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Differences in well-being between GPs, medical specialists, and private physicians: the role of psychosocial factors.

In Finland, health care is mainly publicly funded and responsibility for running health care is devolved to the municipalities (local government). The public health care system provides the largest share of primary and secondary health care services: 71 percent of outpatient physician visits and 95 percent of inpatient care periods (Vuorenkoski 2008). Public primary health care is provided by district health centers employing general practitioners (GPs) who provide most of the day-to-day medical services. Public secondary care is provided by 20 hospital districts employing medical specialists. The hospital district organizes and provides specialist medical services for the population of their member municipalities. Private health care provides both primary and secondary health care services, accounting for 16 percent of outpatient physician visits and 5 percent of hospital inpatient care. In addition to public and private health services, occupational health services provide preventive and day-to-day primary health care for their employees. In addition, occupational health services provide about 13 percent of outpatient physician visits, which are mainly organized by private sector firms (Vuorenkoski 2008).

Each health care system (public, private, and occupational health services) receives some public funding, although the financing mechanisms differ. Municipalities fund public health care services and National Health Insurance (NHI) funds a share of private and occupational health care (the NHI reimburses on average 30 percent of the costs of using private health services). Patients can choose between these three health care systems, but substantial user fees can be a barrier to accessing the private sector, and occupational health care is available only to employed people. The Finnish health care system faces many challenges, including a shortage of GPs (Kokko 2009), rising health care costs, and high physician turnover from the public to private sectors (Kankaanranta et al. 2007). Within the last 10 years, a lack of GPs has led to a new trend of leasing the GPs to health centers from private firms. In 2010, 7 percent of GP posts were managed by private firms and 5 percent of health centers had their staffing arranged entirely by private firms (Parmanne 2010).

A recent study of Finnish physicians showed that private physicians were more satisfied and committed to their job, and had less psychosocial disorders and sleep problems than public sector physicians. This was partly explained by higher organizational justice and job control in the private sector (Heponiemi et al. 2010a). Private physicians in Sweden had better experiences of their work environment than public sector physicians (Hellgren et al. 2006). In New Zealand, radiologists in the private sector reported less work-related stress and they had less burnout compared with secondary care radiologists (Lim and Pinto 2009). A previous study found that GPs were less committed to their organizations than other physicians (Kuusio et al. 2010). In addition, the same study found that work-related psychosocial stressors such as high job demands, low job control, and poor colleague consultation decreased organizational commitment among GPs.

It has repeatedly been shown that a negative psychosocial work environment is associated with health problems such as cardiovascular diseases and symptoms of depression (Umehara et al. 2007; Couser 2008; Nieuwenhuijsen, Bruinvels, and Frings-Dresen 2010). In most theories on stress it has been argued that experienced stress is an outcome of long-term and interactional processes between environmental demands and a physician's ability to meet those demands (Lazarus and Folkman 1984; Selye 1985; McEwen 1998). Thus, it is suggested that environmental factors affect the perception of stress through the appraisal process and this appraisal (perceived psychosocial stressors) may affect psychological and physiological outcomes, such as psychological distress, self-rated health, and work ability (Karasek 1979; Karasek and Theorell 1990). These outcomes can be seen as a continuum. In this study, we expected long-term psychosocial distress to increase physical and mental health problems, and in the long run that may cause deterioration in work ability among physicians. Psychosocial distress, self-rated health, and work ability have been used repeatedly as measures of the different stages of the psychological stress process (Lundberg 1996; Elovainio et al. 2005; von Thiele, Lindfors, and Lundberg 2006).

Possible differences in work-related stress across health care sectors may offer one explanation for differences in physician well-being between sectors. The role of psychosocial factors has been widely tested using the established Job Demand-Control-Support (JDC-S) model of Karasek (1979), which has shown that low job control and high demands predict health risks and lower well-being among physicians (Rodriguez et al. 2001; Elovainio et al. 2005; Heponiemi et al. 2008). Previous studies also show the importance of psychosocial stress factors as mediators. For example, an increase in job control acted as the mechanism by which improvements in mental health and sickness absence rates came about after a work reorganization intervention (Bond and Bunce 2001). Less is known about the effects of specific psychosocial work-related factors on physician well-being, such as patient-related issues, role ambiguity, or problems with teamwork. However, some studies show that patient-related stress and role ambiguity may be associated with well-being outcomes and that complex patient information systems increase the workload of physicians (Firth-Cozens 1998, 2003; Coomber et al. 2002; Likourezos et al. 2004; Couser 2008, Boonstra and Broekhuis 2010; Karsh, Beasley, and Brown 2010). In addition, a lack of social support and problems with teamwork has previously been suggested to decrease well-being and work ability among physicians working in hospitals (Kivimaki et al. 2001; Elovainio et al. 2002; Nieuwenhuijsen, Bruinvels, and Frings-Dresen 2010).

Even less is known about the differences in these specific psychosocial stressors between physicians working in different health care sectors, such as primary and secondary care and private sectors, and the role they play in well-being differences among physicians. This is despite the fact that they may serve as a basis for appropriate interventions for enhancing well-being, such as decreasing psychosocial distress and health problems and increasing work ability among physicians.

This study aimed at extending both theoretically and methodologically on previous studies. One aim was to produce a more detailed description of the specific factors accounting for the differences in well-being of physicians working with patients in different health care sectors. The objective of this study was to explore the role of specific psychosocial stressors that are not usually included in the established stress models/methods (e.g., Rodriguez et al. 2001; Elovainio et al. 2005; Couser 2008; Heponiemi et al. 2010a, b). Thus, we examined the association between working in different health care sectors and well-being indicators (psychosocial distress [GHQ], self-rated health, and work ability) among physicians. In addition, we tested whether specific psychosocial stressors at work (patient-related stress, stresses related to teamwork, stresses related to role ambiguity, and stresses related to patient information systems), in addition to high demands and job control would mediate the potential well-being differences in different health care sectors.

METHODS

Sample

We drew a random sample of 5,000 physicians in Finland from the Finnish Medical Association database in 2006. A total of 2,841 physicians (response rate 57 percent) returned the questionnaire. The sample is representative of the eligible population in terms of age, gender, and employment sector (Elovainio et al. 2007). In this study, we included physicians who were doing patient work as 50 percent or more of their duties. A total of 502 physicians were therefore excluded, with 121 physicians further excluded for working in a foundation or a society, and 141 physicians excluded due to incomplete data. Thus, the final sample numbered 2,047 physicians (1,241 women, 806 men) aged 25-65 years (mean = 45.1, SD = 9.9). Of those, 574 (28 percent) were GPs working in primary health care, 1,087 (53 percent) were medical physicians, and 386 (19 percent) were private physicians. Of the GPs, 69 percent were women, as were 60 percent of medical physicians and 51 percent of private physicians. The final sample was representative of the eligible population in terms of age and employment sector, but women were overrepresented. This was as expected, because a larger share of female physicians compared with male physicians do clinical work in Finland (Elovainio et al. 2007).

Measures

Health care sector was assessed by asking participants their main occupation's employment sector. Health care sector was coded as 1 = primary health care (primary health care and public occupational health care); 2 = secondary care (university hospitals/district hospitals and mental health clinics); and 3 = private sector (private clinics, private occupational health care, and other private employers).

Psychosocial Stressors

Psychosocial stressors except lack of job control were measured with 5-point rating scales, ranging from (1) never to (5) very often to the question "How often have you been distracted, worried or stressed about ... ?"

The subscales were as follows:

1. High job demands were measured by a five-item scale derived from Harris (1989) stress index with, for example, items like "I have too little time in which to do what is expected of me," "work overload," and "not enough staff" (Harris 1989). The mean response of the scale was scored (as with each of the psychosocial stressors) while the Cronbach's alpha for this sample was 0.85.

2. Patient-related stress was measured with a three-item scale ([alpha] = 0.82) derived from the health care stress questionnaire (Kivimaki and Lindstrom 1992). Sample items are, for example, "patients often have different expectations of care" and "patients are not willing to take part in the cure and they are passive."

3. Stresses related to teamwork were measured with a four-item scale ([alpha] = 0.78) derived from the Nurse Stress Index (Harris 1989). Sample items are, for example, "problems in human relationships at work" or "lack of trust and openness in the work place."

4. Stresses related to role ambiguity were measured with a self-developed three-item scale ([alpha] = 0.76) and items were "inconsistent information about job responsibilities and expectations," "pressure to work together with other colleagues," and "minor responsibilities take too much time from my primary duties." This measure was developed especially for this study.

5. Stresses related to patient information systems were measured with a self-developed two-item scale ([alpha] = 0.84) and the two items were "constantly changing data-systems" and "poorly working teleinformatic programmes." This measure was also developed especially for this study.

6. Lack of job control was measured by decision authority with nine items ([alpha] = 0.77) derived from Karasek's Job Content Questionnaire (JCQ) Karasek 1985). Decision authority measures the freedom to make independent decisions and possibilities to choose how to perform work. The response format was 1 = strongly disagree; 2 = disagree; 3 = neither agree not disagree; 4 = agree; 5 = strongly agree.

Well-being Indicators

Psychological distress was assessed using a 12-item version of the GHQ with a Likert Scale ranging from 1 to 4. A mean response score was used, while the Cronbach's alpha was 0.89. The GHQ is a widely used and validated instrument for the identification and measurement of psychological distress in the general population (Goldberg et al. 1997).

Self-rated health was assessed with the question "What kind of health do you have compared to others of your age?" Answer options were 1 = poor; 2 = rather poor; 3 = average; 4 = rather good; and 5 = good. This measure is widely used and the reliability is supported, for example, in relation to mortality (Mossey and Shapiro 1982; Idler and Benyamini 1997; Manderbacka et al. 2003).

Work ability was assessed with an item from the work ability index (Ilmarinen, Tuomi, and Klockars 1997): "Assume that your work ability at its best has a value of 10 and 0 means that you could not work at all. How many points would you give to your current work ability (range 0-10)?" This single-item work ability has previously been associated with health, for example, among Finnish nurses (Elovainio et al. 2010).

Other variables measured were age and sex, which were obtained from self-report data.

Statistical Analysis

To test the mediating effects, a series of covariance analyses were performed following the procedures outlined by Baron and Kenny (1986). The hypothesized mediating effects are supported if the following conditions are met. First, the health care sector is related to outcome variables (distress, self-rated health, and work ability). The interrelation between these outcome variables was measured using Pearson's two-tailed correlation test. If a significant difference was presented between the health care sector and outcome variables, we performed a post hoc analysis using the pairwise Tukey--Kramer method.

Second, the health care sector is associated with potential mediating variables (high job demands, patient-related stress, stresses related to team work, stresses related to role ambiguity, stresses related to patient information systems, and lack of job control), while mediating variables are also associated with outcome variables. If there were significant health care sector differences, these were additionally analyzed using the pairwise Tukey--Kramer method.

Third, adding mediating variables into the analysis reduces the association between employer sector and outcome. The analyses were adjusted for gender and age. Analyses were performed using SAS statistics 9.2 (SAS Institute Inc., Cary, North Carolina).

RESULTS

High to moderate correlations (p < .001) were found between psychosocial distress and self-estimated health (-.29) and between psychosocial distress and work ability (-.47) and also between self-estimated health and work ability (.54). Table 1 shows the results and means regarding the associations between health care sector and the well-being indicators. The strongest association was found between health care sector and psychosocial distress. The pairwise Tukey-Kramer method showed that GPs and medical specialists experienced more psychosocial distress than private physicians. Health care sector was also significantly associated with work ability. A pairwise comparison indicated significant differences between primary care and the private sector. GPs' work ability was lower than that of private physicians. Moreover, health care sector was significantly associated with self-rated health and the pairwise analyses showed that GPs' self-rated health was lower than that of medical physicians and private physicians. Thus, the first condition of the mediation test was met regarding all outcomes.

As Table 2 shows, health care sector was significantly associated with high job demands, patient-related stress, stresses related to team work, stresses related to role ambiguity, and stresses related to patient information systems. However, health care sector was not associated with a lack of job control. GPs experienced higher levels of job demands and patient-related stress compared with medical specialists and private physicians (Table 3). Medical specialists experienced more stresses related to team work and to patient information systems compared with GPs and private physicians. Physicians working in the private sector experienced psychosocial stressors which were tested in this study to a lesser degree than GPs and medical specialists.

All psychosocial stressors were significantly associated with all the well-being indicators (Table 2). High job demands, patient-related stress, stresses related to team work, stresses related to role ambiguity, stresses related to patient information systems, and a lack of job control were associated with higher levels of distress, lower self-estimated health, and lower work ability. Thus, the second condition of the mediation test was met with regard to all other psychosocial factors except lack of job control.

Mediating Testing

Table 4 shows the results of testing for the third condition for mediation. A lack of job control was not associated with health care sector (second condition of mediation was not met); thus, it was not included in these analyses. A clear attenuation in the association between health care sector and psychosocial distress could be detected after taking into account job demands, stress related to team work, and stress related to role ambiguity. The effect of health care sector on work ability seemed to be reduced after adding job demands, patient-related stress, stresses related to team work, and stresses related to role ambiguity into the models. In addition, job demands, patient-related stress, and stresses related to role ambiguity reduced the association between health care sector and self-rated health.

DISCUSSION

Our results show that there are clear differences in well-being among physicians working in the different health care sectors. GPs and medical specialists seemed to experience more distress than private physicians, while GPs' self-rated health and work ability were lower than physicians working in secondary care and the private sector. Furthermore, these well-being differences were partly explained by higher levels of psychosocial stressors among physicians working in primary health care and secondary care.

The present study found that GPs and medical specialists seemed to report more psychological distress than private physicians. The lowest level of self-rated health and work ability were reported by GPs, and the highest level by private physicians. Our results are consistent with previous studies suggesting that private physicians experience better well-being, have less burnout, and their job satisfaction is better than physicians working in primary or secondary care (Bohle et al. 2001; Lim and Pinto 2009; Mache et al. 2009). Previous studies have also shown that GPs are less satisfied with their job than medical specialists (Landon, Reschovsky, and Blumenthal 2003). Moreover, a previous Finnish study suggests that physicians working in the private sector have higher levels of job satisfaction and organizational commitment and lower levels of psychological distress and sleeping problems when compared with physicians working in the public sector (Heponiemi et al. 2010a).

Our results showed that high job demands and stresses related to role ambiguity accounted for the differences in the studied well-being indicators between physicians working in different health care sectors. Patient-related stress was shown to be partly responsible for lower self-rated health and work ability but not for higher psychosocial distress. Thus, this may indicate that job demands and stresses related to role ambiguity are factors behind the higher levels of psychosocial distress, the poorer self-estimated health, and lower work ability among GPs. Moreover, patient-related stress may also be a factor behind poorer self-rated health and the lower work ability among GPs. These findings add to those of previous studies that show that high job demands decrease job satisfaction, increase turnover, and predict health risks among physicians and also other health workers both directly and indirectly (Vanagas and Bihari-Axelsson 2005; Umehara et al. 2007). Moreover, role ambiguity has been shown to be the predominant psychosocial stressor associated with sick leave among Swedish dentists (Petren et al. 2007). Dealing with difficult patients has also been shown to be particularly stressful among GPs (Calnan et al. 2000).

Stresses related to team work seemed to be partly responsible for the lower levels of psychosocial distress and work ability among GPs and medical specialists. In addition, stresses related to patient information systems were partly responsible for the lower work ability among these groups. Stresses related to teamwork have previously shown to have a mediating role in decreased well-being among physicians (Kivim/iki et al. 2001; Nieuwenhuijsen, Bruinvels, and Frings-Dresen 2010). Similarly, Likourezos et al. (2004) reported that medical specialists expressed concern about the amount of time patient information systems take from the patient work while they were also worried about the confidentiality of these systems. In Finland, the patient information system was introduced during the 1990s; however, according to a previous study, the patient information system's functionality and usability are still provoking criticism. According to the same study, medical specialists were most unhappy with the patient information systems and especially the existence of several different systems was stressful (Vanska et al. 2010).

In Finland, being a physician is generally a highly valued occupation and well paid regardless of the working sector; however, working as a GP has lost much of its attractiveness as a career option among Finnish physicians over the last 15 years (Parmanne 2010), resulting in GPs switching from the public sector to the private sector (Kankaanranta et al. 2006). Although in our data the physicians working in private health care were actually slightly older (48 years) than those in primary care (44 years) and in hospitals (43 years), according to a previous study, physicians aged below 40 years in particular were considering moving from primary health care to the private sector (Kumpusalo et al. 2002). Prospect of a higher income is a key factor favoring the private sector; however, this switching may also be a consequence of increased job demands and psychosocial stress in primary care. A GP's area of expertise is especially multifaceted, covering patients of all ages and care provision ranging from preventive health to the management of chronic diseases. In addition, a larger share of the provision of long-term care has been transferred from secondary care to primary care within the last 15 years in Finland and also in other European countries, such as in the United Kingdom and the Netherlands (Schrijvers and Freeman 2005). These factors may have lessened the attractiveness of primary health care for physicians. In addition, providing medical training within a high-tech framework in hospitals has shown to reduce the number of medical students moving into primary health care (Hyppola et al. 2000). Physicians in the private sector have been found to have better freedom to negotiate their working hours and vacations flexibly and the opportunity to earn the same amount of money as in the public sector, but with fewer working hours (Palukka and Tiilikka 2007). The average monthly incomes of physicians who work full-time for the private sector are about 17 percent higher than the corresponding figure in the public sector (Kankaanranta et al. 2006).

Our results suggest that lessening psychosocial stressors in primary care may improve GPs' well-being. Paying attention to physicians' job demands, for example, by providing support and improving working conditions, may improve physicians' well-being. Moreover, improving teamwork could promote physicians' well-being and attitudes toward their job and, hence, may increase the attractiveness of general practice as a career option. According to Firth-Cozens (2003), the better teams have less stressed staff; this is probably because they support each other and when they notice that one person is performing below par, they may step in to help. Similarly, it is important to clarify the role and performance expectations, for example, by promoting a prompt and constructive resolution of conflicts.

This study made use of a large representative sample of Finnish physicians, covering a broad age range. However, the fact that the study was conducted in one country means that the results are anchored to the Finnish context. Moreover, the cross-sectional design prevents us from making causal interpretations, while the use of self-report data means that results may be overinflated. Self-selection bias may also influence the results and partly explain the differences. To minimize problems with self-reports, we have used well-known validated measures that have shown good reliability; however, we have also incorporated less frequently used measures that are specific to physicians' work to find new perspectives for stress-related factors among physicians. Even though we controlled for many variables, residual confounding cannot be ruled out in survey studies. All our outcomes were interrelated and this may produce random effects due to the large number of statistical manipulations. However, the outcomes we used represent different stages of a stress process that extend from psychological distress through to health problems to lower work ability. Thus, using all these outcomes may also increase the concurrent validity of the results. In addition, all our main effects remained statistically significant (p = 0.024) after Bonferroni corrections. In this study, we have focused on work-related factors only. However, testing psychosocial stressors in different health care sectors is a more detailed approach, and it may offer a useful tool for finding specific areas to develop in the psychosocial work environment of physicians. It would also be important to study factors other than psychosocial stressors, for example, different allocations between sectors of resources for physicians, and community and physical settings, which may influence a physician's choice of workplace.

CONCLUSION

Our study showed that GPs and medical specialists had lower well-being than private physicians. Well-being differences were partly explained by different psychosocial stressors. Job demands and patient-related stress were both strong stressors among GPs, whereas stresses related to teamwork and patient information systems seemed to be the most severe stressors among medical specialists. In improving primary care, several steps could be taken to decrease GPs' workload. Some routine tasks could be provided by nurses, while telephone or e-mail consultations could be improved. Improving teamwork by, for example, specifying roles within secondary care may also be important in lessening stress for medical specialists.

ACKNOWLEDGMENTS

Joint Acknowledgment/Disclosure Statement: The authors would like to thank statistician Martti Arffman for his help in statistical questions in the analysis. The study was supported by the Finnish Work Environment Fund (project number 107154) and Academy of Finland (project number 128002).

Disclosures: None.

Disclaimers: None.

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SUPPORTING INFORMATION

Additional supporting information may be found in the online version of this article:

Appendix SA1: Author Matrix.

Please note: Wiley-Blackwell is not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.

Address correspondence to Hannamaria Kuusio, M.A., National Institute for Health and Welfare (THL), Service System Research Unit, Mannerheimintie 103b, FI-00271 Helsinki, Finland; e-mail: hannamaria.kuusio@thl.fi. Hannamaria Kuusio, M.A., Tarja Heponiemi, Ph.D., Anna-Mari Aalto, Ph.D., Timo Sinervo, Ph.D., and Marko Elovainio, Research Professor, are with the National Institute for Health and Welfare (THL), Service System Research Unit, Helsinki, Finland.

DOI: 10.1111/j.1475-6773.2011.01313.x
Table 1: The Results of Covariance Analyses, Means and 95 Percent
Confidence Intervals (CIs) of the Well-being Indicators in Physicians
Working in Different Health Care Sectors (Adjusted for Age and Sex)

 Psychological Distress
 (Scale Range: 1-4) *

 Means (95% CI) SD

Primary health care 1.99 (1.96-2.03) (0.44)
Secondary care 1.99 (1.97-2.02) (0.43)
Private sector 1.89 (1.85-1.93) (0.41)
p-value <.001
F 8.16

 Self-Related Health
 (Scale Range: 1-5) ([dagger])

 Means (95% CI) SD

Primary health care 4.09 (4.02-4.17) (1.30)
Secondary care 4.19 (4.13-4.24) (1.31)
Private sector 4.24 (4.15-4.33) (0.41)
p-value .033
F 3.43

 Work Ability
 (Scale Range: 0-10)

 Means (95% CI) SD

Primary health care 8.47 (8.36-8.58) (0.91)
Secondary care 8.57 (8.49-8.65) (0.87)
Private sector 8.70 (8.57-8.83) (0.91)
p-value .031
F 3.49

Note. * Answer options: (1) not at all; (2) not more than usual;
(3) somewhat more than usual; (4) much more than usual.

([dagger]) Answer options: (1) poor, (2) rather poor, (3) average,
(4) rather poor; (5) good.

Table 2: The Results of Covariance Analyses Regarding the Associations
of Health Care Sector and Well-being Indicators with Psychosocial
Stressors (Adjusted for Age and Sex)

 Patient-Related
 High Job Demands Stress

 F p-value F p-value

Health care sector 168.65 <.001 84.34 <.001
GHQ 213.37 <.001 57.01 <.001
Work ability 85.91 <.001 58.39 <.001
Self-rated health 53.41 <.001 30.91 <.001

 Stresses Related Stresses Related to
 to Team Work Role Ambiguity

 F p-value F p-value

Health care sector 56.45 <.001 154.08 <.001
GHQ 140.08 <.001 213.70 <.001
Work ability 55.57 <.001 80.43 <.001
Self-rated health 32.50 <.001 49.04 <.001

 Stresses Related to
 Patient Information Lack of Job
 Systems Control

 F p- value F p-value

Health care sector 48.75 <.001 2.29 .102
GHQ 56.35 <.001 81.62 <.001
Work ability 48.67 <.001 55.08 <.001
Self-rated health 37.85 <.001 15.09 <.001

Notes. GHQ, General Health Questionnaire.

Table 3: Estimated Means of Psychosocial Stressors in Physicians
Working in Different Health Care Sectors (Adjusted for Age and Sex)

 High job Patient-Related
 Demands (Scale Stress (Scale
 Range: 1-5) * Range: 1-5) *

 Means SD Means SD

Primary health care 3.7 (0.82) 2.7 (0.76)
Secondary care 3.5 (0.84) 2.3 (0.81)
Private sector 2.7 (0.96) 2.0 (0.74)

 Stress Related
 Stress Related to Patient
 to Team Work Information
 (Scale Range: System (Scale
 1-5) * Range: 1-5) *

 Means SD Means SD

Primary health care 2.2 (0.75) 3.0 (1.13)
Secondary care 2.3 (0.80) 3.2 (1.16)
Private sector 1.8 (0.78) 2.6 (1.14)

Notes. Only means that are statistically significantly different
between the groups are shown; thus, means for lack of job control are
not shown.

* Answer options were 5-point rating scales, ranging from (1) never to
(5) very often.

Table 4: The Differences in Well-being Indicators between Physicians
Working in Different Health Care Sectors after Adjustment for
Psychosocial Stress Factors (All Adjusted for Age and Sex). The
Mediation Effects Testing

Adjusted for (in Addition to Psychological
Age and Sex) Distress Work Ability

Health care sector F p-value F p-value

1. No adjustments 8.16 <.001 3.49 .031
2. Job demands 1.76 .173 0.83 .434
3. Patient-related stress 4.24 .015 0.25 .779
4. Stresses related to team work 1.71 .182 2.26 .105
5. Stresses related to role 0.80 .448 1.16 .313
 ambiguity
6. Stresses related to patient 3.80 .023 2.64 .071
 information systems

Adjusted for (in Addition to
Age and Sex) Self-Rated Health

Health care sector F p-value

1. No adjustments 3.43 .033
2. Job demands 1.51 .222
3. Patient-related stress 0.70 .494
4. Stresses related to team work 3.21 .041
5. Stresses related to role 2.06 .128
 ambiguity
6. Stresses related to patient 3.58 .028
 information systems
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Author:Kuusio, Hannamaria; Heponiemi, Tarja; Aalto, Anna-Mari; Sinervo, Timo; Elovainio, Marko
Publication:Health Services Research
Article Type:Survey
Geographic Code:4EUFI
Date:Feb 1, 2012
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