Soal Selidik Stress Manual

HHoossppii ttaall CCoonnssuull ttaannttss’’ JJoobb SSttrreessss &&

SSaatt iissffaacctt iioonn QQuueesstt iioonnnnaaii rree ((HHCCJJSSSSQQ))

User Manual

February 2008

Emma Teasdale

Sinead Drew

Cath Taylor

Amanda Ramirez

Cancer Research UK London Psychosocial Group

© Cancer Research UK London Psychosocial Group 2008

2

Contents

1. INTRODUCTION 3

1.1 Administration 4

1.2 Scoring and Interpretation of Results 4

2. DEVELOPING THE HOSPITAL CONSULTANTS’ JOB STRESS AND SATISFACTION QUESTIONNAIRE 5

2.1 Construction of the 1994 HCJSSQ 5

2.2 Development of the 2002 HCJSSQ 6

3. PSYCHOMETRIC PROPERTIES OF THE HCJSSQ 8

3.1 Factor Analyses of the HCJSSQ 8

3.2 Reliability of the HCJSSQ 8 Internal consistency 8 Test retest reliability 9

3.3 Validity of the HCJSSQ 9 Content validity 9 Construct validity 9 Criterion validity 9

4. THE CONSULTANTS’ JOB STRESS & JOB SATISFACTION Q UESTIONNAIRE (2002) 10

4.1 Global Ratings of Job Stress and Job Satisfacti on 13

4.2 Speciality Specific sources of Job Stress & Job Satisfaction 13

5. SUMMARY OF DATA FROM STUDIES OF UK CONSULTANTS 1 5

5.1 Survey 1 (1994) 15

5.2 Survey 2 (2002) 15

REFERENCES 20

APPENDICES 21

Appendix A: Loadings of the 2002 Consultants’ Job S tress and Job Satisfaction items on to stress and satisfaction factors 21

Appendix B: 1994 Core Consultants Job Stress & Job Satisfaction Questionnaire 24

Appendix C: 1994 Loadings of Consultants’ Job Stres s and Satisfaction Questionnaire items on to the stress and satisfaction factors. 26

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1. Introduction

There is ongoing concern about the mental health of doctors. In the UK the suicide rate for medical

practitioners is approximately twice the national average (Charlton et al., 1993). Approximately one third of

junior doctors have been shown to experience psychiatric morbidity (Firth-Cozens, 1987). Between a third

and a quarter of hospital consultants experience psychiatric morbidity at any one time (Graham & Ramirez,

1997; Taylor et al., 2005; Grunfeld et al., 2000).

In 1994 (Ramirez et al., 1996) and 2002 (Taylor et al., 2005), two national surveys were carried out to

examine the mental health of hospital consultants, from 5 specialities (gastroenterology, radiology, clinical

oncology, medical oncology and surgical oncology). A major finding of these studies was that the

prevalence of psychiatric morbidity was higher amongst hospital consultants (27%) than in the general

working population (18%) and furthermore, psychiatric morbidity rose significantly from 27% in 1994 to 32%

in 2002. This deterioration in mental health varied by consultant specialty and was particularly marked in

clinical and surgical oncologists, with a similar trend for medical oncologists (Taylor et al., 2005). In both of

these national surveys, poor mental health (PMH) was related to high job stress, whereas high levels of job

satisfaction were found to be protective from the harmful effects of job stress (Figure 1). The decrease in

mental health during this 8 year period from 1994 to 2002 seemed to be the consequence of increased

stress at work, without a comparable increase in job satisfaction.

Figure 1: Explanatory framework for poor mental hea lth among hospital consultants

The continued exposure of hospital consultants to a high risk of psychiatric morbidity is of concern not only

because it involves the ongoing personal suffering of doctors and their families, but because it may also

constitute a threat to the quality of patient care they deliver. Hospital consultants with poor mental health are

substantially more likely to report harmful consumption of alcohol (Taylor et al., 2007), may have poorer

communication skills (Heaven et al, 1998; Ramirez et al, 1996, Taylor et al, 2007) or impaired clinical

performance (Firth-Cozens et al, 1997), or be unable to deliver any care due to long-term sick leave

(Kivimaki et al, 2001) or taking early retirement (Pattini et al, 2001, Taylor et al, 2007). These findings

highlight the need for research to assess levels of job stress and job satisfaction among hospital consultants

and to search for ways to decrease their level of job stress and/or increase their levels of job satisfaction in

Psychiatric morbidity

Burnout

Job stress

Job satisfaction

Poor quality patient care Lack of empathy Poor communication skills Errors and mistakes

No patient care Long-term sick leave Early retirement Death/suicide -

+

-

+

+

4

order to improve the mental health of consultants and, in turn, ensuring that better quality patient care is

delivered.

The Hospital Consultants’ Job Stress and Satisfaction Questionnaire (HCJSSQ) is a 42-item self-report

questionnaire designed to assess the levels and sources of job stress and satisfaction of consultants.

Developed in 1994, the original questionnaire was modified for use in a further national survey in 2002. In

both surveys the HCJSSQ was administered by post. Maintaining consultants’ confidentiality was perceived

as vital in encouraging them to return the questionnaires and this was achieved by assigning each consultant

with a code number, the key to which was held by an independent person not involved with the study. The

code was used only to enable a second mailing which, together with the inclusion of letters of support from

the relevant Royal College or professional group, were thought to be crucial in achieving the high response

rates of 78% (1994) and 73% (2002).

1.1 Administration

The HCJSSQ takes approximately 20 minutes to fill out. It is self-administered. Complete instructions are

provided for the respondent.

1.2 Scoring and Interpretation of Results

Each source of job stress and job satisfaction is rated according to the contribution it has made to the overall

stress / satisfaction experienced at work. The scores on the questionnaire can be analysed in the following

ways:

1) Individual Items: The relative importance of different sources of stress / satisfaction can be assessed

by calculating the percentage of doctors reporting each item as contributing “quite a bit” or “a lot” to

their job stress / satisfaction (vs. “a little” or “not at all”). These item scores are split into 0/1 (a little /

not a lot) vs. 2/3 (quite a bit / a lot) and treated as binary scores.

2) Total Overall Scores: Overall job stress and job satisfaction scores can be calculated for by summing

ratings given to each item. Total job stress and job satisfaction scores are analysed as continuous

data.

3) Factor scores: Stress and satisfaction factors scores can be calculated by aggregating the ratings for

the individual items within that factor. Factor scores can be analysed as continuous data or as the

percentage of doctors reporting each factor as contributing “quite a bit” or “a lot” to their job stress /

satisfaction

4) Additional speciality-specific sources of job stress and satisfaction: If additional speciality-specific

items are used these items should be analysed separately from the core 36 stress and 22 satisfaction

items, as in Graham (1996).

5) Global ratings of job stress and satisfaction: The final question in each of the stress and satisfaction

questionnaires asks consultants to give an overall rating of the stress and satisfaction they experience

in their work, from 0 (Not at all) to 4 (Extremely stressful). This can be analysed categorically

according to the percentage of consultants scoring at each point on the scale.

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2. Developing the Hospital Consultants’ Job Stress and Satisfaction Questionnaire

In 1994, the Hospital Consultants’ Job Stress and Satisfaction Questionnaire was developed to capture the

specific sources of job stress and job satisfaction experienced by UK hospital consultants. There were a

number of measures of job stress already in existence which could have potentially been used to assess job

stress in hospital consultants, such as the Occupational Stress Indicator (Cooper et al, 1988) which was

designed for managerial and professional staff or the Health Professionals Stress Inventory (Wolfgang,

1988) which was developed to compare sources of stress across a variety of health professionals in the

USA. However, these questionnaires were not sufficiently sensitive to capture the unique and complex

working lives of hospital consultants and so they did not depict the specific sources of job stress experienced

by UK medical consultants. As was the case for job stress, existing questionnaires which measured job

satisfaction, such as the job satisfaction scale of the Occupational Stress Indicator (Cooper et al, 1988) were

rather too generalist to assess the particular aspects of work contributing to job satisfaction for hospital

consultants. It was therefore necessary to develop a questionnaire to assess the specific sources of stress

and satisfaction experienced by UK consultants.

2.1 Construction of the 1994 HCJSSQ

The original questionnaire was developed as follows:

1) A review of the literature was carried out in order to identify potential sources of stress and satisfaction for

consultants. The literature search covered the core occupational stress and satisfaction literature, specific

literature on occupational stress and satisfaction and specific literature on occupational stress and

satisfaction in medicine.

2) Interviews were carried out with a sample of 29 consultants. Consultants were chosen from five

specialities: two with on-call responsibilities (gastroenterologists and surgeons), two with considerable

exposure to death and dying (oncologists and palliative physicians) and providing a clinical support service

(radiologists). The consultants interviewed were selected to be representative of different institution types in

which these doctors work (teaching hospital, District General hospital, specialist centre and hospice)

geographical locations and gender.

In order to give the interview a framework, the potential sources of stress were organised according to the

six major categories of occupational stress identified by Cooper (1983):

1. Job specific Factors 2. Relationships at work 3. Role in the organisation 4. Career Development 5. Organisational Structure & Climate 6. Conflict between work & home life

This framework also ensured that the focus was not entirely on the clinical aspects of the consultants work

but rather on the full range of potentially stressful aspects of work. In the interviews, consultants were asked

to rate each source of stress / satisfaction according to how much of a source of stress it was in their work on

a 4-point scale of 0 (not at all), 1 (a little), 2 (quite a bit), 3 (a lot). They were also asked to describe any

6

additional aspects of work which they felt contributed to their job stress or satisfaction. All interviews were

tape recorded to enable the researchers to have access to the actual words hospital consultants used to

describe sources of stress and satisfaction at work.

For each of the sources of stress and satisfaction a mean “relevance score” was calculated. If the mean

score was greater than or equal to 1 then the item was automatically included in the questionnaire. The

items excluded at this stage on empirical grounds were then rated independently by four members of the

study team according to how strongly it was felt they should be retained for clinical reasons. For example,

items relating to stress from relationships with junior doctors and administrative staff had a low mean

relevance score, but were retained on the ground that this provided important negative information.

Additional aspects of work which the consultants had raised in the interviews as being relevant to their

experience of job stress and satisfaction were also rated according to their importance by the members of

the study team. The items derived from this process were piloted on a further sample of 37 consultants from

the five specialities.

The 1994 HCJSSQ consisted of 25 core sources of stress and 17 core sources of satisfaction relevant to all

of the specialist groups studied. Consultants are asked to rate each item on the extent to which it has

contributed to the stress / satisfaction they had experienced in their jobs in the past few months on a scale of

0 (not at all) to 3 (a lot). Global ratings of stress and satisfaction were also obtained by asking: “Overall, how

stressful/satisfying do you find your work?” on a scale of 0-4 (“not at all” to “extremely”). This questionnaire is

shown in full in Appendix B.

In addition to the generic items, some sources of stress were identified which were only specific to

consultants working in one of the specialties studied (surgery, gastroenterology, oncology/palliative

medicine, radiology). In the 1994 survey these additional items were incorporated into the questionnaire for

the relevant specialty. These additional items are shown in section 4.2 and can be used in addition to the

generic items in any studies of consultants from the same speciality group.

2.2 Development of the 2002 HCJSSQ

Since the creation of the 1994 questionnaire, many changes had taken place within the National Health

Service (NHS) and it was recognised that consultants were now facing new aspects of job stress and

satisfaction.. Additional funding had been put in place for health care, the work force had expanded and new

ways of working had been introduced, such as the introduction of Multi Disciplinary Team working (MDT’s).

In 2000 the NHS plan had also been created which saw the introduction of work targets such as those to

reduce patient time spent on waiting lists. Formal procedures for consultant appraisal and changes to

consultants’ employment contracts were also introduced. Consequently, the 2002 Job Stress and

Satisfaction questionnaire sought to include these new sources of job stress and job satisfaction.

Using the 1994 questionnaire, interviews were carried out with 28 consultants from the five specialities

(gastroenterologists, clinical oncologists, medical oncologists, surgeons and radiologists). Consultants were

asked to suggest any additional aspects of stress or satisfaction that they experienced at work. They were

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asked to rate each additional item according to the extent to which it has contributed to the stress /

satisfaction they experienced in their jobs in the past few months on a scale of 0 (not at all) to 3 (a lot). They

were also asked to rate any additional items suggested in interviews with other consultants prior to their own

interviews.

Each new item that received a mean rating of 1.5 or more from the pilot interviewees were selected and then

judged by members of the study team to ensure that they were not already covered by existing questionnaire

items. Three members of the study team rated these new items according to:

o The extent to which it was not covered by other items

o The extent to which it covered issues which appear to be important at that time from literature /

reports / talking to other consultants

Ratings for each potential new item were made on the following scale: 0 = this item should not be included, 1

= unsure, 2 = this item should be included. Items given a rating of “2” by two or more of the raters were

included in the final questionnaires.

No items from the original 1994 questionnaire were removed, in order that comparisons over time would be

possible. The revised version of the questionnaire consists of 36 core sources of stress - 25 from 1994 and

11 new (table1) and 22 core sources of satisfaction -17 from 1994 and 5 new (table 2). As with the 1994

questionnaire, items specific to consultant speciality were incorporated into the 2002 Health professionals’

Job Stress and Satisfaction Questionnaire for the relevant speciality. These additional items are shown in

section 4.2 and can be used in addition to the core items in any studies of consultants from the same

speciality groups.

Table 1: New Core Stress added to the 2002 Question naire Item Number

Stress Item

26 Having performance targets which are unrealistic or unattainable (e.g. due to lack of resources).

27 Dealing with patients or relatives having high expectations of care that cannot be met.

28 Having to comply with increasing bureaucratic and regulatory procedures. 29 Feeling concerned about keeping your skills up to date due to your Trust not

investing in new technologies. 30 Providing patient care within multidisciplinary teams. 31 Feeling that you are loosing generalist skills as your job becomes more specialised. 32 Having difficulties recruiting high calibre staff. 33 Having insufficient formalised time for teaching, training and research. 34 Having inadequate administration systems (e.g. IT, filing procedures for notes). 35 Having to submit a job plan and undergo performance appraisal. 36 Being required to provide routine NHS clinical services (e.g. outpatient clinics)

outside normal working hours.

8

Table 2: New Core Satisfaction added to the 2002 Qu estionnaire Item Number

Satisfaction Item

18 Being an expert in a specialist area. 19 Being perceived to do the job well by patients. 20 Having the opportunity to practice medicine privately. 21 Providing patient care within multi-disciplinary teams. 22 Being able to complete a difficult clinical procedure successfully.

3. Psychometric Properties of the HCJSSQ

3.1 Factor Analyses of the HCJSSQ The 1994 HCJSSQ was subject to principal component analysis using direct oblimin rotations (as there were

grounds for supposing that the factors might correlate). Factors were considered if they had an eigenvalue

over 1, and individual sources were included if they had a loading ≥0.4. This resulted in 4 job stress factors

and 4 job satisfaction factors (table 3). Nine sources of job stress and 2 sources of satisfaction did not

aggregate to factors. Details of the factor loadings can be seen in appendix C. The 2002 HCJSSQ was

subject to principal component analysis using both oblimin and varimax rotations; these produced the same

factor structures. The 2002 factor analysis of the core items confirmed the 4 job stress and satisfaction

factors from 1994 (with minimal amount of item shift) and resulted in 3 new job stress factors (table 4). The

factor loadings are detailed in appendix A.

3.2 Reliability of the HCJSSQ

Internal consistency Reliability coefficients reported here are based on the data from our two national surveys of UK hospital

consultants (n=1133 in 1994 & n= 1308 in 2002). Cronbach’s alphas indicate acceptable internal consistency

for the job stress scale in both the1994 and 2002 HCJSSQ (α = 0.86, 0.92) and for the job satisfaction scale

(α = 0.85, 0.87). The internal consistency of the job stress and satisfaction factors is shown in tables 3 & 4.

Table 3: 1994 Job Stress and Job Satisfaction Facto rs

Factor Number

Job Stress Factors No. of items per factor

Cronbach’s Alpha

1 2 3 4

Feeling overloaded and its impact on home life Feeling poorly managed and resourced Dealing with patients’ suffering Having managerial responsibilities

6 6 2 2

0.84 0.74 0.75 0.52

Factor Number

Job Satisfaction Factors

1 2 3 4

Feeling well managed and resourced Having good relationships with patients, relatives and staff Deriving intellectual stimulation Having professional status and esteem

5 4 4 3

0.77 0.62 0.63 0.68

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Table 4: 2002 Job Stress and Job Satisfaction Facto rs

Factor Number

Job Stress Factors No. of items per factor

Cronbach’s Alpha

1 2 3 4 5 6 7

Feeling overloaded and its impact on home life Feeling poorly managed and resourced Dealing with blame and anger from patients’ and relatives’ Dealing with changes in clinical practice Encountering difficulties in relationships with NHS staff/colleagues Dealing with patients’ suffering Having managerial responsibility

7 7 3 3 3 2 3

0.85 0.81 0.75 0.40 0.51 0.81 0.61

Factor Number

Job Satisfaction Factors

1 2 3 4

Feeling well managed and resourced Having good relationships with patients and relatives Having professional status / esteem Deriving Intellectual Stimulation

4 3 4 4

0.72 0.59 0.57 0.60

Test retest reliability The test re-test of the questionnaire has not yet been formally evaluated. However, a psychometric study,

which will allow for the test retest of the HCJSSQ to be determined, is planned for the future.

3.3 Validity of the HCJSSQ

Content validity Questionnaire content was developed on the basis of interviews with a representative group of 29

consultants in survey 1 (1994) and 28 consultants in survey 2 (2002). The inclusion of a wide range of

interviewees during the stages of questionnaire development provides good evidence for content validity.

Construct validity The construct validity of the HCJSSQ has been demonstrated by the confirmation of the hypothesised

relationship between job stress/satisfaction and mental health (as measured by the GHQ-12) and burnout

(as measured by the Maslach Burnout Inventory). As hypothesised in figure 1, high job stress is associated

with poor mental health and burnout in hospital consultants. Job satisfaction protects consultants’ mental

health against job stress (Ramirez et al, 1996; Taylor et al, 2005).

Criterion validity As there is no “gold standard” measure of consultant job stress and satisfaction, criterion validity cannot be

evaluated. Instead, a psychometric study, which will assess the convergent and discriminate validity of the

HCJSSQ is planned.

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4. The Consultants’ Job Stress & Job Satisfaction Q uestionnaire (2002) Stressful aspects of your work

To what extent have the following factors contributed to any stress you have experienced in your job in the past few months ? Please rate each factor by circling the relevant number on the 0 to 3 scale. If not applicable, please rate ‘0’.

Extent contributes to stress

Not

at all

A

Little

Quite

A bit

A

Lot

1 Being involved with the physical suffering of patients 0 1 2 3

2 Encountering difficulties in relationships with junior

medical staff

0 1 2 3

3 Feeling you have insufficient input into the management

of your unit or institution

0 1 2 3

4 Disruption of your home life through spending long

hours at work

0 1 2 3

5 Having inadequate facilities (e.g. equipment, space) to

do your job properly

0 1 2 3

6 Having to deal with distressed, angry or blaming

relatives

0 1 2 3

7 Keeping up to date with current clinical and research

practices

0 1 2 3

8 Having to take on more managerial responsibilities 0 1 2 3

9 Encountering difficulties in relationships with consultant

colleagues

0 1 2 3

10 Feeling under pressure to meet deadlines 0 1 2 3

11 Being responsible for the quality of the work of other

staff

0 1 2 3

12 Being involved with the emotional distress of patients 0 1 2 3

13 Encountering difficulties in relationships with

administrative staff, e.g. secretaries

0 1 2 3

14 Having too great an overall volume of work 0 1 2 3

15 Feeling you are poorly paid for the job you do 0 1 2 3

16 Encountering difficulties in relationships with managers 0 1 2 3

17 Having conflicting demands on your time (e.g. patient

care/management/research/College)

0 1 2 3

11

Extent contributes to stress

Not

at all

A

Little

Quite

A bit

A

Lot

18 Having inadequate staff to do your job properly 0 1 2 3

19 Dealing with the threat of being sued for malpractice 0 1 2 3

20 Disruption of your home life as a result of taking

paperwork home

0 1 2 3

21 Feeling that your accumulated skills and expertise are

not being put to their best use

0 1 2 3

22 Disruption of your home life as a result of being on call

0 1 2 3

23 Having a conflict of responsibilities (e.g. clinical vs.

managerial; clinical vs. research)

0 1 2 3

24 Uncertainty over the future funding of your

unit/institution

0 1 2 3

25 Being responsible for the welfare of other staff 0 1 2 3

26 Having performance targets which are unrealistic or

unattainable (e.g. due to lack of resources)

0 1 2 3

27 Dealing with patients or relatives having expectations of

care that cannot be met

0 1 2 3

28 Having to comply with increasing bureaucratic and

regulatory procedures

0 1 2 3

29 Feeling concerned about keeping your skills up to date

due to your Trust not investing in new technologies

0 1 2 3

30 Providing patient care within multi-disciplinary teams 0 1 2 3

31 Feeling that you are losing generalist skills as your job

becomes more specialised

0 1 2 3

32 Having difficulties recruiting high calibre staff 0 1 2 3

33 Having insufficient formalised time for teaching, training

and research

0 1 2 3

34 Having inadequate administration systems (e.g. IT, filing

procedures for notes)

0 1 2 3

35 Having to submit a job plan and undergo performance

appraisal

0 1 2 3

36 Being required to provide routine NHS clinical services

(e.g. outpatient clinics) outside normal working hours

0 1 2 3

12

Satisfying aspects of your work

To what extent have the following factors contributed to the satisfaction you have derived from your job in the past few months ? Please rate each factor by circling the relevant number on the 0 to 3 scale. If not applicable, please rate ‘0’. Extent contributes to

satisfaction Not

at all

A

little

Quite

a bit

A

Lot

1 Having a high level of responsibility 0 1 2 3

2 Being perceived to do the job well by your colleagues 0 1 2 3

3 Being able to bring about positive change in your

unit/institution

0 1 2 3

4 Having good relationships with patients 0 1 2 3

5 Feeling you have the staff necessary to do a good job 0 1 2 3

6 Deriving intellectual stimulation from research 0 1 2 3

7 Having a high level of autonomy 0 1 2 3

8 Having opportunities for personal learning (developing

clinical/research/management skills)

0 1 2 3

9 Having good relationships with other staff members 0 1 2 3

10 Having variety in your job 0 1 2 3

11 Feeling you have adequate financial resources to do a

good job

0 1 2 3

12 Being involved in activities that contribute to the

development of your profession

0 1 2 3

13 Feeling you have a high level of job security 0 1 2 3

14 Deriving intellectual stimulation from teaching 0 1 2 3

15 Feeling you have adequate facilities to do a good job 0 1 2 3

16 Feeling your clinical experience is used to the full in the

job you do

0 1 2 3

17 Feeling you deal well with relatives 0 1 2 3

18 Being an expert in a specialist area 0 1 2 3

19 Being perceived to do the job well by patients 0 1 2 3

20 Having the opportunity to practice medicine privately 0 1 2 3

21 Providing patient care within multi-disciplinary teams 0 1 2 3

22 Being able to complete a difficult clinical procedure

successfully

0 1 2 3

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4.1 Global Ratings of Job Stress and Job Satisfacti on

In both the 1994 and 2002 questionnaires the following two questions were asked to ascertain a ‘global

measure’ of stress and satisfaction for each individual consultant.

a) Overall, how stressful do you find your work? Not at all stressful 0 1 2 3 4 Extremely stressful b) Overall, how satisfying do you find your work? Not at all satisfying 0 1 2 3 4 Extremely satisfyin g

4.2 Speciality Specific sources of Job Stress & Job Satisfaction

All statements were rated within both versions of the questionnaire, unless explicitly stated otherwise. There

is some overlap between speciality groups and their additional sources of job stress and job satisfaction.

However, for ease of presentation, additional items are presented by speciality group.

Box 1: Medical / Clinical Oncologists Additional Sources of Stress

� Being unable to cure patients. � Having to make treatment decisions where mistakes have severe consequences. � Being responsible for treatment toxicity caused by treatments you prescribe. � Having to break bad news to patients and their relatives. � Having your clinical decision making restricted by financial considerations. � Encountering difficulties in relationships with nurses. � Being unable to control patients’ symptoms. � Being involved with fatal illness and death. � Encountering difficulties in relationships with paramedics, e.g. social workers, occupational

therapists. � Frustration from NICE guidelines (Added in 2002) � Having long waiting times for patient investigations and treatments (Added in 2002) � Having to work on several hospital sites (Added in 2002)

Additional Sources of Satisfaction

� Helping patients thorough controlling their symptoms. � Feeling you manage death and dying well for patients. � Helping patients through curing cancer / disease.

Box 2: Radiologists Additional Sources of Stress

� Dealing with clinicians’ requests for inappropriate examinations. � Dealing with continuous expectations of clinicians that you do their work immediately. � Being concerned about the effect of diagnostic errors on patients. � Dealing with complaints from patients and GP’s � Being involved in audit and in particular errors and complications meetings. � Running clinical / radiological meetings. � Encountering difficulties in relationships with radiographers.

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Box 3: Surgeons Additional Sources of Stress

� Being concerned about missing the diagnosis of cancer. � Dealing with the impact of Junior Doctors’ new deal. � Being unable to use operating time effectively due to the organisation of theatres being under

control of others. � Dealing with patients whose symptoms are benign but who remain anxious about having

cancer. � Dealing with the impact of NHS reforms (1994 only, replaced with new items in 2002). � Being unable to cure patients. � Having to make treatment decisions where mistakes have severe consequences. � Being responsible for treatment toxicity caused by treatments you prescribe. � Having to break bad news to patients and their relatives. � Having your clinical decision making restricted by financial considerations. � Encountering difficulties in relationships with nurses. � Being unable to control patients’ symptoms. � Being involved with fatal illness and death. � Encountering difficulties in relationships with paramedics, e.g. social workers, occupational

therapists. � Frustration from NICE guidelines (Added in 2002) � Having long waiting times for patient investigations and treatments (Added in 2002)

Additional Sources of Satisfaction

� Helping patients thorough controlling their symptoms. � Feeling you manage death and dying well for patients. � Helping patients through curing cancer / disease.

Box 4: Gastroenterologists Additional Sources of Stress

� Being unable to cure patients. � Having to make treatment decisions where mistakes have severe consequences. � Being responsible for treatment toxicity caused by treatments you prescribe. � Having to break bad news to patients and their relatives. � Having your clinical decision making restricted by financial considerations. � Encountering difficulties in relationships with nurses. � Being unable to control patients’ symptoms. � Being involved with fatal illness and death. � Encountering difficulties in relationships with paramedics, e.g. social workers, occupational

therapists. � Being concerned about missing the diagnosis of cancer. � Dealing with the impact of Junior Doctors’ new deal. � Dealing with patients whose symptoms are benign but who remain anxious about having

cancer. � Management of patients with medically unexplained symptoms. � Frustration from NICE guidelines (Added in 2002) � Having long waiting times for patient investigations and treatments (Added in 2002) � Having to work on several hospital sites (Added in 2002)

Additional Sources of Satisfaction

� Helping patients thorough controlling their symptoms. � Feeling you manage death and dying well for patients. � Helping patients through curing cancer / disease.

15

5. Summary of Data from Studies of UK Consultants

Our national cross-sectional surveys collected data from 882 consultants in 1994 (Ramirez et al., 1996) and

1308 consultants in 2002 (Taylor et al., 2005), working in five different specialties: gastroenterology,

radiology, surgical oncology, clinical oncology and medical oncology. The aim of these surveys was to

examine the relationship between consultants’ mental health (as measured by the GHQ-12), burnout (as

measured by the Maslach Burnout Inventory) and their job stress and satisfaction. In 2002, the initial 1994

cohort were re-surveyed, along with a cohort of consultants from the same specialities who were new to the

grade. This approach enabled us to assess the changes in the job stress and job satisfaction of comparable

cohorts of consultants across time and included a group of consultants who responded at both time points.

5.1 Survey 1 (1994) One thousand, one hundred and thirty three consultants were asked to respond to the 1994 questionnaire.

These comprised of a 2 in 3 random sample of gastroenterologists who were members of the British society

of Gastroenterology (299); all surgeons who were members of the British Association of Surgical Oncology

(252), a 1 in 5 random sample of clinical radiologists ascertained through the Royal College of Radiologists

(260) and all British clinical and medical oncologists, ascertained through the Royal College of Radiologists

and Physicians (322). The overall response rate across all specialties was 78% (882/1113). The main

findings showed that the level of poor mental health was high (27%) and that poor mental health and burnout

were related to high job stress. High levels of job satisfaction were found to be protective from the harmful

effects from job stress (Ramirez et al., 1996). Differences in the sources of job stress and satisfaction for the

overall sample were observed, for example, a predominant source of job stress for consultants was ‘feeling

overloaded at work and its effect on home life’ (see table 9) . In addition, differences in the levels and

sources of job stress and satisfaction between specialist groups were also observed.

5.2 Survey 2 (2002)

One thousand, seven hundred and ninety four consultants were asked to response to the 2002

questionnaire. Three hundred and sixty consultants from the 1994 cohort had retired, the 2002 survey was

sent to the remaining 773 consultants. Additionally, consultants from each of the five specialties who were

new to the grade since 1994 were sampled with the same techniques as 1994. The overall response rate

across al specialties was 73% (1308/1794). The findings of the 2002 survey indicated that psychiatric

morbidity had risen significantly within hospital consultants since 1994 to 32% and, again, poor mental health

was related to high job stress, and high levels of job satisfaction were found to be protective from the harmful

effects from job stress (Taylor et al, 2005). Again differences in the sources of job stress and satisfaction for

the overall sample were observed with ‘feeling overloaded at work and its effect on home life’ being a

predominant source of stress. Differences in levels and sources of job stress and satisfaction between

specialist groups, and changes over time in the levels and sources of job stress and satisfaction for the

overall sample and by specialist group were also observed.

16

Table 5: Percentage of consultants reporting source of stress as contributing “quite a bit” or “a lot” to overall job stress (1994) Source of stress Hospital

Consultants %

Having too great an overall volume of work 75 Having conflicting demands on your time e.g. patient care/management/research/College 70 Disruption of your home life through spending long hours at work 56 Feeling under pressure to meet deadlines 56 Having inadequate staff to do your job properly 55 Having inadequate facilities (e.g. equipment/space) to do your job properly 49 Having to take on more managerial responsibilities 46 Having a conflict of responsibilities (e.g. clinical vs. managerial; clinical vs. research) 46 Feeling you have insufficient input into the management of your unit/institution 45 Keeping up to date with current clinical and research practices 43 Disruption of your home life as a result of taking paperwork home with you 42 Uncertainty over the future funding of your unit/institution 38 Being responsible for the quality of the work of other staff 36 Having to deal with distressed, angry or blaming relatives 35 Feeling that your accumulated skills and expertise are not bring put to their best use 30 Encountering difficulties in relationships with managers 29 Disruption of your home life as a result of being on-call 26 Being involved with the emotional distress of patients 25 Encountering difficulties in relationships with consultant colleagues 25 Being involved with the physical suffering of patients 24 Dealing with the threat of being sued for malpractice 19 Feeling you are poorly paid for the job you do 15 Being responsible for the welfare of other staff 14 Encountering difficulties in relationships with junior medical staff 14 Encountering difficulties in relationships with administrative staff, e.g. secretaries 12 Table 6: Percentage of consultants reporting source of satisfaction as contributing “quite a bit” or “a lot” to overall job stress (1994) 1994 Source of satisfaction Hospital

Consultants %

Having good relationships with patients 94 Having good relationships with other staff members 84 Being perceived to do the job well by your colleagues 84 Having variety in your job 83 Having a high level of responsibility 80 Feeling you deal well with relatives 66 Having a high level of autonomy 60 Being able to bring about positive change in your unit/institution 60 Feeling your clinical expertise is used to the full in the job you do 59 Deriving intellectual stimulation from teaching 54 Feeling you have a high level of job security 51 Being involved in activities which contribute to the development of the profession 49 Feeling you have the staff necessary to do a good job 46 Deriving intellectual stimulation from research 40 Having opportunities for personal learning (developing clinical skills) 40 Feeling you have adequate facilities to do a good job 36 Feeling you have adequate financial resources to do a good job 27

17

Table 7: Percentage of consultants reporting source of stress as contributing “quite a bit” or “a lot” to overall job stress (2002) 2002 Source of stress Hospital

Consultants %

Having too great an overall volume of work 76 Having conflicting demands on your time e.g. patient care/management/research/College 75 � Having to comply with increasing bureaucratic and regulatory procedures 71 Having inadequate staff to do your job properly 65 � Having inadequate administrative systems e.g. IT, filling procedures for notes 64 Having inadequate facilities (e.g. equipment/space) to do your job properly 64 Disruption of your home life through spending long hours at work 62 � Having difficulties recruiting high calibre staff 58 � Having insufficient formalised time for teaching, training and research. 58 Feeling under pressure to meet deadlines 57 Feeling you have insufficient input into the management of your unit/institution 53 � Having performance targets which are unrealistic or unattainable e.g. due to lack of

resources 51

� Dealing with patients or relatives having high expectations of care that cannot be met 47 Having to deal with distressed, angry or blaming relatives 47 Having to take on more managerial responsibilities 46 Having a conflict of responsibilities (e.g. clinical vs. managerial; clinical vs. research) 46 Disruption of your home life as a result of taking paperwork home with you 42 Being responsible for the quality of the work of other staff 41 Feeling that your accumulated skills and expertise are not bring put to their best use 37 Disruption of your home life as a result of being on-call 37 � Feeling concerned about keeping your skills up to date due to you Trust not investing in

new technologies 34

Keeping up to date with current clinical and research practices 34 � Having to submit a job plan and undergo performance appraisal 32 Encountering difficulties in relationships with managers 32 Encountering difficulties in relationships with consultant colleagues 31 Feeling you are poorly paid for the job you do 30 � Feeling that you are loosing your generalist skills as your job become more specialised 29 Dealing with the threat of being sued for malpractice 28 Uncertainty over the future funding of your unit/institution 27 Being involved with the emotional distress of patients 25 Being involved with the physical suffering of patients 24 � Being required to provide routine NHS clinical services e.g. outpatient clinics, outside

normal working hours. 23

� Providing client care within multidisciplinary teams 17 Encountering difficulties in relationships with junior medical staff 16 Being responsible for the welfare of other staff 14 Encountering difficulties in relationships with administrative staff, e.g. secretaries 13

� 11 ‘New Core’ sources of job stress added to the 2002 questionnaire.

18

Table 8: Percentage of consultants reporting source of satisfaction as contributing “quite a bit” or “a lot” to overall job stress (2002) Source of satisfaction Hospital

Consultants %

Having good relationships with patients 94 � Being perceived to do the job well by patients 92 Having good relationships with other staff members 92 Being perceived to do the job well by your colleagues 89 � Being an expert in a specialist area 84 Having variety in your job 82 � Being able to complete a difficult clinical procedure successfully 79 Having a high level of responsibility 78 Feeling you deal well with relatives 74 � Providing patient care within multidisciplinary teams 66 Feeling you have a high level of job security 63 Having a high level of autonomy 61 Feeling your clinical expertise is used to the full in the job you do 59 Being able to bring about positive change in your unit/institution 58 Deriving intellectual stimulation from teaching 54 Feeling you have the staff necessary to do a good job 53 Being involved in activities which contribute to the development of the profession 50 Having opportunities for personal learning (developing clinical skills) 43 Deriving intellectual stimulation from research 40 � Having the opportunity to practice medicine privately 37 Feeling you have adequate facilities to do a good job 36 Feeling you have adequate financial resources to do a good job 30

� 5 new sources of job satisfaction added to the 2002 questionnaire Table 9: Stress factor scores for hospital consulta nts in 1994 and 2002 (% of responses rated as contributing “quite a bit” or “a lot” to o verall job satisfaction)

Stress Factor Score %

Stress Factor

1994 2002 Feeling overloaded and its effect on home life 58 60 Feeling poorly managed and resourced 41 46* Having managerial responsibilities 30 30 Dealing with patients’ suffering 24 24

*Significant change over time. Table 10 – Stress factor scores for the five groups of hospital consultants

% of responses in factor rated as contributing “qui te a bit” or “a lot” to overall job stress Gastroenterologists

Radiologists Surgical Oncologists

Clinical Oncologists

Medical Oncologists

1994 Factor

1994 2002 1994 2002 1994 2002 1994 2002 1994 2002 Feeling overloaded and its effect on home life

61 57 51 56 63 62 55 63* 61 63

Feeling poorly managed and resourced

39 43 45 47 41 50* 42 46* 32 42

Having managerial responsibilities

31 27* 28 24 33 31 29 33* 34 39

Dealing with patients’ suffering

17 13 13 11 31 31 38 40 30 28

*Significant change over time within that specialty.

19

Table 11: Satisfaction factor scores for hospital c onsultants (% of responses rated as contributing “quite a bit” or “a lot” to overall jo b satisfaction)

Stress Factor Score %

Satisfaction Factor

1994 2002 Good relationships with patients, relatives & staff 58 78* Professional status and esteem 41 75 Deriving intellectual stimulation 30 47 Well managed & resourced. 24 48*

*Significant change over time. Table 12 – Satisfaction factor scores for the four groups of hospital consultants

% of responses in factor rated as contributing “qui te a bit” or “a lot” to overall job stress Gastroenterologists

Radiologists Surgical Oncologists

Clinical Oncologists

Medical Oncologists

Factor

1994 2002 1994 2002 1994 2002 1994 2002 1994 2002 Good relationships with patients, relatives & staff

61 79 51 69* 63 82 55 80* 61 81

Professional status and esteem

39 73 45 74 41 78 42 74 32 80

Deriving intellectual stimulation

31 47 28 40 33 50* 29 44 34 58

Well managed & resourced.

17 48 13 47* 31 51 38 46 30 48

*Significant change over time within specialty

20

References Charlton J, Kelly S, Dunnell K, Evans B, Jenkins R, (1993). Suicide deaths in England and Wales: trends in factors associated with suicide deaths. Popular Trends, 69: 34-42. Cooper C, Sloan S, Williams S, (1988). Occupational Stress indicator management guide. Windsor: NFER-Nelson. Cooper C, (1983). Identifying stressors at work: recent research developments. Journal of Psychosomatic Research, 27 (5): 369-376 Firth-Cozens, J., & Greenhalgh, J (1997) Doctors’ perceptions of the links between stress and lowered clinical care. Social Science & Medicine, 44, 7: 1017-1022. Firth-Cozens J, (1987). Emotional distress in junior house officers. BMJ, 295: 533-536. Graham J & Ramirez AJ, (1997) Mental Health of hospital consultants. Journal of Psychosomatic Research, 43: 227-231. Grunfeld E, Whelan TJ, Zitzelsberger L et al., (2000). Cancer care workers in Ontario: prevalence of burnout, job stress and job satisfaction. Canadian Medical Association Journal, 163: 166-169. Heaven C, Maguire P, Clegg J (1998). Impact of communication skills training on self efficacy, outcome expectancy and burnout. Psycho-Oncology,7, 61.

Kivimaki, M., Sutinen, R., Elovainio, M., Vahtera, J., et al (2001) Sickness absence in hospital physicians: 2 year follow up study on determinants. Occupational & Environmental Medicine, 58: 361-366.

Pattani, S., Constantinovici, N. Williams, S. (2001) Who retires early from the NHS because of ill health and what does it cost? A national cross sectional study. British Medical Journal, 322: 208-209.

Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM, (1996). Mental Health of hospital consultants: the effects of stress and satisfaction at work. Lancet, 347: 724-728. Taylor C, Graham J, Potts H, Candy J, Richards M, Ramirez A, (2007). Impact of hospital consultants poor mental health on patient care. British Journal of Psychiatry, 190: 268-269. Taylor C, Graham J, Potts HWW, Richards MA, Ramirez AJ (2005). Changes in mental health of UK hospital consultants since the mid-1990. Lancet, 366: 724-744. Wolfgang A, (1988). Job stress in health professions: A study of physicians, nurses and pharmacists. Behavioural Medicine, 14: 43-47.

21

Appendices Appendix A: Loadings of the 2002 Consultants’ Job S tress and Job Satisfaction items on to stress and satisfaction factors Table 1: 2002 Loadings of job stress items on the stress factors Questionnaire Items Factor

1 Factor 2

Factor 3

Factor 1: Overload disruption to home life

Item 4 : Disruption of your home life through spending long hours at work

.62

Item 10: Feeling under pressure to meet deadlines .63 Item 14: Having too great an overall volume of work .70 Item 17: Having conflicting demands on your time (e.g. patient

care/ management / research. College) .75

Item 20: Disruption of your home life as a result of taking paperwork home

.63

Item 23: Having a conflict of responsibilities (e.g. clinical vs. managerial; clinical vs. research)

.65

Item 33: Having insufficient formalised time for teaching, training and research

.56

Factor 2: Feeling poorly managed and resourced

Item 3: Feeling you have insufficient input into the management of your unit / institution

.66

Item 5: Having inadequate facilities (e.g. equipment, space) to do your job properly

.70

Item 16: Encountering difficulties in relationships with managers

.57

Item 18: Having inadequate staff to do your job properly .59 Item 21: Feeling your accumulated skills and expertise are not

being put to their best use .51

Item 29: Feeling concerned about keeping your skills up to date due to your Trust not investing in new technologies

.51

Item 34: Having inadequate administration systems 9e.g. IT, filing procedures for notes)

.55

Factor 3: Dealing with blame and anger from patient s and relatives

Item 6: Having to deal with distressed, angry or blaming relatives

.72

Item 19: Dealing with the threat of being sued for malpractice .70 Item 27: Dealing with patients or relatives having expectations

of care that cannot be met .70

22

Table 1(continued): 2002 Loadings of job stress items on the stress factors Questionnaire Items Factor

4 Factor 5

Factor 6

Factor 7

Factor 4: Dealing with change in clinical practice

Item 7: Keeping up to date with current clinical and research practices

.61

Item: 30: Providing patient care within multi disciplinary teams.

.60

Item: 31: Feeling you are loosing generalist skills as your job become more specialised.

.64

Factor 5: Encountering difficulties in relationship s with NHS staff / colleagues

Item 2: Encountering difficulties in relationships with junior medical staff

.67

Item 9: Encountering difficulties in relationships with consultant colleagues

.61

Item 13: Encountering difficulties in relationships with administration staff

.55

Factor 6: Dealing with patients’ suffering

Item 1: Being involved with the physical suffering of patients

.85

Item 12: Being involved with the emotional distress of patients

.81

Factor 7: Having Managerial Responsibilities

Item 8: Having to take on more managerial responsibilities

.54

Item 24: Uncertainty over the future funding of your unit/institution

.69

Item 25: Being responsible for the welfare of other staff .64

Individual sources of stress that did not aggregate to any factors

Item 15 Item 11 Item 26 Item 28 Item 32 Item 35 Item 22 Item 36

Feeling you are poorly paid for the job you do. Being responsibility for the quality of the work of other staff. Having unrealistic or unattainable performance targets. Increasingly bureaucratic and regulatory procedures. Difficulties recruiting high calibre staff. Having to undergo job plan and performance appraisal. Disruption of your home life as a result of being on-call. Providing routine NHS clinical services outside normal hours.

23

Table 2: 2002 Loadings of job satisfaction items on the satisfaction factors Questionnaire Items Factor

1 Factor 2

Factor 3

Factor 4

Factor 1: Feeling well managed and resourced

Item 5: Feeling you have the staff necessary to do a good job

.69

Item 11: Feeling you have adequate financial resources to do a good job

.84

Item 15: Feeling you have adequate facilities to do a good job

.85

Item 16: Feeling your clinical experience is used to the full in the job you do

.56

Factor 2: Having good relationships with patients, relatives and staff

Item 4: Having good relationships with patients .78 Item 17: Feeling you deal well with relatives

.74

Item 19: Being perceived to do the job well by patients .76 Factor 3: Having professional status/esteem

Item 1: Having a high level of responsibility .73 Item 2: Being perceived to do the job well by your

colleagues .68

Item 3: Being able to bring about positive change in your unit / institution

.48

Item 7: Having a high level of autonomy

.58

Factor 4: Deriving intellectual satisfaction

Item 6: Deriving intellectual stimulation from research .81 Item 8: Having opportunities for personal learning .54 Item 12: Being involved in activities which contribute to

the development of the profession .50

Item 18: Being an expert in a specialist area .47

Individuals sources of satisfaction that did not aggregate to factors

Item 10 Item 14 Item 20 Item 21 Item 22 Item 13 Item 9

Having variety in your job. Deriving intellectual stimulating from teaching. Having the opportunity to practice medicine. Providing care within MDT’s. Completing a difficult clinical procedure successfully. Feeling you have a high level of job security. Having good relationships with other staff members.

24

Appendix B: 1994 Core Consultants Job Stress & Job Satisfaction Questionnaire Stressful aspects of your work

To what extent have the following factors contributed to any stress you have experienced in your job in the past few months ? Please rate each factor by circling the relevant number on the 0 to 3 scale. If not applicable, please rate ‘0’.

Extent contributes to stress

Not

at all

A

Little

Quite

A bit

A

Lot

1 Being involved with the physical suffering of patients 0 1 2 3

2 Encountering difficulties in relationships with junior medical

staff

0 1 2 3

3 Feeling you have insufficient input into the management of

your unit or institution

0 1 2 3

4 Disruption of your home life through spending long hours at

work

0 1 2 3

5 Having inadequate facilities (e.g. equipment, space) to do

your job properly

0 1 2 3

6 Having to deal with distressed, angry or blaming relatives 0 1 2 3

7 Keeping up to date with current clinical and research

practices

0 1 2 3

8 Having to take on more managerial responsibilities 0 1 2 3

9 Encountering difficulties in relationships with consultant

colleagues

0 1 2 3

10 Feeling under pressure to meet deadlines 0 1 2 3

11 Being responsible for the quality of the work of other staff 0 1 2 3

12 Being involved with the emotional distress of patients 0 1 2 3

13 Encountering difficulties in relationships with administrative

staff, e.g. secretaries

0 1 2 3

14 Having too great an overall volume of work 0 1 2 3

15 Feeling you are poorly paid for the job you do 0 1 2 3

16 Encountering difficulties in relationships with managers 0 1 2 3

17 Having conflicting demands on your time (e.g. patient

care/management/research/College)

0 1 2 3

18 Having inadequate staff to do your job properly 0 1 2 3

19 Dealing with the threat of being sued for malpractice 0 1 2 3

20 Disruption of your home life as a result of taking paperwork

home

0 1 2 3

25

Extent contributes to stress Not

at all A little

Quite a bit

A lot

21 Feeling that your accumulated skills and expertise are not

being put to their best use

0 1 2 3

22 Disruption of your home life as a result of being on call 0 1 2 3

23 Having a conflict of responsibilities (e.g. clinical vs.

managerial; clinical vs. research)

0 1 2 3

24 Uncertainty over the future funding of your unit/institution 0 1 2 3

25 Being responsible for the welfare of other staff 0 1 2 3

Satisfying aspects of your work

To what extent have the following factors contributed to the satisfaction you have derived from your

job in the past few months ? Please rate each factor by circling the relevant number on the 0 to 3

scale. If not applicable, please rate ‘0’.

Extent contributes to satisfaction

Not at all

A little

Quite a bit

A Lot

1 Having a high level of responsibility 0 1 2 3

2 Being perceived to do the job well by your colleagues 0 1 2 3

3 Being able to bring about positive change in your

unit/institution

0 1 2 3

4 Having good relationships with patients 0 1 2 3

5 Feeling you have the staff necessary to do a good job 0 1 2 3

6 Deriving intellectual stimulation from research 0 1 2 3

7 Having a high level of autonomy 0 1 2 3

8 Having opportunities for personal learning (developing

clinical/research/management skills)

0 1 2 3

9 Having good relationships with other staff members 0 1 2 3

10 Having variety in your job 0 1 2 3

11 Feeling you have adequate financial resources to do a good

job

0 1 2 3

12 Being involved in activities that contribute to the

development of your profession

0 1 2 3

13 Feeling you have a high level of job security 0 1 2 3

14 Deriving intellectual stimulation from teaching 0 1 2 3

15 Feeling you have adequate facilities to do a good job 0 1 2 3

16 Feeling your clinical experience is used to the full in the job

you do

0 1 2 3

17 Feeling you deal well with relatives 0 1 2 3

26

Appendix C: 1994 Loadings of Consultants’ Job Stress and Satisfaction Questionnaire items on to the stress and satisfaction factors. Table 5: 1994 Loadings of job stress items on the stress factors Questionnaire Items Factor

1 Factor 2

Factor 3

Factor 4

Factor 1: Feeling overloaded and its effect on home life

Item 4: Disruption of your home life through spending long hours at work.

.75

Item 10: Feeling under pressure to meet deadlines. .59 Item 14: Having too great an overall volume of work .74 Item 17: Having conflicting demands on your time .72 Item 20: Disruption of your home life as a result of taking

paperwork home .77

Item 23: Having a conflict of responsibilities

.60

Factor 2: Feeling poorly managed and resourced Item 3: Feeling you have insufficient input into the

management of your unit / institution. .74

Item 5: Having inadequate facilities (e.g. equipment / space) to do your job properly.

.68

Item 16: Encountering difficulties in relationships with managers.

.58

Item 18: Having inadequate staff to do your job properly. .52 Item 21: Feeling your accumulated skills and expertise

are not being put to their best use. .57

Item 24: Uncertainty over the future funding of your unit / institution.

.54

Factor 3: Dealing with patients’ suffering Item 1: Being involved with the physical suffering of

patients. .86

Item 12: Being involved with the emotional distress of patients.

.83

Factor 4: Having Managerial Responsibility Item 8: Having to take on more managerial

responsibilities. .58

Item 25: Being responsible for the welfare of other staff. .67

27

Table 6: 1994 Loadings of job satisfaction items on the satisfaction factors Questionnaire Items Factor

1 Factor 2

Factor 3

Factor 4

Factor 1: Feeling well managed and resourced Item 5: Feeling you have the staff necessary to do a

good job. .66

Item 11: Feeling you have adequate financial resources to do a good job.

.79

Item 13: Feeling you have a high level of job security. .51 Item 15: Feeling you have adequate facilities to do a good job.

.86

Item 16: Feeling your clinical experience is used to the full in the job you do.

.57

Factor 2: Having good relationships with patients, relatives and staff

Item 4: Having good relationships with patients. .71 Item 9: Having a good relationships with other staff

members .52

Item 14: Deriving intellectual stimulation from teaching. .51 Item 17: Feeling you deal well relatives.

.75

Factor 3: Deriving intellectual stimulation Item 6: Deriving intellectual stimulation from research .84 Item 8: Having opportunities fro personal learning .57 Item 12: Being involved in activities which contribute to the development of the profession

.61

Item 14: Deriving intellectual stimulation from teaching

.54

Factor 4: Having professional status and esteem Item 1: Having a high level of responsibility .71 Item 2: Being perceived to do the job well by your

colleagues .71

Item 3: Being able to bring about positive change in your unit / institution

.58