Quality of working life in relation to occupational stress, anxiety and depression of workers in primary and secondary healthcare workplaces.

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Quality of working life in relation to occupational stress, anxiety and depression of workers in primary and secondary healthcare workplaces.

https://doi.org/10.21203/rs.3.rs-3407001/v1

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Background

Healthcare professionals work in a demanding working environment, due to which they may develop high levels of stress, anxiety and depression.

Aims

To assess the quality of working life of healthcare professionals and to investigate the association between stress, anxiety and depression and the quality of working life.

Methodology:

A cross-sectional study implemented in two primary healthcare centers and a general hospital in Greece, between January to February 2020. A total of 248 healthcare professionals participated. The Depression, Anxiety and Stress Scale (DASS 21) and the Professional Quality of Life Scale (ProQOL) were used.

Results

Healthcare professionals had normal stress (10.11), depression (6.69), anxiety (5.10) and appeared to had moderate quality in their working life. The quality of the working life was found to be influenced by educational level, as the level of education increases, occupational burnout (p = 0.015) and secondary traumatic stress (p = 0.001) decrease. Correlation of the demographic characteristics of the sample and the DASS-21 scale showed that as the level of education increases, depression, stress and anxiety decrease (p < 0.05). Multivariable linear regression analysis showed that increased depression, anxiety and stress were associated with increased occupational burnout and secondary traumatic stress and on the other hand, decreased depression, anxiety and stress were associated with increased compassion satisfaction.

Conclusions

The study emphasized the significance of the management of healthcare organizations to achieve a reduction of stress, depression and anxiety among healthcare professionals in order to ensure a better-quality working life.

Health Policy

Anxiety

burnout

depression

healthcare

occupational

quality of working life

stress

satisfaction

traumatic stress

Professional Quality of Life (ProQOL) is the quality one feels in relation to one’s work as a helper. Healthcare professionals belong to the category of helping professions. ProQOL can have a positive dimension (compassion satisfaction) or a negative dimension (compassion fatigue), with the negative dimension consisting of burnout and secondary trauma (Stamm, 2010).

Studies that have been conducted in different care settings including different healthcare professionals have highlighted the relatively high prevalence rates of compassion fatigue, burnout, and secondary trauma, which over time have an increasing trend (Branch and Klinkenberg, 2015; Cavanagh et al., 2020; Van Mol et al., 2015; Ruiz-Fernández et al., 2020; Xie et al., 2021). Organizational factors associated with the development of compassion fatigue, burnout and secondary trauma include the unhealthy work environments, poor communication, stigma, the lack of time and resources to provide comprehensive care, the poor collegial nurse–physician relationships and the decreased nurses' participation in hospital affairs (Kelly, 2020; Moisoglou et al., 2021; Pérez-García et al., 2021). At the same time, however, the way in which the working environment of healthcare professionals is organized seriously affects their mental health. Workload, lack of organizational support, lack of adequate resources and inadequate and poor equipment are some of the elements of the work environment that have been associated with the development of depression, anxiety and stress (Elbay et al., 2020; Foster et al., 2021; Khamisa et al., 2015). Healthcare professionals who are exposed to high levels of work-related stress, depression and anxiety are at high risk for developing compassion fatigue (Barr, 2017; Duarte, 2017; Hegney et al., 2014) and experiencing a deterioration in the quality of their working life (Bakhshi et al., 2018; Eisapareh et al., 2022).

Therefore, healthcare professionals are often caught in a vicious work cycle, where one factor (stress, anxiety, depression) feeds the other (poor quality of working life). The effects of compassion fatigue are multidimensional, affecting the physical and mental health of healthcare professionals, their work performance, the quality of care provided and increasing the likelihood of suicide (Haik et al., 2017; Kelly, 2020; Sorenson et al., 2017). The managements of health service organizations are called upon to improve the working conditions of healthcare professionals in order to remove the factors that contribute to the deterioration of the quality of working life. In addition to improving organizational factors in order to reduce the likelihood of compassion fatigue, programs with self-care, mindfulness and resiliency have been successfully implemented for the optimal management of compassion fatigue by the healthcare professionals themselves (Abernathy and Martin, 2019; Kestler et al., 2020; Klein et al., 2018).

The aim of this study was to assess the quality of working life of primary and secondary healthcare professionals and to measure their symptoms of depression, anxiety and stress. The existence of associations between the quality of working life and these symptoms was also investigated.

Study design and settings

A cross-sectional study was performed in a public hospital and two primary healthcare centers in a provincial city in Greece. The convenience sampling was used. A total of 300 self-completed questionnaires were distributed and a response rate of 82.7% was achieved (248/300). All methods were carried out in accordance with Helsinki guidelines. The study protocol was approved by the hospital ethics committee and the administration of the 3rd Health Region Authority, to which the two primary healthcare centers belong administratively (No:15310/2019, No:53235/2019). The study questionnaire was accompanied by a letter of information and consent, which provided the details of the researchers, the purpose of the study, the assurance of anonymity and the voluntary participation of the nurses. The duration of the study was from January 1st to February 29th 2020.

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were followed throughout the research process (Vandenbroucke et al., 2007).

Instruments

Professional Quality of Life Scale (ProQOL)

The ProQOL Scale is a 30 item self-report questionnaire designed to measure two aspects of professional quality of life, the Compassion Satisfaction (pleasure you derive from being able to do your work well) and the Compassion Fatigue, which breaks into two parts, the Burnout (exhaustion, frustration, anger and depression related to work) and the Secondary Traumatic Stress (feeling fear in relation to work-related primary or secondary trauma) (Stamm, 2010). The 30-item Likert scale used in ProQOL ranges from 1 (never) to 5 (very often). Each scale of the questionnaire (satisfaction, burnout, secondary trauma) consists of 10 items. Higher scores on the satisfaction scale represent a greater satisfaction related to one’s ability to be an effective caregiver in one’s job. Higher scores on the burnout scale mean that the person is at a higher risk for burnout. Higher scores on the secondary traumatic stress scale do not mean that a person has a problem, but there is an indication that may want to examine how the person feels about his work environment and he may wish to discuss this with his supervisor, a colleague, or a healthcare professional.

DASS 21 questionnaire

The Depression, Anxiety and Stress Scale (DASS-21) is a 21 item self-report scale designed to measure the emotional states of depression, anxiety and stress. The scale developed by Lovibond and Lovibond in 1995 (Lovibond and Lovibond, 1995). For the purpose of this study, the Greek version of the DASS-21 was used, which was translated and validated by Lyrakos et al (Lyrakos et al., 2011). The DASS-21 uses four-point item responses (0 to 3), with the lowest scoring being "Did not apply to me at all" and the highest scoring being "Applied to me very much or most of the time." Higher scores indicating greater levels of distress. The DASS-21 has cut-off scores for conventional severity labels, as follows: Normal 0–9, mild 10–13, moderate 14–20, severe 21–27 and extremely severe > 28.

Furthermore, a number of demographic and occupational characteristics were collected, including sex, age, marital status, number of children, educational level, work setting, working position and years of work experience.

Data analysis

We used numbers and percentages to present categorical variables. Also, we used mean and standard deviation to present continuous variables. We used Pearson’s correlation coefficient to assess the correlation between two continuous variables. To investigate the association between the DASS-21 scale and the ProQOL regression analysis was conducted after adjusting for demographic and job characteristics, i.e. sex, education level, family status, having children, working setting, working position, and working experience. Regarding multivariable linear regression analysis, we presented coefficient beta, 95% confidence interval, p-values and R². All reported p values were two tailed. Statistical significance was set at p < 0.05 and analyses were conducted using SPSS statistical software (version 18.0).

Most of the sample of healthcare professionals were women (70.2%). The mean age of the sample was 44.9 years (standard deviation; 8.3). Almost, 80% of the questionnaires were collected by the General Hospital, 55.6% of the sample were nursing staff, 29.4% were physicians and 14.9% were administrative staff. The mean of years of experience was 16.4 (standard deviation; 9.8). Sample characteristics are presented in Table 1.

Insert table 1 here

According to the results, most of the healthcare professionals had indications of anxiety, stress, and depressive symptoms. Scale measures have shown that healthcare professionals had normal stress (10.11), normal depression (6.69) and normal anxiety (5.10). In terms of results from working quality of life, healthcare professionals appear to have moderate quality in their professional life and, moderate occupational satisfaction (37.47) moderate occupational exhaustion (24.26) and moderate secondary traumatic stress (23.09).

Correlation of the demographic characteristics of the sample and DASS-21 scale showed that as the level of education increases, depression, anxiety and stress decrease (p < 0.05). Divorced people also have a higher average rate of depression than unmarried, married, and widowed people. Correlation between level of education and depression, anxiety and stress are provided in Table 2.

Insert Table 2 here

Correlation of the demographic characteristics of the sample and the quality of working life revealed that as the level of education increases, occupational burnout, and secondary traumatic stress decrease. Importantly, as the number of years of service increases, so does the secondary traumatic stress of healthcare professionals. The results of ProQOL regarding the level of education and quality of working life are given in Table 3.

Insert table 3 here

Finally, the dimensions of quality of working life were correlated with the dimensions of DASS-21 and it was shown that as professional satisfaction increases, then depression (r = 0.294), anxiety decreases (r = -0.254) and stress decreases (r = -0.159), while as occupational exhaustion increases, depression (r = 0545), stress (r = 0.476) and anxiety (r = 0.424) and as secondary traumatic stress increases, depression (r = 0.431), anxiety (r = 0.381) and stress increases (r = 0.504). The results are given in Table 4.

Insert table 4 here

Multivariable linear regression analysis with quality of working life as the dependent variable is presented in Table 5. Multivariable analysis confirmed the results of correlation analysis. Increased depression, anxiety and stress were associated with increased occupational burnout and secondary traumatic stress. On the other hand, decreased depression, anxiety and stress were associated with increased professional satisfaction.

Insert table 5 here

According to the findings of this study, healthcare professionals in Greece although they experience normal levels of stress, anxiety and depression, these nevertheless have a negative impact on the quality of working life. At the same time a correlation was found between the dimensions of quality of working life and the dimensions of DASS-21. Our findings are consistent with those of the literature regarding the impact of stress, anxiety and depression on the quality of working life and vice versa (Alharbi et al., 2022; Pang et al., 2020; Su et al., 2021). The quality of working life of employees in helping professions is determined by the satisfaction experienced by professionals through the offer to those who receive their services. The compassion satisfaction is the positive aspect of the quality of working life and it is extremely important to ensure the factors that promote it, as compassion satisfaction has multiple benefits at a professional level. In particular, low compassion satisfaction is associated with unacceptable behavior towards patients and colleagues and a desire for early retirement (Dasan et al., 2015), non-compliance with hand hygiene (Zhou et al., 2021), poor performance and commitment to work (Sacco and Copel, 2018) and doubting of competence by health professionals themselves (Clark et al., 2022). In the case of healthcare professionals, on the one hand, the constant contact with trauma and death and, on the other hand, the inability to ensure a healthy working environment can have a negative impact on their mental health and lead to a deterioration in the quality of their working life. Research has highlighted the important impact of mental health on the quality of working life. However, it appears that little progress has been made towards removing the factors that burden the mental health of healthcare professionals, resulting in a high prevalence of mental health problems (Hill et al., 2022). Also, working conditions do not seem to have improved to the extent that they have reduced the occurrence of compassion fatigue (Singh et al., 2020). There are, however, demographic and occupational characteristics of healthcare professionals that are predictors of stress, anxiety, depression and compassion fatigue. The findings of the present study highlighted the protective role of educational attainment and the aggravating role of years of service. These findings are consistent with those of other studies (Kelbiso et al., 2017; Khademian et al., 2021; Mangoulia et al., 2015; Olashore et al., 2022). Regarding the educational level, presumably healthcare professionals with a bachelor's or master's degree have the knowledge to better manage stressful situations, as well as the training to deal with difficult situations such as understaffing, workload or conflict management. In terms of work experience, healthcare professionals with more years have more exposure to pain, death and combined with difficult working conditions, they are more likely to experience a deterioration in the quality of work life. Interventions by health organization managements to improve working conditions can include providing opportunities for healthcare professionals to undertake continuing education, moving staff to departments with lower workloads and work intensity, while ensuring all the resources needed for a healthy work environment.

The present study has a number of limitations. Firstly, the study was conducted on a relatively small sample of healthcare professionals and therefore the results should be interpreted with caution. Also, the study was carried out in one provincial hospital and two healthcare centers and therefore the results cannot be generalized to all healthcare professionals.

Employees in helping professionals derive pleasure through their service to individuals. However, difficult working conditions and constant exposure to pain and death, as healthcare professionals, are factors that lead to compassion fatigue and burnout. In the present study, healthcare professionals were found to experience moderate levels of stress, anxiety and depression, but these have a statistically significant impact on the quality of work life. The negative effects of a degraded quality of working life make it imperative to improve the working environment of healthcare professionals. Through these interventions the quality of working life will be improved, both directly and indirectly through the improvement of the mental health of health professionals.

Competing interests:

The authors declare no competing interests.

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Table 1. Sample characteristics.

Characteristic

N (%)

Sex

Women
Men
Age (years) mean, (SD)

174 (70.2)

74 (29.8)

44.9 ± 8.3

Degree

University

Technical University

Two‐year education

80 (32.3)

103 (41.5)

65 (26.2)

Postgraduate degree

Master

PhD

217 (87.5)

27 (10.9)

4 (1.6)

Family status

Unmarried

Married

Divorced

Widowed

49 (19.8)

171 (69.2)

22,(8.9)
5 (2.0)

Children

None

One

Two

Three

Four

24 (11.3)

43 (19.7)

96 (45.1)

36 (16.9)

15 (7.0)

Working position

Nurse

Physician

Administrator

138 (55.6)

73 (29.4)

37 (14.9)

Working Sector

Primary Healthcare Center

General Hospital

50 (20.2)

198 (79.8)

Totals years of working experience, mean (SD)

16.4 ± 9.8

Table 2: Correlation between education and depression, anxiety and stress.

Level of education		Depression	Anxiety	Stress
Two‐year education	Mean	8.34	11	6.8
	N	65	64	65
	Standard deviation	8.54	9.22	7.06
Technical University	Mean	8.06	11.18	6.02
	N	99	102	103
	Standard deviation	8.46	8.3	6.74
University	Mean	3.5	8	3.06
	N	76	79	80
	Standard deviation	4.7	6.78	3.8
P value		0.001	0.021	0.001

Table 3: Correlation between education and quality of working life.

Level of education		Professional satisfaction	Occupational burnout	Secondary traumatic stress
Two‐year education	Mean	36,75	25,14	24,95
	N	64	64	63
	Standard deviation	7,26	5,29	7,49
Technical university	Mean	37,37	24,87	23,81
	N	103	102	100
	Standard deviation	7,49	5,44	6,63
University	Mean	39,08	22,76	20,65
	N	76	79	78
	Standard deviation	6,29	5,94	5,74
P value		0.121	0.015	0.001

Table 4: Correlation between quality of working life and depression, anxiety and stress.

ProQOL Scales		Depression	Anxiety	Stress
Professional satisfaction	Pearson correlation	-0,288**	-0.146**	-0,252*
	Sig. (2-tailed)	<0,001	<0,001	<0,001
	N	235	240	243
Occupational burnout	Pearson correlation	0,531**	0,427**	0,480**
	Sig. (2-tailed)	<0,001	<0,001	<0,001
	N	237	242	245
Secondary traumatic stress	Pearson correlation	0,406**	0,480**	0,347**
	Sig. (2-tailed)	<0,001	<0,001	<0,001
	N	233	238	241

** Correlation is significant at 0.01 level (2-tailed)

* Correlation is significant at 0.05 level (2-tailed)

Table 5: Multivariable linear regression analysis with quality of working life as the dependent variable.

Dependent variable Independent variable	Coefficient beta	95% confidence interval	P-value	R²
Professional satisfaction				11%
Depression	-0.32	-0.56 to -0.09	0.007
Anxiety	-0.15	-0.30 to -0.002	0,046
Stress	-0.22	-0.33 to -0.11	<0.001
Occupational burnout				26%
Depression	0.38	0.30 to 0.46	<0.001
Anxiety	0.37	0.26 to 0.47	<0.001
Stress	0.32	0.24 to 0.40	<0.001
Secondary traumatic stress				22%
Depression	0.32	0.22 to 0.42	<0.001
Anxiety	0.49	0.01 to 0.24	0.04
Stress	0.26	0.16 to 0.35	<0.001

All models were adjusted for demographic and job characteristics.

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Quality of working life in relation to occupational stress, anxiety and depression of workers in primary and secondary healthcare workplaces.

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Background

Aims

Methodology:

Results

Conclusions

INTRODUCTION

MATERIALS AND METHODS

Study design and settings

Instruments

Professional Quality of Life Scale (ProQOL)

DASS 21 questionnaire

Data analysis

RESULTS

DISCUSSION

CONCLUSION

Declarations

References

Tables

Status:

Version 1