED physicians are facing much more pressure and stress compared with the general population and with physicians from other specialties. Additionally, the huge population base and increasing health consciousness in recent years in China have led to an overload of patients for Chinese doctors. Chinese doctors experience work overloads and extra shifts quite often, and studies have reported that 57.5% of Chinese doctors work more than 40 h per week. 7 Doctors are more likely to experience time and energy deficiency, which can lead to burnout. Although Chinese physicians are facing work overloads, they are also in a critical social crisis. In recent years, they

PSYCHOLOGICAL DISTRESS, BURNOUT LEVEL AND JOB SATISFACTION 539 have faced increasing threats to their personal safety at work. 8 Doctors have been abused, injured and even murdered by patients or relatives of patients in hospitals and clinics across the country because of mistrust between patients and doctors. 9 Working in the ED is therefore more stressful than working in other specialties. However, there have been few studies describing the psychological distress, burnout level and job satisfaction of ED physicians in China. Therefore, the primary objective of the present study was to measure the psychological distress, burnout level and job satisfaction among Chinese emergency physicians. Materials and methods We conducted the present study with survey methodology and selected three large, general, public-owned hospitals: Beijing Chaoyang Hospital, Peking University People s Hospital and Beijing Anzhen Hospital. In these public-owned hospitals, ED physicians encounter emergent diseases from nearly all specialty areas of medicine. They work under high pressures and need to attend 2 days of day shift then 2 days of night shift. As teaching hospitals, the work characteristics in these three hospitals are similar. We chose three liaison officers from these hospitals, and they were responsible for recruiting all the physicians from ED by face-to-face conversation. After obtaining informed consent to conduct this survey, we distributed a self-administered questionnaire to these participants during March and April 2012. Every participant was required to complete the questionnaires in a quiet room and when he/she was rested at least 1 day after a shift. After completing the survey, each participant sealed the questionnaire in an envelope that was not opened until the data analysis phase to keep the respondent s identity confidential. Data were collected using demographics (age, sex, marital status, children and duration working for the hospital) and the following psychometrically validated self-report measures. The questionnaire was composed of three sections: 1. The Hospital Anxiety and Depression Scale (HADS) 10 contains two scales, anxiety and depression, both comprising seven questions rated on a scale from 0 to 3 to indicate severity. The anxiety and depression scores can be categorised clinically as normal (0 7), mild (8 10), moderate (11 14) and severe (15 21). A threshold score of 8 or above is suggested as most appropriate to indicate clinical significance. 11 The Chinese version, which has demonstrated good reliability and validity, 12 was used. 2. The Chinese version of the Maslach Burnout Inventory-General Survey (MBI-GS) is a widely used instrument for measuring burnout. 13 The 15-item MBI-GS questionnaire uses a six-point scale, 14 including three dimensions: emotional exhaustion, cynicism and personal accomplishment. High scores on the emotional exhaustion or cynicism dimensions indicate burnout, as do low scores on the personal accomplishment dimension. In our study, the Cronbach s alpha of the MBI- GS was 0.85. The Cronbach s alpha for the subscale emotional exhaustion, cynicism and personal accomplishment were 0.91, 0.89 and 0.92, respectively. 3. The Minnesota Satisfaction Questionnaire (MSQ) 15 is a well regarded measure of job satisfaction, which has been used effectively in some Chinese studies after simple adjustment. 16 The 20-item shortform MSQ uses a five-point scale (from 1 = very dissatisfied to 5 = very satisfied), including two dimensions: intrinsic job satisfaction and extrinsic job satisfaction. Intrinsic job satisfaction includes 12 items that refer to activity, ability utilisation, achievement, and so forth. Extrinsic job satisfaction includes items that refer to supervision human relations, company policies, compensation, and so forth. Increasing intrinsic and extrinsic job satisfactions generate a higher score. Overall job satisfaction is a total of 20 items and can be considered as a composite of all the facets of job satisfaction. The score of overall job satisfaction ranges from 20 to 100. A score of either very dissatisfied or dissatisfied with their job is 40 and below; of dissatisfied to moderately dissatisfied is from 41 to 59; of moderate is 60; of moderate to not fully satisfied is from 61 to 79; of satisfied or very satisfied is 80 and above. 17 In the present study, the Cronbach s alpha for the overall job satisfaction, intrinsic job satisfaction and extrinsic job satisfaction of the MSQ were 0.91, 0.92 and 0.84, respectively. All qualifying questionnaires were double-entered by two independent professional data processors with Epidata 3.0 (EpiData Association, Odense, Denmark). If the amount of missing data in the questionnaire was <10%, the questionnaires were considered qualified ; if the amount was >10%, the questionnaire was excluded from analysis. Statistical analysis was performed using the Statistical Package for Windows v. 17.0 (spss, Chicago, IL, USA). All data were shown as number (n), percentage (%), mean and standard deviation. Correlations between job satisfaction and psychological distress and burnout were calculated using the Pearson correlation. All independent variables were entered into the spss to determine the degree to which these accounted for variance in job satisfaction: anxiety, depression, emotional exhaustion, cynicism and personal accomplishment were entered. An outcome was considered statistically significant if P < 0.05. Results Demographics Completed questionnaires were received from 205 (82.0%) physicians. Age, sex and marital status are shown in Table 1. Psychological distress The ED physicians experienced higher levels of anxiety and depression as measured by the HADS, compared with the general population. 5 Seventysix (37.1%) ED physicians had the anxiety or depression subscale over 8, indicating at least mild psychological distress. The mean HADS anxiety subscale scores for the ED physicians

540 Y XIAO ET AL. TABLE 1. Demographic characteristic of the samples Characteristics Male (n = 125) Female (n = 80) Age group (years) <30 34 (27.2%) 21 (26.3%) 30-47 (37.6%) 35 (43.7%) 40-44 (35.2%) 24 (30.0%) Marital status Single 26 (20.8%) 14 (17.5%) Married 78 (62.4%) 59 (73.8%) Divorced 21 (16.8%) 7 (8.7%) Children Yes 77 (61.6%) 45 (56.3%) No 48 (38.4%) 35 (43.7%) Work length (years) 9.3 ± 4.1 8.7 ± 3.9 TABLE 2. Psychological distress of ED physician and the general population Scales ED physician General population and general population 18 were 7.8 ± 3.4 and 4.7 ± 3.5, respectively (t = 1.526, P < 0.05). Additionally, the mean HADS depression subscale scores were 7.9 ± 3.6 and 4.7 ± 3.9, respectively (t = 1.567, P < 0.05) (Table 2). Burnout and job satisfaction Of the responders, 52 (25.4%) exhibited high levels of career burnout. The mean value for overall job satisfaction was closer to moderate than satisfied among male physicians (67.28 ± 10.13) and female physicians (70.03 ± 10.76). All aspects of job satisfaction were significantly lower in the ED physicians compared with a previous report on community health workers 16 (P < 0.05). A percentage of 9.3 were either very dissatisfied or dissatisfied with their jobs; 16.6% were dissatisfied to moderately dissatisfied ; 38.2% were moderately dissatisfied ; 29.1% were moderately to not fully satisfied, whereas 6.8% were satisfied or very satisfied with their jobs (Table 3). t-test HADS Anxiety subscale 7.8 ± 3.4 4.7 ± 3.5 t = 1.526, P < 0.05 Depression subscale 7.9 ± 3.6 4.7 ± 3.9 t = 1.567, P < 0.05 Scoring standard: normal (0 7), mild (8 10), moderate (11 14) and severe (15 21). HADS, Hospital Anxiety and Depression Scale. Correlations between job satisfaction, psychological distress and burnout The correlations range from 0.044 (personal accomplishment with intrinsic job satisfaction) to 0.483 (emotional exhaustion with intrinsic job satisfaction). The two subscales (anxiety subscale and depression subscale) of the psychological distress and the three subscales (emotional exhaustion, cynicism and personal accomplishment) of burnout were correlated significantly with intrinsic and extrinsic job satisfaction in the sampled population, but the correlations between personal accomplishment and extrinsic job satisfaction were not significant (Table 4). A multiple regression analysis entering those significant variables shows: Overall job satisfaction= 3.724 Emotional exhaustion 3.168 Cynicism 0.979 Depression 0.831 Anxiety +127.1 (R 2 = 0.487). This indicates that overall job satisfaction could be largely estimated if emotional exhaustion and cynicism scores are known, whereas depression and anxiety scores would bring the estimation close to an accurate value. Discussion The present study reveals that the physicians from ED experienced a moderate degree of psychological distress, burnout and job satisfaction. We tentatively put forward that this might partly be related to the worsening physician/patient relationship and the mistrust for doctors. 19 Previous studies have demonstrated that emergency physicians are at increased risk of psychological distress. 3 In the present study, we have similar results, and clinically significant levels of general psychological distress in ED physicians were above general population levels. This is largely related to the intense nature of work in the ED, and physicians have to deal with a lot of critical situations, so that their psychological condition is undermined. We did not find any differences in psychological distress, burnout and job satisfaction in terms of age, marital status, child bearing and years of work. In the present study, 52 (25.4%) participants exhibited high levels of career burnout, specifically emotional exhaustion, which is considered the core symptom of burnout. The present study has a result similar to that in a group of neurosurgeons in the USA. 20 In another US study, emergency physicians were found to have the highest rate of burnout, in excess of 60%, compared with 38% among physicians in general. 21 Also, the results indicated that Chinese ED physicians only had a moderate level of job satisfaction, and the physicians are generally not satisfied with their working conditions. The correlation analysis showed a negative correlation between job satisfaction and emotional exhaustion and cynicism, and a positive correlation with reduced personal accomplishment. These results are consistent with other studies. 22,23 However, in a longitudinal study of US emergency physicians, 65% were highly satisfied with their career and 31% reported burnout as a significant problem. 24 The present study indicates that the Chinese ED physicians are facing critical psychological conditions, which

PSYCHOLOGICAL DISTRESS, BURNOUT LEVEL AND JOB SATISFACTION 541 TABLE 3. Level of burnout and job satisfaction Scale Male (n = 125) Female (n = 80) Total (n = 205) MBI-GS Emotional exhaustion 7.15 ± 5.37 6.77 ± 5.75 6.98 ± 5.79 Cynicism 3.49 ± 4.17 3.22 ± 4.31 3.37 ± 4.35 Personal accomplishment 24.38 ± 10.70 25.32 ± 10.45 24.79 ± 10.81 MSQ Overall job satisfaction 67.28 ± 10.13 70.03 ± 10.76 68.72 ± 10.90 Intrinsic job satisfaction 40.61 ± 6.07 42.29 ± 6.50 41.38 ± 6.72 Extrinsic job satisfaction 19.42 ± 3.58 20.01 ± 4.11 19.67 ± 4.20 MBI-GS: Emotional exhaustion scoring standard: low (0 7), average (9 13), high (>13). Cynicism scoring standard: low (0 3), average (3 9), high (>9). Personal accomplishment scoring standard: low (>30), average (30 18), high (<18). MSQ: Job satisfaction scores: very dissatisfied or dissatisfied ( 40), dissatisfied to moderately dissatisfied (41 59), moderate (60), not fully satisfied (61 79), satisfied or very satisfied ( 80). MBI-GS, Maslach Burnout Inventory-General Survey; MSQ, Minnesota Satisfaction Questionnaire. TABLE 4. Correlation analysis for psychological distress, burnout and satisfaction Scale Intrinsic Extrinsic HADS Anxiety 0.101 0.114 Depression 0.182 0.206 MBI-GS Emotional exhaustion 0.483* 0.355* Cynicism 0.301* 0.336* Personal accomplishment 0.044 0.048 *P < 0.05. HADS, Hospital Anxiety and Depression Scale; MBI-GS, Maslach Burnout Inventory-General Survey. might deteriorate to significant mental health problems. The previous literature has demonstrated that workrelated psychological status was found to be crucial for anxiety disorders among Chinese doctors. 25 Therefore, a series of comprehensive measures should be enforced to reduce psychological distress and burnout and increase job satisfaction in Chinese ED physicians. The present study describes the psychological condition, burnout and job satisfaction of a group of ED physicians in China and provides a view of the work characteristics of these physicians in this fast-changing country. Also, the present study is conveying a message that ED physicians, especially in China, are at risk of having their mental health undermined gradually. This needs to be noticed by healthcare administrators. However, a number of limitations should be considered in interpreting the results. First, the study had a crosssectional design. As for other crosssectional studies, we cannot draw any causal associations between burnout and job satisfaction. Second, all measures were based on self-reporting, which likely yielded recall/report bias. However, no particular motivation existed for the participants to underreport or overreport, for this survey result is confidential until published. The recall/report error might randomly occur in the population, which was unlikely to have affected the direction of the associations between burnout and other factors. Third, regarding the generalisability of the study, the subjects were recruited from three general comprehensive hospitals in Beijing, which might not be representative of the entire population of ED physicians in China. The subjects in the present study can fairly represent the ED physicians in city hospitals but might not be representative of those working in township health centres or private clinics. In the future, we could tentatively plan a long-term cohort study to investigate the psychological distress, burnout and job satisfaction changes along with work duration and investigate the impacts of social pressure and patient/physician mistrust on physician s job satisfaction and quality of life. Meanwhile, the present study shows us that Chinese ED physicians are in a vulnerable condition. The whole society needs to care about them, instead of igniting conflict between patients and physicians. Furthermore, the national healthcare administrators need to legislate regulations to forbid attacking healthcare staff, guarantee physicians resting time and increase their income. In conclusion, we have found that psychological distress is prevalent in Chinese ED physicians, and this deserves attention from the whole society. Burnout and job satisfaction are at a moderate level, and burnout is negatively associated with higher job satisfaction. Competing interests None declared.

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