European Journal of Anaesthesiology

33 Pages·2016·2.41 MB·English

European Journal of Anaesthesiology

Stressors in anaesthetists - development and validation of a new questionnaire Cross-
sectional study
--Manuscript Draft--

Manuscript Number:
Full Title: Stressors in anaesthetists - development and validation of a new questionnaire Cross-
sectional study
Short Title: Stress evaluation in anaesthetists
Article Type: Original Article
Corresponding Author: Teresa Lapa, MD
Coimbra Hospital and University Centre
Coimbra, PORTUGAL
Corresponding Author Secondary
Information:
Corresponding Author's Institution: Coimbra Hospital and University Centre
Corresponding Author's Secondary
Institution:
First Author: Teresa Lapa, MD
First Author Secondary Information:
Order of Authors: Teresa Lapa, MD
Sérgio A. Carvalho, Msc
Joaquim S. Viana, MD, PhD
Pedro L. Ferreira, PhD
José Pinto-Gouveia, MD, PhD
Order of Authors Secondary Information:
Manuscript Region of Origin: PORTUGAL
Abstract: Background: Stress in anaesthetists is a common problem due to multiple factors
related to patients, colleagues and organizations. This can lead to serious
consequences such as depression, work-home conflicts and burnout.
Decrease anaesthetists stress and its consequences can be reached by reducing the
number and magnitude of stressors or by increasing resilience strategies.
Evaluating stressors in the day-to-day life of anaesthetists is complex, and the existing
tools are not sufficiently accurate.
Objective: We have created the Stressors Questionnaire in Anaesthetists (SQA), in
order to qualify the sources of stress in anaesthetists` professional lives, and to
measure the level of stress associated to these factors.
Design: A questionnaire-based cross-sectional design.
Settings: The study was conducted between 1st January 2014 and 30th December
2014, throughout different anaesthesia departments in Portuguese hospitals, in which
710 participants responded the questionnaires.
Method: We performed an exploratory analysis and two confirmatory analyses. The
construct validity of the SQA was assessed via correlation with other stress measures,
burnout and satisfaction with life, across these samples. Internal consistency reliability
was assessed by Cronbach α.
Results: The exploratory analysis showed the SQA is a tri-dimensional instrument and
confirmatory analysis showed the tri-dimensional structure presented good model fit.
The three dimensions of SQA correlated positively with other stress measures and
burnout and negatively with satisfaction with life.
Conclusions: SQA is a well-adjusted measure for assessing stressors in anaesthetists
and includes clinical, organizational and team stress factors. Results showed that SQA
is a robust and reliable instrument. SQA contributes for a better understanding of the
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stress induction factors, which can lead to better stress management and
anaesthetists' wellbeing.
Suggested Reviewers: Pablo Rama-Maceiras
[email protected]
This author published a stress and burnout review article in EJA ("Job satisfaction,
stress and burnout in anaesthesia: relevant topics for anaesthesiologists and
healthcare managers?")
Opposed Reviewers:
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Article Title
Stressors in anaesthetists – development and validation of a new questionnaire
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3 Cross-sectional study
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6 Running head
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Stress evaluation in anaesthetists
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14 Authors
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Lapa TA 1,2; Carvalho S3; Viana JS 1,2; Ferreira PL4,5; Pinto-Gouveia J3
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19 1 Coimbra Hospital and University Centre, Portugal
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2 Faculty of Health Sciences, University of Beira Interior, Portugal
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24 3 Cognitive-Behavioural Research Centre (CINEICC), University of Coimbra, Portugal
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27 4 Faculty of Economics, University of Coimbra, Portugal
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5 Centre for Health Studies and Research, University of Coimbra, Portugal
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35 Author for correspondence:
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Teresa Alexandra Santos Carvalho Lapa
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40 Anaesthesiology Service
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43 Coimbra Hospital and University Centre. Praceta Prof. Mota Pinto, 3000-075 Coimbra,
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45 Portugal
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phone number: 00351 964090762
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50 e-mail: [email protected]
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- Number of words in Abstract – 267
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- Number of words in Introduction – 314
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- Number of words in Discussion - 1161
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1
2 ABSTRACT
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Background. Stress in anaesthetists is a common problem due to multiple factors
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8 related to patients, colleagues and organizations. This can lead to serious
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consequences such as depression, work-home conflicts and burnout.
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14 Decrease anaesthetists stress and its consequences can be reached by reducing the
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number and magnitude of stressors or by increasing resilience strategies.
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Evaluating stressors in the day-to-day life of anaesthetists is complex, and the existing
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tools are not sufficiently accurate.
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Objective: We have created the Stressors Questionnaire in Anaesthetists (SQA), in
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28 order to qualify the sources of stress in anaesthetists` professional lives, and to
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31 measure the level of stress associated to these factors.
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34 Design: A questionnaire-based cross-sectional design.
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Settings: The study was conducted between 1st January 2014 and 30th December
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40 2014, throughout different anaesthesia departments in Portuguese hospitals, in which
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710 participants responded the questionnaires.
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46 Method: We performed an exploratory analysis and two confirmatory analyses. The
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construct validity of the SQA was assessed via correlation with other stress measures,
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51 burnout and satisfaction with life, across these samples. Internal consistency reliability
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was assessed by Cronbach α.
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57 Results. The exploratory analysis showed the SQA is a tri-dimensional instrument and
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confirmatory analysis showed the tri-dimensional structure presented good model fit.
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The three dimensions of SQA correlated positively with other stress measures and
burnout and negatively with satisfaction with life.
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4 Conclusions. SQA is a well-adjusted measure for assessing stressors in anaesthetists
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and includes clinical, organizational and team stress factors. Results showed that SQA
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9 is a robust and reliable instrument. SQA contributes for a better understanding of the
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stress induction factors, which can lead to better stress management and
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14 anaesthetists’ wellbeing.
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Key words: Stress, anxiety, burnout.
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1 INTRODUCTION
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Professional stress is a well-described problem in clinical anaesthesia that can lead to | 4
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7 burnout 1-3 and may have a negative impact on physical and mental well-being, life
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situation and even patient care and health care system3,4.
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13 Managing the effects of stress in professional environments can occur through two
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pathways5,6. One is by limiting the exposure to work-related stressors, including the
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18 improvement of organizational factors7,8. A recent Cochrane review 9 concluded that
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the interventions need better focus on the reduction of specific stressors. However,
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the reduction of stressors in anaesthetic practice is limited by ineluctable
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26 characteristics of this speciality such as loss of control over practice and
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unpredictability. A logical alternative is the development of emotional-regulation
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31 strategies with potential to increase personal resilience to adverse conditions 8,10 and
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reduce pervasive psychological processes, which maintains psychopathological
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36 symptoms, such as rumination 11.
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A significant number of tools are available for measuring the effects of stress in
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42 healthcare providers´ well-being 4, burnout 12,13, mental distress 14 and professional
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performance 15,16. These tools are broadly used in studies evaluating these conditions
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47 in medical doctors of different specialities, including anaesthesia, and also in studies to
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50 measure the value of interventions to increase resilience against stress. Nevertheless,
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in order to accurately assess the efficacy and efficiency of an intervention in stress
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55 effects, we need to quantify not only the effects (the consequences of stress) but also
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the number and amplitude of stressors (the causes of effects).
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To our knowledge, no appropriate instrument exists at the moment specifically for
stressors evaluation in anaesthetists.
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4 This paper describes the development of the Stress Questionnaire in Anaesthetists
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(SQA), the examination of its factor structure in an anaesthetist’s sample, followed by
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9 item reduction. It further examines its factor structure in two other samples, and
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examines the concurrent, divergent and incremental validity through its correlation
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14 with a wide range of other measures of psychological processes and functioning.
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1 MATERIALS AND METHODS
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An anonymous questionnaire-based survey was conducted across different Portuguese | 6
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7 hospitals’ anaesthesia departments. It included anaesthesia specialists and residents
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and was conducted between 1st January 2014 and 30th December 2014. Data was
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12 collected through self-reported questionnaires formed by demographic information,
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15 work experience, and measures of stress, anxiety, depression, burnout, emotional
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regulation psychological indicators and life satisfaction.
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This study was approved by ethic commission of University. All questionnaires were
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completed anonymously and all participants gave informed consent, in a separate
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Construction of the scale / Item development
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36 In order to qualify the sources of stress in anaesthetists’ professional lives and to
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measure the level of stress associated with these factors, a questionnaire with 10
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41 items was developed. Items in SQA were based on the items often reported as
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stressors2,7,14,17, on expert knowledge and practice, and on definitions from
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46 autobiographical reports or descriptions made by anaesthetists suffering from stress
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disorders.
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52 A panel of 12 experts, including anaesthetists, psychiatrists and experienced
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psychotherapists, agreed that items reflected pertinence and theoretical relevance and
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57 its terminology was accurate. This panel came up with a set of the following 10 items
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considered as inductors of stress in anaesthetists´ professional life:
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 Patients in the highest degree of ASA classification;
 Complex surgical interventions;
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3  Anticipation of difficulty in intubation;
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 Work off-site, with different team and equipment;
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8  Relationships with surgeons;
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 Lack of working conditions;
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16  Inability to keep up to date (theoretical knowledge and new technologies);
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 Organization of the anaesthesiology department;
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21  Lack of time or difficulty in organizing it.
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Each SQA item contains a 0-10 visual analogue scale (VAS), a continuous measurement
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27 device 18, with higher values reflecting more severe stress induction. This type of scale
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allows reliable detection of small changes and is especially used in the fields of pain
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32 and fatigue research 19.
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SQA was originally written in Portuguese, translated into English by a native English
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38 professional translator and then back translated into Portuguese by a bilingual
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Portuguese psychologist. The similarity of these Portuguese versions was judged to be
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43 satisfactory. Subsequent testing has been performed with the original Portuguese
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46 version (see SQA appendix).
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49 Participants
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The total sample was composed by 710 Portuguese anaesthetists (599 specialists and
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55 111 residents) enrolled in public and private hospital anaesthesia departments, in total
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of 1254 portuguese specialists and 291 residents.
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The specialists were randomly assigned into two different samples. In sample 1
(n=209) an exploratory factorial analysis was conducted. In sample 2 (n=390), we
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3 conducted a confirmatory factorial analysis. A second confirmatory factorial analysis
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was performed in a third sample composed of residents (n=111). The main
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8 characteristics of these samples are described in table 1.
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-------------------------- (Table 1) --------------------------------------------------------------
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Reliability and validity tests
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19 The reliability of SQA was assessed by computing Cronbach’s α and composite
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reliability.
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25 Construct validity was assessed via correlation with different measures, across the
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three different samples. We used the following measurement instruments:
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31  The short-form version of the Depression, Anxiety and Stress Scales (DASS-21),
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was developed by Lovibond and Lovibond 20 and translated and validated to
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36 Portuguese by Pais-Ribeiro, Honrado and Leal 21. This is a self-reported scale
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composed by 21 items distributed in three subscales developed to measure
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41 symptoms of depression, anxiety and stress. In the original version, the authors
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found that all subscales have an adequate to good internal consistency with
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alpha’s values of .81 for depression .73 for anxiety and .81 for stress subscales.
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49  The Copenhagen Burnout Inventory (CBI) proposed by Kristensen Borritz,
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Villadsen and Christensen22 and translated and validated to Portuguese by
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54 Cesaltino Fonte 23. It considers the fatigue and exhaustion as a central
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construct. The CBI is a 19-item questionnaire measuring three burnout sub-
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