Estrs ocupacional en personal de salud

Occupational stress in health care personnel

Marcelo Trucco B, Paulina Valenzuela A1, Daniela Trucco H2

Background: Occupational stress results from the interaction of multiple risk factors, such as the physical environment, biological function disturbances, work content and organization and diverse psychosocial components. Aim: To study the frequency of symptoms and the main sources of job stress, perceived by professional and non professional health care workers and to compare gender differences. Subjects and methods: A group of specially designed, self-administered, questionnaires adapted by the main author and independently validated, were applied. The results of two symptoms, one work satisfaction, and one job stress scales are reported. Results: One hundred sixteen women and 89 men were studied, 143 are professionals and 62 non professionals (clerical and nurse auxiliaries). Forty percent had symptoms of job stress and 82 subjects were defined as "probable cases", according to the ratings on the symptom scales. There were significant differences in the frequency of symptoms between professionals and non professionals (34.3 and 69.2% respectively). The main differences in symptoms, sources of job stress and dissatisfaction were more closely associated to the occupational level than to gender. Conclusions: A high frequency of job stress symptoms was observed in this sample of health care workers and the risk of occupational stress varies more with the occupational level than with gender. (Key Words: Health, Personnel; Occupational Health; Stress, Psychological)
Trabajo recibido el 6 de julio, 1999. Aceptado en versin corregida el 25 de octubre, 1999. Este trabajo fue financiado en parte con fondos de la Comisin de Investigacin de la ACHS. Hospital del Trabajador, Asociacin Chilena de Seguridad. Facultad de Matemticas, Pontificia Universidad Catlica de Chile. Universidad de Maryland, EEUU. 1 Estadstico 2 Sociloga De acuerdo con el modelo conceptual que hemos utilizado a lo largo de varios aos investigando sobre estrs ocupacional, definiremos estrs como "el conjunto de

procesos y respuestas fisiolgicas, emocionales y conductuales ante situaciones que son percibidas e interpretadas por el individuo como amenaza o peligro, ya sea para su integridad biolgica o psicolgica"1. La amenaza puede ser objetiva o subjetiva; aguda o crnica. Lo crucial es el componente cognoscitivo de la apreciacin que el sujeto hace de la situacin2. Se produce estrs cuando existe una discrepancia importante entre las capacidades del individuo y las demandas o exigencias de su medio ambiente. El estrs de origen ocupacional es producto de la interaccin entre mltiples factores de riesgo, incluyendo aquellos que provienen del ambiente fsico, trastornos de las funciones biolgicas, el contenido y organizacin del trabajo, y diversos componentes psicosociales, tanto laborales como extra laborales 1. Entre stos se ha descrito: el contexto macrosocial y el estrato socioeconmico; el tipo de trabajo; el apoyo social, dentro y fuera del trabajo; los sentimientos de autoestima y de control; tipo de personalidad; la edad y el gnero3-9. Uno de los grupos ocupacionales en los que se ha descrito riesgos significativos de estrs ocupacional es el personal de instituciones de salud. Este, cuando evoluciona crnicamente, puede provocar el cuadro de agotamiento emocional, distanciamiento afectivo, trato despersonalizado y a un sentimiento general de ausencia de logros personales que se ha denominado "burnout", cuadro que, junto con significar un menoscabo del bienestar de la persona, se traduce en prdida de productividad para la organizacin10. Tradicionalmente una elevada proporcin del personal de salud ha sido femenino. La participacin femenina en la fuerza laboral ha ido creciendo rpidamente en la mayora de los pases, pero, al mismo tiempo, han ocurrido relativamente pocos cambios en las responsabilidades de la mujer en el hogar y la familia11. Al parecer, las condiciones laborales afectaran indirectamente la salud mental de hombres y mujeres. Existen, sin embargo, diferencias entre los factores que afectan a uno y a otro sexo. Estas diferencias guardan relacin con los roles y autoconceptos de hombres y mujeres. De ah la conveniencia de estudiar separadamente las causas y los efectos del estrs ocupacional en mujeres y hombres12. Otras variables importantes en la investigacin del estrs que afecta al personal de salud son: la profesin y el status profesional; la interaccin entre diferentes grupos; la edad y la etapa en la carrera profesional. Existe evidencia que los factores que afectan la salud y la salud mental y cmo se manifiestan dichos problemas puede variar en mdicos, enfermeras, auxiliares y personal administrativo13-19. Medicin del estrs ocupacional. Cmo se mide el estrs, tanto en individuos como en grupos, es un tema importante desde el punto de vista metodolgico y como fundamento para el diseo de programas de salud y prevencin en las organizaciones7,20. El autor principal y sus cols han desarrollado un conjunto de instrumentos destinados a medir diversos componentes del estrs de origen ocupacional. El modelo conceptual subyacente y la metodologa empleada han sido motivo de publicaciones previas21,22. Ese modelo concibe el estrs como un proceso y supone que se detecta por medio de sntomas inespecficos, incluyendo sntomas de la esfera emocional y de tipo somtico, que no configura un cuadro mrbido definido. Su presencia puede afectar la calidad de vida y el desempeo de las personas y seala el riesgo de enfermar.

El instrumento consiste en una batera de cuestionarios, diseados para ser autoadministrados. Se ha demostrado que son econmicos, fciles de aplicar, aceptables para los sujetos de estudio y que discriminan entre diferentes grupos ocupacionales22. Dicha batera ha sido independientemente validada en nuestro medio23. OBJETIVO Este trabajo forma parte de una lnea de investigacin acerca de la cual se ha informado previamente22. Su objetivo es investigar la frecuencia de sntomas y principales fuentes de estrs ocupacional percibidas por dos grupos de trabajadores de la salud, uno de profesionales universitarios y el otro, no profesional, comparando hombres y mujeres en ambos. MTODO La muestra incluye 205 sujetos que se constituy agregando varios grupos encuestados en diferentes perodos, habindose descrito su origen en una publicacin previa22. Parte de esa muestra se ha ocupado en este trabajo, en el cual se han incluido los siguientes grupos: A) Profesionales de la salud. Incluye mdicos (aproximadamente la mitad), enfermeras, y otros profesionales (n=143). D) No profesionales. Incluye personal administrativo, de secretara y auxiliares de enfermera (n=62). Los cuestionarios utilizados en este trabajo miden: A y B) Sntomas de estrs (12 y 22 preguntas, respectivamente); C) Fuentes de satisfaccin/insatisfaccin laboral (13 preguntas); D) Fuentes de tensiones y problemas en el trabajo (16 preguntas). Las escalas de sntomas empleadas son traducciones del General Health Questionnaire de Goldberg en su versin de 12 preguntas, GHQ-1224,25; y el Cuestionario de Sntomas Psicosomticos de Stress de Cooper, CSPS26. Los dems cuestionarios han sido adaptados de una batera desarrollada por B Israel y cols, en la Universidad de Michigan en Ann Arbor, con su autorizacin27,28. Otras caractersticas de estas escalas han sido informadas en el trabajo previamente publicado22. Todos los cuestionarios se responden en escalas de 4 puntos y estn referidos a un perodo definido ("ltimo mes"). Se dicotomizaron las respuestas, asignndose el puntaje mayor a aquellas dos respuestas que indican, en general, lo ms "negativo". De este modo, los mayores puntajes indican mayores problemas, malestar, tensin o deficiencias. Anlisis. Se describe la muestra segn las variables de origen: sexo, edad y grupo ocupacional. Luego se describen los resultados globales de los diferentes cuestionarios aplicados para la muestra y segn sexo, edad y grupo ocupacional. Se presentan las diferencias significativas en los resultados globales de los cuestionarios segn las variables de origen y con respecto a las principales asociaciones detectadas.

Se construyeron grupos secundarios de "probables casos" y "normales" sobre la base de los puntajes obtenidos en los cuestionarios de sntomas. Se utiliza como punto de corte los puntajes determinados en un estudio anterior que inclua parte de la muestra actual22. Estos se determinaron convencionalmente, para los efectos del estudio, como aquellos puntajes correspondientes a una desviacin estndar sobre el promedio y mayores. De este modo, se definieron como "probables casos" (sintomticos) aquellos sujetos que obtuvieron 6 o ms puntos en el GHQ-12 (rango posible: 0 a 12), y/o 19 o ms puntos en el CSPS (rango posible: 0 a 44). La metodologa empleada permite sospechar, pero no diagnosticar, posibles casos de morbilidad mental. Es bsicamente, una tcnica de tamizado, utilizada corrientemente en estudios epidemiolgicos 24. RESULTADOS La muestra incluye 116 mujeres y 89 hombres (Tabla 1) con un promedio de edad de 36,5 aos (desviacin estndar = 7,7). No hay diferencias significativas en la composicin por edad entre los cuatro subgrupos.

Tabla 1. Distribucin segn sexo y grupo ocupacional

Grupo ocupacional

Mujeres

Hombres

Total

A D

87 29

56 33

143 62

Totales

116

89

205

En la Tabla 2 se presenta el nmero de sujetos clasificados como "probables casos" y "normales", de acuerdo con el criterio descrito arriba. La diferencia entre la proporcin de mujeres y hombres clasificados como "casos" no es significativa (mujeres = 42,3%; hombres = 46,3%). Sin embargo, al comparar separadamente los grupos A (profesionales universitarios) y D (no profesionales), se comprueba que la diferencia en la proporcin de casos es altamente significativa (p <0,001), ya que 34,3% del grupo profesional (A) y 69,2% del grupo no profesional (D) es clasificado como "probables casos". La diferencia es mayor entre las mujeres (A= 31,3%; D = 79,2%; p <0,001), que entre los hombres (A = 38,8%; D = 60,7%; no significativa).

Tabla 2. Nmero de "casos" y "normales"

segn grupo ocupacional y sexo

Grupo Normales A Casos

Mujeres 55

Hombres 33

25

21

Normales D Casos

11

19

17

Los sujetos clasificados como probables "casos" y "normales" difieren significativamente en las cuatro escalas: (A) GHQ-12; (B) CSPS; (C) Fuentes de insatisfaccin laboral; y (D) Fuentes de tensin por el trabajo. En todas las escalas los "casos" registran puntajes significativamente mayores que los "normales" (p <0,001). Por otra parte, encontramos correlaciones positivas significativas (p <0,001) entre los puntajes globales de las escalas siguientes: GHQ-12/CSPS: r=0,59; GHQ-12/Fuentes de tensin en el trabajo: r=0,33; CSPS/Fuentes de tensin en el trabajo: r=0,37. Los puntajes de las escalas de sntomas son independientes del puntaje global de insatisfaccin, existiendo slo una dbil correlacin entre la escala CSPS y la escala C de insatisfaccin (r=0,17). Las escalas de insatisfaccin (C) y de fuentes de tensin laboral (D) aparecen como dimensiones independientes, cada una con una distribucin de puntajes aproximadamente normal. Sntomas, insatisfaccin y tensin en el trabajo. En las Figuras 1, 2 y 3 se presentan los sntomas ms frecuentemente referidos por los 205 sujetos del estudio, las mayores causas de insatisfaccin laboral y los principales factores de tensin y molestia en el trabajo, respectivamente.

FIGURA 1. Sntomas ms frecuentes en porcentajes (n = 205)

FIGURA 2. Causas de mayor insatisfaccin en porcentajes (n = 205).

FIGURA 3. Causas de tensin en el trabajo en porcentajes (n = 205).

Entre los sntomas informados por ms de 25% de la muestra predominan los de ansiedad y depresivos. Las mayores causas de insatisfaccin, que afectan a ms de la mitad de los sujetos, son: sentir su trabajo poco reconocido y valorado y la escasa posibilidad de controlarlo (baja autonoma). Entre los factores de tensin, destaca el sentimiento de tener que responder a muchas personas, el apremio de tiempo y las condiciones de trabajo fsico ambientales inadecuadas. A continuacin se describen las principales diferencias segn grupo ocupacional y sexo. 1. Diferencias en la frecuencia de sntomas en los grupos ocupacionales A y D. Slo se encontraron diferencias significativas en la escala de sntomas "psicosomticos" (CSPS) entre ambos grupos ocupacionales (Tabla 3). 2. Diferencias en la frecuencia de sntomas en mujeres y hombres. En el grupo A: se encontraron diferencias significativas en 6 de 24 sntomas por los cuales se indag (Tabla 4). En el Grupo D: la nica diferencia significativa se encontr en el sntoma: (B11) "Dolor de cuello, hombros, brazos": Mujeres = 53,3% >Hombres = 24,2%. 3. Diferencias en las fuentes de insatisfaccin laboral en los grupos ocupacionales A y D. Se encontraron importantes diferencias en la frecuencia de fuentes de insatisfaccin entre los grupos profesionales y no profesionales (Tabla 5). 4. Diferencias en las fuentes de insatisfaccin laboral en mujeres y hombres. En el grupo profesional (A): de los 13 temes en la escala de satisfaccin/insatisfaccin, slo se encontr una diferencia significativa: (C3) "Trabajo poco variado": Mujeres (26,1%) <Hombres (42,9%). En el grupo no profesional (D): p = ns segn sexo. 5. Diferencias en las fuentes de tensin laboral entre grupos ocupacionales. Difieren significativamente los profesionales (A) y no profesionales (D). En los tres temes, son los profesionales quienes perciben significativamente ms tensin (Tabla 6). 6. Diferencias en las fuentes de tensin

laboral en mujeres y hombres. Las diferencias entre mujeres y hombres son escasas: slo dos temes en el grupo profesional y uno en el grupo no profesional (Tabla 7).

Tabla 3. Diferencias significativas en la frecuencia de sntomas en los grupos ocupacionales A y D.

Sntomas psicosomticos de estrs (CSPS)

A (%)

D (%)

(B2) Dificultad para permanecer dormido (B5) Aumento del apetito (B6) Cansancio (B7) Molestias estomacales o digestivas (B11) Dolor de cuello, hombro, brazos (B12) Dolor de espalda o cintura (B14) Palpitaciones o taquicardia (B18) Temblor de manos o prpados (B19) Mentalmente agotado (B20) Dolor u opresin en el pecho (B22) Desea que se le deje solo

18,1 12,5 22,2 7,6 19,4 16,7 9,0 5,6 7,6 0,7 17,4

36,5 27,0 41,3 41,3 38,1 39,7 27,0 19,0 19,0 9,5 34,9

Tabla 4. Diferencias significativas en la frecuencia de sntomas entre mujeres y hombres del grupo A

Mujeres Hombres % %

(A1) Ha dejado de dormir por preocupaciones (A2) Se ha sentido constantemente tenso (B8) Le cuesta levantarse en la maana (B12) Dolor de espalda o cintura (B13) Muy sensible o con deseos de llorar (B22) Desea que se le deje solo

28,4

51,8

45,5 28,4 21,6 12,5 9,1

62,5 44,6 8,9 3,6 30,4

Tabla 5. Diferencias significativas en la frecuencia de fuentes de insatisfaccin en los grupos ocupacionales A y D

Fuentes de insatisfaccin laboral (C2) Mi trabajo permite tomar muchas decisiones Mi trabajo es variado Mi trabajo requiere que aprenda cosas nuevas Mi trabajo requiere que sea creativo Puedo decidir velocidad de mi trabajo y cuando descansar

A (%) 43,8

D (%) 66,7

(C3) (C4)

32,6 43,1

63,5 60,3

(C5) (C8)

13,9 54,9

57,1 73,0

(C11) Tengo la posibilidad de opinar y participar en decisiones que afectan mi trabajo (C12) Mis opiniones influyen en decisiones que afectan a la empresa en su conjunto (C13) Satisfecho con la posibilidad de opinar y participar en decisiones referentes a mi trabajo

40,3

58,7

61,1

82,5

47,9

71,4

Tabla 6. Fuentes de tensin en el trabajo. Diferencias significativas entre grupos ocupacionales

Fuentes de tensin

A (%)

D (%)

(D10) No estar suficientemente capacitado para este trabajo (D13) Mi trabajo perturba mi vida familiar (D14) Mi trabajo me impide desarrollar actividades sociales o recreativas que me agradan

14,6

3,2

25,0 27,1

12,7 9,5

Tabla 7. Fuentes de tensin en el trabajo. Diferencias significativas segn sexo

Fuentes de tensin

Mujeres Hombres % %

Grupo A (profesionales) (D4) Demasiado trabajo: falta tiempo... (D6) No saber qu opinan y cmo evalan mi desempeo... 31,8 20,5 48,2 39,3

Grupo D (no profesional) (D5) Tener que satisfacer o responder a muchas personas 63,3 36,4

DISCUSIN La muestra analizada forma parte de un contingente mayor y fue elegida as con el propsito de tener dos subgrupos ocupacionales dentro de un mismo campo de actividad, servicios de salud. Sin embargo, no se ha pretendido investigar aspectos que pudieran ser ms especficos a los trabajos relacionados con los cuidados de la salud. De este modo, no se ha diferenciado, por ejemplo, entre mdicos y enfermeras universitarias u otros profesionales de la salud; ni se ha distinguido entre mdicos de sexo masculino y femenino. En este sentido, debe considerarse el presente trabajo como una aproximacin metodolgica al tema propuesto. Lo primero que destaca de los resultados obtenidos en esta muestra es el elevado nivel sintomtico. La clasificacin en "probables casos" y "normales" en el sentido que habitualmente se usa con el General Health Questionnaire, es convencional y podra ser cuestionable, dado que no se ha efectuado un estudio de validacin clnica para esta muestra. Sin embargo, los puntajes empleados para definir un "caso" son ms exigentes, al menos con el GHQ-12, que lo encontrado en un estudio de validacin con poblacin chilena. Humphreys y cols25determinaron, en ese estudio, un punto de corte de 4 puntos o ms para definir un "caso". En otro estudio de validacin nacional de una versin de 30 preguntas del GHQ, se determin un punto de corte de 7/829. En el

actual se ha utilizado 6 o ms puntos de un total de 12, lo que constituye un requisito sumamente estricto para sospechar un "probable caso" de trastorno emocional. De acuerdo con lo expuesto en la introduccin, la presencia de "estrs" se detecta por los sntomas. Los "probables casos", entonces, pueden incluir "casos" de trastornos ansiosos, depresivos u otros trastornos emocionales. Sin embargo, dado que se trata de una muestra de personas presuntivamente sanas, que estn trabajando, la probabilidad de encontrar "enfermos" es relativamente baja en la poblacin econmicamente activa. Por eso, la mayora de las personas sintomticas probablemente presentan las molestias emocionales o somticas inespecficas que representan el fenmeno de estrs. Definidos as los "casos", se comprob que diferan significativamente de los "normales" en todos los cuestionarios, pese a que exista una correlacin significativa de las escalas sintomticas slo con la escala (D) "fuentes de tensin en el trabajo". Las causas de mayor insatisfaccin guardan relacin con la relativa ausencia de posibilidades de participar e influir, as como la falta de control sobre el desempeo de su trabajo y el sentir poco valorado ese trabajo. Las causas de mayor tensin o molestia son similares: tener que responder o satisfacer a muchas personas, trabajar demasiado apremiado, y condiciones fsicas inadecuadas. Posiblemente no sorprenda al lector informado estas descripciones de lo que puede estar sucediendo con el personal de salud. Nos ha parecido interesante destacar, sin embargo, la magnitud y frecuencia de los problemas sealados y su relacin con sntomas que permiten sugerir su repercusin sobre la salud de las personas encargadas de cuidar de la salud de otros. Las diferencias entre los dos grupos ocupacionales, uno compuesto por profesionales universitarios y otro por personal no profesional, de menor nivel educacional, ingresos econmicos y status social, son altamente significativas, tanto para los puntajes globales en varias escalas, como en el anlisis de la frecuencia de determinados sntomas y las principales fuentes de insatisfaccin y de tensin en el trabajo. Esto es concordante con diversos estudios que indican que el nivel de estrs y sus efectos sobre la salud de las personas dista de ser un fenmeno puramente individual y est determinado tambin por variables macroeconmicas y el nivel socioeconmico de las personas3,4,30. Encontramos diferencias significativas en el nivel de sntomas y en el de "tensin laboral" entre hombres y mujeres, pero estas diferencias son menores que las que existen entre los grupos ocupacionales. Tales diferencias de gnero varan, adems, en uno y otro grupo ocupacional. Las mujeres, por ejemplo, declaran con mayor frecuencia que los hombres, dolor lumbar y crvico-braquial. La asociacin de enfermedades msculo-esquelticas con factores psicosociales de estrs en el trabajo ha sido motivo de numerosos estudios, aun cuando la naturaleza de la relacin es controvertida31. Por otro lado, Lundberg32, tambin encuentra que las mujeres presentan mayores problemas musculares en el trabajo que los hombres. Ello podra obedecer, segn el autor, a que las mujeres estn generalmente empleadas en trabajos ms montonos y repetitivos; se mantienen ms tiempo en estos trabajos mientras los hombres ascienden; y estaran expuestas a mayor cantidad de trabajo sin paga, lo que les permite menos tiempo para relajarse.

Las fuentes de insatisfaccin diferencian claramente a los niveles ocupacionales, encontrndose que la mayora de stas guardan relacin con el sentido de autonoma y control que el trabajador tiene en el desempeo de su trabajo. Todas las diferencias encontradas indican una situacin menos favorable para el grupo no profesional, lo cual tiende a apoyar las tesis de Karasek y cols en trminos del mayor riesgo de estrs y morbilidad, en general, de las personas que trabajan sometidas a altas demandas, pero con escasa autonoma o control sobre el modo cmo realizan su trabajo 33. En contraste con lo anterior, no encontramos mayores diferencias entre mujeres y hombres. En cuanto a las fuentes de tensin en el trabajo, los hombres del grupo profesional refieren tener demasiado trabajo y poco tiempo; y no obtener retroalimentacin de sus superiores con mayor frecuencia que las mujeres; en tanto que las mujeres del grupo no profesional dicen tener que responder a demasiadas personas con mucho mayor frecuencia que los hombres. Algunas limitaciones del trabajo son las siguientes: la muestra no es necesariamente representativa del personal de salud de Santiago o del pas; los resultados expuestos no incluyen otras variables que influyen en el grado de estrs que las personas experimentan en su vida cotidiana, tal como la interaccin entre el trabajo y las obligaciones del hogar y aquellas dificultades asociadas a ingresos econmicos insuficientes, todas las cuales forman parte de la realidad del grupo no profesional ms que del grupo profesional. Por otra parte, un estudio de corte transversal no puede establecer relaciones de causalidad, si bien las asociaciones encontradas son concordantes con los estudios internacionales revisados. Finalmente, la metodologa de tamizado empleada para detectar casos sintomticos puede incluir algunos casos de trastornos mentales que no son necesariamente atribuibles a variables laborales. El diagnstico de esos casos requiere de otra metodologa y no constituy objetivo de este estudio. CONCLUSIONES En esta muestra de personal de salud en Santiago de Chile, se ha encontrado un elevado nivel de sntomas comnmente asociados a estrs. Se encuentra que el riesgo de estrs vara ms con el nivel ocupacional que con el gnero. Las principales fuentes de insatisfaccin son la escasa posibilidad de participacin, la percepcin de un trabajo poco valorado y las dificultades para controlar su propio trabajo. Las causas ms frecuentes de tensin son el apremio por el tiempo, tener que responder a muchas personas y condiciones fsicas de trabajo inadecuadas. La aplicacin sistemtica de este tipo de metodologa en grupos ocupacionales definidos podra orientar a los directivos y administradores de instituciones de salud respecto de ciertos factores subyacentes a comportamientos disfuncionales, ausentismo y morbilidad en el personal de salud, que afecta la productividad y la calidad de los servicios. Por otra parte, podra ayudar al propio personal a asumir una participacin activa e informada en el mejoramiento de sus condiciones de trabajo. Correspondencia a: Dr. Marcelo Trucco B. Hospital del Trabajador. Vicua Mackena 200, Santiago, Chile. Fax: (56-2) 634 1834. REFERENCIAS

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16. FIRTH COZENS J, GREENAHLGH J. Doctors perceptions of the links between stress and lowered clinical care.Soc Sci Med 1997; 44: 1017-22. [ Links ] 17. PROSSER D, JOHNSON S, KUIPERS E, SZMUKLER G, BEBBINGTON P, THORNICROFT G. Perceived sources of work stress and satisfaction among hospital and community mental health staff, and their relation to mental health, burnout and job satisfaction. J Psychosom Res 1997; 43: 51-9. [ Links ] 18. SEAGO JA, FAUCETT J. Job strain among registered nurses and other hospital workers. J Nurs Adm 1997; 27: 19-25. [ Links ] 19. TRINKOFF AM, STORR CL. Work schedule characteristics and substance use in nurses. Am J Ind Med 1998; 34: 266-71. [ Links ] 20. COX T, FERGUSON E. Measurement of the subjective work environment. Work & Stress 1994; 8: 98-109. [ Links ] 21. TRUCCO M, CAMPUSANO ME, LARRAN S. Un cuestionario para detectar desrdenes emocionales: estudio de validacin preliminar. Rev Ch Neuro-Psiq 1979; 17: 20-5. [ Links ] 22. TRUCCO M, VALENZUELA P. Una batera de cuestionarios para el estudio de estrs ocupacional. Rev Ch Neuro-Psiq 1998; 36: 159-65. [ Links ] 23. PRIETO T. Construccin de un instrumento global para medir stress laboral. Tesis de Grado para Licenciatura en Psicologa. Santiago, Universidad Diego Portales, Santiago (Chile), 1995. [ Links ] 24. GOLDBERG D, WILLIAMS P. A users guide to the General Health Questionnaire. Windsor, Berkshire. NFER-NELSON, 1988. [ Links ] 25. HUMPHREYS D, IBEZ C, FULLERTON C, ACUA J, FLORENZANO R, MARCHANDON A. Validacin preliminar en Chile de una versin abreviada del Cuestionario General de Salud de Goldberg (GHQ-12). Presentado en: III Congreso Chileno de Ciencias Neurolgicas y Psiquitricas y XLVI Jornadas Anuales de la Sociedad Chilena de Neurologa, Psiquiatra y Neurociruga. Santiago, 16-19 de octubre, 1991. [ Links ] 26. COOPER CL. The Stress Check. Englewood Cliffs, NJ. Prentice-Hall (Spectrum), 1981. [ Links ] 27. ISRAEL BA, SCHUMAN SJ, HOUSE JS. Action research on occupational stress: involving workers as researchers. International Journal of Health Services 1989(a); 19: 135-55. [ Links ] 28. ISRAEL BA, HOUSE JS, SCHUMAN SJ, HEANEY CA, MERO RP. The relation of personal resources, participation, influence, interpersonal relationships and coping strategies to occupational stress, job strains and health: A multivariate analysis. Work & Stress 1989(b); 3: 163-94. [ Links ]

29. TRUCCO M, REBOLLEDO M, BUCHHEISTER E, OYARZN F. Validacin del Cuestionario de Salud de Goldberg en pacientes traumatolgicos hospitalizados. Presentado en: XLIII Jornadas Anuales de Neurologa, Psiquiatra y Neurociruga, Via del Mar, noviembre de 1988. [ Links ] 30. ARAYA R, ROJAS G, LEWIS GH. Desrdenes mentales comunes, depresin y salud pblica. Rev Md Chile 1998; 126: 582-9. [ Links ] 31. BONGERS PM, DE WINTER CR, KOMPIER MAJ, HILDEBRANDT VH. Psychosocial factors at work and musculoskeletal disease. Scan J Work Environ Health 1993; 19: 297-312. [ Links ] 32. LUNDBERG U. Influence of paid and unpaid work on psychophysiological stress responses of men and women. J Occup Health Psychol 1996; 2: 117-30. [ Links ] 33. KARASEK RA, THEORELL T. Healthy work: Stress, productivity and the reconstruction of working life. New York, Basic Books, 1990. [ Links ]

Medical journal of Chile

printed version ISSN 0034-9887

Rev. md. Santiago Chile December v.127 n.12. 2006

doi: 10.4067/S0034-98871999001200006

Occupational stress in health personnel

Occupational stress in health care personnel

Marcelo Trucco B, Paulina Valenzuela A Trucco H 2
1

, Daniela

Background : Occupational stress results from the interaction of multiple Risk Factors, Such as the physical environment, biological function Disturbances, work content and organization and diverse psychosocial components. Aim : To study the frequency of the main sources and Symptoms of job stress, Perceived by professional and non professional health care Workers and to compare gender differences. Subjects and methods : A group of Specially designed, self-administered, Questionnaires adapted by the main author and Independently Validated, Were Applied. The results of two symptoms, one work satisfaction, job stress and one scales are reported. Results : One hundred sixteen women and 89 men Were Studied, 143 are professionals and 62 non professionals (clerical and nurse auxiliaries). Forty percent Clot Symptoms of job stress HAD and 82 subjects as defined Were "probable cases", According To the ratings on the symptom scales. Were There Differences in the frequency significant of Symptoms Between professionals and non professionals (34.3 and 69.2%

respectivamente). Differences in the main symptoms, sources of job stress and dissatisfaction Were more Closely associated to the occupational level than to gender. Conclusions: A high frequency of job stress WAS Symptoms Observed In This sample of health care Workers and the Risk of occupational stress varies more With The occupational level than with gender. ( Key Words : Health, Personnel, Occupational Health, Stress, Psychological)
Manuscript received on July 6, 1999. Accepted in revised version October 25, 1999. This work was funded in part with funds from the Research Committee of the ACHS. Hospital Worker, Chilean Safety Association. Faculty of Mathematics, Catholic University of Chile. University of Maryland, USA. 1 Statistical 2 Sociologist

According to the conceptual model we have used over several years of research on occupational stress, define stress as "the set of processes and physiological responses, emotional and behavioral situations that are perceived and interpreted by the individual as a threat or danger, either biological or psychological integrity " 1 .The threat may be objective or subjective, acute or chronic. The crucial thing is the cognitive component of the assessment that the subject makes the situation 2 . Stress occurs when there is a significant discrepancy between the abilities of the individual and the demands or requirements of their environment.
Occupational-related stress is the product of multiple interacting risk factors, including those from the physical environment, disruption of biological functions, content and organization of work, and various psychosocial components, both working as an extra job 1 . Among these have been described: the macro context and socioeconomic status, the type of work social support within and outside of work, feelings of selfesteem and control, personality type, age and sex 3 - 9 . One of the occupational groups in which they described a significant risk of occupational stress is the staff of health institutions. This, when it evolves chronically, may cause the picture of emotional exhaustion, emotional detachment, impersonal treatment and a general feeling of lack of personal accomplishment has been called "burnout" chart, along with mean neglect the welfare of the person, translates into lost productivity for the organization 10 . Traditionally a high proportion of health personnel have been female. Female participation in the workforce has been growing rapidly in most countries, but at the same time, there have been relatively few changes in the responsibilities of women in the home and family 11 . Apparently, working conditions indirectly affect the mental health of men and women. There are, however, differences among the factors that affect one another and sex.These differences are related to roles and self-concepts of men and women. Hence the advisability of studying separately the causes and effects of occupational stress in women and men 12 .

Other important variables in stress research that affects the health personnel are the profession and the professional status, interaction between different groups, the age and stage career. There is evidence that the factors that affect health and mental health and how these problems manifest themselves vary from doctors, nurses, technicians and administrative staff 13 - 19 . Measurement of occupational stress . How to measure stress in individuals and in groups, is an important issue from the methodological point of view and as a foundation for the design of health and prevention programs in organizations 7 , 20 . The author and his colleagues have developed a set of instruments to measure various components of the stress of occupational origin. The underlying conceptual model and methodology have been the subject of previous publications 21 , 22 . This model views stress as a process and assumed to be detected by nonspecific symptoms, including symptoms of the emotional sphere and body type, which do not set a definite morbid picture. Their presence can affect the quality of life and performance of people and points to the risk of disease. The instrument consists of a battery of questionnaires designed to be selfadministered. It has been shown that are affordable, easy to implement, acceptable to study subjects and discriminate between different occupational groups 22 . This battery has been independently validated in our 23 . OBJECTIVE This work is part of a line of investigation which has been reported previously 22 . Its aim is to investigate the frequency of symptoms and major sources of occupational stress perceived by two groups of health workers, one of academics and other nonprofessional, comparing men and women both. METHOD The sample included 205 subjects that was established by adding various groups surveyed at different times, having been originally described in a previous publication 22 . Part of this sample has been busy at work, which included the following groups: A) Health professionals. Includes physicians (about half), nurses and other professionals (n = 143). D) No professional. Includes administrative, secretarial and nursing assistants (n = 62). The questionnaires used in this work measured, A and B) Symptoms of stress (12 and 22 questions, respectively), C) Sources of satisfaction / job dissatisfaction (13 questions); D) Sources of stress and problems at work (16 questions .) Symptom scales used are translations of Goldberg's General Health Questionnaire in its version of 12 questions, GHQ-12 24 , 25 , and the Psychosomatic Symptom Questionnaire Stress Cooper, CSPS 26 . Other questionnaires have been adapted from a battery developed by B Israel and colleagues at the University of Michigan in Ann

Arbor, with permission 27 , 28 . Other features of these scales have been reported in previously published work 22. All questionnaires were answered in 4-point scale and are referenced to a defined period ("last month").Responses were dichotomized, assigning the highest score those two answers that indicate, in general, as "negative." Thus, higher scores indicate greater problems, discomfort, stress or deficiencies. Analysis . Describes the sample according to background variables: sex, age and occupational group. It then describes the overall results of the different questionnaires used for the sample and by sex, age and occupational group. Presents the significant differences in the overall results of the questionnaires according to the variables of origin and with regard to major associations detected. Side groups were constructed of "probable cases" and "normal" based on scores on the symptom questionnaires.It is used as the cutoff scores determined in a previous study that included part of the current sample 22 . These were determined conventionally, for the purposes of the study, as those scores corresponding to one standard deviation above average and above. Thus, defined as "probable cases" (asymptomatic) subjects who received 6 or more points on the GHQ-12 (possible range: 0 to 12), and / or 19 or more points in the CSPS (possible range: 0 to 44). The methodology used to suspect, but did not diagnose any cases of mental morbidity. It is basically a screening technique, commonly used in epidemiological studies 24 . RESULTS The sample included 116 women and 89 men (Table 1 ) with a mean age of 36.5 years (SD = 7.7). No significant differences in age composition between the four subgroups.

Table 1. Distribution by sex and occupational group Group occupational A D Total Women Men Total

87 29 116

56 33 89

143 62 205

In Table 2 presents the number of subjects classified as "probable cases" and "normal", according to the criteria described above. The difference between the proportion of women and men classified as "cases" is not significant (women = 42.3%, men = 46.3%). However, when comparing separate groups A (university graduates) and D (non-professional), it is found that the difference in the proportion of cases is highly significant (p <0.001), as the professional group 34.3% (A ) and 69.2% of nonprofessional group (D) is classified as "probable cases". The difference is greater among women (A = 31.3%, D = 79.2%, P <0.001), than among men (A = 38.8%, D = 60.7%, not significant).

Table 2. Number of "cases" and "normal" occupational group and sex Group Normal A Cases Normal D Cases 19 17 25 5 21 11 Women 55 Men 33

Subjects classified as probable "cases" and "normal" differ significantly in the four scales: (A) GHQ-12 (B) CSPS, (C) Sources of job dissatisfaction, and (D) Sources of stress for the work. In all scales the "cases" reported significantly higher scores than "normal" (p <0.001). Moreover, we found significant positive correlations (p <0.001) between the overall scores of the following scales: GHQ-12/CSPS: r = 0.59, GHQ-12/Fuentes of stress at work: r = 0.33 ; CSPS / Sources of stress at work: r = 0.37. Scores on symptom scales are independent of overall dissatisfaction score, with only a weak correlation between the scale and scale CSPS C of dissatisfaction (r = 0.17). The scales of dissatisfaction (C) and sources of job strain (D) appear as independent dimensions, each with an approximately normal distribution of scores. Symptoms, dissatisfaction and stress at work . In Figures 1 , 2 and 3 are the symptoms most often mentioned by the 205 study subjects, the major causes of job dissatisfaction and the main factors of tension and discomfort at work, respectively. FIGURE 1. Most frequent symptoms in percentages (n = 205)

FIGURE 2. Causes of dissatisfaction in higher percentages (n = 205).

FIGURE 3. Causes of stress at work in percentages (n = 205).

Among the symptoms reported by more than 25% of the sample is dominated by anxiety and depression. The major causes of dissatisfaction, affecting more than half of the subjects, are feeling their work recognized and valued little and little ability to control (low autonomy). Among the stress factors, emphasizes the feeling of having to answer to many people, time pressure and physical environmental working conditions inadequate.

Here are the main differences by occupational group and sex. 1. Differences in the frequency of symptoms in occupational groups A and D. Only significant differences in symptom scale "psychosomatic" (CSPS) between occupational groups ( Table 3 ). 2. Differences in the frequency of symptoms in women and men. Group A: significant differences were found in 6 of 24 symptoms which were investigated ( Table 4 ). In Group D: the only significant difference was found in the symptom: (B11) "Neck, shoulders, arms": 53.3% Female => Male = 24.2%.3. Differences in sources of job dissatisfaction in occupational groups A and D. We found important differences in the frequency of sources of dissatisfaction among professional and nonprofessional groups ( Table 5 ). 4.Differences in sources of job dissatisfaction in women and men. In the professional group (A) of the 13 items in the scale of satisfaction / dissatisfaction, only found a significant difference (C3) "Working unvaried": Women (26.1%) <Men (42.9% .) In the nonprofessional group (D): p = ns by sex. 5. Differences in sources of job stress among occupational groups. Professionals differ significantly (A) and non-professionals (D). In the three items are professionals who perceive significantly more stress ( Table 6 ). 6. Differences in sources of job stress in women and men. The differences between women and men are scarce: only two items in the professional group and one in the nonprofessional group ( Table 7 ).

Table 3. Significant differences in the frequency of symptoms in groups A and D. occupational Psychosomatic symptoms stress (CSPS) (B2) Difficulty staying asleep (B5) Increased appetite (B6) Fatigue (B7) Upset stomach or digestive (B11) Neck, shoulder, arms (B12) Back pain or waist (B14) Palpitations or tachycardia (B18) Shaking hands or eyelids (B19) Mentally exhausted (B20) Pain or tightness in the chest (B22) You want to be left alone A (%) D (%)

18.1 12.5 22.2 7.6 19.4 16.7 9.0 5.6 7.6 0.7 17.4

36.5 27.0 41.3 41.3 38.1 39.7 27.0 19.0 19.0 9.5 34.9

Table 4. Significant differences in the frequency of symptoms between women and men in the group A Women Men

% (A1) He stopped sleeping by concerns (A2) Have you felt constantly tense (B8) It costs up in the morning (B12) Back pain or waist (B13) Very sensitive or wanting to mourn (B22) You want to be left alone 28.4 45.5 28.4 21.6 12.5 9.1

% 51.8 62.5 44.6 8.9 3.6 30.4

Table 5. Significant differences in the frequency sources of dissatisfaction in occupational groups A and D Sources of job dissatisfaction (C2) My work can make many decisions (C3) My work is varied (C4) My job requires me to learn new things (C5) (C8) My job requires you to be creative I can choose speed of my work and when to rest A (%) 43.8 32.6 43.1 13.9 54.9 D (%) 66.7 63.5 60.3 57.1 73.0

(C11) I have a say and participate in decisions that affect my work (C12) My views influence decisions affect the company as a whole (C13) Satisfied with the ability to review and participate in decisions concerning my work

40.3 61.1 47.9

58.7 82.5 71.4

Table 6. Sources of stress at work. Significant differences between groups occupational Voltage sources (D10) Insufficiently trained to A (%) 14.6 D (%) 3.2

this work (D13) My work disturbs my family life (D14) My work keeps me from developing activities social or recreational activities that I like

25.0 27.1

12.7 9.5

Table 7. Sources of stress at work. Significant differences by sex Voltage sources Women % Men %

Group A (professional) (D4) Too much work: take time ... (D6) Not knowing what to say and how to evaluate my performance ... Group D (not professional) (D5) Having to meet or respond to many people
DISCUSSION

31.8 20.5

48.2 39.3

63.3

36.4

The analyzed sample is part of a larger contingent and was well chosen for the purpose of having two occupational subgroups within the same field of activity, health services. However, we have investigated aspects that may be specific to the work related to health care. Thus, not differentiated, for example, between doctors and nurses, university or other health professionals, nor has distinguished between male doctors and female. In this sense, this work should be seen as a methodological approach to the theme. The first thing that stands out from the results of this sample is the high level symptomatic. The classification into "probable cases" and "normal" in the sense usually used with the General Health Questionnaire, is conventional and may be questionable, since no study has conducted a clinical validation for this show. However, the scores used to define a "case" are more demanding, at least with the GHQ-12, that the findings of a validation study with Chilean population. Humphreys et al 25 determined in this study, a cutoff of 4 points or more to define a "case". In another country validation study of a 30-item version of the GHQ, we determined a cutoff point of 7/829. In the current has been used 6 or more points out of 12, which is a very strict requirement to suspect a "probable case" of emotional distress.

According to what stated in the introduction, the presence of "stress" is detected by symptoms. The "probable cases" then, might include "cases" of anxiety disorders, depression or other emotional disorders. However, since this is a sample of presumably healthy people who are working, the probability of finding "sick" is relatively low in the economically active population. So most people have probably symptomatic emotional discomfort or nonspecific somatic representing the phenomenon of stress. Well defined "cases" they were found to differ significantly from the "normal" in all questionnaires, although there was a significant correlation of symptomatic scales only with the scale (D) "sources of stress at work." The major causes of dissatisfaction related to the relative absence of opportunities to participate and influence, and lack of control over the performance of their work and feeling undervalued the work. The causes of increased stress or discomfort are similar: having to answer or satisfy many people, work too hard pressed, and inadequate physical conditions. May not surprise readers informed these descriptions of what may be happening with the health personnel. We thought it interesting to note, however, the magnitude and frequency of reported problems and their relationship with symptoms to suggest its impact on the health of caregivers of the health of others. The differences between the two occupational groups, one composed of university professors and other non-professional personnel, lower educational level, income and social status are highly significant for both overall scores on various scales, as in the analysis frequency of certain symptoms and major sources of dissatisfaction and stress at work. This is consistent with several studies that indicate that the level of stress and its effects on health of people is far from being a purely individual and is also determined by macroeconomic variables and socioeconomic status of persons 3 , 4 , 30 . We found significant differences in the level of symptoms and the "job strain" between men and women, but these differences are smaller than those between occupational groups. Such gender differences vary also in either occupational group. Women, for example, report more frequently than men, back pain and cervical-brachial.The association of musculoskeletal diseases with psychosocial stress at work has been the subject of numerous studies, although the nature of the relationship is controversial 31 . On the other hand, Lundberg 32 , also finds that women have higher muscle problems at work than men. This may be due, according to the author, that women are generally employed in monotonous, repetitive jobs, they remain longer in these jobs while the men rise, and be exposed to more work without pay, allowing them less time to relax. The sources of dissatisfaction clearly differentiate occupational levels, finding that most of these relate to the sense of autonomy and control that workers have in carrying out their work. All the differences indicate a less favorable situation for the nonprofessional group, which tends to support the thesis of Karasek et al in terms of increased risk of stress and disease, in general, people working under high demands, but with little autonomy or control over the way how they work 33 . In contrast to the above, we found no major differences between women and men.

As for the sources of stress at work, professional group of men reported having too much work and little time, and not get feedback from their superiors more frequently than women, while women in the nonprofessional group have to say too many people respond much more frequently than men. Some limitations of the study are as follows: the sample is not necessarily representative of health of Santiago or the country, the results presented do not include other variables that influence the degree of stress that people experience in their daily lives, such as interaction between work and home obligations and those difficulties associated with inadequate income, all of which are part of the reality of non-professional group rather than the professional group. On the other hand, a crosssectional study can not establish causality, although the associations found are consistent with international studies reviewed. Finally, the screening methodology used to detect symptomatic cases may include some cases of mental disorders that are not necessarily attributable to labor variables. The diagnosis of such cases requires a different methodology and did not constitute objective of this study. CONCLUSIONS In this sample of health workers in Santiago de Chile, found a high level of symptoms commonly associated with stress. It is found that the risk of stress varies more with the occupational level than gender. The main sources of dissatisfaction are the lack of possibility of participation, the perception of an undervalued work and the difficulties in controlling their own work. The most common causes of stress are the pressure for time, having to answer to many people and inadequate physical working conditions. The systematic application of this methodology in defined occupational groups could guide the directors and managers of health institutions on certain factors underlying dysfunctional behaviors, absenteeism and morbidity in the health workforce, affecting productivity and quality services. On the other hand, could help to the employees to take an active and informed participation in improving their working conditions. Correspondence to : Dr. Marcelo Trucco B. Hospital Workers. Vicua Mackenna 200, Santiago, Chile. Fax: (56-2) 634 1834. REFERENCES 1. TRUCCO M. Promoting mental health in the workplace . Washington, DC. Pan American Health Organization.June, 1998. [ Links ] 2. Lazarus R. Emotion and adaptation . New York, Oxford University Press, 1991. [ Links ] 3. DR Williams, JS HOUSE. Stress, social support, control and coping: A Social Epidemiological View. In: Badura B, Kickbusch I. (Eds), Health Promotion Research . Copenhagen, WHO Regional Publications, European Series No. 37, 1991, 147-72. [ Links ]

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