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

OBJECTIVES: To explore and discuss the changes in the levels of work stress for Norwegian doctors in different job positions (hospital doctors, general practitioners (GPs), private practice specialists, doctors in academia) from 2010 to 2019. DESIGN: Repeated questionnaire surveys in 2010, 2016 and 2019, where samples were partly overlapping. SETTING: Norway. PARTICIPANTS: A representative sample of 1500-2200 doctors in different job positions. Response rates were 66.7% (1014/1520) in 2010, 73.1% (1604/2195) in 2016 and 72.5% (1511/2084) in 2019. MAIN OUTCOME MEASURE: Validated 9-item short form of the 'Effort-Reward Imbalance' questionnaire. A risky level of work stress was defined as an effort/reward ratio above 1.0. ANALYSES: Linear mixed models with estimated marginal means of job positions controlled for gender and age. Proportions with 95% CIs. RESULTS: From 2010 to 2016 and further to 2019, GPs reported a significant increase in levels on the effort scale (ES: 2.96, 3.25, 3.51) and significant decrease in levels on the reward scale (RS: 4.27, 4.05, 3.67). No significant changes were reported by hospital doctors (ES: 3.13, 3.10, 3.14; RS: 4.09, 3.98, 4.04), private practice specialists (ES: 2.58, 2.61, 2.59; RS: 4.32, 4.32, 4.30) and doctors in academia (ES: 2.63, 2.51, 2.52; RS: 4.09, 4.11, 4.14). The proportion of doctors with risky levels of work stress increased significantly for GPs (10.3%, 27.7%, 40.1%), but did not significantly change for hospital doctors (23.0%, 27.3%, 26.9%), private practice specialists (8.2%, 12.7%, 9.4%) and doctors in academia (11.9%, 19.0%, 16.4%). CONCLUSION: During a 9-year period, the proportion of risky levels of work stress increased significantly for GPs but did not significantly change for other job positions. This may be partly due to changes in expectations of younger GPs and several healthcare reforms and regulations.

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

OBJECTIVE: To assess job satisfaction for different categories of Norwegian doctors from 2010 to 2016-2017. DESIGN: Cross-sectional surveys in 2010, 2012, 2014 and 2016-2017 of partly overlapping samples. SETTING: Norway from 2010 to 2016-2017. PARTICIPANTS: Doctors working in different job positions (hospital doctors, general practitioners (GPs), private practice specialists, doctors in academia). Response rates were 67% (1014/1520) in 2010, 71% (1279/1792) in 2012, 75% (1158/1545) in 2014 and 73% (1604/2195) in 2016-2017. The same 548 doctors responded at all four points in time. MAIN OUTCOME MEASURE: Job Satisfaction Scale (JSS), a 10-item widely used instrument, with scores ranging from 1 (low satisfaction) to 7 (high satisfaction) for each item, and an unweighted mean total sum score. ANALYSIS: General Linear Modelling, controlling for gender and age, and paired t-tests. RESULTS: For all doctors, the mean scores of JSS decreased significantly from 5.52 (95% CI 5.42 to 5.61) in 2010 to 5.30 (5.22 to 5.38) in 2016-2017. The decrease was significant for GPs (5.54, 5.43 to 5.65 vs 5.17, 5.07 to 5.28) and hospital doctors (5.14, 5.07 to 5.21 vs 5.00, 4.94 to 5.06). Private practice specialists were most satisfied, followed by GPs and hospital doctors. The difference between the GPs and the private practice specialists increased over time. CONCLUSIONS: From 2010 to 2016-2017 job satisfaction for Norwegian doctors decreased, but it was still at a relatively high level. Several healthcare reforms and regulations over the last decade and changes in the professional culture may explain some of the reduced satisfaction.

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

OBJECTIVES: To examine 12-month prevalence of perceived bullying at work for doctors in different job categories and medical disciplines in 1993, 2004 and 2014-2015, and personality traits, work-related and health-related factors associated with perceived workplace bullying. DESIGN: Cross-sectional questionnaire surveys in 1993, 2004 and 2014-2015 where the 2004 and the 2012-2015 samples are partly overlapping. SETTING: Norway. PARTICIPANTS: Response rates were 72.8% (2628/3608) in 1993, 67% (1004/1499) in 2004 and 78.2% (1261/1612) in 2014-2015. 485 doctors responded both in 2004 and 2014-2015. OUTCOME MEASURE: Perceived bullying at work from colleagues or superiors at least a few times a month during the last year. RESULTS: Between the samples from 1993, 2004 and 2014-2015, there were no significant differences in the prevalence of perceived bullying at work. More senior hospital doctors and surgeons reported being bullied. Doctors with higher scores on the personality trait neuroticism were more likely to perceive bullying, as were female doctors, doctors with poor job satisfaction and poor self-rated health. CONCLUSIONS: The fraction of doctors who experienced bullying at work was stable over a 20-year period. Psychological, psychosocial and cultural factors are predictors of perceived bullying.

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

OBJECTIVES: The aim of this study was to investigate whether reported prevalence of experienced threats, real acts of violence and debilitating fear of violence among Norwegian doctors have increased over the last two decades. DESIGN: Repeated cross-sectional survey. SETTING: All healthcare levels and medical specialties in Norway. PARTICIPANTS: Representative samples of Norwegian doctors in 1993 (n=2628) and 2014 (n=1158). MAIN OUTCOME MEASURES: Relative risk (RR) of self-reported prevalence of work-time experiences of threats and real acts of violence, and of being physically or psychologically unfit during the last 12 months due to fear of violence, in 2014 compared with 1993, adjusted by age, gender and medical specialty. RESULTS: There were no differences in self-reported threats (adjusted RR=1.01, 95% CI 0.95 to 1.08) or real acts (adjusted RR=0.90, 95% CI 0.80 to 1.03) of violence when comparing 2014 with 1993. The proportion of doctors who had felt unfit due to fear of violence decreased from 1993 to 2014 (adjusted RR=0.53, 95% CI 0.39 to 0.73). Although still above average, the proportion of doctors in psychiatry who reported real acts of violence decreased substantially from 1993 to 2014 (adjusted RR=0.75, 95% CI 0.60 to 0.95). CONCLUSIONS: A substantial proportion of doctors experience threats and real acts of violence during their work-time career, but there was no evidence that workplace violence has increased over the last two decades. Still, the issue needs to be addressed as part of the doctors' education and within work settings.

Is imperfection becoming easier to live with for doctors?

OBJECTIVE: Being involved in serious patient injury is devastating for most doctors. During the last two decades, several efforts have been launched to improve Norwegian doctors' coping with adverse events and complaints. METHODS: The method involved survey to a representative sample of 1792 Norwegian doctors in 2012. The questions on adverse events and its effects were previously asked in 2000. RESULTS: Response rate was 71%. More doctors reported to have been involved in episodes with serious patient harm in 2012 (35%) than in 2000 (28%), and more of the episodes were reported as required by law. Doctors below age 50 report better support from colleagues, more collegial retrospective discussion on the event and less patient/family blame. In all, 27% of the doctors had been reported to the Norwegian Board of Health Supervision; 79% of these complaints were rejected; 73% of the doctors who had received a reaction from the health authorities found the reaction reasonable, but almost one out of five practiced more testing and referrals after a complaint and 25% claimed that the complaint had made them into a more fearful doctor. CONCLUSION: Our results indicate that adverse events are being met more openly in 2012 than in 2000, and that coping with imperfection and patient complaints is less devastating for new generations of doctors.

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

RATIONALE: Peer support can entail collegial responsibility for counselling and support as well as reactions to academic or ethical failure. These considerations can be complementary, but also conflicting. OBJECTIVE: This article focuses on how the peer support programme in Norway addresses these considerations. METHODS: Focus group interviews held with Norwegian peer counsellors from August 2011 to June 2012 were analysed by a stepwise deductive-inductive method. RESULTS: Based on organisational theory, two "ideal types" of counsellors were identified from the data, and these were then used to reanalyse the text. We found that the organisational framework is associated with the peer counsellors' role conception and thereby the relationship between the counsellor and the help-seeking doctor. The relationship between informal frameworks like collegiality, confidence and discretion, and more formalized incentive-driven frameworks, appear to influence the accessibility to peer support, the mandate to provide relevant help and the understanding of what peer support represents. CONCLUSION: The study showed the need for a continuous awareness of a balance between the informal and the more formalized elements in the framework for peer support. This is of importance for how the service can contribute to better health among doctors and to secure quality and safety in the treatment of patients. The analysis can also be used to demonstrate the consequences of how the peer support program is designed - such as the degree of formalisation and the balance between "hard" and "soft" ways to regulate the interaction between peer counsellors and doctors - for the ability to achieve the stated objectives of the service.

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

BACKGROUND: The aim of establishing the medical school in Tromsø in 1973 was to improve access to doctors and standards of health care for the previously underprivileged rural population of Northern Norway. In this study we examine how the aim of supplying doctors to the north has been achieved. MATERIAL AND METHODS: By utilising a cross-sectional design we have analysed 34 classes of Tromsø medical graduates (1979-2012) with regard to occupations in 2013 by the year of graduation and by successive pools of cohorts. RESULTS: In 2013 altogether 822 of 1611 doctors (51%) were working in Northern Norway. The proportions working in the north for old, intermediate and young cohorts were 37%, 48% and 60%, respectively. Doctors graduating during recent years tended to start their careers in the north to a higher degree than doctors graduating in previous periods. Among doctors from the older classes a relatively large minority have their end-careers in Northern Norway, with a noticeable inclination for long term work in primary care. CONCLUSION: Our results support that the first rural oriented medical education model in Europe established in Tromsø 40 years ago is sustainable, achieving its aims.

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

OBJECTIVES: To examine the weekly working hours of Norwegian hospital doctors from 1994 to 2012 with special emphasis on the quality of postgraduate training and work-home balance, and in relation to the requirements of the European Working Time Directive (EWTD). DESIGN: Panel study based on postal questionnaires. SETTING: Norway. PARTICIPANTS: Unbalanced cohort of 1300-1600 doctors in 1994, 1995, 1996, 1997, 2000, 2002, 2004, 2006, 2008, 2010 and 2012. OUTCOME MEASURES: Self-reported total weekly working hours and whether 45 weekly working hours are too short, sufficient, or too long to meet the quality requirements of obligatory postgraduate training for junior doctors. RESULTS: From 1994 to 2012, the number of weekly working hours was stable for senior (46-47 h) and junior (45-46 h) hospital doctors. In 2012, significantly more senior (27-35%) than junior (11-20%) doctors reported suboptimal work-home balance, defined as working more than 48 h a week. The majority perceived the present situation with an average of 45 h per week for juniors as sufficient for obligatory postgraduate specialist training, but doctors of higher age (OR 1.04, 95% CI 1.01 to 1.08), senior doctors (1.07, 1.04 to 1.11) and doctors working in surgical specialties (OR 1 vs laboratory medicine 0.03, 0.01 to 0.25, internal medicine 0.31, 0.17 to 0.58, psychiatry 0.12, 0.04 to 0.36, paediatrics 0.36, 0.12 to 1.07, anaesthesiology 0.08, 0.02 to 0.39, gynaecology 0.07, 0.01 to 0.56 and others 0.39, 0.04 to 3.56) were more likely to want the work-week to be longer. CONCLUSIONS: The weekly working hours of Norwegian hospital doctors were always below the EWTD requirements. A significant growth of hospital doctor density over the past two decades, national regulations and cultural values might be important factors. Specialty differences in perception of sufficient training time may call for more flexibility in working time regulations.

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

BACKGROUND: Doctors have a low prevalence of sickness absence. Employment status is a determinant in the multifactorial background of sickness absence. The effect of doctors' employment status on sickness absence is unexplored. The study compares the number of sickness absence days during the last 12 months and the impact of employment status, psychosocial work stress, self-rated health and demographics on sickness absence between self-employed practitioners and employed hospital doctors in Norway. METHODS: The study population consisted of a representative sample of 521 employed interns and consultants and 313 self-employed GPs and private practice specialists in Norway, who received postal questionnaires in 2010. The questionnaires contained items on sickness absence days during the last 12 months, employment status, demographics, self-rated health, professional autonomy and psychosocial work stress. RESULTS: 84% (95% CI 80 to 88%) of self-employed and 60% (95% CI 55 to 64%) of employed doctors reported no absence at all last year. In three multivariate logistic regression models with sickness absence as response variable, employment category was a highly significant predictor for absence vs. no absence, 1 to 3 days of absence vs. no absence and 4 to 99 days of absence vs. no absence), while in a model with 100 or more days of absence vs. no absence, there was no difference between employment categories, suggesting that serious chronic disease or injury is less dependent on employment category. Average or poor self-rated health and low professional autonomy, were also significant predictors of sickness absence, while psychosocial work stress, age and gender were not. CONCLUSION: Self-employed GPs and private practice specialist reported lower sickness absence than employed hospital doctors. Differences in sickness compensation, and organisational and individual factors may to a certain extent explain this finding.

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

BACKGROUND: Thinking about suicide is an indicator of suicide risk. Suicide rates are higher among doctors than in the population. The main aims of this study are to describe the changes in the lifetime prevalence of suicidal feelings from 2000 to 2010 and the possible predictors of serious suicidal thoughts in 2010 among Norwegian doctors. Differences in lifetime prevalence of suicidal feelings between Norwegian doctors in 2010 and German doctors in 2006 will be also described. METHODS: Longitudinal and cross-sectional study based on questionnaire data from 2000 and 2010, including approximately 1,600 Norwegian doctors. In Germany, cross-sectional study based on questionnaire data from 2006 among a sample of 3,295 doctors. The main outcome measures were the lifetime prevalence of suicidal feelings (felt life was not worth living, wished own death, had thoughts of taking own life). RESULTS: The prevalences in 2000 and 2010 of ever had feelings of life not worth living were 48 (44 to 52) % and 45 (41 to 49) %, of ever wished own death 27 (23 to 30) % and 23 (20 to 26) %, and of ever had thoughts of taking own life 29 (16 to 33) % and 24 (21 to 27) %. Paired t-tests among those who responded both in 2000 and 2010 show significant reductions for felt life not worth living (t = -3.4; p = 0.001), wished own death (t = -3.1; p = 0.002) and had thoughts of taking own life (t = -3.5; p < 0.0001). In 2010, significant predictors of serious suicidal thoughts in a multivariate model were low subjective well-being (OR 0.68; 95% CI 0.52-0.90), poor or average self-rated health (2.36; 1.25-4.45) and high psychosocial work stress (1.92; 1.06-3.46), controlled for age, gender, speciality and job satisfaction. Norwegian doctors in 2010 compared with their German counterparts in 2006 reported quite similar prevalences of suicidal feelings. CONCLUSIONS: Suicidal feelings among Norwegian doctors decreased from 2000 to 2010. Individual and work-related factors may to certain explain these findings. Compared with other professionals in Norway and doctors in Germany, Norwegian doctors showed no higher risk of suicidal thoughts.

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

AIMS: To describe changes in the patterns and consequences of alcohol use among Norwegian doctors from 2000 to 2010. METHODS: Longitudinal study based on data from nation-wide postal surveys in 2000 and 2010 among a representative sample of 682 doctors in Norway. The Alcohol Use Disorder Identification Test (AUDIT) was used to measure the changes in drinking patterns (frequency of drinking, frequency of heavy drinking and quantity of drinking), symptoms of alcohol dependence and adverse consequences of drinking. A score above 8 was defined as hazardous drinking. RESULTS: From 2000 to 2010, the proportion of doctors who used alcohol twice a week or more significantly increased from 31.4 (27.9-34.9) % to 48.7 (44.9-48.7) %, and the proportion of those who drank to intoxication weekly or more decreased significantly from 6.6 (4.7-8.6) % to 2.5 (1.3-1.7) %. The proportion who scored above 8 on the AUDIT decreased from 10.7 (8.4-13.0) % in 2000 to 8.2 (6.2-10.3) % in 2010. There was a significant increase in the partial AUDIT-score for drinking patterns (t = 2.4; P = 0.016), and a significant decrease in the partial AUDIT-score for adverse consequences of drinking (t = -3.6; P < 0.001). The partial AUDIT-score for symptoms of alcohol dependence did not change significantly (t = -1.6; P = 0.112). There were gender differences in drinking patterns. Females had less frequent alcohol consumption and fewer episodes of heavy and hazardous drinking in 2000 and 2010. CONCLUSION: The drinking pattern of Norwegian doctors has changed over the past decade towards more moderate alcohol consumption and less negative alcohol-related consequences. Changes in the attitude towards alcohol consumption may to a certain extent explain these findings.

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

INTRODUCTION: Burnout and mental distress in working doctors increase the risk for both suboptimal treatment of patients and negative health consequences for the doctors. Doctors have low rates of sickness absence and are reluctant to seek help, especially for mental distress. We examined whether a spell of sickness absence after a counselling intervention could predict reduction in emotional exhaustion among doctors at work 3 years later. METHODS: A 3-year follow up after a counselling intervention for burnout at the Resource Centre Villa Sana in Norway in 2003-05 was completed by 184/227 doctors. Self-report assessments were administered at baseline, 1-, and 3-years. The effect of number of weeks of sickness absence on reduction in emotional exhaustion among doctors working 3 years after the intervention was assessed by linear regression. RESULTS: Of the 184 doctors completing assessment, 149 were working at 3-year follow up. Emotional exhaustion (scale 1-5) was significantly reduced at follow up (from 3.00±0.96 to 2.37±0.79, p<0.001). The number of weeks of sickness absence after the intervention was a significant positive predictor of this reduction (ß=0.31, p<0.001), also after including sex, age, neuroticism, reduction of work hours, and other forms for treatment in the model. CONCLUSIONS: The number of weeks of sickness absence after a counselling intervention for burnout had a positive predictive effect on reduction in emotional exhaustion among doctors at work 3 years later. Sick leave thus seems to "prevent" later burnout, which can be of importance both for their patients and for the doctors themselves.

Job stress and job satisfaction of physicians in private practice: comparison of German and Norwegian physicians.

PURPOSE: This study examined job satisfaction and job stress of German compared to Norwegian physicians in private practice. METHODS: A representative sample of physicians in private practice of Schleswig-Holstein, Germany (N = 414) and a nationwide sample of Norwegian general practitioners and private practice specialists (N = 340) were surveyed in a cross-sectional design in 2010. The questionnaire comprised the standard instruments "Job Satisfaction Scale (JSS)" and a short form of the "Effort-Reward Imbalance Questionnaire (ERI)". RESULTS: Norwegian physicians scored significantly higher (<0.01) on all items of the job satisfaction scale compared to German physicians (M 5.57, SD 0.74 vs. M 4.78, SD 1.01). The effect size was highest for the items freedom to choose method (d = 1.012), rate of pay (d = 0.941), and overall job satisfaction (d = 0.931). While there was no significant difference in the mean of the overall effort scale between German and Norwegian physicians, Norwegian physicians scored significantly higher (p < 0.01) on the reward scale. A larger proportion of German physicians (27.6%) presented with an effort/reward ratio beyond 1.0, indicating a risky level of work-related stress, compared to only 10.3% of Norwegian physicians. Working hours, effort, reward, and country differences accounted for 37.4% of the explained variance of job satisfaction. CONCLUSIONS: Job satisfaction and reward were significantly higher in Norwegian than in German physicians. An almost threefold higher proportion of German physicians exhibited a high level of work-related stress. Findings call for active prevention and health promotion among stressed practicing physicians, with a special focus on improved working conditions.

The working hours of general practitioners 2000-2008.

BACKGROUND: There is little reliable information available on the working hours of general practitioners (GPs). The purpose of our study is to describe the development of weekly working hours of Norwegian general practitioners in the period from 2000 to 2008, as well as the length of their patient lists and their perceived workload. MATERIAL AND METHODS: General practitioners in the reference panel of the Research Institute of the Norwegian Medical Association have reported their weekly working hours for 2000, 2002, 2004, 2006 and 2008, and the length of their patient lists for 2002 and 2008. We used non-overlapping 95 per cent confidence intervals for testing inter-group differences in interval variables and proportions. RESULTS: From 227 to 316 general practitioners responded to each survey round. Average weekly working hours constituted 45.1 hours (95 per cent CI: 43.6-46.5 hours) in 2000 and 46.4 hours (95 per cent CI: 45.2-47.6 hours) in 2008. The number of hours increased for women GPs, while the number of hours remained basically unchanged for men from 2000 to 2008. Average length of the patient lists in 2002 and 2008 constituted 1,325 and 1,278 for men, and 1,155 and 1,144 for women GPs respectively. The proportion of GPs who responded that they perceived their workload as unacceptable decreased significantly, from 38.1 per cent in 2000 to 25.5 per cent in 2008. INTERPRETATION: Average weekly working hours for GPs increased by approximately one hour from 2000 to 2008, and this increase is found mainly among women GPs. We believe that the reduction in the proportion reporting to have an unacceptable workload can be explained by the introduction of the list-patient system, which has given the doctors better control of their own workload.