Job stress and satisfaction in faculty of a teaching hospital in south India: A cross-sectional survey.

Background: There are multiple economic, psychological, and physical consequences of high job stress, low job satisfaction and burnout in faculty of a teaching hospital in South India. Data from developing countries on these domains are sparse. Materials and
Methods: In a cross-sectional study we assessed the prevalence and sources of perceived job stress, job satisfaction and burnout in faculty, as well as ways of coping with stress among consenting faculty of a large, private, charitable, teaching hospital in India using standardized, self-rated questionnaires.
Results: A total of 304 respondents, 156 (51.3%) were Assistant Professors; 71 (23.4%) were Associate Professors, and 77 (25.3%) were Professors. The majority (175; 58%) were male, younger than 45 years (235; 76%) and from clinical departments (248; 81.5%) A third (96; 31%) reported high overall levels of perceived job stress. In multivariate analyses, age less than 45 years, designation as Assistant or Associate Professor, and working in a clinical department were associated with perceived high job stress; reporting high perceived job satisfaction was protective. Nearly two-thirds (217; 71.4%) of faculty reported high levels of job satisfaction. In multivariate analysis, age less than 45 years and reporting high job stress were associated with low perceived job satisfaction. Causes of stress and satisfaction differed by age, gender and designation. On the Maslach Burnout Inventory (MBI), 88 (29%) had high scores on the emotional exhaustion subscale, 63 (20.8%) had high scores on the depersonalization subscale, and 90 (29.7%) had low scores on the personal achievement subscales. High job stress and low job satisfaction were significantly associated with burnout on the three domains. Conclusions: High job stress and low job satisfaction were inversely related in this survey of medical faculty and were significantly associated with levels of burnout. The sources of job stress and job satisfaction identified provide insights that could inform formal institutional mechanisms to prevent burnout in doctors.

Introduction

Stress in the work context (defined as “undue, inappropriate or exaggerated response to a situation) has been associated with negative outcomes at individual and organizational levels and is associated with higher psychiatric and medical morbidity and mortality as well as job dissatisfaction, poor productivity and decreased quality of output.[123456] Burnout is commonly defined as “a psychological response to chronic interpersonal job stressors, characterized by overwhelming exhaustion, feelings of cynicism and detachment from the job”.[78] Job satisfaction is not determined merely by the absence of job stress but also the presence of positive qualities in the workplace.[9101112] The medical profession has been found to be more prone to stress and burnout than other professions.[131415]

Various factors have been shown to be associated with job stress, job satisfaction and burnout including individual, organizational and work related factors.[101112161718] Studies regarding the modifying effect of religious faith and spiritual beliefs have contradictory findings.[1920]

There have been few studies in this area among physicians in India.[9212223] This paper reports the prevalence and sources of perceived job stress, satisfaction, burnout and ways of coping with job stress among faculty of a faith-based, teaching, medical college in India; and the relationship between spiritual beliefs influencing attitudes to work on perceived job stress, satisfaction and burnout.

Materials and Methods

In this cross-sectional study, after approval from the Institutional Review Board, we requested consenting faculty members (Assistant Professors, Associate Professors and Professor) of clinical and non-clinical departments to fill in anonymized structured questionnaires that were made available in paper or digital formats. All faculty members who were not on sabbatical or medical leave were invited to participate in this study. Written informed consent was taken from all participants prior to inclusion in the study. We ensured that the anonymity was protected during data collection and during analysis.

The questionnaire collected data on socio-demographic variables (age, sex, marital status, number of children, post-graduate qualification, department, years after completing post-graduation, and designation). Among other questionnaires administered, pertinent to this paper was the Consultants Job Stress and Satisfaction Questionnaire (CJSSQ).[24] The CJSSQ includes 25 statements relating to specific sources of job-stress and 17 statements relating to sources of job-satisfaction experienced over the previous few months. Statements were rated on a scale of 0 to 3 (“not at all” to “a lot”). Ratings were dichotomized with a score of 3 denoting the source as a cause of stress/satisfaction. Global ratings of stress and satisfaction were obtained by asking clinicians: “Overall, how stressful/satisfying do you find your work?”on a scale of 0 to 4 (“not at all” to “extremely”). Scores of 3 or 4 denoted high perceived overall job stress/satisfaction. We evaluated the proportion of participants endorsing each source of stress and satisfaction, and endorsing high perceived overall job stress/satisfaction. This questionnaire is simple to use, as it only elicits the frequencies of those endorsing each question and does not compute a total score with cut-off scores based on the total score (as is done with rating scales) that requires re-validation in different settings. It has been used in previous studies in the Indian setting.[25]

Burnout was measured using the Maslach Burnout Inventory (MBI) as designed for use in service providers.[26] This tool measures the three components of the burnout syndrome on separate subscales of Emotional exhaustion (EE), Depersonalisation (DP) and Personal accomplishment (PA).

Each job-related feeling/attitude is rated on a 7-point scale according to how often it is experienced, from “never” to “every day”. The total score for each subscale is categorized “low”, “average”, or “high” according to predetermined cut-off scores based on normative data from samples of health professional. A high degree of burnout is indicated by high scores on the emotional exhaustion and depersonalization subscales and low scores on the personal accomplishment subscale. It has been previously used in the Indian population.[2327]

We also assessed participants spiritual beliefs through a question worded, “My religious or spiritual beliefs strongly influence my approach to my work and patients”. This was rated on a 7-point Likert scale. Ratings were dichotomized with those scoring 6 (agree) or 7 (strongly agree) considered as viewing their work ethic as an extension of their spiritual beliefs. Ways of coping with job stress was assessed through a questionnaire containing 15 questions taken from the 66-item revised ways of coping questionnaire that assessed practical ways people use to cope with stress.[28] Each item is scored on a 4-point Likert scale (0 not used/not applicable to 3 used a great deal), and we dichotomized those selecting the highest two ratings to denote that the way of coping was used quite often or a great deal. Questionnaires used in this study were either in the public domain; or were purchased for use in the study.

Statistical analysis

We used EpiData Software for data entry and SPSS, version 16, for statistical analysis.[29] We used frequencies and percentages for categorical data in descriptive statistics, and the mean and standard deviation for continuous variables. We used the Student t-test or analysis of variance (ANOVA) for continuous variables. We used the Chi-square or Fischer's exact tests for categorical and dichotomous variables. We used the dichotomized scores on the global ratings of overall job stress and satisfaction to estimate their prevalence in this sample and in subgroups based on age, gender, specialty, and designation. The total MBI scores for EE, DP and PA were dichotomized according to the range of scores obtained in each domain as 'high' or 'low', based on sample score ranges provided in the MBI manual. Mean scores on the EE, DP and PA subscales were also analysed by the independent samples Kruskal-Wallis test for multiple groups and Independent-Samples Mann Whitney U Test when data were skewed. Differences in mean scores as well as dichotomized scores of each domain were used to identify significant correlates burnout. We used the dichotomized scores for each statement on the CJSSQ to assess the proportions endorsing them as sources of stress and satisfaction in univariate analysis. We compared the frequency of reporting of these sources among those with high versus low stress/satisfaction and computed Odds ratios (OR) and 95% confidence intervals (CI). We entered the sources of stress and satisfaction identified as significant in univariate analysis (OR >2 with 95% CI not including 1) into stepwise logistic regression (forward-likelihood ratio method).

Results

The completed questionnaires were returned by 304 (58%) of 520 eligible faculty from 42 departments. The majority (175; 58%) were male, younger than 45 years (235; 76%), married (271; 89%), and had two children (135; 44%); with an average of 9 years of experience after graduation. The majority were Assistant Professors (156; 51.3%); 71 (23.4%) were Associate Professors, and 77 (25.3%) were Professors. The majority were from clinical departments (248; 81.5%) and among these, 120 (39.5%) were from surgical specialties and 63 (20.7%) were from medical specialties. The remainder were from departments providing chronic or palliative care (49; 16.1%) or from non-clinical/support services (68; 22.4%).

Prevalence and correlates of job stress

About a third of respondents (96; 31.6%; 95% CI 26.6% to 37.0%) reported high perceived levels of job stress. Job stress did not vary significantly with gender. There were significantly more Assistant Professors (38.5%) and Associate Professors (33.8%) reported high perceived job stress compared to Professors (15.6%). The majority of those aged <45 years (73%) reported high perceived job stress compared to 18% of those aged >45 years. Faculty from surgical specialities reported being highly stressed most frequently (41.7%), followed by acute medical specialities (33.3%), non-clinical specialities (22.1%) and chronic care specialities (20.4%).

The factors that emerged as contributory to job stress in multivariate analysis were: Age < 45 years (OR 2.88, 95% CI 1.39 to 5.96; P = 0.00); designation of Assistant or Associate Professor (OR 2.61, 95% CI 1.01 to 6.71; P = 0.04); and working in a clinical specialty (OR 2.04, 95% CI 1.07 to 3.89; P = 0.02); while high perceived job satisfaction was protective (OR 0.29, 95% CI 0.17 to 0.49; P = 0.00).

Prevalence and correlates of job satisfaction

In contrast to job stress, nearly two-thirds (217; 71.4%, 95% CI 66.1-76.2) reported high levels of job satisfaction. Prevalence of job satisfaction did not vary by gender or between clinical or non-clinical specialties. Professors were more likely to report high job satisfaction (87%) than Associate Professors (62%) and Assistant Professors (69%). The factors that emerged significant in multivariate analysis as contributory to low job satisfaction were: Age < 45 years (OR 0.35, 95% CI 0.16 to 0.76; P = 0.01), and high levels of job stress (OR 0.29, 95% CI 0.17 to 0.49; P = 0.00). Designation was not significantly associated with job satisfaction after adjusting for age and gender.

Sources of job stress

Table 1 details the sources of stress identified on logistic regression as contributing to high perceived job stress according to designation, and gender. Men were more likely to report structural and administrative sources of stress like having less autonomy or more paperwork. Women were more likely to recall interpersonal sources of stress like encountering difficulties in relationships with colleagues. Assistant and associate professors were more likely to state concerns about salary, uncertainty about future prospects and insufficient resources at work as sources of stress while Professors were more likely to report sources of stress related to dealing with patients and relatives; as well as having multiple responsibilities and role conflicts.

Table 1

Sources of job stress among faculty: results of multivariate analysis

Source of stress	Adjusted Odds Ratios (95% Confidence Interval)
By Gender
In Men
Disruption of your home life as a result of taking your paperwork home.	11.97 (3.96-36.19)
Uncertainty over the future funding of your unit/institution.	9.26 (2.02-42.53)
Having too great an overall volume of work.	6.36 (2.22-18.24)
Feeling you have insufficient input into the management of your unit or institute.	5.67 (1.82-17.63)
Being involved with the physical suffering of patients.	4.35 (1.08-17.42)
Feeling you are poorly paid for the job you do.	3.83 (1.35-10.85)
In Women
Encountering difficulties in relationships with consultant colleagues.	7.38 (2.09-25.94)
Disruption of your home life as a result of taking your paperwork home.	5.83 (1.96-17.27)
Having inadequate housing facilities.	4.81 (1.31-17.57)
Feeling you are poorly paid for the job you do.	4.03 (1.12-14.49)
Feeling you have insufficient input into the management of your unit or institute.	3.78 (1.02-14.01)
By designation
In Assistant and Associate Professors
Feeling you are poorly paid for the job you do.	25.13 (4.46-141.58)
Uncertainty about the future of your unit/institution.	7.81 (1.46-41.81)
Having insufficient facilities (equipment space) to do your job properly.	20.23 (2.59-157.95)
In Professors
Being involved in the physical suffering of patients.	75.83 (2.45-2346.7)
Being responsible for the quality of work of other staff.	53.77 (2.08-1388.0)
Having inadequate housing facilities.	25.46 (1.29-500.62)
Encountering difficulties with consultant colleagues.	19.50 (1.54-246.24)
Feeling you have insufficient input into the management of your unit or institution.	16.52 (1.19-229.03)

Sources of job satisfaction

Table 2 details the sources of job satisfaction identified on logistic regression as contributing to high perceived job satisfaction according to designation and gender

Table 2

Sources of job satisfaction among faculty: results of multivariate analysis

Source of satisfaction	Adjusted Odds Ratios 95% Confidence Intervals)
By gender
Men
Feeling you have a high level of job security.	5.46 (2.48-12.03)
Being perceived to do the job well by your colleagues	3.94 (1.69-9.18)
Having a high level of responsibility.	2.95 (1.24-7.01)
Feeling you deal well with relatives.	2.25 (1.002-5.05)
Women
Feeling your clinical experience is used to the full.	4.90 (1.89-12.71)
Having adequate housing facilities.	3.50 (1.31-9.33)
Having a high level of autonomy.	2.52 (1.002-6.36)
By designation
Assistant Professors
Feeling you have a high level of job security.	6.19 (2.86-13.39)
Associate Professors
Deriving intellectual stimulation from teaching.	81.73 (4.59-1452.52)
Having adequate housing facilities.	69.53 (6.17-782.62)
Feeling your clinical experience is used to the full.	36.68 (2.70-497.27)
Having opportunities for personal learning (developing skills).	15.90 (1.63-154.42)
Professors
Being perceived to do the job well by your colleagues.	17.67 (3.50-89.14)
Feeling you have a high level of job security.	6.41 (1.02-40.11)

Men were more likely to recognise sources of satisfaction linked to job security and getting professional status and esteem, while women were more likely to report sources of satisfaction linked to feeling well resourced and managed. Assistant and associate professors were more likely to mention sources of satisfaction linked to feeling to professional satisfaction, as well as feeling well resourced and managed. Professors were more likely to identify sources of satisfaction linked to professional status and job security.

Prevalence of burnout and correlates with job stress and satisfaction

A total of 303 participants who completed the MBI, 88 (29%, 95% CI 24.2% to 34.4%) scored high on the EE subscale, 63 (20.8%, 95% CI 16.6% to 25.7%) scored high on the DP subscale and 90 (29.7%, 95% CI 24.8% to 35.1%) had low PA scores.

Additionally, 58 (19.1%, 95% CI 15.1% to 24%) of the sample scored high on two or more domains of the Burnout Inventory, and 3 (0.9%, 95% CI 0.3% to 2.9%) scored high on all three domains of the MBI.

Mean scores on the EE domain of the MBI were significantly higher in participants younger than 45 years (20.50, SD 11.92) compared to those above 45 years (15.94, SD 12.30; P = 0.002). Higher mean EE scores were also evident among Assistant Professors (20.60, SD 11.76) and Associate Professors (21.31, SD 13.10), compared to Professors (15.43, SD 11.14; P = 0.002). Scores on the EE domain did not significantly differ across specialities, or by gender or marital status. Mean scores on the DP domain of the MBI did not differ significantly across specialities, or by age, gender or marital status. Those younger than 45 years scored significantly lower on the PA domain (32.24, SD 8.78) than those above 45 years (35.98, SD 7.11; P = 0.02). This was also reflected in significantly lower PA scores in Assistant (32.24; SD 8.78) and Associate Professors (32.56, SD 8.26) compared to Professors (35.61, SD 7.49; P = 0.016).

In multivariate analysis, high EE was significantly associated with high job stress (OR 14.53, 95% CI 7.93 to 26.63; P = 0.00) and low job satisfaction (OR 3.57, 95% CI 2.07 to 6.13; P = 0.00). High DP was also significantly associated with high job stress (OR 3.78, 95% CI 2.10 to 6.79; P = 0.00) and low job satisfaction (OR 2.30, 95% CI 1.28 to 4.12; P = 0.00). Respondents with high job stress and low job satisfaction had significantly lower mean scores on the PA domain (P < 0.001).

Spiritual beliefs influencing attitudes to work

Among 300 faculty who responded to this statement, 175 (58%; 95% CI 53% to 64%) agreed that their spiritual or religious beliefs strongly influenced their work. Significantly fewer Assistant Professors (49.4%) compared to Associate Professors (72.7%) or Professors (57.6%) endorsed this statement (P = 0.003). Significantly more faculty from surgical specialities (62.5%) and medical specialties (65.1%) endorsed this statement than non-clinical or chronic care specialities (P = 0.044). Women (64.3%) endorsed this statement more frequently than men (52.6%; OR 1.63, 95% CI 1.02 to 2.60; P = 0.04). More faculty older than 45 years endorsed this statement than those younger than 45 years (77.9% versus 55.5%; OR 3.33; 95% CI = 1.78 to 6.24; P = 0.000). There were no significant differences in levels of perceived job stress or satisfaction between those who did or did endorse this statement. However, in multivariate analysis, significantly greater proportions of those who endorsed this statement reported higher scores on the PA domain of the MBI (OR 1.72; 95% CI 1.01-2.93; P = 0.04).

Ways of coping with stress

Most commonly reported strategies used to cope with stress were constructive in nature; like talking to family or friends (82.6%), pursuing hobbies (69.7%), talking informally to colleagues (64.1%) or taking physical exercise/playing sports (58.2%). However, 141 respondents (46.4% of sample) reported using a coping strategy that could be potentially harmful (working longer hours, eating unhealthily, drinking alcohol etc). Only 2.9% of the sample reported using supported forms of coping like formal psychological help or prescription drugs.

There were a few significant differences in coping strategies by age and gender. People older than 45 years were more likely to learn relaxation strategies, talk to colleagues informally and take prescription drugs compared to those younger than 45 years. Male respondents were more likely to report smoking cigarettes or drinking alcohol and female respondents more likely to report eating unhealthily as a coping strategy.

Discussion

The key findings of this study are that a third of faculty experience high levels of perceived job-related stress and this was more likely to be experienced by those younger than 45 years who were Assistant or Associate Professors. A larger proportion of faculty reported high levels of job-satisfaction and this was more likely to be reported by people older than 45 years who were also more likely to be Professors and who were also more likely to report low levels of job stress. A clear finding from this study is that job stress and job satisfaction were inversely related across designations. Clinicians showed significantly higher job stress as compared to non-clinical specialties; interestingly, job satisfaction did not show statistically significant differences when compared among specialties, highlighting the complex reactions that individuals have to their work environment. A higher job stress and lower job satisfaction were also clearly associated with higher levels of burnout.

The proportion of respondents reporting high job stress was similar to that reported by other studies looking at job stress in doctors.[2430] A significant point of difference in the results of this study, compared to studies in the West was the clear trend of declining job stress with increasing age and seniority found in this study.[313233] Levels of burnout in this study were significantly lower than in studies from Western countries.[3334] Cultural variations in the levels of burnout are well documented and can easily be understood as occupational stressors vary significantly in differing work environments.[33]

Levels of job stress and satisfaction in this study are comparable to other similar studies in Indian doctors.[92122233536] Sources of stress and satisfaction however varied across studies, a fact that may point to the important role of individual organizational structure in these areas. The participants in this study had lower levels of burnout as compared to most other studies done among doctors in India with the exception of a single study among private practitioners that has similar results.[232737] Some reasons for this difference could be the inclusion of trainees and residents in the samples in other studies; differences in instruments used for assessment; as well as differences in organizational structure. For example, the faith based nature of this institution may be a protective factor against some aspects of burnout, since those in this sample who endorsed spiritual beliefs as influencing their attitudes towards work reported higher scores on the PA domain of the MBI.

The strengths of this study include a relatively large sample, the use of standard instruments for assessment and the use of multivariate statistical analysis, and the focus on assessing sources of stress and satisfaction that provide insights for intervention. Since the recommended cut-off scores on the MBI have not been validated in an Indian population, we supplemented the evaluations using the recommended cut-off scores by evaluating differences in the mean scores on the three domains. The limitations of this study include a modest response rate from among eligible faculty, the cross-sectional nature of the enquiry, and the omission of other factors, such as personality, that could influence perceptions of job-related stress and satisfaction. Nevertheless, this investigation, adds to the limited literature on this subject in India.

While job stress and job satisfaction were inversely related in this study, the design does not permit us to draw firm conclusions regarding the primacy of either in this relationship. However, the various sources of stress and satisfaction identified differed across designations and by gender, emphasizing the need to tailor interventions to the individual. The results show that formal sources of psychological support are underutilized in this population and informal sources of support like discussion groups and departmental social activities may be more acceptable. This study supports the need for periodic evaluation of work stress and job satisfaction among doctors and the need for formal institutional support mechanisms to help faculty cope with the routine demands of the profession.

Financial support and sponsorship

Internal/institutional funding.

Conflicts of interest

There are no conflicts of interest.

This paper reports on part of the MD Dissertation of Dr. Abhinav Chichra titled, “Job Stress, Job Satisfaction and Burnout in faculty of a teaching hospital in South India: a cross-sectional follow-up survey, submitted to the Dr MGR Medical University, Tamil Nadu in April 2017”