by Angela King
Stress in the workplace is often referred to as ‘occupational stress’. The basic rationale underpinning the concept is that the work situation has certain demands, and that problems in meeting these can lead to illness or psychological distress. Occupational stress is a major health problem for both individual employees and organizations, and can lead to burnout, illness, labour turnover, absenteeism, poor morale and reduced efficiency and performance (Sutherland & Cooper 1990). Work-related stress is estimated to be the biggest occupational health problem in the United Kingdom, after musculoskeletal disorders such as back problems, and stress related sickness absences cost an estimated £4 billion annually (Gray 2000). Current evidence suggests that health care professionals in the UK have higher absence and sickness rates than staff in other sectors (Nuffield Trust 1998). Wall et al (1997) found that 27% of health care staff suffered serious psychological disturbances, compared with 18% of the general working population, and it has been suggested that stress may be a reason for nurses leaving their jobs (Seecombe & Ball 1992).
Relevant issues
Canon in 1914 first described the pattern of physiological responses to stress as the fight or flight response, a pattern of physiological responses (as discussed in McCance & Huether 2002). Stressors initiate a complex physiological response that prepares the body for fleeing or fighting. The manifestations of this fight/flight response are through two channels. The sympathetic branch of the autonomic nervous system (ANS) and the endocrine system; both are closely interconnected (Atkinson et al 1996, Carlson 1994). The ANS affects many bodily functions instantly and directly, while hormones have a slower yet wider effect on the body (Gross 1998). Both hormones and neurones communicate with cells and create the delicate dynamic balance between the body and it’s surrounding, through paired systems and feedback mechanisms (Jacobs 1973, Morgan 1991). However, the human rarely requires the fight or flight response in society today, but the physiological response continues to be evoked in non-life threatening situations. In relation to occupational stress, for example, this could be as a result of working closely and intensely with patients over an extended period of time (Rees & Smith 1991). Long-term activation of the stress responses can damage health in numerous ways. Over time the associated cardiovascular changes promote high blood pressure, contribute to heart disease, strokes as well as affecting a wide range of body functions. That nursing is a stressful job has been widely and consistently recognized (Hipwell et al 1989, Plant et al 1992, Farrington 1995). That stress is linked to disease and illness has also been shown empirically (Norrie 1995). Stress-related illnesses are a serious hazard to the health of nurses; in the first half of the 1990s nurses, midwives and health visitors topped the league table for female suicides in the United Kingdom (Day 1995). Nurses who are stressed are more likely to have more absenteeism (Larson 1987), have more conflicts with colleagues (Mac Neil & Weisz 1987), experience feelings of inadequacy, and have self-doubt, lowered self-esteem, irritability, depression, somatic disturbance, sleep disorders and burnout, all of which jeopardize the quality of care they provide (Foxall et al 1990). Nurses who are stressed also report less satisfaction with work (Callaghan & Field 1991). The most frequently reported sources of stress for nurses working in the community include large caseloads, reorganization of community teams, increased workload, increased administrative duties, reduced time for service users, and reduced time for family contact. However, Cox (1993) has shown that a worker's perception of the demands presented by an occupational setting is generally more predictive of work-related distress than more objective features of the work situation. Pritchett & Pound (1998) call stress “the invisible epidemic.” They suggest looking at how we can make changes in the way we handle stress to enable a shift from behaving in ways that create stress for ourselves to getting better at adapting to stress. However, people use the term 'stress' to mean different things; there is no single agreed definition. The HSE (1999) defines work-related stress as: 'The reaction people have to excessive pressure or other types of demands placed upon them. It arises when they worry that they can't cope.' A survey of UK nurses' stress conducted by the Nursing Times reported that talking to colleagues was the coping strategy used by most nurses (Cole 1992). Cole's study also shows that some of the coping strategies used by nurses may be detrimental to their health, e.g. smoking, taking other drugs, and drinking alcohol. Other coping strategies used by nurses to manage, or counteract their stress and dissatisfaction include: seeking social support, accepting responsibility, positive reappraisal and avoidance (Sullivan 1993). More recent work reported by Hope et al (1998) also found that nurses cope with stress by eating more.
Tackling the Issues
Stress can affect individuals in many different ways, as people develop different symptoms in response to excessive pressure in and out of the workplace. Usually, the effects of stress are short-lived and when the pressure on the individual recedes there is a quick return to normal behaviour. In some cases, however, particularly where pressures are intense and sustained, stress can lead to long-term psychological and physical ill health.
Available literature suggests that most workplace stress management programmes are based mainly on individual strategies, which often combine different types of activities such as relaxation, exercise and time management (Newman & Beehr 1979, DeFrank & Cooper 1987, van der Hek & Plomp 1997). It would seem, however, that the most effective way of managing occupational stress is to tackle the problem at several levels. Although all interventions are intended to prevent and combat stress, they produce different effects.
The first step is to prevent problems occurring in the first instance in the workplace by eliminating or minimizing the stressors themselves. To achieve this, management strategies must be proactive rather than re-active with respect to the organisational environment, and there is a lack of research into interventions at the organisational level. The next step would be to minimize the negative effects of stress via education and management strategies, and the last step would be to assist individuals who are experiencing the effects of stress. Gray (2000), in the report Mental Health in the Workplace: Tackling the Effects of Stress, suggests that organisations need to recognise and accept that mental health is an important issue while the Health and Safety Executive recommends that a mental health policy should be an integral part of any organisation's health and safety policy. This should not just be limited to large corporate organizations, but should also be developed within the NHS with the intention of addressing the issue of retaining nurses in the workforce.
Recent guidance from the Health and Safety Executive (2001) informs employers of their legal duty to ensure their employees are not made ill by their work as a result of increasing pressure and change. Three factors appear to influence the high profile and impact of stress among healthcare workers (Muncer et al 2001):
The NHS has a prominent profile and is one of the largest employers in the UK.
There is evidence that stress can affect the efficiency of treatment. Medical personnel are less likely than other professionals to acknowledge the effects of stress. Because of the culture in which health professionals work, they might feel that they should not fail or acknowledge difficulties.
The nature of their work means that nurses are more exposed than other employees to factors known to be causes of stress, for example, role conflict, role ambiguity and significant work demands.
Improved compliance with health and safety law and changes based on research findings have significantly influenced strategies for preventing workplace stress in hospitals. Many NHS trusts have developed stress-reduction policies. There is, however, much room for improvement in stress management, and in viewing nurses as a resource that needs investment. The concept that members of staff are an asset to be nurtured and are central to the survival of trusts highlights the importance of a national policy and a culture that favours cooperation rather than competition.
A summary report, More than Brown Bread and Aerobics: Developing and Sustaining Workplace Health in the NHS (HEA 1998), discusses recent changes which state that, where organisations want to benefit from a committed and motivated staff, the impact of management on their health must be considered central to business planning and change management. In reality, while many organisations reflect this in short-term priorities, relatively few take a longer-term proactive approach (HEA 1998).
Occupational stress management interventions have been defined as, 'any activity program or opportunity initiated by an organisation which focuses on reducing the presence of work related stressors or on assisting individuals to minimise the negative outcomes of exposure to these stressors' (Ivancevich et al 1990 p. 252). Such interventions have been categorised in terms of the focus or level of intervention described (Murphy et al 1992), with primary, secondary and tertiary level interventions found at both individual and organisational levels targeting stressors, responses and symptoms, respectively (Cox 1993, Carson & Kuipers 1998) Considering Stress Management within the health Care Profession from this perspective, interventions can be
focused on the environment to reduce the potential for stress
focused on individuals to modify their appraisal of it via training and supervision
individual or group work to facilitate more effective coping mechanisms for responding to stressors
Organisational interventions target problematic job and role designs in an attempt to reduce occupational stress at source, or may amend organisational structures to increase the responsiveness and effectiveness of managerial support (Quick et al 1997).
In the model of occupation stress management developed by (Carson & Kuipers 1998) three levels of the stress process are proposed which are stressors, moderators of the stress process and stress outcomes. The model suggests that there are three major sources of external stress. There are, firstly, specific occupational stressors, which vary depending on the unique stress facing each professional group. The second major source of external stressors is major life events. The third set comes from ‘hassles’ or ‘uplifts’ These are not major events, but small stressors that can have a cumulative effect on individuals. The critical factor in the stress process is the moderators on which an individual can call to help cope with external stressors that are impinging upon them. (Carson & Kuipers 1998) identify seven such factors: high levels of self-esteem, good social support networks, hardiness, good coping skills, mastery and personal control, emotional stability and good physiological release mechanisms. Possession of these buffering factors serves to minimize the effects of stress. An individual's self-esteem is probably one of the most important of these moderators (Turner & Roszell 1994). Those with high self-esteem are more likely to have a greater sense of self-efficacy and self-worth (Branden 1994), and are likely to be more confident in dealing with stressors. The final level of the model is that of stress outcomes. These include positive stress outcomes such as psychological health and high job satisfaction, or negative stress outcomes such as psychological ill health, burnout and low job satisfaction. Burnout is described as a syndrome consisting of three dimensions: emotional exhaustion (inability of individuals to give of themselves at a psychological level), depersonalization (development of cold negative attitudes towards those who provide public services) and personal accomplishment (the loss of the ability to value one's achievements at work).
However, I would contend that the effectiveness of stress management programmes depends on the accuracy of the initial diagnosis. Stress in the workplace can be diagnosed in many different ways, questionnaires, interviews; indirect observation (staff turnover, sickness records) etc. Whilst work-related distress has been defined from a range of perspectives, Dewe (1987) suggests that definitions of stress should reflect its relationship to adaptive factors. The concept of stress being closely linked with the ability to cope is inherent within Atkinson’s (1988) definition of stress; that is an ‘excess of demands over the individual’s ability to meet them’. This definition conceptualizes stress as both a dynamic (effect) and as a transaction. The individual’s ability to cope with external pressures is dependent upon a cognitive appraisal of the stressor and the coping strategies the person has available to them. Therefore stress is perceived in relation to the person’s previous experience, success or failures in dealing with similar situations and their familiarity with the situation (Lazarus & Folkman 1984). Dunn & Ritter (1995) further elaborate this view in suggesting that the person’s response to stress will depend on their particular physiological and psychological state in association with their cognitive appraisal of the threat or stress they encounter. The concept of adaptive ability suggests that nurses working in stressful situations may be able to engage strategies, which allow them to reduce the stressfulness of their work environments. These may include the use of appropriate support systems to enhance coping abilities. Studies of stress and burnout frequently advocate the need for improved support of nurses within their work (Fagin et al 1995)). Social support may be formal taking the form of clinical supervision and staff support groups, or involve the use of informal networks such as support from colleagues in the office or family and friends. It is often postulated but seldom demonstrated that this support, oblivious of its form, will reduce levels of stress and burnout.
Berg et al (1994) found that nurses who received clinical supervision demonstrated more creativity in their work and experienced less burnout. They hypothesized that the supervision received helped the nurses to feel more supported and hence more likely to innovate in their practice. Given that social support is such an important predictive factor of work stress and burnout it would seem pertinent for nurses to be aware of the need for increasing this type of support during particularly stressful periods. However, to a large extent it may be that nurses fail to recognize that individual characteristics such as self-esteem, mastery and personal control, emotional stability and physiological release mechanisms may be important mediating factors over which some control can be exercised (Carson & Kuipers 1998). Butterworth et al (1999) conducted an evaluation project of clinical supervision on 586 nurses in 23 centres using standardized measures to measure levels of stress, coping and job satisfaction and burnout. This study concluded that it was more stressful to work in the community than in hospital. It also found that job satisfaction was higher amongst community nurses and that different grades of staff find different elements of their roles stressful.
If managers and nurses understand work-based stress then nurses, whatever their personal predisposition to stress, have more chance of their concerns being dealt with. Effective action, however, requires understanding of the causal mechanisms by those with relevant influence, a real desire to act thereon but also, crucially, the power to implement what could be radical organisational, economic or cultural changes. A work-site coping skills intervention targeting nurses should incorporate a didactic element to facilitate an increase in participants' self-awareness of potential sources of stress in their work-setting (Michie & Ridout 1990). An approach incorporating discussion of critical incidents associated with participants' distress experience should be adopted, and augmented with coping skills training (Heaman 1995). Such coping skills training may include relaxation and assertiveness training (Lee & Crockett 1994), cognitive restructuring, time management training (West et al 1984) and problem solving techniques (Michie & Ridout 1990) amongst others. Coping training which supplements applied relaxation with further opportunities to address concerns using problem solving and cognitive self-management methods, prior to real life application and practice, may be particularly effective (Jones & Johnston 1998). Planned contact time of any such intervention must be considered; a contact time of 3 hours in 1-hour sessions spread over 5-8 weeks has been shown to be insufficient in promoting reliable changes in participant distress (von Baeyer & Krause 1983). Longer contact times, i.e. 9 hours, in at least weekly, 1-hour sessions are needed to advance reliable adaptive changes in psychological well-being (Gray-toft & Anderson 1983, McIntyre et al 1984). However, although occupational health departments in the NHS provide a range of professional support mechanisms to manage stress in the workplace, including a confidential staff counselling facility and an on-site occupational health consultant or specialist nurses to receive referrals for specific medical problems, staff should be helped to explore stress management techniques and to devise individual strategies for coping with, and reducing, stress at work with their managers and colleagues. Employees should have access to direct management support and assistance. Line managers should receive specialist training and management development, while education and skills development opportunities should be available for all employees.
In my work as a Health Visitor, I have been involved in providing half-day stress management workshops to Primary Health Care workers, at one GP surgery. This experience has shown me that although Health workers may have knowledge about the causes and management of stress, they are, at times, slow in applying the knowledge to their own needs. The workshops provided an overview of strategies to manage stress. The overall aim was to help individuals to find the stress reduction system that worked for them, whether laughter, mellow music, self-massage, vigorous activity, relaxation, imagery or cognitive restructuring.
One Sheffield NHS trust set up a 'staff wellbeing' service in 1992 and also provides a health and fitness complex for staff which is linked to the occupational health department. However, these examples treat the problem, not the cause, and, therefore, do not reflect an agenda of tackling organisational causes of stress, but strategies for reducing individual stress levels. The strategies do not necessarily affect all staff, only those who take advantage of the services.
Conclusion
In understanding work and stress in health care, it is important to acknowledge increasing pressures on employers to meet more, and often complex, goals. Healthcare targets have become the norm and professional staff are encouraged to practise in a transparent and consumer-sensitive way. Organisations have had to respond to short-term, even urgent, demands, as well as plan strategically for initiatives, improvements in performance, and needs that are likely to develop in coming years. Human resources are finite, so employers face the paradox that staff are their greatest asset, and also the resource with the greatest demands. Work pressures could be viewed as stimuli and judged in terms of their volume and quality, as are pressures in other areas of life. Just as too little pressure can lead to boredom and disengagement in an activity, so too, excessive pressure can lead to exhaustion and anxiety. Combinations of stimuli, under difficult physical conditions or time constraints, mean that tasks or goals can be seen as stressful. It is the circumstances under which we must meet goals that can lead us to describe them as problematic. Therefore, what individuals describe as uncomfortable stress or as motivating stress does not rely solely on their capacity to cope, but is a feature of the working environment and changes in that environment.
There is no easy way to predict what will cause harmful levels of stress. People respond to different types of pressure in different ways. In general, harmful levels of stress are most likely to occur in situations where pressures accumulate or are prolonged. Problems at work can be triggered or made worse where people feel a high degree of uncertainty about their work, their objectives, or their job or career prospects. Conflicting organisational demands lead to confusion, while inflexible and/or over-demanding schedules increase work pressures. Prolonged conflict between individuals, or situations where staff are treated with contempt or indifference, can cause harmful levels of stress, as can the pressures people experience outside work, such as bereavement, family sickness or financial worries. While these factors are beyond a manager's responsibilities, they are relevant to stress management at work, since they could make staff more vulnerable to stress, or affect their performance or judgement.
The most important strategy in tackling occupational stress is to develop a co-ordinated approach to reduce levels of stress in staff and to deal effectively with any difficulties that arise. Any organisation considering interventions to reduce stress will benefit from targeting managers first (Allen 2001). It is essential to introduce policies, procedures and guidelines to help managers implement change and manage stress levels in their work environment. Management should be actively involved in creating a healthy workplace and implementing policies to improve sickness absence within trusts. It is important to establish a proactive occupational health service that provides a counselling service for all staff. Trusts might wish to publish examples of good and poor management, sickness absence and high staff turnover and identify systems that work to give areas that are struggling help and guidance. It is important to promote compliance with relevant workplace legislation, to audit the progress of improving the quality of working lives of staff, and to share good practice with other trusts. Finally, it is vital to consult the workforce on proposed improvements and obtain their views and ideas on the progress of initiatives that have already been introduced.
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