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Hospital Consultants Job Stress & Satisfaction Questionnaire (HCJSSQ)

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

Contents
1. INTRODUCTION
1.1 Administration 1.2 Scoring and Interpretation of Results

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


2.1 Construction of the 1994 HCJSSQ 2.2 Development of the 2002 HCJSSQ 5 6

3. PSYCHOMETRIC PROPERTIES OF THE HCJSSQ


3.1 Factor Analyses of the HCJSSQ 3.2 Reliability of the HCJSSQ Internal consistency Test retest reliability 3.3 Validity of the HCJSSQ Content validity Construct validity Criterion validity

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8 8 8 9 9 9 9 9

4. THE CONSULTANTS JOB STRESS & JOB SATISFACTION QUESTIONNAIRE (2002)


4.1 Global Ratings of Job Stress and Job Satisfaction 4.2 Speciality Specific sources of Job Stress & Job Satisfaction

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13 13

5. SUMMARY OF DATA FROM STUDIES OF UK CONSULTANTS


5.1 Survey 1 (1994) 5.2 Survey 2 (2002)

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REFERENCES APPENDICES

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Appendix A: Loadings of the 2002 Consultants Job Stress 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 Stress and Satisfaction Questionnaire items on to the stress and satisfaction factors. 26

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 health among hospital consultants

Poor quality patient care

+
Job stress

Lack of empathy Poor communication skills Errors and mistakes

+
Burnout

Psychiatric morbidity

Job satisfaction

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

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

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.

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

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 (MDTs). 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

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


Item Number 26 27 28 29 30 31 32 33 34 35 36 Stress Item

Having performance targets which are unrealistic or unattainable (e.g. due to lack of resources). Dealing with patients or relatives having high expectations of care that cannot be met. Having to comply with increasing bureaucratic and regulatory procedures. Feeling concerned about keeping your skills up to date due to your Trust not investing in new technologies. Providing patient care within multidisciplinary teams. Feeling that you are loosing generalist skills as your job becomes more specialised. Having difficulties recruiting high calibre staff. Having insufficient formalised time for teaching, training and research. Having inadequate administration systems (e.g. IT, filing procedures for notes). Having to submit a job plan and undergo performance appraisal. Being required to provide routine NHS clinical services (e.g. outpatient clinics) outside normal working hours.

Table 2: New Core Satisfaction added to the 2002 Questionnaire


Item Number 18 19 20 21 22 Satisfaction Item

Being an expert in a specialist area. Being perceived to do the job well by patients. Having the opportunity to practice medicine privately. Providing patient care within multi-disciplinary teams. 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). Cronbachs alphas indicate acceptable internal consistency for the job stress scale in both the1994 and 2002 HCJSSQ ( = 0.86, 0.92) and for the job satisfaction scale ( = 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 Factors


Factor Number 1 2 3 4 Factor Number 1 2 3 4 Job Stress Factors No. of items per factor 6 6 2 2 Cronbachs Alpha 0.84 0.74 0.75 0.52

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

Table 4: 2002 Job Stress and Job Satisfaction Factors


Factor Number 1 2 3 4 5 6 7 Factor Number 1 2 3 4 Job Stress Factors No. of items per factor 7 7 3 3 3 2 3 Cronbachs Alpha 0.85 0.81 0.75 0.40 0.51 0.81 0.61

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 Job Satisfaction Factors 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.

4. The Consultants Job Stress & Job Satisfaction Questionnaire (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 A Quite A at all 1 2 Being involved with the physical suffering of patients Encountering difficulties in relationships with junior medical staff 3 Feeling you have insufficient input into the management of your unit or institution 4 Disruption of your home life through spending long hours at work 5 Having inadequate facilities (e.g. equipment, space) to do your job properly 6 Having to deal with distressed, angry or blaming relatives 7 Keeping up to date with current clinical and research practices 8 9 Having to take on more managerial responsibilities Encountering difficulties in relationships with consultant colleagues 10 11 Feeling under pressure to meet deadlines Being responsible for the quality of the work of other staff 12 13 Being involved with the emotional distress of patients Encountering difficulties in relationships with administrative staff, e.g. secretaries 14 15 16 17 Having too great an overall volume of work Feeling you are poorly paid for the job you do Encountering difficulties in relationships with managers Having conflicting demands on your time (e.g. patient care/management/research/College) 0 0 0 0 1 1 1 1 2 2 2 2 3 3 3 3 0 0 1 1 2 2 3 3 0 0 1 1 2 2 3 3 0 0 1 1 2 2 3 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 0 Little 1 1 A bit 2 2 Lot 3 3

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Extent contributes to stress Not at all 18 19 20 Having inadequate staff to do your job properly Dealing with the threat of being sued for malpractice Disruption of your home life as a result of taking paperwork home 21 Feeling that your accumulated skills and expertise are not being put to their best use 22 Disruption of your home life as a result of being on call 0 1 2 3 0 1 2 3 0 0 0 A Little 1 1 1 Quite A bit 2 2 2 A Lot 3 3 3

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

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Uncertainty over the future funding of your unit/institution

25 26

Being responsible for the welfare of other staff Having performance targets which are unrealistic or unattainable (e.g. due to lack of resources)

0 0

1 1

2 2

3 3

27

Dealing with patients or relatives having 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 31

Providing patient care within multi-disciplinary teams Feeling that you are losing generalist skills as your job becomes more specialised

0 0

1 1

2 2

3 3

32 33

Having difficulties recruiting high calibre staff Having insufficient formalised time for teaching, training and research

0 0

1 1

2 2

3 3

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

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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 A Quite a bit 2 2 2 A Lot 3 3 3 at all little 1 2 3 Having a high level of responsibility Being perceived to do the job well by your colleagues Being able to bring about positive change in your unit/institution 4 5 6 7 8 Having good relationships with patients Feeling you have the staff necessary to do a good job Deriving intellectual stimulation from research Having a high level of autonomy Having opportunities for personal learning (developing clinical/research/management skills) 9 Having good relationships with other staff members 0 0 0 1 1 1 2 2 2 3 3 3 0 0 0 0 0 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 0 0 0 1 1 1

10 Having variety in your job 11 Feeling you have adequate financial resources to do a good job 12 Being involved in activities that contribute to the development of your profession 13 Feeling you have a high level of job security 14 Deriving intellectual stimulation from teaching 15 Feeling you have adequate facilities to do a good job 16 Feeling your clinical experience is used to the full in the job you do 17 Feeling you deal well with relatives 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

0 0 0 0

1 1 1 1

2 2 2 2

3 3 3 3

0 0 0 0 0 0

1 1 1 1 1 1

2 2 2 2 2 2

3 3 3 3 3 3

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4.1 Global Ratings of Job Stress and Job Satisfaction


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 satisfying

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 GPs 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.

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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.

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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 %
75 70 56 56 55 49 46 46 45 43 42 38 36 35 30 29 26 25 25 24 19 15 14 14 12

Having too great an overall volume of work Having conflicting demands on your time e.g. patient care/management/research/College Disruption of your home life through spending long hours at work Feeling under pressure to meet deadlines Having inadequate staff to do your job properly Having inadequate facilities (e.g. equipment/space) to do your job properly Having to take on more managerial responsibilities Having a conflict of responsibilities (e.g. clinical vs. managerial; clinical vs. research) Feeling you have insufficient input into the management of your unit/institution Keeping up to date with current clinical and research practices Disruption of your home life as a result of taking paperwork home with you Uncertainty over the future funding of your unit/institution Being responsible for the quality of the work of other staff Having to deal with distressed, angry or blaming relatives Feeling that your accumulated skills and expertise are not bring put to their best use Encountering difficulties in relationships with managers Disruption of your home life as a result of being on-call Being involved with the emotional distress of patients Encountering difficulties in relationships with consultant colleagues Being involved with the physical suffering of patients Dealing with the threat of being sued for malpractice Feeling you are poorly paid for the job you do Being responsible for the welfare of other staff Encountering difficulties in relationships with junior medical staff Encountering difficulties in relationships with administrative staff, e.g. secretaries

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

Hospital Consultants %
94 84 84 83 80 66 60 60 59 54 51 49 46 40 40 36 27

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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
Having too great an overall volume of work Having conflicting demands on your time e.g. patient care/management/research/College Having to comply with increasing bureaucratic and regulatory procedures Having inadequate staff to do your job properly Having inadequate administrative systems e.g. IT, filling procedures for notes Having inadequate facilities (e.g. equipment/space) to do your job properly Disruption of your home life through spending long hours at work Having difficulties recruiting high calibre staff Having insufficient formalised time for teaching, training and research. Feeling under pressure to meet deadlines Feeling you have insufficient input into the management of your unit/institution Having performance targets which are unrealistic or unattainable e.g. due to lack of resources Dealing with patients or relatives having high expectations of care that cannot be met Having to deal with distressed, angry or blaming relatives Having to take on more managerial responsibilities Having a conflict of responsibilities (e.g. clinical vs. managerial; clinical vs. research) Disruption of your home life as a result of taking paperwork home with you Being responsible for the quality of the work of other staff Feeling that your accumulated skills and expertise are not bring put to their best use Disruption of your home life as a result of being on-call Feeling concerned about keeping your skills up to date due to you Trust not investing in new technologies Keeping up to date with current clinical and research practices Having to submit a job plan and undergo performance appraisal Encountering difficulties in relationships with managers Encountering difficulties in relationships with consultant colleagues Feeling you are poorly paid for the job you do Feeling that you are loosing your generalist skills as your job become more specialised Dealing with the threat of being sued for malpractice Uncertainty over the future funding of your unit/institution Being involved with the emotional distress of patients Being involved with the physical suffering of patients Being required to provide routine NHS clinical services e.g. outpatient clinics, outside normal working hours. Providing client care within multidisciplinary teams Encountering difficulties in relationships with junior medical staff Being responsible for the welfare of other staff Encountering difficulties in relationships with administrative staff, e.g. secretaries 11 New Core sources of job stress added to the 2002 questionnaire.

Hospital Consultants %
76 75 71 65 64 64 62 58 58 57 53 51 47 47 46 46 42 41 37 37 34 34 32 32 31 30 29 28 27 25 24 23 17 16 14 13

17

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
Having good relationships with patients Being perceived to do the job well by patients Having good relationships with other staff members Being perceived to do the job well by your colleagues Being an expert in a specialist area Having variety in your job Being able to complete a difficult clinical procedure successfully Having a high level of responsibility Feeling you deal well with relatives Providing patient care within multidisciplinary teams Feeling you have a high level of job security Having a high level of autonomy Feeling your clinical expertise is used to the full in the job you do Being able to bring about positive change in your unit/institution Deriving intellectual stimulation from teaching Feeling you have the staff necessary to do a good job Being involved in activities which contribute to the development of the profession Having opportunities for personal learning (developing clinical skills) Deriving intellectual stimulation from research Having the opportunity to practice medicine privately Feeling you have adequate facilities to do a good job Feeling you have adequate financial resources to do a good job 5 new sources of job satisfaction added to the 2002 questionnaire

Hospital Consultants %
94 92 92 89 84 82 79 78 74 66 63 61 59 58 54 53 50 43 40 37 36 30

Table 9: Stress factor scores for hospital consultants in 1994 and 2002 (% of responses rated as contributing quite a bit or a lot to overall job satisfaction) Stress Factor Stress Factor Score % 1994 2002
58 60 41 46* 30 30 24 24 *Significant change over time.

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

Table 10 Stress factor scores for the five groups of hospital consultants 1994 Factor % of responses in factor rated as contributing quite a bit or a lot to overall job stress
Gastroenterologists 1994 61 2002 57 Radiologists 1994 51 2002 56 Surgical Oncologists 1994 2002 63 62 Clinical Oncologists 1994 2002 55 63* Medical Oncologists 1994 2002 61 63

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

39

43

45

47

41

50*

42

46*

32

42

31 17

27* 13

28 13

24 11

33 31

31 31

29 38

33* 40

34 30

39 28

*Significant change over time within that specialty.

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Table 11: Satisfaction factor scores for hospital consultants (% of responses rated as contributing quite a bit or a lot to overall job satisfaction) Satisfaction Factor Stress Factor Score % 1994 2002
58 78* 41 75 30 47 24 48* *Significant change over time.

Good relationships with patients, relatives & staff Professional status and esteem Deriving intellectual stimulation Well managed & resourced.

Table 12 Satisfaction factor scores for the four groups of hospital consultants Factor % of responses in factor rated as contributing quite a bit or a lot to overall job stress
Gastroenterologists 1994 61 2002 79 Radiologists 1994 51 2002 69* Surgical Oncologists 1994 2002 63 82 Clinical Oncologists 1994 2002 55 80* Medical Oncologists 1994 2002 61 81

Good relationships with patients, relatives & staff Professional status and esteem Deriving intellectual stimulation Well managed & resourced.

39 31 17

73 47 48

45 28 13

74 40 47*

41 33 31

78 50* 51

42 29 38

74 44 46

32 34 30

80 58 48

*Significant change over time within specialty

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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: 208209. 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.

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Appendices
Appendix A: Loadings of the 2002 Consultants Job Stress 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: Overload disruption to home life Item 4 : Disruption of your home life through spending long hours at work Item 10: Feeling under pressure to meet deadlines Item 14: Having too great an overall volume of work Item 17: Having conflicting demands on your time (e.g. patient care/ management / research. College) Item 20: Disruption of your home life as a result of taking paperwork home Item 23: Having a conflict of responsibilities (e.g. clinical vs. managerial; clinical vs. research) Item 33: Having insufficient formalised time for teaching, training and research Factor 2: Feeling poorly managed and resourced Item 3: Feeling you have insufficient input into the management of your unit / institution Item 5: Having inadequate facilities (e.g. equipment, space) to do your job properly Item 16: Encountering difficulties in relationships with managers Item 18: Having inadequate staff to do your job properly Item 21: Feeling your accumulated skills and expertise are not being put to their best use Item 29: Feeling concerned about keeping your skills up to date due to your Trust not investing in new technologies Item 34: Having inadequate administration systems 9e.g. IT, filing procedures for notes) Factor 3: Dealing with blame and anger from patients and relatives Item 6: Having to deal with distressed, angry or blaming relatives Item 19: Dealing with the threat of being sued for malpractice Item 27: Dealing with patients or relatives having expectations of care that cannot be met

Factor Factor Factor 1 2 3


.62 .63 .70 .75 .63 .65 .56

.66 .70 .57 .59 .51 .51

.55

.72 .70 .70

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

Questionnaire Items
Factor 4: Dealing with change in clinical practice Item 7: Keeping up to date with current clinical and research practices Item: 30: Providing patient care within multi disciplinary teams. Item: 31: Feeling you are loosing generalist skills as your job become more specialised. Factor 5: Encountering difficulties in relationships with NHS staff / colleagues Item 2: Encountering difficulties in relationships with junior medical staff Item 9: Encountering difficulties in relationships with consultant colleagues Item 13: Encountering difficulties in relationships with administration staff Factor 6: Dealing with patients suffering Item 1: Being involved with the physical suffering of patients Item 12: Being involved with the emotional distress of patients Factor 7: Having Managerial Responsibilities Item 8: Having to take on more managerial responsibilities Item 24: Uncertainty over the future funding of your unit/institution Item 25: Being responsible for the welfare of other staff

Factor Factor Factor Factor 4 5 6 7


.61 .60 .64

.67 .61

.55

.85 .81

.54 .69 .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.

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

Questionnaire Items
Factor 1: Feeling well managed and resourced Item 5: Feeling you have the staff necessary to do a good job Item 11: Feeling you have adequate financial resources to do a good job Item 15: Feeling you have adequate facilities to do a good job Item 16: Feeling your clinical experience is used to the full in the job you do Factor 2: Having good relationships with patients, relatives and staff Item 4: Having good relationships with patients Item 17: Feeling you deal well with relatives Item 19: Being perceived to do the job well by patients Factor 3: Having professional status/esteem Item 1: Having a high level of responsibility Item 2: Being perceived to do the job well by your colleagues Item 3: Being able to bring about positive change in your unit / institution Item 7: Having a high level of autonomy Factor 4: Deriving intellectual satisfaction Item 6: Deriving intellectual stimulation from research Item 8: Having opportunities for personal learning Item 12: Being involved in activities which contribute to the development of the profession Item 18: Being an expert in a specialist area

Factor 1
.69 .84 .85 .56

Factor Factor 2 3

Factor 4

.78 .74 .76

.73 .68 .48 .58

.81 .54 .50 .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 MDTs. Completing a difficult clinical procedure successfully. Feeling you have a high level of job security. Having good relationships with other staff members.

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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 1 2 Being involved with the physical suffering of patients Encountering difficulties in relationships with junior medical staff 3 Feeling you have insufficient input into the management of your unit or institution 4 Disruption of your home life through spending long hours at work 5 Having inadequate facilities (e.g. equipment, space) to do your job properly 6 7 Having to deal with distressed, angry or blaming relatives Keeping up to date with current clinical and research practices 8 9 Having to take on more managerial responsibilities Encountering difficulties in relationships with consultant colleagues 10 11 12 13 Feeling under pressure to meet deadlines Being responsible for the quality of the work of other staff Being involved with the emotional distress of patients Encountering difficulties in relationships with administrative staff, e.g. secretaries 14 15 16 17 Having too great an overall volume of work Feeling you are poorly paid for the job you do Encountering difficulties in relationships with managers Having conflicting demands on your time (e.g. patient care/management/research/College) 18 19 20 Having inadequate staff to do your job properly Dealing with the threat of being sued for malpractice Disruption of your home life as a result of taking paperwork home 0 0 0 1 1 1 2 2 2 3 3 3 0 0 0 0 1 1 1 1 2 2 2 2 3 3 3 3 0 0 0 0 1 1 1 1 2 2 2 2 3 3 3 3 0 0 1 1 2 2 3 3 0 0 1 1 2 2 3 3 0 1 2 3 0 1 2 3 0 1 2 3 0 0 A Little 1 1 Quite A bit 2 2 A Lot 3 3

24

21

Feeling that your accumulated skills and expertise are not being put to their best use

Extent contributes to stress Not A Quite a A lot at all little bit 0 1 2 3

22 23

Disruption of your home life as a result of being on call Having a conflict of responsibilities (e.g. clinical vs. managerial; clinical vs. research)

0 0

1 1

2 2

3 3

24 25

Uncertainty over the future funding of your unit/institution Being responsible for the welfare of other staff

0 0

1 1

2 2

3 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


1 2 3 Having a high level of responsibility Being perceived to do the job well by your colleagues Being able to bring about positive change in your unit/institution 4 5 6 7 8 Having good relationships with patients Feeling you have the staff necessary to do a good job Deriving intellectual stimulation from research Having a high level of autonomy Having opportunities for personal learning (developing clinical/research/management skills) 9 Having good relationships with other staff members 0 0 0 1 1 1 2 2 2 3 3 3 0 0 0 0 0 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 Not at all 0 0 0 A little 1 1 1 Quite a bit 2 2 2 A Lot 3 3 3

10 Having variety in your job 11 Feeling you have adequate financial resources to do a good job 12 Being involved in activities that contribute to the development of your profession 13 Feeling you have a high level of job security 14 Deriving intellectual stimulation from teaching 15 Feeling you have adequate facilities to do a good job 16 Feeling your clinical experience is used to the full in the job you do 17 Feeling you deal well with relatives

0 0 0 0

1 1 1 1

2 2 2 2

3 3 3 3

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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: Feeling overloaded and its effect on home life
Item 4: Item 10: Item 14: Item 17: Item 20: Item 23: Disruption of your home life through spending long hours at work. Feeling under pressure to meet deadlines. Having too great an overall volume of work Having conflicting demands on your time Disruption of your home life as a result of taking paperwork home Having a conflict of responsibilities .75 .59 .74 .72 .77 .60 Factor 1 Factor 2 Factor Factor 3 4

Factor 2: Feeling poorly managed and resourced


Item 3: Item 5: Item 16: Item 18: Item 21: Item 24: Feeling you have insufficient input into the management of your unit / institution. Having inadequate facilities (e.g. equipment / space) to do your job properly. Encountering difficulties in relationships with managers. Having inadequate staff to do your job properly. Feeling your accumulated skills and expertise are not being put to their best use. Uncertainty over the future funding of your unit / institution. .74 .68 .58 .52 .57 .54

Factor 3: Dealing with patients suffering


Item 1: Being involved with the physical suffering of patients. Item 12: Being involved with the emotional distress of patients. .86 .83

Factor 4: Having Managerial Responsibility


Item 8: Having to take on more managerial responsibilities. Item 25: Being responsible for the welfare of other staff. .58 .67

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Table 6: 1994 Loadings of job satisfaction items on the satisfaction factors Questionnaire Items Factor 1: Feeling well managed and resourced
Item 5: Feeling you have the staff necessary to do a good job. Item 11: Feeling you have adequate financial resources to do a good job. Item 13: Feeling you have a high level of job security. Item 15: Feeling you have adequate facilities to do a good job. Item 16: Feeling your clinical experience is used to the full in the job you do. .66 .79 .51 .86 .57 Factor 1 Factor 2 Factor Factor 3 4

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


Item 4: Having good relationships with patients. Item 9: Having a good relationships with other staff members Item 14: Deriving intellectual stimulation from teaching. Item 17: Feeling you deal well relatives. .71 .52 .51 .75

Factor 3: Deriving intellectual stimulation


Item 6: Deriving intellectual stimulation from research Item 8: Having opportunities fro personal learning Item 12: Being involved in activities which contribute to the development of the profession Item 14: Deriving intellectual stimulation from teaching .84 .57 .61 .54

Factor 4: Having professional status and esteem


Item 1: Having a high level of responsibility Item 2: Being perceived to do the job well by your colleagues Item 3: Being able to bring about positive change in your unit / institution .71 .71 .58

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