Chiropractors’ perception of occupational stress and its influencing factors: a qualitative study using responses to open-ended questions

Background Job stress and emotional exhaustion have been shown to have a negative impact on the helping professional. The development and causal relations of job stress and emotional exhaustion are rather unclear in the chiropractic profession. The objective of this study is to understand the main sources of occupational stress and emotional exhaustion among doctors of chiropractic. Methods Analysis of the written responses to web-based open-ended questionnaire was performed using an interpretive research methodology. Additionally, cross tabulation and Chi square statistical tests were conducted to match and couple the demographic data with the categorical themes. Results Fourteen professional stress categories emerged from the 970 completed surveys. “Managed Care Organization regulation”, “Managed Care reimbursement” and “Scope of Practice Issues” were the most common stressors that negatively influenced chiropractors’ professional and personal lives. The results of the categorical analysis suggests that age, marital status, number of years in practice and location of practice may have an influence on the category of stress reported by chiropractors. Conclusions The qualitative approach revealed common, conventional and culture-specific job stressors in doctors of chiropractic. Notably, these findings suggest an association between third-party payer influences (increased regulation/decreased reimbursement) with that of increased job stress. Further research will be undertaken to refine the stress and satisfaction parameters and address stress interventions.


Background
Occupational stress and emotional exhaustion (EE) are extensive problems for health-care workers [1][2][3][4]. Occupational stress refers to environmental conditions and situations that prompt an emotional response such as anger or anxiety [5]. Similarly, but operationally and conceptually distinctive, EE is a chronic state of physical and emotional depletion that results from excessive job demands, depletion of resources and continuous hassles [6][7][8][9]. The relationship between occupational stress and EE is outlined in a collection of theoretical models, such as the control-stress model [5] and job-demands control model [10,11]. The conceptual framework underlying occupational stress models [4,10,11] provide insight to the disputable relationship between job-demands, job resources and perception [5].
Accumulated research on occupational stress has generated a wealth of knowledge about the stress process and how stress affects workers in a wide variety of jobs [12][13][14][15].
McManus et al. [16] suggest that EE and occupational stress may have reciprocal causationthat is, high levels of EE may cause stress, and high levels of occupational stress caused may EE. Either way, the end-result of escalating occupational stressors in the health-care the arena is that the provider(s) experiences a shift from energy to exhaustion, engagement to cynicism and efficacy to infectiveness [1]. Similar processes have been observed in a comprehensive group of health professionals [2,4,17], and more recently in the chiropractic profession [18,19]. A recent study [18] exploring burnout in the chiropractic profession suggests that although overall values of burnout are relatively low (~2 %), higher levels of EE (~21 %) remain workplace issues for this professional group.
As changes in the political sector of the health care arena continue to mount, and new socioeconomic trends occupy the environment of health care, the nature and construct of occupational stress and EE may continue to develop as a serious threat to workers' well-being [5,10,[20][21][22][23]. As such, despite being common in health-care workers [2][3][4]17], the development and causal relations of occupational stress and EE are rather unclear in the chiropractic profession, in part due to an absence of adequate exploratory qualitative studies. Thus, the current study attempted to understand chiropractors' perceptions of job-related stress and consequently EE (as per the symbiotic relationship that exist between the two constructs). The objective of this study was to explore the opinions and perceptions of occupational stress among Doctors of Chiropractic (DCs). In this study, the aim was to assess what reasons (if any) DCs give as their precursors of occupational stress. The use of qualitative methods to analyze the material derived from open-ended answers in a questionnaire was employed with the intent of creating occupational stress categories that could help increase an understanding of the phenomenon as it applies to the chiropractic profession. A greater understanding of the perceptions of occupational stress may, in turn, provide a means to understand and improve chiropractic services.

Methods
A demographic survey including six socio-demographic categorical questions and one open-ended question was emailed (July 2013) to a randomized and convenience sample of DCs whose email addresses were included in the database of a leading chiropractic-marketing agency [24]. The invitation letter included a description of the nature of the study, a notation guaranteeing anonymity, and an embedded hyperlink to the web-based survey (via Survey Monkey). Descriptions of the constructs (occupational stress and EE) were operationally defined in the instructional section of the invitation letter. Non-DCs and/or DCs that were not involved in chiropractic fieldwork were identified and excluded from the study via two qualification questions. The remaining participants were asked (in open-ended format) to describe the occupational stressor(s) -if any -that they believed had a negative impact on their professional and personal life. The openended question (dependent variable) read as such: 'What factors do you feel influence the levels of occupational stress and emotional exhaustion in the chiropractic profession?' A mixed methods approach was used to explore respondents' perceptions of occupational stress and EE. The qualitative portion of this research design used content analysis [25,26], inductively, coupled with an epistemological assumption(s) and interpretational approach, as the foundation of analysis to the open ended responses. Moreover, the qualitative analytic strategy employed in this study relied on a general approach that involved interpretive description as a means of developing an understanding of occupational stress and EE endured by DCs. The aim was to generate categories of reason for occupational stress and EE by using content analysis [27,28]. Each open-ended response was read thoroughly and organized into categories of reason. If the response included two or more different statements of reasonit was identified and categorized accordingly to form the separate responses. For example, a typical response like "…low fees, too much paperwork, too much government regulation, deny-minded IME interfering with care, staff training, high expenses" includes many items that could fall in one (Business & Administration) or more (MCO regulation and reimbursement) categories. Categories were not preconceived and were named using respondents' own terminology where possible. The principle investigator (PI) read all of the statements in the initial sample and carried out this analysis on two additional separate occasions. The initial analysis generated almost identical sets of categories. A set of 14 categories was composed based directly on the respondents' statements.
The quantitative analysis integrated summaries of the categorical themes that were obtained after the openended responses, with similar themes grouped together. Descriptive statistics involving the frequency and percentage summaries were conducted to determine the number of respondents that chose each of the categorical themes. Cross tabulation(s) were conducted to match the demographic data of gender, age, years in practice, marital status, current professional status, and location of practice with the categorical themes of the open-ended responses. Chi square statistical test(s) were conducted to determine if the demographic data was significantly related to, or differed with, the categorical themes of the open-ended responses. A level of significance of 0.05 was used in the statistical analysis. During the study, several methods were used to ensure the data trustworthiness (i.e. practices supporting credibility, transferability, dependability, confirmability) as outlined by Zhang [25]. All analyzes were conducted in SPSS. Ethics approval for the study was obtained by Seton Hall University's IRB in January 2013.

Descriptive statistics
Most of the respondents were solo-practitioners and practicing in the United States. Additionally, most of the respondents were male and were married. It was observed that the age of those that answered the open-ended questions were between 31 and 60 years old.
In the 14 categorical themes of response, it was observed that many of the respondents practiced chiropractic in California, Colorado, Connecticut, Florida, Georgia, Illinois, New Jersey, New York, North Carolina, Ohio, Pennsylvania, and Texas. The percentage distribution of gender, the number of years in the professions and the practice location found in this study was reflective of current industry data [29,30].

Qualitativecontent analysis
There were a total of 970 analyzed open-ended responses out of the 1149 total respondents (Table 1); thus resulting in an 84 % completing rate. Those remaining 179 surveys were deemed incomplete. The initial analysis of 2022 statements generated 14 subcategories that collectively described perceptions and/or potential sources of occupational stress and EE. A further grouping of these subcategories was executed reflecting the context of the healthcare system, at-large. This stage of analysis produced three main categories, which is also described in the literature as common, conventional, and cultural specific [27,31]. For the purpose of understanding the causes of occupational stress in DCs the three main categories were observed as (1) Health Care System -Conventional, (2) Intra-professional conflict-Cultural Specific, (3) Personal / Individual attributes -Common. Table 2 represents the frequencies and a percentage for all subcategories found, and just equally as important reflects, the magnitude / impact of DCs perception(s) of occupational stress.
Conventional: deficiencies of the health care system The statements expressing external sources of stress with the way health care services are organized were further compartmentalized into respective subcategories. One of the assumptions of such categorization is that many similar helping professions share similar sources of occupational stress and EE. Globally, these statements reflect the respondents' dissatisfaction with the perceived dysfunction of the MCOs including perceived problems with regulation of the health care system, legislation and implementation of it or cost for services. These reasons were grouped into major distinctive groups, such as: MCO regulation and MCO reimbursement. Cultural-specific: deficiencies of the chiropractic profession The statement expressing intra-professional sources of stress and exhaustion with the way the chiropractic profession is organized. Globally, these statements reflect the respondents' sources of stress with the chiropractic profession as a unit. Further, the statements describe problems that appear to be unique to the chiropractic profession and/or may be reflective of the occupational stressors that other alternative medicine professions, at-large, experience. These reasons were grouped into distinctive groups: Deficiencies of the DCs attitudes, skills and work These statements described perceived deficiencies of individual practitioners. Globally, the statements describe basically all aspects of practice: knowledge, skill, behaviors and attitudes. These reasons were grouped into distinctive groups: Self-Perception, Isolation, Working too hard and Business and Administrative.
'Having no goals, having a poor vision for the future and not willing to grow. Also, a long term view is necessary with goals to match and some risk taking make practice more interesting and exciting.
Collectively, this indicates that the two gender groups, the six age groups, the seven categories of years in practice and the five categories of marital status have significant different responses in the open-ended responses. As per the various DC working characteristics, the results of the chi-square test showed that current professional status was significantly related with the responses of Intra-Professional Stress (X 2 (4) = 14.94, p = 0.01), Patients (X 2 (4) = 26.11, p <0.001), and Student Loan Debt (X 2 (4) = 12.40, p = 0.02). Additionally, location of practice (Table 3)

Discussion
The primary aim of the current study was to examine the perceptions of occupational stress among a representative sample of chiropractors in the US. This mixed methods approach, with emphasis on the qualitative analysis, generated three main categories and 14 subcategories representing the perceived occupational stressors among DCs. Overall, the results showed that the most of the participants believed that MCO regulation, MCO reimbursement, and Scope of practice issues were the most common stressors that negatively influenced their professional and personal lives. Interestingly, scope of practice amongst DCs is highly variable [32][33][34] in the US, and when coupled with cost of living differences, a strong connection between these factors became apparent. The participants responses indicated their perception of a cause effect relationship between occupational stress, emotional exhaustion and "cultural authority, government / Obama, education, long hours, time, tools, medical, competition for other professions, documentation, scope, expectations; overhead; risk; scope of practice; paperwork; State associations; college / school; unethical; pay; EHR/EMR; communicating; balance; respect; unity; reward; AMA; boredom". High student loans, the non-recognition by the medical community, and the administrative aspects of operating a business, also have a significant negative implication(s) on DCs' practice life; by means of reducing resources and increase demands, as outlined in the control-stress model [5] and jobdemands control model [10,11]. However, collectively it appeared that most significant stressor within the chiropractic profession is "the frustration with the insurance companies". Complaints of constantly getting denied, the extremely low reimbursement (gets lower every year), the raising of co-pays to make patients not want to come in appear to be overwhelming the modern day DC. These findings are consistent with much of the current occupational stress research [10,[20][21][22]27]; which lends the notion that major changes in the health care system have been driven by increase-regulation via third-party payer systems. Similar precursors/processes to occupation stress and EE have been observed in a comprehensive group of health professionals [2,4,17,[35][36][37] and while some stressors were consistent across occupations, others were more rare or occupation specific. Across health professions, it appears that healthcare workers suffer from occupational stress because of higher expectations, not enough time, lack of skills and social support at work [21,[35][36][37]. Notably, interpersonal conflict appears to be the most prevalent stressor across all occupations [20,22] organizational constraints and workload are just as commonly reported in the literature. Interpersonal conflict occurs when a person or group of people frustrates or interferes with another person's efforts at achieving a goal [38] and may be reflective of the unique cultural-specific perceptions of stress that occur in the chiropractic profession.
As the content analysis progressed, a conceptual pattern amongst the participants began to unfold. It appears that many of the participants agreed -Chiropractic's lack of internal consensus and legitimacy (cultural authority) inhibits chiropractic's ability to keep up with rapidly changing events. Further, participants repeatedly noted/suggested that in order for the chiropractic profession to progress, that is keep up with external health care events, e.g., the Affordable Care Act, Health Care Education Reform Act, etc., the profession would needs to come to some modicum of internal consensus. Internal consensus will be needed if the profession is going to achieve cultural authority [39]. Keeping the profession rooted in metaphorsi.e., Universal Intelligence, Innate Intelligence, Subluxation, dis-ease, etc.which for some have become unquestionable myths and dogma inhibits chiropractic's achievement of legitimacy, the other necessary ingredient of cultural authority [40].

Limitation of the analysis
The limitation of the categorical analysis involving determining the relationship between the demographics with the categorical themes of open-ended responses is that causality cannot be determined. Also, finding a significant relationship between two variables with a correlation coefficient does not take into account the possibility of other variables playing a part. In addition, the direction (positive or negative) of the relationship and the strength of the relationship (weak, moderate, and strong) cannot be determined with a chi-square test. The variables of demographic and categorical themes of open-ended responses are categorical variables. Thus, correlation test cannot be conducted. The analysis merely determined the relationship between variables by investigating whether there is significance different in the categorical responses according to the results of the chi-square analysis.

Conclusion
The findings from this current study add to a continuous dialog on the unique causes of stress, emotional exhaustion and occupational stress for chiropractic professionals. These findings in this study add to the notion of directional association between third party payer influences (increased regulation/decreased reimbursement) with that of increased job stress. Further research will be undertaken to refine the stress and satisfaction parameters and address stress interventions.