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Regulating Exposure to Occupational Stress: A Guide for Hospitals

Editor’s Note: This article was reprinted with permission. Mention of any company or product does not constitute endorsement by the National Institute for Occupational Safety and Health (NIOSH). Citations to websites external to NIOSH or HMP Communications do not constitute endorsement. Neither the NIOSH nor HMP is responsible for the content of these websites. 

Occupational stress has long been a concern in healthcare. Studies indicate that healthcare workers have higher rates of substance abuse and suicide than other professions as well as elevated rates of depression and anxiety linked to job stress. In addition to psychological distress, other outcomes of job stress include burnout, absenteeism, employee intent to leave, reduced patient satisfaction, and diagnosis and treatment errors. This article will identify the sources and the adverse health effects of occupational stress and recommend work practices to reduce occupational stress. 

SOURCES OF OCCUPATIONAL STRESS 

The NIOSH defines occupational stress as “the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker.” The following workplace factors (job stressors) can result in stress: 

• Job or task demands (work overload, lack of task control, role ambiguity) 

• Organizational factors (poor interpersonal relations, unfair management practices) 

• Financial and economic factors 

• Conflict between work and family roles and responsibilities 

• Training and career development issues (lack of opportunity for growth or promotion) 

• Poor organizational climate (lack of management commitment to core values, conflicting communication styles, etc.) 

Stressors common in healthcare settings include: 

• Inadequate staffing levels 

• Long work hours 

• Shift work 

• Role ambiguity 

• Exposure to infectious and hazardous substances 

Stressors vary among healthcare occupations and even within occupations, depending on the task being performed. In general, studies have found the following factors to be linked with stress: 

• Work overload 

• Time pressure 

• Lack of social support at work (especially from supervisors and higher management) 

• Exposure to infectious diseases 

• Needlestick injuries 

• Exposure to work-related violence or threats 

• Sleep deprivation 

• Role ambiguity and conflict 

• Understaffing 

• Career-development issues 

• Dealing with difficult or seriously ill patients 

Among physicians, the following factors are associated with stress: 

• Long hours 

• Excessive workload 

• Dealing with death and dying 

• Interpersonal conflicts with other staff 

• Patient expectations 

• Threat of malpractice litigation 

The quality of patient care provided by a hospital may also affect healthcare worker stress. Beliefs about whether the institution provides high-quality care may influence the perceived stress of job pressures and workload, because higher quality care may be reflected in greater support and availability of resources. 

POTENTIAL ADVERSE HEALTH EFFECTS OF OCCUPATIONAL STRESS 

Stress may be associated with the following types of reactions: 

• Psychological (irritability, job dissatisfaction, depression) 

• Behavioral (sleep problems, absenteeism) 

• Physical (headache, upset stomach, changes in blood pressure) 

An acute traumatic event could cause post-traumatic stress disorder (PTSD). Not every traumatized person develops PTSD. Although individual factors (such as coping strategies) and social resources can modify the reaction to occupational stressors to some degree, working conditions can play a major role in placing workers at risk for developing health problems. 

CONTROLLING STRESS IN THE WORKPLACE 

As a general rule, actions to reduce job stress should give top priority to organizational changes that improve working conditions. But even the most conscientious efforts to improve working conditions are unlikely to eliminate stress completely for all workers. For this reason, a combination of organizational change and stress management is often the most successful approach for reducing stress at work. 

ORGANIZATIONAL CHANGE INTERVENTION 

The most effective way of reducing occupational stress is to eliminate the stressors by redesigning jobs or making organizational changes. Organizations should take the following measures: 

• Ensure that the workload is in line with workers’ capabilities and resources 

• Clearly define workers’ roles and responsibilities 

• Give workers opportunities to participate in decisions and actions affecting their jobs 

• Improve communication 

• Reduce uncertainty about career development and future employment prospects 

• Provide opportunities for social interaction among workers 

The most commonly implemented organizational interventions in healthcare settings include: 

• Team processes 

• Multidisciplinary healthcare teams 

• Multi-component interventions 

Team process or worker participatory methods give workers opportunities to participate in decisions and actions affecting their jobs. Workers receive clear information about their tasks and role in the department. Team-based approaches to redesign patient care delivery systems or to provide care (eg, team nursing), have been successful in improving job satisfaction and reducing turnover, absenteeism, and job stress. Multidisciplinary healthcare teams (composed of doctors, nurses, managers, pharmacists, psychologists, etc.) have become increasingly common. Teams can accomplish: 

• Allow services to be delivered efficiently, without sacrificing quality 

• Save time (a team can perform activities concurrently that one worker would need to provide sequentially) 

• Promote innovation by exchanging ideas 

• Integrate and linking information in ways that individuals cannot 

Multi-component interventions are broad-based and may include: 

• Risk assessment 

• Intervention techniques 

• Education 

Successful organizational stress interventions have several commonalities: 

• Involving workers at all stages of the intervention 

• Providing workers with the authority to develop, implement, and evaluate the intervention 

• Significant commitment from top management and buy-in from middle management 

• An organizational culture that supports stress interventions 

• Periodic evaluations of the stress intervention 

Without these components (in particular, management support), it is not likely that the intervention will succeed. 

STRESS MANAGEMENT INTERVENTION 

Occupational stress interventions can focus on organizational change or the worker. Worker-focused interventions often consist of stress-management techniques such as: 

• Training in coping strategies 

• Progressive relaxation 

• Biofeedback 

• Cognitive-behavioral techniques 

• Time management 

• Interpersonal skills 

Another type of intervention that has shown promise for reducing stress among healthcare workers is innovative coping, or the development and application by workers of strategies such as changes in work methods or skill development to reduce excessive demands. 

The goal of these techniques is to help the worker deal more effectively with occupational stress. Worker-focused interventions have been the most common form of stress reduction in workplaces throughout the United States. Although worker interventions can help workers deal with stress more effectively, they do not remove the sources of workplace stress, and thus may lose effectiveness over time. Mental health support intervention may be needed in the event of a significant event at a healthcare organization. 

CASE REPORT 

The following case report offers some context to the education shared within this article. Researchers evaluated a participative intervention program at an acute care hospital. A baseline (initial) risk evaluation was conducted at an acute care “experimental” hospital and a similarly sized acute care “control” hospital using a 30-minute telephone interview with employees to obtain answers pertaining to psychological demands, reward at work, social support, psychological distress, burnout, and sleeping problems. Similar stress indices were measured at both the experimental and control hospitals. A participative intervention program was then implemented at the experimental hospital. This program used a participative problem-solving process that included an intervention team of employees led by an external moderator. The intervention team held regularly scheduled meetings over several months to identify adverse working conditions and recommended solutions ranked according to priority and feasibility. Hospital management assisted the intervention team with implementation of several of the recommendations. One year post-intervention, the telephone survey was repeated at both hospitals. Significant reduction in sleeping problems and work-related burnout were found in the hospital with the intervention team versus the control hospital. 

CONCLUSION 

Healthcare occupations have long been known to be highly stressful and associated with higher rates of psychological distress than many other occupations. Healthcare workers are exposed to a number of stressors, ranging from work overload, time pressures, and lack of role clarity to dealing with infectious diseases and difficult, ill, and helpless patients. Such stressors can lead to physical and psychological symptoms, absenteeism, turnover, and medical errors. However, the literature points to both organizational and worker-focused interventions that can successfully reduce stress among healthcare workers. Although organizational interventions (because they address the sources of stress) are preferred, interventions that combine worker and organizational components may have the broadest appeal, as they provide both long-term prevention and short-term treatment components.n 

For more information on occupational stress, visit the NIOSH Job Stress topic page at www.cdc.gov/niosh/topics/stress. To locate a psychologist or consultant in your area, visit the American Psychological Association website at www.apa.org. For more information on PTSD, visit the National Institute of Mental Health website at www.nimh.nih. gov/health/topics. For a list of resources used to compile this article, visit www.cdc.gov/ niosh/docs/2008-136/pdfs/2008-136.pdf 

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