Work-related stress: Nature and management

Introduction

It is widely recognised that work-related stress is one of the major contemporary challenges facing occupational health and safety. It is commonly understood that a need for stress prevention activities is prevalent in all European countries and across all types of organisations. This article will summarise the key issues in relation to work-related stress and will discuss how stress at work can best be managed.

What is work-related stress?

Many people are motivated by the challenges encountered within their work environment. However, when pressure due to work demands, and other so-called ‘stressors’, becomes excessive and prolonged in relation to the perceived ability to cope this can lead to the experience of stress. The concept of stress is often confused with challenge; sometimes leading people to refer to ‘good’ and ‘bad’ stress. However, these concepts are not the same. Experiencing challenges in our work can energise us psychologically and physically, and encourage us to learn new skills. Feeling challenged by one’s work is an important ingredient in developing and sustaining a psychologically healthy work environment. However, excessive and prolonged pressure and demands that exceed the worker’s perceived resources, capabilities and skills to cope should not be understood as a ‘healthy pressure’ or ‘good stress’, but rather as the defining components of work-related stress.

Contemporary theories of stress have been used to inform the definition of work-related stress. There is a growing consensus around the definition of stress as a negative psychological state with cognitive and emotional components, and its effect on the health of both the individual and the organisation. That is, stress is defined by a dynamic interaction between the individual and their environment, and is often inferred by the existence of a problematic person-environment fit and the emotional reactions which underpin those interactions^[1]. Central to this approach is the role that environmental factors, particularly the role of psychosocial and organisational factors, play in work stress. The following section seeks to provide the reader with a concise overview of the leading contemporary theories of stress.

Theories of work-related stress

Contemporary theories of stress have moved away from understanding the construct as either a response or as an external event, but rather view it as a dynamic interaction between the individual and their environment. Contemporary theories of stress, either explicitly or implicitly, recognise the central role of psychological processes (such as perception, cognition and emotion) in understanding (for example see Cox & Griffiths, 2010):

• how the individual recognises, experiences, and responds to stressful situations,
• how they attempt to cope with that experience, and
• how it might affect their physical, psychological and social health).

There are several key contemporary theories in the scientific literature that have helped to clarify the causes and mechanisms that underpin work-related stress. Many of these theories have been extensively researched and have been used to guide approaches to intervention. The first three are structural model and they describe the key variables and interactions among those variables in relation to outcomes of interest. The fourth is a process model which describes the mechanisms that underpin the relationship between the antecedent and outcomes. Four prominent theories are presented here^[1].

Person-Environment Fit theory (P-E Fit theory)

Much of contemporary stress theory finds its origins in the early work of the social science research group at the University of Michigan and in particular the work of Kahn, French, Caplan and van Harrison. Together they developed the Person-Environment (P-E) Fit theory^[2][3][4]. P-E Fit theory argues that stress can arises due to a lack of fit between the individual’s skills, resources and abilities, on the one hand, and the demands of the work environment, on the other hand.

The P-E Fit theory makes explicit the interaction between the individual and the environment in shaping their response to work situations and events, but also highlights the importance of the individual’s perception of the environment; and the interaction between them. Logically, this lack of fit can take three forms (Edwards, Caplan, & van Harrison, 1998): (1) the demands of the work environment exceed the employee’s ability; (2) the employee’s needs consistently fail to be met by the work environment; and (3) a combination of the two situations exists (i.e., where an employee’s needs are not being met while at the same time their abilities are over-stretched).

Job Demand-Control (Support) Theory

The Job Demand-Control (JCD) model^[5] and its expanded version the Job Demand-Control-Support model^[6][7] have dominated the field of occupational stress research for more than two decades. The JCD model postulates that job strain results from the interaction between two dimensions of the work environment: psychological job demands and job control.

Psychological demands traditionally referred to workload, operated mainly in terms of time pressure and role conflict (Karasek, 1985). However, more recently, cognitive and emotional demands and interpersonal conflict dimensions define the contemporary construct of psychological demand^[8]. Job control (also often also referred to decision latitude in the literature) refers to the person’s ability to control their work activities, and is defined by two key components: (a) decision authority (worker’s ability to make decisions about their job); and (b) skill discretion (the breadth of skills used by the worker on the job). The JCD theory suggests that individuals experiencing high demands paired with low control are more likely to experience psychological strain, work-related stress, and, in the long term, poor physical and mental health.

The model was later extended to include a social dimension: social support^[6][7]. The JCDS model postulates that social support can moderate the negative impact of job strain on worker’s physical and mental health. This model suggests that the most at-risk group of poor physical and mental health are those workers who are exposed to job strain (high demands and low control) paired with low workplace support (a phenomenon referred to as iso-strain^[9].

Effort-Reward Imbalance Model (ERI model)

The ERI model was developed by Johannes in the early 1990’s^[10]. This theory assumes that effort at work is spent as part of a psychological contract, based on the norm of social reciprocity, where effort spent at work is paired with rewards provided in terms of money, esteem, career opportunities. An imbalance (non-reciprocal) relationship between the effort spent and rewards received can result in the emotional distress associated with a stress response, and an increased risk of ill-health. Siegrist suggests that stress related to the imbalance between effort and rewards can arise under three conditions: namely,

• has a poorly defined work contract or where the employee has little choice concerning alternative employment opportunities;
• accepts the imbalance for reasons such as the prospect of improved working conditions and
• copes with the demands at work through over commitment.

Transactional Model

Transaction models^[11][12][13] build upon the interaction between the individual and their environment, but provide an additional focus on the underlying psychological and physiological mechanisms which underpin the overall process. Cox and MacKay (1976) suggested that stress is the result of a dynamic interaction between the individual and the environment. However, unlike previous models of stress, central to this model is the individual’s cognitive assessment of the perceived demands made on the worker, and their perceived capability, skills and resources to deal with those demands. That is, stress results when the perceived demands outweigh the perceived capability of the workers. What an individual finds or perceives to be stressful can vary both between and within individuals, and can differ over occasions and time (Probst, 2010). In this way, any aspect of the work environment can be perceived as a stressor, and therefore unlike previous models transactional models are not limited by the types and number of psychosocial hazards they can account for. The cognitive assessment by the worker of the perceived demands and capabilities can be influenced by a number of factors: personality, situational demands, coping skills, pervious experiences, and any current stress state already experienced. In addition, this model acknowledges that stress can manifest physiologically, psychologically, behaviourally and socially with detrimental consequences to both the individual and the organisation. Research indicates that the relationship between psychosocial hazards and health outcomes is mediated by a variety of factors; the transactional model accounts for the complex relationship by acknowledging individual variation and differences in the stress process^[1].

Work-related stress: reported prevalence and costs

The 4th European Working Condition Survey found that 22% of workers from 25 Member States and two Acceding Countries of the EU reported experiencing stress in the workplace. The reported prevalence of stress is markedly different between the new Member states and the old EU-15. Results from the 4th European Working Conditions Survey showed that 20% of workers from the EU-15 and 30% of the 10 new Member states believed their health was at risk due to stress at work. At a national level, the highest reported levels of stress were observed in Greece (55%), Slovenia (38%), Sweden (38%), and Latvia (37%)^[14].

The European Commission reported in 2002 that the cost of work-related stress in the EU15 was approximately €20, 000 million annually^[15]. Studies estimate that 50-60% of all lost working days have some links with work-related stress^[1]. At a national level, stress has been found to have significant and real costs to employers and to society-at-large. In Germany, the cost of psychological disorders was estimated to be €3,000 million in 2001^[16]. In the Netherlands in 1998, mental disorders were the main cause of incapacity (32%) and the cost of psychological illness was estimated to be €2.26 million a year (Koukoulaki, 2004).

In the UK, an estimated 70 million working days are lost annually through poor mental health and 10 million of these are the result of anxiety, depression and stress. In 2005/06 stress, depression and anxiety was estimated to cost Great Britain in excess of £530 million^[17]. Undoubtedly, the causes and effects of work stress reflect the changing nature and demands of work and the work environment.

Work-related stress: causes and consequences

The poor management and organisation of work can lead to work stress. Often both the causes and management of work-related stress involve the way in which work is designed, managed and organised. The literature of stress often recognises several sources of stress (often termed ‘psychosocial hazards’, for definition): these include, those stressors intrinsic to the job, role in the organization, relationships at work, career development, organisational structure and climate, and home-work interface. The stress process can be summarised in a model (Figure 1) that illustrates the causes of stress, (short-term) stress reactions, long-term consequences of stress and individual characteristics, as well as their interrelations^[18].

• cognitive responses: such as, reduced attention and perception, forgetfulness;
• emotional responses: such as, feeling nervous or irritated;
• behavioural reactions: such as, aggressive, impulsive behaviour or making mistakes;
• physiological responses: such as, increase in heart rate, blood pressure and hyperventilation.

A growing body of evidence indicates that when stress reactions persist over a prolonged period of time, this may result in more permanent, less reversible health outcomes: such as chronic fatigue, burnout, musculoskeletal problems or cardiovascular disease. Individual characteristics such as personality, values, goals, age, gender, level of education and family situation can influence one’s ability to cope. These characteristics can either exacerbate or alleviate the effects of risk factors at work and, in turn, the experience of stress^[1][19].

The health impact of psychosocial risks and work-related stress extends beyond individual health, and can also affect the productivity and resiliency of the organisation (a concept termed ‘organisational healthiness'^[1]. In the literature there are several outcomes related to stress and a poor psychosocial working environment that affects the productivity and, moreover, health of the organisation: namely, job satisfaction, morale, performance, turnover, absence, presenteeism and organisational commitment^[1].

Managing and preventing work-related stress

The following section presents an overview of the methods and strategies used to manage and prevent work-related stress. Actions and strategies are often targeted at either the individual worker or the workplace. More commonly, interventions to prevent and manage stress are often categorised into one of three levels of interventions: primary, secondary and tertiary^[20]. A simple schema is usually used to describe the three different levels of interventions. Although debatable in some of its detail, at a superficial level it is a useful aid to understanding and practice. Often policy-level interventions are ignored in such schema: some but not all can be included as primary or preventive measure (see Policy, law and guidance for psychosocial issues in the workplace: an EU perspective for more in-depth discussion). Table 1 provides a summary of the definition of each level of intervention, its primary target, and some examples^[21].

Primary-level interventions, also commonly referred to as “organisational-level" interventions^[22] or as “stress prevention"^[1], are concerned with taking action to modify or eliminate sources of stress (i.e., psychosocial risks) inherent in the workplace and work environment, thus reducing their negative impact on the individual or reduce exposure to them^[24]. The design of primary intervention should be informed by the results of a risk assessment^[24] . Elkin and Rosch (1990) summarised a useful range of possible strategies to reduce workplace stressors:^[25]

• redesign the task,
• redesign the work environment,
• establish flexible work schedules,
• encourage participative management,
• include the employee in career development,
• analyze work roles and establish goals,
• provide social support and feedback,
• build cohesive teams,
• establish fair employment policies, and
• share the rewards.

Secondary-level interventions are concerned with the detection and management of experienced stress, and the enhancement of workers’ ability to more effectively manage stressful conditions by increasing their awareness, knowledge, skills and coping resources (Sutherland & Cartwright, 2000); these strategies, are thus, directed at ‘at-risk’ groups within the workplace^[20]. In short, “… the role of secondary prevention is essentially one of damage limitations, often addressing the consequences rather than the sources of stress which may be inherent in the organization’s structure or culture"^[24]. Although these strategies are usually conceptualised as ‘individual’ level stress management options, these approaches also embrace the notion that individual employees work within a team or work-group^[26]. Thus, these strategies often have both an individual and a workplace orientation. Some examples of secondary intervention include: stress education with the aim to help employees recognise symptoms and reduce stigma, or stress management training.

Tertiary-level interventions have been described as reactive strategies^[27] in that they are seen as a curative approach to stress management for those individuals suffering from ill-health as a result of stress^[26]. This approach is concerned with minimizing the effects of stress-related problems once they have occurred through the management and treatment of symptoms of occupational disease or illness^[28][24][21].

Comprehensive approach to stress management and prevention

Stress management and prevention must involve the development of strategies that comprehensively address the antecedents of work stress (psychosocial and organisational hazards) and their effects on employee health^[29]. This usually requires practitioners and organisations to move beyond single interventions or types of intervention to programmes that call on a combination of interventions as appropriate to an appropriate and sufficient analysis of the problem^[1](Sutherland & Cooper, 2001). Such strategies are usually drawn from all three intervention levels: eliminating psychosocial risks in the workplace to prevent or reduce the experience of stress (primary); training employees to better handle their work situation while providing them with resources to optimize their coping abilities and to enhance their resiliency to stress in order to reduce its impact on their health and well-being (secondary); and, for those who are badly affected by stress and ill health, providing them with opportunities for treatment and recovery and the necessary services and resources to ensure their effectiveness (tertiary).

Whatever the nature of the intervention programmes designed to reduce work stress, they have to be evidence based, tailored to the problems which exist, comprehensive and timely. Its implementation has to be well planned and resourced and involve those who are affected by stress, or potentially affected. Employee engagement is critical. Finally, all such programmes should be adequately evaluated with the results of the evaluation feeding into a cycle of continuous improvement^[1].

Do interventions for work-related stress work?

The existing evidence suggests that stress management interventions are effective in improving workers’ psychological and physical health, however some key question still remain (for a more in-depth discussion see Nielsen, Randall, Holten and Rial-González, 2010^[30]. LaMontagne and colleagues (2007) recently conducted a review of job stress interventions during the period of 1990–2005^[21]. This study identified and reviewed 90 interventions meeting the study’s pre-defined inclusion criteria. The study categorised the interventions into those that had both an organisational and individual focus (rated high), only organisationally-focused (rated moderate), or only individually-focused (rated low). The review found that low-rated approaches were found to be effective only at the individual-level. In short, these interventions were found to have a favourable impact on individual outcomes, but tended not to have a positive impact at the organisational-level. In contrast, high and moderate rated interventions were found to have a favourable and beneficial impact at both the individual and organisational levels. Similar results have been observed in earlier reviews^[31][32]. This review highlights the importance and, in turn, the benefits of using a comprehensive approach to stress management and prevention. Therefore, in order to effectively manage and prevent stress, organisations should use a host of actions and strategies aimed at both the worker and the workplace.

Often the process issues associated with interventions are ignored not only in the planning of those interventions but also in their evaluation^[33][30]. This is an important area for future research and development.

Conclusions

Since the 1990s, stress has been widely recognised as one of the most problematic work-related health problems. Contemporary theories have been used to inform the definition of work-related stress and guide the development of workplace interventions. There is a growing consensus that stress is defined by a dynamic interaction between the individual and their environment, and is often inferred by the existence of a problematic person-environment fit and the emotional reactions which underpin those interactions^[1]. Interventions to manage and prevent work-related stress have been traditionally targeted at either the worker or at the workplace. However, increasingly multi-model interventions that seek to both prevent and manage the causes and consequences of stress are being advocated. Managing stress in the workplace has clear benefits for the individual, the organisation and society at large.