Stress of Medical Practitioners in Private Healthcare Industry

Stress is a universal and inevitable component of life. The article reports findings of a study aimed to determine the sources of stress among medical practitioners in private hospitals. The context of the study is medical practitioners in private hospitals and clinics in Bahawalpur, Pakistan. Field study was conducted and primary data collection instrument was questionnaires. The questionnaire was based on five dimensions: workload, working conditions, role overload, sleep deprivation and unrealistic demands of the patients. The data was analyzed through statistical techniques using SPSS Version 16. Findings of the study revealed that sleep deprivation was the most important source of stress, followed by workload, working conditions, role overload and unrealistic demands of patients. The study provides a piece of evidence which may be used to illustrate the stress level of private practitioners in the healthcare industry in a developing country. Results of this study are useful to guide and inform healthcare management and policy measures.


Introduction
One of the most stressful occupations is healthcare practitioners (Aziz, 2004) due to their significant impact on human life (Rees, 1995).A cross-sectional and longitudinal study confirms that doctors experienced stress much above the threshold level compared to the general working population (Firth-Cozens, 2003).Studies have shown stress adversely impacts the physical and psychological well-beings of doctors (Burke & Deszca, 1986;Sonneck & Wagner, 1996).Considerable work has been done in the area of stress among healthcare practitioners throughout the world.However, most have focused in the European countries and very few have investigated the issue in Pakistan.It is widely acknowledged that developing countries lack appropriate standards and working conditions to ensure work-life balance.As such, this triggers the selection of Pakistan.The prime concern of the study was to reveal the true side job stress among doctors in Pakistan.Bahawalpur region was chosen as a representative city because it is one of the least developed regions in Pakistan in terms of working conditions and living standards.Findings originating from this context would contribute to management and policy suggestions.This topic is significant because of it leads to better provision of health services to general public which should be a very basic necessity in life.Against this backdrop, a study was conducted to investigate the sources and causes of stress among doctors in hospitals in Pakistan with a specific focus on those working in the private healthcare providers located in the region of Bahawalpur.

Literature Review
Stress is defined as an 'adaptive response to a situation that is perceived as challenging or threatening to a person's well-being' (McShane & Glinow, 2010, p. 114).It is a result of the physical, mental and emotional strains exposed to a person due to his / her surrounding environment that exceeds his/her capacities to adapt.Stress occurs when there is an imbalance between demands and resources and an individual surpasses his / her professed ability to manage (Lazarus & Folkman, 1984).Research shows that work stress is a global phenomenon affecting the working population in North America, Europe and Asia (McShane & Glinow, 2010).Stress can be categorized into positive stress (i.e.distress) and negative stress (i.e.eustress) (ibid.).Long exposure to negative stress often results to job burnout which involves gradual emotional exhaustion, cynicism and loss of personal accomplishment (Maslach et al., 2001).Negative stress has been a major concern both in research and practice due to its adverse consequences to individuals and organizations.Doctors are facing an increased pressure which directly impacts their performance (Caplan, 1994).Some of the factors that make doctor's life seriously stressful are the long hours, dealing with critically-ill patients, emergency and night calls, sustaining medical education and personal development, and aspiring for higher goals attainment (Shiwani, 2009).The stress will further worsen when the work environment provides lack of control over work environment, job recognition, inflexible organization structure, and monetary reward (Imtiaz & Ahmad, 2009).Lower job satisfaction and abandoning work owing to stress was highly complained by physicians and surgeons (Anthony, 2001).Stress may depend on the type of medical practice.Doctors who work in hospitals were found to experience higher levels of stress than those working in other healthcare areas such as private clinics (Lim & Pinto, 2009).Tyson and Pongruengphant (2004) in their 5-year longitudinal study involving in 14 private and public hospitals in Thailand conclude that those working in public hospitals generally reported more stress than their counterpart in the private hospitals.However, an earlier study by Tyler et al. (1991) found that nurses in both practices reported similar high level of stress.A decade-long of literature review shows that stress-related and mental disorder among doctors in China is highly prevalent particularly for public hospital doctors (Chen et al., 2013).The causes listed include workload, highly demanding patients, occupational risks, effort-reward imbalance and highly-competitive environment for promotion.Addiction to opioids remains the most common substance abuse among doctors particularly anesthesiologists (Bryson & Silverstein, 2008).Brooke et al. (1993) revealed that depression mainly due to work stress was one of the most frequent pathways leading to substance abuse among doctors.
The cause of stress (i.e.stressors) among doctors is a widely-researched topic (e.g.Maslach et al., 2001;Gray-Tofta & Anderson, 2002).Wong (2008) enlisted that doctor stress is caused by five factors: 1) job itself, the organization; 2) personal factors; 3) relationship with others; and 5) work-life balance.On a similar note, McShane & Glinow (2010) highlighted three most common stressors being: 1) harassment and incivility in the workplace; 2) work overload; and 3) low task control.Knowledge derived from the literature is used to develop the following research theoretical framework (Figure 1).

Figure 1. Model measuring the stress level among doctors
The first factor, workload, refers to the amount of hours and efforts required to perform tasks.The importance of this factor as a contributor to job stress among medical practitioners has been found by previous researchers such as Smith (2001), Happel et al. (2013), Gray-Tofta and Anderson (2002), Aziz (2004), andMcGowan et al. (2013).Excessive workload reduces productivity and leads to stress.The second factor, working conditions, refers to various job relevant factors that directly or indirectly affect the job performance.These include basic pay, job hours, health and job security, recognition, benefits, and organizational culture and climate.Negative working conditions are detrimental to personal and organizational well-beings (Kaur et al., 2009;Khuwaja et al., 2004).For instance, unsupportive workplace climate (Happel et al., 2013) and depressing relationships with other doctors (Branthwaite & Ross, 1988) has been found as causes of doctor's stress.Right working condition is crucial since it affects practitioners' job satisfactions and consequently the service they provide to patients (Stanowski, 2009).Thirdly, role overload refers to the extent to which an individual regards him or herself being pressured due to multiple commitments and responsibilities (Reilly, 1982).It includes professional and personal life roles.Role overload contributes to an increased workload.Role overload is different from role conflict and role ambiguity.Role overload as an important contributor to job stress has been found by previous researchers such as Branthwaite and Ross (1988), Cooper et al. (1989) and Maslach et al. (1997).The fourth factor, sleep deprivation is also one of the important sources of stress (Khuwaja et al., 2004;French et al., 2001).This is caused by their long hours and the need to be on-call.A study in Pakistan showed that sleep deprivation is a very common problem among doctors and badly affects their work performance, physical and mental health (Mustahsan et al., 2013).Doctors who did not get enough sleep were more prone in making medical errors, experienced mood-related symptoms, personality changes and other health problems (ibid.).And the fifth factor, unrealistic expectations from patients also a contributor to stress in doctors (Kushnir et al., 1997;D. Bonn & J. Bonn, 2000;Hayter et al., 1996).Edwards et al. (2002) has given example that patients sometimes expect doctors to spend longer time examining them.Another example includes expecting doctors to completely cure their diseases.From these findings, the following hypotheses are developed.Against the backdrop of these literatures, the following hypotheses are developed: H0: There is no significant relationship between workload and stress level among doctors.
H1: There is a significant relationship between workload and stress level among doctors.H0: There is no relationship between working conditions and stress level among doctors.
H1: There is a relationship between working conditions and stress level among doctors.H0: There is no relationship between role overload and stress level among doctors.
H1: There is a relationship between role overload and stress level among doctors.H0: There is no relationship between sleep deprivation and stress level among doctors.H1: There is a relationship between sleep deprivation and stress level among doctors.H0: There is no relationship between unrealistic patient's demands and stress level among doctors.H1: There is a relationship between unrealistic patient's demands and stress level among doctors.

Methodology
The subjects in the present study consisted of doctors and medical practitioners of the private hospitals and clinics in Bahawalpur, Pakistan.The data was collected through survey method in which the questionnaire was mailed to 250 doctors and practitioners.A total of 235 questionnaires were returned in which 223 (89%) were found correct and utilizable.The questionnaire consisted of 24 items representing 5 dimensions of stress: sleep deprivation, work overload, working conditions, role overload and unrealistic patient's demands.Responses were recorded against a five-point Likert scale comprising of 1=strongly agree; 2=agree; 3=uncertain; 4=disagree; 5=strongly disagree.The respondents were asked to respond on each of the item and indicate the degree to which each of the items on the questionnaire contributed to stress on the Likert scale.The questionnaire was adapted from Nayak (2008).The result for Cronbach Alpha for the 24 items on the questionnaire determining sources of stress was 0.805, designating high level of internal consistency of the scale.

Findings and Discussion
The mean, standard deviation and variance were obtained using SPSS.The highest mean score items were workload (3.124), working environment/conditions of the hospital (3.104), and deprivation of sleep (3.101).The items with lower mean scores were monotonous routine (2.21), norms and expectations (2.13), and unrealistic hopes to the patients (1.91).The analysis of the impact of stress variables on doctors through coefficient of correlation was: workload showed a relatively strong positive significant relationship with stress with correlation value of 0.665 at 0.000 significance value.Working conditions showed a positive significant relationship with stress among doctors with correlation value of 0.589 at 0.000 significance value.Role overload showed a moderately significant relationship with stress with correlation value of 0.512.Sleep deprivation showed strong positive correlation value of 0.775.The last dimension unrealistic patient's hopes showed low positive correlation with stress with a value of 0.219.On the basis of the above results obtained from correlation, our alternate hypothesis H1, H2, H3, H4, H5 are accepted.
Table 1 represents the model summary.The value of R that is the correlation coefficient value is used to measure the linear association between variables.The value of R in the model summary (Table 1) is 0.850, which shows that there is a strong linear relationship between the variables.R square is known as coefficient of determination and measures the total variation in the dependent variable that is explained by the relationship with the independent variable.The value of R square in the model summary is 0.730 which means that the 73.0 percent of the variation in dependent variable (stress) is explained by the relationship between independent variables (workload, working conditions, role overload, sleep deprivation and unrealistic patient's demands).

Discussion
The study aimed to determine the factors that caused stress in doctors and medical practitioners in private hospitals.The study showed that workload was the most important stressor for the doctors with a mean score value of 3.124 and a correlation value of 0.665.Based on this the first hypothesis is accepted.The second dimension, working conditions showed a mean score value of 3.104 and correlation value of 0.589.Hence, the second hypothesis is also accepted.The third dimension, role overload, also showed a positive significant relationship with stress with correlation value of 0.512, thus, leads to the acceptance of the third hypothesis.Fourthly, sleep deprivation also reported a strong positive correlation value of 0.775 which suggests that the dimension is a strong stressor for the doctors.Lastly, unrealistic patient's demand dimension shows a weak correlation value of 0.219.This result shows that there is a low positive correlation between unrealistic demands of the patients and stress among doctors.Despite of the weak correlation, the hypothesis H5 is also accepted due to its positive relationship.The study shows that the five dimensions are important stressors of doctors in private doctors in the Bahawalpur region in Pakistan.These findings concur with earlier studies (e.g.Gray-Tofta & Anderson, 2002;Aziz, 2004;Smith, 2001;Happel et al., 2013;Agdelen et al., 2010;Cooper et al., 1989;Branthwaite & Ross, 1988;Maslach et al., 1997).Comparatively, this suggests that the stressors of medical practitioners have been somewhat standard and consistent throughout the world regardless of the types of healthcare providers.It is interesting to note that out of the five factors included in the study, unrealistic patient's demand only records a weak correlation value.Since perception towards this factor is most likely stemmed from the kinds of patients that the respondents dealt with, it may be assumed that the respondents covered in the study may not have been exposed to difficult and demanding patients.

Conclusion
The article has reported findings of a study which aims to identify the sources of stress among medical practitioners in Pakistan with a specific focus of the Bahawalpur region.The study revealed that all five factors contributed to the respondents' stress.Sleep deprivation showed a strong positive correlation with stress (0.775), workload ranked second (0.665), working conditions ranked third (0.589), role overload was fourth with (0.512) and unrealistic patient's demands ranked with a low positive correlation value (0.219).Hence, all alternate hypotheses H1, H2, H3, H4, and H5 were accepted.The study provides a piece of evidence to describe the stress level in the context of a developing country.To further understand this issue, future studies can be conducted to explore stress coping strategies among the practitioners.Comparative studies between private and public hospitals in the country are also useful to analyze the what and how stress affects the well-being of the practitioners.Results of this study are useful to guide and inform healthcare management and policy measures.It highlights the actual scenario regarding job stress in the medical profession.Since this group is very prone to job stress, appropriate standards and interventions particularly in those five factors must be implemented by relevant parties to create an environment of healthy work-life balance.Being a developing country, it is understandable that lacks of systems and scarcity of talents are common challenges in the nation development.In this landscape, issues such as employee welfare may be easily compromised and fallen into a less priority area.However, it is crucial to remember that this issue should not be taken for granted as stress is a silent killer which directly and indirectly affects the economic and social health of many parties.

Table 1 .
Model summary b

Table 2 .
Analysis of variance b

Table 2
highlights the regression results through ANOVA table.F-statistics in the ANOVA table shows a value of 137.252 which means that there is a statistical significance of the relationship between dependent variable and the independent variables when taken in the form of group.It is obtained by dividing the mean square of regression to the mean square of residual.The significance of this value is mentioned in the next column of the ANOVA table that is 0.000 which depicts highly significant relationship.