Development, validation, and cut-off points for a questionnaire to measure Sources of Stress in Veterinary Medicine (SOS-Vetmed)

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Osca, L. Millán, L. Vela, J. Barrado This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4477907/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Aug, 2024 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background Occupational stress is a serious problem in veterinary medicine; however, validated instruments to measure this problem are lacking. The aim of the current study was to address this literature gap by designing and validating a questionnaire and establishing the cut-off points for identifying veterinarians with high and low levels of stress. Methods The study involved two sub-studies with two Spanish samples. The first study ( N = 30 veterinarians; 66.7% women; 63.33% from small animal clinics) investigated the factors related to the work environment that caused the most stress; the results were analyzed using thematic content analysis. The second study ( N = 1082; 70.8% women; 71.4% from small animal clinics) involved designing and validating a questionnaire to measure sources of stress in veterinary medicine, as well as establishing the cut-off points for interpreting the results using receiver operating characteristics (ROC) curve analysis. Results The first study showed the main sources of stress and allowed items to be defined for the questionnaire. The second study validated the Sources of Stress in Veterinarian Medicine (SOS-VetMed) questionnaire and confirmed five sources of stress with adequate reliability and validity indices: “work overload,” “work–family conflict,” “emotional burden of work,” “organizational factors,” and “emergency problems.” The confirmatory factor analysis verified their structure with χ 2 (265) = 1967.23, χ 2 /degree of freedom = 7.42, comparative fit index = 0.89, and standardized root mean square residual = 0.073. The five subscales of the SOS-VetMed questionnaire were positively correlated with two indicators of distress: “psychological complaints” and “psychosomatic complaints.” The cut-off points indicated that 45.83% and 19.95% of the veterinarians surveyed had high and low levels of stress, respectively. Conclusions The results confirmed that the SOS-VetMed questionnaire could be used to determine the stress levels of veterinarians and to design intervention programs to improve their workplace health. Veterinary Medicine Source of Stress Questionnaire Psychometric Properties Cut-off Point Figures Figure 1 Figure 2 BACKGROUND Most studies on workplace stress in veterinary medicine focus more on describing its consequences on health and less on its causes. Different classifications of the main problems veterinarians face in their workplace have been proposed [ 1 – 4 ]; however, only a few offer questionnaires with psychometric guarantees and cut-off points for adequate diagnoses. Some studies focus on the symptoms of psychological distress in these professionals, including burnout, anxiety, and depression [ 3 , 5 ], compassion fatigue [ 6 ], or post-traumatic stress [ 6 , 7 ]. Other studies have focused on physical symptoms (including pain and psychosomatic disorders) [ 8 ] and suicidal tendencies [ 9 ]. In describing this symptomatology, reference is made to three sources of stress: stress specific to the profession, stress associated with interactions with animals, and stress associated with interactions with individuals responsible for the animals, but progress has not been made in the assessment of these sources of stress [ 10 ]. Several systematic reviews[ 11 – 13 ] confirm the absence of evaluation instruments and terminological confusion. Scotney et al.[ 11 ] concluded by alluding that the disparity in terminologies used renders the determination of differences between workplace stress and its consequences. Stetina and Krouzecky[ 12 ] subsequently identified three categories of stressors: biological, psychological, and social. However, some of the items included in these categories are stress precursors but not stressors in the strict sense, for example, sex and age are biological stressors, and rumination and alcohol abuse are psychological stressors. The last systematic review [ 13 ], distinguished between stress as a source and strain as an outcome. Although it does not refer to this distinction, it confirms that more studies exist on the consequences of stress rather than on its causes. Other studies analyzing the sources of workplace stress in the veterinary medicine can be described in terms of their qualitative [ 14 – 16 ] and quantitative nature [ 17 , 2 , 18 – 21 ]. First, qualitative studies using interviews were conducted to identify and describe the main sources of stress. For example, O’Connor [ 14 ] describes five stressors: “poor work–life balance,” “interaction with animal owners,” “specific aspects of euthanasia,” “dealing with poor animal welfare,” and “staff management responsibilities.” To date, qualitative studies are still being conducted to delve into specific stressors such as violent reactions from clients [ 15 ] and bullying and cyberbullying [ 16 ]. Gardner [ 17 ] was one of the first authors to use a quantitative methodology to assess the sources of stress in this profession. In a study involving 927 Australian veterinarians, he identified of the seven most important blocks of stressors: working hours, client expectations, unexpected outcomes, the need to update, personal relationships, economic issues, and personal expectations. Vande Griek et al. [ 2 ] subsequently identified a taxonomy of 15 major categories of stressors and 40 subcategories of more specific stressors ( N = 1422 United States veterinarians). The most common stressor categories included “financial insecurity,” “client issues,” “coworker or interpersonal issues,” and “work–life balance,” although the most common subcategories were “clients unwilling to pay,” “low income,” “cost of maintaining practice,” and “government or state board policies.” Other quantitative studies assessed the stress levels of veterinarians using questionnaires designed for other healthcare professionals, usually nursing or emergency medicine [ 18 ]. These studies focused on work overload [ 19 ], lack of control [ 20 ] or emotional stress [ 21 ]. Only two studies offered specific questionnaires for identifying sources of stress in this profession. The first questionnaire is the Veterinary Job Demands and Resources Questionnaire (Vet-DRQ) [ 22 ], developed in the Netherlands. The authors combined qualitative and quantitative methodologies. They began with three group interviews involving 13 recently graduated veterinarians in different fields. The gathered information was used to design a questionnaire comprising 32 questions covering seven sources of stress, although they were not specific to veterinary medicine: “task ambiguity,” “work overload,” “physical demands,” “job insecurity,” “working conditions,” “work–self conflict,” and “role conflicts.” The questionnaire was tested, using a sample of 727 recently graduated veterinarians, and the subscales were assessed using exploratory factor analysis. Andela [ 23 ] in France also combined qualitative and quantitative methodologies to design the Veterinarians Stressors Inventory. First, she interviewed 25 professionals and developed a 39-question questionnaire that she tested on a sample of 490 veterinarians. Through factor analyses, she categorized eight valid and reliable sources of stress: “negative work–home interactions,” “issues with coworkers,” “workload,” “responsibilities,” “financial issues,” “emotional demands,” “issues with clients,” and “feelings of being in danger.” Finally, two questionnaires were used to assess stress caused by the relationship with animal owners, which is one of the most common sources of stress. These were the Burden Transfer Inventory [ 24 ] and the Positive and Negative Experiences Scale [ 25 ]. However, none of the proposed questionnaires offer information on the cut-off points that allow identifying stress levels. Cut-off points are essential to make reliable diagnoses and formulate appropriate recommendations. Considering this background, the objective of this study was to develop and validate the Sources of Stress in Veterinary Medicine (SOS-VetMed) questionnaire with regard to circumstances faced by veterinary professionals in Spain, and to establish the cut-off scores for identifying professionals who have high levels of stress and may have more health issues. This study focused on (1) analyzing the internal consistency and reliability of the SOS-VetMed; (2) examining its factor solution through confirmatory factor analysis; and (3) exploring cut-off scores or thresholds for identifying high levels of stress using receiver operating characteristics (ROC) curve analysis. METHODS Two studies were conducted. In the first one, 30 veterinarians from different sectors were asked to describe the situations that caused the most stress in their daily work. Their answers were analyzed by using thematic content analysis. This procedure allowed the investigation of problems as they were experienced by the affected individuals. Based on the information from the first study, the second study involved designing a questionnaire and testing its psychometric characteristics by using a final sample of 1082 veterinarians. Finally, cut-off points for identifying veterinarians with stress were determined. This study was approved by the Ethics Committee of the National University of Distance Education (Madrid, Spain; reference no.: 26-SISH-PSI-2023). Written informed consent was obtained from all survey participants. Qualitative study Convenience sampling was used for the qualitative study. The interviews were conducted by a practicing veterinarian with a degree in psychology. This procedure allowed the interviewees to be candid and provide adequate information. Thirty veterinarians were interviewed about different aspects of their profession. Two questions were asked in this study: “What do you find most stressful in your daily work?” and “Do you think that being self-employed can increase problems?” Thematic saturation was achieved with the first 15 interviews. Therefore, the sample was expanded to include another 15 younger professionals from different sectors. Eleven (36.6%) interviews were conducted face-to-face, and the rest were conducted via videoconference. The audio and video recordings were subsequently transcribed and anonymized. The responses were analyzed independently by two graduate researchers in psychology, using thematic content analysis. The objective was to identify categories of the sources of stress referred to by the interviewees. Two meetings were held to reach a consensus on all the categories and their identifying characteristics. Quantitative study Based on the responses from the previous study, an online questionnaire comprising 35 questions was developed from October 2023 to December 2023. The questionnaire was distributed to veterinarians from different sectors. The responses were used to validate the questionnaire and determine the cut-offs for detecting stress levels in veterinarians. RESULTS Qualitative study Sample characteristics The final sample consisted of 30 veterinarians, 66.7% of whom were women. The average age (standard deviation [SD]) was 42.37 (8.65) years, and the average (SD) length of service as a working professional was 16.80 (7.24) years. Fifty percent of the sample were self-employed. The veterinarians working in small animal clinics (63.33%), in hospitals (20%) and livestock farms (16.66%). Findings The following categories of statements related to the sources of stress were obtained, and they were ordered, based on the number of times they were reported in interviews. The first category of statements was related to stress caused by problems with animal owners. These statements were recorded in 17 (56.6%) of 30 interviews. These statements were made by 10 self-employed veterinarians and seven regularly employed veterinarians. These statements were also most frequently made by veterinarians working in hospitals, working with large animals, or working on livestock farms. This category grouped problems with animal owners because they have to manage their own emotional reactions when delivering bad news (e.g., “Owners are very upset because they consider their animals members of their families”) or they do not understand the diagnoses or follow the recommendations. A veterinarian working on a livestock farm explained: “The most stressful thing, an argument with a farmer who did not agree with what I was telling him ... These are people who have been working all their lives and do not deal well with changes ... My job is to convince them with good words that they are doing it wrong, so that they will do it right.” The other statements in this category were related to stress due to the lack of recognition for the work they do and allusions to not being considered on the same level as human doctors (e.g., “They don’t realize that we are the doctors for their animals”). The second category included statements related to work overload. These statements were made by self-employed veterinarians (4 individuals) and regularly employed veterinarians (5 individuals), with allusions to fatigue caused by “excessive working hours” or “excessive bureaucratic burden.” These statements were made on nine (30%) occasions. For veterinarians working on livestock farms or in the countryside, the burden is increased by the time spent on “commuting.” Emergencies and on-call duty also represent an overload to the point that some veterinarians indicated having stopped performing such jobs. One veterinarian spoke of the uncertainty and fear these cause: “We no longer do emergencies, but I used to warn all my friends in case I didn’t come back from duty.” The third category included responses related to “problems with the organization and working conditions.” These problems included conflicts between colleagues or between bosses and employees, lack of coordination, inadequate distribution of tasks and responsibilities, and low salaries. This was observed in five (16.66%) responses from veterinarians working as employees. The fourth category comprised statements related to ethical dilemmas. These statements were made by four (13.33%) respondents: three veterinarians were regularly employed, and one veterinarian was self-employed. These dilemmas arise primarily because of economic reasons and to avoid confrontations with animal owners who are used to many medical services being free of charge. The interviewees recognized the pressure they receive to reduce treatments and make them more economical (e.g., one veterinarian explained: “To have the feeling that you could have done more, that the animal could have been saved. I've had several of those cases. That creates stress for me because you could do more, and it’s not done for money”). To the second question regarding whether “being self-employed can increase stress problems,” all 30 respondents answered in the affirmative. However, the self-employed veterinarians, as expected, highlighted the most common reasons as “because of problems with employees,” “because of economic issues,” “because of being ultimately responsible for everything,” and “because of the loneliness of the self-employed.” Quantitative study Sample characteristics The questionnaire was answered by 1215 veterinarians involved in small animal care (71.4%), large animals (13.9%), intensive production (3.7%), animal health (1.8%), agriculture (1.7%), research (1%), sales (1.1%), administration (2.1%), and other jobs (3.2%). The professionals were fewer in healthcare than in other sectors, and they were excluded from the study. Thus, the final sample comprised 1082 veterinarians dedicated to small animal medicine (71.4%) and large animal and intensive production (28.6%). Women accounted for 70.8% of the respondents. The average (SD) age was 41.60 (10.33) years, and the average (SD) length of service in the profession was 16.67 (9.97) years. In all, 39.7% had a bachelor’s degree, and the rest had a doctorate, master’s, or postgraduate degree. With regard to their employment status, 52.9% were contracted workers. Only 30.2% stated that they worked 40 hours per week; 26% stated that they worked between 41 hours and 50 hours per week, and 15.9% stated that they worked for more than 50 hours per week. Findings Table 1 shows the 30 items for the general sources of stress for all veterinarians. Table 2 presents the five specific items for veterinarians who were self-employed. No veterinarian considered work–family conflict as their main source of stress in the first study, but five questions related to this stressor were included because it appeared throughout the interviews. In addition, the sample predominantly comprised women for whom this is a significant source of stress. Table 1 Subscales and items of the SOS-VetMed questionnaire and descriptive data (means and standard deviations) Subscales and items X SD Workload 3.95 .72 1. Workload 4.04 .93 2. Working long hours 3.90 1.03 3. Performing tasks that require more time than expected 3.78 1.00 4. Bureaucratic administrative tasks, which are also increased by new laws and regulations 4.11 1.04 Work – family conflict 3.91 .96 5. Difficulties in reconciling work and family life 4.06 1.03 6. Work keeps me away from my family activities 4.10 1.02 7. The time I devote to my work prevents me from participating in family responsibilities 3.74 1.16 8. After work I am too stressed out to participate in family activities 3.77 1.17 9. Having trouble reconciling family and work 3.88 1.15 Emotional burden of work 3.62 .79 10. Communicating bad news to clients about their pets 3.58 .99 11. Demands from difficult clients 4.25 .88 12. Arguments with customers over financial issues 3.90 1.09 13. The emotional overload of work due to the bond with animals 3.80 1.08 14. The feeling of being in danger due to dealing with difficult customers 3.14 1.29 15. Cruelty to animals 3.64 1.23 16. Believing that much more can be done for the animal, but nothing else being done due to economic issues 3.87 1.08 17. Clients come with a diagnosis that has already been arrived at and only want one to confirm it 3.26 1.29 18. Clients do not accept the death of their pets 3.42 1.19 19. Clients’ emotional attachment to their pets 3.52 1.14 20. Performing euthanasia 3.29 1.21 Organizational factors 3.31 .90 21. Lack of social recognition 3.93 1.17 22. Having no one to turn to for help and advice 3.25 1.25 23. Problems with colleagues 3.11 1.29 24. Problems with responsible bosses 2.86 1.50 35. Difficulties in professional development 3.44 1.17 Emergency problems 3.05 1.05 26. On-call duty 3.27 1.57 27. Always being reachable 3.73 1.46 28. Having no one to turn to for help and advice in emergencies 3.00 1.37 29. The feeling of being in danger during on-call time 2.49 1.42 30. The feeling of being in danger from handling and caring for animals 2.75 1.17 N = 1082 veterinarians; Response: 1 = “It never affects me”–5 = “It always affects me” PLEASE INSERT Table 1 HERE Table 2 Items of the “Stress of being self-employed” subscale and descriptive data (means and standard deviations). Stress of being self-employed 3.40 0.96 1. Competition with other veterinarians’ businesses 3.25 1.23 2. Fear of not being able to cover expenses at the end of the month 3.51 1.36 3. Problems with employees 3.21 1.54 4. Problems with colleagues 3.09 1.36 5. The lonely feeling of being the one ultimately responsible for everything 3.98 1.24 N = 509 veterinarians; Response: 1 = “It never affects me”–5 = “It always affects me” Construct and criterion validity and reliability The construct validity of the questionnaire was calculated by using confirmatory factor analysis of the 30 items of the general questionnaire. The indicators showed that the best fit was obtained using the five-factor solution. The fit indices of the model were satisfactory: χ 2 (265) = 1967.23; χ 2 /degree of freedom = 7.42; root mean square error of approximation = .073; and comparative fit index = .89. All reliabilities were adequate, with Cronbach’s alpha values ranging between .92 for work–family conflict and .69 for emergency problems (Table 3 ). With regard to the descriptive results, all mean scores of the subscales were above the central point of the response scale and ordered from the highest to the lowest, as follows: work overload (x̅ = 3.95; SD = .72), work–family conflict (x̅ = 3.91; SD = .73), emotional burden of work (x̅ = 3.62; SD = .79), organizational factors (x̅ = 3.31; SD = .90), and emergency problems (x̅ = 3.05; SD = 1.05). The mean score of the subscale “stress of being self-employed” was also above the midpoint (x̅ = 3.40; SD = .96). The criterion validity of the questionnaire was tested by calculating the correlations between the five sources of stress and two indicators of distress, using “psychological complaints” and “psychosomatic complaints” from the Burnout Assessment Tool [ 26 ] (Table 3 ). The correlations were highly significant for all cases, although the highest correlations were for the “emotional burden of work” (correlation was .49 for psychological distress and .42 for physical distress) and “work–family conflict” (correlation of .45 for psychological distress and .36 for physical distress). The source of stress that showed weaker correlations, although also highly significant, was “emergency problems” (correlation of .39 for psychological distress and .36 for physical distress). Table 3 Means, standard deviations, correlations and reliabilities DT 1 2 3 4 5 6 7 8 1.Emotional burden 3.62 .79 .89 2. W/F Conflict 3.91 .96 .45** .92 3. Emergency problems 3.05 1.05 .51** .50** .80 4. Organizational factors 3.31 .90 .54** .50** .56** .74 5. Workload 3.95 .72 .42** .57** .40** .38** .69 6. Stress self-employed 3.40 .96 .57** .49** .42** .67** .39** .76 7. Psychological complains 3.27 .98 .49** .45** .39** .43** .40** .47** .83 8. Psychosomatic complains 2.68 .91 .42** .36** .36** .35** .33** .35** .70** .78 Response: 1 = “It never affects me”, 5 = “It always affects me” p ** The correlation is significant at .01 (bilateral) Cronbach's alpha in the diagonal Cut-off points The cut-off points were calculated for the 30 items of the SOS-VetMed questionnaire to differentiate veterinarians who have high levels of stress (i.e., above the high threshold) from those who do not (i.e., below the low threshold). Based on a previous report [ 27 ], two gold standards related to stress were used: “psychological complaints” scores and “psychosomatic complaints” scores [ 26 ]. For both cases, the maximum threshold corresponded to the 75th percentile, whereas the minimum threshold corresponded to the 25th percentile. The following scores were obtained: (1) lower threshold scores were below 2.60 for “psychological complaints” and below 2.00 for “psychosomatic complaints” (i.e., 75th percentile). These two thresholds made it possible to draw two ROC curves for the upper and lower thresholds. Each had a graph of sensitivity (i.e., true-positive rate) and specificity (i.e., false-positive rate) for all possible cut-off scores (Figs. 1 and 2 ). The area under the curve (AUC) for the high threshold cut-off point was .776 (95% CI = .741-.810; p < .000) (Table 4 ) and that for the low threshold cut-off point was .831 (95% CI = .780-.882; p < .000) (Table 5 ). An AUC close to 1 indicates high accuracy [ 28 ]. Therefore, both thresholds were good. The optimal cut-off scores were determined by using the Youden index [ 29 ], which identifies the minimum score for type I and II errors, false-negatives, and false-positives by using the formula J = sensitivity + (specificity − 1). As shown in Tables 4 and 5 , the optimal cut-off points were 3.68 for the upper threshold and 2.98 for the lower threshold. Veterinarians with scores of ≤ 2.98 on the SOS-VetMed questionnaire were consequently considered not stressed, whereas veterinarians with scores of ≥ 3.68 were considered highly stressed. Based on these results, 45.83%, 19.95%, and 34.20% of the sample had high, low, and intermediate stress scores, respectively. Table 4 SOS (VetMed) higher threshold cutoff score SOS (VetMed) Sensitivity Specificity Youden index 3.55 .865 .472 .393 3.58 .860 .455 .405 3.62 .848 .432 .416 3.65 .815 .408 .407 3.68 .809 .378 .431 3.72 .781 .360 .421 3.75 .742 .348 .394 3.78 .719 .329 .390 3.82 .697 .318 .378 3.85 .669 .303 .365 Table 5 SOS (VetMed) lower threshold cutoff score SOS (VetMed) Sensitivity Specificity Youden index 2.85 .883 .437 .446 2.88 .872 .423 .449 2.92 .863 .366 .497 2.95 .855 .352 .503 2.98 .841 .296 .546 3.02 .836 .296 .540 3.05 .827 .296 .531 3.08 .820 .282 .538 3.12 .804 .268 .537 3.15 .788 .254 .535 DISCUSSION As we have observed, research on workplace stress in veterinary medicine has focused more on its health consequences rather than on its causes. Descriptive studies and taxonomies for the different sources of stress among veterinarians exist, but questionnaires that provide sufficient information on the psychometric characteristics of questionnaires are few. Therefore, the objective of this study was to develop and validate the SOS-VetMed questionnaire and establish cut-off points for identifying veterinarians who have high levels of stress and may have more health issues. None of the existing studies have provided cut-off points, but these are essential for accurate diagnoses and the design of effective and efficient prevention programs. Two sub-studies were conducted. In the first, which was qualitative, a significant number of professionals were asked about the main sources of stress in their daily work. By, using the information obtained from the qualitative study, an online questionnaire was then developed and applied in a quantitative study that allowed the corroboration of the main sources of stress among Spanish veterinarians. The analyses allowed us to assert that the SOS-MedVet questionnaire assesses different sources of stress with psychometric guarantees, and the determination of the cut-off points allowed us to identify veterinarians who have high stress levels and an increased risk of health issues. In line with the results of research in this area, a high proportion of the participants showed high levels of workplace stress. This article has two other strengths. The first involves the quality of the sample related to the number and diversity of the participants. Thirty interviews were conducted, and more than 1000 veterinarians in small and large animal care were surveyed. They had numerous years of professional experience, which is not common in research. This factor allowed us to gather valuable information. In addition, we included a scale to specifically assess the stress levels of the self-employed veterinarians because being self-employed is an additional source of stress. For the qualitative and quantitative studies, relationships with the respondents responsible for the animals and work overload were the main sources of stress for veterinarians who participated in this research. The qualitative study showed that “problems with animal owners” were the main sources of stress, which is consistent with reports of reviews on the subject [ 24 ]. In the quantitative study, questions on this source of stress were grouped with questions referring to negative emotions produced by these relationships (because of cruelty to animals, ethical aspects, etc.), and a subscale called “emotional burden of work” was created. In the quantitative study, the main source of stress was “work overload,” confirming one of the main issues in the profession, which is also reflected in the reviews on the subject [ 5 ]. For both studies, the discrepancy in the order of importance of these two sources of stress may be explained by the differences in assessment. The interviews asked about the most stressful situations, whereas the questionnaire used the Likert scale. Work–family conflict was considered the next most important source of stress. This finding was consistent with the reports of several studies and can be explained by long working hours and the high proportion of women [ 30 ] [ 31 ]. Stress due to “organizational factors” and “emergency problems” had lower scores that were above the midpoint of the scale. Organizational factors [ 32 ] have also been identified in other studies and include problems between colleagues, problems between employees and employers, or difficulties in career advancement. The source of stress with the lowest score was “emergency problems.” However, this finding may be attributed to the large proportion of veterinarians with considerable seniority and who performed the fewest shifts, as several interviewees acknowledged. Nevertheless, it is a source of stress to be considered, as observed in other studies [ 33 ]. The correlations between the sources of stress and health were highly significant for psychological and psychosomatic complaints [ 12 , 24 ] and the strongest correlations were for stress due to the “emotional burden of work” and “work–family conflict.” In addition to the aforementioned contributions, one of the main contributions of this study is that it has provided cut-off points for the developed questionnaire. These data confirmed that nearly 50% of the sample analyzed were at risk because they showed high stress levels (45.83%). This finding has been reported in other reviews on the subject [ 11 , 13 ], albeit it is empirically confirmed. Only approximately 20% of participants had low levels of stress; the remaining participants had intermediate levels. As with any research, this study has some limitations that should be addressed in the future. First, the sample was collected in Spain, and therefore it would be useful to use information from other countries to improve generalizability. Second, the cut-off points for the subscale that assesses “stress of the self-employed” were not determined, which would be interesting to know. Third, determining whether the different stressors could be grouped into clusters that may be dangerous to health would be useful [ 34 ]. Some clusters may have deleterious effects such as working as a freelancer in a bad working environment and spending many hours in the emergency room. In addition, future studies should include sociodemographic data because differences may exist, depending, for instance, on sex or age. Other variables that may modulate the correlations between sources of stress and health issues, such as coping strategies [ 35 ] or family or work support [ 35 , 36 ], should also be included in future studies. Finally, longitudinal studies should be considered to more accurately explain the correlations found in this study and to investigate whether reverse correlations exist (i.e., whether veterinarians with more health issues also perceive their work as more stressful). Despite these limitations, we believe that this article is valuable from theoretical and applied perspectives. It allowed us to theoretically describe and classify the main sources of stress with regard to circumstances faced by veterinary professionals in Spain and to develop and validate a questionnaire, the SOS-MedVet questionnaire, with psychometric guarantees. As we have observed, many studies refer to stress in the profession, but very few offer questionnaires [ 22 – 23 ] and we have not found any study that provided cut-off points. The cut-off points allowed clinicians to know what the obtained scores indicated. From an applied perspective, the value of this study is that it permitted a diagnosis of the sources of stress that cause the most health issues and/or design intervention programs. For example, if two of the most significant sources of stress were “emotional burden” and “work overload,” specific activities could be organized in an attempt to reduce them. In particular, training programs aimed at improving communication with animal owners and helping them manage their emotions and the problems that may arise in their relationship can be implemented [ 15 ]. Employers should create safe environments where employees feel comfortable to seek help and foster healthy work cultures [ 32 ]. To reduce the perception of work overload, veterinarians can also be trained in organizational skills and task design because an adequate and balanced distribution of tasks [ 37 ] can reduce physical fatigue and emotional exhaustion. In addition, these types of interventions would indirectly contribute to decreasing other stressors that we also found to cause many issues such as difficulty in balancing work and family demands, and conflicts with colleagues. Finally, by knowing the cut-off points of this questionnaire, veterinarians who require individual psychological care by specialists may be diagnosed. CONCLUSIONS This study provided a validated tool to assess stress in veterinary professionals. By identifying specific stressors and quantifying stress levels, the SOS-VetMed questionnaire allows for targeted interventions to promote veterinarian well-being and improve workplace health. Furthermore, given the growing awareness of mental health issues in the veterinary profession, this study offered valuable information for practitioners, researchers, and policymakers alike. The findings enhance the understanding of the challenges faced by veterinarians and pave the way for evidence-based interventions to mitigate stress and promote health. Abbreviations AUC, area under the curve; ROC, receiver operating characteristic; SD, standard deviation Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of the National University of Distance Education (Madrid, Spain; reference no.: 26-SISH-PSI-2023). All the methods included in this study are in accordance with the declaration of Helsinki. Written informed consent was obtained from all survey participants. Acknowledgements We are thankful of all veterinarians who participated in this research. Author contributions AO was involved in the study design, data analysis, creation of data collection tools, data analysis, interpretation of results, writing and editing the manuscript. LM was involved in the study design, data analysis, creation of data collection tools, data analysis (qualitative study) and interpretation of results. LV was involved in data analysis (qualitative study). JB was involved in the data analysis (quantitative study), interpretation of results and writing the manuscript. Funding This research was supported by the grant of Boehringer Ingelheim Animal Health Spain. Data availability The dataset used and/or analyzed for the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Consent for publication Not applicable. References Volk JO, Schimmack U, Strand EB, Lord LK, Siren CW. Executive summary of the Merck Animal Health Veterinary Wellbeing Study. J Am Vet Med Assoc [Internet]. 2018 May 15 [cited 2024 May 21];252(10):1231-1238. doi: 10.2460/javma.252.10.1231. PMID: 29701527. 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Professional help-seeking behaviour for mental health problems among veterinarians in Norway: a nationwide, cross-sectional study (The NORVET study). BMC Public Health [Internet]. 2022 Jul 7 [cited 2024 May 21];22(1):1308. doi: 10.1186/s12889-022-13710-y. PMID: 35799295; PMCID: PMC9263054. Available from: https://pubmed.ncbi.nlm.nih.gov/35799295/ Guzman Villegas M, Jubin J, Bucher CO, Bachmann AO. Self-efficacy, mindfulness, and perceived social support as resources to maintain the mental health of students in Switzerland's universities of applied sciences: a cross-sectional study. BMC Public Health [Internet]. 2024 Jan 31 [cited 2024 May 21];24(1):335. doi: 10.1186/s12889-024-17692-x. PMID: 38297239; PMCID: PMC10829234. Available from: https://pubmed.ncbi.nlm.nih.gov/38297239/ Aronsson G, Theorell T, Grape T, Hammarström A, Hogstedt C, Marteinsdottir I, Skoog I, Träskman-Bendz L, Hall C. A systematic review including meta-analysis of work environment and burnout symptoms. BMC Public Health [Internet]. 2017 Mar 16 [cited 2024 May 21];17(1):264. doi: 10.1186/s12889-017-4153-7. PMID: 28302088; PMCID: PMC5356239. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5356239/ Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 09 Aug, 2024 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 30 May, 2024 Editor assigned by journal 27 May, 2024 Submission checks completed at journal 27 May, 2024 First submitted to journal 25 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4477907","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308576326,"identity":"ea9d97a6-1481-4fec-924b-974c8aad1135","order_by":0,"name":"A. 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Different classifications of the main problems veterinarians face in their workplace have been proposed [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]; however, only a few offer questionnaires with psychometric guarantees and cut-off points for adequate diagnoses.\u003c/p\u003e \u003cp\u003eSome studies focus on the symptoms of psychological distress in these professionals, including burnout, anxiety, and depression [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], compassion fatigue [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], or post-traumatic stress [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Other studies have focused on physical symptoms (including pain and psychosomatic disorders) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and suicidal tendencies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In describing this symptomatology, reference is made to three sources of stress: stress specific to the profession, stress associated with interactions with animals, and stress associated with interactions with individuals responsible for the animals, but progress has not been made in the assessment of these sources of stress [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral systematic reviews[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] confirm the absence of evaluation instruments and terminological confusion. Scotney et al.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] concluded by alluding that the disparity in terminologies used renders the determination of differences between workplace stress and its consequences. Stetina and Krouzecky[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] subsequently identified three categories of stressors: biological, psychological, and social. However, some of the items included in these categories are stress precursors but not stressors in the strict sense, for example, sex and age are biological stressors, and rumination and alcohol abuse are psychological stressors. The last systematic review [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], distinguished between stress as a source and strain as an outcome. Although it does not refer to this distinction, it confirms that more studies exist on the consequences of stress rather than on its causes.\u003c/p\u003e \u003cp\u003eOther studies analyzing the sources of workplace stress in the veterinary medicine can be described in terms of their qualitative [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and quantitative nature [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. First, qualitative studies using interviews were conducted to identify and describe the main sources of stress. For example, O\u0026rsquo;Connor [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] describes five stressors: \u0026ldquo;poor work\u0026ndash;life balance,\u0026rdquo; \u0026ldquo;interaction with animal owners,\u0026rdquo; \u0026ldquo;specific aspects of euthanasia,\u0026rdquo; \u0026ldquo;dealing with poor animal welfare,\u0026rdquo; and \u0026ldquo;staff management responsibilities.\u0026rdquo; To date, qualitative studies are still being conducted to delve into specific stressors such as violent reactions from clients [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and bullying and cyberbullying [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGardner [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] was one of the first authors to use a quantitative methodology to assess the sources of stress in this profession. In a study involving 927 Australian veterinarians, he identified of the seven most important blocks of stressors: working hours, client expectations, unexpected outcomes, the need to update, personal relationships, economic issues, and personal expectations. Vande Griek et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] subsequently identified a taxonomy of 15 major categories of stressors and 40 subcategories of more specific stressors (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1422 United States veterinarians). The most common stressor categories included \u0026ldquo;financial insecurity,\u0026rdquo; \u0026ldquo;client issues,\u0026rdquo; \u0026ldquo;coworker or interpersonal issues,\u0026rdquo; and \u0026ldquo;work\u0026ndash;life balance,\u0026rdquo; although the most common subcategories were \u0026ldquo;clients unwilling to pay,\u0026rdquo; \u0026ldquo;low income,\u0026rdquo; \u0026ldquo;cost of maintaining practice,\u0026rdquo; and \u0026ldquo;government or state board policies.\u0026rdquo;\u003c/p\u003e \u003cp\u003eOther quantitative studies assessed the stress levels of veterinarians using questionnaires designed for other healthcare professionals, usually nursing or emergency medicine [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These studies focused on work overload [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], lack of control [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] or emotional stress [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOnly two studies offered specific questionnaires for identifying sources of stress in this profession. The first questionnaire is the Veterinary Job Demands and Resources Questionnaire (Vet-DRQ) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], developed in the Netherlands. The authors combined qualitative and quantitative methodologies. They began with three group interviews involving 13 recently graduated veterinarians in different fields. The gathered information was used to design a questionnaire comprising 32 questions covering seven sources of stress, although they were not specific to veterinary medicine: \u0026ldquo;task ambiguity,\u0026rdquo; \u0026ldquo;work overload,\u0026rdquo; \u0026ldquo;physical demands,\u0026rdquo; \u0026ldquo;job insecurity,\u0026rdquo; \u0026ldquo;working conditions,\u0026rdquo; \u0026ldquo;work\u0026ndash;self conflict,\u0026rdquo; and \u0026ldquo;role conflicts.\u0026rdquo; The questionnaire was tested, using a sample of 727 recently graduated veterinarians, and the subscales were assessed using exploratory factor analysis. Andela [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] in France also combined qualitative and quantitative methodologies to design the Veterinarians Stressors Inventory. First, she interviewed 25 professionals and developed a 39-question questionnaire that she tested on a sample of 490 veterinarians. Through factor analyses, she categorized eight valid and reliable sources of stress: \u0026ldquo;negative work\u0026ndash;home interactions,\u0026rdquo; \u0026ldquo;issues with coworkers,\u0026rdquo; \u0026ldquo;workload,\u0026rdquo; \u0026ldquo;responsibilities,\u0026rdquo; \u0026ldquo;financial issues,\u0026rdquo; \u0026ldquo;emotional demands,\u0026rdquo; \u0026ldquo;issues with clients,\u0026rdquo; and \u0026ldquo;feelings of being in danger.\u0026rdquo;\u003c/p\u003e \u003cp\u003eFinally, two questionnaires were used to assess stress caused by the relationship with animal owners, which is one of the most common sources of stress. These were the Burden Transfer Inventory [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and the Positive and Negative Experiences Scale [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, none of the proposed questionnaires offer information on the cut-off points that allow identifying stress levels. Cut-off points are essential to make reliable diagnoses and formulate appropriate recommendations.\u003c/p\u003e \u003cp\u003eConsidering this background, the objective of this study was to develop and validate the Sources of Stress in Veterinary Medicine (SOS-VetMed) questionnaire with regard to circumstances faced by veterinary professionals in Spain, and to establish the cut-off scores for identifying professionals who have high levels of stress and may have more health issues. This study focused on (1) analyzing the internal consistency and reliability of the SOS-VetMed; (2) examining its factor solution through confirmatory factor analysis; and (3) exploring cut-off scores or thresholds for identifying high levels of stress using receiver operating characteristics (ROC) curve analysis.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eTwo studies were conducted. In the first one, 30 veterinarians from different sectors were asked to describe the situations that caused the most stress in their daily work. Their answers were analyzed by using thematic content analysis. This procedure allowed the investigation of problems as they were experienced by the affected individuals. Based on the information from the first study, the second study involved designing a questionnaire and testing its psychometric characteristics by using a final sample of 1082 veterinarians. Finally, cut-off points for identifying veterinarians with stress were determined. This study was approved by the Ethics Committee of the National University of Distance Education (Madrid, Spain; reference no.: 26-SISH-PSI-2023). Written informed consent was obtained from all survey participants.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eQualitative study\u003c/h2\u003e \u003cp\u003eConvenience sampling was used for the qualitative study. The interviews were conducted by a practicing veterinarian with a degree in psychology. This procedure allowed the interviewees to be candid and provide adequate information. Thirty veterinarians were interviewed about different aspects of their profession. Two questions were asked in this study: \u0026ldquo;What do you find most stressful in your daily work?\u0026rdquo; and \u0026ldquo;Do you think that being self-employed can increase problems?\u0026rdquo; Thematic saturation was achieved with the first 15 interviews. Therefore, the sample was expanded to include another 15 younger professionals from different sectors. Eleven (36.6%) interviews were conducted face-to-face, and the rest were conducted via videoconference. The audio and video recordings were subsequently transcribed and anonymized. The responses were analyzed independently by two graduate researchers in psychology, using thematic content analysis. The objective was to identify categories of the sources of stress referred to by the interviewees. Two meetings were held to reach a consensus on all the categories and their identifying characteristics.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative study\u003c/h2\u003e \u003cp\u003eBased on the responses from the previous study, an online questionnaire comprising 35 questions was developed from October 2023 to December 2023. The questionnaire was distributed to veterinarians from different sectors. The responses were used to validate the questionnaire and determine the cut-offs for detecting stress levels in veterinarians.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eQualitative study\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eSample characteristics\u003c/h2\u003e \u003cp\u003eThe final sample consisted of 30 veterinarians, 66.7% of whom were women. The average age (standard deviation [SD]) was 42.37 (8.65) years, and the average (SD) length of service as a working professional was 16.80 (7.24) years. Fifty percent of the sample were self-employed. The veterinarians working in small animal clinics (63.33%), in hospitals (20%) and livestock farms (16.66%).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eFindings\u003c/h3\u003e\n\u003cp\u003eThe following categories of statements related to the sources of stress were obtained, and they were ordered, based on the number of times they were reported in interviews. The first category of statements was related to stress caused by problems with animal owners. These statements were recorded in 17 (56.6%) of 30 interviews. These statements were made by 10 self-employed veterinarians and seven regularly employed veterinarians. These statements were also most frequently made by veterinarians working in hospitals, working with large animals, or working on livestock farms. This category grouped problems with animal owners because they have to manage their own emotional reactions when delivering bad news (e.g., \u0026ldquo;Owners are very upset because they consider their animals members of their families\u0026rdquo;) or they do not understand the diagnoses or follow the recommendations. A veterinarian working on a livestock farm explained: \u0026ldquo;The most stressful thing, an argument with a farmer who did not agree with what I was telling him ... These are people who have been working all their lives and do not deal well with changes ... My job is to convince them with good words that they are doing it wrong, so that they will do it right.\u0026rdquo; The other statements in this category were related to stress due to the lack of recognition for the work they do and allusions to not being considered on the same level as human doctors (e.g., \u0026ldquo;They don\u0026rsquo;t realize that we are the doctors for their animals\u0026rdquo;).\u003c/p\u003e \u003cp\u003eThe second category included statements related to work overload. These statements were made by self-employed veterinarians (4 individuals) and regularly employed veterinarians (5 individuals), with allusions to fatigue caused by \u0026ldquo;excessive working hours\u0026rdquo; or \u0026ldquo;excessive bureaucratic burden.\u0026rdquo; These statements were made on nine (30%) occasions. For veterinarians working on livestock farms or in the countryside, the burden is increased by the time spent on \u0026ldquo;commuting.\u0026rdquo; Emergencies and on-call duty also represent an overload to the point that some veterinarians indicated having stopped performing such jobs. One veterinarian spoke of the uncertainty and fear these cause: \u0026ldquo;We no longer do emergencies, but I used to warn all my friends in case I didn\u0026rsquo;t come back from duty.\u0026rdquo;\u003c/p\u003e \u003cp\u003eThe third category included responses related to \u0026ldquo;problems with the organization and working conditions.\u0026rdquo; These problems included conflicts between colleagues or between bosses and employees, lack of coordination, inadequate distribution of tasks and responsibilities, and low salaries. This was observed in five (16.66%) responses from veterinarians working as employees.\u003c/p\u003e \u003cp\u003eThe fourth category comprised statements related to ethical dilemmas. These statements were made by four (13.33%) respondents: three veterinarians were regularly employed, and one veterinarian was self-employed. These dilemmas arise primarily because of economic reasons and to avoid confrontations with animal owners who are used to many medical services being free of charge. The interviewees recognized the pressure they receive to reduce treatments and make them more economical (e.g., one veterinarian explained: \u0026ldquo;To have the feeling that you could have done more, that the animal could have been saved. I've had several of those cases. That creates stress for me because you could do more, and it\u0026rsquo;s not done for money\u0026rdquo;).\u003c/p\u003e \u003cp\u003eTo the second question regarding whether \u0026ldquo;being self-employed can increase stress problems,\u0026rdquo; all 30 respondents answered in the affirmative. However, the self-employed veterinarians, as expected, highlighted the most common reasons as \u0026ldquo;because of problems with employees,\u0026rdquo; \u0026ldquo;because of economic issues,\u0026rdquo; \u0026ldquo;because of being ultimately responsible for everything,\u0026rdquo; and \u0026ldquo;because of the loneliness of the self-employed.\u0026rdquo;\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative study\u003c/h2\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eSample characteristics\u003c/h2\u003e \u003cp\u003eThe questionnaire was answered by 1215 veterinarians involved in small animal care (71.4%), large animals (13.9%), intensive production (3.7%), animal health (1.8%), agriculture (1.7%), research (1%), sales (1.1%), administration (2.1%), and other jobs (3.2%). The professionals were fewer in healthcare than in other sectors, and they were excluded from the study. Thus, the final sample comprised 1082 veterinarians dedicated to small animal medicine (71.4%) and large animal and intensive production (28.6%). Women accounted for 70.8% of the respondents. The average (SD) age was 41.60 (10.33) years, and the average (SD) length of service in the profession was 16.67 (9.97) years. In all, 39.7% had a bachelor\u0026rsquo;s degree, and the rest had a doctorate, master\u0026rsquo;s, or postgraduate degree. With regard to their employment status, 52.9% were contracted workers. Only 30.2% stated that they worked 40 hours per week; 26% stated that they worked between 41 hours and 50 hours per week, and 15.9% stated that they worked for more than 50 hours per week.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFindings\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the 30 items for the general sources of stress for all veterinarians. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the five specific items for veterinarians who were self-employed. No veterinarian considered work\u0026ndash;family conflict as their main source of stress in the first study, but five questions related to this stressor were included because it appeared throughout the interviews. In addition, the sample predominantly comprised women for whom this is a significant source of stress.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSubscales and items of the \u003cem\u003eSOS-VetMed\u003c/em\u003e questionnaire and descriptive data (means and standard deviations)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubscales and items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorkload\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.95\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.72\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Workload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Working long hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Performing tasks that require more time than expected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Bureaucratic administrative tasks, which are also increased by new laws and regulations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork\u003c/b\u003e\u003cem\u003e\u0026ndash;\u003c/em\u003e\u003cb\u003efamily conflict\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.91\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.96\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Difficulties in reconciling work and family life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Work keeps me away from my family activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. The time I devote to my work prevents me from participating in family responsibilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. After work I am too stressed out to participate in family activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Having trouble reconciling family and work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmotional burden of work\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.62\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.79\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. Communicating bad news to clients about their pets\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. Demands from difficult clients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Arguments with customers over financial issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. The emotional overload of work due to the bond with animals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. The feeling of being in danger due to dealing with difficult customers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. Cruelty to animals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16. Believing that much more can be done for the animal, but nothing else being done due to economic issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17. Clients come with a diagnosis that has already been arrived at and only want one to confirm it\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18. Clients do not accept the death of their pets\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19. Clients\u0026rsquo; emotional attachment to their pets\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20. Performing euthanasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOrganizational factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.31\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.90\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21. Lack of social recognition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22. Having no one to turn to for help and advice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23. Problems with colleagues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24. Problems with responsible bosses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35. Difficulties in professional development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmergency problems\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26. On-call duty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27. Always being reachable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e28. Having no one to turn to for help and advice in emergencies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29. The feeling of being in danger during on-call time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30. The feeling of being in danger from handling and caring for animals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eN\u0026thinsp;=\u0026thinsp;1082 veterinarians; Response: 1 = \u0026ldquo;It never affects me\u0026rdquo;\u0026ndash;5 = \u0026ldquo;It always affects me\u0026rdquo;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePLEASE INSERT Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e HERE\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eItems of the \u0026ldquo;Stress of being self-employed\u0026rdquo; subscale and descriptive data (means and standard deviations).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStress of being self-employed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.40\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Competition with other veterinarians\u0026rsquo; businesses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Fear of not being able to cover expenses at the end of the month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Problems with employees\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Problems with colleagues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. The lonely feeling of being the one ultimately responsible for everything\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eN\u0026thinsp;=\u0026thinsp;509 veterinarians; Response: 1 = \u0026ldquo;It never affects me\u0026rdquo;\u0026ndash;5 = \u0026ldquo;It always affects me\u0026rdquo;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eConstruct and criterion validity and reliability\u003c/h2\u003e \u003cp\u003eThe construct validity of the questionnaire was calculated by using confirmatory factor analysis of the 30 items of the general questionnaire. The indicators showed that the best fit was obtained using the five-factor solution. The fit indices of the model were satisfactory: χ\u003csup\u003e2\u003c/sup\u003e(265)\u0026thinsp;=\u0026thinsp;1967.23; χ\u003csup\u003e2\u003c/sup\u003e/degree of freedom\u0026thinsp;=\u0026thinsp;7.42; root mean square error of approximation\u0026thinsp;=\u0026thinsp;.073; and comparative fit index\u0026thinsp;=\u0026thinsp;.89.\u003c/p\u003e \u003cp\u003eAll reliabilities were adequate, with Cronbach\u0026rsquo;s alpha values ranging between .92 for work\u0026ndash;family conflict and .69 for emergency problems (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). With regard to the descriptive results, all mean scores of the subscales were above the central point of the response scale and ordered from the highest to the lowest, as follows: work overload (x̅ = 3.95; SD\u0026thinsp;=\u0026thinsp;.72), work\u0026ndash;family conflict (x̅ = 3.91; SD\u0026thinsp;=\u0026thinsp;.73), emotional burden of work (x̅ = 3.62; SD\u0026thinsp;=\u0026thinsp;.79), organizational factors (x̅ = 3.31; SD\u0026thinsp;=\u0026thinsp;.90), and emergency problems (x̅ = 3.05; SD\u0026thinsp;=\u0026thinsp;1.05). The mean score of the subscale \u0026ldquo;stress of being self-employed\u0026rdquo; was also above the midpoint (x̅ = 3.40; SD\u0026thinsp;=\u0026thinsp;.96).\u003c/p\u003e \u003cp\u003eThe criterion validity of the questionnaire was tested by calculating the correlations between the five sources of stress and two indicators of distress, using \u0026ldquo;psychological complaints\u0026rdquo; and \u0026ldquo;psychosomatic complaints\u0026rdquo; from the Burnout Assessment Tool [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The correlations were highly significant for all cases, although the highest correlations were for the \u0026ldquo;emotional burden of work\u0026rdquo; (correlation was .49 for psychological distress and .42 for physical distress) and \u0026ldquo;work\u0026ndash;family conflict\u0026rdquo; (correlation of .45 for psychological distress and .36 for physical distress). The source of stress that showed weaker correlations, although also highly significant, was \u0026ldquo;emergency problems\u0026rdquo; (correlation of .39 for psychological distress and .36 for physical distress).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMeans, standard deviations, correlations and reliabilities\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.Emotional burden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. W/F Conflict\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.45**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Emergency problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.51**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.50**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Organizational factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.54**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.50**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.56**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Workload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.42**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.57**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.40**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.38**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Stress self-employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.57**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.49**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.42**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.67**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.39**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Psychological complains\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.49**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.45**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.39**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.43**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.40**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.47**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Psychosomatic complains\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.42**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.36**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.36**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.35**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.33**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.35**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.70**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eResponse: 1 = \u0026ldquo;It never affects me\u0026rdquo;, 5 = \u0026ldquo;It always affects me\u0026rdquo;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ep ** The correlation is significant at .01 (bilateral)\u003c/p\u003e \u003cp\u003eCronbach's alpha in the diagonal\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCut-off points\u003c/h2\u003e \u003cp\u003eThe cut-off points were calculated for the 30 items of the SOS-VetMed questionnaire to differentiate veterinarians who have high levels of stress (i.e., above the high threshold) from those who do not (i.e., below the low threshold). Based on a previous report [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], two gold standards related to stress were used: \u0026ldquo;psychological complaints\u0026rdquo; scores and \u0026ldquo;psychosomatic complaints\u0026rdquo; scores [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. For both cases, the maximum threshold corresponded to the 75th percentile, whereas the minimum threshold corresponded to the 25th percentile. The following scores were obtained: (1) lower threshold scores were below 2.60 for \u0026ldquo;psychological complaints\u0026rdquo; and below 2.00 for \u0026ldquo;psychosomatic complaints\u0026rdquo; (i.e., \u0026lt;\u0026thinsp;25th percentile) and (2) upper threshold scores were higher than 4.00 for \u0026ldquo;psychological complaints\u0026rdquo; and 3.40 for \u0026ldquo;psychosomatic complaints\u0026rdquo; (i.e., \u0026gt;\u0026thinsp;75th percentile).\u003c/p\u003e \u003cp\u003eThese two thresholds made it possible to draw two ROC curves for the upper and lower thresholds. Each had a graph of sensitivity (i.e., true-positive rate) and specificity (i.e., false-positive rate) for all possible cut-off scores (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The area under the curve (AUC) for the high threshold cut-off point was .776 (95% CI\u0026thinsp;=\u0026thinsp;.741-.810; p\u0026thinsp;\u0026lt;\u0026thinsp;.000) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) and that for the low threshold cut-off point was .831 (95% CI\u0026thinsp;=\u0026thinsp;.780-.882; p\u0026thinsp;\u0026lt;\u0026thinsp;.000) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). An AUC close to 1 indicates high accuracy [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Therefore, both thresholds were good.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe optimal cut-off scores were determined by using the Youden index [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], which identifies the minimum score for type I and II errors, false-negatives, and false-positives by using the formula J\u0026thinsp;=\u0026thinsp;sensitivity + (specificity \u0026minus;\u0026thinsp;1). As shown in Tables\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, the optimal cut-off points were 3.68 for the upper threshold and 2.98 for the lower threshold. Veterinarians with scores of \u0026le;\u0026thinsp;2.98 on the SOS-VetMed questionnaire were consequently considered not stressed, whereas veterinarians with scores of \u0026ge;\u0026thinsp;3.68 were considered highly stressed. Based on these results, 45.83%, 19.95%, and 34.20% of the sample had high, low, and intermediate stress scores, respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSOS (VetMed) higher threshold cutoff score\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSOS (VetMed)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSensitivity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYouden index\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.865\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.472\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.393\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.860\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.455\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.405\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.848\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.432\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.416\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.815\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.408\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.407\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3.68\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e.809\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.378\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.431\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.781\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.360\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.421\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.742\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.348\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.394\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.719\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.390\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.697\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.378\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.669\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.303\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.365\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSOS (VetMed) lower threshold cutoff score\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSOS (VetMed)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSensitivity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYouden\u003c/p\u003e \u003cp\u003eindex\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.883\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.437\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.446\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.423\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.449\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.863\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.497\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.855\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.352\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.503\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2.98\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e.841\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.296\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.546\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.836\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.540\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.827\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.531\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.820\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.282\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.538\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.804\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.537\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.788\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.535\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAs we have observed, research on workplace stress in veterinary medicine has focused more on its health consequences rather than on its causes. Descriptive studies and taxonomies for the different sources of stress among veterinarians exist, but questionnaires that provide sufficient information on the psychometric characteristics of questionnaires are few. Therefore, the objective of this study was to develop and validate the SOS-VetMed questionnaire and establish cut-off points for identifying veterinarians who have high levels of stress and may have more health issues. None of the existing studies have provided cut-off points, but these are essential for accurate diagnoses and the design of effective and efficient prevention programs.\u003c/p\u003e \u003cp\u003eTwo sub-studies were conducted. In the first, which was qualitative, a significant number of professionals were asked about the main sources of stress in their daily work. By, using the information obtained from the qualitative study, an online questionnaire was then developed and applied in a quantitative study that allowed the corroboration of the main sources of stress among Spanish veterinarians. The analyses allowed us to assert that the SOS-MedVet questionnaire assesses different sources of stress with psychometric guarantees, and the determination of the cut-off points allowed us to identify veterinarians who have high stress levels and an increased risk of health issues. In line with the results of research in this area, a high proportion of the participants showed high levels of workplace stress.\u003c/p\u003e \u003cp\u003eThis article has two other strengths. The first involves the quality of the sample related to the number and diversity of the participants. Thirty interviews were conducted, and more than 1000 veterinarians in small and large animal care were surveyed. They had numerous years of professional experience, which is not common in research. This factor allowed us to gather valuable information. In addition, we included a scale to specifically assess the stress levels of the self-employed veterinarians because being self-employed is an additional source of stress.\u003c/p\u003e \u003cp\u003e For the qualitative and quantitative studies, relationships with the respondents responsible for the animals and work overload were the main sources of stress for veterinarians who participated in this research.\u003c/p\u003e \u003cp\u003eThe qualitative study showed that \u0026ldquo;problems with animal owners\u0026rdquo; were the main sources of stress, which is consistent with reports of reviews on the subject [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In the quantitative study, questions on this source of stress were grouped with questions referring to negative emotions produced by these relationships (because of cruelty to animals, ethical aspects, etc.), and a subscale called \u0026ldquo;emotional burden of work\u0026rdquo; was created.\u003c/p\u003e \u003cp\u003eIn the quantitative study, the main source of stress was \u0026ldquo;work overload,\u0026rdquo; confirming one of the main issues in the profession, which is also reflected in the reviews on the subject [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. For both studies, the discrepancy in the order of importance of these two sources of stress may be explained by the differences in assessment. The interviews asked about the most stressful situations, whereas the questionnaire used the Likert scale.\u003c/p\u003e \u003cp\u003eWork\u0026ndash;family conflict was considered the next most important source of stress. This finding was consistent with the reports of several studies and can be explained by long working hours and the high proportion of women [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Stress due to \u0026ldquo;organizational factors\u0026rdquo; and \u0026ldquo;emergency problems\u0026rdquo; had lower scores that were above the midpoint of the scale. Organizational factors [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] have also been identified in other studies and include problems between colleagues, problems between employees and employers, or difficulties in career advancement.\u003c/p\u003e \u003cp\u003eThe source of stress with the lowest score was \u0026ldquo;emergency problems.\u0026rdquo; However, this finding may be attributed to the large proportion of veterinarians with considerable seniority and who performed the fewest shifts, as several interviewees acknowledged. Nevertheless, it is a source of stress to be considered, as observed in other studies [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe correlations between the sources of stress and health were highly significant for psychological and psychosomatic complaints [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and the strongest correlations were for stress due to the \u0026ldquo;emotional burden of work\u0026rdquo; and \u0026ldquo;work\u0026ndash;family conflict.\u0026rdquo;\u003c/p\u003e \u003cp\u003eIn addition to the aforementioned contributions, one of the main contributions of this study is that it has provided cut-off points for the developed questionnaire. These data confirmed that nearly 50% of the sample analyzed were at risk because they showed high stress levels (45.83%). This finding has been reported in other reviews on the subject [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], albeit it is empirically confirmed. Only approximately 20% of participants had low levels of stress; the remaining participants had intermediate levels.\u003c/p\u003e \u003cp\u003eAs with any research, this study has some limitations that should be addressed in the future. First, the sample was collected in Spain, and therefore it would be useful to use information from other countries to improve generalizability. Second, the cut-off points for the subscale that assesses \u0026ldquo;stress of the self-employed\u0026rdquo; were not determined, which would be interesting to know. Third, determining whether the different stressors could be grouped into clusters that may be dangerous to health would be useful [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Some clusters may have deleterious effects such as working as a freelancer in a bad working environment and spending many hours in the emergency room. In addition, future studies should include sociodemographic data because differences may exist, depending, for instance, on sex or age. Other variables that may modulate the correlations between sources of stress and health issues, such as coping strategies [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] or family or work support [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], should also be included in future studies. Finally, longitudinal studies should be considered to more accurately explain the correlations found in this study and to investigate whether reverse correlations exist (i.e., whether veterinarians with more health issues also perceive their work as more stressful).\u003c/p\u003e \u003cp\u003eDespite these limitations, we believe that this article is valuable from theoretical and applied perspectives. It allowed us to theoretically describe and classify the main sources of stress with regard to circumstances faced by veterinary professionals in Spain and to develop and validate a questionnaire, the SOS-MedVet questionnaire, with psychometric guarantees. As we have observed, many studies refer to stress in the profession, but very few offer questionnaires [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] and we have not found any study that provided cut-off points. The cut-off points allowed clinicians to know what the obtained scores indicated. From an applied perspective, the value of this study is that it permitted a diagnosis of the sources of stress that cause the most health issues and/or design intervention programs. For example, if two of the most significant sources of stress were \u0026ldquo;emotional burden\u0026rdquo; and \u0026ldquo;work overload,\u0026rdquo; specific activities could be organized in an attempt to reduce them. In particular, training programs aimed at improving communication with animal owners and helping them manage their emotions and the problems that may arise in their relationship can be implemented [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Employers should create safe environments where employees feel comfortable to seek help and foster healthy work cultures [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. To reduce the perception of work overload, veterinarians can also be trained in organizational skills and task design because an adequate and balanced distribution of tasks [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] can reduce physical fatigue and emotional exhaustion. In addition, these types of interventions would indirectly contribute to decreasing other stressors that we also found to cause many issues such as difficulty in balancing work and family demands, and conflicts with colleagues. Finally, by knowing the cut-off points of this questionnaire, veterinarians who require individual psychological care by specialists may be diagnosed.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis study provided a validated tool to assess stress in veterinary professionals. By identifying specific stressors and quantifying stress levels, the SOS-VetMed questionnaire allows for targeted interventions to promote veterinarian well-being and improve workplace health. Furthermore, given the growing awareness of mental health issues in the veterinary profession, this study offered valuable information for practitioners, researchers, and policymakers alike. The findings enhance the understanding of the challenges faced by veterinarians and pave the way for evidence-based interventions to mitigate stress and promote health.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAUC, area under the curve; ROC, receiver operating characteristic; SD, standard deviation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee\u0026nbsp;of the\u0026nbsp;National\u0026nbsp;University\u0026nbsp;of Distance Education (Madrid, Spain; reference no.:\u0026nbsp;26-SISH-PSI-2023).\u0026nbsp;All the methods\u003c/p\u003e\n\u003cp\u003eincluded in this study are in accordance with the declaration of Helsinki. Written informed consent was obtained from all survey participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are thankful of all veterinarians who participated in this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;AO was involved in the study design, data analysis, creation of data collection tools, data analysis, interpretation of results, writing and editing the manuscript. LM was involved in the study design, data analysis, creation of data collection tools, data analysis (qualitative study) and interpretation of results. LV was involved in data analysis (qualitative study). JB was involved in the data analysis (quantitative study), interpretation of results and writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the grant of Boehringer Ingelheim Animal Health Spain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used and/or analyzed for the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVolk JO, Schimmack U, Strand EB, Lord LK, Siren CW. 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Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5356239/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Veterinary Medicine, Source of Stress, Questionnaire, Psychometric Properties, Cut-off Point","lastPublishedDoi":"10.21203/rs.3.rs-4477907/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4477907/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOccupational stress is a serious problem in veterinary medicine; however, validated instruments to measure this problem are lacking. The aim of the current study was to address this literature gap by designing and validating a questionnaire and establishing the cut-off points for identifying veterinarians with high and low levels of stress.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study involved two sub-studies with two Spanish samples. The first study (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30 veterinarians; 66.7% women; 63.33% from small animal clinics) investigated the factors related to the work environment that caused the most stress; the results were analyzed using thematic content analysis. The second study (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1082; 70.8% women; 71.4% from small animal clinics) involved designing and validating a questionnaire to measure sources of stress in veterinary medicine, as well as establishing the cut-off points for interpreting the results using receiver operating characteristics (ROC) curve analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe first study showed the main sources of stress and allowed items to be defined for the questionnaire. The second study validated the Sources of Stress in Veterinarian Medicine (SOS-VetMed) questionnaire and confirmed five sources of stress with adequate reliability and validity indices: \u0026ldquo;work overload,\u0026rdquo; \u0026ldquo;work\u0026ndash;family conflict,\u0026rdquo; \u0026ldquo;emotional burden of work,\u0026rdquo; \u0026ldquo;organizational factors,\u0026rdquo; and \u0026ldquo;emergency problems.\u0026rdquo; The confirmatory factor analysis verified their structure with χ\u003csup\u003e2\u003c/sup\u003e(265)\u0026thinsp;=\u0026thinsp;1967.23, χ \u003csup\u003e2\u003c/sup\u003e/degree of freedom\u0026thinsp;=\u0026thinsp;7.42, comparative fit index\u0026thinsp;=\u0026thinsp;0.89, and standardized root mean square residual\u0026thinsp;=\u0026thinsp;0.073. The five subscales of the SOS-VetMed questionnaire were positively correlated with two indicators of distress: \u0026ldquo;psychological complaints\u0026rdquo; and \u0026ldquo;psychosomatic complaints.\u0026rdquo; The cut-off points indicated that 45.83% and 19.95% of the veterinarians surveyed had high and low levels of stress, respectively.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe results confirmed that the SOS-VetMed questionnaire could be used to determine the stress levels of veterinarians and to design intervention programs to improve their workplace health.\u003c/p\u003e","manuscriptTitle":"Development, validation, and cut-off points for a questionnaire to measure Sources of Stress in Veterinary Medicine (SOS-Vetmed)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-07 15:08:50","doi":"10.21203/rs.3.rs-4477907/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-30T08:57:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-27T10:06:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-27T10:06:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-05-25T19:12:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"494b2dfd-d24a-486f-9cf5-7f84ded4297c","owner":[],"postedDate":"June 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-12T16:00:41+00:00","versionOfRecord":{"articleIdentity":"rs-4477907","link":"https://doi.org/10.1186/s12889-024-19704-2","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2024-08-09 15:57:14","publishedOnDateReadable":"August 9th, 2024"},"versionCreatedAt":"2024-06-07 15:08:50","video":"","vorDoi":"10.1186/s12889-024-19704-2","vorDoiUrl":"https://doi.org/10.1186/s12889-024-19704-2","workflowStages":[]},"version":"v1","identity":"rs-4477907","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4477907","identity":"rs-4477907","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}