RESEARCH PAPER

Research Paper #1

Adam Ingram

MBA 6200

Prof. Don Eskew

February 9, 2016

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Stress and Management in the Healthcare Workplace

My research paper will be focusing on emotional, mental, and overall stressors within the

healthcare workplace and subsequent management styles and practices to help regulate and

deescalate a variety of stressful scenarios that can arise after examining how these stressors arise

and our managed on an individual basis.

Article Summaries:

Fiabane, E., Giorgi, I., Sguazzin, C., & Argentero, P. (2013). Work engagement and

occupational stress in nurses and other healthcare workers: The role of organizational and

personal factors. Journal of Clinical Nursing, 22 (17-18) , 2614-2624.

Fiabane et. al were looking to identify the role of organizational and personal factors that

would predict engagement in healthcare workers, as well as, compare work engagement and

occupational stress perceptions of healthcare professional categories (Fiabane et al., 2013).

Compared to other professions, healthcare workers have been shown to have a higher risk of

developing emotional distress related to job stress, as well as, becoming burnout, developing

anxiety and depression, and having an increased risk of suicide and substance abuse (Thomsen et

al., 1999; Weinberg & Creed, 2000; McVicar, 2003; Akvardar et al., 2004; Escribà-Agüir et al.,

2006; Pompili et al.; 2006; Lindsay et al., 2008; Lim et al., 2010; Laranjeira, 2011; Fiabane et

al., 2013). Due to the such risks as mentioned, it is important to identify which factors can hinder

and also improve healthcare personnel well-being within the workplace, in order both to prevent

occupational diseases and to increase the quality of performance, as well as, increase the

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effectiveness of the clinical practice and the competitiveness of the organizations (Fiabane et al.,

2013).

To study this, Fiabane et al. studied (n=110) healthcare professionals on the correlation

of work engagement, organizational factors (workload, control, reward, community, fairness, and

values), and personal factors (type A personality, locus of control, job satisfaction, mental health,

and physical health)- these factors were selected based off of literature that had identified these

as related to occupational stress and burnout (Fiabane et al., 2013). Surprisingly, Fiabane et al.

illustrated that there is an important (p < 0.001) association between personal factors and the

energy and involvement dimensions, while the relation with professional efficacy was weak

(Fiabane et al., 2013).

These results show that the relation between personal factors and workplace stressors are

significantly higher than those related between professional efficacy and workplace stressors.

This has great implications in the executive healthcare area because it illustrates the need for

more personal development and personal trainings related to the workplace (mediation outside of

work, depression and anxiety counseling outside of work, access to physical well-being

resources outside of work), instead of workplace core values training (Fiabane et al., 2013). The

main conclusion was that to improve work engagement and to protect nurses and other

healthcare staff from the risk of developing occupational stress and burnout, their results

suggested that workload and lack of resources should primarily be focused on to for intervention

to deescalate occupational stressors and burnout (Fiabane et al., 2013).

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Haraway, D. L., & Haraway, W. M. (2005). Analysis of the Effect of Conflict-Management and

Resolution Training on Employee Stress at a Healthcare Organization. Hospital Topics,

83 (4) , 11-17.

Conflict is inevitable, not only in healthcare, but everywhere. Data indicates that mangers

spend approximately 30% to 40% of their workday, everyday, dealing with some form of

conflict [it is suggested that for healthcare organizations, managers spend approximately 45% to

73% of their workday, everyday, dealing with some form of conflict] (Thomas, 2002; Haraway

& Haraway, 2005). Kagan, Kagan, and Watson (1995), in their study of stress reduction in the

healthcare field, conceptualized workplace stress as “the emotional, mental, and behavioral

reaction to vulnerability caused by elements in the job environment that are . . . out of the

awareness of the worker (Kagan, Kagan, and Watson, 1995).” They maintain that, because of the

unpredictable environment “and ambiguity of job definition by the public and medical staff at

hospitals,” healthcare professionals and staff are “especially vulnerable to job-related stress

(Kagan, Kagan, and Watson, 1995).” Their study indicates that professional conflict

management and resolution training can reduce workplace stress by providing interpersonal

awareness and skills for coping with people. Simply put, “health care leaders are recognizing that

proficiency at identifying sources of friction before trouble flares up, and at managing and

resolving disputes that do break out, is an essential part of their executive ‘toolbox’ (Kagan,

Kagan, and Watson, 1995; Weber 1999).”

Haraway and Haraway recognized the need [as it was long overdue, more than ten years

had passed since the recognition of occupational burnout and stress] for healthcare managers to

be able to add to their “toolbox,” as put by Webber (1999), specifically in the nature of

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managerial conflict resolution for staff and for patients. To do so, Haraway and Haraway

conducted a conflict-management and resolution training class of (n=36) hospital mangers,

directors, or supervisors that consisted of a pre test, six hours of conflict management training

spread over two days within the same week, and then a subsequent post test to be administered

one month after the second day of training (Haraway & Haraway, 2005).

The results presented by Haraway and Haraway indicated that conflict management and

resolution training does make a difference (Haraway & Haraway, 2005). As well, outside of the

standardized paired T-tests, interpersonal strain subtests were also used- overall scores were

decreased [scoring high on the interpersonal strain subtest frequently (Haraway & Haraway,

2005).

Farquharson, B., Allan, J., Johnston, D., Johnston, M., Choudhary, C., & Jones, M. (2012).

Stress amongst nurses working in a healthcare telephone-advice service: Relationship

with job satisfaction, intention to leave, sickness absence, and performance. Journal of

Advanced Nursing, 68 (7), 1624-1635.

Farquharson et al. were out to study levels of stress in nurses who worked in a healthcare

telephone-advice service [diagnostic, poison control, insurance based, etc.] and the relation of

stress to performance, sickness absence, and intention to leave (Farquharson et al., 2012). The

background of the study was based off of knowing that call-centered workers are under immense

stress, as well, knowing that healthcare workers [specifically nurses] were also under immense

levels of stress in their facilities; therefore, stress associated with call-centre nursing may lead to

stress associated implications for nurses, patients, and service provisions (Farquharson et al.,

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2012). This study by Farquharson et al. was the first study published examining stress levels

within call-centered healthcare workers (Farquharson et al., 2012).

An interesting aspect of the paper focuses on the pure nature of call-centered based

healthcare [as] they work largely independently with few opportunities for interaction with

colleagues. Theory would suggest that such a combination of low control, high demand, and low

social support would generate stress, which was determined to be true by Farquharson et al.

(Karasek et al. 1998; Farquharson et al., 2012). Farquharson et al. go on to talk about how nurses

cannot predict the nature of the calls they will receive, [they] are required to help patients with a

wide range of symptoms varying from minor to life-threatening. [Some of the hardest parts of

non-face-to-face interactions are] there are potentially grave consequences should a nurse fail to

recognize a patient with a serious illness [should the patient be unable to dictate over the phone

what is happening]. The nature of the calls may also be emotionally demanding [compared to in

person interactions]. Nurses may be required to suddenly deal with distressing issues such as

suicide or child abuse. All calls are recorded and call-center technology means that nurses’

performance can be monitored closely, a practice which can be perceived negatively (Lankshear

et al. 2001, Snooks et al. 2007). Furthermore, a feature of these services is that they provide

access to healthcare at times when GP [general practice] surgeries are closed (known as the ‘out

of hours’ period) and so are busiest [for call-center nurses] in the evenings, overnight, weekends,

and during public holidays. This means that nurses are required to work mostly unsocial hours,

another factor which may be associated with increased stress (Coffey et al. 1988).

The study was conducted over the course of a year, between March 2008 and March

2009, each participant (n=152) was given self-report assessments [GHQ-12, PANAS, Work-

Family Conflict Scale, 10-item JSS, Intention to leave employment from one to four {1-no

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intention to leave, 4- I intend to leave within 24 hours}, Sickness Absence days were measured,

Work Performance data relating to eight key performance targets] before the study and then

again at the end (Farquharson et al., 2012)

The paper concluded that overall levels of stress amongst nurses working in a telephone

health advice line were comparable to those found in the general population, unlike levels of

stress found in other studies of nurses, as well as, work-family conflict was a significant

predictor of a job satisfaction and intention to leave employment, and was related to sickness

absence amongst nurses working in a telephone health advice line (Farquharson et al., 2012).

Saleem, M., Tufail, M. W., Atta, A., & Asghar, S. (2015). Innovative Workplace Behavior,

Motivation Level, and Perceived Stress among Healthcare Employees. Pakistan Journal

of Commerce and Social Sciences, 9 (2) , 438-446.

Saleem et al. were studying the levels of workplace stress and motivation levels amongst

healthcare workers (n=100) through three highly valid scales: Perceived Stress Scale (PSS),

Motivation Questionnaire (MQ), and Innovative Work Scale (IWS) (Saleem et al., 2015). This

study is actually the most recent [as of January, 2016], conclusive study examining healthcare

workplace stress management and how it affects levels of motivation. The results of the study

indicated that there is a highly significant inverse relationship (

b=−0.461 ; r2=0.212 , p−value=0.05¿ that exists between perceived stress and motivation [of

doctors and nurses only]- thus conclusively leading to the potential negative effect of perceived

stress on motivation and innovative work behavior among health care employees (Saleem et al.,

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2015). As motivation levels significantly affect the performance of employees, Saleem et al.

point out that internally driven, highly motivated employees perform well and behave in a

positive manner, as well, in contrast, those with a higher PSS level rate lower on the MQ and

general performance evaluation. Saleem et al. go on to note that it is responsibility of

administration of management to facilitate their employees in terms of less stressful and

conducive working, reason being, to create a highly workable environment that allows for the

maximum level of motivation for those employees (Saleem et al., 2015).

Magnavita, N. (2014). Workplace Violence and Occupational Stress in Healthcare Workers: A

Chicken-and-Egg Situation-Results of a 6-Year Follow-up Study. Journal of Nursing

Scholarship, 46 (5) , 366-376.

Occupational stress and workplace violence are both everyday concerns in the

healthcare industry- more so than any other industry (Farquharson et al., 2012; Magnavita,

2014). However, no study had addressed the cause and effects of workplace violence that is

associated with work-related stress (i.e. occupational stress). Dr. Nicola Magnavita, MD

conducted a long-term (2003- 2009) study that focused on healthcare workers’ (n=698) work-

related stress and aggression reporting through the Demand/Control/Support (DCS)

Questionnaire, Violent Incident Form, Goldberg Questionnaire, and 12-Item General Health

Questionnaire (Magnavita, 2014). Dr. Magnavita concluded that [similar to Farquharson et al.

and Haraway & Haraway] job strain and lack of social support were predictors of the occurrence

of nonphysical aggression, whereas workplace violence was reported by those with the highest

level of strain and lowest support at work from management- those that went through prolonged

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states of strain were more likely to report social isolation and higher levels of violence at work

(Magnavita, 2014). The results of this study may very well lead to subsequent designs and

intervention programs that are implemented for the prevention of violence in healthcare

facilities, as work-related stress and workplace violence are bidirectional, measures that

intervene in both of these areas would hopefully lead to a reduction overall of workplace

violence, occupational stress, and an increase in job satisfaction (Magnavita, 2014).

In reporting of workplace violence, almost all physical aggression reports were

exclusively patients or visitors to the healthcare facility, subsequently, nonphysical aggression

was more common- but it was still almost exclusively patients or visitors to the healthcare

facility. However, the occurrence of workplace violence perpetrated by colleagues or superiors

were severely-underreported; only “in exceptional cases was a report made to the Accident and

Emergency Department, the Health Department, or the police (Magnavita, 2014).” Healthcare

workers who experience some type of workplace violence in the previous year(s) were at a

higher risk for work-related stress (evaluated through the DCS Questionnaire), as well as, having

low social support from management (Magnavita, 2014).

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Combined Article Importance:

As a healthcare professional, my views on stress within the healthcare workplace,

healthcare workforce are first-hand; however, the above articles help delve into and support the

argument that stress amongst healthcare workers is generally higher than most professions. This

notion of having higher levels of stress within healthcare is critical to understand for managers,

administrations, and executives- because the ones experiencing the highest levels of stress are the

employees that have the greatest levels of interaction with patients and visitors (i.e. patient care

assistants, nurses, doctors).

These five articles exhibit a clear, understandable, and distinct view of stress in a

healthcare setting. Each paper narrows down a very large notion of what stress within the

healthcare workplace is; although there is overlap between papers, they all support each other.

In my opinion, the conclusions can be summarized into one as such:

Within the healthcare workplace, the relationship of occupational stress, motivational

levels, and social support from management at the workplace are a tight wound trichotomy, each

one influences the other and vice versa. Healthcare managers need to fully understand this as

trichotomy versus a dichotomy, because if one of the three elements is left out- the overall

performance and motivation of the employee may be negatively impacted quickly- leading to

whirl wind effect on other coworkers. This negative impact may be higher perceived levels of

workplace stress, higher levels of workplace violence, and increased depression and anxiety from

a lack of social support at work.

Our overall understanding of stress within the healthcare workplace has expanded

greatly and into more depth from 2005 to 2015; however, the conclusions made ten years ago,

are still valid today- indicating that stress within the healthcare workplace is consistently high.

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The results from these papers can easily be shared and applied to healthcare

executives’ framework. Due to their methodology involving active healthcare practices and

employees, the results gained can be indicated to be similar around the healthcare industry. A

note to be made, however, because all of the studies did not include vastly large sample sizes (n

> 500), the results should be applied to large organizations with the understanding that the results

may not be as aggressive as those found within the studies. Though implementation (regardless

of field or area) is generally a tricky situation, I believe that conflict-resolution classes, discussed

by Haraway & Haraway, are supported by the other four articles- indicating the need for more of

a managerial based reduction of occupational stress and increased amount of social support.

Because these papers do not specifically target emergency medical service (EMS)

providers, they do not directly relate to my profession; however, it is my belief that the patterns

of low motivation-high perceived stress, that I witness, can be more than likely applied to EMS.

As I share this information with my managers at work, I’m hoping that there can be a significant

take away for them- that is subsequently implemented into my company to reduce occupational

stressors and improve company morale.

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References

Akvardar Y., Demiral Y., Ergor G. & Ergor A. (2004) Substance use among medical students and physicians in a

medical school in Turkey. Social Psychiatry and Psychiatric Epidemiology, 39, 502–506.

Coffey L.C., Skipper J. & Jung F. (1988) Nurses and shiftwork: effects on job performance and job-related stress.

Journal of Advanced Nursing, 13, 245–254.

Escriba`-Agu¨ ir V., Martı`n-Baena D. & Pe´rez- Hoyos S. (2006) Psychological work environment and burnout

among emergency medical and nursing staff. International Archives of Occupational and Environmental

Health, 80, 127–133.

Farquharson, B., Allan, J., Johnston, D., Johnston, M., Choudhary, C., & Jones, M. (2012). Stress amongst nurses

working in a healthcare telephone-advice service: Relationship with job satisfaction, intention to leave,

sickness absence, and performance. Journal of Advanced Nursing, 68(7), 1624-1635.

Fiabane, E., Giorgi, I., Sguazzin, C., & Argentero, P. (2013). Work engagement and occupational stress in nurses

and other healthcare workers: The role of organizational and personal factors. Journal of Clinical Nursing,

22(17-18), 2614-2624.

Haraway, D. L., & Haraway, W. M. (2005). Analysis of the Effect of Conflict-Management and Resolution Training

on Employee Stress at a Healthcare Organization. Hospital Topics, 83(4), 11-17.

Karasek R.A., Gordon G., Pietrokovsky C., Frese M., Pieper C., Schwartz J., Fry L. & Schirer D. (1998) The Job

Content Questionnaire (JCQ): an instrument for internationally comparative assessments of psychosocial

job characteristics. Journal of Occupational Health Psychology, 3, 322–355.

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Lankshear G., Cook P., Mason D., Coates S. & Button G. (2001) Call center employees’ responses to electronic

monitoring: some research findings. Work, Employment and Society, 15, 595–605.

Laranjeira C.A. (2011) The effects of perceived stress and ways of coping in a sample of Portuguese health workers.

Journal of Clinical Nursing, 21, 1755– 1762.

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Nursing Review, 57, 22–31.

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working in regional public hospitals. Australian Journal of Rural Health, 16, 194–200.

Magnavita, N. (2014). Workplace Violence and Occupational Stress in Healthcare Workers: A Chicken-and-Egg

Situation-Results of a 6-Year Follow-up Study. Journal of Nursing Scholarship, 46(5), 366-376.

McVicar A. (2003) Workplace stress in nursing: a literature review. Journal of Advanced Nursing, 44, 633–642.

Pompili M., Rinaldi G., Lester D., Girardi P., Ruberto A. & Tatarelli R. (2006) Hopelessness and suicide risk

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Psychiatric Nursing, 20, 135–143.

Saleem, M., Tufail, M. W., Atta, A., & Asghar, S. (2015). Innovative Workplace Behavior, Motivation Level, and

Perceived Stress among Healthcare Employees. Pakistan Journal of Commerce and Social Sciences, 9(2),

438-446.

Snooks H., Williams A.M., Griffiths L.J., Peconi J., Rance J., Snelgrove S., Sarangi S., Wainwright P. & Cheung

W.-Y. (2007) Real nursing? The development of telenursing. Journal of Advanced Nursing, 61, 631–640.

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Thomsen S., Soares J., Nolan P., Dallender J. & Arnetz B. (1999) Feeling of professional fulfilment and exhaustion

in mental health personnel: the importance of organisational and individual factors. Psychotherapy and

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