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March 30, 2019

Work-Related Stress, Organisations and Culture

Assessed Coursework for Applied Psychology Postgraduate Courses

Module Title: Workplace Health and Wellbeing

Module Code: C84WOC

Grade Awarded: Merit

Abstract

Few people would question the impact of work-related stress on the psychological and physical health of workers which can result in job dissatisfaction, accidents, absenteeism, decreased quality of life, and illness. This has huge social and societal implications while employers must bear the financial consequences. This literature review considers which stress management interventions are the most effective and the challenges associated with their implementation. Whilst the scientific literature recognises primary interventions as the most useful and valuable strategy for reducing work-related stress, secondary and combined interventions have a crucial part to play. Workplace psychosocial risks that negatively impact the health and wellbeing of workers is examined, in conjunction with the role of employers who are responsible for reducing the stress which is associated with the hazards. Challenges in implementing methodologically sound and setting appropriate intervention programmes is emphasized with recommendations for the main theoretical models to be incorporated more frequently into intervention frameworks. Proposals for future research is highlighted including a need to design interventions around robust and setting appropriate risk assessments. To determine the most effective stress management interventions, research was conducted from randomly selected, published, peer-reviewed journals using Google Scholar that focused on workplace intervention programmes, i.e. primarily meta-analysis and systematic reviews, which have synthesised the best available evidence.

Keywords: SMI, stress management intervention, WRS: work-related stress, RCI: randomised controlled trial.

A Review to Determine Which Interventions are the most Effective in Reducing Work-Related Stress.

The scale of work-related stress (WRS) cannot be overstated in terms of its negative impact on individuals, organisations, and society. The Health and Safety Executive (HSE) estimated that in 2015/16, there were 488,000 cases of work-related stress, depression, or anxiety, or 1,510 cases per 100,000 workers, which resulted in a loss of 11.7 million working days. Additionally, it accounts for 37% of all work-related ill health (HSEa, n.d.). The issue was further highlighted by The European Agency for Safety and Health at Work (EU-OSHA) in the 2009 European Risk Observatory Report “Work-related stress is one of the biggest health and safety challenges that we have in Europe. Stress is the second most frequently reported work-related ill health problem affecting 22% of workers” (EU-OSHAa, 2016).

Psychosocial risks are commonly referred to as organisational stressors. These are defined as “those aspects of work design and organisation and management of work, and their social and environmental contexts, which have the potential for causing psychological, social and physical harm” (Cox & Griffiths, 1995).

It is incumbent upon employers to identify potential causes of stress and to take the necessary steps to reduce the impact on employees, as far as is reasonably practicable. This is set out in the Management of Health and Safety at Work Regulations (1999). Furthermore, employers are legally responsible for taking the measures to control the risk, which translates into a duty of care under the Health and Safety at Work Act (HSEc, n.d.).

With respect to corporate social responsibility, organisations are increasingly being expected to meet ethical expectations and solve problems that could impact the global, social, or local arena. This requires organisations to own the consequences of their actions to combat or alleviate work-related stress

 Work-related stress arises when individuals do not have the capacity or capability to cope with the demands or expectations being placed upon them. It is linked to numerous detrimental outcomes, such as high levels of absence, high staff turnover, and impaired performance (HSEb, 2015).

Depending on the individual’s circumstances, skills, and capacity to cope, symptoms can manifest physically, behaviourally, or emotionally, and if the condition is sustained for a considerable length of time, a deterioration in health can develop, resulting in conditions such as heart disease, irritable bowel syndrome, or depression (EU-OSHAa).

Work-related stress results when working conditions are not conducive to the well-being of the employee, such as poorly planned change management, excessive workloads, job insecurity, bullying and harassment, ineffective communication, and a lack of involvement in decision making (EU-OSHAa, 2016).

Leka, Griffiths, and Cox (2003) identified the psychosocial hazards which can cause physiological or physical harm as “job content, workload and pace, work schedule, control, environment and equipment, organisational culture and function, interpersonal work relationships, role in organisation, career development and work-home interface” (p125). It should be noted that EU-OSHAb (2002) highlighted the fact that a reasonable and realistic exposure to pressure in the workplace, can act as a catalyst in helping to motivate the individual to perform efficiently and effectively, thus contributing to his/her well-being.

Three principle levels of interventions are used to reduce work-related stress; primary, secondary, and tertiary (Leka & Houdmont, 2010). They also identified a distinction between organisational (task/job level or design) and individual orientated interventions, with the latter often being coordinated as programmed activities at the secondary level.

Tertiary interventions were excluded from this review since they can be considered as taking action ‘too late’ and purely a rehabilitative/reactive strategy, whereby the symptoms of occupational disease and illness are managed and treated (Leka & Cox, 2008).

The Value and Role of Theories

Within the context of work-related stress and the interventions utilised to remedy or remove its effects, “theories provide not only an explanation of how things work but, through such explanation, an ability to predict what might happen next and a vehicle for intervening and controlling those events” (Leka & Houdmont, 2010, p33). Consequently, when formulating and implementing an intervention programme, it is imperative to have a clear understanding of the role and purpose of theories and how they can be utilised to deliver the project’s objectives.

 Two theoretical or job stress models have dominated research on occupational stress in the last 20 years, namely the Job Demand-Control model (JD-C) (Karasek, 1979) and the Effort-Reward Imbalance model (ERI) (Siegrist, 1996). These two main theories display some commonalities in that they both describe a holistic process of events and procedures which involve a combination of environmental elements and individual psychological, physiological, and behavioural factors (Leka & Houdmont, 2010). Intrinsic to this system of events is the way in which these elements interact, since their value regarding the social, organisational, and societal environments is fundamental. These factors are conceptualised and perceived in the workplace as hazards, exposures, and pathways to harm (Leka & Houdmont, 2010).

 The JD-C model “predicts that mental strain results from the interaction of job demands and job decision latitude” and “the combination of low decision lattitude and heavy job demands is associated with mental strain” (Karasek, 1979, p1). Thus he devised a job strain model which allows for four job types:

  • High strain jobs: High demand and low control being the riskiest to health
  • Active jobs: High levels of demand but also high levels of control which is considered average levels of job strain
  • Low strain: Low demand and high control that is consistent with below-average job strain
  • Passive jobs: Low demands and low control. This has a demotivating effect which can ultimately lead to some job strain

(Karasek, 1979)

Semmer (2006) identified a study on an intervention in a confectionery company with high staff turnover, low morale, and poor worker/manager relations (conditions consistent with high job strain). The group was given autonomy on how to do their jobs, i.e. the procedures and processes for completing tasks and frequency of rest breaks. This approach, consistent with the JD-R model, resulted in improvements in intrinsic motivation, job fulfilment, performance, and mental health. Johnson (1994) also reiterated the value of empowering employees, since they become more proactive, less risk averse, more creative, and willing to suggest constructive and tangible solutions.

An extension to the JD-R model was devised by Johnson and Hall (1988) who found in several prospective studies that workers who were given work-related social support were less likely to suffer from the symptoms of stress. They identified higher incidents of coronary heart disease, psychological problems, and higher cholesterol in cases where social support was limited, since it has a buffering effect against perceived stress and job strain. By combining this approach with the JD-C theory, an additional model was developed – the Iso-Strain model. With this model, the emphasis is not only on the relation between the person and the job, as is the case in the JD-C model, but also regards social interactions as an integral component in worker satisfaction and effective performance. Dollard, Winefield, Winefield, and De Jong (2000) defined social support within this context, as workers and managers who are friendly, approachable, and supportive of one another.

The concept of the ERI theoretical model as proposed by Siegrist (1996) is based on the principle that people want to be sufficiently recognised and rewarded for the effort they put in at work. This can be money, esteem, job security, praise, or career opportunities. If workers perceive that effort expended is disproportionate to the reward (high ‘costs’ and low ‘gains’), then health risks may arise. Siegrist (1996) suggested that this imbalance can arise under 3 conditions:

  • The employment contract is inadequately designed and the employee has few alternative options for work.
  • The worker accepts or tolerates the imbalance with the perception that things ‘can only get better’
  • The worker over commits and expends more effort than should be required

 (Leka & Houdmont, 2010)

An additional theoretical model focuses on whether the worker is suitable for the working environment and vice versa. Called the Person-Environment Fit theory (P-E Fit) theory (Edwards, Caplan and Van Harrison, 1998) it suggests that stress can arise when the worker is not suited to the job role and related environment. This can occur under 3 conditions; 1) The demands being placed on the individual exceeds his/her ability to cope. 2) The working environment fails to meet the expectations and particular needs of the individual. 3) A combination of the above mentioned conditions. “The notion of ‘fit’ suggests a balancing or matching mechanism, between on the one hand, environment demands and individual needs and on the other, what the environment supplies and the individual’s ability to cope” (Leka & Houdmont, 2010).

Primary Interventions

This is defined as a proactive approach, concerned mostly with acting on the problem before it arises in the first instance, i.e. to modify or eliminate the problem at source (Cooper & Cartwright, 1997). Root causes which can be identified as the source of stressors are ineffective design of work processes, job content, implementation of systems, controls and procedures, and management practices (Leka & Houdmont, 2010).

With this perspective in mind, researchers generally agree that primary or organisational-level interventions are the most effective in reducing work-related stress since staff are less likely to be afflicted by the stressors that arise from adverse working conditions and processes, which reduces the likelihood of requiring secondary and tertiary interventions.

Managers and leaders have the responsibility to implement organisational changes, but often lack the knowledge and skills to actualise the necessary adaptations and practices that promote and embed well-being. This issue was identified by Goldruber and Ahrens (2010), who conducted a review of 17 workplace primary intervention programmes. While they agreed that primary interventions involving the reorganisation of work were not only effective but feasible, ineffective management practices were consistently identified as one of the major causes of stress in the workplace.

Parker and Wall (2015) found that most job redesign research specifically focused on five work characteristics; autonomy, variation, task significance, task identity, and task feedback. However, they noted the tendency to focus on traditional job designs, which often failed to consider a broad range of outcomes, productivity indicators, and learning and development pathways. This illustrates the challenges for managers to think outside the box, which may require appropriate training to equip them with the right skills.

Excellent leadership can transform organisations and the implications for employee performance, productivity, and well-being is vast, while leadership development programmes provide an ideal opportunity for furthering this aim. This was demonstrated by Biggs, Brough, and Barbour (2013) who successfully utilised the JD-R theory to develop leadership behaviours in 2 separate Australian police forces to decrease WRS and improve immediate subordinates’ perceptions of psychosocial work characteristics, motivation, attitudes, commitment, and productivity. However, the limitations of the study should be noted, specifically that it was a quasi-experimental project involving non-random allocation of workers with a response rate being less than optimal.

Dollard and Gordon (2014) conducted a study to evaluate a participatory risk management work stress intervention in an Australian public sector organisation. They recognised the importance of gaining the commitment and ‘buy in’ of senior managers who had the authority to encourage worker participation in job redesign and action plan implementation. To economise and for sustainability reasons, the existing Organisational Development survey on working conditions and well-being was used. This provided valuable historic data and information on work group structures to generate risk assessments and change plans. The disadvantage of this approach was that anonymous data could only be matched at the workgroup level. Furthermore, being a quasi-experimental cohort study, it precluded the advantages of random assignment which limited the validity of the findings.

The value of healthy interpersonal dynamics in the workplace should not be overlooked. Social conflict and a lack of social support is a dynamic that prevails in many organisations, but can also be alleviated through effective leadership (Semmer, 2006) and use of the Iso-Strain theoretical model as mentioned earlier.

Considering organisational restructuring has become a common theme in the business landscape, it is imperative that effective and robust change management programmes are utilised during the transition. This was highlighted by McHugh (1997) when links were found between organisational change and the psychological well-being of employees. She argued that by addressing stress factors when planning and implementing change, the psychological well-being of workers could not be overlooked. This also provides an ideal opportunity for managers to demonstrate a commitment to well-being by encouraging worker participation in job-redesign and provides sufficient recognition and rewards for effort expended. However, it should be noted that workers who do not possess sufficient self-efficacy can become defensive and reluctant to relinquish their ‘comfort zone’ (Semmer, 2016). Similarly, Leka and Houdmont (2010) commented on research conducted by Bond, Flaxman, and Bunce (2008) which found that “employees with well-developed psychological flexibility benefited the most from primary interventions”. This illustrates the importance of designing interventions that accommodate the demographic diversity of workers in organisations, to ensure that the values of equality and inclusion are not overlooked.

To assist employers in meeting statutory compliance, and to help tackle work-related stress, the Health and Safety Executive introduced a set of Management Standards. This primary intervention encompasses 6 key areas of work design, which, if not properly managed, can lead to ill health, absenteeism, and low productivity. The indicator tools are standards of ‘states to be achieved’ or good practice – demands, control, support, relationships, role, and change. A preventative risk assessment-based approach is conducted which promotes active discussion, demonstrates good practice, and identifies the main risk factors (HSEd, n.d).

Secondary Interventions

These methods of reducing stress relate to the treatment of the effects of exposure to unfavourable working conditions. Workers are encouraged to develop their stress management skills by partaking in activities such as cognitive behavioural therapy (CBT), stress reduction programmes, and relaxation techniques (Cooper & Cartwright, 1997).

The activities can be distinguished as either individual or organisational. Individual stress reduction techniques are adopted by the individual, i.e. acting on their own initiative, while organisational techniques (or interventions) are utilised by management to minimise the harmful effects of stressors in the workplace (Matteson & Ivancevich, 1987).

Richardson and Rothstein (2008) recognised the value in utilising stress management training programmes to assist in alleviating the effects of stress, which is vital for maintaining overall health, improving perceived well-being by boosting confidence, strengthening the immune system, and improving productivity and performance in the workplace.

Stress management training is the most commonly used secondary intervention since it motivates the employee to be more aware of the sources of stress and the impact it has on perception and well-being. Consequently, this process serves as a catalyst for the worker to engage in personal strategies and coping styles which will help them to respond more positively to the work environment (Leka & Houdmont, 2010).

Cognitive Behavioral Interventions

These are defined as active secondary interventions, which encourage and promote workers to constructively and proactively recognise their problems and take the necessary steps to overcome them or lessen their impact. This includes the detrimental effect of negative thoughts on well-being and the benefits of replacing them with positive ones (Leka & Houdmont, 2010). “The core premise purports that maladaptive cognitions contribute to the maintenance of emotional distress and associated behavioural problems” (Querstret, Cropley, Kruger, & Heron, 2016, p6).

 A longitudinal quasi-experimental study conducted by Querstret et al. (2016) aimed to evaluate the success of a CBT-based one-day workshop intervention on work-related rumination, chronic fatigue, and improvement in sleep quality. At follow up, the researchers concluded that participants in the programme were experiencing significantly less rumination and fatigue, compared with those who did not engage in the experiment. However, the limitations of the study design should be noted, in particular the difference in groups at baseline (workshop and non-workshop groups were formed from convenience samples) and the participants being primarily from the same occupational group (lawyers). The latter may account for the high level of engagement and cooperation and consequent positive outcome.

Additionally, the workshop was designed by the organisation in isolation from the research team which precluded the opportunity to anticipate and then assess the mechanisms which gave rise to change (Querstret et al., 2016). This technique, defined as process evaluation, could have provided the opportunity to collect valuable data on the perceptions of both workers and facilitators, to determine actual exposure patterns (perception and experience) and whether participants were appropriately placed in the intervention or control group (Randall, Griffiths, & Cox, 2005). Similarly, Semmer (2006) also identified the benefits of identifying exactly what happened at what time, which facilitates a stronger focus on process variables.

 A high quality secondary intervention involving a randomised controlled multi-centre trial with 1,193 participants was conducted by Reme, Grasdak, Lovik, Lie, and Overland (2015) to evaluate the effectiveness of utilising CBT therapy in conjunction with individual job support for workers with common mental disorders. At the 12 month follow up, a large proportion of the participants reported a reduction in depression and anxiety and increased health-related quality of life compared with the control group. The outcome for workers on long term sickness was even more promising. The strength of this study was attributed to the large sample size, the multicentre randomised control trial design, provision of an ecologically sound setting, and a research group which maintained an objective perspective since they were not involved in the treatment processes. Additionally, they had access to relevant and robust data on attendance, rehabilitation service use, and social security benefits (Reme et al., 2015). In comparison, Ebert et al. (2016) conducted an RCT/internet and mobile-based (iSMI) study to determine the efficacy of online learning. Having utilised an open recruitment strategy from the general population, participants demonstrated a higher reduction in stress and improvement in confidence levels from baseline to 7 weeks and at the 6 month follow up compared with the control group. Surprisingly absenteeism and quality of life (health-related) did not improve. This suggests that future iSMIs should utilise recruitment methods which included workers from within the organisation to determine if they would react differently. In terms of future research, there should be a focus on iSMIs, since the trend of organisations is to capitalise on technological advancements and utilise more online training (rather than face-to-face).

Relaxation-Based Stress Management Training

This training is defined as a passive approach to combating stress and is used to train the mind to recognise when the body is tense. Meditation, muscular relaxation techniques, yoga, use of constructive positive imagery, and focusing on inner stillness are some of the methods used to help workers cope better with WRS (Leka & Houdmont, 2010).

Hartfiel, Havenhand, Khalsa, Clarke, and Krayer (2011) conducted an RCT (with wait-list control group) with 48 employees at a British university. Dru Yoga was offered by a certified teacher for 6 weeks of 60 minutes per week. The results revealed a substantial improvement to well-being and resilience consistent with findings of Granath, Ingvarsson, von Thiele, and Lundbery (2006) who conducted a study in a large Swedish company of 33 employees, who were offered 10 weekly sessions of yoga. Consideration must be given, however, to the different assessment measures used in the programmes. The limitations of the Hartfiel et al. (2011) study included a selection of staff who volunteered for the project so it is assumed that they were highly motivated, which could have inflated the positive results.

Additionally, regarding the control group in waiting, no activity restrictions were placed on them during the trial and an increase in general emotional well-being may have been attributed to the seasons moving from winter to spring during the study. These factors demonstrate the complexity of designing interventions which should consider all the elements that can adversely influence the outcome.

Combined Interventions Including Group and Person Focused

When selecting an SMI, the key question to ask is “which one is the most effective?” Since every organisation’s culture is unique, encompassing a myriad of values and behaviours that are shaped by the collective ideals and beliefs of the workers, so consideration must also be given to its strategy, history, market positioning, technological advancement, and product or service. As Goldgruber and Ahrens (2009) point out, it is necessary to analyse all influences prior to conducting a systematic workplace health promotion programme so that it can be adjusted to the needs of the individuals.

Interventions often overlap or bridge prevention stages which results in combined interventions (Leka, Cox, & Zwetsloot, 2008). By combining appropriate primary and secondary SMIs, the best possible outcome can be achieved because choosing to exclusively use either one or the other is generally not realistic or feasible. This conclusion was reached after a review of 16 studies on organisational SMIs by Giga, Noblet, Faragher, and Cooper (2003). They stated: “SMIs that focus on both the sources and symptoms of occupational stress are widely acknowledged as offering the greatest opportunity for combating chronic job stress” (p163). Indeed, it would make business sense for an organisation to implement solutions to reduce or eradicate the causes of stress, yet also utilise interventions to treat the effects of stressors. Notably, the study identified a need for more RCTs and measuring the long-term effects of more comprehensive programmes, especially for organisational change strategies.

Furthermore, in a review of 3 workplace stress-related interventions, Goldgruber and Ahrens (2009) found that reducing work demands, job redesigning, improving relationships (particularly between the worker and line manager), and training in conflict resolution were the most effective ways to reduce stress. Their conclusion demonstrated the benefits of utilising the 2 main theoretical models, i.e. DC-R and ERI, in conjunction with both organisational and individual interventions.

Awa, Plaumann, and Walter (2009) reviewed 6 studies on combined SMIs (person and organisation directed) involving 2,735 participants. Their study demonstrated the advantages of utilising a variety of intervention methods, such as work schedule reorganisation, works shift revaluation, supervision, cognitive behavioural therapy, coping skills and communication. Consequently, the results substantiated their hypothesis and the positive outcomes in reducing burnout were significant, with 80% lasting up to a year.

Kim et al. (2014) conducted a comprehensive SMI programme to reduce work-related stress in a medium-sized Korean organisation which focused on both organisational and individual level interventions. Because of work re-design, team-based participatory workshops, and open communication strategies, the blue collar workers (n=129) experienced a significant reduction in work-related stress while the white-collar workers (n=123) demonstrated improved morale and productivity. The success of this programme is likely to be attributed to an effective promotional campaign which disseminated stress-related information 7 times via the computer network on stress. Additionally, staff were offered CBT sessions, anger management exercises, and relaxation techniques before and during the programme. The human resources department encouraged participatory action-orientated training, e.g. in the planning, implementation, and review of the programme which encouraged ownership, promoted inclusion, and helped to alleviate their perception of stress (Kim et al., 2014). 

There were numerous limitations to the intervention; it was a voluntary initiative which suggests that participants were in a more positive frame of mind from the beginning and therefore more likely to meet the intervention’s objectives (this is termed as the Hawthorne effect). The authors argued that it was essential to utilise voluntary initiatives in intervention processes, but one could argue that this may exclude the workers who were unwilling to engage and who were most in need of help and support.

In a review of 25 burnout intervention programmes, Awa et al. (2009) supported the view that person-directed interventions reduced burnout for 6 months or less and a combination of person-directed and organisation-directed had longer effects, for 12 months and more. They emphasised the importance of utilising refresher courses to encourage recall and reinforcement of acquired skills and knowledge obtained from interventions, whereas, in the absence of these courses, positive outcomes waned more rapidly. They noted that in all cases, the positive effects of the interventions diminished over time. Hence, this is an issue that needs more focus and research.

Conclusion

Although there is some support for the benefits of primary and secondary interventions, more and better evidence is needed. Selecting the right criteria, which will ultimately establish the success or failure of the intervention, is crucial and the measures of effectiveness must be reliable, valid, and sensitive (Houdmont and Leka, 2010). 

Awa et al. (2010) suggested better designed RCTs or controlled trials with comparable participants, a justifiable and relevant baseline, and at least 2 post-intervention measurements points (with 1 up to a year later). Researchers generally agree that a more systematic analysis, design, implementation, and evaluation of workplace health promotion programmes is essential (Goldgruber and Ahrens, 2010). This suggests that researchers need to be more innovative in the way they conduct their studies on imperfect designs (Semmer, 2006).

Intervention strategies must be designed around a rigorous risk assessment with an integrated approach that is selected and adapted to meet the organisation’s challenges and the needs of the individuals (Houdmont & Leka, 2010). Houdmont and Leka (2010) pointed out that more interventions should be designed around the main theoretical frameworks since “good theory can inform the selection and design of interventions to protect and promote occupational health” (p90).

Semmer (2006) observed that “interventions are likely to be most promising if they involve a participative approach, are based on a sound analysis of pressing problems, from which necessary steps are inferred in a systematic way, combining work-directed and person directed interventions and ensure management support” (p524).

It is criticall that management is convinced of the benefits of primary interventions with tangible cost-benefit analysis, as this will surely be the catalyst for their commitment to reducing WRS and increasing employee well-being. Indeed, Semmer (2006) identified this need for a stronger emphasis on the economic benefits for organisations who often focus on the bottom line to the exclusion of employee well-being. This is a topic for future research and focus.

The literature reviewed in this essay points to the overall benefits of utilising primary interventions. However, as this is not always feasible, an integrated approach designed around combined interventions, should be adopted to promote and embed health and well-being in the workplace. In all instances, the problem must be analysed and fully understood in order to translate the risks effectively into an action plan.

Despite these findings, and in the final analysis, Leka and Houdmont (2010) pointed out that the most effective, robust, and valid primary interventions “would need to occur in the initial design of the working environment, before the job role becomes active” (p92).

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