As we hypothesized, higher stress clinicians were more verbally dominant, offered less psychosocial information, and received lower ratings for overall quality of care from their patients compared with low-stress clinicians. However, clinicians in the moderate-stress group—while still more verbally dominant—offered more partnering statements and demonstrated more positive affect compared with lower stress clinicians. Therefore, although our findings support the hypothesis that clinician stress is associated with communication behaviors, they also raise interesting hypotheses regarding how this occurs across the continuum of stress.
Few studies have examined potential associations between clinician well-being and observable communication behaviors or patient satisfaction,20,38,49
and none have examined these relationships in chronic HIV care, despite concerns for the well-being of these clinicians.21–25
Our study focused on the personal stress experienced by healthcare clinicians, rather than work-related stress or burnout. While capturing the emotional response resulting from environmental demands outweighing resources,1
the PSS asks clinicians about their problems and control in their overall life, which could include professional life.2
In other provider well-being studies, the PSS correlated with work factors and risk of burnout.50–52
Nursing home staff PSS scores were correlated with control of work, mastery of work, and workplace social interactions, leadership, organizational culture, and commitment to organization.50
Medical students with higher PSS scores had increased odds of developing burnout and decreased odds of recovering from burnout in a longitudinal study.51
Finally, a workplace mindfulness-based stress reduction program for neonatal intensive care staff led to reductions in PSS and increases in SF-36 Mental Component Scores.52
These studies suggest that the healthcare work environment can contribute to overall personal stress, which could then increase or decrease risk of burnout at work. So, although the PSS does not specifically focus on stress limited to workplace stressors, it offers a useful metric for clinician well-being.
Stress may be more modifiable than clinician burnout, an enduring negative emotional state.3,53
However, stress and burnout may be linked in a causal cycle, as in a longitudinal study which found that stress makes clinicians more emotionally exhausted and that emotional exhaustion makes clinicians feel more stressed.53
If a clinician stress could be alleviated by reducing demands or increasing coping resources, the cycle leading to burnout could be mitigated, which could enhance workforce retention in settings serving patients with complex needs.1,2,4,5,53
Our findings raise questions about how stress may affect and be affected by communication, and how these associations may differ for burnout. We hypothesized that higher clinician stress would be associated with poorer communication behaviors and patient ratings because reduced well-being may make clinicians less empathic or reduce their capacity to be mindful in their communication.54–58
However, this may be more applicable to only higher levels of stress or the resulting emotional exhaustion accompanying burnout, which was not measured in our study. Our findings that patients of high-stress clinicians were less likely to rate their care as excellent are congruent with outpatient studies that found that components of burnout—depersonalization and exhaustion—were associated with lower patient satisfaction.38,49
In our study, there is no clear difference in communication behavior to explain why patients of high-stress clinicians had lower patient satisfaction with care, particularly since patients’ overall ratings of provider communication did not differ for this group. The only communication behavior associated with high clinician stress was verbal dominance, but this was true for moderate-stress clinicians without any difference in provider ratings. It is possible that some unmeasured common factors heightened both clinician stress and the patients’ experiences of their care (such as larger patient panel sizes or shorter patient visits), and that these factors—rather than provider communication—are what affect patient satisfaction.4,5
However, it is important to note that this analysis did not examine objective measures of quality of care, but rather patients’ experiences of that care.
Meanwhile, the findings may suggest that moderate-stress clinicians are working harder to communicate with their patients than those with higher or lower stress. A moderate level of stress may be a marker of highly conscientious clinicians responding to the perceived needs of their patients, thus explaining its association in our study with greater provision of both medical and psychosocial information, rapport-building, partnering, and positive affect. Although some of these associations became statistically insignificant when controlling for visit length, this may belie a tendency for moderate-stress clinicians to have longer encounters with their patients, enabling these communication behaviors. Another explanation is that these clinicians may work harder to engage in their relationships with patients because they work in more stressful environments that lack of resources outside of the encounter to enhance chronic disease outcomes.4,5
Alternatively, the process of working harder to communicate and engage with patients may actually lead to moderate levels of stress. A previous study found that primary care patients engaged in more rapport-building with physicians with lower well-being, theorizing that these clinicians may experience patient engagement as increased demands and develop compassion fatigue.20
Thus, at moderate stress, clinicians may communicate more effectively than their colleagues, but at the highest levels of stress, clinicians may exceed their capacity to exert this additional effort. This supports the concept of an “inverse U” relationship between stress and job performance, as found in a study of nurses’ self-reported stress and job performance.59,60
Cohen theorized that individuals exposed to uncontrollable and unpredictable stressors show greater arousal, which leads to improved performance. However, when stress becomes too great, performance diminishes, in part due to a narrowing of attention during arousal that can lead to “insensitivity to social cues.”59
Our study had several limitations. First, clinician stress may have changed from the date of the questionnaire to the dates of patient visits; however, the PSS has been found to have validity for up to 12 weeks after administration, and our encounters were conducted 1 to 16 weeks after PSS administration.2,3
Second, we specifically measured personal stress, and future studies may wish to examine both personal and professional stress, and coping strategies or resiliency. Third, the process of audiotaping may have changed patients’ or clinicians’ communication behaviors, but previous studies have revealed this observational methodology provides valid data about encounter behaviors,61
and we have no reason to believe that the “Hawthorne effect” would have differential effects by clinician stress. Fourth, this study aimed to examine outcomes related to communication and patients’ experiences of care, and we did not analyze process or clinical outcomes representing the quality of care delivered. Fifth, although this was a multisite study with a diverse patient and clinician population, our findings may not be generalizable to other clinical settings serving different populations, or to those with different chronic medical conditions. Sixth, we may have been underpowered to detect differences in communication behaviors or missed non-verbal communication behaviors, such as visual cues. Finally, these cross-sectional findings cannot offer conclusions regarding causality.
In summary, although higher stress was associated with verbal dominance and lower patient ratings, moderate stress was associated with some positive communication behaviors. Prospective mixed methods studies should investigate associations among clinician well-being, patient–clinician communication, and quality of care. Given recent evidence of the effectiveness of mindfulness interventions in improving clinician empathy and well-being, systems-based interventions to improve the experience of care for HIV-infected patients should consider targeting clinician stress as a potentially modifiable factor in patient-reported experiences of care.58