Determinants of Stress Coping Strategies of Doctors in Poland’s Silesian Voivodeship

Introduction

Stress levels are heightened in certain professions, notably in the medical sector [1–4]. Occupational stress adversely affects doctors’ work performance and quality of life, potentially leading to absenteeism, reduced productivity, inferior medical services, increased error risks, and burnout [2,5–11]. The issue of physician burnout in terms of its prevalence, definition, and standardization of measurement tools used to assess the impact of chronic occupational stress is presented in a comprehensive review of research on this topic [12].

High burnout rates and secondary traumatic stress have been observed among doctors in the United Kingdom [2,8]. Significant stress levels were noted among intensive care unit physicians in Poland [3] and emergency department physicians and were exacerbated by extended work hours [13] and challenging conditions, including psychological demands, resource shortages, and inadequate support [11]. The mental and physical well-being of Polish doctors was found to be unsatisfactory, especially among women, people with less professional experience, and those working in non-surgical wards [14]. German doctors reported higher occupational stress than their Australian counterparts [15], while Indian doctors experienced stress variably by specialization, with pediatricians being the most stressed and general practitioners the least [1]. Romanian doctors also faced varying stress levels depending on their discipline, with surgeons reporting the highest stress related to work relationships, work-life imbalance, and job insecurity. Internists more strongly felt the stress generated by the overload they experienced in relation to their work, their work schedule, and the resources needed for patient care and communication with their supervisors. Psychiatrists reported the highest levels of stress in association with working conditions [4].

The intensity of stress-inducing factors and an increase in the incidence of post-traumatic stress disorder symptoms among doctors and other healthcare workers were observed particularly during the COVID-19 pandemic [16–19].

Coping strategies in response to stress can be categorized into adaptive methods, such as active coping and planning, and maladaptive methods, such as substance use and denial [8,20–22]. Coping with stress is primarily aimed at aiding individual adaptation to stress. Despite limited publications on stress coping across different specialties, global reports reveal varied findings. UK doctors predominantly used maladaptive coping mechanisms [8], particularly those experiencing burnout [2]. Pakistani female gynecologists favored problem-focused strategies [23], while Saudi Arabian resident and specialist physicians leaned toward adaptive strategies, including planning and religious engagement, compared with non-constructive strategies, which consisted of focusing on emotions; an infrequently used strategy was the use of alcohol and other stimulants, which may have been related to culturally determined disapproval of these substances. Maladaptive strategies showed an association with higher levels of stress and negative mental health impacts and were more common in female residents than in male residents. In contrast, among specialist doctors, women were more likely to use both maladaptive and adaptive strategies than were men [21,22]. In a study by Taft et al [20], gastroenterologists used both problem-focused and emotion-focused strategies. Among German emergency physicians, women displayed more negative coping strategies [24]. Kelly et al [25] observed that women using less positive coping strategies showed more depressive symptoms than did women using positive coping strategies. Australasian emergency clinicians preferred adaptive strategies but also engaged in maladaptive methods such as substance use [26]. The predominant stress coping style among clinical doctors was task-oriented coping. High levels of neuroticism correlated positively and extraversion negatively with the adoption of an emotion-oriented coping style for coping with stress. The tendency to choose an avoidance style decreased with age and seniority of doctors [27]. In doctors working in intensive care units, adaptive coping strategies were more frequently used than maladaptive strategies. Planning, active coping, and support-seeking were the most frequently reported coping strategies, while denial, turning to religion, activity suppression, and psychoactive substance use were the least frequently reported coping strategies. Women were more likely than men to use adaptive and maladaptive coping strategies to cope with stress [3]. Substance use was a common coping method among medical trainees of hospital emergency departments in France [13]. Brazilian primary healthcare doctors exhibited diverse coping strategies ranging from problem-solving to avoidance [28]. No significant differences were found between surgical and non-surgical residents in Pakistan, although surgical doctors were more prone to exhaustion [29]. Polish surgical specialists displayed more optimism and used denial more than did non-surgical specialists, with men specialized in surgical fields reporting higher alcohol use, and women with a non-surgical specialty turning to religion during stress [30]. Another study shows that Polish doctors who use active methods of coping with stress are characterized by a high level of resilience [14].

Due to the high stress levels associated with the medical profession, research into stress management strategies is important. These strategies appear to vary depending on the specific nature of the work, particularly the specialization, the sex of the respondents, and cultural connections in different regions of the world. There is little research available on this issue among doctors working in Poland, and an innovative approach is to identify the links between stress coping strategies and personality type, taking into account their sex and specialization. In view of the above, the aim of this study was to identify the factors determining stress coping strategies among Polish doctors who are employed in hospitals in the Silesian Voivodeship (region).

Material and Methods

STATISTICAL ANALYSIS:

Statistical analyses were conducted using the SPSS 24 software. Descriptive statistics of quantitative variables were compiled, and their distribution normality was checked using the Shapiro-Wilk test. Due to significant deviations from normal distribution, non-parametric tests were used. The Cronbach alpha was calculated for each scale. The chi-square test of independence determined dependencies between nominal variables and both the sex and specialization of the surveyed doctors. The Mann-Whitney U test was used to verify statistically significant differences between sexes and between surgical and non-surgical doctors, while the Kruskal-Wallis ANOVA test was used to compare men and women across these specializations. Post hoc analysis using a Dunn test with a Bonferroni correction was conducted when significant differences were found. The chi-square test of independence and the Mann-Whitney U test or Kruskal-Wallis ANOVA, respectively, were used to determine relationships between personality variables and coping strategies or psychological wellbeing. Hierarchical multiple regression analysis (multiple regression analysis) was used to identify independent determinants of coping strategies (Mini-COPE). The model building process aimed to determine the extent to which demographic and psychophysical factors explain the variance in individual coping strategies. Modeling was performed using the enter method, which allowed for the assessment of the unique contribution of each predictor while controlling for the influence of all others. The model included variables that showed a significant relationship (P<0.20) with a given coping strategy in bivariate analyses, as well as the variables under study that were considered key predictors. Before proceeding with the regression analysis, the risk of multicollinearity between predictors was assessed. The tolerance coefficient and the variance inflation factor were checked. In all models, the variance inflation factor values were found to be significantly lower than the critical value of 10 (the highest recorded variance inflation factor value was 2.87), and all tolerance values were higher than 0.10, confirming that there was no significant multicollinearity problem between the variables. The fit of each regression model was checked using the F test and the coefficient of determination R², which measures the proportion of variance in the dependent variable explained by the predictors. To assess the strength of the effect, unstandardized coefficients (B) are presented, representing the direction and strength of the relationship. Finally, all necessary measures of uncertainty, including standard errors (SE) and 95% confidence intervals (CI) for each B coefficient, were included in the graphical and tabular part. The regression assumptions (normality of the residual distribution, homoscedasticity, and linearity) were checked by analyzing residual scatter plots and histograms. The assumptions were found to be met, allowing for a correct interpretation of the results. Statistical significance was set at P≤0.05.

Results

CHARACTERISTICS OF THE PARTICIPANTS:

The study involved 655 physicians, including 401 women and 254 men. Within this cohort, 266 doctors (134 women and 132 men) specialized in surgical fields, whereas 389 (267 women and 122 men) were engaged in non-surgical specialties. The participants either held a medical specialization or were in the process of obtaining one. The age of the respondents ranged from 26 to 75 years, with an average age of 38.9 years (SD, 11.0). Surgical specialists had an average age of 37.9 years (SD, 10.3), while their non-surgical counterparts averaged 39.6 years (SD, 11.4), with age ranges between 26 to 73 years for surgical doctors and 27 to 75 years for non-surgical doctors. The mean job tenure among the doctors was 12.9 years (SD, 11.0). For surgical doctors, tenure ranged from 2 to 47 years (mean, 11.8; SD, 10.3), and for non-surgical doctors, it spanned from 2 to 51 years (mean, 13.6; SD, 11.4). Statistical analysis showed no significant differences in age and job tenure between surgical and non-surgical doctors (P>0.05).

Table 1 outlines the general characteristics of the study group by sex, specialization, marital status, on-call duties, and additional work.

Of those participants surveyed, 66.1% were married. Nearly 79% of the doctors had on-call responsibilities. Approximately 72% of the respondents reported engaging in additional work, including self-employment (Table 1).

COPING WITH STRESS:

The stress coping mechanisms of the doctors, categorized by sex and specialty, are shown in Table 2. Among those in surgical specialties, female doctors scored significantly higher than male doctors in seeking emotional social support, instrumental social support, denial, self-blame, and emotional behaviors (P<0.05–0.001) and had lower scores in substance use (P=0.006). In non-surgical specialties, female respondents scored higher in turning to religion, seeking emotional social support, instrumental social support, denial, self-blame, and emotional behaviors (P<0.05–0.001) and lower in humor (P=0.02), compared with male respondents. In a comparison between female surgical and non-surgical doctors, turning to religion was notably higher in those practicing non-surgical specialties (P=0.004). For men, substance use was higher among surgical doctors (P=0.02). The Kruskal-Wallis ANOVA test confirmed these differences in stress coping strategies by sex and specialty (Table 2). Due to low reliability of the Cronbach alpha coefficient in the domains of mental disengagement (Cronbach alpha=0.29) and focus on and venting of emotions (Cronbach alpha=0.25) on the Mini COPE scale, these were excluded from analysis. The Cronbach alpha for other domains ranged from 0.63 to 0.9.

RESILIENCE: Doctors with low resilience, compared with those with average and high resilience levels, showed lower values in coping strategies such as active coping, planning, positive reinterpretation, acceptance, humor, and problem-oriented strategies (P<0.02–0.01), while exhibiting higher values in denial, substance use, behavioral disengagement, and self-blame (P<0.01; Table 3). Similar trends were observed between groups with average and high resilience levels (P<0.02), except for substance use, for which results were comparable (P=0.32; Table 3). Cronbach alpha values for resilience scale components were 0.62 to 0.93.

TYPE A/B BEHAVIOR PATTERNS: Most stress coping strategies did not significantly differ between type A, intermediate, and type B behavior patterns. However, strategies such as self-blame, behavioral disengagement, and seeking instrumental social support were significantly lower in doctors with a type B behavior pattern than in those with types A and intermediate (P<0.02–0.01; Table 4). The Cronbach alpha value was 0.62, which was suboptimal.

DETERMINANTS OF COPING STRATEGIES:

To identify the factors determining the coping strategies used by physicians, a multiple regression model was used to analyze the data. Factors such as sex, specialization, level of psychological resilience, behavior patterns, and psychophysical well-being were considered. This model, illustrating the interrelationships between variables, is shown in Figure 1. For binary variables, the coefficient of strength and direction of the relationship B indicates the influence on the dependent variable. The model also shows the interrelationships between dependent variables. Positive B values indicate women, while negative values indicate men.

Stress coping strategies were dependent variables. Based on consistent coping strategies, 4 groups were identified: problem-oriented, emotion-oriented, adaptive, and maladaptive strategies. Only statistically significant independent variables (P≤0.05) were included in each group.

Higher levels of resilience in physicians (B=0.428; P<0.001), especially among women (B=0.117; P=0.001) with a tendency toward type A behavior (B=−0.106; P=0.003), increased the use of mainly adaptive strategies, such as planning, active coping, and acceptance, as well as problem-focused strategies (Figure 1, group 1).

The occurrence of coping strategies focused on emotional behavior, turning to religion, and seeking social support was significantly associated with female physicians (B=0.195; P<0.001) in non-surgical specialties (B=0.079; P=0.043) (Figure 1, group 2).

Lower scores on the well-being scale (B=−0.174; P<0.001) and resilience level (B=−0.166; P<0.001), especially among men (B=−0.080; P=0.024), were positively correlated with the use of maladaptive strategies such as withdrawal, self-blame, denial, and substance use (Figure 1, group 3).

The overall level of resilience was positively correlated with adaptive strategies, including humor and positive reinterpretation (B=0.618; P<0.001; Figure 1, group 4).

The coping strategies listed in group 1 are significantly related to the strategies in group 2 (B=0.349; P<0.01) and group 4 (B=0.399; P<0.01) (Figure 1).

Discussion

STRENGTHS AND LIMITATIONS:

The study’s anonymity encouraged participation and honest responses regarding sensitive personal experiences and behaviors, resulting in a high response rate and a large, representative sample of doctors in Silesian hospitals, allowing for result generalization. However, it should be noted that 16% of respondents did not provide complete answers. Demonstrating the existence of selection bias excluding those respondents who may have been more stressed or burned out from participating in the study was impossible for ethical reasons and due to the anonymity of the study.

Standardized tools with high or medium reliability were used in the study. However, the self-assessment nature poses limitations, such as potential social desirability bias. Another limitation is the static approach to analyzing personality types and stress coping, limiting interpretative possibilities. Other limitations include a suboptimal Cronbach alpha value (0.62) for the Framingham A Scale and the exclusion of 2 Mini-COPE subscales due to low reliability. It should also be noted that, due to the large number of tests performed, comparisons with statistical significance values close to 0.05 increase the risk of type I error; therefore, they should be interpreted with caution.

Conclusions

Stress coping strategies of physicians differ by sex and specialty. Women in non-surgical fields are more likely to turn to religion than are their surgical counterparts, while men in surgical specializations are more prone to alcohol or psychoactive substance use than are those in non-surgical fields.

The key factors influencing stress coping strategies among physicians in the Silesian region of Poland are resilience, sex, specialization, and psychophysical well-being. Adaptive coping strategies are associated with higher levels of resilience, especially among women specializing in non-surgical fields. Maladaptive coping strategies, mainly among men, are associated with poorer well-being and lower resilience. Based on this study, it can be hypothesized that the implementation of screening and psychological training, taking into account sex, medical specialization, and personality, may improve stress coping and prevent burnout among physicians.