Research article
Open Access

Does sector matter in House Officers performances?; A Cross sectional study

Muhammad Fazal Hussain Qureshi[1], Sara Sadiq[1], Danish Mohammad[1], Mahira Lakhani[1], Muzna Shah[1], Nuzhat Tariq[2]

Institution: 1. Ziauddin University, 2. Institute of Business Administration
Corresponding Author: Mr Muhammad Fazal Hussain Qureshi ([email protected])
Categories: Learning Outcomes/Competency, Behavioural and Social Sciences, Clinical Skills
Published Date: 18/06/2019

Abstract

Introduction

House officers experience extreme levels of stress during their training period. There is significant variation in level of stress among house officers of public sector hospitals to those of private hospitals because of the OPD input per day, excessive paper work and sample collection for lab investigations. None of the study has been done to find any variation in the stress level of house officers among different hospitals.

Objective

Objective of current study is to compare the stress levels among house officers working in Public and Private Hospitals of Karachi.

Method

A descriptive, cross-sectional study was conducted using a self-designed and self-explanatory questionnaire for identification of stress among house officers of government and private tertiary care hospitals of Karachi. Cronbach Alpha was calculated which was found to be 0.804. A multistage, non-probability sampling technique was used. The data gathered was analyzed with SPSS version 22. ANOVA with Post Hoc Tukey’s test and a five-point Likert scale was used.

Results

The mean age of the participants in this study was 24 ± 1.2 years. About ¾ of the total sample was female, making it the majority. Variations was non-significant in positive attitudes in-between hospitals, but in negative attitudes, was highly significant (p=<0.001). To check for inter hospital variations, the post hoc Tukey’s test was applied and significant variation was observed between Altamash Hospital (Private) and Civil (Public) (<0.001) and that of JPMC (Public) was also significant (p=0.027). Other than Altamash, the only other significant variation was observed for Civil (Public) and Baqai (Private) hospital with a p-value of 0.016. Weekly working hours played no significant role in positive attitudes in both sectors, while in negative attitudes it was significant in Public sector (p=0.008)

Conclusion

It can be concluded that house officers of Public sectors are suffering from high levels of stress, as compared to that of Private sector, but are more confident in making decisions at the workplace. It is important that concern authorities should take action to reduce working hours and emergency calls so that we can control chronic stress which is a risk factor towards depression.

Keywords: Stress; House officers; Sector; misdiagnosis.

Introduction

Mental health comprises of an individual’s psychological, emotional and social well -being. It determines his/her ability to think and function. A threat to mental well -being includes the phenomenon of stress which can be defined as any emotional experience, causing discomfort, and which is accompanied by biochemical, physiological, and behavioral changes which cause bodily or mental tension (Sorenson, 2007; Christian, 2018). A stressor is the stimulus that induces stress (Sonnentag and Fritz, 2015). In the field of medicine, workplace stress is particularly commonplace. Approximately 28% of doctors, and other health care workers, have been perceived to have stress levels above the threshold. (Imran, Haider and Bhatti, 2011). Job stress has been linked inversely to quality working life and directly to hospital employees’ intentions of leaving their work (Mosadeghrad, Ferlie and Rosenberg, 2011). Common stressors in field of medicine include: long working hours, lack of adequate sleep and hence sleep deprivation, un-cooperative co-workers, problems with the family, and the fear of a patient’s expiry. (Maroof Hassan et al., 2014; Sadiq et al., 2018).

Several studies have suggested that the one-year training period after graduation is when house officers suffer enormous levels of stress. Karachi based study, in 2013, found that 47.9% of house officers were stressed, of whom 24.8% were male and 47.9% were female (Maroof Hassan et al., 2014). Such high levels of stress can lead to anger, cognitive impairment, cynicism and even family conflicts (Small, 1981).  The common mistakes by house officers include: errors in making a diagnosis (33%), wrong drug prescribing (29%), inappropriate evaluation (21%), lack of proper communication (5%) and procedural complications (11%) (Wu et al., 2003). Inexperience and incomplete knowledge was reasons for error made in diagnosis and evaluation.

Several studies related to stress in house officers have been carried out but hospital to hospital variation specifically considering the public and private sector hospitals has not been taken into account. It is a well-known fact that in government hospitals, house officers have to do work like taking the patients for lab investigations, filing in the paper work and the OPD input per day is much greater than that of private hospitals. Excessive stress in the workplace can compromise the young doctors’ ability to deliver effective patient care and hamper efficient learning (Shanafelt et al., 2002). Previously, a study has been conducted to find out different levels of stress on paramedical staff in government and private hospitals. Nurses working in a government hospital reported more stress compared to those in a private hospital (Tyson and Pongruengphant, 2004) but no study so far has looked particularly at house officers. Therefore, the aim of the current study is to compare the stress levels amongst the house officers who are working in Public and Private Hospitals of Karachi.

Methods

A descriptive cross-sectional study was conducted using a self-designed and self-explanatory questionnaire for identification of stress among house officers of government and private tertiary care hospitals of Karachi. Questionnaire includes questions related to demographics i.e. age, gender, ethnicity, year of study, lifestyle, weekly calls, weekly working hours, lifestyle changes due to stress. A pilot testing study with a sample of 20 house officers was used to validate the questionnaire. Cronbach Alpha was calculated which was found to be 0.804. The questionnaire was disseminated personally; names of students were not recorded. Sample Size was calculated using Openepi and was found to be 278 at 95% confidence interval.

Study was conducted in 6 months i.e. August 2018 to January 2019. Multistage non-probability sampling technique was used, in first stage 13 hospitals from both Public and Private sector (Jinnah Hospital, Civil Hospital, National institute of cardiovascular disease, PNS Shifa, Liaquat National Hospital, Patel Hospital, Fatima Jinnah Dental Hospital, Ziauddin Hospital, DOW Ojha Hospital, Baqqai Hospital, Altamash Hospital, Aga Khan Hospital and Abbasi Shaheed Hospital) were selected, while in the second stage house officers from different departments were randomly selected for the study. All participants gave informed, verbal consent prior to taking part in this study. Ethical approval was taken by ethical review committee of Ziauddin University.

Statistical Package for Social Sciences (SPSS-22) was used for analyzing data. The mean with standard deviation were calculated for quantitative variables while frequencies and percentages were calculated for qualitative variables. For Likert scale, the values (0-5) were assigned to each option, starting from 0, meaning ‘never’ and up to 5, meaning ‘very frequently’. The association of stress with gender, working hours, weekly calls and duration of house job was calculated by using ANOVA. Furthermore, where applicable, the Post Hoc Tukey’s test was also used to analyze the intragroup variations.

Results/Analysis

About 340 questionnaires was given among house officers of different public and private hospitals of Karachi. 297 duly filled questionnaire were received, giving a response rate of 87.3%. Participants from thirteen different Public and Private sector hospitals of Karachi were included in the study. The mean age of the participants was 25 ± 1.2 years. The majority, about ¾ of the sample, was female, of which 84.6% reported their marital status to be single. 43% of the total participants reported working 96 hours weekly. Responding to a question about emergency calls, 65% said they were on call 7-9 times per month. On call time to sleep was also reported to be very low, that is, 1-2 hours per call. This is mentioned in Table 1.

Using a 5-point Likert scale, positive and negative changes in behavior were assessed. The scale had the following range of options: strongly disagree, disagree, neutral, agree and strongly agree. For the positive attitude scenarios, for male participants the mean score reported was 17.21+6.4, whereas that of female participants was reported to be 19.2+6.1. Likewise, negative attitude scenarios had a lower score reported by male participants (21.55+7.96), while female participants reported a higher score of 23.06+7.93. Variations between hospitals were non-significant in positive attitudes, but in negative attitudes, were highly significant (p=<0.001). Post hoc Tukey’s test was used to check intra hospital variations and significant variation was observed between Altamash Hospital (Private) and Civil (Public) (<0.001) and that of JPMC (Public) was also significant (p=0.027). Other than Altamash, significant variation was reported for Civil (Public) and Baqai (Private) hospital with a p-value of 0.016. Working hours per week had no significant role in positive attitudes in both Public and Private sector hospitals, while in negative attitudes it was significant in Public sector (p=0.008) as well as in the overall results (p=0.002). Post Hoc Turkey’s test was used to infer the negative attitude which inferred that when the hours worked per week were increased, a notable decline in behavior was observed. An increase from 42 to 96 hours resulted in a p-value of 0.01 and an increase from 60 to 96 hours resulted in a p-value of 0.038. House job duration also had a significant effect in the decline of positive attitudes and increased negative attitudes. Notable changes were observed in the final quarter of the house job for both positive (p=0.029) and negative (p=0.005) attitudes. Likewise, sleep deprivation experienced during shifts played an important role in positive attitudes (p=0.001) whereby a positive change of mean by 5.3 demonstrated improvement in positive attitudes. On the other hand, for negative attitudes, the perceived change was extremely noteworthy (p= 0.002), but with a further decline in negative behavior with a mean difference of -6.07. Significant increase was observed in positive attitudes, if the sleep time given was 5-6 hours (p= 0.001) but a worsening of negative attitudes was observed with 1-2 hours of sleep time. The main characteristics of study participants of both Public and Private sector were mentioned in Table 1.

Table 1 Characteristics of Participants

 

Government Hospitals

Private Hospitals

Combined

N

%

Positive Attitude

(P Value)

Negative Attitude (P Value)

N

%

Positive Attitude

(P Value)

Negative Attitude (P Value)

N

%

Positive Attitude

(P Value)

Negative Attitude (P Value)

Gender

Male

19

9.9

0.871

0.797

28

26.4

0.52

0.238

47

15.8

0.045

0.231

Female

172

90.1

78

73.6

250

84.2

Marital Status

Single

164

85.9

0.430

0.269

88

83

0.009

0.246

252

84.8

0.025

0.546

Married

27

14.1

17

16

44

14.8

Divorced

0

0

1

1

1

0.3

Working Duration

1-3 Months

53

27.7

0.661

0.134

6

5.7

0.197

0.222

59

19.9

0.042

0.005

3-6 Months

108

56.5

16

15.1

124

41.8

7-9 Months

22

11.5

44

41.5

66

22.2

10-12 Months

8

4.2

40

37.7

48

16.2

Working Hours/ week

42 hours

37

19.4

0.253

0.008

35

33

0.082

0.091

72

24.2

0.881

0.002

60 hours

36

18.8

4

3.8

40

13.5

78 hours

35

18.3

23

21.7

58

19.5

96 hours

83

43.5

44

41.5

127

42.8

On call/ month

1-3

19

10

0.578

0.907

26

24.5

0.152

0.109

45

15.2

0.421

0.228

4-6

44

23

17

16

61

20.5

7-9

128

67

63

59.4

191

64.3

Sleep on call

1-2 hours

102

53.4

0.593

0.766

42

39.6

0.005

0.010

144

48.5

0.001

0.003

3-4 hours

85

44.5

46

43.4

131

44.1

5-6 hours

4

2.1

18

17

22

7.4

 

The mistakes commonly observed by the house officers were categorized into five broad groups. Out of all the participants in the study, 28 of them (9.4%) reported no significant medical mistake, out of which 20 belonged to the government sector while 8 belonged to the private sector. Issues and mistakes resulting from knowledge deficit or incompetency, which led to wrong diagnosis of patients, was reported by 61 (20.5%) respondents. Of these 61 participants, 38 were from the public sector. 47 participants (15.8%) reported errors in patient’s evaluation, including missing laboratory reports, vitals or inaccurate treatment modalities. 86 participants (29%) were found responsible for poor judgments (excluding errors due to knowledge deficit or incompetency) or poor decision-making (includes unattended patient, making a patient wait due to work overload or for lunch or talking).

The most frequent reason reported for errors was work overload (36.3%), making it the most likely underlying cause of mistakes. The second most important reason was inexperience, which led to wrong diagnosis or mishandling. Knowledge deficit, as well as substandard guidance or supervision from seniors, were some of the other important causes, as shown in Table 02. Another significant result observed in house officers was the fear of patient’s expiry, but this was found to decrease over time. Multiple strategies, mentioned in Table 2, were used by the house officers in order to cope with this fear. This led to passive acceptance for most, but with 12 participants (4%) out of the total still failed to cope with the fear of a patient expiry.

Table 2 Mistakes, Causes of Mistakes and Coping Strategies

 

Government

Private

Combined

N

%

N

%

n

%

Major mistakes conducted by House Officers

Error in diagnosis

38

19.9

23

21.7

61

20.5

Error in evaluation

32

16.8

15

14.2

47

15.8

Error in Prescription

48

25.1

27

25.5

75

25.5

Negligence

53

27.7

33

31.1

86

28.9

No mistakes

20

10.5

8

7.5

28

9.4

Causes of mistakes done by house officers

Negligence

3

1.5

0

0

3

1.1

Work Overload

70

36.6

31

29.2

101

36.6

Work Environment

14

7.3

13

12.2

27

9.8

Inexperience

37

19.3

25

23.5

62

22.5

Lack of guidance

46

24

12

11.3

58

21

Disease Complexity

5

2.6

9

8.4

14

5.1

Behaviour of colleagues

12

6.2

3

2.8

15

5.4

Attitude of attendant

3

1.5

13

12.2

16

5.8

Coping strategies adopted by house officers to overcome the fear of expiry

Rationalized/ accepted

44

23

25

23.6

69

23.2

Supported patient

26

13.6

12

11.3

38

12.8

Talked to others for support

52

27.2

20

18.9

72

24.2

Avoid

10

5.2

7

6.6

17

5.7

Optimistic faith

18

9.4

19

17.9

37

12.5

Deny responsibility

2

1

0

0

2

0.7

Expressed emotion

35

18.3

15

14.2

50

16.8

Failed to cope

4

2.1

8

7.5

12

4

 

Few questions about lifestyle were asked with two options same as usual or more than usual in order to analyze the quality of life and effect of stress in their life. Increased capability of decision and facing problems were two positive qualities observed as a result of stress while loss of sleep, constant strain and feeling of sadness and depression was observed as negative effects of stress. The main lifestyle changes are explained in table 3.

Table 3 Effect of stress on lifestyle

 

Government

Private

Combined

Same as Usual

More than usual

Same as Usual

More than usual

Same as Usual

More than usual

N

%

N

%

N

%

n

%

n

%

n

%

Been able to concentrate

115

60.2

76

39.8

56

52.8

50

47.2

171

57.6

126

42.6

Lost much sleep over worry

84

44

107

56

47

44.3

59

55.7

131

44.1

166

55.9

Felt that you were playing a useful part in things

81

42.4

110

57.6

44

41.5

62

58.5

124

42.1

172

57.9

Felt capable of making decisions

57

29.8

134

70.2

42

39.6

64

60.4

99

33.3

198

66.7

Felt constantly under strain

81

42.4

110

57.6

47

44.3

59

55.7

128

43.1

169

56.9

Felt you could not overcome difficulties

133

69.6

58

30.4

78

73.6

28

26.4

211

71

86

29

Been able to enjoy normal activities

134

70.2

57

29.8

57

53.8

49

46.2

191

64.3

106

35.7

Been able to face up to problems

72

37.7

119

62.3

41

38.7

65

61.3

113

38

184

62

Been feeling unhappy and depressed

96

50.3

95

49.7

74

69.8

32

30.2

170

57.2

127

42.8

Been losing confidence

145

75.9

46

24.1

87

82.1

19

17.9

232

78.1

65

21.9

Been thinking of yourself as worthless

144

75.4

47

24.6

80

75.5

26

24.5

225

75.8

72

24.2

Discussion

Stress has a higher prevalence in government hospital house officers than private hospital house officers. Furthermore, the mean score for stressors causing negative attitudes in government house officers are more than that of private sector. Further effects of these stressors seem to be that government house officers are unhappier, yet are confident in decision making at the workplace. In contrast, private house officers are happier, yet are less confident in decision making in the workplace.

A study on senior house officers pointed out that 51 percent of senior house officers were considered to be in psychological distress due to their occupation (McPherson et al., 2003). This reinforces the fact that there are high levels of stress amongst house officer. Another study on junior house officers claimed that 50% of them were considered stress, and 28% of subjects were considered depressed (Firth-Cozens, 1987). This example highlights the risk of stress leading to depression (Azodo and Ezeja, 2013). Literature review revealed that articles do not focus on specific differences of stress among house officers of public and private hospitals while one of the study suggests that paramedical staff like nurses who work in private setups are highly satisfied with their work environment (Chien and Yick, 2016). This may infer that the satisfaction in private hospitals are higher than government hospitals on an overall scale. It is important to point out that even though many participants in current study were dental students we can infer the high levels of stress in government institutions across the globe seem to be similar. Another article specific to government hospitals in Pakistan stated that 47.9% percent of house officers seem to be under high levels of stress (Hassan et al., 2014).

Our study highlights that government house officers are less happy, yet more confident in decision making, whereas private house officers are happier, yet less confident in decision making. In terms of confidence, a study by William et al states that that individuals with high levels of psychological distress often tend to have low levels of confidence (Williams et al., 1997). However, current study negates this finding because stress levels tend to be higher in public hospitals, yet house officers are much more confident in decision making than private house officers. A reason for this could be the point raised by Krautheim et al that confidence is likely to come through experience based intuition (Krautheim et al., 2017) and the current results suggest that government house officers have higher workloads than private house officers. It is also a known fact that government hospitals have a higher flow of patients which gives them more experience. On the other hand, private house officers claim to have less experience than government house officers which explains the lack of confidence. Therefore, these could be reasons why government house officers are more confident than private house officers.

Kalmbach et.al reported that poorly sleeping physician trainees are at an increased risk of depression (Kalmbach et al., 2017). In another study a group of house officers and post graduate trainees were surveyed on sleep deprivation. In the study 78.84% of participants were considered sleep deprived, and 30% of participants were considered depressed (Mustahsan et al., 2013). These figures are important because in current study, 53.4% of government house officers state that they obtain 1-2 hours of sleep on call while only 39.6% of private house officers seem to get 1-2 hours of sleep. Overall, sleep on call plays a significant role in negative attitudes. Since private house officers seem to get more sleep than government house officer, there tends to be a greater sense of happiness amongst private house officers. After comparison we can state that both hospital setups have high stress, but government house officers have higher levels of stress. Actions can be taken to improve both hospital setups. It is important to understand that we cannot control acute stress, rather we must control chronic stress (Yang et al., 2015).

Conclusion

It can be concluded that house officers of Public sectors are suffering from high levels of stress, as compared to that of Private sector, but are more confident in making decisions at the workplace. It is important that concern authorities should take action to reduce working hours and emergency calls so that we can control chronic stress which is a risk factor towards depression.

Take Home Messages

  • It can be concluded that the house officers of Public sectors are suffering from high levels of stress leading to depression, as compared to that of Private sector.
  • Government Sector doctors are more confident in making decisions at the workplace.
  • It is important to facilitate doctors and the concern authorities should take action to reduce working hours and emergency calls so that we can control chronic stress which is a risk factor towards depression.

Notes On Contributors

Muhammad Fazal Hussain Qureshi: Conceptualized and designed this study, both the intervention described and the rigorous measurement and analysis; spearheaded the acquisition of data and helped in the analysis and interpretation of the collected data; revised the drafted article critically for important intellectual content; provided final approval of the version to be published. I am currently a third year Medical Student doing MBBS from Ziauddin University.

Dr Sara Sadiq: Conceptualized and designed this study, both the intervention described and the rigorous measurement and analysis; spearheaded the acquisition of data and helped in the analysis and interpretation of the collected data; revised the drafted article critically for important intellectual content; provided final approval of the version to be published. She is Assistant Professor working in Department of Physiology of Ziauddin University.

Mr Danish Mohammad: Conceptualized and designed this study, both the intervention described and the rigorous measurement and analysis; spearheaded the acquisition of data and helped in the analysis and interpretation of the collected data; revised the drafted article critically for important intellectual content; provided final approval of the version to be published. He is currently a third year Medical Student doing MBBS from Ziauddin University.

Mahira Lakhani: Conceptualized and designed this study, both the intervention described and the rigorous measurement and analysis; spearheaded the acquisition of data and helped in the analysis and interpretation of the collected data; revised the drafted article critically for important intellectual content; provided final approval of the version to be published. She is currently a third year Medical Student doing MBBS from Ziauddin University.

Muzna Shah: Conceptualized and designed this study, both the intervention described and the rigorous measurement and analysis; spearheaded the acquisition of data and helped in the analysis and interpretation of the collected data; revised the drafted article critically for important intellectual content; provided final approval of the version to be published. She is currently a third year Medical Student doing MBBS from Ziauddin University.

Nuzhat Tariq: Conceptualized and designed this study, both the intervention described and the rigorous measurement and analysis; spearheaded the acquisition of data and helped in the analysis and interpretation of the collected data; revised the drafted article critically for important intellectual content; provided final approval of the version to be published. She is currently a third year Student doing bachelor's in Social Sciences from Institute of Business Administration (IBA).

Acknowledgements

None.

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Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

Ethical Approval was obtained by ethical review committee of Ziauddin University. Reference No SS2019.

External Funding

This article has not had any External Funding

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Ken Masters - (05/10/2019) Panel Member Icon
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An interesting paper dealing with stress in house officers across sectors in Pakistan. This is a good study, but the paper suffers from several issues that need to be addressed.

• The title mentions neither stress nor Pakistan. Both of these should be in the title, otherwise it is far too vague.

• “Approximately 28% of doctors, and other health care workers, have been perceived to have stress levels above the threshold. (Imran, Haider and Bhatti, 2011).” There are two problems with this statement:
o “the threshold” is not defined, and needs to be.
o It is quite true that Imran et al make this statement, but they base that statment off other studies, and the reader could find themselves going down a rabbit hole to find the original study that determined this figure. Please find and cite that original study.

• “Karachi based study, in 2013, found that 47.9% of house officers were stressed, of whom 24.8% were male and 47.9% were female” There appears to be an error in these percentages.

• “About 340 questionnaires” “About” is not good enough. How many questionnaires were given out OR how many house officers were there? Only with an exact number can the response rate be calculated.

• The authors should supply another table in which the basic demographic and other information is given per hospital. This is especially important because the authors have conducted further statistical tests to look at differences between the hospitals.

• When the statistics are reported, the raw numbers and then the percentages should be reported, not percentages only.

• Although the authors performed more detailed statistical tests for information between the hospitals, and found differences, they appear to report on them briefly only, and then never return to them. Indeed, in the conclusion, these differences appear to have not been mentioned. Either these results are important, or they are not. If they are not important, then reporting on them serves little purpose. If they are important (as I suspect they are), then they should be addressed in the Discussion and the Conclusion.

• In many places in the paper, the authors refer to studies without giving detail. Although they do correctly cite the study, more information is required for the context to be clearer. For example, “A study on senior house officers pointed out that 51 percent…” should at the very least mention the country and the size of the study.

• “It is also a known fact that government hospitals have a higher flow of patients which gives them more experience….. more confident than private house officers.” These statements will need to be supported by appropriate citations.

There are many small language errors and typographical errors that frequently interfere with the flow and understanding of the paper. It would be better if the authors could carefully proof-read their paper to remove these errors.

Minor:
“Openepi” should be written as “OpenEpi” and a link given.

So, a useful study, but the paper does need quite a bit of work.
Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish. However I have posted this review as a member of the review panel with relevant expertise and so this review represents a personal, not institutional, opinion.

Azizullah Langah - (03/07/2019)
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Thank you so much for inviting me to review this article.
This is a very interesting article which has explored the important area of a medical graduate for whom the educational environment paves the way to learn a lot during the course and how difference among different sectors can leads to stress and mistakes.
The authors research in this area led to a very structured intervention that I hope will demonstrate effectiveness in the future- I appreciated the fact that the authors point to this longer-term evaluation.
I strongly recommend this paper.
Lubna Jahanzeb - (26/06/2019)
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A very well written and informative article.