Changes in work stress among doctors in Norway from 2010 to 2019: a study based on repeated surveys

OBJECTIVES

To explore and discuss the changes in the levels of work stress for Norwegian doctors in different job positions (hospital doctors, general practitioners (GPs), private practice specialists, doctors in academia) from 2010 to 2019.

DESIGN

Repeated questionnaire surveys in 2010, 2016 and 2019, where samples were partly overlapping.

SETTING

Norway.

PARTICIPANTS

A representative sample of 1500-2200 doctors in different job positions. Response rates were 66.7% (1014/1520) in 2010, 73.1% (1604/2195) in 2016 and 72.5% (1511/2084) in 2019.

MAIN OUTCOME MEASURE

Validated 9-item short form of the 'Effort-Reward Imbalance' questionnaire. A risky level of work stress was defined as an effort/reward ratio above 1.0.

ANALYSES

Linear mixed models with estimated marginal means of job positions controlled for gender and age. Proportions with 95% CIs.

RESULTS

From 2010 to 2016 and further to 2019, GPs reported a significant increase in levels on the effort scale (ES: 2.96, 3.25, 3.51) and significant decrease in levels on the reward scale (RS: 4.27, 4.05, 3.67). No significant changes were reported by hospital doctors (ES: 3.13, 3.10, 3.14; RS: 4.09, 3.98, 4.04), private practice specialists (ES: 2.58, 2.61, 2.59; RS: 4.32, 4.32, 4.30) and doctors in academia (ES: 2.63, 2.51, 2.52; RS: 4.09, 4.11, 4.14). The proportion of doctors with risky levels of work stress increased significantly for GPs (10.3%, 27.7%, 40.1%), but did not significantly change for hospital doctors (23.0%, 27.3%, 26.9%), private practice specialists (8.2%, 12.7%, 9.4%) and doctors in academia (11.9%, 19.0%, 16.4%).

CONCLUSION

During a 9-year period, the proportion of risky levels of work stress increased significantly for GPs but did not significantly change for other job positions. This may be partly due to changes in expectations of younger GPs and several healthcare reforms and regulations.

Changes in work stress among doctors in Norway from 2010 to 2019: a study based on repeated surveys

Background

Changes in the organization of health care can influence the doctors` working conditions, which may in turn impact on doctors` perception of work stress. Since high levels of work stress can affect both the doctors’ own health and the quality of patient care, it is of importance for public health. We studied changes in work stress among Norwegian doctors from 2010 to 2018-19, and the associations of high work stress with job positions, self-rated health and sickness absence in 2018-19.

Methods

The study populations consisted of representative samples of 1,500 to 2,200 doctors working as hospital doctors, general practitioners (GPs), private practice specialists and doctors in academia. Data were drawn from nationwide repeated postal surveys in 2010, 2016 and 2018-19 in Norway. Response rates were between 67%-73%. The main outcome measure was perception of work stress as measured by the validated short form of the Effort-Reward Imbalance Questionnaire (ERI). Linear mixed models, proportions with 95% confidence intervals and logistic regression model were used in the analyses.

Results

From 2010 to 2018-19, the scores on the effort items (time pressure, responsibility, demands) increased significantly and the scores on the reward items (recognition, job stability, promotion prospects, prestige) decreased significantly for GPs, but remained stable for doctors in other positions. The proportion of doctors with high levels of work stress increased significantly for GPs. In 2018-19, high levels of work stress were associated with being a GP as compared with other job positions, younger age groups, average or poor health vs. very good or good health, but not with sickness absence or gender.

Conclusions

During a nine-year-period, work stress increased significantly for GPs, but remained stable for other job positions. This may be partly due to several health care reforms. Less work stress may improve both the doctors` own health and the quality of health care.

Key messages

From 2010 to 2018-19 in Norway, the proportion of GPs with high levels of work stress increased, while it remained stable for doctors in other job positions. This study supports previous findings on the association between high levels of work stress and health.

Changes in job satisfaction among doctors in Norway from 2010 to 2017: a study based on repeated surveys

OBJECTIVE

To assess job satisfaction for different categories of Norwegian doctors from 2010 to 2016-2017.

DESIGN

Cross-sectional surveys in 2010, 2012, 2014 and 2016-2017 of partly overlapping samples.

SETTING

Norway from 2010 to 2016-2017.

PARTICIPANTS

Doctors working in different job positions (hospital doctors, general practitioners (GPs), private practice specialists, doctors in academia). Response rates were 67% (1014/1520) in 2010, 71% (1279/1792) in 2012, 75% (1158/1545) in 2014 and 73% (1604/2195) in 2016-2017. The same 548 doctors responded at all four points in time.

MAIN OUTCOME MEASURE

Job Satisfaction Scale (JSS), a 10-item widely used instrument, with scores ranging from 1 (low satisfaction) to 7 (high satisfaction) for each item, and an unweighted mean total sum score.

ANALYSIS

General Linear Modelling, controlling for gender and age, and paired t-tests.

RESULTS

For all doctors, the mean scores of JSS decreased significantly from 5.52 (95% CI 5.42 to 5.61) in 2010 to 5.30 (5.22 to 5.38) in 2016-2017. The decrease was significant for GPs (5.54, 5.43 to 5.65 vs 5.17, 5.07 to 5.28) and hospital doctors (5.14, 5.07 to 5.21 vs 5.00, 4.94 to 5.06). Private practice specialists were most satisfied, followed by GPs and hospital doctors. The difference between the GPs and the private practice specialists increased over time.

CONCLUSIONS

From 2010 to 2016-2017 job satisfaction for Norwegian doctors decreased, but it was still at a relatively high level. Several healthcare reforms and regulations over the last decade and changes in the professional culture may explain some of the reduced satisfaction.

Perceived bullying among Norwegian doctors in 1993, 2004 and 2014-2015: a study based on cross-sectional and repeated surveys

OBJECTIVES

To examine 12-month prevalence of perceived bullying at work for doctors in different job categories and medical disciplines in 1993, 2004 and 2014-2015, and personality traits, work-related and health-related factors associated with perceived workplace bullying.

DESIGN

Cross-sectional questionnaire surveys in 1993, 2004 and 2014-2015 where the 2004 and the 2012-2015 samples are partly overlapping.

SETTING

Norway.

PARTICIPANTS

Response rates were 72.8% (2628/3608) in 1993, 67% (1004/1499) in 2004 and 78.2% (1261/1612) in 2014-2015. 485 doctors responded both in 2004 and 2014-2015.

OUTCOME MEASURE

Perceived bullying at work from colleagues or superiors at least a few times a month during the last year.

RESULTS

Between the samples from 1993, 2004 and 2014-2015, there were no significant differences in the prevalence of perceived bullying at work. More senior hospital doctors and surgeons reported being bullied. Doctors with higher scores on the personality trait neuroticism were more likely to perceive bullying, as were female doctors, doctors with poor job satisfaction and poor self-rated health.

CONCLUSIONS

The fraction of doctors who experienced bullying at work was stable over a 20-year period. Psychological, psychosocial and cultural factors are predictors of perceived bullying.

Changes in prevalence of workplace violence against doctors in all medical specialties in Norway between 1993 and 2014: a repeated cross-sectional survey

OBJECTIVES

The aim of this study was to investigate whether reported prevalence of experienced threats, real acts of violence and debilitating fear of violence among Norwegian doctors have increased over the last two decades.

DESIGN

Repeated cross-sectional survey.

SETTING

All healthcare levels and medical specialties in Norway.

PARTICIPANTS

Representative samples of Norwegian doctors in 1993 (n=2628) and 2014 (n=1158).

MAIN OUTCOME MEASURES

Relative risk (RR) of self-reported prevalence of work-time experiences of threats and real acts of violence, and of being physically or psychologically unfit during the last 12 months due to fear of violence, in 2014 compared with 1993, adjusted by age, gender and medical specialty.

RESULTS

There were no differences in self-reported threats (adjusted RR=1.01, 95% CI 0.95 to 1.08) or real acts (adjusted RR=0.90, 95% CI 0.80 to 1.03) of violence when comparing 2014 with 1993. The proportion of doctors who had felt unfit due to fear of violence decreased from 1993 to 2014 (adjusted RR=0.53, 95% CI 0.39 to 0.73). Although still above average, the proportion of doctors in psychiatry who reported real acts of violence decreased substantially from 1993 to 2014 (adjusted RR=0.75, 95% CI 0.60 to 0.95).

CONCLUSIONS

A substantial proportion of doctors experience threats and real acts of violence during their work-time career, but there was no evidence that workplace violence has increased over the last two decades. Still, the issue needs to be addressed as part of the doctors' education and within work settings.

Is imperfection becoming easier to live with for doctors?

OBJECTIVE

Being involved in serious patient injury is devastating for most doctors. During the last two decades, several efforts have been launched to improve Norwegian doctors' coping with adverse events and complaints.

METHODS

The method involved survey to a representative sample of 1792 Norwegian doctors in 2012. The questions on adverse events and its effects were previously asked in 2000.

RESULTS

Response rate was 71%. More doctors reported to have been involved in episodes with serious patient harm in 2012 (35%) than in 2000 (28%), and more of the episodes were reported as required by law. Doctors below age 50 report better support from colleagues, more collegial retrospective discussion on the event and less patient/family blame. In all, 27% of the doctors had been reported to the Norwegian Board of Health Supervision; 79% of these complaints were rejected; 73% of the doctors who had received a reaction from the health authorities found the reaction reasonable, but almost one out of five practiced more testing and referrals after a complaint and 25% claimed that the complaint had made them into a more fearful doctor.

CONCLUSION

Our results indicate that adverse events are being met more openly in 2012 than in 2000, and that coping with imperfection and patient complaints is less devastating for new generations of doctors.

Work characteristics and morbidity as predictors of self-perceived health status in Norwegian physicians

Aims: The purpose of this study was to assess whether work characteristics and morbidity are predictors of physical, psychological, and social functioning in physicians. Methods: A cross-sectional study was undertaken of 1,126 Norwegian physicians. For comparison of health status scores, the Short Form 36 questionnaire was used, adjusting for differences in age and gender where applicable. Somatic morbidity was classified on the basis of self-reported conditions and psychiatric morbidity with score on the 25-item Hopkins symptom checklist using a cut-off indicating clinical psychiatric disease. Multiple logistic regression analysis was used with SF-36 dimension score below/above the 10th percentile as the dependent variable. Results: In the multivariate model, psychiatric comorbidity was a significant predictor in 7 of 8 dimensions of health status (odds ratio 0.17 to 0.49), and somatic comorbidity in 6 of 8 dimensions of health status (odds ratio 0.33 to 0.59). Working hours was a significant predictor of only one dimension of health status, general health, after adjustment for demographic and work-related variables. Conclusions: The most important predictors for most dimensions of health status among Norwegian physicians were the presence or absence of self-reported somatic or psychiatric morbidity, while working hours, choice of specialty, and position were less important.

Peer counselling for doctors in Norway: A qualitative study of the relationship between support and surveillance

RATIONALE

Peer support can entail collegial responsibility for counselling and support as well as reactions to academic or ethical failure. These considerations can be complementary, but also conflicting.

OBJECTIVE

This article focuses on how the peer support programme in Norway addresses these considerations.

METHODS

Focus group interviews held with Norwegian peer counsellors from August 2011 to June 2012 were analysed by a stepwise deductive-inductive method.

RESULTS

Based on organisational theory, two "ideal types" of counsellors were identified from the data, and these were then used to reanalyse the text. We found that the organisational framework is associated with the peer counsellors' role conception and thereby the relationship between the counsellor and the help-seeking doctor. The relationship between informal frameworks like collegiality, confidence and discretion, and more formalized incentive-driven frameworks, appear to influence the accessibility to peer support, the mandate to provide relevant help and the understanding of what peer support represents.

CONCLUSION

The study showed the need for a continuous awareness of a balance between the informal and the more formalized elements in the framework for peer support. This is of importance for how the service can contribute to better health among doctors and to secure quality and safety in the treatment of patients. The analysis can also be used to demonstrate the consequences of how the peer support program is designed - such as the degree of formalisation and the balance between "hard" and "soft" ways to regulate the interaction between peer counsellors and doctors - for the ability to achieve the stated objectives of the service.

Supply of doctors to a rural region: Occupations of Tromsø medical graduates 1979-2012

BACKGROUND

The aim of establishing the medical school in Tromsø in 1973 was to improve access to doctors and standards of health care for the previously underprivileged rural population of Northern Norway. In this study we examine how the aim of supplying doctors to the north has been achieved.

MATERIAL AND METHODS

By utilising a cross-sectional design we have analysed 34 classes of Tromsø medical graduates (1979-2012) with regard to occupations in 2013 by the year of graduation and by successive pools of cohorts.

RESULTS

In 2013 altogether 822 of 1611 doctors (51%) were working in Northern Norway. The proportions working in the north for old, intermediate and young cohorts were 37%, 48% and 60%, respectively. Doctors graduating during recent years tended to start their careers in the north to a higher degree than doctors graduating in previous periods. Among doctors from the older classes a relatively large minority have their end-careers in Northern Norway, with a noticeable inclination for long term work in primary care.

CONCLUSION

Our results support that the first rural oriented medical education model in Europe established in Tromsø 40 years ago is sustainable, achieving its aims.

Weekly working hours for Norwegian hospital doctors since 1994 with special attention to postgraduate training, work-home balance and the European working time directive: a panel study

OBJECTIVES

To examine the weekly working hours of Norwegian hospital doctors from 1994 to 2012 with special emphasis on the quality of postgraduate training and work-home balance, and in relation to the requirements of the European Working Time Directive (EWTD).

DESIGN

Panel study based on postal questionnaires.

SETTING

Norway.

PARTICIPANTS

Unbalanced cohort of 1300-1600 doctors in 1994, 1995, 1996, 1997, 2000, 2002, 2004, 2006, 2008, 2010 and 2012.

OUTCOME MEASURES

Self-reported total weekly working hours and whether 45 weekly working hours are too short, sufficient, or too long to meet the quality requirements of obligatory postgraduate training for junior doctors.

RESULTS

From 1994 to 2012, the number of weekly working hours was stable for senior (46-47 h) and junior (45-46 h) hospital doctors. In 2012, significantly more senior (27-35%) than junior (11-20%) doctors reported suboptimal work-home balance, defined as working more than 48 h a week. The majority perceived the present situation with an average of 45 h per week for juniors as sufficient for obligatory postgraduate specialist training, but doctors of higher age (OR 1.04, 95% CI 1.01 to 1.08), senior doctors (1.07, 1.04 to 1.11) and doctors working in surgical specialties (OR 1 vs laboratory medicine 0.03, 0.01 to 0.25, internal medicine 0.31, 0.17 to 0.58, psychiatry 0.12, 0.04 to 0.36, paediatrics 0.36, 0.12 to 1.07, anaesthesiology 0.08, 0.02 to 0.39, gynaecology 0.07, 0.01 to 0.56 and others 0.39, 0.04 to 3.56) were more likely to want the work-week to be longer.

CONCLUSIONS

The weekly working hours of Norwegian hospital doctors were always below the EWTD requirements. A significant growth of hospital doctor density over the past two decades, national regulations and cultural values might be important factors. Specialty differences in perception of sufficient training time may call for more flexibility in working time regulations.

Differences in sickness absence between self-employed and employed doctors: a cross-sectional study on national sample of Norwegian doctors in 2010

Background

Doctors have a low prevalence of sickness absence. Employment status is a determinant in the multifactorial background of sickness absence. The effect of doctors’ employment status on sickness absence is unexplored. The study compares the number of sickness absence days during the last 12 months and the impact of employment status, psychosocial work stress, self-rated health and demographics on sickness absence between self-employed practitioners and employed hospital doctors in Norway.

Methods

The study population consisted of a representative sample of 521 employed interns and consultants and 313 self-employed GPs and private practice specialists in Norway, who received postal questionnaires in 2010. The questionnaires contained items on sickness absence days during the last 12 months, employment status, demographics, self-rated health, professional autonomy and psychosocial work stress.

Results

84% (95% CI 80 to 88%) of self-employed and 60% (95% CI 55 to 64%) of employed doctors reported no absence at all last year. In three multivariate logistic regression models with sickness absence as response variable, employment category was a highly significant predictor for absence vs. no absence, 1 to 3 days of absence vs. no absence and 4 to 99 days of absence vs. no absence), while in a model with 100 or more days of absence vs. no absence, there was no difference between employment categories, suggesting that serious chronic disease or injury is less dependent on employment category. Average or poor self-rated health and low professional autonomy, were also significant predictors of sickness absence, while psychosocial work stress, age and gender were not.

Conclusion

Self-employed GPs and private practice specialist reported lower sickness absence than employed hospital doctors. Differences in sickness compensation, and organisational and individual factors may to a certain extent explain this finding.

Changes in the lifetime prevalence of suicidal feelings and thoughts among Norwegian doctors from 2000 to 2010: a longitudinal study based on national samples

BACKGROUND

Thinking about suicide is an indicator of suicide risk. Suicide rates are higher among doctors than in the population. The main aims of this study are to describe the changes in the lifetime prevalence of suicidal feelings from 2000 to 2010 and the possible predictors of serious suicidal thoughts in 2010 among Norwegian doctors. Differences in lifetime prevalence of suicidal feelings between Norwegian doctors in 2010 and German doctors in 2006 will be also described.

METHODS

Longitudinal and cross-sectional study based on questionnaire data from 2000 and 2010, including approximately 1,600 Norwegian doctors. In Germany, cross-sectional study based on questionnaire data from 2006 among a sample of 3,295 doctors. The main outcome measures were the lifetime prevalence of suicidal feelings (felt life was not worth living, wished own death, had thoughts of taking own life).

RESULTS

The prevalences in 2000 and 2010 of ever had feelings of life not worth living were 48 (44 to 52) % and 45 (41 to 49) %, of ever wished own death 27 (23 to 30) % and 23 (20 to 26) %, and of ever had thoughts of taking own life 29 (16 to 33) % and 24 (21 to 27) %. Paired t-tests among those who responded both in 2000 and 2010 show significant reductions for felt life not worth living (t = -3.4; p = 0.001), wished own death (t = -3.1; p = 0.002) and had thoughts of taking own life (t = -3.5; p < 0.0001). In 2010, significant predictors of serious suicidal thoughts in a multivariate model were low subjective well-being (OR 0.68; 95% CI 0.52-0.90), poor or average self-rated health (2.36; 1.25-4.45) and high psychosocial work stress (1.92; 1.06-3.46), controlled for age, gender, speciality and job satisfaction. Norwegian doctors in 2010 compared with their German counterparts in 2006 reported quite similar prevalences of suicidal feelings.

CONCLUSIONS

Suicidal feelings among Norwegian doctors decreased from 2000 to 2010. Individual and work-related factors may to certain explain these findings. Compared with other professionals in Norway and doctors in Germany, Norwegian doctors showed no higher risk of suicidal thoughts.

Changes in alcohol drinking patterns and their consequences among Norwegian doctors from 2000 to 2010: a longitudinal study based on national samples

AIMS

To describe changes in the patterns and consequences of alcohol use among Norwegian doctors from 2000 to 2010.

METHODS

Longitudinal study based on data from nation-wide postal surveys in 2000 and 2010 among a representative sample of 682 doctors in Norway. The Alcohol Use Disorder Identification Test (AUDIT) was used to measure the changes in drinking patterns (frequency of drinking, frequency of heavy drinking and quantity of drinking), symptoms of alcohol dependence and adverse consequences of drinking. A score above 8 was defined as hazardous drinking.

RESULTS

From 2000 to 2010, the proportion of doctors who used alcohol twice a week or more significantly increased from 31.4 (27.9-34.9) % to 48.7 (44.9-48.7) %, and the proportion of those who drank to intoxication weekly or more decreased significantly from 6.6 (4.7-8.6) % to 2.5 (1.3-1.7) %. The proportion who scored above 8 on the AUDIT decreased from 10.7 (8.4-13.0) % in 2000 to 8.2 (6.2-10.3) % in 2010. There was a significant increase in the partial AUDIT-score for drinking patterns (t = 2.4; P = 0.016), and a significant decrease in the partial AUDIT-score for adverse consequences of drinking (t = -3.6; P < 0.001). The partial AUDIT-score for symptoms of alcohol dependence did not change significantly (t = -1.6; P = 0.112). There were gender differences in drinking patterns. Females had less frequent alcohol consumption and fewer episodes of heavy and hazardous drinking in 2000 and 2010.

CONCLUSION

The drinking pattern of Norwegian doctors has changed over the past decade towards more moderate alcohol consumption and less negative alcohol-related consequences. Changes in the attitude towards alcohol consumption may to a certain extent explain these findings.

Will sick leave after a counselling intervention prevent later burnout? A 3-year follow-up study of Norwegian doctors

INTRODUCTION

Burnout and mental distress in working doctors increase the risk for both suboptimal treatment of patients and negative health consequences for the doctors. Doctors have low rates of sickness absence and are reluctant to seek help, especially for mental distress. We examined whether a spell of sickness absence after a counselling intervention could predict reduction in emotional exhaustion among doctors at work 3 years later.

METHODS

A 3-year follow up after a counselling intervention for burnout at the Resource Centre Villa Sana in Norway in 2003-05 was completed by 184/227 doctors. Self-report assessments were administered at baseline, 1-, and 3-years. The effect of number of weeks of sickness absence on reduction in emotional exhaustion among doctors working 3 years after the intervention was assessed by linear regression.

RESULTS

Of the 184 doctors completing assessment, 149 were working at 3-year follow up. Emotional exhaustion (scale 1-5) was significantly reduced at follow up (from 3.00±0.96 to 2.37±0.79, p<0.001). The number of weeks of sickness absence after the intervention was a significant positive predictor of this reduction (β=0.31, p<0.001), also after including sex, age, neuroticism, reduction of work hours, and other forms for treatment in the model.

CONCLUSIONS

The number of weeks of sickness absence after a counselling intervention for burnout had a positive predictive effect on reduction in emotional exhaustion among doctors at work 3 years later. Sick leave thus seems to "prevent" later burnout, which can be of importance both for their patients and for the doctors themselves.

Mortality among Norwegian doctors 1960-2000

BACKGROUND

To study the mortality pattern of Norwegian doctors, people in human service occupations, other graduates and the general population during the period 1960-2000 by decade, gender and age. The total number of deaths in the study population was 1 583 559.

METHODS

Census data from 1960, 1970, 1980 and 1990 relating to education were linked to data on 14 main causes of death from Statistics Norway, followed up for two five-year periods after census, and analyzed as stratified incidence-rate data. Mortality rate ratios were computed as combined Mantel-Haenzel estimates for each sex, adjusting for both age and period when appropriate.

RESULTS

The doctors had a lower mortality rate than the general population for all causes of death except suicide. The mortality rate ratios for other graduates and human service occupations were 0.7-0.8 compared with the general population. However, doctors have a higher mortality than other graduates. The lowest estimates of mortality for doctors were for endocrine, nutritional and metabolic diseases, diseases in the urogenital tract or genitalia, digestive diseases and sudden death, for which the numbers were nearly half of those for the general population. The differences in mortality between doctors and the general population increased during the periods.

CONCLUSIONS

Between 1960 and 2000 mortality for doctors converged towards the mortality for other university graduates and for people in human service occupations. However, there was a parallel increase in the gap between these groups and the rest of the population. The slightly higher mortality for doctors compared with mortality for other university graduates may be explained by the higher suicide rate for doctors.

A three-year cohort study of the relationships between coping, job stress and burnout after a counselling intervention for help-seeking physicians

BACKGROUND

Knowledge about important factors in reduction of burnout is needed, but there is a dearth of burnout intervention program studies and their effects among physicians. The present three-year follow-up study aimed to investigate the roles of coping strategies, job stress and personality traits in burnout reduction after a counselling intervention for distressed physicians.

METHODS

227 physicians who attended a counselling intervention for burnout at the Resource Centre Villa Sana, Norway in 2003-2005, were followed with self-report assessments at baseline, one-year, and three-year follow-up. Main outcome measures were emotional exhaustion (one dimension of burnout), job stress, coping strategies and neuroticism. Changes in these measures were analyzed with repeated measures ANOVA. Temporal relationships between changes were examined using structural modelling with cross-lagged and synchronous panel models.

RESULTS

184 physicians (81%, 83 men, 101 women) completed the three-year follow-up assessment. Significantly reduced levels of emotional exhaustion, job stress, and emotion-focused coping strategies from baseline to one year after the intervention, were maintained at three-year follow-up.Panel modelling indicated that changes in emotion-focused coping (z = 4.05, p < 0.001) and job stress (z = 3.16, p < 0.01) preceded changes in emotional exhaustion from baseline to three-year follow-up. A similar pattern was found from baseline to one-year follow-up.

CONCLUSION

A sequential relationship indicated that reduction in emotion-focused coping and in job stress preceded reduction in emotional exhaustion. As a consequence, coping strategies and job stress could be important foci in intervention programs that aim to reduce or prevent burnout in help-seeking physicians.

Healthcare reforms and job satisfaction among doctors in Norway

Aims: To examine the trend in job satisfaction from 2000 to 2006 among Norwegian doctors, and the possible impact of two comprehensive healthcare reforms on doctors’ job satisfaction. Methods: The study population consisted of a representative sample of approximately 1,600 Norwegian doctors, selected from nationwide repeated postal surveys in 2000, 2002, 2004 and 2006. The questionnaires contained the validated 10-item job satisfaction scale (JSS). Each item was scored on a seven-point Likert scale from 1 (very dissatisfied) to 7 (very satisfied). General linear modelling (GLM) controlled for gender, age, specialty and type of job was used to describe the trend in the score of JSS from 2000 to 2006. Results: The overall job satisfaction among Norwegian doctors was high and relatively stable from 2000 to 2004, with a non-significant dip in 2002. There was a significant increase in job satisfaction from 2000 to 2006. The job satisfaction was generally higher for older doctors than for younger doctors, but no gender difference was found. Private practice specialists were the most satisfied at all points in time, and general practitioners were more satisfied than hospital doctors. No significant or persistent impact of two healthcare reforms was found. Conclusion: Job satisfaction among Norwegian doctors is high and increasing. The lack of impact on this even from comprehensive healthcare reforms points to a robust satisfaction based on internal values more than external changes. The consistent finding of increasing — rather than declining — job satisfaction among Norwegian doctors, contrasts with widely held opinions in the public.

Age differences in alcohol drinking patterns among Norwegian and German hospital doctors--a study based on national samples

AIMS

To describe and discuss the alcohol drinking patterns of the younger generation of hospital doctors in Norway and Germany - respectively the abstainers, frequent drinkers, episodic heavy drinkers and hazardous drinkers.

METHODS

Data were collected in nationwide postal surveys among doctors in Norway (2000) and Germany (2006). A representative sample of 1898 German and 602 Norwegian hospital doctors aged 27-65 years were included in the analyses (N=2500). Alcohol drinking patterns were measured using the first three items of AUDIT in Norway and the AUDIT-C in Germany, scores of >or=5 (ranking from 0 to 12) indicating hazardous drinking. Episodic heavy drinking was defined by the intake of >or=60 g of ethanol, on one occasion, at least once a week. Frequent drinkers were who drank alcoholic beverages at least twice a week. Abstainers were persons who drank no alcohol. The analyses were performed separately for age groups (27-44 years versus 45-65 years) and genders.

RESULTS

Compared to the age groups 45 to 65 years in the Norwegian and German samples, the younger age groups (27-44 years) tend to have higher rates of abstainers, higher rates of infrequent drinking of moderate amount of alcoholic drinks, lower rates of episodic heavy drinking and lower rates of hazardous drinking.

CONCLUSION

The younger generation of hospital doctors in Norway and Germany showed tendencies to healthier drinking habits. Changes in professional life, and in the attitude towards alcohol consumption, may go some way towards explaining these findings.

A self-referral preventive intervention for burnout among Norwegian nurses: one-year follow-up study

OBJECTIVE

Burnout among nurses is an issue of concern, and preventive interventions are important to implement and evaluate. This study investigated levels and predictors of change in burnout dimensions after an intervention for help-seeking nurses.

METHODS

Nurses participating in a self-referral, counseling intervention, from 2004 to 2006 in Norway, were followed with self-reporting assessments. One-year follow-up was completed by 160/172 (93%, 155 women and 5 men).

RESULTS

Mean level of emotional exhaustion (one dimension of burnout, scale 1-5) was significantly reduced from 2.87 (SD 0.79) to 2.52 (SD 0.8), t=5.3, p<0.001, to the level found in a representative sample of Norwegian nurses. The proportion of nurses seeking psychotherapy increased after the intervention, from 17.0% (25/147) to 34% (50/147), p<0.001. Less reduction in emotional exhaustion was independently predicted by reporting a work-related conflict (beta -0.53 (SE 0.13), p<0.001) or by getting a period of sick leave (beta -0.28 (SE 0.12), p<0.05) after the intervention.

CONCLUSIONS

A short-term preventive intervention could contribute to reduction of emotional exhaustion in nurses. Work-related conflict and sick leave after the intervention were negatively associated with this reduction.

PRACTICE IMPLICATIONS

Preventive interventions to reduce burnout for nurses should be considered, as well as programs for preventing or handling conflicts at work.

Alcohol expectancy and hazardous drinking: a 6-year longitudinal and nationwide study of medical doctors

AIM

The study's aim was to determine whether medical doctors' expectancy that alcohol use reduces tension predicts the extent of their hazardous drinking and whether this effect is mediated by drinking to cope.

METHODS

A group of Norwegian medical doctors' (n = 288) alcohol use was followed for 6 years. The expectancy that alcohol reduces tension and the use of alcohol to cope with tension were measured 3.5 years after graduation (T1), and hazardous drinking was evaluated at T1 and 9.5 years after graduation (T2).

RESULTS

At T1, 15% of men and 3% of women reported hazardous drinking. At T2, these proportions were 16 and 2%, respectively. Men reported a higher expectancy than women that alcohol reduces tension (p = 0.03), whereas there was no sex difference in drinking to cope. Adjusted predictors of hazardous drinking at T2 were male sex (p < 0.01), alcohol expectancy (p < 0.01) and hazardous drinking at T1 (p < 0.001). The effect of alcohol expectancy on hazardous drinking at T2 was not mediated by drinking to cope. Hazardous drinking at T1 mediated the effect of drinking to cope on hazardous drinking at T2.

CONCLUSION

Efforts to reduce drinking among medical students and doctors should target both alcohol expectancies (beliefs) and hazardous drinking (behavior).

Study-related health and behavior patterns of medical students: A longitudinal study

BACKGROUND

Little is known about specific health risks and resources and their development influencing medical students' stress.

AIM

To evaluate the development of quality of life and study-related behavior and experience patterns among medical students.

METHODS

Data were collected in the first (n = 112 of 182 in 2006) and the fourth semesters (n = 164 of 176 in 2008). The instruments "Work-Related Behavior and Experience Patterns" (AVEM, including four main patterns: "Health", "Unambitious," "Overexertion," "Burnout") and "Short Form-12 Health Survey (SF-12)" were used at both points in time.

RESULTS

The medical students scored significantly lower on mental health compared with reference samples of young adults. The proportion of students with a healthy pattern decreased from 47.3% (95% CI 38.1-56.5%) in the first semester to 36.9% (29.4-44.4%) in the fourth semester. This corresponded to an increase in the proportion of students at risk for burnout from 7.1% (2.3-11.9%) to 20% (13.8-26.2%). At both time points, female students had a higher risk for overexertion and a lower prevalence of a healthy pattern than male students.

CONCLUSION

Our data provide evidence for a decrease in the healthy pattern and an increase in the burnout pattern. Intervention is needed, especially for students at risk for burnout.

Job satisfaction among hospital doctors in Norway and Germany. A comparative study on national samples

Aims: To compare German and Norwegian hospital doctors on 10 different aspects of job satisfaction and general life satisfaction. Methods: The study population consisted of a representative sample of 1,448 German and 484 Norwegian hospital doctors aged 33—65 years (n = 1,932), selected from nationwide postal surveys in 2006. The questionnaires contained items on subjective life satisfaction and the validated 10-item Job Satisfaction Scale. Each item was scored on a seven-point Likert scale from 1 (very dissatisfied) to 7 (very satisfied). A mean sum score was calculated, ranging from 1 to 7. Regression analyses and generalized-linear-model-estimated means controlled for age and gender with 95% confidence intervals were used for comparison. Results: Norwegian hospital doctors had significantly higher life satisfaction (mean 5.31 vs. 5.15) and job satisfaction (mean 5.09 vs. 4.55) than their German colleagues. Item by item, doctors in Norway were significantly more content with seven aspects of their work: ``Freedom to choose your own methods of working'' (mean 5.00 vs. 4.72), ``opportunities to use your skills'' (mean 5.49 vs. 5.01), ``physical working conditions'' (mean 4.62 vs. 4.08), ``recognition you get for good achievements'' (mean 4.83 vs. 4.26), ``overall job situation'' (mean 5.57 vs. 4.64), ``work hours'' (mean 4.39 vs. 3.39), ``rate of pay'' (mean 4.70 vs. 3.70). General life satisfaction and age, but not gender, were positively associated with job satisfaction in both countries. Conclusions: Norwegian hospital doctors enjoy a higher level of life and job satisfaction than German hospital doctors. The most likely reasons for this are more acceptable work hours, salary and control over clinical work in Norway.

Counselling for burnout in Norwegian doctors: one year cohort study

OBJECTIVE

To investigate levels and predictors of change in dimensions of burnout after an intervention for stressed doctors.

DESIGN

Cohort study followed by self reported assessment at one year.

SETTING

Norwegian resource centre.

PARTICIPANTS

227 doctors participating in counselling intervention, 2003-5.

INTERVENTIONS

Counselling (lasting one day (individual) or one week (group based)) aimed at motivating reflection on and acknowledgement of the doctors' situation and personal needs.

MAIN OUTCOME MEASURES

Levels of burnout (Maslach burnout inventory) and predictors of reduction in emotional exhaustion investigated by linear regression.

RESULTS

185 doctors (81%, 88 men, 97 women) completed one year follow-up. The mean level of emotional exhaustion (scale 1-5) was significantly reduced from 3.00 (SD 0.94) to 2.53 (SD 0.76) (t=6.76, P<0.001), similar to the level found in a representative sample of 390 Norwegian doctors. Participants had reduced their working hours by 1.6 hours/week (SD 11.4). There was a considerable reduction in the proportion of doctors on full time sick leave, from 35% (63/182) at baseline to 6% (10/182) at follow-up and a parallel increase in the proportion who had undergone psychotherapy, from 20% (36/182) to 53% (97/182). In the whole cohort, reduction in emotional exhaustion was independently associated with reduced number of work hours/week (beta=0.17, P=0.03), adjusted for sex, age, and personality dimensions. Among men "satisfaction with the intervention" (beta=0.25, P=0.04) independently predicted reduction in emotional exhaustion.

CONCLUSIONS

A short term counselling intervention could contribute to reduction in emotional exhaustion in doctors. This was associated with reduced working hours for the whole cohort and, in men, was predicted by satisfaction with the intervention.

Moral distress among Norwegian doctors

BACKGROUND

Medicine is full of value conflicts. Limited resources and legal regulations may place doctors in difficult ethical dilemmas and cause moral distress. Research on moral distress has so far been mainly studied in nurses.

OBJECTIVE

To describe whether Norwegian doctors experience stress related to ethical dilemmas and lack of resources, and to explore whether the doctors feel that they have good strategies for the resolution of ethical dilemmas.

DESIGN

Postal survey of a representative sample of 1497 Norwegian doctors in 2004, presenting statements about different ethical dilemmas, values and goals at their workplace.

RESULTS

The response rate was 67%. 57% admitted that it is difficult to criticize a colleague for professional misconduct and 51% for ethical misconduct. 51% described sometimes having to act against own conscience as distressing. 66% of the doctors experienced distress related to long waiting lists for treatment and to impaired patient care due to time constraints. 55% reported that time spent on administration and documentation is distressing. Female doctors experienced more stress that their male colleagues. 44% reported that their workplace lacked strategies for dealing with ethical dilemmas.

CONCLUSION

Lack of resources creates moral dilemmas for physicians. Moral distress varies with specialty and gender. Lack of strategies to solve ethical dilemmas and low tolerance for conflict and critique from colleagues may obstruct important and necessary ethical dialogues and lead to suboptimal solutions of difficult ethical problems.

Doctors' learning habits: CME activities among Norwegian physicians over the last decade

BACKGROUND

Coping with the increasing body of medical knowledge is a main challenge to all doctors. The aim of this study was to investigate self reported reading and learning habits among Norwegian doctors and their subjective ability to keep professionally updated.

METHODS

A cross sectional survey among a randomised sample of Norwegian doctors was undertaken in 2004 (n = 1005, response rate 71%). A similar study with many identical questions was done in 1993 (n = 1041, response rate 71%) and a comparison of the results was made.

RESULTS

Attending courses/congresses and reading medical literature were reported to be the most important sources of professional information in 2004, just like in 1993. Less time was spent on courses/congresses in 2004 than in 1993, and more time was spent on medical reading. The internet was regarded as useful for their professional life for three out of five, mostly among the younger and least among GPs. Two out of three doctors felt that they could obtain sufficient information for keeping updated in 2004, the same proportion as in 1993. A correlation was found between subjective coping with the information and a high level of continuing medical education (CME)-activities. The information copers had a higher level of job satisfaction than non-copers.

CONCLUSION

Over the last decade Norwegian doctors spend less time on attending courses/congresses and more time on medical reading, while the level of self perceived coping with information has been unchanged. The changing pattern of professional updating may reflect a more general individualistic trend in society. The consistent finding of a correlation between reading and attending courses, subjective coping and job satisfaction gives good reasons for recommending a high level of CME-activities among doctors.

Does a self-referral counselling program reach doctors in need of help? A comparison with the general Norwegian doctor workforce

BACKGROUND

Doctors have a relatively high degree of emotional distress, but seek help to a lesser degree and at a later stage than other academic groups. This can be deleterious for themselves and for their patients. Prevention programs have therefore been developed but it is unclear to what extent they reach doctors in need of help. This study describes doctors who participated in a self-referrral, easily accessible, stress relieving, counselling program in Norway, and compares them with a nationwide sample of Norwegian doctors.

METHODS

Two hundred and twenty seven (94%) of the doctors, 117 women and 110 men, who came to the resort centre Villa Sana, Modum, Norway, between August 2003 and July 2005, agreed to participate in the study. Socio-demographic data, reasons for and ways of help-seeking, sick-leave, symptoms of depression and anxiety, job stress and burnout were assessed by self-reporting questionnaires.

RESULTS

Forty-nine percent of the Sana doctors were emotionally exhausted (Maslach) compared with 25% of all Norwegian doctors. However, they did not differ on empathy and working capacity, the other two dimensions in Maslach's burnout inventory. Seventy-three percent of the Sana doctors could be in need of treatment for depression or anxiety based on their symptom distress scores, compared with 14% of men and 18% of women doctors in Norway. Twenty-one percent of the Sana doctors had a history of suicidal thoughts, including how to commit the act, as compared to 10% of Norwegian doctors in general.

CONCLUSION

Sana doctors displayed a higher degree of emotional exhaustion, symptoms of depression and anxiety as well as job related stress, compared with all Norwegian doctors. This may indicate that the program at Villa Sana to a large extent reaches doctors in need of help. The counselling intervention can help doctors to evaluate their professional and private situation, and, when necessary, enhance motivation for seeking adequate treatment.

General practitioners' relationship to sickness certification

OBJECTIVE

GPs' role conflict in connection with sickness certification is widely accepted. The authors explored the relationship between GPs and this difficult task.

DESIGN

Cross-sectional questionnaire study of experiences, attitudes, and management of sickness certification. Data were analysed by hierarchical cluster analysis.

SETTING

Norway.

SUBJECTS

Representative sample of 308 general practitioners from a nationwide panel established by the Research Institute of the Norwegian Medical Association.

MAIN OUTCOME MEASURES

Differentiation of response patterns regarding perceived burden, self-evaluation, doubt, permissiveness, opinions on whether sickness certification is a medical task, and sociopolitical attitude. Associations with hours of patient contact per week, number of sickness certifications per week, job satisfaction, degree of paternalism, and personality characteristics.

RESULTS

Four groups evolved, one (12%) with low burden, high self-esteem, little doubt, and permissiveness, another (12%) with the opposite characteristics. They displayed similar sociopolitical attitudes. The third group (32%) was primarily characterized by a biomedical attitude, while the fourth represented a middle position in all dimensions. The first two groups differed on personality characteristics. There were no differences between groups regarding number of sickness certifications per week, job satisfaction, or degree of paternalism.

CONCLUSIONS

Prominent differences in experiences with sickness certification between groups of doctors exist. No evidence was found of associations between group-level GP differences and sickness certification rates.

[Enough resources to the care of the elderly?]

BACKGROUND

The increasing numbers of elderly in need of basic medical and nursing care challenges prioritization and quality assurance within the Norwegian health care system.

MATERIAL AND METHODS

A questionnaire on health care to patients aged 75 years or older was sent to 2103 doctors and nurses employed in hospitals and primary community care.

RESULTS

67% returned the questionnaire. 92% of the nurses and 79% of the doctors stated that lack of resources related to all levels of medical and nursing care for ill elderly patients cause personal strain. Personnel shortage, lack of time and lack of money were the three most frequently mentioned causes of unsatisfactory coverage of basic needs. 29% said they experience reduced quality of medical treatment weekly or daily, while 25% stated that they meet reduced quality of diagnostics just as frequently. Even more often, the respondents experienced unsatisfactory coverage of hygiene and nutrition, but social needs and exercise were the most neglected areas. Nurses and doctors employed in nursing care institutions most frequently expressed that lack of resources have serious consequences for patients aged 75 years or older.

INTERPRETATION

Basic medical care for elderly ill patients is not sufficient with respect to diagnostics and medical treatment. In particular, nursing care and meeting the individuals' psychosocial needs are not prioritised highly enough. Both doctors and nurses frequently describe shortage of time as a problem. Poorly organized medical care, including lack of coordination, seems to be a continuous problem in health care for the elderly.

[Doctors' use and assessment of a fee-for-service life-style advice scheme]

BACKGROUND

Fee-for-service life-style advice, a "green prescription" was introduced in Norway in 2003 as an alternative to the prescription of drugs to patients with moderate hypertension or risk of type 2 diabetes. The prescription includes an assessment of diet and/or physical activity, and an individual plan for change with systematic follow up from the GP. Material was provided by the Directorate of Health and Social Affairs, and a special fee of NOK 200 was established. The Research Institute of the Norwegian Medical Association has evaluated GPs' attitudes to and use of this scheme.

MATERIAL AND METHODS

A representative sample of 1134 Norwegian GPs, of whom 59% responded. Ten of the respondents were also interviewed comprehensively over the telephone.

RESULTS AND INTERPRETATION

Green prescriptions has low legitimacy among Norwegian GPs. Advise on lifestyle to patients with moderate hypertension or risk of type 2 diabetes is already an integral and natural component of GP work and calls for no extra fee or bureaucratic procedures. There is a risk of medicalisation in that non-patients become patients. On the other hand, patients who already are on drugs, but who may be able to reduce or eliminate these if they change their lifestyle, are not included in the scheme. Further development of the concept should to a larger degree include collaboration with the GPs.

Job satisfaction among Norwegian general practitioners

OBJECTIVE

To explore the level of job satisfaction among general practitioners (GPs) and to compare it with that of hospital doctors.

DESIGN

Postal questionnaire among Norwegian doctors in 2002 and similar data from 1994 and 2000 for most of the respondents.

MATERIAL

A total of 295 GPs out of 1174 doctors completed the questionnaire (73% response rate). Main outcome measures. Self-reported levels of job satisfaction according to the Job Satisfaction Scale (JSS).

RESULTS

Norwegian GPs reported a high level of job satisfaction with a mean score on the JSS of 52.6 (10 is minimum and 70 maximum). The reported level of satisfaction was highest for their opportunities to use their abilities, cooperation with colleagues and fellow workers, variation in work, and freedom to choose own method of working. The GPs' level of job satisfaction remained stable in 1994, 2000, and 2004 in spite of major health reforms. GPs report a higher level of job satisfaction than hospital doctors.

CONCLUSIONS

In spite of international discussions on unhappy doctors and doctors' discontent, Norwegian GPs do report a high and stable level of job satisfaction.

FEMALE SURGEONS' ALCOHOL USE: A STUDY OF A NATIONAL SAMPLE OF NORWEGIAN DOCTORS

AIMS

This study was designed to describe the alcohol use by female surgeons and the hazards of their drinking habits for them compared with the habits of female doctors from non-surgical specialities, and with those of their male colleagues in surgery, and to identify the variables associated with hazardous drinking.

METHODS

The data were collected in 2000 from a representative national sample of 1120 Norwegian doctors. Alcohol use was measured using a modified version of the Alcohol Use Disorders Identification Test. A score of 9 or more was used as an indicator of hazardous drinking.

RESULTS

Female surgeons compared with female non-surgeons had tendencies for more frequent moderate alcohol consumption accompanied by more frequent consumption of larger amounts of alcohol, and a significantly higher rate of hazardous drinking (18 vs 7.6%). Being a surgeon (OR = 1.7, 95% CI 1.2-2.4), male (OR = 2.7, 1.7-4.1) and aged 45 years or over (OR = 1.5, 1.1-2.2) were significant predictors of hazardous drinking. With separate gender analyses, being a surgeon was a significant predictor for both females (OR = 2.8, 1.2-6.6) and males (OR = 1.5, 1.0-2.3).

CONCLUSION

Female surgeons practising in Norway drink more frequently and more hazardously than other female doctors. There are a number of possible explanations for this. Surgical culture may be an important factor.

[Differences in workload for male and female physicians]

BACKGROUND

In this article we describe differences in workload for male and female physicians according to the gender of their patients.

MATERIAL AND METHODS

Data from the National Insurance Service for the autumn of 2001 (1637 general practitioners) and from a comprehensive questionnaire survey among general practitioners in the autumn of 2002 (2306).

RESULTS

62 % of the patients of female physicians are women, compared to 47 % of the patients of male physicians. Female physicians have a mean of 200 fewer patients on their lists than have their male colleagues. Female physicians also have a high proportion of women on their list irrespective of the length of their list. Of those with a long patient list (>1800 patients), almost 50 % of the female physicians wanted a shorter list, compared to only 26 % of their male colleagues.

INTERPRETATION

The total workload in terms of length of patient list and gender distribution of patients on the list is not necessarily different for male and female physicians. Female physicians may have chosen to have a shorter patient list in order to compensate for the fact that their patients on average have more consultations and receive more services. On the other hand, male physicians may allow themselves to have a longer patient list because they have patients who on average require less treatment.