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Quality of life among healthcare workers: A multicentre cross-sectional study in Italy
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Original Research
Quality of life among healthcare workers: A multicentre cross-sectional study in Italy F. Kheiraoui a, M.R. Gualano a, A. Mannocci b, A. Boccia b, G. La Torre b,* a b
Institute of Hygiene, Catholic University of the Sacred Heart, Rome, Italy Department of Public Health and Infectious Diseases, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
article info
summary
Article history:
Objective: To evaluate the quality of life among doctors, nurses, and occupational safety and
Received 25 March 2011
health technologists (OSHT).
Received in revised form
Study design: Cross-sectional study was undertaken in a population of healthcare workers
10 February 2012
in 10 Italian regions.
Accepted 15 March 2012
Methods: The Italian version of Short Form-36 (SF-36) was anonymously and voluntarily
Available online 22 May 2012
self-administered by participants to assess the perceived health-related quality of life (HRQOL). The HRQOL scores for the sample and the Italian population were compared. A
Keywords:
multiple linear regression was performed to assess the influence of age, gender, role,
Quality of life
socializing time, working time, years spent in healthcare and years spent in the specific
SF-36
department on the SF-36 score.
Healthcare workers
Results: The sample included 324 healthcare workers [57.1% women, mean age 39.0
Italy
(standard deviation 10.2) years]: 52.6% were medical doctors, 36.8% were nurses and 10.5% were OSHTs. Workers with a career of >15 years achieved a general health score lower than that of workers with a shorter career, while those who spent more time in socializing activities achieved a higher mental health score. The multivariate analysis showed that increasing age is positively related to role emotional levels (b ¼ 0.243; P ¼ 0.002), while it appears to be inversely related to general health (b ¼ 0.218; P ¼ 0.007) and physical function (b ¼ 0.246; P ¼ 0.001). Nurses had lower scores for bodily pain (b ¼ 0.214; P < 0.001), social function (b ¼ 0.242; P ¼ 0.001) and role emotional (b ¼ 0.211; P ¼ 0.006) compared with doctors. Compared with the general Italian population, healthcare workers had higher scores for general health, physical function, role physical, bodily pain and mental health, and lower scores for vitality, social function and role emotional. Conclusions: Healthcare workers have different levels of HRQOL related to their professional role. In particular, nurses have lower quality of life. These results may help to identify the main roles and attitudes that could cause frustration, dissatisfaction and emotional stress in healthcare workers. ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ39 (0)6 49970388; fax: þ39 (0)6 49972473. E-mail address: [email protected] (G. La Torre). 0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2012.03.006
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Introduction
Methods
Quality of life in biomedical disciplines corresponds, in reality, to what UK authors call ‘health-related quality of life’ (HRQOL), and concerns those aspects of quality of life that are related to health and disease and can therefore be addressed by medicine.1 The perception of health and quality of life in patients has been the subject of extensive investigation in recent years, but research focussing on quality of life among healthcare personnel is scarce and these issues need to be better appreciated. It is important to understand the specific characteristics of healthcare personnel, and explore the relationship of their level of job burden with quality of life parameters and psychosocial aspects of their work. This could be used to optimize the use of support and interventional measures, and help to reduce negative effects on their lives. Minimizing the burden on healthcare personnel will possibly improve the quality of life and medical outcomes of their patients, and the relationship with their private life. There is evidence that elevated rates of psychological stress and stress-related disorders do exist among hospital staff,2 and this also can be witnessed by the high prevalence of smoking among healthcare workers.3 Hospitals and health prevention units are characterized by a high level of work-related stress, a factor known to increase the risk of low quality of life.4e7 Among the possible causes of high levels of work-related stress are: tiredness; high turnover; night shift; workload; stressful work environments (e.g. intensive care unit); severity of illness; and conflicts with coworkers or patients.8 The workload of intensive care unit doctors, for example, is physically demanding, allows limited rest, and is associated with sleep deprivation and objective markers of physiological stress (ketonuria, arrhythmia or heart rate abnormalities)9 that may affect their private and social lives. Occupational safety and health technologists (OSHTs) are also exposed to high levels of stress. They have a civil and legal liability, their workload is often related to the needs of health service surveillance, and they have to guarantee continuous availability in their activities. As such, they often have no spare time for personal relationships, except for those with their colleagues. Work environment and psychosocial factors have also been considered key determinants of the health problems observed in hospital workers. Psychosocial aspects are represented by the interaction between work environment, content and conditions, worker capacity, needs and culture, and personal issues. This may, according to perception and experiences, influence health, satisfaction and work performance.10e12 The main aim of this study was to evaluate if there were differences in self-perceived health status among healthcare workers, focussing in particular on medical doctors, nurses and OHSTs. A secondary aim of this study was to assess if differences exist between healthcare workers and the general population.
Population and setting
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A cross-sectional study was undertaken in a population of healthcare workers drawn from the following Italian regions: Abruzzo; Calabria; Emilia Romagna; Lazio; Liguria; Lombardy; Marche; Sicily; Apulia and Tuscany. Participants were selected from healthcare workers who attended voluntary continuous professional development (CPD) courses in the above regions. A questionnaire was anonymously and voluntarily self-administered to doctors, nurses and OHSTs during courses on health management, diabetes care, psoriasis treatment and hospital infection control. Doctors and nurses were selected from various wards and backgrounds from all the regions considered. OHST technicians were drawn from all branches of prevention departments (safety and prevention at the workplace, public health service, veterinary service and food safety service) in central Italy, specifically Rome, the province of Rome and the province of Latina.
Quality of life measurement The health status of participants was assessed using the Italian version of Short Form-36 (SF-36). The crude estimates were transformed using the procedure described by Apolone and Mosconi and others.13e16
Statistical analysis Sample size calculations were based on the following assumptions: medical and non-medical personnel were sampled, with a difference in the general health score of 6, and a standard deviation (SD) of 22.13 According to these parameters, EpiCalc 2000 (Joseph Gilman and Mark Myatt of Brixton Health) was used to determine that 308 individuals were needed. Descriptive analysis was used to show quantitative and categorical variables: means and SDs were used for quantitative variables, and frequencies were used for categorical variables. Differences in the SF-36 scores between groups were tested using t-test and analysis of variance. Moreover, the means of the variables (SF-36 scores) were compared with the means of the Italian general population13 using t-test. Furthermore, a multivariate analysis using linear regression was conducted in order to assess the influence of age, gender, role, socializing time (h/week), working time (h/ week) week, years spent in the healthcare system, and years spent in the specific department on the SF-36 score (as dependent variables). Variables with a P-value <0.25 in the univariate analysis were selected, in accordance with Kleinbaum’s procedure.17 The level of significance was set at P 0.05. Statistical analysis was performed using Statistical Package for the Social Sciences Version 12.0 (SPSS Inc., Chicago, IL, USA). The presentation of results was made according to the STROBE statement.18
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Results The sample included 324 healthcare workers, 57.1% of whom were women. The mean age of this sample was 39.0 (SD 10.1) years. The response rate was 98%, without differences by region and healthcare groups studied. The characteristics of the sample are shown in Table 1. More than half of the sample (52.6%) were medical doctors, 36.8% were nurses and 10.5% were OHSTs. The mean number of years spent in healthcare was 16.6 (SD 9.1). Within the different occupational groups, no gender differences were found for socializing activities, length of career and number of working hours per week, with the exception of length of career for OHSTs (>15 years in healthcare system, 16.7% for females vs 64.3% for males; P ¼ 0.033). The characteristics of the sample, in comparison with the Italian population,13 showed that healthcare workers achieved higher scores with significant differences for general health (P ¼ 0.002), physical function (P < 0.0001) and mental health (P ¼ 0.042), but lower scores for vitality (P ¼ 0.019), social function (P < 0.0001) and role emotional (Limitations related to the own role in life for emotional problems) (activities as a result of emotional problems) (P ¼ 0.015) (Table 2). In the univariate analysis (Tables 3 and 4), women had lower bodily pain scores than men, and this result was significant (P ¼ 0.005). Nurses had lower scores than medical doctors and OHSTs for role physical (Limitations of activities related to the own role: Spending less time at work, limitations in the type of work, difficulty in performing the work or other activities) (P ¼ 0.011) and bodily pain (P ¼ 0.001), while OHSTs had higher scores for vitality (P ¼ 0.008). Differences were found in mental health, positively related to the amount of socializing time: those who spent more time in social activities seemed to have a higher mental health score (P ¼ 0.009; t-test). Moreover, healthcare workers with a career of >15 years had a lower general health score than those who reported a shorter career in the healthcare system (P ¼ 0.005).
Table 1 e Characteristics of the sample. Characteristics
Mean (SD)
Age (years) Gender Role
Macro-regions Working time (h) Socializing time per week (h) Years in healthcare system
Male Female Doctors Nurses OSHTs NortheCentral Italy SoutheCentral Italy 40 40 8 8 15 15
39.0 (10.1) n (%) 133 (42.9) 182 (57.1) 166 (52.6) 118 (36.8) 31 (10.5) 105 (33.1) 212 (66.8) 185 (58.4) 131 (41.4) 176 (55.6) 140 (44.3) 211 (66.7) 105 (33.2)
OSHTs, occupational safety and health technologists; SD, standard deviation.
Table 2 e Comparisons of Short Form-36 (SF-36) mean scores between healthcare workers and the Italian general population. SF-36 scores
Physical function Role physical Bodily pain General health Vitality Social function Role emotional and status Mental health
General population (Italy, 1995) Mean (SD) 84.5 78.2 73.7 65.2 61.9 77.4 76.2
(23.2) (35.9) (27.6) (22.3) (20.7) (23.3) (37.2)
66.6 (20.9)
Healthcare workers (2009) Mean (SD) 92.8 79.3 75.9 69.1 59.1 67.7 71.0
(11.7) (31.1) (22.7) (17.0) (18.9) (22.2) (35.3)
68.9 (17.1)
P-values
<0.0001 0.601 0.149 0.002 0.019 <0.0001 0.015 0.042
Bold: statistically significant results.
Healthcare workers who spent >8 h/week in socializing activities had a higher mental health score than others (P ¼ 0.009), while those who worked for >40 h/week had a lower vitality score (P ¼ 0.005). All the other results of the univariate analysis are shown in Tables 3and 4. As shown in Table 5, results of the multivariate analysis showed that increasing age was associated with a higher role emotional score (b ¼ 0.243; P ¼ 0.002), while was an inverse relationship with general health and physical function scores (b ¼ 0.218; P ¼ 0.007 and b ¼ 0.246; P ¼ 0.001, respectively). Nurses had lower scores for bodily pain (b ¼ 0.214; P < 0.001), social function (b ¼ 0.242; P ¼ 0.001) and role emotional (b ¼ 0.211; P ¼ 0.006) compared with doctors. In terms of gender, women had lower scores for vitality and mental health (b ¼ 0.210; P ¼ 0.007 and b ¼ 0.168; P ¼ 0.046, respectively) than men.
Discussion To the authors’ knowledge, this is the first Italian study evaluating the quality of life in healthcare workers and its perception among different subcategories (medical doctors, nurses and OHSTs). The high response rate, which did not differ between the regions or the groups of healthcare workers studied, gives robust results representative at the national level. While a strong association between healthcare work and occupational stress has been described previously by several Italian studies, the way in which different categories of healthcare workers face the potential effects of working in healthcare has not been fully explored before.19e23 This study revealed that, compared with the Italian general population,13 healthcare workers achieved higher scores for general health, physical function, role physical, bodily pain and mental health, but lower scores for vitality, social function and role emotional. The findings suggest that healthcare workers have a more positive attitude towards their health status compared with the general population, probably because of their daily activities which are closely connected with physical suffering, pain and emotional distress. Additionally, this study shows that
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Table 3 e Results of univariate analysis for Short Form-36 scales by gender and age groups. Variables (n)
Gender Males (133) Females (182) P Age (years) <40 (180) 40 (136) P
General health
Physical function
Role physical
Bodily pain
Social functioning
Vitality
Role emotional and status
Mental health
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
70.4 (15.2) 68.2 (18.4) 0.19
93.1 (12.6) 92.6 (11.0) 0.39
82.7 (29.1) 76.6 (32.1) 0.068
80.2 (21.5) 73.1 (22.1) 0.005
69.6 (20.9) 66.3 (23.2) 0.12
62.3 (17.8) 56.7 (19.5) 0.008
75.1 (34.3) 67.9 (35.9) 0.084
71.6 (15.5) 67.1 (18.1) 0.015
71.2 (17.6) 66.4 (16.1) 0.012
93.9 (9.3) 91.4 (14.2) 0.048
77.1 (31.4) 82.1 (30.9) 0.10
75.7 (23.0) 76.7 (21.8) 0.53
64.6 (22.6) 71.7 (21.4) 0.004
56.7 (19.4) 62.1 (17.9) 0.007
65.5 (36.0) 78.3 (33.2) 0.002
66.7 (17.3) 72.1 (16.6) 0.006
SD, standard deviation. P-values on t-test.
women seem to be more sensitive (women achieved lower vitality and mental health scores) to healthcare-work-related stress, probably because of greater empathy relative to men, and increased risk of current work-related violence were found among nurses.24 Healthcare workers are constantly called on to handle feelings and ‘strong emotions’. Differences could exist in the perception of stress in the different groups of healthcare workers,25 as well as, according to Yang et al. (2002), differences in stress levels among healthcare workers in different wards (emergency department vs general medical).26 In this context, it is important to underline that workplace and individual factors as well as social situations appear to increase the risk for absence due to stress among healthcare
workers,27 and stress management programmes at the workplace have an impact on reducing absenteeism, at least in the short term.28 The lower vitality of healthcare workers may be due to the restrictions that working hours have imposed on their personal time, as well as a sense of failure regarding their hopes and expectations at work. Two courses of action could be useful: increasing education and training responsibilities would be effective in re-awakening the ideals intrinsic to health-related professions and in mustering energy and enthusiasm; and giving healthcare workers professional support for coping with the sense of failure and physical stress (e.g. individual counselling or continued informal support). Improvement of relationships with coworkers and better
Table 4 e Results of univariate analysis for Short Form-36 scales by professional factors. Variables (n)
General health
Physical function
Role physical
Bodily pain
Social functioning
Vitality
Role emotional and status
Mental health
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
94.6 (9.9) 91.1 (10.6) 90.2 (20.2) 0.043
82.8 (29.2) 72.5 (33.1) 86.3 (30.8) 0.011
80.5 (19.9) 69.5 (24.2) 79.0 (22.8) 0.001
69.5 (21.9) 64.3 (23.8) 71.4 (17.1) 0.095
56.9 (18.2) 59.9 (19.5) 68.1 (18.3) 0.008
73.7 (34.4) 66.2 (36.6) 74.7 (35.7) 0.211
67.9 (16.1) 70.0 (18.9) 72.2 (14.4) 0.337
93.3 (10.9) 92.6 (12.3) 0.773
77.1 (32.1) 80.7 (30.5) 0.355
74.9 (21.8) 77.1 (23.0) 0.495
66.2 (22.6) 68.9 (22.8) 0.347
54.8 (18.3) 62.4 (18.8) <0.001
68.5 (35.1) 73.0 (35.6) 0.243
66.1 (16.4) 71.0 (17.4) 0.009
91.1 (13.5) 94.2 (10.0) 0.038
79.4 (32.0) 79.2 (30.7) 0.86
75.2 (22.6) 76.1 (22.0) 0.576
69.5 (23.4) 66.4 (21.4) 0.214
61.3 (17.6) 57.4 (19.7) 0.050
71.2 (36.4) 70.8 (34.8) 0.954
70.1 (16.8) 68.3 (17.4) 0.341
93.6 (9.6) 91.4 (14.9) 0.097
77.6 (31.4) 82.6 (30.6) 0.205
78.8 (22.8) 76.8 (21.9) 0.897
65.5 (22.4) 72.0 (21.5) 0.016
57.7 (19.2) 61.1 (18.3) 0.054
68.0 (35.5) 76.9 (34.5) 0.041
68.0 (17.7) 71.1 (15.8) 0.141
93.1 (9.9) 93.2 (10.9) 0.882
77.9 (30.6) 79.2 (32.2) 0.823
74.6 (22.0) 77.6 (22.9) 0.378
67.3 (21.5) 67.4 (24.5) 0.98
56.2 (19.1) 60.7 (18.1) 0.48
69.6 (34.5) 71.9 (36.7) 0.553
67.1 (17.5) 70.9 (17.2) 0.090
Role Doctors (166) 71.0 (16.8) Nurses (118) 66.8 (17.7) OHSTs (31) 68.5 (15.8) 0.133 Pa Socializing time per week (h) <8 (140) 68.1 (18.1) 8 (176) 69.5 (16.3) 0.772 Pb Working time (h) <40 (131) 66.8 (17.1) 40 (185) 70.9 (17.0) 0.036 Pb Years in healthcare system <15 (211) 71.0 (16.9) 15 (105) 65.4 (17.1) 0.005 Pb Years on specific ward <6 (160) 70.4 (17.2) 6 (124) 67.1 (17.4) 0.200 Pb
a P-values on analysis of variance. b P-values on t-test.
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Table 5 e Results of multivariate analyses for Short Form-36 scales (only significant results of linear regressions are shown). General health Age (1-year increase) Femalesa Nursesb Socializing time (h) Working time (h) R2 of the model
Physical function
Social function
Role physical
Bodily pain
Vitality
0.218 (0.007) 0.246 (0.001)
Role emotional and status 0.243 (0.002)
0.210 (0.007) 0.243 (0.001) 0.204 (0.006)
0.048
0.061
Mental health
0.059
0.214 (< 0.001)
0.042
0.046
0.168 (0.046) 0.211 (0.006)
0.151 (0.048) 0.291 (<0.001) 0.137
0.124
0.028
a Reference ¼ males. b Reference ¼ doctors.
coping mechanisms could contribute to the prevention of depression.29 A review of the workload in the Italian health system may be necessary, as the survey suggests that high turnover, frequent night shifts and a heavy workload are very likely to affect private and social life.30 This study has some limitations, because a cross-sectional study was performed, but the SF-36 questionnaire could be considered a widely used and reliable tool to investigate these topics. Bias may derive from the fact that the comparison between the sample population and the general population was made using data collected 14 years apart; in the latter group in 1995, and in healthcare workers in 2009. In reality, the score may have changed over time. A second version of the survey on the general population is ongoing.31 Moreover, the CPD courses were not compulsory, so the possibility that only the more interested and personally motivated people attended them cannot be excluded. However, the authors are confident that the results are robust due to the high response rate throughout the regions and among the different groups of healthcare workers. Finally, gender differences in the length of career were only seen for the OHST group, and this could influence the results in some way. However, it is likely that this is related not to the responsibilities of women outside of work (child care, domestic and family commitments), but to the low representation of females in this group of healthcare workers. In terms of strengths of the study, the sample was drawn from different Italian regions and different categories of healthcare workers in order to provide previously missing data about quality of life in the Italian health system.32e34 Moreover, a multivariate analysis was performed so that the results were adjusted for possible confounders. This study shows that healthcare workers have different perceptions of quality of life based on their particular role. Nurses and women, as opposed to other healthcare workers and men, respectively, seem to experience the worst results in terms of emotional factors. Healthcare workers have a better perception of life compared with the general population, even if they are exposed daily to physical suffering, pain and emotional distress. The authors strongly believe that it is important to recognize roles and the attitudes that could cause frustration, dissatisfaction and emotional stress in order to prevent development of these symptoms, and thus protect colleagues
and the people, patients or not, that healthcare workers meet every day at work.
Acknowledgements The authors would like to thank Luca Valerio for help revising the English grammar and language. Ethical approval None sought as Italian legislation does not require ethical approval for cross-sectional studies. Funding None declared. Competing interest None declared.
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Original Research
Quality of life among healthcare workers: A multicentre cross-sectional study in Italy F. Kheiraoui a, M.R. Gualano a, A. Mannocci b, A. Boccia b, G. La Torre b,* a b
Institute of Hygiene, Catholic University of the Sacred Heart, Rome, Italy Department of Public Health and Infectious Diseases, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
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summary
Article history:
Objective: To evaluate the quality of life among doctors, nurses, and occupational safety and
Received 25 March 2011
health technologists (OSHT).
Received in revised form
Study design: Cross-sectional study was undertaken in a population of healthcare workers
10 February 2012
in 10 Italian regions.
Accepted 15 March 2012
Methods: The Italian version of Short Form-36 (SF-36) was anonymously and voluntarily
Available online 22 May 2012
self-administered by participants to assess the perceived health-related quality of life (HRQOL). The HRQOL scores for the sample and the Italian population were compared. A
Keywords:
multiple linear regression was performed to assess the influence of age, gender, role,
Quality of life
socializing time, working time, years spent in healthcare and years spent in the specific
SF-36
department on the SF-36 score.
Healthcare workers
Results: The sample included 324 healthcare workers [57.1% women, mean age 39.0
Italy
(standard deviation 10.2) years]: 52.6% were medical doctors, 36.8% were nurses and 10.5% were OSHTs. Workers with a career of >15 years achieved a general health score lower than that of workers with a shorter career, while those who spent more time in socializing activities achieved a higher mental health score. The multivariate analysis showed that increasing age is positively related to role emotional levels (b ¼ 0.243; P ¼ 0.002), while it appears to be inversely related to general health (b ¼ 0.218; P ¼ 0.007) and physical function (b ¼ 0.246; P ¼ 0.001). Nurses had lower scores for bodily pain (b ¼ 0.214; P < 0.001), social function (b ¼ 0.242; P ¼ 0.001) and role emotional (b ¼ 0.211; P ¼ 0.006) compared with doctors. Compared with the general Italian population, healthcare workers had higher scores for general health, physical function, role physical, bodily pain and mental health, and lower scores for vitality, social function and role emotional. Conclusions: Healthcare workers have different levels of HRQOL related to their professional role. In particular, nurses have lower quality of life. These results may help to identify the main roles and attitudes that could cause frustration, dissatisfaction and emotional stress in healthcare workers. ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ39 (0)6 49970388; fax: þ39 (0)6 49972473. E-mail address: [email protected] (G. La Torre). 0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2012.03.006
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Introduction
Methods
Quality of life in biomedical disciplines corresponds, in reality, to what UK authors call ‘health-related quality of life’ (HRQOL), and concerns those aspects of quality of life that are related to health and disease and can therefore be addressed by medicine.1 The perception of health and quality of life in patients has been the subject of extensive investigation in recent years, but research focussing on quality of life among healthcare personnel is scarce and these issues need to be better appreciated. It is important to understand the specific characteristics of healthcare personnel, and explore the relationship of their level of job burden with quality of life parameters and psychosocial aspects of their work. This could be used to optimize the use of support and interventional measures, and help to reduce negative effects on their lives. Minimizing the burden on healthcare personnel will possibly improve the quality of life and medical outcomes of their patients, and the relationship with their private life. There is evidence that elevated rates of psychological stress and stress-related disorders do exist among hospital staff,2 and this also can be witnessed by the high prevalence of smoking among healthcare workers.3 Hospitals and health prevention units are characterized by a high level of work-related stress, a factor known to increase the risk of low quality of life.4e7 Among the possible causes of high levels of work-related stress are: tiredness; high turnover; night shift; workload; stressful work environments (e.g. intensive care unit); severity of illness; and conflicts with coworkers or patients.8 The workload of intensive care unit doctors, for example, is physically demanding, allows limited rest, and is associated with sleep deprivation and objective markers of physiological stress (ketonuria, arrhythmia or heart rate abnormalities)9 that may affect their private and social lives. Occupational safety and health technologists (OSHTs) are also exposed to high levels of stress. They have a civil and legal liability, their workload is often related to the needs of health service surveillance, and they have to guarantee continuous availability in their activities. As such, they often have no spare time for personal relationships, except for those with their colleagues. Work environment and psychosocial factors have also been considered key determinants of the health problems observed in hospital workers. Psychosocial aspects are represented by the interaction between work environment, content and conditions, worker capacity, needs and culture, and personal issues. This may, according to perception and experiences, influence health, satisfaction and work performance.10e12 The main aim of this study was to evaluate if there were differences in self-perceived health status among healthcare workers, focussing in particular on medical doctors, nurses and OHSTs. A secondary aim of this study was to assess if differences exist between healthcare workers and the general population.
Population and setting
625
A cross-sectional study was undertaken in a population of healthcare workers drawn from the following Italian regions: Abruzzo; Calabria; Emilia Romagna; Lazio; Liguria; Lombardy; Marche; Sicily; Apulia and Tuscany. Participants were selected from healthcare workers who attended voluntary continuous professional development (CPD) courses in the above regions. A questionnaire was anonymously and voluntarily self-administered to doctors, nurses and OHSTs during courses on health management, diabetes care, psoriasis treatment and hospital infection control. Doctors and nurses were selected from various wards and backgrounds from all the regions considered. OHST technicians were drawn from all branches of prevention departments (safety and prevention at the workplace, public health service, veterinary service and food safety service) in central Italy, specifically Rome, the province of Rome and the province of Latina.
Quality of life measurement The health status of participants was assessed using the Italian version of Short Form-36 (SF-36). The crude estimates were transformed using the procedure described by Apolone and Mosconi and others.13e16
Statistical analysis Sample size calculations were based on the following assumptions: medical and non-medical personnel were sampled, with a difference in the general health score of 6, and a standard deviation (SD) of 22.13 According to these parameters, EpiCalc 2000 (Joseph Gilman and Mark Myatt of Brixton Health) was used to determine that 308 individuals were needed. Descriptive analysis was used to show quantitative and categorical variables: means and SDs were used for quantitative variables, and frequencies were used for categorical variables. Differences in the SF-36 scores between groups were tested using t-test and analysis of variance. Moreover, the means of the variables (SF-36 scores) were compared with the means of the Italian general population13 using t-test. Furthermore, a multivariate analysis using linear regression was conducted in order to assess the influence of age, gender, role, socializing time (h/week), working time (h/ week) week, years spent in the healthcare system, and years spent in the specific department on the SF-36 score (as dependent variables). Variables with a P-value <0.25 in the univariate analysis were selected, in accordance with Kleinbaum’s procedure.17 The level of significance was set at P 0.05. Statistical analysis was performed using Statistical Package for the Social Sciences Version 12.0 (SPSS Inc., Chicago, IL, USA). The presentation of results was made according to the STROBE statement.18
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Results The sample included 324 healthcare workers, 57.1% of whom were women. The mean age of this sample was 39.0 (SD 10.1) years. The response rate was 98%, without differences by region and healthcare groups studied. The characteristics of the sample are shown in Table 1. More than half of the sample (52.6%) were medical doctors, 36.8% were nurses and 10.5% were OHSTs. The mean number of years spent in healthcare was 16.6 (SD 9.1). Within the different occupational groups, no gender differences were found for socializing activities, length of career and number of working hours per week, with the exception of length of career for OHSTs (>15 years in healthcare system, 16.7% for females vs 64.3% for males; P ¼ 0.033). The characteristics of the sample, in comparison with the Italian population,13 showed that healthcare workers achieved higher scores with significant differences for general health (P ¼ 0.002), physical function (P < 0.0001) and mental health (P ¼ 0.042), but lower scores for vitality (P ¼ 0.019), social function (P < 0.0001) and role emotional (Limitations related to the own role in life for emotional problems) (activities as a result of emotional problems) (P ¼ 0.015) (Table 2). In the univariate analysis (Tables 3 and 4), women had lower bodily pain scores than men, and this result was significant (P ¼ 0.005). Nurses had lower scores than medical doctors and OHSTs for role physical (Limitations of activities related to the own role: Spending less time at work, limitations in the type of work, difficulty in performing the work or other activities) (P ¼ 0.011) and bodily pain (P ¼ 0.001), while OHSTs had higher scores for vitality (P ¼ 0.008). Differences were found in mental health, positively related to the amount of socializing time: those who spent more time in social activities seemed to have a higher mental health score (P ¼ 0.009; t-test). Moreover, healthcare workers with a career of >15 years had a lower general health score than those who reported a shorter career in the healthcare system (P ¼ 0.005).
Table 1 e Characteristics of the sample. Characteristics
Mean (SD)
Age (years) Gender Role
Macro-regions Working time (h) Socializing time per week (h) Years in healthcare system
Male Female Doctors Nurses OSHTs NortheCentral Italy SoutheCentral Italy 40 40 8 8 15 15
39.0 (10.1) n (%) 133 (42.9) 182 (57.1) 166 (52.6) 118 (36.8) 31 (10.5) 105 (33.1) 212 (66.8) 185 (58.4) 131 (41.4) 176 (55.6) 140 (44.3) 211 (66.7) 105 (33.2)
OSHTs, occupational safety and health technologists; SD, standard deviation.
Table 2 e Comparisons of Short Form-36 (SF-36) mean scores between healthcare workers and the Italian general population. SF-36 scores
Physical function Role physical Bodily pain General health Vitality Social function Role emotional and status Mental health
General population (Italy, 1995) Mean (SD) 84.5 78.2 73.7 65.2 61.9 77.4 76.2
(23.2) (35.9) (27.6) (22.3) (20.7) (23.3) (37.2)
66.6 (20.9)
Healthcare workers (2009) Mean (SD) 92.8 79.3 75.9 69.1 59.1 67.7 71.0
(11.7) (31.1) (22.7) (17.0) (18.9) (22.2) (35.3)
68.9 (17.1)
P-values
<0.0001 0.601 0.149 0.002 0.019 <0.0001 0.015 0.042
Bold: statistically significant results.
Healthcare workers who spent >8 h/week in socializing activities had a higher mental health score than others (P ¼ 0.009), while those who worked for >40 h/week had a lower vitality score (P ¼ 0.005). All the other results of the univariate analysis are shown in Tables 3and 4. As shown in Table 5, results of the multivariate analysis showed that increasing age was associated with a higher role emotional score (b ¼ 0.243; P ¼ 0.002), while was an inverse relationship with general health and physical function scores (b ¼ 0.218; P ¼ 0.007 and b ¼ 0.246; P ¼ 0.001, respectively). Nurses had lower scores for bodily pain (b ¼ 0.214; P < 0.001), social function (b ¼ 0.242; P ¼ 0.001) and role emotional (b ¼ 0.211; P ¼ 0.006) compared with doctors. In terms of gender, women had lower scores for vitality and mental health (b ¼ 0.210; P ¼ 0.007 and b ¼ 0.168; P ¼ 0.046, respectively) than men.
Discussion To the authors’ knowledge, this is the first Italian study evaluating the quality of life in healthcare workers and its perception among different subcategories (medical doctors, nurses and OHSTs). The high response rate, which did not differ between the regions or the groups of healthcare workers studied, gives robust results representative at the national level. While a strong association between healthcare work and occupational stress has been described previously by several Italian studies, the way in which different categories of healthcare workers face the potential effects of working in healthcare has not been fully explored before.19e23 This study revealed that, compared with the Italian general population,13 healthcare workers achieved higher scores for general health, physical function, role physical, bodily pain and mental health, but lower scores for vitality, social function and role emotional. The findings suggest that healthcare workers have a more positive attitude towards their health status compared with the general population, probably because of their daily activities which are closely connected with physical suffering, pain and emotional distress. Additionally, this study shows that
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Table 3 e Results of univariate analysis for Short Form-36 scales by gender and age groups. Variables (n)
Gender Males (133) Females (182) P Age (years) <40 (180) 40 (136) P
General health
Physical function
Role physical
Bodily pain
Social functioning
Vitality
Role emotional and status
Mental health
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
70.4 (15.2) 68.2 (18.4) 0.19
93.1 (12.6) 92.6 (11.0) 0.39
82.7 (29.1) 76.6 (32.1) 0.068
80.2 (21.5) 73.1 (22.1) 0.005
69.6 (20.9) 66.3 (23.2) 0.12
62.3 (17.8) 56.7 (19.5) 0.008
75.1 (34.3) 67.9 (35.9) 0.084
71.6 (15.5) 67.1 (18.1) 0.015
71.2 (17.6) 66.4 (16.1) 0.012
93.9 (9.3) 91.4 (14.2) 0.048
77.1 (31.4) 82.1 (30.9) 0.10
75.7 (23.0) 76.7 (21.8) 0.53
64.6 (22.6) 71.7 (21.4) 0.004
56.7 (19.4) 62.1 (17.9) 0.007
65.5 (36.0) 78.3 (33.2) 0.002
66.7 (17.3) 72.1 (16.6) 0.006
SD, standard deviation. P-values on t-test.
women seem to be more sensitive (women achieved lower vitality and mental health scores) to healthcare-work-related stress, probably because of greater empathy relative to men, and increased risk of current work-related violence were found among nurses.24 Healthcare workers are constantly called on to handle feelings and ‘strong emotions’. Differences could exist in the perception of stress in the different groups of healthcare workers,25 as well as, according to Yang et al. (2002), differences in stress levels among healthcare workers in different wards (emergency department vs general medical).26 In this context, it is important to underline that workplace and individual factors as well as social situations appear to increase the risk for absence due to stress among healthcare
workers,27 and stress management programmes at the workplace have an impact on reducing absenteeism, at least in the short term.28 The lower vitality of healthcare workers may be due to the restrictions that working hours have imposed on their personal time, as well as a sense of failure regarding their hopes and expectations at work. Two courses of action could be useful: increasing education and training responsibilities would be effective in re-awakening the ideals intrinsic to health-related professions and in mustering energy and enthusiasm; and giving healthcare workers professional support for coping with the sense of failure and physical stress (e.g. individual counselling or continued informal support). Improvement of relationships with coworkers and better
Table 4 e Results of univariate analysis for Short Form-36 scales by professional factors. Variables (n)
General health
Physical function
Role physical
Bodily pain
Social functioning
Vitality
Role emotional and status
Mental health
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
94.6 (9.9) 91.1 (10.6) 90.2 (20.2) 0.043
82.8 (29.2) 72.5 (33.1) 86.3 (30.8) 0.011
80.5 (19.9) 69.5 (24.2) 79.0 (22.8) 0.001
69.5 (21.9) 64.3 (23.8) 71.4 (17.1) 0.095
56.9 (18.2) 59.9 (19.5) 68.1 (18.3) 0.008
73.7 (34.4) 66.2 (36.6) 74.7 (35.7) 0.211
67.9 (16.1) 70.0 (18.9) 72.2 (14.4) 0.337
93.3 (10.9) 92.6 (12.3) 0.773
77.1 (32.1) 80.7 (30.5) 0.355
74.9 (21.8) 77.1 (23.0) 0.495
66.2 (22.6) 68.9 (22.8) 0.347
54.8 (18.3) 62.4 (18.8) <0.001
68.5 (35.1) 73.0 (35.6) 0.243
66.1 (16.4) 71.0 (17.4) 0.009
91.1 (13.5) 94.2 (10.0) 0.038
79.4 (32.0) 79.2 (30.7) 0.86
75.2 (22.6) 76.1 (22.0) 0.576
69.5 (23.4) 66.4 (21.4) 0.214
61.3 (17.6) 57.4 (19.7) 0.050
71.2 (36.4) 70.8 (34.8) 0.954
70.1 (16.8) 68.3 (17.4) 0.341
93.6 (9.6) 91.4 (14.9) 0.097
77.6 (31.4) 82.6 (30.6) 0.205
78.8 (22.8) 76.8 (21.9) 0.897
65.5 (22.4) 72.0 (21.5) 0.016
57.7 (19.2) 61.1 (18.3) 0.054
68.0 (35.5) 76.9 (34.5) 0.041
68.0 (17.7) 71.1 (15.8) 0.141
93.1 (9.9) 93.2 (10.9) 0.882
77.9 (30.6) 79.2 (32.2) 0.823
74.6 (22.0) 77.6 (22.9) 0.378
67.3 (21.5) 67.4 (24.5) 0.98
56.2 (19.1) 60.7 (18.1) 0.48
69.6 (34.5) 71.9 (36.7) 0.553
67.1 (17.5) 70.9 (17.2) 0.090
Role Doctors (166) 71.0 (16.8) Nurses (118) 66.8 (17.7) OHSTs (31) 68.5 (15.8) 0.133 Pa Socializing time per week (h) <8 (140) 68.1 (18.1) 8 (176) 69.5 (16.3) 0.772 Pb Working time (h) <40 (131) 66.8 (17.1) 40 (185) 70.9 (17.0) 0.036 Pb Years in healthcare system <15 (211) 71.0 (16.9) 15 (105) 65.4 (17.1) 0.005 Pb Years on specific ward <6 (160) 70.4 (17.2) 6 (124) 67.1 (17.4) 0.200 Pb
a P-values on analysis of variance. b P-values on t-test.
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Table 5 e Results of multivariate analyses for Short Form-36 scales (only significant results of linear regressions are shown). General health Age (1-year increase) Femalesa Nursesb Socializing time (h) Working time (h) R2 of the model
Physical function
Social function
Role physical
Bodily pain
Vitality
0.218 (0.007) 0.246 (0.001)
Role emotional and status 0.243 (0.002)
0.210 (0.007) 0.243 (0.001) 0.204 (0.006)
0.048
0.061
Mental health
0.059
0.214 (< 0.001)
0.042
0.046
0.168 (0.046) 0.211 (0.006)
0.151 (0.048) 0.291 (<0.001) 0.137
0.124
0.028
a Reference ¼ males. b Reference ¼ doctors.
coping mechanisms could contribute to the prevention of depression.29 A review of the workload in the Italian health system may be necessary, as the survey suggests that high turnover, frequent night shifts and a heavy workload are very likely to affect private and social life.30 This study has some limitations, because a cross-sectional study was performed, but the SF-36 questionnaire could be considered a widely used and reliable tool to investigate these topics. Bias may derive from the fact that the comparison between the sample population and the general population was made using data collected 14 years apart; in the latter group in 1995, and in healthcare workers in 2009. In reality, the score may have changed over time. A second version of the survey on the general population is ongoing.31 Moreover, the CPD courses were not compulsory, so the possibility that only the more interested and personally motivated people attended them cannot be excluded. However, the authors are confident that the results are robust due to the high response rate throughout the regions and among the different groups of healthcare workers. Finally, gender differences in the length of career were only seen for the OHST group, and this could influence the results in some way. However, it is likely that this is related not to the responsibilities of women outside of work (child care, domestic and family commitments), but to the low representation of females in this group of healthcare workers. In terms of strengths of the study, the sample was drawn from different Italian regions and different categories of healthcare workers in order to provide previously missing data about quality of life in the Italian health system.32e34 Moreover, a multivariate analysis was performed so that the results were adjusted for possible confounders. This study shows that healthcare workers have different perceptions of quality of life based on their particular role. Nurses and women, as opposed to other healthcare workers and men, respectively, seem to experience the worst results in terms of emotional factors. Healthcare workers have a better perception of life compared with the general population, even if they are exposed daily to physical suffering, pain and emotional distress. The authors strongly believe that it is important to recognize roles and the attitudes that could cause frustration, dissatisfaction and emotional stress in order to prevent development of these symptoms, and thus protect colleagues
and the people, patients or not, that healthcare workers meet every day at work.
Acknowledgements The authors would like to thank Luca Valerio for help revising the English grammar and language. Ethical approval None sought as Italian legislation does not require ethical approval for cross-sectional studies. Funding None declared. Competing interest None declared.
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