• Tiada Hasil Ditemukan

RELATIONSHIP BETWEEN JOB FACTORS AND STRESS LEVEL AMONG POSTGRADUATE EMERGENCY MEDICINE

N/A
N/A
Protected

Academic year: 2022

Share "RELATIONSHIP BETWEEN JOB FACTORS AND STRESS LEVEL AMONG POSTGRADUATE EMERGENCY MEDICINE "

Copied!
78
0
0

Tekspenuh

(1)

RELATIONSHIP BETWEEN JOB FACTORS AND STRESS LEVEL AMONG POSTGRADUATE EMERGENCY MEDICINE

TRAINEES IN HOSPITAL UNIVERSITI SAINS MALAYSIA

by

DR LAI JOON THIAN

DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE DEGREE OF THE

MASTER OF MEDICINE (EMERGENCY MEDICINE)

SCHOOL OF MEDICAL SCIENCES UNIVERSITI SAINS MALAYSIA

2017

(2)

ii ACKNOWLEDGEMENT

First and above all, I praise God, the almighty for providing me this opportunity and granting me the capability to proceed successfully.

First and foremost, I would like to express my sincere gratitude to my supervisor, Dr Shaikh Farid Abdul Wahab for all his support, guidance and encouragement during the duration of this study. I might have lost the direction of my journey without the support. His valuable suggestions and exceptional guidance allowed me to gain and advance my knowledge in Emergency Medicine.

A special thanks to Dr Mohd Azhar Mohd Yasin, Psychiatrist and senior lecturer; Dr Erica Kueh Yee Cheng, from Department of Biostatistics and Research Methodology for their assistance and advice during the statistical analysis and presentation of my data.

My sincere thanks to Professor Dr Nik Hisamuddin Nik Ab. Rahman, Head of Emergency Department, Universiti Sains Malaysia and all the lecturers for their continuous guidance, assistance, encouragement and cooperation throughout this period.

I would like to thank all the members of my family; my parents and my parents-in- law for their endless love and encouragement. Last but not least, I greatly thank my lovely wife Dr Tan Chai Lee for her immeasurable support and utmost understanding throughout this journey.

(3)

iii TABLE OF CONTENTS

TITLE PAGE i

ACKNOWLEDGEMENTS ii

TABLE OF CONTENTS iii

ABSTRAK (BAHASA MALAYSIA) vi

ABSTRACT (ENGLISH) viii

CHAPTER 1: INTRODUCTION 2

1.1 Effects of Stress on Health and Occupation 2

1.2 Stress in Postgraduate Training 2

1.3 Rational of Study 3

CHAPTER 2: OBJECTIVES 7

2.1 GENERAL OBJECTIVES 8

2.2 SPECIFIC OBJECTIVES 8

CHAPTER 3: MANUSCRIPT 9

3.1 TITLE PAGE 10

3.2 ABSTRACT 11

3.3 INTRODUCTION 13

3.4 METHODOLOGY 16

3.5 RESULTS 19

3.6 DISCUSSION 21

3.7 CONCLUSION 25

(4)

iv

3.8 REFERENCES 26

3.8 TABLES & FIGURES 29

3.9 JOURNAL GUIDELINE 32

CHAPTER 4: STUDY PROTOCOL 37

4.1 BACKGROUND 38

4.2 RATIONALE OF STUDY 39

4.3 RESEARCH OBJECTIVE 40

4.4 RESEARCH QUESTION 40

4.5 RESEARCH HYPOTHESIS 40

4.6 METHODOLOGY 41

4.6.1 Study Design 41

4.6.2 Study Location 41

4.6.3 Study Duration 41

4.6.4 Study Reference Population 41

4.6.5 Source Population 41

4.6.6 Sampling Frame 41

4.6.7 Inclusion and Exclusion Criteria 42

4.6.8 Sample Size Calculation 42

4.6.9 Sampling Method 42

4.6.10 Examination Procedure 43

4.6.11 Research Tools 43

4.6.12 Statistical Analysis 46

4.6.13 Ethical Considerations 46

4.6.14 Flow Chart 47

(5)

v

4.6.15 Dummy Tables 48

4.7 REFERENCES 49

4.8 GANTT CHART 51

CHAPTER 5: APPENDICES 52

(6)

vi ABSTRAK

Pengenalan

Kursus latihan perubatan pascasiswazah merupakan salah satu proses yang memberi kesan tekanan yang tinggi. Menurut satu kajian yang telah dilakukan di Malaysia, sebanyak 36.4% pelatih pascasiswazah mengalami stres.

Objektif

Mengkaji hubungan antara faktor pekerjaan dan tahap stres di kalangan pelatih pascasiswazah Perubatan Kecemasan di Hospital Universiti Sains Malaysia.

Metodologi

Satu kajian keratan rentas telah dijalankan di Jabatan Kecemasan dan Trauma, Hospital Universiti Sains Malaysia, Kelantan antara tempoh September 2014 hingga Mei 2016 melibatkan pelatih pascasiswazah Perubatan Kecemasan. Min skor tekanan dinilai menggunakan soal selidik Depression, Anxiety, Stress Scale – 21 (DASS – 21) manakala faktor pekerjaan dinilai dengan soal selidik Job Content Questionnaire (JCQ). Hubungan antara stres dan faktor pekerjaan ditentukan dengan menggunakan analisis regresi linear mudah serta regresi linear pelbagai.

Keputusan

Seramai 61 orang pelatih pascasiswazah telah menyertai kajian ini. Min skor stres adalah 6.85  2.97. Sebanyak 39.3% pelatih pascasiswazah Perubatan Kecemasan melaporkan mengalami stres (22.9% stres ringan, 11.5% stres serdahana, manakala 4.9% stres teruk). Umur (p = 0.026), tahun dalam servis (p = 0.015), pertimbangan

(7)

vii kemahiran (p = 0.011) dan permintaan psikologi pekerjaan (p = 0.044) dikenalpasti mempunyai hubung kait dengan stres yang signifikan melalui regrasi linear pelbagai.

Kesimpulan

Majoriti pascasiswazah Perubatan Kecemasan di Hospital Universiti Sains Malaysia mengalami tahap stres normal, manakala 4.9% menglami tahap stres yang teruk.

Data menunjukkan umur, tahun dalam servis, pertimbangan kemahiran dan permintaan psikologi pekerjaan merupakan faktor pekerjaan yang menpunyai hubungkait dengan stres.

(8)

viii ABSTRACT

Background

Postgraduate residency training is a stressful process for physicians. Previous study in Malaysia showed 36.4% of postgraduate trainees experienced stress. Academic and performance pressure were the stressors among trainees. A stressful psychological condition may diminish job satisfaction and results in negative attitude towards work, interfere with intrapersonal and interpersonal relationship.

Objective

To study the relationship between job factors and stress level among Emergency Medicine Postgraduate trainees in Hospital Universiti Sains Malaysia (HUSM), Kelantan.

Methodology

A cross-sectional study was conducted in Emergency department, Hospital Universiti Sains Malaysia, Kelantan between the period of September 2014 till May 2016 and involving postgraduate Emergency Medicine trainees. Mean stress score was assessed using Depression, Anxiety, Stress Scale – 21 (DASS – 21) and job factors were evaluated using Job Content Questionnaire (JCQ). Simple linear regression and multiple linear regression analysis were used to determine the association of stress with job factors.

(9)

ix Results

A total of 61 postgraduate trainees were recruited for the study. Their mean stress score was 6.85  2.97. 39.3% of trainees experienced stress (22.9% mild stress, 11.5% moderate stress and 4.9% severe stress). Multiple linear regression showed age (p = 0.026), years of service (p = 0.015), skill discretion (p = 0.011) and psychological job demand (p = 0.044) has statistically significant association with stress.

Conclusion

More than half of the Emergency Medicine postgraduate trainees in Hospital Universiti Sains Malaysia experienced normal level of stress and 4.9% suffered severe stress. Age, year of service, skill discretion and psychological job demand were significantly associated with stress among postgraduate Emergency Medicine trainees.

(10)

Chapter 1

Introduction

(11)

2 1.0 INTRODUCTION

1.1 Effects of Stress on Health and Occupation

Stress can be defined as the inability to cope or the fear of not coping (Baldwin PJ et al, 1997). Job stress is the harmful physical and emotional response that occurs when the requirements of a job do not match the capabilities, resources or needs of the worker. Occupational stress is a recognised problem among health-care workers, and doctors are considered to be at particular risk. The suicide rate among medical practitioners is higher than among other, similar professional groups (Meltzer, H. et al., 2008).

Increased stress levels tend to lead to burnout or physical illness and to decreased quality of life and reduced ability to provide patient care services (Ruotsalainen, J. H.

et al., 2015). This results in increased absenteeism and turnover (Michie, S., 2002).

Increased stress is also associated with low job satisfaction and harassmentand low levels of involvement in decision-making (Weinberg A et al., 2000) (Okada N et al., 2005). The association of psychological stress with disease has been established, particularly in relation to depression, cardiovascular disease and HIV/AIDS (Cohen S et al., 2007).

1.2 Stress in Postgraduate Training

The first year of postgraduate residency training has been found to be the most stressful year for trainees (Abdulghani, H. M. et al., 2015) (Saini, N. K. et al., 2010).

A similar investigation concluded that there is a high level of work related stress among resident doctors registered for postgraduate clinical studies in tertiary hospitals (Rajan, P. and B. Bellare, 2011). A study at the Hospital Universiti Sains

(12)

3 Malaysia reported the prevalence of stress among postgraduate students to be 36.4%

(MSB Yusoff et al., 2010). In the study, major stressors were shown to be related to academic and performance pressure.

In Malaysia, the average training duration for clinically-based medical postgraduate study ranges from 4 to 7 years. During this period, most of the postgraduate trainees have to juggle their work, studies, dissertation, and professional examinations with family and personal issues. While they are providing health-care services, trainees are also under constant pressure to fulfil the coursework requirements and to keep up with the latest knowledge in their respective field. This all contribute to putting these individuals at risk for high level of stress.

1.3 Rationale of Study

The field of Emergency Medicine in Malaysia is new in comparison to other medical disciplines. The role of emergency physicians in Malaysia has increased immensely, and the emergency department has shifted from being only a triage centre to become the front line in patient management. The expanding role and consequent increased workload of emergency physicians expose them to increased occupational stress. A stressful psychological condition may diminish job satisfaction and results in negative attitude towards work, interfere with intrapersonal and interpersonal relationship.

Following an extensive literature search, to the best of our knowledge, there is no published study on stress level among emergency medicine trainees in Malaysia. We aim to study the level of stress and evaluate the relationship between stress and job

(13)

4 factors among postgraduate emergency medicine trainees in one tertiary centre in this country.

(14)

5 References

Abdulghani, H. M., Al-Harbi, M. M., & Irshad, M. (2015). Stress and its association with working efficiency of junior doctors during three postgraduate residency training programs. Neuropsychiatr Dis Treat, 11, 3023-3029.

Baldwin, P. J., Dodd, M., & Wrate, R. W. (1997). Young doctors' health—I. How do working conditions affect attitudes, health and performance? Social science &

medicine, 45(1), 35-40.

Cohen, S., Janicki-Deverts, D., & Miller, G. E. (2007). Psychological stress and disease. JAMA, 298(14), 1685-1687.

Meltzer, H., Griffiths, C., Brock, A., Rooney, C., & Jenkins, R. (2008). Patterns of suicide by occupation in England and Wales: 2001–2005. The British Journal of Psychiatry, 193(1), 73-76.

Michie, S. (2002). Causes and management of stress at work. Occup Environ Med, 59(1), 67-72.

Okada, N., Ishii, N., Nakata, M., & Nakayama, S. (2005). Occupational stress among Japanese emergency medical technicians: Hyogo Prefecture. Prehospital and Disaster Medicine, 20(02), 115-121.

(15)

6 Rajan, P., & Bellare, B. (2011). Work related stress and its anticipated solutions among post-graduate medical resident doctors: a cross-sectional survey conducted at a tertiary municipal hospital in Mumbai, India. Indian J Med Sci, 65(3), 100-106.

Ruotsalainen, J. H., Verbeek, J. H., Marine, A., & Serra, C. (2015). Preventing occupational stress in healthcare workers. Cochrane Database Syst Rev(4), Cd002892.

Saini, N. K., Agrawal, S., Bhasin, S. K., Bhatia, M. S., & Sharma, A. K. (2010).

Prevalence of stress among resident doctors working in Medical Colleges of Delhi.

Indian J Public Health, 54(4), 219-223.

Weinberg, A., & Creed, F. (2000). Stress and psychiatric disorder in healthcare professionals and hospital staff. the Lancet, 355(9203), 533-537.

Yusoff, M. S. B., & Rahim, A. F. A. (2010). Prevalence and sources of stress among postgraduate medical trainees: initial findings. ASEAN Journal of Psychiatry, 11(2), 180-189.

(16)

Chapter 2

Objectives

(17)

8 2.0 OBJECTIVES

2.1 General Objective

To study the relationship between job factors and stress level among postgraduate Emergency Medicine trainees in Hospital Universiti Sains Malaysia (HUSM).

2.2 Specific Objectives

i. To determine the mean level of stress among postgraduate Emergency Medicine trainees in HUSM.

ii. To determine the associated factors of job-related stress among postgraduate Emergency Medicine trainees in HUSM.

(18)

Chapter 3

Manuscript

(19)

10 Relationship between Job Factors and Stress Level among Postgraduate Emergency Medicine Trainees in Hospital Universiti Sains Malaysia

Joon Thian-Lai1, Abdul Wahab-Shaik Farid1, Mohd Yasin-Mohd Azhar2

1Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia

2Department of Psychiatry, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia

Correspondence to:

Abdul Wahab-Shaik Farid

Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia,

16150 Kubang Kerian, Kelantan, Malaysia.

Email:shaikfarid@kb.usm.my Tel: +09-7676991

Fax: +09-7673219

(20)

11 ABSTRACT

Background

Postgraduate residency training and clinical studies are related to high level of work stress among physicians. There is limited data on the stress levels and the job factors related to stress among emergency medicine postgraduate trainees in Malaysia.

Objectives

We aimed to study the relationship between job factors and stress level among emergency medicine postgraduate trainees in Hospital Universiti Sains Malaysia (HUSM), Kelantan.

Methodology

This was a cross-sectional study conducted in a tertiary postgraduate training centre in Malaysia between September 2014 and May 2016, which involved postgraduate emergency medicine trainees. Level of stress were assessed from scores on the Depression, Anxiety, Stress Scale – 21 (DASS – 21), and job factors were evaluated by using the Job Content Questionnaire (JCQ). Simple linear regression and multiple linear regression were used to determine the relation of stress to job factors.

(21)

12 Results

A total of 61 postgraduate trainees were recruited for the study. Their mean stress score was 6.85  2.97. Over half of trainees experienced normal level of stress, 23%

reported mild stress, 11% moderate stress and 5% suffered from severe stress.

Multiple linear regression showed that age (p = 0.026), years of service (p = 0.015), skills discretion (p = 0.011) and psychological job demand (p = 0.044) had statistically significant associations with stress.

Conclusion

More than half of the Emergency Medicine postgraduate trainees in Hospital Universiti Sains Malaysia experienced normal level of stress and 5% suffered severe stress. Age, year of service, skill discretion and psychological job demand were significantly associated with stress among postgraduate Emergency Medicine trainees.

Keywords

Postgraduate Emergency Medicine, Stress, Job factors

(22)

13 INTRODUCTION

Stress is defined as a ‘non-specific response of body to any demand for change’1. It can also be defined as the inability to cope or the fear of not coping2. Job stress is the harmful physical and emotional response that occurs when the requirements of a job do not match the capabilities, resources or needs of the worker3. Occupational stress is a recognised problem among health-care workers, and doctors are considered to be at particular risk4. The suicide rate among medical practitioners is higher than among other, similar professional groups5,6.

Increased stress levels tend to lead to burnout or physical illness and to decreased quality of life and reduced ability to provide patient care services. This results in increased absenteeism and turnover7,8. Increased stress is also associated with low job satisfaction and harassment9 and low levels of involvement in decision- making10. The association of psychological stress with disease has been established, particularly in relation to depression, cardiovascular disease and HIV/AIDS11.

Postgraduate medical training was found to be a stressful period for resident trainees12.Emergency Medicine trainees showed highest level of stress in comparison to Internal Medicine and Family Medicine counterparts12. Several studies also reported the highest level of stress was experienced during the first year of postgraduate training12,13.In another study, there was a high level of work related stress among resident doctors registered for postgraduate clinical studies in tertiary hospitals14. A study at the Hospital Universiti Sains Malaysia reported the prevalence of stress among postgraduate students to be 36.4%15. In the study, the major stressors were found to be related to academic and performance pressures.

(23)

14 In Malaysia, the average training duration for clinically-based medical postgraduate study ranges from 4 to 7 years. Emergency Medicine in the country is considered a relatively new medical specialty in contrast to other specialities.

Postgraduate training of Emergency Medicine in the country was started in 1986, and it was the 14th specialty recognized by the Ministry of Health16. Since 2004, the medical school for postgraduate training in Emergency Medicine grew from only one school to a total of three medical schools which offers the program.

In general, the Emergency Medicine postgraduate training structure involves a 4-year training program. The program is divided into three phases: namely, phase 1 (year 1), phase 2 (includes year 2 and 3), and phase 3 (year 4)16. Phase 1 training includes basic specialty knowledge and clinical skills acquisition. Phase 2 involves supervised specialized apprenticeship program, and in the following final year of training in phase 3 is the specialist in training program. During the 4-year training duration, there are two professional board examinations (during phase 1 and phase 3), phase assessment and dissertation preparation requirement. The aim of this training program is to ensure future Emergency Physicians are adequately trained and well equipped with knowledge and skills to provide emergency services upon completion of training16.

During the training period, the demand to juggle between work, academic, dissertation and professional examinations with family and personal issues are burdened upon trainees. While they are providing health-care services, trainees are also under constant pressure to fulfil the coursework requirements and to keep up with the latest knowledge in their respective fields. These all contributed to putting this group of individuals at risk for high levels of stress. A stressed psychological

(24)

15 condition may diminish their job satisfaction and result in negative attitudes towards work and towards intrapersonal and interpersonal relationships.

Following an extensive literature search, to the best of our knowledge, there is no published study on stress level among emergency medicine trainees in Malaysia. We aim to study the level of stress and evaluate the relationship between stress and job factors among postgraduate emergency medicine trainees in one tertiary centre in this country.

(25)

16 METHODS

This was a cross-sectional study involving postgraduate Emergency Medicine trainees of the Emergency Department, Hospital Universiti Sains Malaysia, conducted between September 2014 and May 2016. Participants were recruited by convenience sampling. An information leaflet explaining the details of the study was given to potential participants and written, informed consent taken. Potential participants included all emergency medicine postgraduate trainees.

The self-administered questionnaire booklet consisted of three parts. The participant’s sociodemographic data was gathered in part one; this included age, gender, marital status, number of children, personal income, years in training and years of service. Part two and three contained the Depression Anxiety Stress Score – 21 (DASS – 21) and the Job Content Questionnaire (JCQ), respectively. Participants were asked to give their responses in the questionnaire booklet within 15 minutes, on the same day that it was distributed. The questionnaire booklet distribution and collection was done by hand.

The Depression, Anxiety and Stress 21 Items Questionnaire (DASS 21) is a shorter version of the DASS 4217. It is a set of three self-reported scales designed to measure the negative emotional states of depression, anxiety and stress. Each domains comprises of seven items, assessing the mental health symptoms that are:

depression, anxiety and stress. Participants were required to report the presence of any symptoms over the previous one week. The answers were based on a Likert scale of four: 0 point (did not apply to me at all), 1 point (applied to me to some degree, or some of the time), 2 points (applied to me to a considerable degree), or 3points

(26)

17 (applied to me very much, or most of the time). The score was then calculated according to the domain and categorized as normal, mild, moderate, severe or extremely severe based on the DASS manual (Table 1).

The JCQ questionnaire was developed by Kareasek to measure the content of a work tasks18. It is one of the most frequently used instruments for psychosocial job analysis. For this study, 21 items from the full version of 49 items are used to measure the three major scales of job factors which are: decision latitude (consists of 8 items), psychological job demands (consists of 7 items), and social support (consists of 6 items). The answers were scored on a Likert scale of 1 to 4 (strongly disagree, disagree, agree and strongly agree; or often, sometimes, rarely and never) and the total scores were calculated based on Karasek’s recommended format.

Data collected were analysed using the Statistical Package for Social Sciences (SPSS) Version 22 (SPSS Inc, Chicago, IL, USA). All values were tested for normal distribution and equal variance. Demographic data and stress scores were analysed using descriptive analysis, frequency and percentage, mean values and standard deviation (SD).

The dependent variable was the stress score. Independent variables included age, gender, marital status, number of children, personal income, years in training, years of service, skills discretion, decision authority, psychological job demands, co- workers’ support and supervisor support. A p-value < 0.05 was taken as the cut-off for statistical significance. The relationships between job factors and stress were analysed using multiple linear regression.

(27)

18 Data exploration and simple linear regression were conducted for all variables. In the multiple linear regression analysis, stepwise and backward procedures were performed on all job factors and socio-demographic data to obtain a preliminary main effect model. The model was also tested for two-ways interaction and multi-collinearity.

The study was approved by the Research and Ethical Committee, School of Medical Sciences, Universiti Sains Malaysia [Ref no: USM/JEPeM/15030088] and was conducted in accordance with the guidelines of the International Conference on Harmonization (ICH).

(28)

19 RESULTS

Demographic Data

A total of 61 postgraduate emergency medicine trainees completed the questionnaire. All the trainees participated in the study. There were slightly more male trainees (59%) (Table 2). Their mean age was 32.2 years (SD 2.13). Sixty percent of the trainees were married. The mean number of children was 1 (SD 1).

The mean duration in service was 6.7 years (SD 1.74) and the mean personal annual income was RM 6226.16 (SD 1244.01).

Stress and Job Characteristics

Of the 61 trainees who were practicing in the Hospital Universiti Sains Malaysia, over half were experiencing normal levels of stress, 23% reported mild stress, 11% moderate stress, and 5% had severe stress. Table 3 shows simple linear regression (SLR) analysis of the socio-demographic factors, the job factors and stress levels. Skills discretion was found to be associated with stress (p = 0.017).

With multiple linear regression analysis, age (b = -0.57 (95% CI -1.07 - - 0.07) p = 0.026), years in service (b = 0.79 (95% CI 0.16 - 1.42) p = 0.015), skills discretion (b = 0.27 (95% CI -0.48 - -0.06) p = 0.011) and psychological job demands (b = 0.04 (95% CI 0.09 - 0.64) p = 0.044) were associated with stress among trainees (Table 4).

There was a negative relationship between age and stress score. For example, an increase of 1 year of age reduced the stress score by 0.57. It follows that with an

(29)

20 increase of 10 years of age the stress score was reduced by approximately six units (b

= 0.57, (95% CI -1.07 - -0.07) therefore, 10. 0.57 = 5.7 ~ 6).

(30)

21 DISCUSSION

Emergency and critical care of patients invariably takes place in a stressful working environment. The provision of immediate intervention to patients attending the emergency department demands knowledge and skills and patients have to be managed within a limited time. Stressors experienced by trainees in Emergency Medicine are distinct from other specialty, these include sleep deprivation, patient overload, low status in hospital hierarchy and lack of negotiation skills19. 39.3% of trainees experienced mild to severe stress in this study. This finding is almost similar to report by Saini, N.K. et al. where the overall prevalence of stress among resident doctors pursuing postgraduate study was 32.8%13.

Age was found to be statistically significant contributor to stress. Our finding differ from other studies conducted among Emergency Medicine trainees, where age was not found to be a factor to stress12,13,20. We postulate the greater stress experienced by younger trainees may be due to inadequate clinical experience and skills, the lack of authority in decision making and their weaker stress coping mechanisms.

The years in service was found to be positively associated with stress among trainees. Contrary to the earlier finding of younger age contributes to more stress, the delay of enrolment into postgraduate study which translates into longer duration in service, may have contributed this to be a stressor during training. Trainees who are admitted later into the program would encounter a step down in seniority ranks in postgraduate studies, despite registered more years of working experience. These trainees will also assume new role of responsibility, higher work load, in addition to

(31)

22 academic needs and patient care during training, which can create more stress. The selection criteria for enrollment into Emergency Medicine postgraduate training is determined by the medical school and Management Unit of the Ministry of Health for specialty training. Potential candidate must possess at least two years of clinical experience after graduation, and further selection is based on pre-entry assessment examination and merit points. The strict requirements for trainee selection ensures only the best candidate is chosen. Hence, the years in service does not guarantee entrance into training. Trainee may only be accepted after multiple attempts, which may also become a potential source of stressor upon successful entrance into postgraduate study.

The concept of decision latitude comprises two constructs: decision authority, referring to the employee’s authority to make job related decisions; and skills discretion, which measures the extent of the skills that employees use on the job18. Skills discretion is defined as the level of skills and creativity required on the job and the flexibility which permits the worker to decide which skills to employ and when to learn new things18. In this study, the higher the level of skills discretion, the lower the stress scores.

This finding is similar to that of two previous studies. In the study at Universiti Kebangsaaan Malaysia, skills discretion had a negative correlation with stress among assistant medical officers21. Similarly, among lecturers in the School of Medical Sciences, Universiti Sains Malaysia, a lower stress score correlated with higher skills discretion22.

(32)

23 With the emergence of evidence-based medicine, new instruments and updates in the management of critically ill patients are constantly being presented and trainees need to adapt to the new skills and knowledge. Flexibility in learning and the ability to make clinical decisions translates into better work performance.

With higher skills discretion lower levels of stress are experienced.

The emergency department provides an around-the-clock clinical service, regardless of the time of day. Prompt clinical judgements and quick clinical decision making are needed to provide timely interventions for every ill patient. At the same time, critical care patients are frequently managed in the department due to access problem.

Excessive workloads and time constraints may jeopardize the care of patients.

Psychological job demands and decision latitude were positively associated with psychosocial well-being (mental health) among emergency medical and nursing staff in Spain23. However, in this study the mental health assessment was measured by the Short Form (36) Health Survey instead of DASS 21. Three other studies also found positive associations between psychological job demands and stress21,24,25. In these studies, the stress levels were measured by DASS, which was similar to our study.

There are several limitations to our study. This was a single centre, cross sectional study involving only one postgraduate training group. Together with the small sample size, the results may not represent the true level of stress experienced by the full population of trainees. Data collection during the study duration reflects only the level of stress of each participant at a single point in time, and from this a

(33)

24 true estimation of stress levels cannot be attained. Possible misinterpretation of questions and to a lack of direct communication is another limitation of a self- administered, questionnaire-based study.

(34)

25 CONCLUSION

39.3% of Emergency Medicine postgraduate trainees in Hospital Universiti Sains Malaysia experienced stress. Age, years in service, skills discretion and psychological job demands are factors associated with stress. A multi-centre, larger sample size study should be conducted to improve the accuracy regarding the levels of stress in Emergency Medicine postgraduate trainees and the job factors associated with stress.

(35)

26 REFERENCES

1. Selye H. Stress and the adaptation syndrome. Cyclopedia Of Medicine, Surgery And Specialities. 1963;111:365-66.

2. Baldwin, P., M. Dodd, and R. Wrate, Young doctors' health—I. How do working conditions affect attitudes, health and performance? Social science &

medicine, 1997. 45(1): 35-40.

3. National Institute For Occupational Safety And Health. STRESS...At Work [Internet]. Centers For Disease Control And Prevention; 1999 [Updated June 6, 2014]. Available From http://www.cdc.gov/niosh/docs/99-101/default.html 4. Agius RM, Blenkin H, Deary IJ, Zealley HE, Wood RA. Survey of perceived

stress and work demands of consultant doctors. Occupational And Environmental Medicine. 1996;53(4):217-24.

5. Lindeman S, Laara E, Hakko H, Lonnqvist J. A systematic review on gender- specific suicide mortality in Medical Doctors. The British Journal Of Psychiatry.

1996;168(3):274-9.

6. Meltzer, H., et al., Patterns of suicide by occupation in England and Wales:

2001-2005. Br J Psychiatry, 2008. 193(1): 73-6.

7. Ruotsalainen, J.H., et al., Preventing occupational stress in healthcare workers.

Cochrane Database Syst Rev, 2015(4): p. Cd002892.

8. Michie, S., Causes and management of stress at work. Occup Environ Med, 2002. 59(1): 67-72.

9. Weinberg A, Creed F. Stress and psychiatric disorder in healthcare professionals and hospital staff. Lancet. 2000;355(9203):533-7.

(36)

27 10. Okada N, Ishii N, Nakata M, Nakayama S. Occupational stress among Japanese Emergency Medical technicians: Hyogo Prefecture. Prehospital And Disaster Medicine. 2005;20(2):115-21.

11. Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease.

JAMA: The Journal Of The American Medical Association. 2007;298(14):1685- 7.

12. Abdulghani, H.M., M.M. Al-Harbi, and M. Irshad, Stress and its association with working efficiency of junior doctors during three postgraduate residency training programs. Neuropsychiatr Dis Treat, 2015. 11: p. 3023-9.

13. Saini, N.K., et al., Prevalence of stress among resident doctors working in Medical Colleges of Delhi. Indian J Public Health, 2010. 54(4): p. 219-23.

14. Rajan P, Bellare B. Work related stress and its anticipated solutions among post- graduate medical resident doctors: a cross-sectional survey conducted at a tertiary municipal hospital in Mumbai, India. Indian Journal Of Medical Sciences. 2011;65(3):100-6.

15. Yusoff, M. S. B., & Rahim, A. F. A. (2010). Prevalence and sources of stress among postgraduate medical trainees: initial findings. ASEAN Journal Of Psychiatry. 2010;11(2), 180-189.

16. Rahman, N. and C. Holliman, Emergency medicine in Malaysia. Hong Kong J Emerg Med, 2005. 12(4): p. 246-251.

17. Lovibond, P.F. and S.H. Lovibond, The structure of negative emotional states:

comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther, 1995. 33(3): p. 335-43.

18. Karasek R, Job content questionnaire and user's guide, Lowell, MA: Department Of Work Environment, University Of Massachusetts-Lowell, 1997.

(37)

28 19. Fix ML. Coping with stress during residency. [Internet]. Medscape; 2007; 2016.

Available from http://www.medscape.com/viewarticle/556498

20. Wrenn, K., et al., Factors affecting stress in emergency medicine residents while working in the ED. Am J Emerg Med, 2010. 28(8): p. 897-902.

21. Yacob MA, Daud A, Noor NM, Mohammad WMZW. Prevalence and associated factors of stress among assistant medical officers in Ministry Of Health (MOH) hospitals in Kelantan and Terengganu, Malaysia. International Medical Journal.

2010;17(1).

22. Huda B, Rusli B, Naing L, Tengku M, Winn T, Rampal K. A study of job strain and dissatisfaction among lecturers in the School Of Medical Sciences Universiti Sains Malaysia. 2004.

23. Escribà-Agüir V, Pérez-Hoyos S. Psychological well-being and psychosocial work environment characteristics among Emergency medical and nursing staff.

Stress And Health. 2007;23(3):153-60.

24. Rusli B, Edimansyah B, Naing L. Prevalence and associated factors of stress in dental healthcare workers of a higher institution of learning in Kelantan.

Archives Of Orofacial Sciences. 2006;1:51-6.

25. Hadi AA, Naing NN, Daud A, Nordin R, Sulong MR. Prevalence and factors associated with stress among secondary school teachers in Kota Bharu, Kelantan, Malaysia. Southeast Asian J Trop Med Public Health.

2009;40(6):1359-70.

(38)

29 Table 1: DASS – 21 - Stress Severity Rating15

Severity Score

Normal 0 – 7

Mild 8 – 9

Moderate 10 – 12

Severe 13 – 16

Extremely severe 17 and over

Table 2: Socio-demographic characteristics of 61 postgraduate Emergency Medicine trainees in Hospital Universiti Sains Malaysia (HUSM)

Demographic characteristics Mean (SD) n (%)

Age 32.16 (2.131)

Gender Male Female

36 (59.0) 25 (41.0) Personal income 6226.16 (1244.011)

Marital Status Single Married Divorce

23 (37.7) 36 (59.0) 2 (3.3) Number of children

0 1 2 3 4

32 (52.5) 9 (14.8) 12 (19.7) 6 (9.8) 2 (3.3) Years of training 2.34 (1.340)

Years of service 6.69 (1.737)

(39)

30 Table 3: Univariate analysis (simple linear regression) of socio-

demographic and job factors predicting stress score (n=61)

Variables Stress

b (95%CI) P value

Age (years) -0.08 (-0.44, 0.29) 0.679

Sex Male Female

0

1.13 (-0.40, 2.66) 0.145 Marital status

Single / divorce Married

0

-0.59 (-2.14, 0.96) 0.451 Number of children -0.18 (-0.82, 0.47) 0.583 Personal income 0.00 (-0.001, 0.001) 0.712 Years of training -0.47 (-0.09, 1.04) 0.098 Years of service 0.30 (-0.14, 0.74) 0.177 Skill discretion -0.25 (-0.45, -0.05) 0.017 Decision authority -0.13 (-0.29, 0.04) 0.120 Psychological Job demand 0.09 (-0.23, 0.40) 0.587 Co-workers support -0.22 (-0.63, 0.19) 0.290 Supervisor support -0.22 (-0.66, 0.22) 0.329

(40)

31 Table 4: Socio-demographic factors and job factors associated with stress among Emergency Medicine trainees in HUSM (n=61)

Variable

Simple Linear Regression Multiple Linear Regression ba (95%CI) P value bb (95% CI) P value Age -0.08(-0.44,0.29) 0.679 -0.57 (-1.07, -0.07) 0.026 Years of service 0.30 (-0.14, 0.74) 0.177 0.79 (0.16, 1.42) 0.015 Skill discretion -0.25 (-0.45, -0.05) 0.017 -0.27 (-0.48, -0.06) 0.011

Psychological

job demand 0.09 (-0.23, 0.40) 0.587 0.04 (0.09, 0.64) 0.044 Backward selection method applied. No interaction and multicollinearity was detected. Model assumptions was fulfilled. Coefficient of determination (R2 = 0.169)

(41)

32

Author Guidelines

Types of manuscripts accepted

MJEM accepts the following types of manuscripts according to these formats given:

A. Editorial

Concise but substantial comments on a particular issue concerning emergency medicine

Abstracts: not more than 150 words

Text: not more than 1200 words

No table or figure

References: not exceeding 15

B. Original article

Emergency medicine related original clinical research

Abstract: according to headings; background, methodology, results and conclusion.

Not more than 300 words

Text: not more than 3500 words

Tables and/or figures: not more than 5 each.

C. Case reports

Series of 3 similar cases in a case report presented at the emergency department or pre hospital care. The topics accepted are either:

Challenges in diagnosis

New treatment modalities

System improvements

Abstract: not more than 200 words

Text: not more than 1500 words

References: not exceeding 20

D. Letters

A short report regarding a particular clinical, system, research or academic issues in emergency medicine

Abstract: not more than 150 words

Text: not more than 1000 words

References: not exceeding 15

E. Comments to the editor

A short comments on articles published in MJEM for the past one year

Text: 400 words

References: not exceeding 10 F. Review article:

The title for a review article is usually identified by the editors or advisors but can also be suggested by the author through communication with the chief editor. The article will be peer reviewed according to m-jem requirements. The topics will be emergency medicine related and the targeted readers are the doctors practising emergency medicine. M-jem will not accept article affiliated with a particular company or brand. A cover letter has to be signed according to m-

(42)

33 jem requirements. The article has to be evidence based clinical practice according to these headings:

Abstract: Concentrating on objectives, controversies, guidelines and conclusion. Not more than 300 words.

Text: Not more than 2700 words

Introduction

Issues and controversies

Local and/or international guidelines

Tables: not more than 3

Graphs/figures: not more than 3

Authors’ conclusions

References: not more than 60 references

Manuscripts preparation:

Manuscripts should be written in UK English using Arial 12 font and double spacing.

Each manuscript must contain the following sections;

1 Title page

2 Abstract and keywords 3 Text

4 Acknowledgements 5 References

6 Figure legends (if stated) 7 Tables (if stated)

8 Figures (if stated)

Each section should begin as a separate document.

1. Title page

This page will not be submitted to the reviewers to assist in the blinding process during reviewing. This page consists of:

1 Title

2 Name of authors and their affiliations

3 Details of corresponding authors who will be communicating with the journal secretariat.

Name

Title

Academic qualification

Corresponding address

Telephone number

Email address

1 Acknowledgement is given to non-contributors based on definition given by ICMJE.

Grants or subsidies have to be stated in this section including the grant number or other external grants.

2. Abstract and keywords

(43)

34 The length depending on the type of manuscript submitted. Abstracts for original articles should include the background, objective, the methodology, results and conclusion. Abstracts for other manuscripts require the above sections.

Keywords are allowed for each manuscript which is present in the title of the manuscript.

3. Text

The subsections depend on the type of manuscripts as shown below:

1. Original articles:

1. Introduction, 2. methods, 3. results, 4. discussion 5. conclusion

1. Case reports:

1. Background 2. Series of cases 3. Discussion 4. Conclusion 5. References

4. References

References should be numbered according to sequence mentioned in the text. The numbering system should follow the Arabic numerals for example 1,2,3. The number of references depends on the types of manuscripts stated previously.

Examples of method to write references are shown below:

A. Journal:

Author(s). Title. Year of publication; Volume (Issue): Page(s) Example:

Chew KS, Idzwan ZM, Hisamuddin NA, Kamaruddin J, Wan Aasim WA. Outcomes of cardiopulmonary resuscitation performed in Emergency Department, Hospital Universiti Sains Malaysia. Med J Malaysia. 2008 Mar;63(1):4-8.

B. Book:

a.Whole book:

Author(s). Title. Edition. Place of publication. Publisher; Year of publication.

Example:

Hastie TJ, Tibshirani RJ. Generalized additive models. 1st Ed. London and New York.

Chapman & Hall; 1990.

b. Chapter in a book:

Author(s). Paper title. In: Editor(s), editors. Title. Place of publication: Publisher;

Year of publication. Page(s).

Example:

(44)

35 Myerburg RJ, Castellanos A. Cardiac arrest and sudden cardiac death. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook on Cardiovascular Medicine. Philadelphia: Saunders Elsevier; 2007:933973

c. Online book /Electronic articles:

Manuscripts available in a website from the internet.

Author(s). Title of article [Internet]. Place of publication: Publisher; Year of publication [Date of citation]. Available from: URL.

Example:

Catharine A Bon, Joshua Schechter et al. Cardiopulmonary resuscitation [Internet].

New York: Medscape; 2016. Available

from http://emedicine.medscape.com/article/1344081-overview#showall

C. Tables

Table should be sent on a separate sheet. Allocate the tables in order using numbers as mentioned in the manuscript for example Insert table 1 here. Footnotes are assigned to the tables using alphabetical order. Tables and figures should be placed after the references. Maximum numbers of tables is 5

D. Illustrations

Illustrations and figures are to be submitted using JPEG or PNG formats. Provide written permission if the illustrations or figures are previously published. Authors are directly responsible to all illustrations or figures published. Maximum numbers of figures is 5.

Submission Preparation Checklist

As part of the submission process, authors are required to check off their

submission's compliance with all of the following items, and submissions may be returned to authors that do not adhere to these guidelines.

1. The submission has not been previously published, nor is it before another journal for consideration (or an explanation has been provided in Comments to the Editor).

2. The submission file is in Microsoft Word document file format.

3. The text is single-spaced; uses a 12-point font; New Time Roman, employs italics, rather than underlining (except with URL addresses);

4. The text adheres to the stylistic and bibliographic requirements outlined in the Author Guidelines, which is found in About the Journal.

5. If submitting to a peer-reviewed section of the journal, the instructions in Ensuring a Blind Reviewhave been followed.

Copyright Notice

Authors who publish with this journal agree to the following terms:

1. Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.

(45)

36 1. Authors are able to enter into separate, additional contractual arrangements for the

non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.

1. Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).

Privacy Statement

The names and email addresses entered in this journal site will be used exclusively for the stated purposes of this journal and will not be made available for any other purpose or to any other party.

(46)

Chapter 4

Study Protocol

(47)

38 4.1 BACKGROUND

Stress is defined as ‘nonspecific response of body to any demand for change’ (Seyle, 1936). Psychological stress and its association with diseases have been established, particularly for depression, cardiovascular disease, and HIV/AIDS (Cohen S et al., 2007).

Chronic stress also is known to cause deficits in working memory (Hinwood M et al., 2012) and increase the risk of developing obesity and elevated blood pressure level.

(Branth S et al., 2007). With the increased stress level, it has been found to lead to burnout or physical illness and decrease in quality of life and patient care service provision which include increase absenteeism and turnover. (Marine A et al., 2009), (Michie S., 2002). The increased stress also is associated with low job satisfaction and harassment (Weinberg A et al, 2000), and low involvement in decision-making (Okada N et al., 2005).

Butterfield (1988) recognized that the first year postgraduate residency training is the most stressful year for physicians. While Rajan P. (2011) concluded there is high level of work related stress among resident doctors registered for postgraduate clinical studies at their tertiary hospital.

In Malaysia, clinical-based medical postgraduate trainees will undergo on average 4 to 7 years of training program. During the same period of time, postgraduate trainees will juggle themselves between work, studies, dissertation, professional examinations, family and personal issues. While providing healthcare services,

(48)

39 trainees are also being under constant pressure to fulfill the coursework requirements and to keep up with the latest knowledge in respective field. This puts such group of individuals possibly at a higher risk for high level of stress.

The prevalence of distressed postgraduate students in a study at Hospital Universiti Sains Malaysia was reported as 36.4%. (MSB Yusoff et al., 2010). In the same study, major stressors were found to be related to academic and performance pressure.

4.2 RATIONALE OF STUDY

In Malaysia, Emergency Medicine discipline is still relatively new and expanding field. The role of Emergency healthcare in Malaysia has immensely increased with introduction of Emergency Physician. This study aims to examine the level of stress and job factors related to stress among postgraduate Emergency Medicine trainees in a tertiary centre. Poor psychological condition may diminish job satisfaction and inevitably results in negative attitude toward work, disrupt interpersonal and intrapersonal relationships. This evaluation may help to understand the state of mental health and job factors relation to stress among trainees. Hence, identification of psychiatry morbidity in these group of individuals may help to improve and possibly incorporate mental health in future policymaking of postgraduate training program structure.

(49)

40 4.3 RESEARCH OBJECTIVE

4.3.1 General Objective

To study the relationship between job factors and stress level among postgraduate Emergency Medicine trainees in Hospital Universiti Sains Malaysia (HUSM).

4.3.2 Specific Objectives

iii. To determine the mean level of stress among postgraduate Emergency Medicine trainees in HUSM.

iv. To determine the associated factors of job-related stress among postgraduate Emergency Medicine trainees in HUSM.

4.4 RESEARCH QUESTION

i. Is there significant level of stress among postgraduate Emergency Medicine trainees in HUSM?

ii. Is there relationship between demographic factor and level of stress among postgraduate Emergency Medicine trainees in HUSM?

iii. Is there relationship between stress and job factors among postgraduate Emergency Medicine trainees in HUSM?

4.5 RESEARCH HYPOTHESIS

i. There will be significant level of stress among postgraduate Emergency Medicine trainees in HUSM.

ii. There will be significant relationship between demographic factor and level of stress among postgraduate Emergency Medicine trainees in HUSM.

(50)

41 iii. There will be significant relationship between stress and job factors among

postgraduate Emergency Medicine trainees in HUSM.

4.6 METHODOLOGY 4.6.1 Study Design

Cross-Sectional Study

4.6.2 Study Location

Emergency and Trauma Department, Hospital Universiti Sains Malaysia (HUSM)

4.6.3 Study Duration

September 2014-May 2016

4.6.4 Study Reference Population Postgraduate trainees in Malaysia

4.6.5 Source population

Postgraduate Emergency Medicine trainees in Emergency and Trauma department HUSM

4.6.6 Sampling Frame

Postgraduate Emergency Medicine trainees in HUSM from September 2014 to May 2016

(51)

42 4.6.7 Inclusion and Exclusion Criteria

Inclusion Criteria:

- All Postgraduate trainees of Emergency Medicine in HUSM

Exclusion Criteria:

- Participant who does not consent

4.6.8 Sample Size Calculation

Objective 1: To determine the mean level of stress among Emergency Medicine Postgraduate trainees in HUSM.

Sample size calculation is not necessary because this is based on descriptive analysis to determine the mean level of stress among postgraduate students

Objective 2: To determine the associated factors of job-related stress among Emergency Medicine Postgraduate trainees in HUSM.

Sample size is calculated based on G*power 3.1.7, with medium effect size = 0.15 (Cohen, 1988), p = 5%, power = 80%, the total sample size is 55. We estimate 10%

non-response rate, therefore total sample size needed is 61.

4.6.9 Sampling Method

Non-probability sample selection of all postgraduate Emergency Medicine trainees at HUSM

(52)

43 4.6.10 Examination Procedure

The study will be conducted after obtaining approval from the Human Research Ethics Committee USM (HREC).

4.6.11 Research Tools

• Demographic data form

• Job Content Questionnaire (JCQ) (Karasek, 1998)

• Depression, Anxiety and Stress Score – 21 items (DASS-21) questionnaire

The questionnaire booklet consists of 3 sections. The first section consists of responder’s demographic data. Second section comprises 21 questions from the Depression, Anxiety and Stress 21 Items Questionnaire (DASS 21). It is a shorter version of the DASS 42. It is a set of three self-reported scales designed to measure the negative emotional states of depression, anxiety and stress. The DASS which was developed by Lovibond SH and Lovibond PF (14) has been increasingly used in diverse settings. It measures negative emotional states based on clinical symptoms and meets the requirements of both researchers and scientists (professional clinicians). The use of the DASS questionnaire as an objective measure of health indicator (depression, anxiety and stress) but not meant for clinical diagnosis. This is because the DASS is based on a dimensional rather than a categorical conception of psychological disorders. A key strength of the DASS is its ability to assess depression, anxiety and stress in a brief and psychometrically sound manner (15).

(53)

44 In the DASS 21 questionnaire, each subject is required to report the presence of any symptoms in the previous one week. Questions on DASS 21 will be answered on a Likert Scale of four:

0 point - Did not apply to me at all - Never

1 point - Applied to me to some degree, or some of the time - Sometimes 2 points - Applied to me to a considerable degree - Often

3 points - Applied to me very much, or most of the time – Almost Always

Once the scores are collected, it would be calculated based on the domain that it represents. The results will then be interpreted using the following table to determine its level of severity. Further interpretation will be done based on the DASS manual provided by the author.

Severity Depression Anxiety Stress

Normal 0-9 0-7 0-14

Mild 10-13 8-9 15-18

Moderate 14-20 10-14 19-25

Severe 21-27 15-19 26-33

Extremely severe 28+ 20+ 34+

Table 2: DASS 21 severity ratings

In terms of permission, the DASS21 questionnaire has been made a public domain and can be copied without restriction. This has been clearly stated in the DASS website (18) that the questionnaire can be used without permission as long as citation has been made to the corresponding website.

(54)

45 The third section in the questionnaire booklet consists of the Job Content Questionnaire (JCQ). JCQ is a questionnaire-based instrument developed by Kareasek to measure the content of a work tasks. It is one of the most frequently used instruments for psychosocial job analysis. In this study, 21 items from the full version of 49 items are used to measure the three major scales of job factors which are: decision latitude (consists of 8 items), psychological job demands (consists of 7 items), and social support (consists of 6 items). The answers will be scored on a Likert scale of 1 to 4 (strongly disagree, disagree, agree and strongly agree; or often, sometimes, rarely and never). The total scores will be calculated using Karasek’s recommended format.

Upon completion of the questionnaire booklet, it will be collected by hand from the respondents.

Upon completion of this study, if a significant parameter is detected, a debriefing among the postgraduate Emergency Medicine trainees will be done in order to discuss the study findings and possibilities of its causes. Suggestions for improvements on working environment will also be taken if significant findings are found. All results including the study and discussion findings will then be forwarded to the respective departments for further actions if required.

In the debriefing later, necessary assistance will be offered to any postgraduate trainees whom found to be suffering from any form of excessive stress or depression or anxiety. However, all attempts will be made to ensure the confidentiality and

(55)

46 study responders are kept anonymous. Referral to appropriate departments will be offered if required.

4.6.12 Statistical Analysis

All data will be entered and analyzed using SPSS version 22.0.

For objective 1 – descriptive analysis is used to determine the mean level of stress level among postgraduate Emergency Medicine trainees in HUSM.

For objective 2 – Multiple linear regression is used to determine the association between job factors and stress level among postgraduate Emergency Medicine trainees in HUSM.

4.6.13 Ethical Considerations

This study is submitted to the Ethical Committee of USM. An information form will be given to all participants prior to data collection. Written consent will be obtained from the participant.

(56)

47 4.6.14 Flow Chart

Postgraduate Emergency Medicine trainees in HUSM (n=61) Informed Consent

Demographic data, DASS 21 and JCQ questionnaire booklet distribution, response and collection

Data collection Data entry Data analysis

Inclusion criteria Exclusion criteria

(57)

48 4.6.15 Dummy Tables

Objective 1: Stress level among Emergency Medicine HUSM trainees

Variables Mean (SD)

Depression Anxiety Stress

Objective 2: Associated factors of job-related stress among Emergency Medicine Postgraduate trainees in HUSM

Job Factor Simple Linear Regression Multiple Linear Regression ba (95%CI) P value bb (95% CI) P value Variable 1

Variable 2 Variable 3 Variable 4

(58)

49 4.7 REFERENCES

1. Stress at Workplace. World Health Organization; 1986 [cited 2013 January 3].

Available from: http://www.who.int/occupational_health/

2. Hotopf M, Wessely S. Stress in the Workplace: Unfinished Business. Journal of Psychosomatics Res. 1997; 43(1):1-6.

3. Philip J Yates, Elizabeth V Benson, Adrian Harris, Rachel Baron. An Investigation of Factors Supporting the Psychological Health of Staff in a UK Emergency Department. Emergency Medicine Journal. 2012; 29: 533-535.

4. Leon Phipps. Stress among Doctors and Nurses in the Emergency Department of a General Hospital. Canadian Medical Association Journal. 1988 September;

139.

5. R Burbeck, S Coomber, S M Robinson, C Todd. Occupational Stress among Consultants in Accident and Emergency Medicine: A National Survey of Levels of Stress at Work. Emergency Medicine Journal. 2002; 19: 234-238.

6. S McPherson, R Hale, P Richardson, A Obholzer. Stress and Coping in Accident and Emergency Senior House Officers. Emergency Medicine Journal. 2003; 20:

230-231.

7. M Laposa, Lynn E, Alden, Louise M. Work Stress and Posttraumatic Stress Disorder in Emergency Department Nurses/Personnel. Journal of Emergency Nursing.2003 February; 29: 1; 23-28.

8. Kirchhof RS, Guido LA, Freitas EO. Stress among Emergency Nurses. Journal of Nursing UFPE. 2012 December; 6(12): 2927-33.

9. Mental Health: Depression. Denmark: World Health Organization; 2013 [cited 2013 July]. Available from: http://www.euro.who.int/en/what-we-do/health- topics/noncommunicable-diseases/mental-health/

10. Baum A. Stress, Intrusive Imagery and Chronic Distress. Health Psychology.

1990;6: 653-675.

11. Alan E. Encyclopedia of Psychology: 8 volume set. USA: Oxford University Press; 2000 March.

12. Krejcie RV, Morgan DW. Determining Sample Size for Research. Education and Psychological Measurement. 1970; 30: 607-610.

13. Lovibond SH, Lovibond PF.Manual for the Depression Anxiety Stress Scales.2nd Edition. Sydney: Psychology Foundation; 1995.

(59)

50 14. Small Sample Techniques. The National Education Association Research

Bulletin. December, 1960: Vol. 38: 99.

15. Brown TA, Chorpita BF, Korotitscw K, Barlow DH. Psychometric Properties of the Depression Anxiety Stress Scales (DASS) in Clinical Samples. Behaviour Research and Therapy JournalElsevier. 1996; 35: 79-89.

16. Ramli M, Ariff F, Zaini Z. Translation, Validation and Psychometric Properties of Bahasa Malaysia Version of the Depression Anxiety and Stress Scales (DASS).ASEAN Journal of Psychiatry. 2007; 8(2): 82-89.

17. Ramli M, Roszaman R, Kartini A, Rosnani S. Concurrent Validity of the Depression and Anxiety Components in the Bahasa Malaysia Version of Depression Anxiety and Stress Scales (DASS). ASEAN Journal of Psychiatry.

2011 Jan-June; 12 (1).

18. Depression Anxiety and Stress Scales (DASS). Australia: School of Psychology University of New South Wales; updated 2013 January [cited February 2013].

Available from http://www2.psy.unsw.edu.au/groups/dass

(60)

51 4.8 GANTT CHART

2015 2016

J F M A M J J A S O N D J F M A M Data

collection Data analysis

Report writing

Submission final draft

(61)

Chapter 5

Appendices

Rujukan

DOKUMEN BERKAITAN

To study the relationship between job factors and stress level among Emergency Medicine Postgraduate trainees in Hospital Universiti Sains Malaysia (HUSM),

Objective: To determine the psychological status, particularly the level of depression, anxiety and stress level among Emergency Department (ED) nurses in

Title : Prevalence Of Depression, Anxiety And Stress Among Obese Patients With Chronic Medical Illness In Klinik Rawatan Keluarga , Hospital Universiti Sains Malaysia

Objective: The aim of this study is to determine the psychological status, particularly level of depression, anxiety and stress level among Emergency Department personnel in

What are the associated factors of depression, anxiety and stress condition among acute coronary syndrome (ACS) patients in Hospital Universiti Sains Malaysia (HUSM) and

Does stress (home-work interference, role conflict, supervisor support and workload) have a significant relationship with job satisfaction among nurses in private hospitals

From the correlation analysis, the result showed that there was a significant and positive relationship between time pressure and job performance among support staff

This study is performed to determine the accuracy of cervical spine radiograph interpretation among the emergency medicine trainees in Hospital Universiti