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Exposure to Stress: Occupational Hazards in Hospitals (Part 2)

How can stress be controlled 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 the 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 health care settings include

• Team processes
• Multidisciplinary health care teams
• Multi-component interventions

Team-process or worker-participatory methods give workers opportunities to participate in the 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 (e.g. team nursing), have been successful in improving job satisfaction and reducing turnover, absenteeism, and job stress.

Multidisciplinary health care teams (e.g. composed of doctors, nurses, managers, pharmacists, psychologists, etc.) have become increasingly common in acute, long-term, and primary care settings. Teams can accomplish the following:

• Allow the 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 link information in ways that individuals cannot.

Multicomponent interventions are broad-based and may include

• Risk assessment
• Intervention techniques
• Education

Successful organizational stress interventions have several things in common:

• 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 interventionwill succeed.

Stress-Management Intervention

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

• 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 health care workers is innovative coping, or the development and application by workers of strategies like 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 U.S. workplaces. Although worker interventions can help staff 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 health care organization (see Case 2, below).

Case Reports

Case 1

Researchers evaluated a participative intervention program at an acute care hospital.^1,2 A baseline (initial) risk evaluation was conducted at an acute care, "experimental" hospital and a similar-size, acute care, "control" hospital. The program used 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, including 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 after the intervention, the telephone survey was repeated at both hospitals. There was a significant reduction in sleeping problems and work-related burnout in the hospital with the intervention team versus the control hospital.

Case 2

The 2003 outbreak of Severe Acute Respiratory Syndrome (SARS) in Hong Kong, Singapore, and Toronto, Canada led to psychological impacts and increased stress in the health care profession. In Toronto, 43 percent of the cases were health care workers; three of the infected workers died. The SARS outbreak substantially changed working conditions and the perception of personal danger. In Toronto, modifications of infection-control procedures and public health recommendations changed day to day, increasing uncertainty. Outpatient clinics were closed; surgeries were canceled; nonessential staff were told to stay home; use of masks, gloves, and gowns were mandatory; and thousands of people were quarantined. Interpersonal isolation was high, as staff members were discouraged from interacting with coworkers outside of the hospital; staff meetings were canceled; and eating and drinking, which require removing a face mask, were done alone or outside the hospital.

The infected and quarantined health care workers

• Experienced interpersonal isolation
• Expressed concern about the infectious risk to staff caring for them
• Expressed fear about the potential lethality of the illness
• Expressed anger because their risk of infectious exposure had not been recognized earlier

Medical residents working during the SARS outbreak at a teaching hospital expressed anxiety over

• Variability of available information
• Perceived poor communications
• The balance between personal safety and duty-to-care

Health care workers who experience a significant event, such as SARS, and today during the COVID-19 pandemic, will benefit from the timely communication of relevant information. Efforts to overcome interpersonal isolation should include effective risk communications, using emails, websites, and video and audio conferencing.

Conclusions

Health care occupations have long been known to be highly stressful and associated with higher rates of psychological distress than many other professions. Health care workers are exposed to a number of stressors, ranging from work overload; time pressures; and the lack of role clarity to dealing with infectious diseases as well as difficult, ill, or 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 health care 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.

References

1. Bourbonnais, R., Brisson, C., Vinet, A., Vézina, M., Abdous, B., & Gaudet, M. (2006). Effectiveness of a participative intervention on psychosocial work factors to prevent mental health problems in a hospital setting. Occupational and Environmental Medicine, 63, 335–342.
2. Bourbonnais, R., Brisson, C., Vinet, A., Vézina, M., & Louer, A. (2006). Development and implementation of a participative intervention to improve the psychosocial work environment and mental health in an acute care hospital. Occupational and Environmental Medicine, 63, 326–334.