MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY LE THI KIEU HANH THE SITUATION OF STRESS AND SOME RELATED FACTORS AMONG HEALTHCARE WORKERS AT SOME MEDIC
Trang 1MINISTRY OF EDUCATION
AND TRAINING
MINISTRY OF HEALTH
HANOI MEDICAL UNIVERSITY
LE THI KIEU HANH
THE SITUATION OF STRESS AND SOME RELATED FACTORS AMONG HEALTHCARE WORKERS AT SOME MEDICAL
UNIVERSITY HOSPITALS IN THE PERIOD OF 2020-2022 AND
EFFECTIVENESS OF SOME INTERVENTIONS
Major : Public Health
Code : 9720701
DOCTORAL THESIS IN PUBLIC HEALTH
HANOI – 2024
Trang 2The thesis is completed at HANOI MEDICAL UNIVERSITY
Supervisors:
1 Assoc Prof Dr.Vu Minh Hai
2 Assoc Prof Dr.Ngo Van Toan Reviewer 1:
Trang 3LIST OF ABBREVIATION
Abbreviation
BRCS Brief resilient coping scale
BRS Brief resilience scale
DASS 21 Depression, anxiety, stress scale
HSE Health and Safety Executive
NVYT Healthcare worker
WHO World health organization
WHOQLO-BREF The World Health Organisation Quality of Life - Bref
Trang 4AN OVERVIEW OF THE THESIS
1 Rationale of the thesis
The terminology of stress is defined as a syndrome that includes nonspecific responses
of the body to the stimulations from the living environment Stress places the subject in the adaptive arrangement process, creating a new balance for the body after being affected by the effects of the environment In other words, stress reaction plays the role as the adapting function of the body to the circumstance If the individual's responses to stress-lated factors are incomplete, inappropriate and the body does not create a new balance, the function of the body will be more or less disturbed Then the signs of the body pathology will appear, causing physical, psychological, behavioral medical manifestations, and create acute or prolonged pathological stress Psychological disorders caused by stress bring serious consequences to workers' health, leading to economic damage, reducing labor productivity
According to the report of the British Labor Association (Health and Safety Executive (HSE) in the period of 2018 to 2021, there were 822,000 cases of workers suffering from career stress, depression and anxiety; In which the health sector is one of the industries reported with stress, depression and anxiety incidence related to high work A number of studies in the world have also shown that stress-related factors in medical staff include (1) work; (2) social relationships; (3) individual issues However, the factors that affect stress in medical staff do not impact independently that they have the synthesis together, but the interventions to reduce stress as well as the traditional approach to improve strength Psychiatric health for medical staff and staff is limited Access to interventions to improve mental health for medical staff has become important in recent times Currently, stress-reducing interventions for medical staff are being geared towards the world-micro-perception, mental and physical relaxation, and improving working organizations In Vietnam, studies on stress response skills as well as stress reduction intervention are still limited
Stemming from the above matters, we aim to find out the situation of stress, stress related factors of health workers and intervention solutions to help health workers
-improve physical health and mental health Therefore, we conduct the thesis: "Situation and a number of factors related to stress in healthcare workers at some medical university hospitals for the period of 2020-2022 and the results of some interventions"
with the following research objectives:
1 To describe the situation and a number of factors related to stress level in medical staff at some Medical University Hospitals in 2021
2 To evaluate the effectiveness of some appropriate intervention solutions to reduce stress of medical staff at Medical University Hospitals
2 Contributions of the thesis
The health sector has been identified as one of the sectors with high rates of mental health disorders and exhaustion in the workforce In particular, in the curcumstance of Covid -19 pandemic, the proportion of medical staff being stressed and depressed is increasing The study has determined the stress situation of healthcare workers, providing updated data about stress level of healthcare workers The study has also identified a number of related factors that cause stress increase in healthcare workers, namely family relationships, workplaces, major events in the past year
- The study also described the relationship between stress and quality of life As stress increases, the index of life quality in physical, mental, social and environmental
Trang 5areas decreases, providing evidence of negative impacts of stress on every aspect of the life of medical staff
The research shows other outcomes of the application of intervention solutions, including (1) health education communications; (2) instructions for relaxation exercises, (3) personal psychological consultation to reduce stress level, to improve the quality of life and resilience coping skill of health workers The research has provided scientific and reliable data on the effectiveness of stress-reducing intervention solutions for medical staff at Thai Binh Medical University Hospital This would be useful for health policy makers to have deeper research and propose more suitable intervention solutions
3 Outline of the thesis
The thesis consists of 147 pages, with 2 pages of rationale, 42 pages of literature review, 26 pages of research objectives and methodology, 39 pages of research findings,
35 pages of reseach discussion, 2 pages of the conclusion and comments, 1 page of the proposal for further study The thesis has 36 tables and 6 charts; 140 reference works The PhD student has 02 articles published on credited specialized magazines, including 01 article published in the Journal of Medical Research; 01 article written in English
Chapter 1 LITERATURE REVIEW 1.1 Some concepts of “stress” and “healthcare workers”
1.1.1 The concept of “stress”
According to Hans Selye "stress isa response of the subject for a need or a correspondence of the relationship between people and the surrounding environment." Stress is defined as an adaptive response of the subject in terms of psychology, biology and behavior Stress places the subject in the process of arranging to adapt to the surrounding environment, giving the body a new balance after being affected by the environment If the individual's ability to respond to stress-related factors is incomplete, inappropriate and the body does not create a new balance, then the functions of the body are more or less disordered Signs of physical, psychological, and behavioral disorders will appear and will create acute or prolonged pathological stress In the view of Jerrold S Greenberg, the concept of stress can also be understood in two aspects Firstly, stress situations indicate stimulating agents (stressor), which are physical, chemical, social, family-related, and occupational agents Secondly, stress response is to indicate the reaction state (reaction), which is referred to physiological reaction and nonspecific psychological reaction
1.1.2 The concept of “healthcare workers”
According to the definition of the World Health Organization (WHO), “Health staff (healthcare workers) are people whose job it is to protect and improve the health of their communities Medical staff include medical service providers such as doctors, nurses, midwives, pharmacists, laboratory technicians-as well as management and support workers-such as hospital managers, officials of financial agencies, chefs, repair maintenance and hygiene staff ”
1.1.3 The concept of “stress of healthcare workers”
The stress of healthcare workers is a state of psychological tension that appears in healthcare workers in the field of health as well as in everyday life This stress is partly
Trang 6due to the impact of difficult and complicated conditions from the care and health protection activities of the people, or from personal problems, partly due to the way it is felt and explained Depending on the ability of each person to handle, stress can affect health workers on physiological, psychological and social aspects
1.2 Some measurement to evaluate stress levels
Currently, in the world as well as in Vietnam, there are many tools used to study and evaluate mental health issues as well as individual stress levels The evaluation scales have the common use of the self-filled multiple-choice questions set Some tools are used
in scientific research to evaluate stress status such as a set of Stress Perceived Scale (PSS); Evaluating scale for stress (GHO 12); Lovibond stress, anxiety, depression scale (DASS 21 and DASS 420); International Stress Management Association; JCQ-Job Content Questionnaire; SRQ-Self Reporting Questionnair-20
1.3 The situation of stress of health workers in Vietnam and the world
1.3.1 In the world
According to WHO, over 25% of the world's population suffers from mental disorders and behaviors at some point in life In particular, stress is also a factor contributing to the situation of poor work performance in the workplace, leading to labors quiting their job, increasing medical costs, reducing work satisfaction, which directly affect the health of workers
The study of Timothy R Jordan and partners conducted at the Central Hospital of West, the United States revealed that, in 2016, stress levels of 92% of nurses ranged from high to very high A study by Li-Ping Chou and partners about career stress and exhaustion
of 1329 medical staff at regional hospitals in Taiwan in 2014 showed that the rate of career stress in nursing was the highest (27.9%); followed by assistant doctors (27.2%); administrative staff (14.7%); technicians (14.4%) and doctors (2%) Research findings of Anne-Claire Durand and his colleagues about stress and exhaustion of medical staff working at the emergency department in a French university hospital in 2019 showed that 19.3 % of 166 medical staff were exhausted and 27.1% were stressed at work
1.3.2 In Vietnam
In the context of Vietnam today, mental health care is increasingly concerned, due
to the fact that mental health issues are accounting for a high proportion in common diseases, and in primary health care of the community Particularly, in health sector, there have been several studies that have shown that health workers with high stress rates related to job performance However, the number of studies is still limited
A cross-sectional survey conducted by Pham Ngoc Thanh and his partners at the Tropical Hospital to determine the level of stress, depression, anxiety of the health workers based on the DASS 21 scale showed that 50% of health workers have problems
of mental health, of which 19% showed the signs of stress; 28.5% showed the signs of depression; 38.8% showed signs of anxiety According to the research findings of Nguyen Ngoc Anh and partners (2018) at Qui Hoa Central Hospital of Leproxy and Dermatology, the ratio of occupational stress of doctors and nurses is 6.4% A research
by Nguyen Manh Tuan and his partners about stress, depression and anxiety of medical staff at Trung Vuong Hospital (2018) showed that out of 653 medical staff participating
Trang 7in the study, 10.5% have stress sufferings; of which 6.9% is at medium level; 3.4% of severe level and 0.2% are at very severe level Research on the status of stress, depression and anxiety of health workers at the Eastern Military Medical Hospital in 2019 by Huynh Ngoc Cuong and Nguyen Thi Phuong Lan shows the stress rate of health workers at the hospital is 15.5%; the doctor's stress rate is 14.05 times more nurses, midwives and technicians (p < 0.001) In which light stress rate is 9.4%; just 0.5% and weighs 1.1%
A Research on the status of stress, depression and anxiety of health workers at the Eastern Military Medical Hospital in 2019 by Huynh Ngoc Cuong and Nguyen Thi Phuong Lan showed the stress rate of health workers at the hospital was 15.5%; the doctor's stress level was 14.05 times more than nurses, midwives and technicians (p
< 0.001) Among those, 9.4% were suffered from serious stress, 0.5 were moderately stressed and 1.1% were slightly stressed
1.4 Stress-driving factors in health workers
1.4.1 Occupation-related factors
- Occupation-related causes of health worker’s stress can be named as: unsafe,
inappropriate working environment, danger levels and high risk of exposure (biological agents, sharp objects, toxic substances .); the working environment is noisy, messy, lacking equipment, not breathable The organization of work arrangement is not reasonable; the work guidance between the doctor, the nursing is not identical, the ineffective management from the superior, staff have to concurrently perform many jobs, not fully trained; staff have to change the position constantly…
- Causes of social circle at work: inter-relation with seniors, colleauges, patients
and patients’ relatives…
1.4.2 Family-related factors
Too much time to get work, family finance troubles, unhappy family life, health problems of family members, family conflicts, long and dangerous journey to work everyday, health problems of spouses, children; lack of compatibility between family and work; bad relationship with neighbors and friends…
1.4.3 Self-driving causes
Being fear of mistakes at work; being worried not to complete the task; lack of communication skills with colleagues, patients, patients' family members and social relationships; unable to use modern technical systems; lack of professional experience
or other factors such as individual’s age, gender, health status
1.5 Some stress -reducing interventions in medical staff
- Individually: a number of stress-reducing interventions for medical staff have been applied in the world, including cognitive behavior intervention; Mindfulness Based Stress Reduction–MMSR); improving behavior based on the Health Believe Model (HBM); relaxing mental and physical; enhancing life quality
- Regarding institutions: the intervention that the organization can apply is to reduce the need for work by having more people do the same task or give each person more time to do the same work, or reduce the volumn of tasks per person Strengthen work control by reducing hierarchy or increasing autonomy Improve social support at the workplace through increasing peer support or supervision support Clearly assign the role/
Trang 8task/ task organization by improving the description of the role, responsibility or supervision Strengthen the assignment of tasks/ working processes by developing new care models Improve communication for employees Therefore, the organization intervention focuses on the main methods of changing working conditions, supporting the organization, changing care services, improving communication skills, changing schedules, improving relationship at work, apply safety management systems, improve feedback between managers and employees as well as feedback among employees Improve relationships of health workers with patients and family members
- Social support: social support includes the structure of social networks (for example, increasing the size of an individual's support ring), close support (providing mental support, providing information ), support for issuance (personal support through
a consultant ) Social support increases the efficiency among individuals, improves the performance and competency of individuals, improves their confrontation skills and reduces their stress Social support is also recognized as a useful strategy for health workers to adapt their behaviors and then reduce stress The purpose of social intervention is to help medical staff dispel the feeling of solitary stress against stress Thanks to that, they feel valuable, bring safety and material and mental assistance The social support network can provide information, bring strategies to solve problems, give advice and guide health workers to seek support when necessary Social support relationships also aid health workers in the process of recovery and reducing the harmful
effects of work overload
Chapter 2 SUBJECTS AND RESEARCH METHODOLOGY
2.1 Subjects and research methodology for objective 1
2.1.1 Subjects, locations and time of research
+ Subject of the research: doctors, nurses, technicians working at Hanoi Medical
University Hospital and Thai Binh Medical University Hospital
Criteria: Doctors, nurses, technicians who have been working at the hospital for 6
months or more, voluntarily approve to participate in the study
The criteria to eliminate from the study
- Studying, including full-time or in-service education
- Being sick and having inpatient treatment
- Pregnant, breastfeeding women
+ Research location: at Hanoi Medical University Hospital and Thai Binh Medical
University Hospital
+ Research period: from June 2021 to December 2021
2.1.2 Research methodology
2.1.2.1 Research design: a descriptive cross -sectional study
2.1.2.2 Sample size and sample selection method
Research sample size: Applying the formula for calculating the size of the sample determining a proportion to the absolute error, the minimum sample size was 517
Trang 9healthcare workers The total number of medical staff with signs of stress in 2 hospitals is: 520 medical staff
Sample selection method:
- Method of selecting samples on purpose: Hanoi Medical University Hospital and
Thai Binh Medical University Hospital were selected on purpose
- Selection of doctors, nurses, technicians: at hospitals, the research author will make a list and survey the doctors, nurses, technicians of each department, with the support of the heads of the department Since then, health workers who go to school, business trips or other reasons are not in accordance with the investigation plan that has been removed from the sample list From the shortened lists from each of the above faculties, the author applies the method of choosing the whole sample for medical staff of Thai Binh Medical University Hospital and randomly selected the number of medical staff in the list of Hanoi Medical University Hospital for 260 subjects at each hospital to determine the rate of healthcare workers having signs of stress sufferings At hospitals, the research author will make a list of doctors, nurses and technicians in different departments
2.1.2.3 The research variables and indexes
- Stress ratio of healthcare workers (DASS 21 scale)
- Life quality of healthcare workers (WHOQLO-BREF scale)
- Factors related to stress situation of healthcare workers
2.1.2.4 Data collection techniques: interviews and evaluation by specialized scale (Dass21; WHOQLO-BREF), and pre-design questions
2.2 Subjects, research methods for objective 2
2.2.1 Subjects, locations and time of research
+ Research subjects: doctors, nurses, and technicians working in some departments or
offices with healthcare workers have expressed stress (after the survey results at target 1) at Thai Binh Medical and Pharmaceutical University Hospital
Selection criteria: doctors, nurses, technicians working at faculties with stressful
and voluntarily participate in the research
Elimination criteria: those who do not agree to participate in the study
+ Research Venue: at Thai Binh Medical and Pharmaceutical University Hospital
+Research period: January 2022 to August 2023
2.2.2 Research methodology
2.2.2.1 Research desgin
Before-After community intervention research
2.2.2.2 Sample size and sample selection method
+ Sample size: applying the formula for calculating the sample size for community research, before- after intervention evaluation (1.3A/WHO) The sample size is 51participants, in fact, there are 161 health workers involved in the research
+ Sampling method: selection of intervention participants: among the medical staff from goal 1, we identify a group of stress medical staff to participate in the intervention Because of the ethical issue, we have chosen all the subjects who agree to participate in the research at the faculties to conduct interventions
Trang 102.2.2.3 The research variables and indexes
- Stress ratio of health workers before and after intervention (DASS21)
- The quality of life of healthcare workers before and after intervention (WHOQOL-BREF)
- The ability to cope with stress of healthcare workers before and after intervention (BRCS)
- The ability to recover after stress of healthcare workers before and after intervention (BRS)
- Cohen's d (Cohen's d effect size) calculates the difference between the two before and
after intervention in the mean scores of stress (DASS 21), the ability to cope with stress (BRCS), the ability to recover after stress (BRS), the quality of life (WHOQOl-BREF)
2.2.2.4 Data collection technique: Interviews and evaluation by scales (DASS21,
WHOQOL-BREF, BRCS, BRS)
2.3 The content of the intervention
Based on the literature review, the findings of the research before the intervention, the intervention goals, the survey results in objective 1, we have chosen a number of community-based intervention activities to build the intervention prpgramme
Solution 1: health education propaganda, improving the ability to cope with stress
of medical staff
- Activity 1: direct communication through group discussion
- Activity 1: supplying documents and distributing leaflets
Solution 2: instructions for physical exercises (breathing and muscle relaxation)
Solution 3: support psychological consultation to help medical staff have positive
responses to stress
2.4 Data processing and analysis
The data is encrypted and entered the computer with EPI Data software, processing data with SPSS 16.0 software Continuous variables are presented in the form of average and standard deviation The qualitative variables are presented as a percentage Using
tests when square, Fisher’s exact test when comparing the difference between two
average values with statistical significance <0.05 The multi -variable logistics regression model identifies factors related to the stress status of medical staff Compare assessment
of the difference between the two ratios at the time before intervention and after
intervention; at the same time, testing the difference between the ratios is equal to test Chi-square, Paired samples T test at the time before the intervention-after the
intervention through the value p
2.5 The research ethics
The study ensures all ethical principles in biomedical research and approved by the Institutiona Review Board for Ethics in Biomedical Research – Hanoi Medical University under Decision No 400/GCN-HDDDNCYSH-DYHNHN dated May 19, 2021
Trang 11Chapter 3
THE FINDINGS 3.1 Characteristics of the research subjects
At the phase 1 of the research, 520 health workers participated in the study, of which mostly were women (accounting for 60.0%) and 78.7% were married The number
of people aged 30-40 years old accounts for a relatively high proportion (51.5%) Education level of the subjeected healthcare workers: postgraduate accounts for the highest proportion of 44.8%; followed by college level, accounting for 26.5%; the university level accounts for 25.4% and the lowest is the intermediate level, with 3.3% Years of working experience of healthcare workers at the hospital is mainly over 5 years (68.6%) 46.5% of the participants are doctors; 40.6% are nurses/midwives and 12.9% are technicians
49.2 % of participants have children aged under 5 and 19.6 % of them must take care of their weak relatives or injured people The per capita income of the participants is mainly from 6-10 million VND (46.5%) and 66.0% of healthcare workers are the main source
of family income The relationship between family members is mostly good (83.1%); participants having relatively good family relationships accounts for 15.7% and only 1.2% of them do not have good family status
The average point for quality of life of health workers is 60.97 ± 11.39 The highest average point is in the physical field (63.41 ± 13.87); the lowest is in the environment aspect (58.31 ± 11.68)
3.2 The situation and stress-related factors in health workers at Hanoi Medical University Hospital and Thai Binh University Hospital in 2021
3.2.1 The situation of stress of health workers
Chart 3.1 Stress incidence of medical staff according to DASS21 scale
Trang 12Chart 3.2 Distribution of stress rate (DASS 21) of medical staff by
professional qualifications (n = 520)
The stress rate of healthcare workers according to the professional level: the doctor's stress rate is 29.3%; followed by the nurse/midwife at 28.0% and the technicians
at 22.4%
Chart 3.3 The level of stress of medical staff according to DASS 21 (n = 145)
The levels of stress of healthcare workers at two hospitals of Thai Binh and Hanoi Medical University on DASS 21 scale are mild, moderate, severe and extremely severe, respectively 38.7%; 31.0%; 20.0%; 10.3%
27.4
3122.9
Trang 13Table 3.1 Stress average score (DASS 21) at medical staff according to the quality of
Physical 65.63 ± 13.66 57.66 ± 12.77 <0.0001 Mental 65.40 ± 12.83 55.57 ± 12.28 <0.0001 Social 61.87 ± 14.12 55.29 ± 13.92 <0.0001 Environment 60.61 ± 11.56 52.35 ± 9.75 <0.0001 Overall 63.30 ± 11.20 54.93 ± 9.52 <0.0001 Table 3.2 shows that the total quality of life, physical health, mental health, social relations and the environment of the subjects without signs of stress is higher than thesubjects showing signs of stress (difference Statistical significance with p < 0.0001)
3.2.2 Some stress-related factors of medical staff
Table 3.2 The relationship between personal factors and stress (DASS21 scale) of
medical staff (n = 520)
Factors Stress No stress OR 95%CI
n (%) n (%) Gender
Education level
Intermediate/Associate 36 (23.2) 119 (76.8)
0.71 0.46-1.10 University/ Post 109 (2.,9) 256 (70.1)
Marital status
Married 30 (29,1) 73 (70,9) 1.08 0.67-1.74 Single/seperated/divorced/Widow 115 (27.6) 302 (72.4)
Table 3.2 shows a difference in the ratio of stress in gender, age group, professional qualifications, education and marriage status of health workers However, these personal characteristics of medical staff have not been closely related to the stress
of the medical staff
Trang 14Table 3.3 The relationship between family factors and stress (scale DASS21) of
medical staff (n = 520)
Factors Stress No stress OR 95%CI
n (%) n (%) Having under 5 year old children
Relationships with family members
Poor/bad/ relatively good 39 (44.3) 49 (55.7)
of health workers (OR = 2.59; 95%CI: 1.54-4.35)