BJA Advance Access published online on August 17, 2007
British Journal of Anaesthesia, doi:10.1093/bja/aem233
Enjoying work or burdened by it? How anaesthetists experience and handle difficulties at work: a qualitative study
1 Department of Public Health and Caring Sciences, University of Uppsala, Uppsala Science Park, SE-751 85 Uppsala, Sweden
2 Clinic of Anaesthesia and Intensive Care, Uppsala Academic Hospital, SE-751 85 Uppsala, Sweden
* Corresponding author: Clinic of Anaesthesia and Intensive Care, Uppsala Academic Hospital, SE-751 85 Uppsala, Sweden. E-mail: jan{at}trolin.net
Accepted for publication June 18, 2007.
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Abstract |
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Background: The aim of this study was to explore difficulties at work from anaesthetists’ own perspective and to examine how anaesthetists handle and cope with situations that are perceived as difficult and potentially stressful.
Methods: Two sets of interviews were conducted with 19 specialist anaesthetists in Sweden. The first set of interviews aimed at finding how the anaesthetists experienced difficulties at work. It consisted of in-depth interviews based on one open-ended question. We analysed the interviews with a phenomenological method, looking for themes in anaesthetists’ descriptions of difficulties at work. In the second set, the interviews were semi-structured with open-ended questions, based on themes found in the first interview set. These interviews aimed at exploring how the interviewees described their ways of handling difficulties and how they coped with potentially stressful situations.
Results: Analysis of the first set of interviews resulted in five themes, describing how the anaesthetists experienced difficulties at work. All interviewees talked about difficulties related to more than one of the themes. The second set of interviews revealed two main categories of ways of handling difficulties. First, problem solving consisted of descriptions of methods for handling difficult situations which aimed at solving problems, and second, coping strategies described ways of appraising potentially stressful situations that minimized stress, despite the problem not being solved.
Conclusions: The anaesthetists interviewed in this study maintained that they enjoyed work and could see no external obstacles to doing a good job. They had arrived at a reconciliation of their work with its inherent difficulties and problems. Getting access to their coping strategies might help young anaesthetists to come to terms with their work.
Keywords: anaesthetist, risks; education, junior staff; stress
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Introduction |
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Previous studies have shown that trainee anaesthetists often feel inadequate at work and are exposed to stress,1 whereas many specialist anaesthetists report being content with their job.2 It would be useful, therefore, for trainees to understand how their senior colleagues have learned to cope well with work, in spite of its demanding and stressful character. Even if stress is an inevitable aspect of anaesthetists' work, it can affect anaesthetists in different ways, depending on how he or she copes with it.3 Coping not only refers to efforts at solving problems that cause stress, but also includes the appraisal of stressful situations in ways that may turn them into positive challenges, whereby the negative physical and psychological effects of stress can be reduced.4
During the last decade, stress had been recognized as a cause of suffering and illness for anaesthetists.3 Inexperienced trainee anaesthetists are even more exposed to stress at work and run a greater risk of burnout.5 They sometimes experience very demanding situations and may feel lonely and inadequate at work.1 Such a situation can make anaesthesia unattractive and may explain why some young doctors have been reluctant to choose it as a career,6 even though recently this does seem to be changing for the better. Furthermore, too much stress is an obstacle to learning and can negatively affect trainees’ learning environment.7
Thus, trainee anaesthetists need seniors' support not only to develop professional competence but also to learn how to handle the stresses of anaesthesia. They would benefit from knowing how their senior colleagues have learnt to cope with work and how they think about problems and difficulties. Trainees could thus learn not only how to become competent anaesthetists but also how to become anaesthetists who feel comfortable with their work. Previous studies of stress among anaesthetists have explored the prevalence of stress symptoms and which stresses may cause mental health problems.8 However, the coping strategies of experienced anaesthetists who are content with work have not been studied.
The aim of this study was to explore difficulties at work from anaesthetists' own perspectives and to examine how anaesthetists handle and cope with situations that are perceived as difficult and potentially stressful.
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Methods |
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Qualitative methods are well suited for studies aimed at increased understanding of how people think and understand the world around them, and these have been increasingly used in health care research.9 In qualitative research, the emphasis is on exploring and understanding a phenomenon rather than on testing a hypothesis. Our design for the present study was therefore a qualitative interview study. Two sets of interviews with specialist anaesthetists were used; that is, each anaesthetist was interviewed twice. The study was approved by the Ethics Committee at the Faculty of Medicine, Uppsala University, Dnr 01–226.
The first set of interviews aimed at finding how the anaesthetists experienced difficulties at work. It consisted of in-depth interviews based on one open-ended question. We analysed the interviews with a phenomenological method, looking for themes in the anaesthetists' descriptions of difficulties at work.
In the second set, the interviews were semi-structured with open-ended questions, based on themes found in the first interview set. These interviews aimed at exploring how the interviewees described their ways of handling difficulties and how they coped with potentially stressful situations.
The interviewees were qualified anaesthetists working in three hospitals in central Sweden. Two of the hospitals were middle-sized county hospitals and one was a smaller hospital. All qualified anaesthetists in active clinical work during the weeks of the interviews, 19 people in total, were asked to participate, and all accepted. The first interviews were done in 2000–2. At the second interview, performed in 2004–5, four of the interviewees had changed workplace to other hospitals in central Sweden; these four anaesthetists were interviewed at their new workplaces.
The interviews were conducted by the first author (J.L.), a consultant anaesthetist with training in qualitative research. They took place in a quiet room at the anaesthetists' workplace, with only the interviewee and J.L. present. In the first set of interviews, the interviewees were asked about difficulties at work, answering the question ‘What is difficult or what hinders you in your work?’ By using reflective comments such as ‘What do you mean by that?’ or ‘Can you tell me more about that’, the interviewer encouraged the interviewees to describe their own experiences of difficult situations at work. Two other open-ended questions were used in the interviews to explore the anaesthetists' different conceptions of their work (When do you feel you have been successful in your work? What is the core of your anaesthesia work?) These results have been reported elsewhere.10 Hence, in the present study, we focused on the parts of these interviews in which the conversation was about difficulties at work.
For the second set of interviews, we used open-ended questions, based on four themes found in the first set of interviews. Altogether, five themes were found in the first interview set and four of them defined different types of difficulties at work (Table 1, Themes A–D); these themes were used for the second interview. For each theme, two questions were asked: (a) Tell me about experiences of difficult situations at work; and (b) How do you think and act to handle such situations?
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All the interviews were tape-recorded and transcribed word-for-word, either by the interviewer or by a secretary, and subsequently verified by the interviewer listening to the tapes. The interviews lasted for 1–1.5 h.
The first set of interviews resulted in narratives about experiences of difficulties at work. Experiences cannot be quantified but still they can be studied using a phenomenological approach. In contrast to natural science, with its focus on physical nature, cause–effect, and impersonal forces, phenomenology focuses on human subjectivity, intentionality, and clarification of meaning.11 In phenomenological studies, the aim is to describe the phenomenon as it is given in the subject's experience. To achieve this, the researchers should set aside theories and their own expectations about the phenomenon.
It is important to adopt a phenomenological attitude to the text, viewing it from the perspective of the interviewees and avoiding one's pre-understanding or prejudices about the phenomenon and theories and models.
For the first set of interviews, an analysis based on Giorgi's descriptive phenomenological method12 was performed. For each interview, preliminary themes were described. The themes of all the interviews were compared and similar themes were grouped together and reformulated. During this step, we returned to the original text and re-adjusted some themes.
In contrast to the first set of interviews with its narratives of the anaesthetists' pre-reflective experiences, the second set of interviews contained reflections, views, and opinions of the interviewees on a more cognitive level. Therefore, for these interviews, we chose content analysis,13 a method used to reduce qualitative data similar to interview texts to find patterns and themes. From the text sections containing statements about handling different types of difficulties, categories, and subcategories were created (Table 2).
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Results |
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The anaesthetists were 37–62 (median 46) yr of age at the time of the first interview and had varying lengths of experience as anaesthetists, from being newly qualified as specialists to having more than 20 yr of experience. Three of the interviewed doctors (16%) were female, a lower percentage than the average (28%) in Sweden.
The analysis of the texts from the first set of interviews resulted in five themes, describing how the anaesthetists experienced difficulties at work. All interviewees talked about difficulties related to more than one of the themes.
The second set of interviews revealed two main categories of ways of handling difficulties. The first category, problem solving, consisted of descriptions of methods for handling difficult situations which aimed at solving problems. In the second category, coping strategies, anaesthetists described ways of appraising potentially stressful situations that minimized stress, despite the problem not being solved.
To look in more detail at the five themes, descriptions of how difficulties were experienced and handled are illustrated by quotes from the interview transcripts.
A. Anaesthesia is inherently difficult; it is a job for the expert
Description
Some patients have complicated disease states and it can be difficult to know what the best treatment is. The work is unpredictable and, if the situation does not go as planned, it can be very stressful. Sometimes, mostly during on-call time, anaesthetists may have to perform difficult procedures, with which they are quite unfamiliar. Finally, every anaesthetist will on some occasion get into a very difficult situation, when the patient's vital functions are compromised.
...he coughed and was irritated by the tube (the interviewee was extubating a 10-year-old boy after incision of a peritonsillar abscess)...I misjudged the situation, I thought he was in a lighter state...so I extubated him. And the airway was completely obstructed. He developed laryngospasm, I had pulled the tube out at the wrong moment. It was impossible to ventilate. His pulse rate increased and so did mine. His pulse rate slowed down, mine went on increasing. Then I felt as if someone was sitting on my back with claws penetrating my skin, I was losing control...and finally, in this darkness of blood and cyanosis, I managed to get a tube down...it was awful, it was traumatic...
- Simplify things and start with the obvious and simple.
The interviewees described their strategy to handle acute situations with critically ill patients as simplifying things, starting with the obvious and simple, aiming at supporting vital functions until a definite diagnosis could be obtained....I mean, you always do these basic things, an airway and an i.v. access... to keep things under control so to speak, as long as possible.
- Ask for advice.
Most of the interviewees had realized that they could not solve all problems themselves. They stressed the need not to think about prestige when asking for advice from other doctors or from experienced nurses.... when you are standing there in the front line and everything depends on you, people around you are so helpful in such situations... if you keep standing there for a while, thinking, you will always be offered some small hint—could we not do this, like that? And I know that sometimes—yes, that is exactly what...those standing around you can sometimes be remarkably helpful.
Some anaesthetists spoke about how they had established a network of colleagues/anaesthetists whom they could consult in difficult cases.
...but there are always younger or older colleagues to discuss things with... we have a network of colleagues in Sweden, and therefore you never feel quite on your own, abandoned.
- Support from colleagues.
The interviewees considered support from colleagues very important in the process of coping with difficult situations as well as for debriefing talks after such situations. Other anaesthetists could understand them in a way that outsiders never would.And if someone looks upon it from the outside, it is easy to say just that you have made a mistake and you will be severely criticized. But colleagues who understand what the problem is about, can help you survive after such situations, even if you realize that you did not do quite the correct thing then...
An open atmosphere among anaesthetists was considered very important.
But it is also very important that there is a good atmosphere, that your colleagues support you, and that you get a good introduction.
- Accept that medically difficult situations are part of work.
Accepting medically difficult situations as part of work was considered essential because such situations will continue to challenge anaesthetists during their work careers.Somehow you must feel inside that you want to accept this challenge – I want to manage this. Someone has to do this work.
...it can be a difficult airway or something like that...it will always be like that in this profession. And you have to keep going so that you dare to be involved in such situations.
- Accept limits of own competence.
Anaesthetists must accept limits of their own competence, and they should be prepared to fail sometimes.... I know that I have done my best and I cannot do more than that. I cannot quit this work only because situations may arise where I do not suffice.
Some of the interviewees said that, when confronted with medically complicated cases, they would tell themselves that nobody else would do it better.
...when I get to the point that I do not manage, there won't be many others who would manage either. And that is enough for me...then I feel calm and safe.
- Accept the limitations of what health care can do.
Anaesthetists must never forget that there is a limit to what even the best of care can do for a critically ill patient.But if you only have got this understanding, that we cannot manage everything, we are not God, we are common anaesthetists and there are limits.
B. Anaesthetists sometimes have to make ethically difficult decisions
Description
The most common ethical problem is about the level of care, either in the intensive care unit (how much should be done when the patient's chances of being cured are very small?) or in the operating theatres (should the patient be exposed to a risky operation when the chance of cure is minimal?). Often, there are different opinions among doctors, and there is sometimes a grey zone between doing everything and doing nothing.
Sometimes I find it difficult when we have to make decisions about people's lives. Abstain from continuing intensive care, it is difficult...in some way it is like—well, today I had to be some kind of God...deciding what will happen.
- Discuss with colleagues.
Even if there were many descriptions of ethical problems in the interviews, strategies for handling such problems were conspicuously scarce; only a few of the interviewees stressed the importance of making the decision process transparent by involving other staff members.I think it is important to make the decision transparent...it is important to make it visible for colleagues and other co-workers so that it can be scrutinized...
C. Anaesthetists' work is often difficult and tiresome because of hard working conditions
Description
Sometimes, most commonly during on-call hours, the workload is much too heavy and anaesthetists have to take on many responsibilities simultaneously. Furthermore, anaesthetists are supposed to be accessible to everybody all the time and are often interrupted by the bleeper.
...it is on those occasions when so much work is laid on you that you lose control of the situation. When you are stretched out like a rubber band...You have too many tasks to juggle with at the same time and you can't control all of them...
- Prioritize and do one thing at a time.
A common challenge described by the interviewees was to be confronted with demands for several work tasks simultaneously. Most of them had accepted this as a part of the work and could usually handle such situations by prioritizing and doing one thing at a time.You learn to sort out somehow, what is important and what is less important, and that is also a way of keeping stress at a low level.
Some of the interviewees even considered potentially stressful situations of work overload as pleasant challenges.
I think it can be quite fun to walk into a chaotic ICU, get a survey and decide—we have to do this and that must wait.
- Delegate work to competent nurses.
The interviewees spoke about how they had learned to make uncontrollable situations possible to handle by delegating part of work tasks to competent nurses. The prerequisite for this was the anaesthetists knowing and trusting the nurses.I trust our anaesthetic nurses, of course. If there is a cardiac arrest somewhere when I am busy putting in an epidural in the delivery ward, one of them will run there.
Delegating was facilitated by explicit work plans, elaborated by staff members.
...those tasks that are primarily mine I can delegate to them [anaesthetic nurses]. I do it differently now compared to five years ago. We have developed routines which I know that they can follow...I can have a remote control over certain things.
- When necessary, get help from other colleagues.
Even for the experienced anaesthetists, there could be moments of work overload which could be managed only by getting help from other anaesthetists. This was usually done by calling the anaesthetist on stand-by duty at home, but, if necessary, the interviewees would not hesitate to call in any of the staff members from their home. Such a way of handling crisis situations was said to be fully accepted by all anaesthetists.Sometimes you are very busy and then you must call in the anaesthetist on-call at home...or you may have to call somebody who is not on-call at all...I would not hesitate if necessary.
- Accept the demands for several work tasks simultaneously as a part of work.
Some of the interviewees pointed out that anaesthetists must accept moments of excessive work demands, as they are inherent in their profession.I have accepted that you cannot fulfil all demands. It is part of it all. It does not make me feel bad.
- Put limits on what is demanded from you.
Not taking on too much work was considered, at least partly, as one of the anaesthetist's own responsibilities; an anaesthetist must sometimes dare to say no.I think that it is important to see your own limitations...do dare to say no...
In order to survive in the long run, anaesthetists should get a breathing space in their working schedule now and then to get periods of time with own control over time, for instance, doing research. Some interviewees had learnt by experience how important it was not to bring work home with them and they could sometimes even completely skip some administrative work tasks....it suits me to have research as a breathing space. I control my own time for a few weeks every year...
D. Other doctors, especially surgeons, sometimes do not respect anaesthetists
Description
Lack of respect from other doctors, especially surgeons, is sometimes a problem. Anaesthetists tend to be looked upon as sort of maid-of-all-work, always at hand to fix everything.
...Some colleagues have a very strange notion of what an anaesthetist has got to do. That's what is most frustrating...some colleague doctors consider us to be a sort of ‘coolie’, you're told to do what they think you should do...
Problem solving
Lack of respect from surgeons and other specialist doctors could be about the surgeon not seeing or understanding the anaesthetist. However, in the second interview, almost all interviewees described lack of respect nowadays as a non-significant problem, easily solved by means of good communication.
I think it is fairly easy to come to terms...if only you have an open communication.
E. There are no external obstacles to doing good work; being an anaesthetist is, strictly speaking, not difficult
Description
Experienced anaesthetists can be confident that if they do their very best, no one can demand more of them, because few others would do the work in a better way. If difficulties are seen as opportunities for learning rather than problems, they can be turned into challenges to further develop competence.
Do you ever feel that it is difficult to be an anaesthetist?
No, I don't think so. I've been in this profession for so long, I know what usually works and what doesn't work...
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The most striking finding of this study was that the experienced anaesthetists used two different strategies for handling difficult situations at work. The first one was characterized by acts aimed at solving the problem at hand, be it a medically complicated situation or a moment of work overload. This strategy was based on being trained to handle the first 10 min, followed by non-prestigious discussions with colleagues in complicated cases. The second strategy was characterized by appraising difficult situations in a way that converted them from threats to challenges. This is a cognitive procedure whereby the anaesthetists understand that, although there can be a serious threat to the patient, there is no threat to them as professional anaesthetists. This strategy was based on anaesthetists accepting the limits of what health care can do and convincing themselves that doing their best should suffice (‘If I can't manage this difficult case, probably no one else can’ either). Instead of a threat, the situation may then constitute a challenge, and anaesthetists' focus will be on potential for gain or growth. Their emotions will be characterized more by eagerness and excitement than by fear, anxiety, and anger.14 Young trainees would benefit much from learning to master this way of transforming stressful situations from threats to challenges; teachers of anaesthesia have an important role in supporting this learning.
Almost all the anaesthetists interviewed had developed coping strategies for problems associated with medically complicated and very acute clinical situations. Most of them also declared that they could handle stressful situations. In these two fields, most anaesthetists quite eloquently described well thought-out coping strategies. However, ethical problems (theme B) were perceived as a difficulty which did not diminish with years of experience. The anaesthetists were not able to find ways of developing their coping strategy in this area and were not able to turn ethically difficult situations into challenging learning experiences in the same way that they did in medically difficult situations. The reason for this lack of coping strategies for ethical problems might be that coping was equated with mastering a situation. This would leave anaesthetists without strategies for coping with ethically difficult situations because such situations cannot be completely controlled in that they cannot be ‘solved’ in the traditional meaning of this word. However, there are ways of lessening the stress caused by such situations. Ethical rounds have been described as a valuable means for doctors and nurses to work with moral dilemmas in ethically complex situations.15
Lack of respect from surgeons and other doctors (theme D) was described as a difficulty by some anaesthetists in the first interview. However, when asked in the second interview how this type of difficulty was handled, most of these anaesthetists said that this was an almost non-existent problem nowadays. Therefore, there were very few descriptions of ways of solving this problem. It was notable how little reference was made to clinical guidelines or the role of the leadership in facilitating problem solving. The anaesthetists seemed to rely mainly on their own expertise combined with advice and help from a network of colleagues; this may be an expression of the strong professional culture in the anaesthetic ‘community of practice’.16 Although the present study includes only a group of anaesthetists in the health care setting of one country, Sweden, which may not transfer to other countries, their statements have important implications. In training anaesthetists, enjoying the professional work has been found to be one of the characteristics of professional excellence among teachers of anaesthesia.17 It is therefore an important task for teachers of anaesthesia to help trainees to become professionals who know how to cope well with work.
As shown by Smith and colleagues,16 anaesthesia practice contains a manifold of adverse events that may threaten patient safety, even though few of these events are formally reported. Not only qualified anaesthetists but also inexperienced trainees will be exposed to such events, often with demands for immediate action. Even if the good teacher of anaesthesia has the ambition not to leave trainees without supervision, these young doctors still have to accept the uncertainties and complexities that are part of their work17 and they will often be on their own in very stressful situations. This is a growing problem, as trainees are getting less experience of clinical theatre work18 and even young consultants of today sometimes may not have the expertise necessary for some of the difficult cases that they will encounter.19 As anaesthetists, they therefore have to develop their ability to cope with uncertainty and error, a personal quality that, according to Kearney,20 belongs to professionalism. Thus, there is ample evidence that the anaesthetists' work is difficult and potentially very stressful, and therefore, anaesthetists need well-functioning coping strategies.
The major task for teachers of anaesthesia is to facilitate trainees' development of clinical competence at giving anaesthetics. However, young physicians should also be helped to develop into specialists who are content with work. Enjoying work promotes the well-being of doctors and patients.21 Most anaesthetists in this study explicitly declared that they were very content with work. To foster job satisfaction by conveying to young anaesthetists what these satisfied anaesthetists told us about their ways of handling potentially difficult or stressful situations is important. This is not only a question of acquiring an increasing amount of knowledge and skills through clinical experience and theoretical studies, but it is also about developing cognitive skills concerning the appraisal of potentially stressful situations14 because the stress effect of such situations depends considerably on how they are appraised. To change from experiencing work as a threat to seeing it as a pleasant challenge is an important step for trainee anaesthetists.
To handle a situation that cannot be mastered is the challenge of coping. If there is a high stake in the outcome (e.g. the patient is a child), any doubt about the power to control the situation can produce severe stress. Inexperienced trainees may try to convert such uncontrollable situations into controllable ones by oversimplifying ambiguous complex situations as a way of avoiding this challenge. Another possible outcome could be the trainee retreating into helplessness, which could be potentially devastating. Admittedly, young doctors today may be put into situations where successful coping is just not possible.22
A group of the anaesthetists interviewed in this study maintained that they very much enjoyed work and they could see no external obstacles to doing a good job. They had arrived at a wise reconciliation with the conditions of anaesthetists' work with its inherent difficulties and problems. The physicians' dilemma of today has been described as ‘doing better but feeling worse’.23 These anaesthetists seemed to have arrived, instead, at a desirable state of doing well enough and feeling content. Getting access to their coping strategies might help young anaesthetists to come to terms with their work.
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The authors wish to thank the participating anaesthetists, who so willingly took the time during busy working days to share their experiences with us.
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