Abstract
Healthcare workers are experiencing high stress and burnout, at rates up to 70%, hindering patient care. Studies often focus on stressors in a particular setting or within the context of the pandemic which limits understanding of a more comprehensive view of stressors experienced by healthcare workers. The purpose of this study was to assess healthcare workers’ self-reported major stressors. Between June 2018 and April 2019, U.S. healthcare workers (N = 2,310) wrote answers to an open-ended question: “What are your biggest stressors as you look back over the last few weeks?” A summative content analysis was used to analyze the data. Healthcare workers described three types of stressors: work stressors (49% of total stressors), personal life stressors (32% of total stressors), and stressors that intersect work and personal life (19% of total stressors). Future research and clinical practice should consider the multi-faceted sources of stress.
Introduction
In the United States, healthcare worker (HCW) well-being has received renewed national attention as high levels of stress and burnout have been well-documented in various patient care settings (National Academies of Sciences, Engineering, and Medicine [NASEM], 2019). HCW stress and burnout has also been exacerbated by the ongoing COVID-19 pandemic (Shechter et al., 2020). Further, stress among healthcare workers is not unique to the United States. For instance, global studies, including ones conducted in Iran (Galehdar et al., 2020), China (Liu et al., 2020), and the United Kingdom (Nyashanu et al., 2020) have demonstrated HCWs have also reported experiencing stress. Current research lacks information on the different types of stressors HCWs are facing. To address this knowledge gap, the purpose of this study was to assess self-reported stressors among HCWs. Understanding the full range of HCW stressors can inform how to develop future interventions that aim to reduce HCW stress and burnout.
Background
Stress among HCWs is pervasive, having been historically studied in advance of the COVID-19 pandemic. Stress, a concept that varies widely across the literature, can broadly be described as “what arises when something you care about is at stake” (McGonigal, 2015). Before the COVID-19 pandemic, HCW stress levels were already above 60% for physicians, advanced care providers, and nurses (Jordan et al., 2016; Linzer et al., 2016). Recent studies also demonstrate stress among HCWs during the COVID-19 pandemic. For instance, a 2022 survey of 11,964 nurses found that over 70% reported recently experiencing stress (American Nurses Foundation [ANF], 2022) and nearly 30% of 2,373 physicians reported high stress (Linzer et al., 2021). Another study with a sample of physicians, nurses, and other advanced care providers during the early COVID-19 pandemic reported 57% had acute stress (Shechter et al., 2020). Extended periods of high stress levels are a precursor to burnout (Williams et al., 2007), defined as prolonged stress that culminates in emotional exhaustion, depersonalization, and diminished professional efficacy (World Health Organization, 2022). Recent evidence has found alarming increases in burnout among nurses during the pandemic from 40.6% reporting a concerning level of emotional exhaustion in 2019 to 49.2% in 2021 to 2022 with increases also seen in physicians and other healthcare workers (Sexton, Adair, Proulx, et al., 2022). Moreover, research has shown that high levels of stress are strongly related with anxiety and depression (Linzer et al., 2021).
HCW’s stress and burnout also has a harmful influence on patients. Increases in medical errors are related to nurse stress (Melnyk et al., 2018) and physician burnout (Tawfik et al., 2019). Another key element of patient safety linked to HCW burnout are hospital-acquired infections (Cimiotti et al., 2012). Lower patient satisfaction has also been reported in the setting of higher burnout (Brooks Carthon et al., 2021). Additionally, and of great significance, research has shown that length of stay is longer and risk of patient mortality is higher in settings with high nurse burnout (Schlak et al., 2021).
These far-reaching effects of stress and burnout on HCWs and patients have garnered widespread attention from the American Nurses Foundation (2022) who is partnering with other nursing organizations for a well-being initiative for nurses and the National Academy of Medicine (NAM), who is leading an action collaborative on clinician well-being and resilience (NASEM, 2019). The 2019 NAM report, “Taking Action Against Clinician Burnout,” recommended increased need to focus on systems-level rather than an individual-level approaches to address HCW burnout (NASEM, 2019). NAM’s recommendations proposes that solutions to ongoing problems with HCW stress and burnout should match the root causes of burnout, which are often systems-level issues (e.g., workload and burdensome information technology tools; NASEM, 2019). However, in contrast, researchers recommend that individual-level interventions (e.g., those that are more personal, such as gratitude practices and increasing social connections) are also needed for the challenges HCWs are currently experiencing with stress and burnout (Rehder et al., 2021). Additionally, recent research has shown that issues with physical and mental health are a close second behind work-related stressors when it comes to factors increasing the odds of physician trainees experiencing stress and burnout (Zhou et al., 2020). Thus, work-related issues are not the only sources of stress and burnout.
Research assessing the sources of stress and burnout among HCWs is often currently focused on work environment (NASEM, 2019). Other recent research has similarly focused on this context of the COVID-19 pandemic (Linzer et al., 2021; Munn et al., 2022; Prasad et al., 2021), where generalizability outside of this extraordinary context may be limited (Munn et al., 2022). Thus, there remains a gap in research that assesses a comprehensive range of stressors among HCWs outside of a narrow context. To better understand the optimal mix of approaches, this study sought to understand the full spectrum of what HCWs report as their major stressors without limiting the assessment to a certain type of stressor, a certain level of stressor, or a certain context. Therefore, this study aimed to answer the following question: what do HCWs report as their most recent major stressors?
Methods
Design
We used a qualitative descriptive design (Sandelowski, 2010), using an inductive approach to guide the analyses (Elo & Kyngäs, 2008; Kondracki et al., 2002). This method requires staying near to the data (Sandelowski, 2010). In health science research, a qualitative descriptive design provides an avenue for rich descriptions that seeks to understand and convey people’s experience (Bradshaw et al., 2017). The epistemological underpinning for the qualitative descriptive design aligns with subjectivism, where the findings are co-created between participant responses and the researcher(s), through the participants sharing their experience and researchers analyzing, interpreting, and reporting the findings (Bradshaw et al., 2017). This qualitative descriptive study used baseline data from HCWs enrolled in the
Sample and Setting
Participants as part of the parent study sample included HCWs who were 18 or older, spoke English, and worked in either clinical or non-clinical work settings across the United States. In the present study, the same inclusion criteria were used, and the sample of those enrolled in the WISER study included U.S. healthcare workers (N = 2,310) who completed the baseline survey between June 1, 2018 to April 19, 2019 when analysis of the dataset was initiated. This timeframe allowed us to assess baseline stressors prior to the COVID-19 pandemic. Additionally, participants included in the present study answered questions about their current level of resilience and responded to the question “What are your biggest stressors as you look back over the last few weeks?” The sample was recruited through educational talks, webinars, and through the WISER team’s website (https://www.hsq.dukehealth.org/,labelledbit.ly/3WISER). Participants received text messages with tool links and surveys to complete. Participants were not compensated for their involvement in the study.
HCWs in this study represented a variety of positions in inpatient and outpatient settings who worked with adults, pediatrics, or both. Both clinical setting and clinical population included an option for HCWs to select “not applicable.” The sample included nurses, physicians, physician assistants/nurse practitioners, other healthcare workers (e.g., clinical support/nurse assistant, dietician/nutritionist, pharmacist, technologist/technician, clinical social worker, chaplain, respiratory therapist, physical therapist, speech therapist, occupational therapist, EMT-B, and paramedic) and the general category of other (environmental support, other manager, administrative support, student, and those who selected “other”).
Data Collection
Data were collected via Qualtrics, an electronic survey platform. Baseline enrollment data collected in the parent study, which used a convenience sample, were evaluated for this analysis. HCWs provided sociodemographic information, including self-reported gender, race, and ethnicity, as well as professional characteristics (e.g., HCW role, shift length, total years of experience, years in current position, work department, clinical population, and clinical setting). Participants were asked to provide an open-text response to the question: “What are your biggest stressors as you look back over the last few weeks?” Length of open-text responses ranged from 1 to 151 words. All open-text responses were included in analysis. HCWs must have provided a response to be included in this sample. The fully de-identified dataset was maintained on a secure password-protected server.
Analytic Procedures
A summative content analysis was chosen to analyze both how HCWs described their stressors and determine the frequency of these stressors (Hsieh & Shannon, 2005). We took an inductive approach that allowed our codes and categories to be identified directly from our data rather than comparing participants’ responses to existing theory or literature (Elo & Kyngäs, 2008; Kondracki et al., 2002). Data were uploaded into the data management software, NVivo 12 (QSR International Pty Ltd., 2018). Throughout analyses, NVivo was used to manage codes and keep track of frequencies of codes. Each time a code was endorsed, it counted toward the total number of references.
Following guidance from Hsieh and Shannon (2005), a summative content analysis allowed for an interpretation of both the words and the frequencies in which HCWs described their stressors. The unit of analysis was each participant’s full response (Elo & Kyngäs, 2008). Next, all responses were read by the first author to gain a comprehensive understanding of the data and reflective notes of the data were written as intermittent memos along the way (Hsieh & Shannon, 2005). The first author then developed descriptive codes to describe the data or used in-vivo codes, which are codes mirroring the participant’s language (Hsieh & Shannon, 2005; Miles et al., 2020). We conducted an iterative process of coding and memo writing to allow for real-time reflexivity of the data analysis process (Miles et al., 2020). Additionally, the full response was often coded in multiple places as HCWs typically discussed several different types of stressors that required different codes. For example, we coded the following response, “Work, to do list at home, money” using three codes: “work,” “to do list at home,” and “money.”
As we coded, we developed our codebook, including codes names, definitions, and quotation exemplars. The second author, a qualitative expert, reviewed multiple iterations of the codebook and also independently coded 15% of the data and compared codes to the first author. Discrepancies in this coding were discussed until consensus was met. The research team engaged in peer debriefing with the third author, who provided expertise on HCW stress and burnout, discussing coding procedures, codes, code definitions, and quotation exemplars periodically. The research team then reviewed the codebook for similar codes that could be grouped into categories to provide for condensed, meaningful representations of the patterns that were identified from the data (Miles et al., 2020). Finally, similar categories were grouped together into themes (Hsieh & Shannon, 2005).
Trustworthiness
Credibility, transferability, dependability, and confirmability were used to increase trustworthiness of finding (Tracy, 2010). Credibility, defined as the believability of the results was achieved through providing a thorough description of methods and context surrounding the study and a detailed description of the findings (e.g., thick description). Transferability, defined as when the reader has a sense that findings could apply to their own experience, was reached through the use of quotation exemplars from the majority of our participants to support each theme as evidence of our findings and to provide an accurate vivid account of the results to allow the reader to determine if findings could apply across settings (Tracy, 2010). Dependability reflects the enduring and consistent nature of the findings across time and settings (Beck, 2009), and was met through use of audit trails that detailed all aspects of the research process. Confirmability, defined as the degree of impartiality of the findings (Beck, 2009), was achieved through use of a research team, peer debriefing, and discussing coding discrepancies until consensus was met.
Results
HCWs (N = 2,310) responded to the open-text question: What are your biggest stressors as you look back over the last few weeks?” Descriptive statistics for this sample are presented in Table 1. Most respondents were female (82.6%) and white (87.3%). Nurses (32%) made up the largest proportion of HCW roles followed by those in the general other category (26.3%; e.g., environmental support, other manager, administrative support, student, and those who selected “other”), and physicians (21.1%). HCWs most often reported working 8-hour shifts (39.2%) followed by 12-hour shift (28.4%). Most HCWs in the sample had 21 or more years of total experience (35.2%) and 1 to 4 years in their current position (37.8%). Most HCWs practiced with an adult patient population (39.4%), worked in the inpatient setting (48.7%), and in the other department category (55.1%; neurology, physical medicine & rehabilitation, preventative medicine, psychiatry, radiology, urology, those who selected not applicable and “other”).
Sample Characteristics (N = 2,310).
Note. N = available data; n of N (%) reported.
Three main themes were identified from HCW responses, including major stressors related to: (a) work, (b) personal life, and (c) the intersection between work and personal life. The total number of times a stressor of any type (total frequency) was referenced by the participants was 4,156. Table 2 presents the different themes, subthemes, and categories of stressors along with the number of times and the percent of the total frequency each stressor theme, subtheme, and category was referenced. Figure 1 depicts the three themes and their relationship with one another.
Health Care Workers’ Descriptions of Recent, Significant Stressors
Relationship among the themes.
Theme 1: Work
Work stressors included any stressor that relates to HCWs professional lives. Of the 4,156 stressors mentioned, approximately 49% were work stressors. Four main subthemes were identified from work stressors, listed in order of frequency, including: (1) systems-level work stressors, (2) core work stressors, (3) team member work stressors, and (4) individual-level work stressors.
Work Subtheme #1: Systems-Level Stressors
Systems-level stressors encompassed inefficiencies in the work setting that may have made work more difficult, including factors largely outside of HCWs’ control and included approximately 16% of total stressors. Two main components of this sub-theme were work demands and systems-level barriers.
Work demands exerted pressure on the individual HCW or their larger work unit, which included about 11% of total stressors. Work demands included high workload, time related stressors, and staffing challenges. Workload described HCWs ever increasing to-do lists often within limited time frames, as one HCW stated: “Too many competing priorities at work and never enough time. Work continues to get piled on, but nothing has been taken away.” Time-related stressors included problems with long shifts, scheduling, impending deadlines, and unfulfilled desires for time off. HCWs commented about having “no control over my schedule” and “slim to zero chances of getting time off soon.” Others talked about the excessive amount of time spent at work, “working 80 hours in inpatient setting during a single week plus 24/7 phone calls resulting in severe sleep deprivation.” Staffing challenges referred to not having enough staff to complete the work assigned, exemplified by comments including, “continued short staffed, too many patients to have time to provide the best care.”
Systems-level barriers, with approximately 5% of stressors, included organizational or institutional requirements that caused additional stress for the HCW. These barriers included technology, administrative responsibilities, and work-related financial issues. Technology stressors focused on challenges using the electronic medical record systems, computer problems, and software updates, demonstrated by comments like “keeping up with electronic documentation.” Administrative responsibilities were described as the high volume of emails, paperwork, and meetings. Work-related financial issues included complaints about salary such as, “No salary increase this year despite doing good work” and larger budgetary issues related to work as in “maintaining monetary reimbursements in my practice.”
HCWs also described a lack of work resources, challenges with the physical environment, regulatory concerns, and broader healthcare system concerns as additional system-level barriers. Lack of work resources included inadequate personnel and resources, as one HCW stated that they were “trying to make a difference at work with minimal resources.” Problems with the physical work environment, included noise, limited space, or having to travel to new work locations as one HCW stated, “working in a new department with new people, lack of office space.” Regulatory and oversight related stressors included concerns regarding visiting accreditors such as “Joint Commission Surveys” and “accreditation prep at work.” Broader health systems concerns had general comments with limited specificity such as, “dismay over current healthcare system” and “red tape at work.” HCWs also listed work processes, workflow, and inefficiencies in general as common stressors.
Work Subtheme #2: Core Work Stressors
Core work stressors were focused on the nature of the work itself including both general and specific work issues. Approximately 14% of the stressors were core work stressors.
The general work category was reported in approximately 9% of stressors and encompassed general comments such as, “work” or “job” without further elaboration. Other unspecified comments about work responsibilities, expectations, requirements, commitments, complications, and changes with personnel were made. Human resource related issues such as retention and recruitment were also discussed, as one HCW stated, “dealing with losing my good friends/coworkers to other jobs.”
About 6% of stressors described specific issues with HCWs’ work related to patient-related challenges including patient acuity, difficult patients, conflict with patient families, patient death, and fear of making patient errors, especially when caring for critically ill patients. Other related patient issues included challenging work assignments and the inability to complete work, demonstrated by statements such as “completing my work and getting out on time.” Other specific work stressors included work projects, presentations, and evaluations. For those also working in the academic or education realm, HCWs reported stressors with research, writing (e.g., “writing deadlines”), and academic workload, as one HCW reported, “. . .academic medicine is a never-ending black hole of potential work without a clear end.”
Work Subtheme #3: Team Member Stressors
Approximately 10% of stressors included relationships with other members of the team as a stressor in this subtheme. Three main relationships with team members were found: (a) lateral, (b) upper-level (e.g., from employee to supervisor), and (c) lower-level (e.g., from supervisor to employee). Additionally, there were stressors that related to toxic work culture and communication issues.
Lateral relationships, reported in about 5% of stressors, included difficult or challenging relationships with coworkers who were at the same level as the HCW or who were not specified as supervisors or subordinates. HCWs shared problems with coworkers, such as “coworker made cruel comments” or characterization of colleagues being negative, lacking competence, being immature, or unprofessional. Upper-level work relationships reported in 2% of total stressors reflected stressors from the employee about their supervisor (or boss, manager, leadership, etc.). HCWs often reported that their leader fell short of their expectations, were intimidating or uncaring including statements like, “poor management,” “bad supervisors that are unprofessional,” or “contentious relationship with supervisor.” Lower-level work relationships reflected stressors from the perspective of the manager or leader about subordinates in about 1% of stressors and included concerns about meeting needs of staff, the number of direct reports, that staff lacked initiative or were unhappy, or difficult leadership decisions, such as firing a staff member and “delivering unwelcome news to staff members.” Toxic work culture, reported in approximately 1% of stressors, was also described as a stressor, where HCWs discussed their “negative work environment” and “toxic office environment.” Relatedly, communication issues related to the culture at work were described as either being poor, lacking, or incomplete and challenges with “workplace gossip” and “politics at work.”
Work Subtheme #4: Individual-Level Stressors
Individual-level stressors were self-focused and included internal concerns (emotions at work, low job satisfaction, unknowns at work, and time away from work), career concerns, and education- and training-related stressors. These individual-level stressors were reported in approximately 9% of stressors.
Internal concerns were reported in approximately 4% of stressors. Emotions at work often included a sense of feeling ‘less than’ at work, such as a feeling of imposter syndrome, where a HCW reported, “Feeling incompetent – I’m good at my job but I feel like I’m not as good as others think I am.” Other emotions included feeling unappreciated, frustrated, sad, or anxious as where one HCW reported, “Anxiety toward working in the ICU.” Those discussing job satisfaction suggested a deficit existed such as comments regarding lack of fulfillment or lack of motivation and enjoyment. The unknowns at work were illustrated as, “Going into work not knowing what assignment I am going to receive and how the workload is going to be.” HCWs also experienced stress related to preparing to take leave from work where a HCW shared “Bringing closure to projects before going on vacation” and returning to work, as seen in this HCW’s comment, “Catching up at work after time off.”
Career changes and concerns, reported in about 3% of the stressors, included job transitions and general career worries, such as getting a new job, job change, or job loss. General career worries encompassed comments such as “career setbacks,” and “no career growth.” An additional individual-level stressor impacting work was education and training related stressors, reported by in about 2% of total stressors, where many HCWs simply reported “school” or taking board exams. Others focused on their own training including training for Extracorporeal Membrane Oxygenation (ECMO) RN specialist or training others where one HCW stated, “Training a new nurse.”
Theme 2: Personal Life Stressors
The personal life theme encompassed stressors that are outside of work and in the HCW’s personal life (reported in 32% of total stressors). The two main subthemes associated with personal life were family-related stressors (e.g., close and extended family and children stressors) and personal life stressors (e.g., issues related to personal life that were outside of the family unit).
Personal Life Subtheme #1: Family Stressors
Family stressors included close and extended family stressors and stressors related to HCWs children. These stressors accounted for 17% of stressors.
HCWs reported family relationships, family health, family responsibilities, family time related issues, and family challenges within close and extended family stressors, which included approximately 11% of total stressors. Close and extended family relationships included marital issues such as statements where one HCW shared, “husband grumpy” or comments about the spouse’s work schedule. HCWs also reported various types of family conflict such as custody issues, arguments with family, and communication issues with one’s partner. Other family relationship stressors included the HCW’s parents such as “moving parents in with us”, in-laws as in, “worry about not wanting to visit my in-laws,” and family challenges, such as divorce. Family health included health of an immediate family member’s health, extended family member, or mention of family health in general. Family caregiving challenges were reported in instances including “caregiving for a parent with cancer” as was family death and settling an estate following death. Family responsibilities included managing family commitments and expectations to care for family. Additionally, lack of time available for family was described, such as “missing family time.”
HCWs concerns regarding their children generated comments about stressors such as childcare, children’s health or education, the role of parent, and family planning and were reported in approximately 6% of stressors. Managing activities and issues surrounding either caring for one’s own child or reports of “childcare” were a particular focus. Child health included children’s physical or mental health illness, as one HCW detailed, “I have a child with a medical illness and when it flares up, all the negative feelings (stress, overwhelmed, worry, anxiety) take over.” Children and their education also were reported stressors among HCWs, with mentions of a child’s educational progress, school selection, and college-aged children away at school such as “child anxious about graduating college.” The role of being a parent was identified as another children-related stressor and was exemplified by comments such as, “parenting worries” or “being a good parent.” Additionally, HCWs discussed stressors related to planning a family, which included the desire to have a family, trying to get pregnant, and expecting or having a baby.
Personal Life Subtheme #2: Personal Life Stressors
Personal life stressors were inclusive of stressors outside of family and contained five main components: personal health, home or housing, personal relationships, time-related stressors, and general life stressors. These personal life stressors accounted for approximately 16% of the stressors.
Personal health, reported in approximately 6% of stressors, included diet, exercise, and weight with HCWs who stated, “lack of motivation to exercise” and “annoyed with myself over poor eating and overweight.” Other health issues included physical injury, pain, and surgery as one HCW shared, “Persistent back injury causing pain.” Mental health was often specified as anxiety or depression. Other health related issues included being pregnant, trying to get pregnant, or experiencing a miscarriage. HCWs also reported low energy and fatigue including, “having no physical energy” or “too tired after work to do things” along with sicknesses of a non-serious or general nature including headaches and colds or serious illnesses such as “chemo for breast cancer.”
Home or housing stressors, reported in about 4% of stressors, included relocation, and household chores or projects. Relocation included a move, buying, selling, or any combination of moving, buying and selling as exemplified by “buying a new house, contractors, moving, and packing.” Household chores or projects included renovations, chores, and household responsibility in general such as “home duties.” Other housing stressors included living situations or mention of change in the number of people living in their home including, “adapting to oldest [child] moving back in.”
Similar to the work theme that included stressors about work relationships, about 3% of stressors included personal relationships as stressors, which were non-familial and outside of work including romantic and non-romantic relationships and the HCW’s social life. Romantic relationships included conflicts: “fights with boyfriend and breakup” while non-romantic relationships included friendships as stressors such as “helping friends deal with loss” and “sick fiend.” Social life stressors involved planning or preparing for events such as the holidays or weddings including, “I’m planning my wedding which is in 45 days. . .,” social obligation, or social anxiety.
Time issues, reported in about 0.4% of stressors, included not having enough time for themselves as one HCW reported, “. . .not having the time or energy to exercise and take care of myself.” The HCW’s general life, reported in approximately 3% of stressors, encompassed finances such as bills, debt, and specific purchases or housing related financial stressors; pet health issues, pet death, or having a new pet. Other general stressors were vacation related such as losing hotel reservations or travel delays.
Theme 3: Intersection Between Work and Personal Life Stressors
The intersection between work and personal life stressors (reported in approximately 19% of stressors) included stressors that either were not distinctly compartmentalized into their work or personal life or intersected both work and personal life. The two subthemes were general stressors that could affect work and/or personal life and dual work and personal life stressors.
Intersection Between Work and Personal Life Stressors Subtheme #1: General Stressors that Could Affect Work and/or Personal Life
General stressors were not clearly delineated between the HCWs’ professional or personal life and included finances, time, mental health, stressors outside of the HCW’s control, volume of things to do, relationships, and existential issues. These general stressors that could affect work and/or life were included in approximately 14% of stressors.
General financial concerns were reported in approximately 5% of stressors and were referenced as “money” and “finances” without clarity as to whether the issue related to personal life as in expenses or to work such as salary. General time issues, reported by about 2% of stressors, were those that did not clearly reside in the work and personal life themes such as “time management” or “not enough time.” About 1% of stressors were mental health that included worry about the future, feeling out of control, powerless, hopeless, and self-focused negative feelings and thoughts such as “feeling like a failure.” Events outside of the HCW’s control, reported in about 2% of stressors, also generated stress including travel, traffic, politics, or the news in general. About 1% of stressors included a high volume of things to do like “too much on my plate” or time constraints with the amount of work, “too much to do, not enough time.” Approximately 1% of stressors were relationships that included relating to other people in general where HCWs shared, “dealing with a few difficult people;” communication: “lack of communication;” and diminished feelings of social connection or support: “lack of support” without specifying the context of work or personal life. About 0.7% of stressors were comprised of existential issues that focused on life purpose as “confused about purpose in life,” changes: “adjusting to change,” or regarding expectations: “not living up to expectations.” Approximately 0.5% of stressors described a lack in sense of focus, organization, and prioritization.
Intersection Between Work and Personal Life Subtheme #2: Dual Work and Personal Life Stressors
Approximately 5% of the stressors were dual work and personal life stressors which encompassed stressors that related to HCWs professional and personal life at the same time including balance, concurrent personal and professional stressors, personal health and work, work-related travel, work encroaching on personal life, and time constraints related to work and personal life.
Balance was the focus of this subtheme where approximately 3% of stressors discussed work-life balance as one HCW described, “Balancing small children, marriage, work, and personal time.” Work and personal life also presented concurrent stressors as shared by approximately 0.6% of stressors, where both stressors were present or related to one another such as, “work and family obligations” and “keeping up with all the demands of home and work.” Health stressors, reported in approximately 0.4% of stressors, that related to both the HCWs’ personal and work life included sleep, “. . .trying to sleep after night shift. I didn’t sleep and had to call out” and physical pain or injuries related to work such as “knee pain from work” or the inability to prioritize self-care over work. Work-related travel primarily in approximately 0.4% of stressors included the HCW’s commute as described, “commute—4 hours a day.” Work encroached on personal life in approximately 0.4% of stressors as evidenced by, “work invading family time” and “too tired after work to do things.” Time constraints, reported in approximately 0.3% of stressors, were also discussed as being related to both work and personal life as one HCW described, “lack of time to meet work and home needs.”
Discussion
The purpose of this study was to investigate what HCWs describe as their most significant stressors. Findings that were identified from the data indicated work stressors, personal life stressors, and the intersection between work and personal life stressors were key themes. Systems-level stressors were the most predominant among work stressors. Close and extended family, children, and personal health comprised the largest portion of personal life stressors. The intersection of work and personal life primarily included stressors that could affect work and/or personal life and was predominately comprised of finances, work-life balance and time stressors. Our study adds to the literature by offering a comprehensive perspective of the multi-faceted stressors that both preceded and will likely follow the pandemic.
While the majority of stressors in the present study related to work, most work stressors discussed were about systems-level work stressors (approximately 16% of stressors). These types of stressors have been identified as the main drivers of burnout among HCWs (NASEM, 2019). Similar to our findings on staffing being a specific workload issue, research has repeatedly demonstrated that HCWs struggle with high demands and low resources to get the job done both prior to (O’Dowd et al., 2018; West et al., 2018) and within the context of the COVID-19 pandemic (Munn et al., 2022); ongoing work stressors suggesting that systems-level work issues are a key driver of stress. Similar to our work, healthcare workers report a heavy workload as a source of stress (Long et al., 2020). Different than our work and more unique to the Covid-19 pandemic, HCWs in our sample did not discuss work-related stressors related to lack of adequate personal protective equipment, and social isolation as frequently as seen in a more recent qualitative systematic review of research on HCWs during the pandemic (Koontalay et al., 2021) as these issues were likely not at the forefront pre-2019. Additionally, as seen in prior research (Gardner et al., 2019; Michel et al., 2017; Rao et al., 2017), our findings highlight the systems-level issues (inadequate staffing, technology, EMR requirements, and administrative tasks) that could detract from the HCWs primary job (i.e., patient care), though this was not explicitly stated. Our findings support the need to continue a substantial focus on addressing stress and burnout through systems-level approaches.
Similar to other studies, the present study demonstrates that stressors extend beyond the work environment to personal life, including family and children (Mullen, 2015) and the HCW’s personal health (Zhou et al., 2020). Our findings of family relationships conflicts and lack of time with family are similar to the literature, which includes the importance of investing in relationships with family (Odom et al., 2022). Family health also was identified as a common stressor which warrants further investigation as to how healthcare organizations might support HCWs with family health issues. We also found that HCWs were concerned about their children’s wellbeing and health. This speaks to the interconnectedness between a child’s suffering and that of the HCW. Similar to recent research within the context of the COVID-19 pandemic (Munn et al., 2022), childcare concerns were illuminated in this study. These findings support recent findings that suggest that research is needed to investigate how family issues, beyond those of a work-life balance perspective, impact the HCW’s work lives and performance (Munn et al., 2022).
Our sample discussed stressors related to overall health such as fatigue, sicknesses, and personal health behaviors (e.g., diet, exercise, and comments regarding body weight). Our findings are similar compared to recent research that found nurses are experiencing health challenges (Melnyk et al., 2022). Workplaces supportive of nurses personal wellness tended to have nurses who had better sleep, ate healthier, and did not experience burnout compared to nurses who felt their workplaces were not as supportive (Melnyk et al., 2022). Future research is needed to address health-related stressors and could focus on ways to improve workplace support of personal wellness.
Most comments regarding time related to the work realm such as length of time spent on work, work deadlines, and work pressures. Experiencing time-related stressors at work likely play a role in the perception of an imbalance between work and life (NASEM, 2019). Further study should be considered on how to reduce time-related burdens on HCWs. Healthcare organizations might start with interventions that address the number of hours worked each week given that longer work hours are associated with association with poorer work-life integration (Tawfik et al., 2021), depression, stress, burnout, and poorer physical health (Melnyk et al., 2022). Study should occur at various settings and across types of healthcare workers whose roles may look different (e.g., bedside nurses, physicians, administrators, and other healthcare roles).
Nearly 3% of stressors were about balance, including work-life balance. Our finding of issues related to work-life balance as a stressor is similar to other research on physicians who reported work-life balance as a reason for leaving practice (Long et al., 2020). The strain of balancing personal life and work life has implications for greater HCW burnout and poorer teamwork (Schwartz et al., 2019). While healthcare organizations can’t control what HCWs experience as stress on a personal level, they can support HCWs by promoting organizational programs that promote culture shifts for a healthier work-life balance or work-life integration, such as encouraging and celebrating time away from work. Focusing on the various aspects of work culture, including work-life balance, is particularly important as work culture is a greater contributor to burnout than the commonly reported stressor of electronic health record use (McPeek-Hinz et al., 2021). Simultaneously, systems-level processes must be in place to allow for efficiency in work processes that facilitates completion of work in a timelier fashion (NASEM, 2019) while also making the possibility of lighter schedules more feasible from the organization’s perspective. Another consideration for the intersection of work and life is the degree to which various stressors in work and personal life have a synergistic effect rather than simply as additive. Future research may consider explicitly asking HCWs about concurrent work and personal life stressors to understand the full extent of these stressors experienced by HCWs.
Relationships both inside and outside of work were an important thread throughout our findings, showing that relationships across HCWs lives, relatively distributed across work and personal life, are a source of stress. Research has demonstrated that work relationships, including teamwork, have an inverse relationship with burnout (Profit et al., 2014). Thus, finding ways to improve work relationships, and particularly teamwork can possibly improve HCWs’ burnout (Profit et al., 2014). In addition, developing and testing interventions that aim to improve HCW’s relationships outside of work is worthwhile as 69% of over 11,000 nurses reported that spending time with family and friends is an important activity to strengthen well-being (ANF, 2022) and spending time with friends is related to greater emotional thriving and emotional recovery, two components of resilience (Rink et al., 2021).
Theoretical Application
While the present study utilized an inductive, qualitative approach, allowing findings to be identified directly from the data (Elo & Kyngäs, 2008; Kondracki et al., 2002), the results have similarities with existing theory. For instance, Bronfenbrenner’s ecological theory contains multiple unique and interdependent levels inclusive of the individual level spanning to larger system levels (Bronfenbrenner, 1977; McLaren & Hawe, 2005). This study’s findings show that stressors among healthcare workers reside at the individual level, as seen in personal life stressors, and extend outward to encompass the broader environment. This broader environment with multiple interrelated factors was evident in the instances where home responsibilities coupled with work system factors such as workload and scheduling created work-life balance stressors. Further knowledge on how stressors may exist and intermingle across the different levels of Bronfenbrenner’s model could extend existing knowledge and inform interventions on how to reduce the occurrence of stressors among healthcare workers.
Additionally, the findings parallel several features of the National Academy of Medicine’s Systems Model of Clinician Burnout and Professional Well-being, including the model’s work system factors and individual mediating factors (NASEM, 2019). In the present study’s findings, HCWs similarly described the work system stressors of workload, administrative inefficiencies, and issues with technology, such as the demands of charting. HCWs also delineated individual stressors outside of these work system factors similar to the NAM model such as personal relationships. The NAM model notes that “relationships can be a source of support as well as of stress” (NASEM, 2019, p. 110). While this study found these similar features with the NAM model, the nature of the present study cannot demonstrate the interactions between the different levels of these systems (e.g., individual factors as a mediator between the work system and outcome of burnout or well-being). However, the multi-faceted stressors reported by HCWs in this study suggest additional inquiry is needed to understand the extent to which individual factors can also influence work system factors.
Strengths and Limitations
This study has numerous strengths, including exploring HCW stressors using a large sample size that includes a variety of HCWs across settings. Given the interdisciplinary teamwork nature of healthcare, assessing stress and burnout across HCWs is important to understand the full picture, rather than only looking at certain groups (e.g., nurses or physicians only). Additionally, the open-text nature of our data allowed for a broader perspective beyond work stressors, uncovering the importance of work, personal life, and the intersection between work and personal life.
However, this study is not without limitations. Limitations of the study include the sometimes-brief responses that HCWs provided in answering the question through the online survey as opposed to an interview where follow-up questions could be asked to gather more details. However, we used a summative content analysis to glean information from even the shortest responses where we could assess how frequently people used certain words. Additionally, participants could describe similar stressors within the same theme, subtheme, or category which has the potential for inflating a particular stressor type (e.g., work stressors). However, each response was only coded multiple times if the response had notable distinctions. For example, the response “Taking time off work, learning new things at work” was coded in two categories within the work theme related to time off and learning at work. Finally, the category of concurrent stressors is likely underrepresented. Many HCWs described several different work and personal life stressor types in their responses that could be related; however, the relationship was not always specified as clearly as seen in this response, “Trying to learn a new job and worrying about the impact to my home life.” Despite this limitation, the various subthemes and categories are representative of the large variety of stressors reported by HCWs.
Future Research
Future research should include all complex sources of stress and burnout, including those from both work and personal life (West et al., 2018) and the intersection between work and personal life. A continued research focus on systems-level drivers of stress, such as inadequate staffing and workforce pipeline issues (e.g., lack of nursing professors available to support an adequate number of nursing students to meet the demand), is needed. Personal life stressors also warrant future study, including how family issues, personal or family health and wellness, and relationships impact HCWs work lives and performance (Munn et al., 2022). Future research should also parse out the synergistic effects of work and personal life stressors while considering ways to improve work-life integration for HCWs.
Conclusion
Our sample of 2,310 HCWs described three main types of stressors including work (49% of stressors), personal life (32% of stressors), and stressors that intersect work and personal life (19% of stressors). This study has produced new insights on day-to-day stressors that are not neatly compartmentalized in one area of life and instead could be related to work, personal life, or the intersection of both. Future researchers should consider developing and testing interventions to address the numerous stressors that affect HCWs on a day-to-day basis. Our findings also suggest that future research is needed to address the complex sources of stress inclusive of work and personal life.
Relevance to Clinical Practice
In alignment with findings from the present study, healthcare leaders may wish to assess common stressors among their healthcare workers. Understanding the degree to which stressors stem from work, personal life, or some combination of the two can inform effective solutions. Our findings indicate that stressors are encompassed by work, personal life, and the intersection between work and personal life in order of most often reported; however, these results could look different across work settings and disciplines. Once the top stressors have been identified, healthcare organizations could test feasible interventions to align with the drivers of stress experienced by their employees. Additionally, interventions that consider the busy clinician’s work and personal life should be prioritized. A recent randomized clinical trial found statistically significant improvements that were sustained at 1 year in HCW symptoms of depression, work-life integration, happiness, emotional thriving, and emotional recovery after exposure to brief positive psychology well-being modules sent via text (Sexton, Adair, Cui, et al., 2022). Finally, nursing and other healthcare leaders may consider ways in which the culture can be shifted from a work-life balance perspective to a life-work balance. This suggests a paradigm shift, from fitting life issues such as family, personal health, and personal relationships into a busy work schedule and instead seeks to integrate work into HCWs busy personal life.
Footnotes
Declaration of Conflicting Interests
The author declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Drs Sexton and Adair reported receiving honoraria for grand rounds or other professional presentations on physician well-being for various health care organizations outside the submitted work.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The WISER study was supported by NIH/NICHD Grant number R01 HD084679-01(PI, Jochen Profit & John Bryan Sexton).
