The role of workplace health promotion in addressing job stress

Abstract

The enormous human and economic costs associated with occupational stress suggest that initiatives designed to prevent and/or reduce employee stress should be high on the agenda of workplace health promotion (WHP) programmes. Although employee stress is often the target of WHP, reviews of job stress interventions suggest that the common approach to combating job stress is to focus on the individual without due consideration of the direct impacts of working conditions on health as well as the effects of working conditions on employees' ability to adopt and sustain ‘healthy’ behaviours. The purpose of the first part of this paper is to highlight the criticisms of the individual approach to job stress and to examine the evidence for developing strategies that combine both individual and organizational-directed interventions (referred to as the comprehensive approach). There is a risk that WHP practitioners may lose sight of the role that they can play in developing and implementing the comprehensive approach, particularly in countries where occupational health and safety authorities are placing much more emphasis on identifying and addressing organizational sources of job stress. The aim of the second part of this paper is therefore to provide a detailed description of what the comprehensive approach to stress prevention/reduction looks like in practice and to examine the means by which WHP can help develop initiatives that address both the sources and the symptoms of job stress.

employee well-being, occupational stress, workplace health promotion

Occupational stress is quickly becoming the single greatest cause of occupational disease (Leigh and Schnall, 2000) and can have far-reaching consequences for both the worker and the workplace. Occupational stress occurs when external demands and conditions do not match a person's needs, expectations or ideals or exceed their physical capacity, skills, or knowledge for comfortably handling a situation (French et al., 1982). For employees, chronic exposure to stressful situations such as work overload, poor supervisory support and low input into decision-making have been cross-sectionally and prospectively linked to a range of debilitating health outcomes, including depression, anxiety, emotional exhaustion, immune deficiency disorders and cardiovascular disease [e.g. (Michie and Williams, 2003; Sapolsky, 2003)]. Stressful working conditions can also have an indirect impact on employee well-being by limiting an individual's ability to make positive changes to lifestyle behaviours (e.g. smoking, sedentary behaviour) or by directly contributing to negative health behaviours (Landsbergis et al., 1998).

Chronic job stress is also considered to be a major barrier to effective organizational functioning. Occupational stress contributes to a number of outcomes that are critical to organizational success, including absenteeism, labour turnover and job performance [e.g. (Dollard et al., 2000; Michie and Williams, 2003)]. Industry overall has suffered considerable losses as a result of occupational stress and, in the UK alone, job stress has been estimated to cost employers between £353 and £381 million pounds per year (1995/1996 prices) (HSE, 1999). The estimated number of days lost due to stress has more than doubled since these calculations were undertaken (Jones et al., 2003) and, in an era of heightened downsizing, work intensification and resource rationalization, this trend appears set to continue (Sparks et al., 2001). The human and economic costs of job stress strongly suggest that it is in everybody's interests—employees, employers and the community at large—that stress prevention/reduction initiatives are high on the agenda of any workplace health promotion (WHP) programme.

Whilst there is evidence that employee stress is often the target of WHP, reviews of job stress interventions indicate that the strategies used to combat stress at work are generally limited to the individual-orientated approach (EASHW, 2002; Giga et al., 2003; Caulfield et al., 2004). This approach has been widely condemned and the first half of this paper will outline the major criticisms that have been directed at strategies that focus solely on individual employees. This section will also examine the impact of work-based sources of stress and outline the benefits of adopting a more comprehensive set of initiatives that simultaneously address the worker and the workplace. The remainder of this paper will then examine the role that WHP practitioners can play in developing comprehensive job stress prevention programmes.

INDIVIDUALLY ORIENTED STRESS MANAGEMENT PROGRAMMES

Worker-directed WHP strategies typically focus on the health-related attitudes and behaviours of individual employees and aim to provide them with information and guidance on how to adapt to, or manage, the pressures and demands faced in everyday work life. Stress management interventions that target the individual include one-to-one counselling, relaxation training, lifestyle education and other behaviour change strategies (Giga et al., 2003). This approach to combating the ill-effects of job stress is reflective of the traditional model of WHP that has focused almost exclusively on individual lifestyle behaviours, such as smoking, diet and exercise, with little or no consideration of the contribution that job conditions make to such behaviours or the direct contributions that adverse working conditions can make to ‘lifestyle-related’ diseases such as heart disease and cancer (LaMontagne, 2004).

This individual-orientated approach to job stress has been strongly criticized by organizational health practitioners, employee representatives and occupational stress researchers. Before examining the specific criticisms that have been directed at this approach, a case study has been provided to illustrate the major weaknesses of individually orientated stress management strategies (Box 1) (Noblet, 2004).

Box 1: Case study (part 1)

The operator-assisted services (OAS) section of Opticom is a 24 h call centre located in the Central Business District of a large Australian city. Approximately 200 employees are employed across three shifts to attend to local and international enquiries. Opticom recently appointed a new manager to the OAS unit who, in her first review of the unit's operations, found that it was experiencing high absenteeism (most of which was sick leave), increasing customer complaints and low morale. Anecdotal evidence from a number of employees also suggested that stress levels were high. The manager was determined to reduce the high rates of sick leave and immediately sought the services of a corporate health promotion company. This company introduced a series of health checks and follow-up counselling covering such issues as diet, blood pressure, fitness and stress. In the case of stress, all staff were also given the opportunity to attend relaxation classes twice a week. After 6 months, an evaluation of the programme revealed that it had very little impact on absenteeism. While the screening sessions held during work hours were well attended, the relaxation classes were not.

The Opticom case study is a typical example of where an organization has used the individual approach to develop initiatives that Baric describes as undertaking ‘health promotion in a setting’ (Baric, 1993). The majority of initiatives were aimed at identifying individuals who are at risk of developing lifestyle-related diseases (e.g. cardiovascular disease), and encouraging them to adopt healthier lifestyles. The health impact of the setting itself—including social, organizational and physical conditions—was largely overlooked.

CRITICISMS OF THE INDIVIDUAL APPROACH

There are three main criticisms that have been directed at stress prevention programmes that are driven by the individual perspective. First, several authors have been highly critical of the practice of focusing on individual employees whilst ignoring the influence of adverse working conditions [e.g. (Corneil and Yassi, 1998; Daykin, 1998)]. The European Agency for Safety and Health at Work reports that individual symptoms of stress are often manifestations of organizational-level problems rather than personal coping deficiencies (EASHW, 2002). Thus, by trying to teach employees to cope with stressful working conditions, proponents of this approach can be seen to be blaming the victim of poor communication channels, inadequate training, autocratic management styles and other common sources of workplace stress. The second criticism often directed at the individual-oriented approach is that strategies aimed at helping people to cope with stressful working conditions, without addressing those conditions, contravene the occupational health and safety legislation that exists in many industrialized countries, including Australia, Canada, the European Union member states, Hong Kong, Malaysia, New Zealand, the UK and the United States (Chu and Dwyer, 2002; Cousins et al., 2004). In the UK, for example, employers must monitor both physical and psycosocial hazards and, as a result, a failure to address adverse working conditions, so far as is reasonably practical, is a breach of that legislation (Mackay et al., 2004). Overlooking the work-based sources of poor health is also a breach of internationally recognized health promotion and public health principles. The Ottawa Charter for Health Promotion (WHO, 1986) and the Luxembourg Declaration on Workplace Health Promotion in the European Union (ENWHP, 1997), for example, both emphasize the need to address the social, economic and environmental determinants of health. Ignoring these principles is not considered unlawful, however, it does contravene best practice in health promotion. The final major criticism directed at the worker-oriented stress prevention strategies is that they often fail to achieve any significant health and/or productivity outcomes. Research examining the outcomes associated with employee-centred strategies have found that, where benefits have been identified, such strategies tend to result in shorter-term psychological benefits are not sustainable over a longer period and have little impact on organizational effectiveness [e.g. (Pelletier et al., 1999; Whatmore et al., 1999)]. Overall the criticism that has been directed at this approach indicates that individually focused stress prevention programmes are ethically unsound, are not supported by OHS legislation or health promotion principles, and generally fail to deliver sustainable benefits for either the employee or the organizations for which they work.

MOVING TOWARDS A COMPREHENSIVE APPROACH

Despite the criticisms directed at stress prevention programmes that focus exclusively on the health-related attitudes and actions of individual employees, worker-directed initiatives can still make valuable contributions to combating stress at work. Comprehensive stress prevention programmes, which address both the organizational origins of stress at work as well as the symptoms of distress exhibited by individual employees, are much more likely to lead to favourable, long-term outcomes than programmes that focus solely on the individual [e.g. (Kompier et al., 2000; Michie and Williams, 2003)]. As acknowledged by Bond, comprehensive programmes provide a balance between organizational and individual-directed interventions that ensure that ‘… preventative benefits of the former can have a widespread impact across an organization, whilst the curative strengths of the latter can target those (fewer) people who have already succumbed to occupational ill-health’ [(Bond, 2004), p.147]. The benefits of comprehensive stress prevention programmes include outcomes that are relevant to the individual (e.g. enhanced psychological health, improved job satisfaction, reduction in ambulatory blood pressure) as well as the organization (e.g. reduced sickness absence, increased organizational commitment, improved job performance). When compared with traditional lifestyle education/counselling programmes, comprehensive WHP initiatives are also much more likely to capture the involvement of low-paid blue-collar workers—a group that traditional lifestyle risk programmes had previously found difficult to reach—and to result in successful behaviour change (Sorensen et al., 2002).

In health promotion terms, comprehensive stress prevention/reduction initiatives reflect the settings approach to promoting health at work (Chu et al., 2000; Noblet, 2003). A hallmark of the settings approach is the attention given to monitoring and addressing the impact that the setting itself has on the health of employees. In the case of job stress, this includes a close examination of the social and organizational conditions that contribute to job stress (Polanyi et al., 2000). The following section will summarize the common sources of job stress and will highlight the relationship between a number of the more influential stressors and measures of individual and organizational health.

ORGANIZATIONAL SOURCES OF JOB STRESS

There is considerable variation in the way individuals perceive and respond to the environments in which they work. Descriptions of the stress process indicate that personal (e.g. coping skills) and situational (e.g. support from supervisors) variables will influence the onset and duration of job stress and what one person finds demanding and stressful others may perceive as challenging and stimulating (Cooper et al., 2001). Despite this variation at the individual level, at the population level (i.e. on average across all individuals) a range of physical, social, organizational and economic conditions have been identified as common sources of job stress (Cox and Cox, 1993). These conditions, referred to as job stressors, are the physical, social, organizational or economic conditions at work that contribute to stress. Job stressors can result from the job itself (e.g. heavy workloads, low input into decision-making) or the social and organizational contexts in which the job is performed (e.g. poor communication, interpersonal conflict).

Although there are a range of organizational-based situations and conditions that often contribute to job stress, several of these variables are thought to play particularly salient roles in the onset and severity of job stress. These variables are captured in two models of job stress that have dominated the occupational health psychology literature over the past two decades—Karasek and Theorell's (Karasek and Theorell, 1990) Demand-Control-Support (DCS) model and the Siergest's Effort-Reward Imbalance (ERI) model. In the DCS model, high levels of job stress occur when the demands of the job are not matched by adequate levels of decision-making authority and/or support from supervisors and colleagues (Karasek and Theorell, 1990). Research has consistently demonstrated that the DCS component variables—particularly job control and social support—are predictive of health and performance outcomes (e.g. sickness absence) [e.g. (Bond and Bunce, 2003; De Lange et al., 2004)]. In the case of Siegrist's effort/reward imbalance (ERI) model, high cost/low gain conditions (i.e. high effort and low reward) have been found to be particularly stressful (Siegrist, 2002). The DCS and ERI overlap to some extent, but also have complementary, independent relationships with adverse health outcomes [e.g. (Kivimaki et al., 2004)]. Taken as a whole, these two models have identified specific working conditions that can have particularly serious consequences for the mental and physical health of working people

After the corporate health programme was found to have little impact on the health and performance of operator-assisted services (OAS) employees at Opticom, informal discussions with employees found there were a number of organizational factors that were particularly stressful for workers. Part 2 of the Opticom case study (Box 2) indicates that conditions such as heavy quantitative workloads, lack of variety, interpersonal conflict, inadequate training and development, and unpredictable and often unsupportive supervisory styles were likely to be key sources of stress for employees. The literature presented in the preceding section clearly indicates that the adverse conditions experienced by Opticom staff are not unique to this particular organization. Furthermore, the far-reaching health consequences of long-term exposure to these situations support the view that working conditions, particularly those reflected in the widely tested job stress models, need to become a high priority for WHP practitioners.

Box 2: Case study (part 2)

There are many problems inherent within the OAS unit. The task of attending to public enquiries is extremely repetitive. In the domestic section, for instance, operators would receive on average of 175 calls per 8 h day, with each lasting between 30 s and 5 min. They often have to attend to irate and sometimes abusive callers and receive next to no training in dealing with this sort of conflict. There is a top-down style of management and operators have virtually no say in decisions directly affecting what they do, despite the fact that they are generally in the best position to identify problems and generate ideas for overcoming them. Exacerbating the situation is an unpredictable style of supervision that swings erratically from overbearing to non-existent.

The first part of this paper has provided considerable evidence supporting the development of comprehensive stress prevention/reduction strategies. Whilst proponents of comprehensive stress prevention programmes call for a dual individual–organizational approach to be adopted, there is a risk that the recent push for organizations to focus much more heavily on psychosocial and organizational hazards, may result in an overemphasis on organizational strategies. This perception is supported by Bond who expressed concern that individual-oriented strategies have been assigned a negligible role in the UK Management Standards and that their value may be lost in an ‘organizationally focused, intellectual milieu’ [(Bond, 2004), p.146]. This situation is often not the fault of OHS authorities themselves, as they have been legislated to address workplace determinants of health and are severely limited in their ability to advise/assist organizations to address ‘lifestyle’ factors (Eakin, 2000). Nevertheless, there has been a shift in the dominant stress prevention/reduction approach promoted by OHS authorities and there is a risk that practitioners may begin to underestimate or even ignore the value of combined individual–organizational initiatives (Kompier, 2004; Walls and Darby, 2004). This risk is particularly true for WHP practitioners, who may be more familiar with education and behaviour change strategies, and feel ill-equipped to help identify and address organizationally based stressors. Such people (and even the organizations for which they work) may begin to ignore occupational stress, believing that they have a limited capacity to address this issue. The overall aim of the second part of the present paper is therefore to provide a more practically oriented description of the comprehensive approach to stress prevention and to demonstrate how WHP practitioners can facilitate the shift from an approach that focuses almost solely on the individual, to one that examines and addresses both the individual and the organizational sources of ill-health.

COMPREHENSIVE, SETTINGS-BASED INTERVENTIONS AND THE IMPLICATIONS FOR WHP

A conceptual framework that mirrors the settings approach to health promotion and which can be used to develop comprehensive stress prevention strategies is DeFrank and Cooper's typology of job stress interventions (DeFrank and Cooper, 1987). DeFrank and Cooper classified interventions according to the level in the organization that the strategy targeted: the individual employee, the organization and the organization–individual interface. The typology has been used to categorize and review occupational stress prevention programmes and can provide WHP practitioners with valuable insights into the types of settings-based interventions that can be used to prevent/reduce job stress (Giga et al., 2003). The following section provides a more detailed description of the three intervention levels and the action that WHP practitioners can take to facilitate the development and implementation of strategies within each level.

The aim of individual-level interventions is to equip people with the knowledge, skills and resources to cope with stressful conditions—whether they are showing stress-related signs and symptoms or not. At this level, WHP programmes need to cover a range of strategies, including training in relaxation, biofeedback and meditation, as well as time management, goal setting and other coping techniques that aim to alter the way in which people structure and organize their working and non-working lives.

The second level of stress intervention refers to the interface between the individual and the organization and targets issues such as role ambiguity, relationships at work, person–environment fit and employee involvement in decision-making. Examples of specific individual–organization level strategies include co-worker support groups, role clarification processes and participatory decision-making programmes. WHP has a major role to play in planning and developing these strategies. Individual–organization initiatives must be based on a sound understanding of the specific psychosocial conditions impacting on worker health (Bond and Bunce, 2001). WHP practitioners therefore need to first ensure managers and supervisors are equipped with the knowledge and skills to identify these problematic issues. They then need to help design initiatives that can clarify the ambiguity, reduce the conflict and generally overcome the source of the stress.

The third level of interventions addresses areas in the physical, organizational and social environments that may produce stress. Interventions that target the organization include job redesign strategies, selection and placement and organizational development programmes. Again, the role of WHP at this level is to enhance the organization's capacity to identify and assess the specific conditions that are contributing to employee stress and to work with all levels of the organization to help develop strategies that can eliminate/reduce their impact. Whilst some high-performing organizations may embrace comprehensive stress prevention programmes as a way of improving organizational functioning, there is evidence that many organizations may be unaware, or even reluctant to acknowledge, the relationship between working conditions and employee health and performance (Mustard, 2004). Another key aim of WHP may therefore be to help raise awareness of the work–health relationship, particularly among senior managers, and to highlight the possible consequences of addressing (or not addressing) organizational sources of job stress. In settings where WHP practitioners encounter resistance to addressing job stressors, they might begin strategically by considering both work and non-work (e.g. child care issues, as illustrated in the Opticom case) sources of stress, and incrementally shift the focus to work-related sources as trusting relationships develop (Eakin, 2000).

Part 3 of the Opticom case study (Box 3) is a good example of where all three levels of job stress interventions have been implemented simultaneously. In the end, the individual-focused efforts of the external WHP practitioners were coordinated with and complemented by management efforts to reorganize the job tasks. The work schedule was modified to better accommodate the non-work commitments of employees (organizational-level intervention), employees were involved in the decision-making processes that lead to the development of the new strategies (individual–organizational level intervention) and employees were given the opportunity to develop and apply relaxation skills that could help them cope with stressful conditions and events (individual-level intervention). The involvement of employees in identifying and addressing their own needs reflects the empowerment approach to health promotion and has enhanced the ability of the organization to address other workplace stressors (i.e. erratic supervision, poor conflict resolution skills and monotonous workloads). In addition, OAS now has a structure (i.e. coordinating committee) and system (i.e. employee and organizational needs assessment) in place to monitor, modify and manage these stressors.

Box 3: Case study (part 3)

After Opticom realized that its strategies had not worked, it decided to undertake a more inclusive and systematic investigation into why OAS was not performing as well as it should. A small committee, consisting of management and employee representatives, was formed to guide and oversee this assessment. The committee quickly found that the unit's performance fluctuated significantly and a period when error rates were particularly high was mid-afternoon on a weekday. Informal discussions with a cross-section of employees later found that a major source of poor performance was mothers worrying about whether their children had got home from school safely. OAS employed a large number of mothers with dependent children and action needed to be taken to address their needs. Through the ideas generated by employees, Opticom gave their operators a 10 min break around 4 p.m. so they could call home to make sure that the kids had arrived safely. This strategy alone resulted in a significant improvement in the service quality and morale. The timing of the relaxation classes was also changed to better accommodate the work and personal commitments of employees.

CONCLUSION

The pressures associated with increasingly competitive and cost-conscious marketplaces will continue to place enormous demands on organizations and their members. Excessive job stress is therefore an issue that is likely, at some stage, to impact on the lives of all employees, irrespective of their position in the organization or the industry in which they work. The stress prevention research clearly recognizes that whilst individual-level strategies can offer short-term solutions, the settings approach to health promotion provides a more effective and sustainable framework for addressing the sources and symptoms of job stress. Practitioners involved in developing WHP programmes therefore need to advocate for more comprehensive, settings-based initiatives to be developed. The job stress intervention literature also recognizes that there are numerous ways in which health promotion professionals can help plan and implement higher level strategies that target the psychosocial and organizational sources of job stress. Given the limitations of individual-level strategies, practitioners must take advantage of these opportunities.