European Journal of Anaesthesiology Stressors in anaesthetists - development and validation of a new questionnaire Cross- sectional study --Manuscript Draft-- Manuscript Number: Full Title: Stressors in anaesthetists - development and validation of a new questionnaire Cross- sectional study Short Title: Stress evaluation in anaesthetists Article Type: Original Article Corresponding Author: Teresa Lapa, MD Coimbra Hospital and University Centre Coimbra, PORTUGAL Corresponding Author Secondary Information: Corresponding Author's Institution: Coimbra Hospital and University Centre Corresponding Author's Secondary Institution: First Author: Teresa Lapa, MD First Author Secondary Information: Order of Authors: Teresa Lapa, MD Sérgio A. Carvalho, Msc Joaquim S. Viana, MD, PhD Pedro L. Ferreira, PhD José Pinto-Gouveia, MD, PhD Order of Authors Secondary Information: Manuscript Region of Origin: PORTUGAL Abstract: Background: Stress in anaesthetists is a common problem due to multiple factors related to patients, colleagues and organizations. This can lead to serious consequences such as depression, work-home conflicts and burnout. Decrease anaesthetists stress and its consequences can be reached by reducing the number and magnitude of stressors or by increasing resilience strategies. Evaluating stressors in the day-to-day life of anaesthetists is complex, and the existing tools are not sufficiently accurate. Objective: We have created the Stressors Questionnaire in Anaesthetists (SQA), in order to qualify the sources of stress in anaesthetists` professional lives, and to measure the level of stress associated to these factors. Design: A questionnaire-based cross-sectional design. Settings: The study was conducted between 1st January 2014 and 30th December 2014, throughout different anaesthesia departments in Portuguese hospitals, in which 710 participants responded the questionnaires. Method: We performed an exploratory analysis and two confirmatory analyses. The construct validity of the SQA was assessed via correlation with other stress measures, burnout and satisfaction with life, across these samples. Internal consistency reliability was assessed by Cronbach α. Results: The exploratory analysis showed the SQA is a tri-dimensional instrument and confirmatory analysis showed the tri-dimensional structure presented good model fit. The three dimensions of SQA correlated positively with other stress measures and burnout and negatively with satisfaction with life. Conclusions: SQA is a well-adjusted measure for assessing stressors in anaesthetists and includes clinical, organizational and team stress factors. Results showed that SQA is a robust and reliable instrument. SQA contributes for a better understanding of the Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation stress induction factors, which can lead to better stress management and anaesthetists' wellbeing. Suggested Reviewers: Pablo Rama-Maceiras [email protected] This author published a stress and burnout review article in EJA ("Job satisfaction, stress and burnout in anaesthesia: relevant topics for anaesthesiologists and healthcare managers?") Opposed Reviewers: Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation Manuscript - No PDF files (including title, all authors, corresponding author email, references and figure legends) Article Title Stressors in anaesthetists – development and validation of a new questionnaire 1 2 3 Cross-sectional study 4 | 1 5 6 Running head 7 8 Stress evaluation in anaesthetists 9 10 11 12 13 14 Authors 15 16 Lapa TA 1,2; Carvalho S3; Viana JS 1,2; Ferreira PL4,5; Pinto-Gouveia J3 17 18 19 1 Coimbra Hospital and University Centre, Portugal 20 21 2 Faculty of Health Sciences, University of Beira Interior, Portugal 22 23 24 3 Cognitive-Behavioural Research Centre (CINEICC), University of Coimbra, Portugal 25 26 27 4 Faculty of Economics, University of Coimbra, Portugal 28 29 5 Centre for Health Studies and Research, University of Coimbra, Portugal 30 31 32 33 34 35 Author for correspondence: 36 37 Teresa Alexandra Santos Carvalho Lapa 38 39 40 Anaesthesiology Service 41 42 43 Coimbra Hospital and University Centre. Praceta Prof. Mota Pinto, 3000-075 Coimbra, 44 45 Portugal 46 47 phone number: 00351 964090762 48 49 50 e-mail: [email protected] 51 52 - Number of words in Abstract – 267 53 54 - Number of words in Introduction – 314 55 56 - Number of words in Discussion - 1161 57 58 59 60 61 62 63 64 65 1 2 ABSTRACT 3 4 | 2 5 Background. Stress in anaesthetists is a common problem due to multiple factors 6 7 8 related to patients, colleagues and organizations. This can lead to serious 9 10 consequences such as depression, work-home conflicts and burnout. 11 12 13 14 Decrease anaesthetists stress and its consequences can be reached by reducing the 15 16 number and magnitude of stressors or by increasing resilience strategies. 17 18 19 Evaluating stressors in the day-to-day life of anaesthetists is complex, and the existing 20 21 22 tools are not sufficiently accurate. 23 24 25 Objective: We have created the Stressors Questionnaire in Anaesthetists (SQA), in 26 27 28 order to qualify the sources of stress in anaesthetists` professional lives, and to 29 30 31 measure the level of stress associated to these factors. 32 33 34 Design: A questionnaire-based cross-sectional design. 35 36 37 Settings: The study was conducted between 1st January 2014 and 30th December 38 39 40 2014, throughout different anaesthesia departments in Portuguese hospitals, in which 41 42 710 participants responded the questionnaires. 43 44 45 46 Method: We performed an exploratory analysis and two confirmatory analyses. The 47 48 construct validity of the SQA was assessed via correlation with other stress measures, 49 50 51 burnout and satisfaction with life, across these samples. Internal consistency reliability 52 53 was assessed by Cronbach α. 54 55 56 57 Results. The exploratory analysis showed the SQA is a tri-dimensional instrument and 58 59 confirmatory analysis showed the tri-dimensional structure presented good model fit. 60 61 62 63 64 65 The three dimensions of SQA correlated positively with other stress measures and burnout and negatively with satisfaction with life. 1 2 3 4 Conclusions. SQA is a well-adjusted measure for assessing stressors in anaesthetists | 3 5 6 and includes clinical, organizational and team stress factors. Results showed that SQA 7 8 9 is a robust and reliable instrument. SQA contributes for a better understanding of the 10 11 stress induction factors, which can lead to better stress management and 12 13 14 anaesthetists’ wellbeing. 15 16 17 Key words: Stress, anxiety, burnout. 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 1 INTRODUCTION 2 3 4 Professional stress is a well-described problem in clinical anaesthesia that can lead to | 4 5 6 7 burnout 1-3 and may have a negative impact on physical and mental well-being, life 8 9 situation and even patient care and health care system3,4. 10 11 12 13 Managing the effects of stress in professional environments can occur through two 14 15 pathways5,6. One is by limiting the exposure to work-related stressors, including the 16 17 18 improvement of organizational factors7,8. A recent Cochrane review 9 concluded that 19 20 the interventions need better focus on the reduction of specific stressors. However, 21 22 23 the reduction of stressors in anaesthetic practice is limited by ineluctable 24 25 26 characteristics of this speciality such as loss of control over practice and 27 28 unpredictability. A logical alternative is the development of emotional-regulation 29 30 31 strategies with potential to increase personal resilience to adverse conditions 8,10 and 32 33 reduce pervasive psychological processes, which maintains psychopathological 34 35 36 symptoms, such as rumination 11. 37 38 39 A significant number of tools are available for measuring the effects of stress in 40 41 42 healthcare providers´ well-being 4, burnout 12,13, mental distress 14 and professional 43 44 performance 15,16. These tools are broadly used in studies evaluating these conditions 45 46 47 in medical doctors of different specialities, including anaesthesia, and also in studies to 48 49 50 measure the value of interventions to increase resilience against stress. Nevertheless, 51 52 in order to accurately assess the efficacy and efficiency of an intervention in stress 53 54 55 effects, we need to quantify not only the effects (the consequences of stress) but also 56 57 the number and amplitude of stressors (the causes of effects). 58 59 60 61 62 63 64 65 To our knowledge, no appropriate instrument exists at the moment specifically for stressors evaluation in anaesthetists. 1 2 3 4 This paper describes the development of the Stress Questionnaire in Anaesthetists | 5 5 6 (SQA), the examination of its factor structure in an anaesthetist’s sample, followed by 7 8 9 item reduction. It further examines its factor structure in two other samples, and 10 11 examines the concurrent, divergent and incremental validity through its correlation 12 13 14 with a wide range of other measures of psychological processes and functioning. 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 1 MATERIALS AND METHODS 2 3 4 An anonymous questionnaire-based survey was conducted across different Portuguese | 6 5 6 7 hospitals’ anaesthesia departments. It included anaesthesia specialists and residents 8 9 and was conducted between 1st January 2014 and 30th December 2014. Data was 10 11 12 collected through self-reported questionnaires formed by demographic information, 13 14 15 work experience, and measures of stress, anxiety, depression, burnout, emotional 16 17 regulation psychological indicators and life satisfaction. 18 19 20 This study was approved by ethic commission of University. All questionnaires were 21 22 23 completed anonymously and all participants gave informed consent, in a separate 24 25 26 page. 27 28 29 30 31 32 Construction of the scale / Item development 33 34 35 36 In order to qualify the sources of stress in anaesthetists’ professional lives and to 37 38 measure the level of stress associated with these factors, a questionnaire with 10 39 40 41 items was developed. Items in SQA were based on the items often reported as 42 43 stressors2,7,14,17, on expert knowledge and practice, and on definitions from 44 45 46 autobiographical reports or descriptions made by anaesthetists suffering from stress 47 48 disorders. 49 50 51 52 A panel of 12 experts, including anaesthetists, psychiatrists and experienced 53 54 psychotherapists, agreed that items reflected pertinence and theoretical relevance and 55 56 57 its terminology was accurate. This panel came up with a set of the following 10 items 58 59 considered as inductors of stress in anaesthetists´ professional life: 60 61 62 63 64 65  Patients in the highest degree of ASA classification;  Complex surgical interventions; 1 2 3  Anticipation of difficulty in intubation; 4 | 7 5  Work off-site, with different team and equipment; 6 7 8  Relationships with surgeons; 9 10 11  Relationships with remaining anaesthetic team; 12 13  Lack of working conditions; 14 15 16  Inability to keep up to date (theoretical knowledge and new technologies); 17 18  Organization of the anaesthesiology department; 19 20 21  Lack of time or difficulty in organizing it. 22 23 24 Each SQA item contains a 0-10 visual analogue scale (VAS), a continuous measurement 25 26 27 device 18, with higher values reflecting more severe stress induction. This type of scale 28 29 allows reliable detection of small changes and is especially used in the fields of pain 30 31 32 and fatigue research 19. 33 34 35 SQA was originally written in Portuguese, translated into English by a native English 36 37 38 professional translator and then back translated into Portuguese by a bilingual 39 40 Portuguese psychologist. The similarity of these Portuguese versions was judged to be 41 42 43 satisfactory. Subsequent testing has been performed with the original Portuguese 44 45 46 version (see SQA appendix). 47 48 49 Participants 50 51 52 The total sample was composed by 710 Portuguese anaesthetists (599 specialists and 53 54 55 111 residents) enrolled in public and private hospital anaesthesia departments, in total 56 57 of 1254 portuguese specialists and 291 residents. 58 59 60 61 62 63 64 65 The specialists were randomly assigned into two different samples. In sample 1 (n=209) an exploratory factorial analysis was conducted. In sample 2 (n=390), we 1 2 3 conducted a confirmatory factorial analysis. A second confirmatory factorial analysis 4 | 8 5 was performed in a third sample composed of residents (n=111). The main 6 7 8 characteristics of these samples are described in table 1. 9 10 11 -------------------------- (Table 1) -------------------------------------------------------------- 12 13 14 15 Reliability and validity tests 16 17 18 19 The reliability of SQA was assessed by computing Cronbach’s α and composite 20 21 reliability. 22 23 24 25 Construct validity was assessed via correlation with different measures, across the 26 27 three different samples. We used the following measurement instruments: 28 29 30 31  The short-form version of the Depression, Anxiety and Stress Scales (DASS-21), 32 33 was developed by Lovibond and Lovibond 20 and translated and validated to 34 35 36 Portuguese by Pais-Ribeiro, Honrado and Leal 21. This is a self-reported scale 37 38 composed by 21 items distributed in three subscales developed to measure 39 40 41 symptoms of depression, anxiety and stress. In the original version, the authors 42 43 found that all subscales have an adequate to good internal consistency with 44 45 46 alpha’s values of .81 for depression .73 for anxiety and .81 for stress subscales. 47 48 49  The Copenhagen Burnout Inventory (CBI) proposed by Kristensen Borritz, 50 51 Villadsen and Christensen22 and translated and validated to Portuguese by 52 53 54 Cesaltino Fonte 23. It considers the fatigue and exhaustion as a central 55 56 construct. The CBI is a 19-item questionnaire measuring three burnout sub- 57 58 59 60 61 62 63 64 65