SafetyDog

Stressors, Strains and Moderators

In I-O Psychology on September 21, 2010 at 9:46 pm

Since staff stress is often mentioned in regard to safety issues in healthcare I thought I would post an overview of some theories of stress.

General Adaptation Syndrome
Seyle identified what is known as the stress response (Landy & Conte, 2010). This response follows the same process in humans whether the source of the stressor is physiological or psychological. This process is known as General Adaptation Syndrome (GAS) and has three stages (Landy & Conte, 2010). In the alarm reaction stage the body prepares to deal with the stressor by releasing hormones that control processes such as heart rate. In the resistance stage the body focuses on the original stressor and copes with that, however responses to any other stressors are lowered (Landy & Conte, 2010). The final stage is exhaustion and in this stage the body decreases all responses to stress (including the original source) and becomes susceptible to psychological and physiological diseases/syndromes (Landy & Conte, 2010). One of the consequences of this stage in terms of the workplace can be the development of burnout. Burnout is an extreme state of psychological strain that occurs from prolonged exposure to stress which exceeds one’s ability to cope (Landy & Conte, 2010). The three components of burnout are emotional exhaustion, depersonalization and low personal accomplishment. The Maslach Burnout Inventory (MBI) is a tool that is validated to measure burnout in nurses (Diestel & Schmidt, 2010).
Lazarus and Folkman theorized that in addition to the GAS theory there is a cognitive appraisal of the situation as well as an appraisal of the resources one has to handle the stressors (Landy & Conte, 2010). Thus the GAS can be modified by coping styles which can be classified as problem-focused coping or emotion-focused coping (Landy & Conte, 2010). These individual coping styles can also be applied to the workplace. The problem- oriented coping attempts to review the source of the stressor and develop actions to solve the problem (Landy & Conte, 2010). Emotion oriented coping is more of a secondary method to control the emotional response to the stressor.
Demand Control Model
In terms of workplace related stress, there is the Demand Control Model developed by Karasek in which there are two domains of job stress: job demands and job control (Landy & Conte, 2010). In this model, stressors strains and modifiers are described in terms of their relationships to demands and control. Job strain is theorized to be at its most intensity when there is high demand and low control. Likewise job strain is believed to be moderated when there are high demands but also a high level of control (Landy & Conte, 2010). The lowest strain jobs are those with high control and low demand (Landy & Conte, 2010). This model has been used to study nurses and researchers have found a correlation between high demand/low control situations and illness as well as an increase usage of personal health care services (Landy & Conte, 2010)
Moderating Stress in the Workplace
In Conservation of Resources (COR) theory resources are defined as the objects, personal characteristics, conditions or energies that act as conduits to gaining or protecting valued resources (Drach-Zahry, 2010). In this theory, Hobfoll argues that stress occurs as a result of a threat to resources, an actual loss of resources or a deficit between what resources are expended in the workplace and what resources are replenished (Drach-Zahary, 2010). Stress over time as viewed from these three tenets often leads to emotional exhaustion which is a key tenet to burnout (Drach-Zahary, 2010; Landy & Conte, 2010). This situation also leads to employees acting with caution in investing new resources leading to another component of burnout which is low personal accomplishment. Making changes to the workplace that replenish resources can decrease stress in employees even when the demands of service are high.

Reducing Stress
Primary Reducers of Stress
Primary reducers of stress work on modifying the stressors in the work environment (Landy & Conte, 2010). These can include work redesign as well as cognitive restructuring (Landy & Conte, 2010). In hospital nursing there often exists a high demand/low control scenario as caring for patients is a high risk, physically and emotionally demanding job that is guided by protocols and standards, leaving little room for personal control. Using the tenets of Demand Control Model applied to Nursing, an I-O psychologist would want to increase nurses’ control over the inherently high demand environment. One way to do this would be to hold staff meetings that were primarily focused on discussions of ways to increase autonomy and implement the suggestions. Using tenets of the GAS theory, the I-O psychologist would want to redesign systems that were causing distractions and interruptions. One such intervention would be to replace simple portable phones which nurses may carry with phones that were capable of text and internet access. Areas of an inpatient unit, such as the medication preparation room and the nurses’ conference room, could also be designated as interruption free zones.
Secondary Reducers of Stress
Secondary reducers of stress do not focus on eliminating the stressor but focus on the elimination of the response to the stressor (Landy & Conte, 2010). Staffing ratios are one source of stress and perception of adequate staffing is as important as objective staffing ratios (Schmalenberg & Kramer, 2009). Nurses’ perception of staffing can be reduced through recurring staff huddles where competing priorities can be discussed. The stressors will still be in the environment but as a group the staff can make a plan for dealing with them. Tracking emotional exhaustion using a tool such as the MBI in nurses can also prompt intervention before the situation progresses to a burnout situation.
Tertiary Reducers of Stress
Tertiary reducers of stress do not focus on elimination of stress but rather healing from the consequences of chronic stress (Landy & Conte, 2010). COR theory might be useful in tertiary stressor plans as stress is reduced when the environment can replenish some lost personal resources (Drach-Zahary, 2010). One way to replenish resources is through service climate. Organizations with a high service climate tend to remove obstacles that cause workarounds, provide job training and provide assistance with tasks (Drach-Zahary, 2010). These same tenets can be applied to units or individuals who have become emotionally exhausted. A final intervention that would assist in healing those under chronic stress would be a schedule or program that facilitated sleep. Sleep of six hours or less is correlated with an increase in reporting of work stress including increased perceived workload and levels of emotional stress (Rutledge, Stucky, Dollarhide, Shively, Jain, Wolfson, Weinger, et.al, 2009).

An I-O psychologist would be useful in assisting nursing management with reducing stress in the workplace by intervening on workflow designs, identifying stressors, creating a climate that is conducive to replenishing personal and group resources and in evaluating any type of burnout prevention program a hospital wishes to initiate. The I-O psychologist could also be instrumental in conducting workplace research on stress in nursing staff. Klumb, Elfering, & Herre (2009) recommend that the I-O psychologist use ambulatory assessment (AA) which encompasses “all methods that assess individual experience and behavior when and where they occur in daily life” (p. 120). Using AA the I-O psychologist can study the individual using objective and subjective methods. The authors cite this method as an effective method to study work strain and coping with work stressors (Klumb, Elfering & Herre, 2009). An example of this would be to have a nurse wear a HR monitor or a body fit monitor while observing them administer medications, documenting the interruptions and risks noted in the task.

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