Cause of stress among HCWs not what it may seem
Major stressor in health care today: Loss of control
Hospital health care workers experience high levels of stress that one might attribute to the nature of their work -- caring for the critically ill and injured, making life-and-death decisions, or remaining at the ready for emergencies. Yet experts say the actual causes of the often debilitating stress among HCWs are not due as much to the type of work they do as to the organizational changes sweeping hospitals and health care systems today.
Hospital mergers, downsizings, acquisitions, and other re-engineerings often create an institutional change of identity that is accompanied by an identity crisis for employees. (See related story on employee problems resulting from mergers and downsizings, Hospital Employee Health, February 1996, pp. 13-19.) Add to that the changes associated with managed health care systems, and the result is employees' perceived -- or actual -- loss of control over their jobs and careers.
"Working with life and death is a normal stressor for health care workers," says Charla Parker, MPA, CEAP, administrative director of behavioral health services at Mills Peninsula Health Services in Burlingame, CA, and administrative liaison with the employee assistance program (EAP) at four hospitals. "You're trained to deal with that. Critical care nurses, for example, have a greater feeling of control in those situations because they are highly trained technical experts. They know what treatments to administer and how to take care of patients. It's not the nature of the work that's stressful -- it's the loss of control."
The external control exerted by third-party payers is a major stressor in health care today, Parker says.
"Every clinical decision is second-guessed by an outside third party, so there is a total loss of autonomy among health care providers," she states.
Physicians and nurses are not the only ones affected. Hospital re-engineering affects personnel across the board because all functions often are redesigned. Parker's hospital recently went through a major merger, becoming part of a 24-hospital system.
"In our organization, we used to have [separate] housekeeping personnel, unit coordinators, and medical records personnel. Now all of those functions are redesigned, and a person who is called a patient service representative is doing all of them," she says. "Housekeepers are now going through training to become certified nursing assistants, so the person who is at the bedside not only takes your temperature but empties your trash as well."
The experience of change-induced stress comes down to the employee's level of control over the changes, which often is minimal or nonexistent.
'Change can become overwhelming'
"The biggest mistake made by people in health care today is worrying about things they cannot control," says Donald N. Lombardi, PhD, principal partner with the Center for Human Resources/ InterVista in Mt. Arlington, NJ, and author of Thriving In an Age of Change (Chicago: Health Administration Press; 1996) and Stress in the Health Care Environment (Chicago: Health Administration Press; 1990).
"Because they are perfectionists, people in health care try to control everything. They can get very frustrated if something doesn't work out exactly right, but all you can control nowadays is how hard you work and the integrity you put into it. [Health care systems] are changing a lot, but it gives health care workers the chance to learn something new every day. They need to see change as invigorating, or it can become overwhelming," Lombardi says.
Signs that change-induced stress has become overwhelming include alterations in physical appearance, dress, work habits, personal habits such as smoking and caffeine consumption, physical fitness, attitudes, decisiveness, and perspectives, he notes.
Illness and injury could result if employees don't receive help in coping with ongoing workplace stress, Parker adds. (See related story, p. 77.)
As both an EAP counselor and a workers' compensation case manager at another hospital, Parker tracked HCW injuries and found that workers who had second injuries also frequently had emotional problems that needed treatment in the EAP.
"We set up a procedure whereby all employees who had an injury, no matter how small, were automatically referred from occupational health to the EAP," she says. "There was no blame or discrimination because they were referred [with the explanation that] being injured can be stressful. We then found a statistically significant difference in the occurrence of second injuries."
Hospital EAPs can provide services on three levels, Parker points out:
* They can serve as consultants to the organization on stress-causing conditions and what to do about them.
* They can offer classes and workshops on stress management and coping with change.
* They can provide short-term individual counseling.
Sometimes, employees refer themselves to an EAP for help, but referrals often come from employee health departments, Parker notes. Employee health practitioners can recognize workers who might benefit from EAP referrals by using simple psychological assessment tools (see the stress measurement test and the "change checklist," both inserted in this issue) or recognizing physiological symptoms. (See related story on p. 78.)
Address work environment problems
But another expert warns hospitals not to use EAPs and other counseling resources for sufferers of stress instead of addressing the workplace conditions causing the stress.
"Don't take work environment problems and try to deal with them in ways that aren't connected intimately with the work environment," says Eileen McNeely, PhD, MS, NP, C, a faculty member at the Boston University School of Public Health in the School of Medicine, department of environmental health, who researched job stress among front-line hospital HCWs for her doctoral dissertation.1
"EAPs or counseling groups or occupational health clinics that advocate personal lifestyle changes -- although they might help fortify someone to deal with the stresses of everyday work -- do little to change the work conditions," she maintains. "Change has to be in the immediate work environment rather than what we think of as these add-on programs. Those are very helpful for certain kinds of issues, but sometimes they are used in place of changing the design of work."
McNeely points out that hospitals do not approach other occupational hazards that way, but instead use a hierarchy of controls -- first trying to engineer the hazard out, then trying to limit worker exposure to it through administrative controls, and finally fortifying the workers with personal protective equipment only if the first two controls fail.
"But we don't do that at all with psychosocial stressors, and they are more threatening because we're cleaning up the dirty workplaces, and now we're in much more of a service economy with more psychosocial exposures than physical exposures," McNeely says.
Psychosocial stress can lead to injuries
Stress is an "ominous threat," she adds. "Stress has traditionally been seen as something we should live with, but we don't do that for physical kinds of assaults. We need to rethink that approach. What allows stress to be treated that way is that we all have our own filters that make each of us more or less vulnerable to stress. But you can say that for any hazard, such as chemical exposures. One person might be more resilient than the next, but there's a point at which we are all going to burst."
McNeely points out that injuries can result from psychosocial stress that exceeds the bursting point.
For her dissertation, McNeely studied several Boston-area hospitals. Hospital A had instituted seemingly effective interventions such as stress management support groups, lifting schools, an EAP, back support belts, and had union representation. Nevertheless, the low-back injury rate among workers there was three times higher than for workers at Hospital B that did not provide those services.
Using a stress-measurement tool, McNeely found that HCW stress and depression levels were higher at Hospital A than at Hospital B.
"You would think that one hospital would be much more worker-friendly or healthier than the other, when in fact if you're looking beyond the physical, it was dramatically more sick. The major differences between the two hospitals were the psychosocial conditions of work. [Hospital A's] workers had less control, less support, and reported more psychological demands," she says.
The main issue fueling worker stress is feeling unable to control the conditions of work, particularly the quality of patient care, she notes.
While McNeely says she can't prove that hospital downsizing and restructuring have worsened stress, "it sounds as though it has if you talk to workers," she notes. "They talk about how much more out of control they are in terms of resources. What is particularly disconcerting to people on the front line is that they have no control over the quality of patient care, and that the quality is not what they would like it to be. Care providers are very invested in the purpose of their work, and when they can't deliver the care according to quality standards, it is very upsetting."
Those concerns have been increasing since managed care systems have begun changing health care delivery. Patients are sicker but are discharged more quickly, while patient-to-staff ratios are higher.
McNeely suggests giving workers more control over their jobs -- but not just any kind of control. There are two kinds of control, she explains. First, "Horizontal control" gives workers increased ability to make decisions about conditions of their work such as scheduling or how they might carry out a doctor's order.
"But there's another kind of control that's probably more important and that is vertical control, which is conditioned over the resources at work [and includes] staffing and budgeting decisions," she says. "Horizontal control is control within the job, while vertical control is control over the job," she explains.
Hospitals usually do not relinquish vertical control "despite all the talk about continuous quality improvement and total quality improvement which are supposed to empower front-line workers more. Despite all that rhetoric, things often don't change," she states. "The answer to giving employees more control over quality of patient care is to change those lines of control or revamp the primary care model to put the reality of the work environment more in line with worker expectations."
In 1992, Minneapolis-based Northwestern National Life Insurance Company (NWNL) surveyed 1,300 full-time employees to examine workplace stress, the toll it takes on workers, and its cost to employers. An NWNL report published that year states that the "clear-cut costs to employers can be measured in terms of high employee turnover, absenteeism and stress-related health and disability claims, but hidden costs -- lower productivity and diminished customer service -- compound the growing problem of too much job stress."2
Job stress is the result of two key ingredients, according to the report: a high level of job demands and too little control over one's work.
To combat the growing problem of job stress and burnout, NWNL developed a tool that employers can use to measure stress-related organizational problems, says NWNL spokeswoman Arlene Wheaton.
Wheaton relates some of the information discovered by the NWNL survey:
* Employees who feel their job is highly stressful are twice as likely to think about quitting than those who do not report high stress levels.
* Employees who report high work stress levels are twice as likely to burn out than those who do not find their jobs highly stressful.
* One-third of workers experience frequent stress-related physical or mental conditions that could increase health costs.
* Half of workers say job stress reduces their productivity.
* Employees who have supportive supervisors report significantly lower rates of burnout and stress, less illness, fewer missed work days, and are less likely to think of quitting.
Barbara Blair, MSN, RN, CS, an assistant professor at the School of Nursing of the Medical College of Pennsylvania and Hahnemann University in Philadelphia, says HCW stress has increased since hospitals became more competitive and determined to keep costs down by slashing staff and resources.
"There was a time [nurses] never had to worry about their jobs. They felt very secure just having that RN after their name, but that's not necessarily true anymore," says Blair, who also is a private practice psychotherapist with many nurse clients. "I tell people to have confidence in their skills. Keep that resume ready and keep your skills and flexibility in the forefront instead of depending upon the employer. That will help ensure that you can get another position."
Work-related stress is a major problem for nurses and other hospital personnel, Blair notes.
"They're on overload, and it has to do with the expectation that they should do more with less time and resources," she says. "If their lives are out of balance in other areas, that just compounds the stress until it can get to a crisis level."
Blair advises workers with high stress levels to "focus energy on what they have control over and give up the things that they don't." Stress management and self-care activities also are important. (See related story, p. 80.)
NIOSH to study stress of downsizing
The effect of downsizings and restructurings on employee stress and health has not escaped the notice of researchers at the National Institute of Occupational Safety and Health (NIOSH). NIOSH researchers are about to launch a year-long study to examine companies' downsizing processes and their stress-related effects on employee health, says Lawrence R. Murphy, PhD, a senior research psychologist in the division of biomedical and behavioral science in Cincinnati.
"Many companies are downsizing, and we're not convinced that they're doing it properly with respect to their employees," Murphy tells HEH. "They can add up the numbers and figure how it's going to affect profitability, but the assumption always is that the job survivors will be functioning at the same levels or maybe better than they were before. However, based on anecdotal evidence, our hunch is that the survivors are under a lot of stress, not only because of increased workload, but also guilt that they retained their jobs while a lot of their co-workers didn't and fear of losing their jobs in the future."
Murphy says the researchers will analyze whether the way companies downsize can either increase or decrease stress and how that stress can affect employee health.
"NIOSH has always considered stress a significant problem," he adds. "We think stress is an insidious hazard. Unlike some other hazards, it respects no occupational boundaries. It affects all aspects of a worker's life."
References
1. McNeely E. In the Shadow of the Organization: Work and Well-being on the Front Line, A Comparative Study of Employee Health in Hospitals. Ann Arbor, MI: University of Michigan Press; 1995.
2. Northwestern National Life Insurance Co. Employee Burnout: Causes and Cures. Minneapolis: NWNL; 1992. *
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