2. Stress among Anesthesiologists and Coping Strategies Doctors are neither infallible nor superhuman Presented by: Dr. Ashraf A. Abdelhalim, MD Professor Alexandria of University, Egypt 1

3. What is Stress? 2 A basic physiological response to real or perceived danger which enables the individual to stand and fight Not All Stress is Bad… When excessive, problems may arise Chronic stress: Harmful and emotional responses that occur when the requirements of a job do not match the capabilities, resources or needs of the worker and can lead to poor health and injury.

4. BURN OUT SYNDROME Emotional exhaustion, depersonalization, and lack of personal accomplishment in response to chronic occupational stress. الانهاك العاطفي، إضفاء الطابع الشخصي، وعدم الإنجاز الشخصي الانهاك العاطفي، إضفاء الطابع الشخصي، وعدم الإنجاز الشخصي It may lead to problems like  Alcoholism, substance abuse,  increased anxiety,irritability and aggression  Marital problems, emotional disorders, decreased empathy, depression  Personality changes are common: paranoid,intellectual impairment with poor concentration, and judgement.  Psychological withdrawal from work 3

5. Why Is Stress Management Important? Organizational Costs Individual Costs –Health Impairment –Job Burnout –Performance Decline

6. Relationship Between Stress and Job Performance

7. Type A Personality A high amount of anxiety. A high amount of anxiety. Increased aggression Increased aggression Susceptible to stress, have a higher incidence of CAD Susceptible to stress, have a higher incidence of CAD Problems in coping with to difficult situations. Problems in coping with to difficult situations. Extreme competitiveness القدرة التنافسية Strong desires for achievement Impatience نفاد الصبر Restlessness الأرق Hyperalertness اليقظة فرط Explosiveness of speech Recent evidence : 30% of all health care workers, including doctors, will experience psychological dysfunction at some time in their career. 6

8. second-hand stress Two recent studies have also confirmed : being around someone who is stressed is "contagious" معدي and can have a huge impact on your mental and physical health. elevated levels of cortisol, was found in the blood stream of those who were around highly stressed people. Another study found that mothers who were stressed were passing their negative emotions to their babies, who were becoming distressed and had increased heart rates.mothers who were stressed 7

9. Stress and its Effects Do you personally suffer from excessive stress? What are the signs of excessive stress? What can you do to help alleviate your stress? 8

10. 9 Common Physical symptoms of stress can include: Rapid heartbeat. Headache. Stiff neck and/or tight shoulders. Backache. Rapid breathing. Sweating and sweaty palms. Upset stomach, nausea, or diarrhea. Sleep trouble. Weakening of the immune system Determining if you suffer from excessive stress

11. 10 Common Mental symptoms of stress include: Irritability التهيج Intolerance حساسية مفرطة Short Temper الانفعال Exhaustion إنهاك Lack of concentration Frustration over minor challenges الإحباط من التحديات الطفيفة Symptoms Continued…

12. Strategic Importance of Workplace Stress In 2012, Only 37 % said they were doing an excellent or very good job managing stress. 65 % Americans cited work as a top source of stress The American Psychological Association's (APA) annual Stress in America Survey

13. Work-Related Stressors Role Ambiguity Work Overload Occupation Resource Inadequacy Working Conditions Management Style Monitoring Job Security الغموض الاحتلال الرصد أسلوب الإدارة ظروف العمل

14. Other Common Sources of Work Stress Low salaries. Few opportunities for growth or advancement. Work that isn't challenging. Lack of social support. Not having enough control over job-related decisions. 13

15. In a survey  30% of anaesthetists felt stressed a lot of the time.  5% felt stressed all the time;  33% described themselves as severely stressed  7% felt their stress was more than severe.  In the work related environment :  Strained Professional relationships (25%), العلاقات المهنية المتوترة  Work overload (24%),  Difficult work (6%) and  Potential litigation (3%). التقاضي المحتمل Administrative and social factors, o Administrative responsibilities (42%) المسؤوليات الإدارية o Work-home conflict (35%) were the most stressful o Money (14%), o Teaching responsibilities (6%). 14

16. Hawton et al. noted that:  Anesthesiologists had higher suicide rate.  A higher rate of suicide in female. Anesthesiologists working in teaching hospitals have :  Better working conditions,  More OR assistance,  Better academic environment resulting in better job satisfaction as compared to those working in community hospitals. resulting in better job satisfaction as compared to those working in community hospitals. 15

17. Where does YOUR stress start? Using the handout مذكرة, take a few minutes to honestly consider what causes your daily stresses Family? Work? Work?Friends? Etc… Etc… 16

18. 17 Job Stress

19. Anaesthetists felt that they do not need the cooperation of other physicians. Because they work alone, therefore,  They have difficulties in trusting their colleagues  Fearing the patient will develop severe sequelae,  Trust only their own performance generating psychological and emotional overload, 18

20. Sleep deficit Sleep deficit (Shift duties and irregular working hours ) leads to: (Shift duties and irregular working hours ) leads to:  Daytime sleepiness and impaired performance.  Increases accidents,  increase GI and CV. diseases,  Increases adverse pregnancy outcomes,  increases risk of breast cancer,  decreases immunity,  Impairs glucose metabolism, a decrease in cerebral metabolic rate and psychological diseases 19

21. Fatigue Fatigue  Decreased attention,  Prolonged reaction time,  Impaired memory, and decision-making leading to errors and accidents.  A stressed person gets fatigued easily than a relaxed person. A study reported an increase in incidence of unintentional dural puncture during epidural anesthesia at night (midnight to 6 am) 20

22. Previous studies reported that recognition of anesthesiologists as a medical doctor by the patients varies from 65% to 82%. Lack of recognition by patients plays a major role in bringing about dissatisfaction 21

23. A study demonstrate that : Anesthesiologists working longer hours are more prone to burnout & dissatisfaction. They usually work longer to earn more. Basic salary usually constitutes a half of the total income, the rest being earnings for staying on duty. One in 10 doctors works continuously for more than 13 hours a day (also on weekends) one in 20 even as long as 18 hours. one in 20 even as long as 18 hours. Life Satisfaction and Work-Related Satisfaction among Anesthesiologists in Poland.Scientific World Journal, Volume 2014, 9 pages Life Satisfaction and Work-Related Satisfaction among Anesthesiologists in Poland.Scientific World Journal, Volume 2014, 9 pages 22

24. Often doctors work continuously for more than 30 hours,especially in smaller, understaffed hospitals Perform procedures quickly, and move between hospitals Working in the operating theatre, the ICU, preoperative assessment, treating chronic and acute preoperative assessment, treating chronic and acute pain, or working in an emergency department pain, or working in an emergency department Providinng services for 50–60% of hospitalized patients Anything goes wrong, they are blamed. 23

25. Surgeries last longer than expected, and an anesthesiologist’s entire schedule gets upset  Disturbing the family time,  Missing many social occasions. 24

26. Poor interpersonal relationship especially the surgeons (powerless to change or control the situation) Surgeons pressurize to proceed with cases instead of postponing in spite of high risk and to hasten anesthetic procedures. Conflicting demands is regarded as a risk factor for overwork. overwork. 25

27. One of the factors causing dissatisfaction is lack of resources for purchasing required equipment and drugs. 26

28. Physical stress results from exhausting factors of surgical environment, including  Noise pollution,  Exposure to anesthetic gases, radiations, latex, infections,  Excessive cold/heat,  use of uncomfortable chairs Noise pollution leads to sympathoadrenal activation which is detrimental in people with chronic anxiety/hypertension 27

29. Distractions like external staff entering, exiting, conversation,irrelevant discussions Acoustic distractions like telephones. (CMEs) and demands for performance pressurize all doctors. Anesthesia trainees have heavy responsibility of service work coupled with post-graduate exam. 28

30. Bosses Cause Employee Stress “75%of working adults say : the most stressful aspect of their job — is their immediate boss,” New Danish study, Surprisingly, a heavy workload has no effect on whether or not employees become depressed. Instead, it is o o The work environment, o o The feeling of being treated unfairly has the greatest effect on an employee’s mood. 29

31. How Can You Cope With Stress? 30

32. Make Action Plan 31

33. Determine YOUR Personal Level of Stress Using the handout for reference, rate how often on a scale of 1 to 10 (1 being never, 10 being more than 5-6 times a week) you experience the below mentioned symptoms: Headaches Back/neck pain Chest pain or discomfort Problems with digestion/nausea Dizziness, numbness or tingling in your fingers or toes IrritabilityFrustration Emotional Fatigue Concentration/Memory Problems 32

34. Options to Alleviate Your Stress If you determine that you are experiencing excessive stress, what can you do?  Find out what is causing stress in your life  Recognize the things which cannot be changed  Personal and family time is very important.  Good communication Prevent many crises in the workplace Prevent many crises in the workplace Remove many irritations which lead to undue stress especially where these are due to misunderstanding Remove many irritations which lead to undue stress especially where these are due to misunderstanding 33

35. 34  Interpersonal relationships, to function smoothly as a team  A proper support system (call for help) A strongly connected friendship network have been associated with better job performance and lower rates of job stress, Effects of Hospital Workers’ Friendship Networks on Job Stress. PLoS One. 2016; 11(2) PLoS One

36. 35  Medicolegal protection and proper assistance  All consultants should be familiar with potential problem areas & signs of strain.  Regular physical and relaxation exercises.  Learning to say “No” in good way  Thoughts, feelings and beliefs must be expressed in a way that does not violate تنتهك the rights of others

37.  The Control of Aggression :is an art and improves with practice.  Try to remain calm but firm هادئ و حازم  The backing of colleagues is invaluable  إن دعم الزملاء لا يقدر بثمن  Tries to be as co-operative as possible  No person has the right to make life miserable for those around them 36

38.  Time Management : Spending time on important matters Spending time on important matters Distinguishing between important tasks versus urgent tasks Distinguishing between important tasks versus urgent tasks Focus on results rather than methods Focus on results rather than methods Not feeling guilty when saying “no” Not feeling guilty when saying “no” Time cannot be expanded infinitely to meet demands) Time cannot be expanded infinitely to meet demands) 37

39.  Schedule : Think about which things are most important, and put those at the top of your schedule/list to do those things first.  Take good care of yourself:. Exercise, get plenty of rest, try to eat well, good sleep pattern & don't smoke Ask for help. People who have a strong network of family and friends manage stress better. 38

40.  Stop negative thoughts. Try writing down your worries المخاوف Try writing down your worries المخاوف Letting things you cannot change. Letting things you cannot change. Don’t worry about things that have past. Don’t worry about things that have past. Focus on the positives and the future that you can still impact. Focus on the positives and the future that you can still impact.  Speak up. Assertive communication can help you express how you feel in a thoughtful, tactful اللباقة way. 39

41.  Do something you enjoy.  A hobby, a bath, meditation التأمل, walking,, imagery exercises, or self-hypnosis التنويم المغناطيسي الذاتي or volunteering التطوعare helpful ways to relieve stress.  Listen to relaxing music.  Focus on the present. Reliving the negative things that happened. Reliving the negative things that happened. There is nothing you can do about it. There is nothing you can do about it. Let it go and look ahead, not behind. Let it go and look ahead, not behind. 40

42.  Laugh it up! Try to look for the humor الفكاهة in life to lighten the load. Try to look for the humor الفكاهة in life to lighten the load. Don’t take yourself so seriously. Don’t take yourself so seriously. Everything will pass eventually. Everything will pass eventually. Laughter الضحكreally can be the best medicine! Laughter الضحكreally can be the best medicine! 41

43.  The Problem of Distorted Thinking الفكير المشوهه  Try to learn from the bad experiences of yourself and others  Do not demand too much of yourself.  Demands, if not realistic should be rejected  Anything less than 100% is not necessarily total failure.  Remember positive experiences; Do not jump to conclusions Do not jump to conclusions Do not magnify mistakes and minimize successes. Do not magnify mistakes and minimize successes. 42

44.  Improving working conditions in terms of  Ensuring availability of proper and latest anesthetic equipment’s at all small/large hospitals, equipment’s at all small/large hospitals,  Better remuneration مكافأة for work done,  Good assistance,  Limiting number of working hours,  “Splitting” weekend call or having a second call available to allow rest periods or to help with complex patients. 43

45.  Allow time for research, vacation and group practice meetings.  Regular morbidity and mortality reviews with other department’s especially surgical colleagues other department’s especially surgical colleagues  Sleep deprived anesthesiologists should never be pressurized to provide anesthesia. pressurized to provide anesthesia. (A study suggested a 40 min nap increased performance (34%) and physiologic alertness (54%) compared with the no nap condition) (A study suggested a 40 min nap increased performance (34%) and physiologic alertness (54%) compared with the no nap condition) 44

46.  Lounges صالات with facilities for recreation (newspapers, treadmill) should be located in close to workplace.  Anesthesiologists should be compulsorily retired for 30 min every 4-5 h for de-stressing themselves.  Stress management workshops should be conducted at regular intervals.  Designated comfortable separate rooms for night duty 45

47. 46 What You Eat! Eat a variety of foods Maintain optimal weight Reduce fat intake Reduce sugar and sodium intake Avoid alcohol and caffeine Take vitamins and supplements Make eating a relaxing time

48. Deep breathing technique is capable to induce an effective improvement in mood and stress both in terms of self-reported evaluations & objective parameters, such as heart rate and salivary cortisol levels. No statistically significant difference was found between men and women. The role of deep breathing on stress. Neurol Sci. 2017 Mar;38(3):451- 458 Neurol Sci.

49. If you feel you've been criticized unfairly by your boss, what's the best way to confront مواجهة the boss with your concerns? Discuss your concerns — not confront your boss. )There is a difference(. Carry out the discussion of your concerns in a non-adversarial way غير عدائية. Handle your complaints in a manner that does not do further damage to your relationship. 48

50. Managers' guide to monitoring stress The key indicators of stress may be;   Change in an employees normal behaviour – eg irritability/ withdrawn/, angry and tearful behaviours.   Change in their appearance.   Sudden Lack of concentration/commitment الالتزامeg. lateness.   Absenteeism. 49

51. What is my role as a manager in relation to work related stress?  Providing support for colleagues   Promote an open and honest environment.   Treat stressed employees in the same way as those with a physical health problem  Discuss the problem with the person involved and seek a solution  Seeking advice from other consultant colleagues  Discuss the matter with the medical director   If work is affected, discuss the problems with Human Resources. 50

52.   Review and if necessary modify the work tasks and responsibilities of individuals  Documentation, witnesses and confidentiality must be respected  It must be remembered that patient safety is paramount 51

53. Negative management behaviours تفويض Delegating تفويض work unequally. Creating unrealistic deadlines. Listening but not taking action. غير حاسم Being indecisive غير حاسم. Not being aware of team pressures. Imposing ‘it’s my way or no way’. Making decisions without consultation. Not listening to new ideas or allowing employee’s to suggest and try improved ways of working. 52

54. Keeps people in the dark. Often makes decisions and holds meeting behind closed doors with no consultation. Does not update and have regular meetings to communicate changes. Not giving credit when jobs done well/deadlines met. Not having knowledge and understanding of your teams tasks/workloads. No consideration of work life balance. Not dealing with complaints/issues 53

55. Taking sides Talks about employee’s issues with others staff members/making personal issues public Makes promises and does not deliver Communicating at the last minute. Not allowing time off for employee’s development and to attend training courses. 54

56. Conclusion Make a commitment التزام to yourself to change the situation(s) causing your stress, Seek new and different ways to cope with the daily stresses and attempt to become more efficient so that you avoid the stresses. 55

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