Mamoona Mushtaq  ( Department of Applied Psychology, Govt. M. A. O. College, Lahore, Pakistan. )

Objective: To explore the correlation of stress and coping strategies among gynaecologists.
Method: The cross-sectional study was conducted at Jinnah, Ganga Ram and Mayo Hospitals, Lahore, from 10th January 2014 to 30th June 2014 and comprised gynaecologists at public-sector hospital with work experience ranging from 5 to 30 years. Demographic Information Form, Perceived Stress Scale and Cope Scale were employed to collect data. Descriptive statistics were used to express stress and coping strategies.
Results: The mean age of the 200 respondents was 35.6±7.98 years (range: 25-59 years). Their mean experience was 15.5±2.65 years (range: 5 to 27 years). Overall, 52(26%) were experiencing mild stress, 82(41%) moderate stress and 66(33%) severe stress. Significant positive correlation was found of stress with problem-focused coping strategies like active coping, planning, instrumental social support, acceptance and positive reframing (p<0.05 each), and demographic factors like age, marital status, monthly income, working shifts, number of dependents, working hours, nature of job and family system (p<0.05 each)gynaecologist. Active coping, planning, instrumental social support, acceptance and positive reframing (p<0.05 each) were significant predicting strategies of stress. Monthly income, working shifts, working hours and nature of job (p<0.05 each) were significant predictors of stress among gynaecologists.
Conclusion: The findings will contribute to knowledge about coping strategies employed by gynaecologists and variables that predict stress among gynaecologists.
Keywords: Stress, Problem-focused, Coping strategies. (JPMA 65: 857; 2015).


Introduction

Medicine is considered an enormously stressful profession. Workplace stress appears to be an established risk factor of physical and psychological health of the professionals. Health professionals are taking into account because of high stress which occurs due to emergency call services and other numerous factors. The negative outcomes of stress diminish not only the health of gynaecologists but also to the standard of patients\' care. Gynaecologist is one of the professions which require high professional skills, long working hours and high availability to patients.¹ They face various challenges and have to cope with those stresses which happen due to their multiple roles.² Job stresses not only affect the health of gynaecologists but also reduce their skill affectively and do not collide with their job demands. Job stress may arise at any time and it includes large number of patients, their behavioural changes in response to tragedies like death, mishandling of disease, patients\' aggression in the form of verbal abuse or physical assault.³ Currently main focus of researchers has shifted to the job stressors faced by health professionals. Gynaecologists sometimes need to visit doctors or psychologists for treating their stress.⁴ It is also observed that job stress is experienced differently and different coping strategies are used to combat it by various health professionals.⁴ If these medical professionals use adequate coping strategies to deal with the stressful situation, it would serve the purpose of psychological well-being and they would not be exposed by stress. Coping is defined as an effort by a person to reduce stress.⁵ Usually it is an autonomic and spontaneous response to environmental stress.⁶ Coping can be divided into two broader categories which are problem-focused and emotion-focused. Among them is problem-focused coping strategy which is applied directly to the stressor. Practical steps are taken to remove and to evade the stressor or to diminish its impact if it cannot be avoided. Emotion-focused coping is aimed at minimizing distress generated by stressors and includes a wide range of responses from self soothing to expression of negative emotions and attempts are made to escape stressful situations by adapting different measures.^7,8
Coping strategies are established as strong psychosocial variables to affect reactivity and to alleviate psychological and physiological reaction to external stress.⁹ Coping strategies are divided into many sub-types including active coping, acceptance, emotional support, instrumental social support, substance use, behaviour disengagement, denial, positive reframing, religion, self-blame, planning and venting.¹⁰ According to Carver et al. (1989), active coping is the process of taking active steps to try to eradicate the stressor.¹⁰ Active coping starts with direct action and maximizing individual efforts and to carry out organized efforts to solve the problem. Active coping is akin to the core of what Lazarus and Folkman (1984)¹¹ term problem- focused coping. Planning is the process of thinking of how to deal with the stressor. This is the process of action tendencies and making up steps to attain the goal and to make active measures to solve the stress induced stimulus. Acceptance is a more practical kind of coping reaction. Positive reappraisal is an emotion which is focused on coping aimed at organizing stressful emotions rather than at dealing with the stressor. This is also included in the category of problem focused coping strategies. Venting means remaining camouflaged from the stressor because focusing on stressors can cause difficulty in the way of environmental adjustment. Behavioural disengagement means to reduce the attempts to deal with the stressful environment. This happens when individual detaches himself/herself from the stressor. The people with this strategy even give up the pursuance of goal and involve themselves in other activities. Denial of problem brings more stress by the end and makes more difficult to find the ultimate solution. The individual with this coping accepts the reality of the problem and tries to deal with that stressful situation. Religion serves as emotional support against the stressor to positive reinterpretation of the problem or as a tactic to cope with the stressor¹⁰ (Carver et al., 1989).
Gynaecologists are most important public servants among all fields of health sector. They face multidimensional challenges at their workplace.² Due to repeated stressful situations and many other factors, their ways of coping are affected. They have numerous implications in terms of the wellbeing of their organization with regard to its productivity and effectiveness.¹² However, the problem is that gynaecologists are still considered responsible for more traditional domestic affairs and child-rearing practices as well as their hospitals responsibilities.¹³ Fulfilling these diverse and demanding roles of wife, mother and employee can lead to role overload and conflict among gynaecologists.¹⁴ It is important to know that how do gynaecologists cope while passing through a critical situation. The concept of coping strategies can assist gynaecologists in functioning more effectively with their multiple roles.¹⁵ With regard to coping strategies it is reported that mostly gynaecologists use active coping, seek social support at the time of stress, positively reinterpret stressful situation and accept stressors.¹⁶ Thus it can be concluded that they always remain alert, active and dynamic in the face of difficulties and solve the stress by using problem focused methods. Therefore the present study was conducted to explore the coping strategies used by gynaecologists while experiencing stress.


Method

The cross-sectional study was conducted at Jinnah, Ganga Ram and Mayo Hospitals, Lahore, from 10th January 2014 to 30th June 2014 and comprised gynaecologists working at public-sector hospitals with experience ranging from 5 to 30 years who were selected using non-probability purposive sampling technique.
Perceived Stress Scale (PSS), a self-reporting questionnaire to assess stress,17 was used for data collection. The highest score on each item indicates the highest perceived stress which allows assessment of perceived stress without any loss of psychometric properties. This scale has concurrent, construct and predictive validity.
Also used was Cope Scale (Brief) which is a 28-itemself-reporting measure to assess different coping strategies.10 The scale has 14 subscales having two items each. These are coping, planning, positive reframing, acceptance, humour, religion, using emotional support, using instrumental support, self-distraction, denial, venting, substance use, behavioural disengagement and self-blame.10 Responses are given on 4-point Likert scale: 1 (not at all) to 4 (extremely happens). High score on each coping strategy indicates more frequent use of that coping strategy.
Before the administration of the questionnaires, all participants were briefed about the nature and purpose of study and their voluntary willingness was obtained. They were assured of confidentiality. Some participants refused to participate after having a sight of the lengthy questionnaires.
Inferential statistics were used to explore the correlation of coping strategies with stress and to find the predictors of stress among gynaecologists.


Results

The mean age of the 200 female respondents was 35.6±7.98 years (range: 25-59 years). Of the total, 156(78%) gynaecologists were in the of 20-40 years age range. Their mean experience was 15.5±2.65 years (range: 5 to 27 years), with 136(68%) having experience of 5 to 9 years. The mean income was Rs34321±15876.12 (maximum: Rs70,000). Mean working hours were 8.16±1.99 (range: 6-15 hours).. Of the total, 56(28%) respondents were working day time, 54(27%) in evening shifts, 44(22%) in nights, and 46(23%) worked on rotation. Besides, 112(56%) participants were living in joint family system and 88(44%) lived in a nuclear family.
Overall, 52(26%) were experiencing mild stress, 82(41%) moderate stress and 66(33%) severe stress. Coping strategies included active coping152(76%), substance use 12(6%), planning 156(78%), instrumental social support 178(89%), acceptance 102(51%), positive reframing 174(87%), self-blame 34(17%), venting 24(12%), denial 10(5%), religion 146(73), humour 46(23%), seeking emotional support 102(51%), self-distraction 122(56%) and behavioural disengagement 64(32%).
Statistically significant correlation was found between perceived stress and active coping (p<0.001), planning (p<0.01), instrumental social support (ISS) (p<0.001), acceptance (p<0.001), positive reframing (p<0.001), self-blame (p<0.05), humour (p<0.05), and coping (p<0.001) (Table-1).


Factors found significantly correlated with perceived stress were age (p<0.01), marital status (MS) (p<0.01), monthly income (p<0.001), working shifts (p<0.001), number of dependents (p<0.01), working hours (p<0.001), nature of job (p<0.001) and family system (p<0.01) (Table-2).


Regression analysis showed active coping (p<0.001), planning (p<0.001), ISS (p< .01), acceptance (p<0.05) and positive reframing (p<0.01) to be significant predicting strategies of stress. Monthly income (p<0.001), working shifts (p<0.01), working hours (p<0.001) and nature of job (p<0.05) appeared as demographic predictors stress among the gynaecologists (Table-3).




Discussion

The study was conducted to assess perceived stress and coping strategies used by gynaecologists and to explore the relationship between the two elements. A lot of studies have been carried out in the West regarding the relationship between stress and coping strategies on multiple samples.^18-20 However, in Pakistan, no data on job stress and coping strategies to deal with that stress by gynaecologists is available.
The study revealed that majority of the gynaecologists were in the age range of 20-40 years. Their mean monthly income was Rs.34,321. Majority of them were working from 9 to 11 hours per day, and majority had job experience of 5 to 9 years. Besides, 54% were living in joint family system, and 70% gynaecologists were doing permanent jobs.
The profession of gynaecologists is a stressful which needs great commitment. Other social factors like financial security, autonomy at workplace, home and workplace environment cannot be overlooked. The study also revealed that 26% gynaecologists were suffering from mild stress, 41% moderate stress and 33% had severe stress. Stress was found significantly correlated with age, marital status, monthly income, number of dependents, working shifts, working hours, nature of job and family system. Moreover, monthly income, long working hours and hectic working shifts appeared as significant predictors of stress among the gynaecologists. The findings coincided with earlier studies.^21,22 In the presence of such a demanding job, it becomes difficult for gynaecologists to maintain a balance between duty and household requirements. Married female gynaecologists, who have children, especially face multidimensional stresses.²³ In Pakistan, doctors serving in public hospitals are getting a meagre salary against long working hours which ultimately increases their stress levels. Increasingly demanding family life may influence the psychological health of the married gynaecologists in the form of severe stress outcome.
So far as coping strategies are concerned, they were found to be significantly correlated with perceived stress. With respect to coping strategies, majority of the gynaecologists used ISS (89%, p<.001), positive reframing (87%, p<.001), planning (78, p<.001 %) and active coping (76%, p<.001). The results corroborate with literature.²⁴ Social support is widely used by doctors and it deteriorates stress levels. It is reported that social support is an important factor in eliminating the stressors and their negative outcomes.²⁵ In a country like Pakistan where joint family system is common, people take advice from old family members in difficult situations. The gynaecologists consult their colleagues or senior specialists when they face complications in some case. As delineated by a study, active coping, planning, ISS and positive reframing are grouped into problem-focused coping strategy.¹⁰ In this strategy gynaecologists are more focused on the problem at hand and use all resources to solve that problem. The findings of the present study revealed that female gynaecologists mostly used problem-focused coping strategies. When emergency state appears, gynaecologists use active coping and get alert to resolve the situation. It is also reported that gynaecologists do not use emotional and avoidance-based coping because it can cause immense harm to patients\' lives.
In terms of limitations, the study comprised only one gender. The inclusion of male gynaecologists could have given more comprehensive results. Age differences on stress and use of coping strategies between young and old gynaecologists were not investigated.


Conclusion

Problem-focused coping strategies are associated with perceived stress among gynaecologists. Besides, monthly income, working shifts, working hours and nature of job were predicting stress among them.


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