Impact of role stress on physical therapists' emotional and physical well-being.

Impact of Role Stress on Physical Therapists' Emotional and Physical Well-being Today's health care system is in a state of flux. With market conditions changing from retrospective reimbursement and expansion to prospective payment and contraction, health service organizations are reacting continuously to tightened fiscal constraints and reduced economic resources. As a result, the organization, its departments, and its health care professionals are being held more accountable for their use of resources and must justify their services and costs. [1] As physical therapy directors strive to balance fiscal management with professional values, the business details of the department, at times, may become overemphasized. [2] For the directors, as well as the therapists working in their departments, this situation can create a conflict between organizational demands and persona and professional values. They may feel torn between their fiscal and organizational responsibilities and their perceived professional responsibilities. Such feelings of being torn in two directions or feelings of uncertainty in responsibilities define the two primary components of role stress--role conflict and role ambiguity. Role conflict resulting from incompatible demands and role ambiguity created by an uncertain organizational environment are potent sources of stress for individual therapists, particularly for those who experience differences between the expectations of hospital or organizational administration and their own personal and professional ideals. [3]

Role Stress--A Personal and

Professional Dilemma

The professional role of physical therapists is deeply rooted in a commitment to "bettering" the state of the client through a positive and productive therapist-patient relationship. [4] Evidence of the strength of this commitment is found in the qualities esteemed and valued by members of the field. For instance, a study of characteristics of self-perceived role models among physical therapists found that 8 of the 10 highest ranked characteristics were personal qualities in the affective realm emphasizing dedication, teamwork, self-sacrifice, sensitivity, and positive attitudinal influence on others. [5]

Physical therapists may experience role stress in two forms: role conflict and role ambiguity. Role conflict may arise in response to incompatible demands such as the desire and expectation to provide a high quality of care in the face of an excessive caseload and increased documentation and paperwork. [6] The frustration of role stress is exemplified by voiced complaints focused on the lack of time to give all patients adequate treatment. Role ambiguity may arise in response to unclear expectations or uncertainty regarding authority and responsibilities. [7] Unclear policies and conflicts within multidisciplinary rehabilitation teams are often the foundation for stressors of role ambiguity.

Whether the source of role stress lies in feelings of conflict or ambiguity or in a combination of these factors, role stress creates a drain on individuals' emotional resources and coping capabilities. Over time, these stressors can contribute to the decrements in personal well-being and performance. Emotional well-being deteriorates as symptoms of job burnout are experienced. Burnout is a psychological syndrome characterized by negative self-concepts including lowered feeings of accomplishment, a loss of feeling or concern for patients (depersonalization), and emotional exhaustion. [8]

Stress and burnout have been associated with numerous detrimental effects for individuals and organizations including increases in psychosomatic complaints such as ulcers and migraine headaches [9]; increases in negative affective states such as anxiety, hostility, and depression [10]; and increases in absenteeism, turnover, and other work-withdrawing behaviors. [11, 12] Moreover, there is little doubt that burnout affects the quality of care provided. [13, 14]

The purpose of this research was to examine the relationship of role stress, in the form of role conflict and role ambiguity, on the emotional and physical well-being of physical therapists. Specifically, we hypothesized that physical therapists who report high levels of role conflict and role ambiguity will also report the depletion of emotional resources, depersonalization of patients, decreased feelings of personal accomplishment, and the existence of job-induced tension and somatic tension. Following the establishment of these relationships, statistical analysis allowed us to identify specific role stress items that are statistically significant predictors of diminished emotional and physical well-being.

Method

Sample

The subjects for our research were obtained on a voluntary basis from a convenience sample of physical therapists working in the state of Missouri. With the approval of the Institutional Review Board from the University of Missouri and the permission of the Missouri Physical Therapy Association, surveys were distributed to 300 participants at an annual statewide meeting. Additional surveys with a cover letter and return envelope were available for participants to voluntarily distribute to fellow therapists unable to attend the meeting. Surveys were totally confidential, and no identifiers were included on the instruments or envelopes.

Questionnaire

The survey included numerous instruments and scales shown to be valid and reliable in previous research such as role conflict and role ambiguity scales, [7] the Maslach Burnout Inventory (MBI), [8] and the Anxiety-Stress Questionnaire. [15] A demographic section included questions on age, sex, marital status, years as a physical therapist, educational preparation, type of employment, salary and organization level.

Role stress was measured by the role ambiguity and role conflict scales. Respondents indicated to what extent each statement described their feelings or opinions on a seven-point Likert scale (1 = very false; 7 = very true). Six of the statements are reverse scored for role ambiguity, and the remaining eight items assess role conflict. Role ambiguity statements included items such as "I feel certain about how much authority I have" and "I know exactly what my responsibilities are." Role conflict statements included items such as "I have to do things that should be done differently" and "I receive incompatible requests from two or more people."

The MBI provides a measure of three dimensions of the burnout syndrome--emotional exhaustion, depersonalization, and lowered feelings of personal accomplishment. The MBI consists of a 26-statement list in which respondents are asked to indicate the extent to which the statements are like or unlike themselves on a seven-point Likert scale (1 = very much unlike me; 7 = very much like me). A sample statement from each dimension is as follows: emotional exhaustion--"I feel emotionally drained from my work," depersonalization--"I feel uncomfortable about the way I have treated some patients," and personal accomplishment--"I feel I'm positively influencing other people's lives through my work."

The Anxiety-Stress Questionnaire measures the existence of tensions and pressures growing out of job requirements, including the possible outcomes in terms of feelings or physical symptoms (eg, having trouble sleeping at night because of one's job or having an ulcer). This research focused on the two job-related subscales: job-induced tension and somatic tension. Responses to statements are scored true or false and averaged for the subscales. Job-induced tension subscale items directly relate physical symptoms with pressures at work with statements such as "Problems associated with my job have kept me awake at night." Somatic tension subscale items relate to more general feelings and include statements such as "I am often bothered by acid indigestion or heartburn."

Data Analysis

Data analysis was generated by the Statistical Package for the Social Sciences (SPSS). [16] The first step in the data analysis detailed a descriptive profile of the sample. Analysis-of-variance techniques were used to test for any significant differences in reported role stress, burnout dimensions, job-induced tension, and somatic tension scores on the basis of demographic and job variables. The relationships between the stress, burnout, and tension factors were established by correlational analyses. Stepwise multiple regression equations were performed on each of the dependent variables (ie, emotional exhaustion, depersonalization, personal accomplishment, job-induced tension, and somatic tension). This procedure assessed the predictive value of each of the role stress items after the values of the other items had been taken into account.

Results

Descriptive Profile of Sample

A total of 187 completed, usable surveys were returned to the researchers (GJD and RMP). Analysis of personal characteristics established that the respondents were an average age of 32 years, 61% were married, and 76% were female. Eighty-three percent of the sample held a Bachelor of Science degree. The largest percentage (35%) earned between $20,000 and $25,000 annually, and another 21% reported earnings of $25,000 to $30,000 annually. The subjects averaged 9.1 years working as a physical therapist and 3.8 years in their current job. Seventy-two percent were staff therapists, and the remaining 28% were physical therapy or rehabilitation directors or private practitioners. Most of the respondents (60%) worked in not-for-profit hospitals, 11% worked in for-profit hospitals, 10% worked in private practice, 9% worked in a rehabilitation facility, 6% worked in home health, and 4% worked in long-term care.

Analysis-of-variance tests demonstrated no significant differences in the emotional exhaustion, depersonalization, personal accomplishment, job-induced tension, and somatic tension scores on the basis of any of the personal or professional characteristics. Examination of the role stress scores (ie, role conflict and role ambiguity) revealed only one significant difference--therapists practicing in long-term care settings reported significantly lower scores on role ambiguity than therapists in other settings, particularly rehabilitative facilities. Physical therapists practicing in long-term care settings, although a small percentage of the total sample, reported experiencing less uncertainty and more clarity in their responsibilities and authority than physical therapists employed in other settings. The results of these tests justify the use of the entire sample in further statistical analyses.

Relationship of Role Stress to

Physical and Emotional

Well-being

The results of the correlational analysis are provided in Table 1. As predicted, role conflict and role ambiguity were significantly associated with emotional exhaustion, depersonalization, somatic tension, and job-induced tension. The strongest relationships appear between emotional exhaustion and job-induced tension (r = .58), depersonalization (r = .52), and role conflict (r = .50).

Stepwise multiple regression analyses, using a combined entry of items from both the role conflict and role ambiguity scales, provided identification of the specific role stress items that are statistically significant predictors of emotional well-being as measured by the burnout dimensions (emotional exhaustion, depersonalization, and personal accomplishment) and physical well-being as measured by somatic tension and job-induced tension. The confidence interval for entry into the equation was set at .05.

Predictors of emotional well-being. The key role stressor affecting the emotional resources and coping capabilities of physical therapists appears to be the perception that one's time is not allocated properly (Tabs. 2-4). This item (from the role ambiguity scale), although weighted differently, is a significant predictor for all three burnout dimensions. Other statistically significant predictors (from the role conflict scale) relate to inadequate staff or resources and conflicts between groups resulting from either incompatible requests or procedures and acceptance activities. The percentage of variance explained by statistically significant role stress items for each of the emotional well-being measures was 36% for emotional exhaustion, 17% for depersonalization, and 20% for personal accomplishment.

Predictors of physical well-being. Somatic tension is best predicted by two role conflict items--differential acceptance activities by two or more groups and inadequate staff--and a role ambiguity item--clarity in role and responsibilities (Tab. 5). Feelings that one's time is not allocated properly and inadequate resources, from the role ambiguity and role conflict components, respectively, are significant predictors of job-induced tension (Tab. 6). The percentage of variance explained by statistically significant role stress items for each of the physical well-being measures was 20% for somatic tension and 23% for job-induced tension.

Discussion

Role stress, particularly the frustrations and strains created by conflicting demands, appears to contribute to diminutions in the emotional and physical well-being of physical therapists. Specifically, the emotional exhaustion and depersonalization characteristic of burnout as well as the physical symptoms associated with job-induced and somatic tensions arise, at least in part, in response to ambiguity and conflict in the organizational environment. Although individual and organizational differences will affect the experience, as well as the relationships between the various factors, a general observation may be drawn. Perceived improper allocation of time, inadequate staff or resources, and receipt of incompatible demands are potent stressors and predictors of decrements in the emotional and physical well-being of individual therapists.

Establishing these relationships and identifying specific role stress contributors to these diminutions in well-being are only the first steps. Indeed, the percentage of variance that role stress plays in these diminutions equates, statistically, to a relatively small percentage of the total variance. Practically, however, that percentage can provide a valuable directional guide for problem identification and appropriate intervention. Efforts to eliminate or minimize the occurrence of role stress as well as its detrimental effects are essential managerial responses. Some practical implications and action interventions are described in the following scenario.

During a period of high demand for physical therapy for hospitalized patients, staff may feel pressured and complain about the lack of time to give all patients adequate treatment. They feel torn between providing service to everyone, which decreases the amount of time they can devote to each treatment, and providing high-quality care to meet the individual needs of their patients. Multidisciplinary team meetings, essential to a coordinated rehabilitative effort, cut into patient care time and often serve to add further stress when team members have conflicting views of patient need and staff responsibilities. Documentation requirements exacerbate the situation, cutting more and more into the time available to provide service.

When role stresses and frustrations become chronic or intensify, therapists deplete their store of emotional and physical energy. Behaviors and moods become characterized by short tempers, curt replies to patients and staff members, and increased hostility toward other hospital departments. Therapists become less sensitive to the needs of their patients, less willing to accept new patients, and increasingly less able to handle the average caseload. These reactions, in turn, may produce in intrapersonal, self-initiated role conflict as one's attitudes and behaviors prove inconsistent with the esteemed values of teamwork, sensitivity, and compassion.

Physical therapy directors may intervene to minimize role stress and mitigate its negative consequences by working with staff to identify the role stress factors salient within their own organizations and to design and implement appropriate intervention strategies. Examples of interventions targeting role stress are provided below to serve as a general guide. At least part of the stress created by conflict and ambiguity of roles and responsibilities may be relieved by the involvement of staff in the development of departmental and organizational policies. [3] Directors and therapists who represent their departments on policy committees should seek to increase the awareness of physical and therapy values and objectives to other organizational members and departments.

Time stress and pressures may be addressed through the provision of a once-a-month "office day" for staff therapists to "catch up" on documentation and continuing education. The department manager becomes responsible for treatment of their patients on their office day. These office days can lighten the burden on all staff and prove to be an effective use of staff time.

Staff support groups can meet on a regular basis, biweekly or monthly, to explore causes of stress, individual coping mechanisms, dysfunctional behavior, and other immediate concerns. Problem identification may be followed by solution identification and proposals to administration. Effective groups may consist of physical therapy staff or all rehabilitation staff.

Future research into the effects of role stress on physical therapists may expand these findings and extend the analyses to include the impact of role conflict and role ambiguity on individual performance, organizational performance, and patient care. Another branch of research might focus on the formation and effective functioning of multidisciplinary teams, specifically on the assimilation of values and delineation of clear roles and responsibilities. Research testing the effectiveness of specific interventions could provide the foundation for an inclusion guide of intervention strategies that reduce role stress and its negative consequences.

Conclusions

Today's turbulent health care environment will continue to impose constraints and restrictions that, more than likely, will increase the indicence of role stress among physical therapists. In turn, the associated personal decrements in emotional and physical well-being will increase as well. Physical therapy directors and staff therapists alike should take an active role in efforts to reduce the causes and consequences of role stress. Departmental and rehabilitative support groups can offer emotional support as well as a means for identifying workable solutions to specific stressors. Directors and staff therapists should become actively involved in organizational and ensure that the role and concerns of the physical therapy department are represented and communicated to other organizational members and departments. Effective communication in organizational committees and policy development can assist in aligning the objectives of the physical therapy department with those of the organization [17] and can establish a clear, united framework for the role of physical therapy and the delivery of services.

References

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[12] Freudenberger H: Burn-out: The organizational menace. Training and Development Journal 31:26-27, 1977

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[14] Maslach C: Burned-out. Human Behavior 5:16-22, 1976

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[16] Norosis M: SPSS/PC+ for the IBM PC/XT/AT. Chicago, IL, SPSS Inc, 1986

[17] Brown GD: Changing health care environments--Implications for physical therapy research, education, and practice: A special communication. Phys Thre 66:1242-1245, 1986

G Deckard, PhD, is Assistant Professor, Health Services Management, University of Missouri-Columbia, 324 Clark Hill, Columbia, MO 65211 (USA).

R Present, MSPH/MBA, was a graduate student, Health Services Management, University of Missouri-Columbia, when this research was conducted in partial fulfillment of the requirements for his master's degree. He is currently a consultant with Ernst & Whinney, Gateway One, Ste 1400, 701 Market St, St Louis, MO 63101.