Exposure to Stress in Hospitals

Occupational stress has been a long-standing concern of the health care industry. Studies indicate that health care workers have higher rates of substance abuse and suicide than other professions and elevated rates of depression and anxiety linked to job stress.

In addition to psychological distress, other outcomes of job stress include burnout, absenteeism, employee intent to leave, reduced patient satisfaction, and diagnosis and treatment errors.

The purpose of this article is to

identify the sources of occupational stress,

identify the adverse health effects of occupational stress, and

recommend work practices to reduce occupational stress.

What causes occupational stress?

The National Institute for Occupational Safety and Health (NIOSH) defines occupational stress as “the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker.”

The following workplace factors (job stressors) can re­sult in stress:

Job or task demands (work overload, lack of task control, role ambiguity)

Organizational factors (poor interpersonal rela­tions, unfair management practices)

Financial and economic factors

Conflict between work and family roles and re­sponsibilities

Training and career development issues (lack of opportunity for growth or promotion)

Poor organizational climate (lack of management commitment to core values, conflicting communi­cation styles, etc.)

Stressors common in health care settings include the following:

Inadequate staffing levels

Long work hours

Shift work

Role ambiguity

Exposure to infectious and hazardous substances

Stressors vary among health care occupations and even within occupations, depending on the task being per­formed.

In general, studies of nurses have found the following factors to be linked with stress:

Work overload

Time pressure

Lack of social support at work (especially from supervisors, head nurses, and higher management)

Exposure to infectious diseases

Needlestick injuries

Exposure to work-related violence or threats

Sleep deprivation


Role ambiguity and conflict


Career development issues

Dealing with difficult or seriously ill patients

Among physicians, the following factors are associated with stress:

Long hours

Excessive workload

Dealing with death and dying

Interpersonal conflicts with other staff

Patient expectations

Threat of malpractice litigation

The quality of patient care provided by a hospital may also affect health care worker stress. Beliefs about whether the institution provides high quality care may influence the perceived stress of job pressures and workload because higher quality care maybe reflected in greater support and availability of resources.

What are the potential adverse health effects of occupational stress?

Stress may be associated with the following types of re­actions:

Psychological (irritability, job dissatisfaction, de­##pression)

Behavioral (sleep problems, absenteeism)##

Physical (headache, upset stomach, changes in ##blood pressure)

An acute traumatic event could cause post traumatic stress disorder (PTSD). Not every traumatized person develops full-blown or even minor PTSD. 4

Although individual factors (such as coping strategies) and social resources can modify the reaction to occupa­tional stressors to some degree, working conditions can play a major role in placing workers at risk for develop­ing health problems.

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 deci­##sions and actions affecting their jobs

Improve communication##

Reduce uncertainty about career development and ##future employment prospects

Provide opportunities for social interaction among ##workers5

The most commonly implemented organizational inter­ventions in health care settings include

team processes,

multidisciplinary health care teams, and

multi-component interventions.

Team process or worker participatory methods give workers opportunities to participate in 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 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, and


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 intervention will 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


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. 7

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 workers deal with stress more effectively, they do not remove the sources of workplace stress, and thus may lose effectiveness over time.