Summary of evidence
Summary of evidence
The Health and Safety Executive (2016) defines work related stress as “the adverse reaction people have to excessive pressures or other types of demand placed on them at work.” In itself stress is not an illness, it is a state, but if stress is experienced for an extended time it can result in mental and physical illness, and can impact on behaviour. A number of theories of stress have informed our understanding of stress at work and more recently numerous aspects of work have been found to cause stress if poorly managed (HSE, 2016; Donaldson-Feilder, Yarker & Lewis, 2011), such as, demands, control, support, work-life balance and career development.
Stress will impact at the individual, organisational and societal levels in various ways, for example at the organisational level, the total number of working days that was lost due to work related stress in 2014/15 was 9.9 million days which is approximately 23 days lost per individual (HSE, 2015). However, it is possible to address stress at work through a variety of interventions.
A stress management intervention (SMI) is “any activity or programme initiated by an organisation which focuses on reducing the presence of work-related stressors or on assisting individuals to minimise the negative outcomes of exposure to these stressors” (Ivancevich, Matteson, Freedman & Phillips, 1990). These can be categorised into primary, secondary or tertiary interventions and can be implemented at the individual, manager or organisational level.
The literature is vast, so this summary is not exhaustive but it aims to synthesise the important findings. In summary, individual interventions such as CBT, relaxation therapies and Mindfulness can be used to help individuals manage the stress they are exposed to at work. Further, research has also demonstrated the benefits of a range of interventions targeted at the manager and organisational level. Current research is heavily weighted towards the individual level and focuses on specific occupational populations, those who tend to experience higher stress such as teaching or healthcare. Furthermore, it tends to draw from larger organisations. There is a paucity of research within small and medium sized enterprises and further research is needed to understand whether findings are transferrable across workplaces (Public Health England, 2016). Future research will help us to understand how these findings translate to smaller organisations and across different sectors, and in particular there is a call for understanding the impact of organisational interventions. While there is still much to learn, it is clear that we have a strong body of evidence to steer our action in a way that prevents and supports people experiencing stress at work.
To explore these studies in more detail, please click on Explore the Evidence.
What is stress at work?
Stress is a complex phenomenon but luckily we have decades of research to inform our understanding and guide our approach to managing stress at work.
It is widely agreed that stress is experienced when the demands of the environment are greater than the resources available to the individual. This imbalance can result in psychological, physiological or behavioural changes (McCoy & Evans, 2005).
The HSE (2016) defines work related stress as “the adverse reaction people have to excessive pressures or other types of demand placed on them at work.” In itself stress is not an illness, it is a state, but if stress is experienced for an extended time it can result in mental and physical illness, and can impact on behaviour. It is also important to differentiate between pressure and stress: pressure can motivate employees to perform at their peak; in the absence of the resources to deal with the demands of the situation, the pressure elevates into stress.
There is some overlap between stress, anxiety, depression and mental health. For the purposes of this review, we have focused on stress at work. There are other bodies of evidence and resources available that look at specific mental health issues and will be detailed more fully in the relevant sections of the hub.
Theories of stress
Historically, a number of different theories have informed our understanding of the impact of stress at work, the following are a few key theories:
- Stress as fight or flight: General Adaptation Syndrome (Selye, 1936). Selye focused on the internal elements of stress. When an individual experiences a threat the body responds in three stages: alarm reaction, resistance and exhaustion.
- Stress due to a misfit: Person – Environment Fit (French & Caplan, 1973). Stress occurs when there is a mismatch between the characteristics of the person and the environment. In the context of work, employees’ attitudes, skills, resources and abilities need to match the demands of their job and the environment should meet the employees’ knowledge, needs and skills potential; a misfit in either the environment or person is likely to result in stress.
- Stress as a transaction: Transactional approach (Lazarus & Folkman, 1984). Stress occurs due to a more active interaction between an individual and stressors, in the workplace the interaction occurs between an individual and their organisation. Where individuals perceive that the demands of work are greater than their resources, this appraisal triggers the stress response and the type of coping strategies used to deal with the stress.
The increasingly blurred boundaries between work and home also has the potential to impact on employees’ health and wellbeing. While it is beyond an organisation’s remit to intervene where stress originates outside the workplace it may be appropriate for organisations (or line managers) to provide additional support or flexibility to allow the individual to leverage their resources to be able to better manage these demands.
Prevalence of stress in the workplace
The recent Labour Force Survey found that in 2014/15 there were 440,000 cases of work related stress, depression or anxiety, which accounted for approximately 35% of all work-related illness. The number of new cases was 234,000. The incidence of stress was found to be greater in public service industries e.g. education, health and social care and public administration and defence. These figures have remained stable for the last decade (HSE, 2015).
Impact of stress at work
Stress can impact at the individual, the organisational and the societal level in different ways:
The individual: Stress can be difficult to explain because the symptoms of stress are diverse: individuals may experience one or more symptoms, to a greater or lesser extent. The symptoms of stress are normally classified into the following: physical symptoms (e.g. headaches, sleep disturbance), psychological (e.g. impaired concentration, increased risk of common mental health problems, reduced self-esteem), social and relational health (e.g. less interest in social interaction impacting negatively on relationships with others, including marriage or relationships with significant others), health behaviours (e.g. drug taking, alcohol dependency) and working health (e.g. effect on the psychological contract which might result in decreased morale and engagement) (Donaldson-Feilder, Yarker and Lewis, 2011).
The organisation: The total number of working days that was lost due to work related stress in 2014/15 was 9.9 million days which is approximately 23 days lost per individual (HSE, 2015). Hoel, Sparks and Cooper (2001) noted seven factors that need to be considered in calculating the full organisational cost of stress: stress-related sickness absence, grievance and compensation costs, accidents and mistakes, work performance and productivity, staff replacements due to turnover, premature retirement and loss of reputation.
Society: A recent European Union funded project estimated that when taking account of presenteeism and absenteeism, lost productivity, and health and social welfare costs, work-related stress costs Europe €617 billion each year (Matrix, 2013).
Causes of stress
There is a large body of evidence to help us understand which aspects of work cause, or exacerbate, work stress. Regardless of sector and country, the following aspects of work have consistently been found to cause stress if poorly managed (HSE, 2016; Donaldson-Feilder, Yarker & Lewis, 2011):
- Demands – such as work load and work patterns
- Control – the influence employees have on how they do their work
- Support – such as resources and encouragement given to employees by line managers, colleagues and the organisation
- Relationships – such as bullying and conflict experienced at work
- Change – the communication and management of organisational change
- Role – role clarity and absence of role conflict
- Work-life balance – being able to balance demands of work with the demands of home
- Career development – such as having the chance for promotion and developing skills
Specifically, stress at work occurs when there is disparity between the job requirements (listed above) and the resources (financial, emotional or material) and capability (skills and knowledge) of the worker to deal with the job demands (HSE, 2016; Work Foundation, 2007; CIPD, 2016).
Managers, Human Resource, Occupational Health and other key professionals often hold pivotal roles in managing the impact of work on an individual – therefore it is vital that employees have opportunities to discuss how they are managing the demands placed upon them. Results from a YouGov and Mind (2014) survey suggest that the dialogue between employees and managers regarding stress at work needs to be improved, 30% of those surveyed said they would not be able to have an open conversation with their line manager if they were stressed and of those who had taken time off work due to stress, only 5% said the key reason they gave their employer was that they were too stressed to work.
It is important not only to understand the causes of work stress, but to also provide support for the line managers – equipping them with the skills necessary to identify and manage the causes of work stress within their teams.
What can we do to address stress at work?
Organisations have a duty of care to protect their employees. Organisations are expected to be proactive in their approach to managing stress at work: organisations should take steps to identify significant and foreseeable risks to employee health; prevent harm that is foreseeable and caused by work; and consider any physical or mental impairment that has an impact on an employee's ability to work and make reasonable adjustments where appropriate. There are a number of legislative principles that underpin an organisations duty of care for work stress.
The evidence shows how important it is to address stress at work and this can be done through a variety of interventions. A stress management intervention (SMI) is “any activity or programme initiated by an organisation which focuses on reducing the presence of work-related stressors or on assisting individuals to minimise the negative outcomes of exposure to these stressors” (Ivancevich, Matteson, Freedman & Phillips, 1990).
Interventions can be categorised into primary, secondary or tertiary.
- Primary interventions are designed to eliminate or decrease potential stressors at work before the employee suffers stress at work and are preventative in nature. These interventions attempt to change stressors at work through for example, redesigning jobs or decreasing workload.
- Secondary interventions are designed to give employees the tools that are necessary for them to cope with the stressful work conditions with the aim of ameliorating stress. Secondary interventions target the responses of employees to stressors by giving them for example, mediation training, coping strategies and Cognitive Behavioural Therapy.
- Tertiary interventions are reactive and are designed to treat employees who have health conditions because of work-related stress or stress-related symptoms. Examples of these interventions are return to work programmes and occupational therapy.
Interventions can also be further classified as they can be implemented at the individual, manager or organisational level. The literature suggests that the majority of interventions target individuals and less is known about the effectiveness of interventions targeted at the manager and organisational level. The literature is vast, so this summary is not exhaustive but aims to synthesise the important findings.
Reviews of Stress Management Interventions
A number of review studies have been conducted to consolidate our understanding of stress management interventions. These reviews typically look across interventions and compare the effectiveness of different types of activity.
The most commonly used intervention reported in reviews are relaxation interventions. Cognitive Behavioural Therapy programmes are also frequently used and tend to show greater effects than other interventions (Richardson & Rothstein, 2008; Bhui, Dinos, Stansfeld & White, 2012). Studies that focus on secondary interventions, improving employees’ personal resources or skills, typically have significantly large effects. Reviews also suggest that CBT interventions should be used on their own as mixing them with other interventions has a deleterious effect, but relaxation and meditation programmes can usefully be combined with other types of interventions (Richardson & Rothstein, 2008).
Supporting earlier research, Ruotsalainen, Verbeek, Marine and Serra (2015) found that those who participated in CBT or CBT and relaxation interventions showed decreased stress however the results were mixed regarding how long these effects lasted. The evidence suggests CBT and mental and physical relaxation did not decrease stress more than alternative interventions, leading the review to conclude there is mixed evidence for the effectiveness of interventions.
Recent evidence suggests the majority of interventions are targeted at the individual and are moderately successful (Public Health England, 2016). Again, CBT was found to have a greater effect than relaxation and meditation on stress and burnout. Organisational interventions including modifying workload or working practices were also linked with decreased stressors and aspects linked with burnout. It is suggested that organisational interventions may have a longer term impact.
Joyce, Modini, Christensen, Mykletun, Bryant, Mitchell & Harvey (2016) concluded that a variety of interventions can be used to assist in the prevention and recovery process of common mental health problems. They found that CBT had a positive effect on symptoms but not on organisational outcomes. Interestingly, a review conducted on behalf of the British Occupational Health Research Foundation (2005), concluded individual interventions such as CBT and counselling are effective however there is a lack of evidence to support the use of organisational level interventions to manage common mental health problems.
LaMontagne, Keegel, Louie, Ostry & Landsbergis (2007) found that interventions with primary interventions as the principal type along with secondary and tertiary are the most successful at positively impacting on organisational and individual consequences of stress at work. Supporting other research, they found that individual level interventions do not impact on organisational outcomes. Similarly, Giga, Noblet, Faragher & Cooper (2003) concluded that individual level interventions impact on mental and emotional wellbeing but that the effects may not be long lasting and tend not to impact on organisational outcomes. The Work Foundation (2007) suggested that individual interventions can have a positive short term benefit but may incorrectly imply that employees are to blame for their stress and encourage organisations implement interventions at the organisational level rather than solely at the individual level.
Bhui, Dinos, Stansfeld & White (2012) noted a lack of organisational level interventions and found that organisational interventions showed mixed evidence regarding their positive impact on individual outcomes and absenteeism. In contrast, Caulfield, Chang, Dollard and Elshaug (2004) found evidence to suggest that organisational interventions may be more successful than individual interventions and The Work Foundation (2007) concluded that interventions should be implemented at the organisational level for example, changing causes of stress that are present in the culture and climate, rather than only at the individual level. This is in line with the view that advocates that there may be a greater link between work stress and aspects of the job or work environment rather than individual aspects. This disparity of findings is likely to be due to the wide variation in the design of organisational interventions, and different ways in which interventions are implemented.
In their report, the HSE (2003) concluded that certain elements that are critical in stress prevention success which should be used in a cyclical process, these are: top management commitment, individual, team and organisational interventions, risk analysis, stress prevention strategy, taking a participative approach and using a comprehensive stress prevention programme.
The majority of evidence from research and practice is focused at the individual, and can be described as secondary interventions i.e. helping employees to develop skills to manage stress at work. There are many different techniques used with Cognitive Behavioural Therapy, Mindfulness and Relaxation Therapies being the most common.
Regehr, Glancy, Pitts & Le Blanc (2014) found that amongst physicians cognitive, behavioural and Mindfulness interventions all significantly decreased anxiety symptoms in physicians and medical students. There was however mixed evidence regarding the effectiveness of interventions to decrease burnout. Simiarly, Tetrick & Winslow (2015) found evidence to suggest Mindfulness, multimodal and recovery interventions have been effective at reducing stress however they also proposed that the Job Demands-Resources model may be a useful framework for interventions, suggesting the need to combine individual approaches with organisational level interventions.
Mindfulness-Based stress reduction has been associated with decreased perceived stress and increased self-compassion, greater life satisfaction and less job burnout and distress (Shapiro, Astin, Bishop & Cordova, 2005). Wolever, Bobinet, McCabe, Mackenzie, Fekete, Kusnick and Baime (2012) also found that Mindfulness and yoga interventions were associated with reduced perceived stress and sleep difficulty. Kaspereen (2012) found that teachers and high school staff who participated in a relaxation intervention showed lower scores on perceived stress and increased life satisfaction. In the report on Mindfulness by the Mental Health Foundation (2010) TfL stated their implementation of a stress reduction workshop which encompassed Mindfulness, psycho-education and CBT resulted in a 71% decrease in the number of sick days for stress, anxiety and depression over the subsequent three years in addition to sickness absence decreasing by 50%.
The success of other less common individual interventions has also been examined. For example, counselling has been associated with decreased emotional exhaustion, job stress and emotion-focused coping (Isaksson Ro, Tyssen, Hoffart, Sexton, Aasland & Gude, 2010). Training programmes have also been found to positively impact on burnout and physical and psychological symptoms and training recovery experiences programmes are associated with better recovery (Siu, Cooper & Phillips, 2014). Supporting this, Hahn, Binnewies, Sonnentag & Mojza (2011) found that recovery training had a positive impact on recovery and well-being. Le Blanc, Hox, Schaufeli, Taris & Peeters (2007) found that an individual team-based burnout intervention was found to be associated with lower emotional exhaustion.
More recently, a study that examined the effectiveness of an internet-based stress management intervention reported reduced stress levels (Heber, Lehr, Ebert, Berking & Riper, 2016). Additionally, there were positive benefits on mental health outcomes, work-related health and stress-related skills. The results imply that an internet-based intervention may be a viable option when face-to-face interventions are not available.
Less academic and practitioner research has focused on organisational interventions, largely due to the complex nature of organisational interventions and the difficulty in reporting this complexity. However, evidence suggests organisational interventions can have significant positive benefits.
In their review, Naghieh, Montgomery, Bonell, Thompson and Aber (2015) found that modifying task characteristics in addition to stress management training was associated with a moderate decrease in stress and improved work ability. Furthermore, an intervention that incorporated mentoring and performance related bonuses was also found to have positive benefits.
A variety of interventions have been found to have equivocal impact on stress, burnout, wellbeing and absenteeism, with little evidence to suggest that one intervention is more effective than another (Bergerman, Corabian and Harstall, 2009). Among those found to decrease stress and burnout were a psychological training programme, an emotion oriented care training programme and participatory approaches. Supporting this, McVicar, Munn-Giddings and Seebohm (2013) found evidence to suggest that using participatory action research (PAR) as a psychosocial intervention may have a beneficial impact on job stress.
LaMontagne and Keegel (2010) concluded it was best to take a comprehensive or systems approach to stress management interventions as these are more likely to have a positive impact in addition to having a positive impact on both individual and organisational level outcomes.
It is widely recognised that the line manager plays a pivotal role in the management of stress at work. Line managers can both cause stress, can influence the design of work within their team, and can provide the route through which employees can access support. Over the last ten years there have been increasing calls to provide line managers with the tools necessary to manage stress at work (Black, 2008).
Yarker, Lewis, Donaldson-Feilder & Flaxman (2007) identified 19 management competencies that were associated with the prevention and reduction of stress at work. Further work (Yarker, Lewis & Donaldson-Feilder, 2009) refined the competency framework to 4 competencies and 12 sub-competencies. The 4 competencies were respectful and responsible: managing emotions and having integrity, managing and communicating existing and future work, reasoning/managing difficult situations and managing the individual within the team. A Stress Management Competency Indicator Tool was developed as a result of this work.
Building on this work, an intervention was developed and evidence suggests that the workshop led to managers having more awareness of their behaviour, the upward feedback that they received was particularly helpful in this process (Donaldson-Feilder, Lewis & Yarker, 2009). The results suggested that feedback from others plays a critical role in enabling managers to improve their behaviour.
A further study conducted an evaluation of the implementation of the manager development toolkit within organisations (Donaldson-Feilder & Lewis, 2011). The results showed that for these interventions to be successful how the intervention fits into the broad organisational strategy needs to be considered, there needs to be a good relationship between the leaders of the different activities and the context of the intervention within the organisation is also critical.
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