Occupational stress is a pattern of physiological, emotional cognitive, and behavioral responses that occur when workers are presented with work demands not matched to their knowledge, skills, or abilities and which challenge their ability to cope. Freudenberger noticed among voluntary health-care workers feelings of emotional exhaustion (EE) and withdrawal (1). Maslach further defined burnout as having three components of EE—are feelings of fatigue and of being drained by one’s work; depersonalization (DP)—are negative attitude toward and a dehumanizing treatment of one’s clients in the work place; and lack of personal accomplishment (PA)—lack of feelings of competence and achievements in one’s work with people (2).

Surgeons play an important role in health-care systems (3), and surgery is a core treatment mode in many medical interventions, including cancer, trauma, and acute-care treatments. Although surgery is considered to be a rewarding profession, it is also a field that may be associated with high levels of occupational stress and burnout (4), possibly due to the hectic and stressful nature of the role and its high physical demands and emotional challenges. The high-pressure environment in which emergency or elective surgeries are often performed; the long hours of work; continual sleep deprivation; frequent emergency calls; and intervening in life-or-death medical situations on a daily basis can eventually cause burnout in surgical staff (5, 6). Occupational burnout may impair a surgeon’s technical performance, cause mental and physical health problems, lead to medical errors, and can (in extreme circumstances) increase suicidal tendency (7).

Studies have shown that surgeons can experience high levels of job stress and low job satisfaction (8, 9). In a 10-year follow-up study on burnout and stress among surgeons, Taylor et al. demonstrated an increased level of EE and psychiatric morbidity in surgical oncologists (10). The study also found that, during an 8-year period, there was an increase in psychiatric morbidity (from 22 to 33%), an increase in burnout (from 27 to 41%), and a decrease in job satisfaction (from 68 to 65%) (10). In the UK, surgeons were shown to exhibit susceptibility to substance abuse, sharps injuries, stress and burnout, and musculoskeletal pain (11). A Korean study demonstrated that, compared with other professions, surgeons were more prone to occupational stress. Factors such as the number of duty days per week and average hours of duty were found to be significantly associated with stress among surgeons (12).

Fiji is a developing country in the South Pacific. The country’s medical system has developed surgical specialties, such as intensive care, urology, plastic surgery, neurosurgery, vascular surgery, pediatric surgery, and ophthalmology (13). Despite the prominent role played by surgeons in Fiji’s health-care system, there are no studies that exclusively examine occupational stress and burnout levels in surgeons in Fiji or the South Pacific (14). We postulate that there are high levels of burnout among surgeons in a developing country like Fiji, which was tested using a cross-sectional survey.

Table 1 shows the sociodemographic and professional characteristics of the surgeons. Thirty-two (88.9%) study participants were male. Ethnically, 12 (33.3%) study participants identified as Fijians, 8 (22.2%) as Indians, and 16 (44.4%) as “other” nationalities.

Table 2 shows the frequency of burnout, stress, and alcohol consumption among the study participants. Twenty-six (72.2%) surgeons demonstrated moderate to high levels of burnout on the MBI scale, while 23 (63.9%) demonstrated burnout on the ProQOL scale. Sixteen (44.4%) surgeons showed high levels of stress per their GHQ-12 scores.

Using ANOVA, the nationalities of the study participants showed a significant effect on the MBI EE [F_{(2, 33)} = 3.702; p = 0.035; f = 0.910] and MBI DP [F_{(2, 33)} = 5.357; p = 0.010; f = 0.946] scores. Bonferroni post hoc tests showed that surgeons of Fijian nationality (mean = 23.50, SD = 5.126) scored significantly higher on the MBI EE scale than those of the “other nationality” category (mean = 17.63, SD = 5.726; p = 0.041). Additionally, Bonferroni post hoc tests showed that surgeons of Fijian nationality (mean = 7.75, SD = 2.051) scored significantly higher than those of Indian nationality (mean = 5.00, SD = 2.673; p = 0.021) or those in the “other nationality” category (mean = 5.56, SD = 1.788; p = 0.029) on MBI DP scores.

In this study, no study participant reported accessing counseling services; however, it was found that those who were aware of the availability of counseling services (mean = 15.40, SD = 3.647) scored significantly lower on the ProQOL burnout score [t₍₃₄₎ = −3.619, p = 0.001; d = 2.051] compared to those who were not aware of the availability of counseling services (mean = 25.97, SD = 6.311) on t-tests. It was found that surgical trainees (mean = 8.94, SD = 4.697) scored significantly higher [t₍₃₄₎ = 3.770, p = 0.001; d = 1.299] than non-trainee registrars (mean = 3.10, SD = 4.553) on the AUDIT score. Furthermore, surgeons who smoked (mean 10.43, SD = 5.503) compared to those that did not smoke (mean = 4.55, SD = 4.822) scored significantly higher on the AUDIT score [t₍₃₄₎ = 2.82, p = 0.008; d = 1.195].

When comparing variables on two-tailed independent-samples T-tests, there were no significant effects found for gender, qualification, visit to a GP, self-medication, or perceptions of low pay/inadequate resources to the MBI, GHQ-12, ProQOL, and AUDIT scales. There was a significant negative correlation between age (r = −0.480, p = 0.003) and number of years as a surgeon (r = −0.513, p = 0.001) when compared to AUDIT scores. There was a significant positive correlation between the number of hours worked per week (r = 0.401, p = 0.015) and SOPD patient load (r = 0.334, p = 0.047) and the MBI EE score. There was a significant negative correlation between the number of hours worked per week (r = −0.338, p = 0.044) and the MBI lack of PA score. The higher number of hours worked per week had a positive correlation (r = 0.377, p = 0.024) with high ProQOL burnout score (r = 00.512, p = 0.001), high GHO-12 scores, and poor ProQOL compassion satisfaction scores (r = 0.442, p = 0.007).

Age and number of years as a surgeon were significantly negatively correlated with AUDIT scores and positively correlated with GHQ-12 and MBI EE scores. The number of hours worked per week negatively correlated to the MBI PA and ProQOL-CS scores and positively correlated with ProQOL-B scores. Finally, the number of patients seen in clinics positively correlated with the MBI EE score.

When comparing questionnaires, significant correlations were found between the ProQOL-CS score and the ProQOL-B, ProQOL-CF, GHQ-12, MBI EE, and MBI DP scores. Furthermore, the ProQOL-B score significantly correlated with the ProQOL-CF and GHQ-12 scores as well as to all the MBI subscale scores. The Professional Quality of Life-30 and GHQ-12 scores also significantly correlated with all MBI subscale scores (see Table 3).

This is the first survey done among surgeons in Fiji to measure levels of occupational stress and burnout. Approximately two-thirds of the study participants surveyed showed significant levels of burnout on the MBI and ProQOL questionnaire. Further, high levels of stress were demonstrated in the study population using the GHQ-12 scale. These findings corroborate the results of Ray who showed an association between compassion fatigue, burnout, and other independent variables in a sample of frontline mental health-care professionals (22). Similar to our study, that study employed the MBI and ProQOL scales to assess burnout, compassion satisfaction, and compassion fatigue.

A major proportion of the participating surgeons had not visited a physician in the last year when sick. Also, a significant proportion of the surgeons were not aware that counseling services were offered by their hospitals and none of the participants had participated in counseling outside their hospitals. These findings illustrate that the study participants may have a lack of awareness and poor assessment of their well-being. These factors could be major barriers to taking proper steps at the right time to care for their mental and physical health (23). A high percentage of the participating surgeons had perceptions of inadequate or low levels of occupational resources and perceptions of low pay. Perceptions of low pay may lead to lower levels of job satisfaction, and these may, in turn, cause psychological stress and burnout (even in other allied medical professionals, such as nurses) (24).

It was observed in this study that surgeons in Fiji had a high workload, evident from the reported high numbers of hours of work per week and high patient load in specialty clinics. Our results are similar to those reported in a study of Korean surgeons where long hours of work, frequent duties at night, and high numbers of patients assigned per day were associated with burnout among those surgeons (12).

Another major finding in the study is that alcohol consumption was frequent in surgeons. These results corroborate the findings of Oreskovich, which demonstrated that approximately 15.4% of that study’s sample of 7,197 surgeons had AUDIT scores that were consistent with dependence on alcohol or alcohol abuse (25). Approximately 41.7% of the surgeons consumed varying amounts of kava during a week. Kava is a traditional and sociocultural drink used widely in the South Pacific and is known to have sedative, analgesic, and anti-stress properties (26).

A major concern identified in this study was that a high majority of the surgeons self-prescribed medications for illnesses during the preceding year. An early decision of the researchers was not to ask about recreational drug use as the small sample size could have led to the identification of an individual participant.

Occupational burnout is a result of job-associated stress that occurs in the long term. Surgeons may have initially viewed their occupations as being challenging and meaningful, but, in due course, found it to be unfulfilling, meaningless, and exhausting. Burnout can cause feelings of involvement and efficacy to transition into cynicism and ineffectiveness (27). This may lead to surgeons resigning, causing further human capacity shortages and increased pressure on surgical services and, thereby, perpetuating the problem.

There are several implications of this study for the health-care system of Fiji. Surgeons with a lack of awareness of counseling services and who neglect their mental and physical well-being could cause significant strain on the quality of the health-care system in the country. This suggests that there is an urgent need to devise interventions offering interactive self-assessment that could, in turn, lead to behavioral changes that improve the mental and physical well-being of the surgeons.

This is the first study of occupational stress and burnout among surgeons in Fiji. Results show similarities to previous studies having larger populations of health professionals, which report high levels of stress and burnout and reduced physical and mental health. There is a clear message about the level of distress in the population studied, and this message is important and should be acted upon to improve the well-being among surgeons in Fiji that could result in improved quality of surgical services available in the country.

All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Fiji Ministry Health Research Committee (Approval Number: FNRERC Reference Number 2009-20).

All authors list have made substantial, direct, and intellectual contribution to the work and approved it for publication.

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this paper.