A Three-year Cohort Study of the Relationships between Coping, Job Stress and Burnout after a Counselling Intervention for Help-seeking Physicians

Karin E Isaksson Ro; Reidar Tyssen; Asle Hoffart; Harold Sexton; Olaf G Aasland; Tore Gude


BMC Public Health. 2010;10(213) 

In This Article


Sample and Attrition Analysis

Three-year follow-up was completed by 184/227(81%), 83 men and 101 women. Data from all three assessment points (baseline, one-year, and three-year follow-up) were collected from 169/227 (74%) (see Figure 1). The included physicians were on average 46.9 years old at baseline. Several of the physicians who were training to become specialists at baseline had completed their training at follow-up (Table 1). The point prevalence and the number of weeks during the past year of full-time sick leave were significantly lower than at baseline (as also found at one-year follow-up[26]) (Table 1). The point prevalence of part-time sick leave, full- and part-time disability/rehabilitation/retirement benefits did not differ significantly from baseline (2–7/184; 1.1%–3.8%).

The decreased number of work hours/week from baseline to one-year persisted at three-year follow-up (Table 1). Eighty-nine/184 (48.4%) reported attending psychotherapy during one-year follow-up. Base-line data for the whole cohort, including a comparison with Norwegian doctors in general, have been presented previously.[33]

There were proportionally more women than men who completed the three-year follow-up (101/117, 86.3%, 95% CI 80.1–92.5 vs. 83/110, 75.5%, 95% CI 67.5–83.5, p = 0.04). Physicians not completing three-year follow-up (n = 43), compared with those completing three-year follow-up (n = 184), had significantly higher baseline levels of emotional exhaustion (3.33 SD 0.88 vs. 3.01 SD 0.94, p = 0.04), job stress (2.65 SD 0.74 vs. 2.39 SD 0.72, p = 0.03) and emotion-focused coping strategies (3.25 SD 0.63 vs. 2.90 SD 0.76, p = 0.006). There were no significant differences in age, the two other burnout dimensions, or active coping strategies.

Changes from Baseline to Three Year Follow-up

There were significant changes from baseline to three-year follow-up in levels of emotional exhaustion, job stress, emotion-focused coping, and neuroticism (see Table 1). Effect sizes were moderate for changes in emotional exhaustion, job stress and emotion-focused coping (0.68, 0.72 and 0.49 respectively) and small for neuroticism (0.34).

Figure 3 shows overall changes and changes from baseline to one year and from one to three years (repeated measures ANOVA) for these variables (for participants who answered at all three time-points). As shown in figure 3, emotional exhaustion, job stress and emotion-focused coping changed mainly from baseline to one-year and not significantly from one- to three-year follow-up. All three subscales of job stress had a pattern similar to the main dimension of job stress. Neuroticism, however, trended to a significant decline from baseline to one year and changed significantly from one to three year follow-up. There were no significant changes in levels of active coping strategies.

Figure 3.

Levels of emotional exhaustion, job stress, coping and neuroticism. Repeated measures ANOVA for time (baseline, 1 yr, 3 yr) with contrasts for baseline-1 yr and 1 yr-3 yr. a. Overall ANOVA F(1.8, 267.0) = 33.1*** n = 147. Baseline-1 yr F(1,146) = 39.3 ***. 1 yr-3 yr F(1,146) = 3.0. b. Overall ANOVA F(2,314) = 43.4*** n = 158. Baseline-1 yr F(1,157) = 66.6***. 1 yr-3 yr F(1,157) = 0.4. c. Overall ANOVA F(2,322) = 2.5 n = 162. d. Overall ANOVA F(2,320) = 24.5*** n = 161. Baseline-1 yr F(1,160) = 27.4***. 1 yr-3 yr F(1,160) = 1.9. e. Overall ANOVA F(2,322) = 10.1*** n = 162. Baseline-1 yr F(1,161) = 3.6. 1 yr-3 yr F(1,161) = 6.7**. *p < 0.05, **p < 0.01, ***p < 0.001. – degrees of freedom corrected with Greenhouse-Geisser estimates, since Mauchly's test showed a violation of the assumption of sphericity.

Panel Modelling of the Temporal Relationships between Change in Emotional Exhaustion and Changes in Job Stress, Coping and Neuroticism

Cross-lagged panel models did not fit adequately or demonstrate significant cross lagged relationships between baseline and one- or three-year follow-up among emotional exhaustion, job stress, coping or neuroticism (not shown).

Synchronous panel models demonstrated several significant relationships, indicating that improvement in one variable was impacting change in the other variable in the model. These models fit well (Comparative Fit Index [CFI] range 0.98–1.00 and a standardized root mean square residual [SRMR] of 0.007–0.043, excepting social job stress and emotional exhaustion at three years that fit satisfactorily CFI 0.93, SRMR 0.073). Change in job stress with critical ratio CR (parameter/standard error distributed as z) = 3.16, p < 0.01 and emotion-focused coping with CR = 4.04, p < 0.001 preceded a reduction in emotional exhaustion at three-year follow-up. Similar relationships were found for one-year follow-up. When examining the three dimensions of job stress we found that social job stress had a similar pattern as total job stress. Change in emotional job stress impacted change in emotional exhaustion measured at one-year follow-up but not at three-year, whereas the temporal relationships between job stress due to fear of litigation and emotional exhaustion had different directions at one- and three-year follow-up. As expected, the relationship between active coping and emotional exhaustion was negative, indicating that more active coping was associated with reduction in emotional exhaustion. This relationship was significant at three-year follow-up, but not at one-year. Reduction in emotional exhaustion was found to occur sequentially before reduction in neuroticism both at one- and three-year follow-up (Table 2).

Role of Psychotherapy

Physicians who received psychotherapy the first year after the intervention (n = 89) reported higher baseline levels of emotional exhaustion (3.17 SD 0.89 vs. 2.85 SD 0.97, p = 0.02) and neuroticism (2.91 SD 1.80 vs. 2.34 SD 1.78, p = 0.03) than the rest of the cohort (n = 95). However, there were no significant differences in coping strategies or job stress at baseline. The two groups had a similar overall change in emotion-focused coping over the three-year period. There was, however, a significant interaction between time and change in emotion-focused coping (F(2,318) = 4.54, p = 0.01). The repeated contrast indicated significant interactions both from baseline to one-year (F(1,159) = 4.96, p = 0.03) and from one- to three-year follow-up (F(1,159) = 8.90, p = 0.003). In repeated measures ANOVA for each group, the group in therapy showed some reduction in emotion-focused coping during the first year of follow-up (F(1,87) = 5.06, p = 0.03) but more change from one-year to three-year follow-up (F(1,87) = 8.94, p = 0.004). The group without therapy showed a reduction from baseline to one year (F(1,72) = 33.6, p < 0.001) but no further reduction from one to three years (F(1,72) = 0.67, ns). Levels at three-year follow-up were not significantly different between the groups. There were no interactions between therapy and time for reduction in emotional exhaustion, job stress, active coping or neuroticism.


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