Problems of stress in various professions have attracted the attention of psychologists of different directions for a long time. A big majority of classical studies have shown that prolonged stress exposure leads to such adverse effects as the decrease in overall mental stability of the organism, the emergence of dissatisfaction of its activities, the tendency to reject assignments in situations of increased requirements, setbacks and defeats. Analysis of the factors that cause similar symptoms in different activities shows that there is a number of professions in which a person begins to feel self emotionally drained by the internal need for continuous contact with other people. It is a well-known fact that the medical profession like any other is related to interpersonal interaction, so timely diagnosis and correction of such violations are highly relevant to doctors and nurses. Thus, we are going to discuss stress in the medical field combining its impact on professional doctors’ activities and personal lives.
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First of all, the interest in occupational stress in doctors is provoked by general trend towards the humanization of modern science, which is reflected in a wide variety of industries – from the theory of management teams, to the fundamental philosophical epistemology and methodology of science. One manifestation of this trend is attracting the attention of researchers to the subject of professional activity, in particular the effect of chosen occupation on the nature and character of the person.
Another reason for interest in this problem is the tightening of requirements for the professionals of different profiles and requirements tempo and rhythm of a modern lifestyle. The requirements for representatives of the so-called ‘helping professions’ need additional attention, because their psycho-physiological state directly influences the effectiveness of their professional activities, whose importance in contemporary society can hardly be overestimated. In particular, studying of this problem in the annex to the medical staff is the question of extremely high importance, because exactly a human life is often the possible ‘price of any mistake’ in their activities. Thus, the group of observation is doctors who provide mental, urgent, or palliative care and doctors in hospices.
In psychology under the term ‘stress’ we should understand the mental stress that occurs in humans under the influence of complicated, difficult, unfortunate circumstances of activities and daily life, or in special, extreme situations. As the stressors (the factors leading to the rise of human stress in short-term, and to the development of severe, long-lasting experiences) can be adverse physical effects of environmental emergencies, physical and psychological trauma, etc.
Mental stress that arises under the influence of stressors may be a useful adaptive significance, mobilizing people to overcome difficulties. This phenomenon, for example, is well known to athletes or actors, ‘prestarting excitement’ which serves as a setting for the upcoming activities. However, if stress is too high because of the intensity of exposure or its unexpectedness, human resources may be insufficient to cope with stress, and it begins to have a destructive effect on the person until the appearance of physiological disorders and complete disorganization of human life.
Observing stress factors among doctors in hospices we see that exactly among people of this occupation the problem of occupational stress acutely announced itself at the present time, because in the modern post-industrial society, people’s attitude to work is changing at a pace that does not come across any previous generation. In developed countries, especially today, when the economic crisis continues, workers are increasingly losing confidence in the stability of their own social and material status, warranty in the workplace, and material well-being. Competition for the prestigious and highly paid job is rather high nowadays. On the one hand, parallel processes are taking a narrow specialization in the profession, and on the other hand – the globalization of related industries is popular. Demand of the labor market is changing rapidly and facing some difficulties, one can not fully realize the accumulated energy due to physiological stress. As a result this energy begins to destroy human character and soul. In this case, instead of completely normal stress reactions the organism begins to literally “tear apart” the mechanisms of distress, when the energy can not be realized in constructive activities.
As a consequence, a mental, emotional stress associated with stress in the workplace increases. People find in their behavior symptoms of revealed anxiety, depression, emotional burnout syndrome, psychosomatic disorders and other malfunctions. It leads to growing dependence on psychoactive substances, including alcohol, tranquilizers and other psychotropic substances. Thus, the data presented in Dollard, Winefield & Winefield work shows that 81,4 % of examined doctors, 85,9% of nurses and 79,8% of medical students use alcohol. Also 33,3% of surveyed students regularly drink beer and other alcoholic drinks. (Dollard, Winefield & Winefield, 2003).
Thinking about the future of medical students and according to Levey we see that “medical students are inundated with stress from the start of their medical training as they attempt to adjust to lifestyle changes and increasing hassles incurred by the demands of medical education. Characteristics commonly associated with medical training and identified as situational or professional stressors include: variable hour shifts, sleep deprivation, cumbersome administrative responsibilities, poor administrative support, and curriculum overload” (Levey, 2001). Dollard, Winefield & Winefield stated that “Additional characteristics are: perceived lack of professional knowledge and skills, health care policy changes, difficult patients, patient care, life and death situations, and unexpected shill in academic performance. Further stressors mentioned in the literature include family responsibilities, incurring financial debt, decreased chances for social, leisure, or physical activities, decreased support network due to relocation, cultural and minority issues, and inadequate coping skills” (Dollard, Winefield & Winefield, 2003).
The interest for the topic of stress in the medical field was provoked by Wicks’ words who wrote in the foreword for his own book, describing the appearance of stress and hardships of medical profession, the following: “Who among us has not identified with the young leukemia patient who is refractory to treatment and scared to death, or the midcareer professional deeply unresponsive and too young to have had this massive stroke, or parents trying to absorb into their consciousness the sudden accidental death of a child? Instead of the afflicted’s “Why me?” the caregiver’s frightened imponderable becomes “Why not me? What roll of the dice, what act of fate, what divine intervention preserves me from any one of these circumstances?” What makes it possible for physicians and nurses to confront these patients and circumstances day after day with caring and therapeutic resolve and to walk the balance beam between the paralyzing fear of their own mortality and the numbness of emotional disengagement or indifference? And while the hospital environment is the epicenter of personal exposure, the reminders are distributed one’s day from office visits with patients to telephone calls with distraught family members. In each encounter, we see ourselves separated from our patient’s circumstances by the luck of the draw but believe at a subconscious level that we are somehow protected. It’s like wearing a Red Cross arm badge in the battlefield.” (Wicks, 2006) This phrase deeply impacts on people who work in the medical field and we can say with confidence that the structure of clinical manifestations of occupational stress among specialists of the ‘helping’ professions (so-called ’emotional burnout’) includes different features that bring together this phenomenon with the number of traditional mental (such as asthenic neurosis), and psychosomatic disorders. This state of affairs suggests the presence of etiopathogenetic structure of occupational stress in psychological level, playing almost the leading role in the origin and development of this phenomenon.
WHO European Ministerial Conference (2005) noted that the stress associated with work, is an important issue for about one-third of workers in the European Union. The cost of solving problems related to mental health in this context includes in average 3-4% of gross national income of developed countries (Wicks, 2006).
Observing literature about stress in medical field it was found that among physicians (as it was mentioned above the focus group for this project is doctors in hospices) as among other health professionals, there is a higher incidence of mental disorders compared with the averages in the population, and it is generally considered that it is connected with the peculiarities of the medical profession. In 1997, one of the issues of the journal ‘Advances in Psychiatric Treatment’ was devoted to the overall theme of mental disorders among physicians with an emphasis on phenomenology and treatment.
Interviewing Dr. Thomas, who is the doctor in hospice it was found that stress greatly influences not only professional life, but also personal life of any doctor. Dr. Thomas stated that “often the patient’s life depends on the timely receipt of adequate medical care for high-quality rendering of which the doctor of hospice requires self-discipline, high level of concentration and clarity of action. The need for rapid decision-making under tough time constraints and information leads to long-term emotional suspense – and, as a consequence, the development of stress.” Dr. Thomas also mentioned during the interview that “among health care workers professionals who are most distinguished by a heightened sense of responsibility, willingness to always come to the aid for the patient, the desire to be important, the desire to provide psychological support, a high degree of moral duty to the patient and the desire to conform to certain ethical-deontological requirements, experiences about their professional competence are in the group of risk for the stress development.”
While making the research of stress in the medical field it was found that according to British researchers as it was stated by Levey, in 41% of the cases among general practitioners high levels of anxiety are revealed, and clinically evident depression is present in 26% of cases. (Levey, 2001). The third part of doctors use medication for correction of emotional stress, and the amount of alcohol use exceeds the average level.
According to Wicks stress is provoked by three types of factors in the big majority of cases (Wicks, 2006). In such situation personal role and organizational factors have the leading place in the medical field.
Personal factor. It describes ‘burning’ doctors as sympathetic, humane, gentle, fond, idealists, people-oriented, and at the dame time unstable, introverted, obsessed by fixed ideas, “fiery” and easily identifying themselves personalities.
Role factor. The relationship between the role conflict, role ambiguity and ’emotional burnout’ was observed many decades ago. Wicks stated that employment in the case of a clear division of responsibility limit the development of stress in the medical field (Wicks, 2006). Moreover, doctors who feel fuzzy or uneven distribution of responsibility for their professional actions, understand that this factor increases sharply, even at much lower workload.
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Organizational factor. The main organizational factors that contribute to stress ‘burnout’ include: high workload, lack or absence of social support from colleagues and management, insufficient remuneration for work, a high degree of uncertainty in assessing the work performed; inability to influence decision-making process; ambiguous requirements for the work; the constant risk of penalties, monotonous and unpromising activities, the need to outwardly show emotion, that is not conform to reality, lack of holidays, vacations and interests outside of the own medical profession. It is also necessary to mention that among the other important factors in the development of stress are the destabilizing organization of activities and unfavorable psychological atmosphere in the team.
Making the accent on the development of stress among doctors of hospice we should mention that high medical pressure, twenty-four-hour regimen with the mandatory duty, the expectation of complications in the condition of patients require a high functional activity of the organism and can be qualified as the leading professional pathogenic factors. In addition, an aggravating effect on the health of workers has the contact with dying patients when the health worker does not see the positive results of the own efforts to save the patient and often feels his own weakness. As a result there can be mentioned developing brain disorders in the form of neurosis, hypertension, stenocardia, ulcers of the gastrointestinal tract and other health problems. It is obvious that professional activities often have an adverse impact on individuals that leads to depression.
The greater medical workload lead to the fact that health care worker experiences less pleasure from the process of his own work. Exceeding regulatory number of patients, a large amount of clerical work-design, low technical equipment of the workplace and the permanent shortage of drugs also contribute to the manifestations of fatigue and nervousness. From the ergonomic factors doctors in the hospice often observe eye strain, overload of the musculoskeletal system.
Thinking about the way how stress in the medical field relates to culture it is possible to say that the recent radical changes in society have an additional psychological burden on the medical staff, since society needs the higher quality workers in a much shorter time since economic restrictions are providing health services. Innovation activities of health care institutions is focused on the practical use of scientific and technical results and intellectual capacity to expand the range of services, methods for their production, to improve quality of care and meet patients’ needs for high quality medical services, and ultimately – to optimize the level of health among population. The most part of health professionals who work in an innovative environment, have long working hours, overtime, associated with combining positions or additional training workload (training, development of new methods of diagnosis and treatment). Intensification of professional activities affects the health, helping to increase the level of overall incidence and prevalence of chronic diseases.
In addition to the above observed facts Dr. Thomas stated that “people working in health care facilities are often subjected to considerable personal stress … They have problems in the private life because they cannot show their feelings to other people and have the predominant feature of the medical profession – to deny the problems related to personal health.” Due to the research work in the medical field we can state that among doctors in hospice there is a widespread idea that the stress at work is like a failure and doctor’s own weakness. That’s why stress calls denials based on the feeling of guilt and leads to the fact that doctors have many difficulties in admitting of the existence of these problems, respectively, it is difficult to share and solve them timely.
Thinking about the negative impact of stress on the work of any doctor we should pay the specific attention to the fact that development of this state contributes to certain personality traits – a high level of emotional lability (neuroticism), high self control, especially when expressing negative emotions with the desire to suppress them, the rationalization of the motives of personal behavior, a tendency to increased anxiety and depressive reactions associated with unattainability of ‘internal standard’ and blocking negative emotions, rigid personality structure. The paradox is that the ability of health care workers to deny their own negative emotions can sometimes be a power in their hands, but often it becomes their weakness. Therefore it is useful to remember that we are always a part of our problem, or part of their solutions is always in our mind.
Thus, the fieldwork shows that the syndrome of “burnout” is accompanied by the daily, routine professional work, often requiring from physicians a sufficiently intense, not spontaneous, unimportantly conflict, but for different reasons emotionally intense communication with patients, and therefore it is not associated with its extreme conditions. So, it becomes clear why frequency and intensity of this syndrome are much higher among oncologists and doctors in hospice than among surgeons or traumatologists.
It is impossible to leave without attention the fact that the restriction of the possibility of using existing personal potential, the monotony of work, a high degree of uncertainty in the assessment of the work, dissatisfaction with social status are noted among the characteristics of communicative professions that have a significant impact on the development of stress. And only after the above numerated factors physicians emphasized that they considered low pay and poor working conditions as stress factors, considering them important, but not leading, as it often seems to be the sources of occupational stress in health care workers.
Conformity / fail capabilities of professional in the medical field and social conditions of his activities lie in the focus of the problem of occupational stress. Therefore, this issue was explored in complex of specialist communication profession and its social environment. Emotional infectiousness ‘burnout’ syndrome, which also emphasizes its social nature plays also an important role in the discussion of the information in this project.
In conclusion, stress in the medical field and occupational stress in its wide sense are not the problem of ‘difficult’ people, but the problem of ‘difficult’ (unsolved) cases in the relationship and structure of interpersonal relations, fuzzy symbols of social roles and responsibilities, lack of emotional support from counterparts and leaders.
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