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1. The Changing Nature Of Work And The Role Of Stress
The nature of work has changed considerably over the past several decades in economically advanced societies. Industrial mass production no longer dominates the labor market. This is due, in part, to technological progress, in part to a growing number of jobs available in the service sector. Many jobs are conﬁned to information processing, controlling, and coordination. Sedentary rather than physically strenuous work is becoming more and more dominant. New management techniques, including quality management, are introduced, and economic constraints produce work pressure, rationalization, and cut-down in personnel. These changes go along with changes in the structure of the labor market. More employees are likely to work on temporary contracts, on ﬁxed term, or in ﬂexible job arrangements. The workforce is getting older, and an increasing proportion of women enters the labor market, with an increase of double exposure among women with children or, more generally, in dual career families. Most importantly, overemployment in some segments of the workforce is paralleled by underemployment, job instability, or structural unemployment in other segments. This latter trend currently hits the economically most advanced societies as well as economies that lag behind. Overall, a substantial part of the economically active population is conﬁned to insecure jobs, to premature retirement, or job loss.
Why is work so important for human well-being, and how does work contribute to the burden of stress and its adverse eﬀects on health? In all advanced societies work and occupation in adult life are accorded primacy for the following reasons. First, having a job is a principal prerequisite for continuous income and, thus, for independence from traditional support systems (family, community welfare, etc.). Increasingly, level of income determines a wide range of life chances. Second, training for a job and achievement of occupational status are the most important goals of socialization. It is through education, job training, and status acquisition that personal growth and development are realized, that a core social identity outside the family is acquired, and that goal-directed activity in human life is shaped. Third, occupation deﬁnes an important criterion of social stratiﬁcation. Amount of esteem in interpersonal life largely depends on type of job and level of occupational achievement. Furthermore, type and quality of occupation, and especially the degree of self-direction at work, strongly inﬂuence personal attitudes and behavioral patterns in areas that are not directly related to work, such as leisure or family life (Kohn and Schooler 1983). Finally, occupational settings produce the most pervasive continuous demands during one’s lifetime, and they absorb the largest amount of active time in adult life, thus providing a source of recurrent negative or positive emotions. It is for these reasons that stress research in organizations where paid work takes place is of particular relevance.
It is important to recognize that traditional occupational hazards, such as exposure to toxic substances, heat, cold, or noise, are no longer the dominant challenges of health at work. Rather, distinct psychological and emotional demands and threats are becoming highly prevalent in modern working life. There has been a recognition that the importance of work goes beyond traditional occupational diseases and, indeed, it is likely that work makes a greater contribution to diseases not thought of as ‘occupational’ in conventional terms. At a descriptive level, recent reports ﬁnd that, for instance, almost half of the workforce are exposed to monotonous tasks or lack of task rotation; 50 percent work at a very high speed or to tight deadlines. Thus, overand underload at work are highly prevalent. Every third employee has no inﬂuence on work rhythm, and every ﬁfth is exposed to shiftwork (Paoli 1997). There is now growing awareness among all parties of the labor market that psychosocial stress at work produces considerable costs, most importantly a high level of absenteeism, reduced productivity, compensation claims, health insurance, and direct medical expenses. Permanent disability and loss of productive life years due to premature death add to this burden. In the European Union, the costs of stress to organizations and countries are estimated to be between 5 and 10 percent of GNP per annum (Cooper 1998). At the same time scientiﬁc evidence on associations between psychosocial stress at work and health is growing rapidly.
2. Concepts Of Work-Related Stress And Selected Findings
Research on psychosocial work-related stress diﬀers from traditional biomedical occupational health research by the fact that stressors cannot be identiﬁed by direct physical or chemical measurements. Rather, theoretical models are needed to analyze the particular nature of the psychosocial work environment. A theoretical model is best understood as a heuristic device that selectively reduces complex reality to meaningful components. Components are meaningful to the extent that they provide the material from which the researcher can deduce explanations and, thus, produce new knowledge. Ideally, a theoretical model of psychosocial stress at work with relevance to health should encompass a wide variety of diﬀerent occupations and should not be restricted to a speciﬁc time or space.
Before describing some prominent theoretical models of occupational stress, the basic terminology needs to be clariﬁed. Much critique has been raised against the ambiguity of the term ‘stress.’ To avoid this, the following terms were suggested: ‘stressor’ is deﬁned as an environmental demand or threat that taxes or exceeds a person’s ability to meet the challenge; ‘strain’ is deﬁned as the person’s response to such a situation in psychological and physiological terms. Psychological responses include speciﬁc cognitions and negative emotions (e.g., anger, frustration, anxiety, helplessness), whereas physiological responses concern the activation of the autonomic nervous system and related neuro-hormonal and immune reactions. Stressors, in particular novel or dangerous ones, are appraised and evaluated by the person, and as long as there is some perception of agency on the part of the exposed person eﬀorts are mobilized to reverse the threat or to meet the demands. Such eﬀorts are termed ‘coping,’ and they occur at the behavioral (even interpersonal), cognitive, aﬀective, and motivational level. Clearly, when judging strain, the quality and intensity of a stressor as well as the duration of exposure have to be taken into account, as well as individual diﬀerences in coping and in vulnerability to strain reactions. Recent research indicates that only part of human strain reactions are subject to conscious information processing, whereas a large amount bypasses awareness. The term ‘stressful experience’ is introduced to delineate that part of aﬀective processing that reaches consciousness. Stressful experiences at work are often attributed to adverse working conditions by exposed people themselves. While they usually refer to some common sense notions of stress, it is crucial to note that these attributions diﬀer from the explanatory constructs of stressful experience at work that have been identiﬁed by science.
2.1 Person–Environment Fit
The ﬁrst signiﬁcant contribution to modern occupational stress research dates back to studies conducted more than 30 years ago at the Institute for Social Research at the University of Michigan. They were guided by a theoretical concept termed ‘person–environment ﬁt’ (Caplan et al. 1980). Stressful experience at work, in this model, is conceptualized in two ways: ﬁrst, as an experience where the work environment does not provide adequate supplies to meet the person’s needs; second, as an experience where the abilities of the person fall short of demands that are prerequisite to receiving supplies. In both conditions stressful experience results from a misﬁt between needs or abilities of the working person and demands or opportunities of the work environment. Further job opportunities may fail to fulﬁll the person’s needs as a consequence of unmet demands. As an example, a worker with limited skills is excluded from any promotion prospects, although, to meet his level of living, he badly needs better pay.
This approach represents a type of theorizing that is termed process theory. As such, it is applicable to a wide range of work but does not specify the particular content dimensions on which person and environment should be examined (Edwards et al. 1998). As its basic terms are rather broad, it may be diﬃcult to reach a consensus on how to measure core constructs. Nevertheless, person–environment ﬁt oﬀers an elaborate set of propositions of how critical constellations of work-related environmental and personal characteristics contribute to the development of stressful experience. At the empirical level, most up-to-date studies have tested adverse eﬀects on subjective health. Therefore, it is not quite evident to what extent these types of misﬁt are capable of eliciting sustained physiological strain and thus contribute to the development of bodily disease.
2.2 Demand, Support, And Control
The argument of how strain reactions aﬀect physiological regulation has received special attention in a second inﬂuential contribution to current occupational stress research that focuses on the theoretical construct of control. Animal stress research and psycho-physiological experiments in humans conﬁrmed the critical impact on physiological and psychological strain reactions produced by lack of control in a challenging situation (Frankenhaeuser 1979, Henry and Stephens 1977). Control is deﬁned as the ability of a person to choose their own actions to cope with a challenge. In the workplace it ranges from task autonomy to participation in decision making, and strain evolves from challenging situations at work that leave the person with limited choice on how to react. This idea was elaborated in terms of the demand–control model of occupational stress by Karasek (Karasek and Theorell 1990, see Occupational Health). This model posits that strain is contingent on the combined eﬀects of high demand and low control; though both high demands and low control may also have independent additive eﬀects on strain and health.
Stress research based on the concept of control resulted in several important discoveries. First, it was shown that physiological strain reactions are not uniform, but may vary according to the degree of perceived control. For instance, stressful experience in terms of striving without success was found to elicit strain reactions that exert particularly harmful eﬀects on the cardiovascular system (Kaplan et al. 1983). Second, epidemiologic studies on work-related control and health, most importantly in the framework of the demand–control model, help explaining the social distribution of some major chronic diseases, especially coronary heart disease (CHD). An inverse social gradient of CHD has been documented. Exposure to low control jobs is more frequent among lower status groups as is the prevalence of CHD. In fact, recent studies found evidence that a considerable part of the social variation in CHD is attributed to adverse psychosocial work conditions (Marmot et al. 1999). Finally, research on control at work has put special emphasis on coping resources, in particular the buffering eﬀects produced by social support. Strain reducing eﬀects of social support are due to positive experience resulting from social relationships at the instrumental, emotional, and cognitive level (House 1981). This evidence has implications both for a broader conceptualization of occupational stress (e.g., the revised demand–support–control model (Karasek and Theorell 1990)) and for the design of workplace intervention measures.
2.3 Eﬀort And Reward
In physiological terms, theories of control at work deal with the experience of power and inﬂuence which, at the psychological level, is paralleled by feelings of autonomy and self-eﬃcacy. An alternative model of stressful experience at work, the model of eﬀort– reward imbalance, is concerned with distributive justice, that is, with deviations from a basic ‘grammar’ of social exchange rooted in the notions of reciprocity and fairness (Siegrist 1996). This model assumes that eﬀort at work is spent as part of a socially organized exchange process to which society at large contributes in terms of rewards. Rewards are distributed by three transmitter systems: money, esteem, and career opportunities including job security. The model of eﬀort–reward imbalance claims that lack of reciprocity between costs and gains (i.e., high ‘cost’ low ‘gain’ conditions) elicits sustained strain reactions. For instance, having a demanding, but unstable job, achieving at a high level without being oﬀered any promotion prospects, are examples of high cost low gain conditions at work. In terms of current developments of the labor market in a global economy, the emphasis on occupational rewards including job security reﬂects the growing importance of fragmented job careers, of job instability, underemployment, redundancy, and forced occupational mobility including their ﬁnancial consequences.
According to this model, strain reactions are most intense and long-lasting under the following conditions: (a) lack of alternative choice in the labor market may prevent people from giving up even unfavorable jobs, as the anticipated costs of disengagement (e.g., the risk of being laid-oﬀ) outweigh the costs of accepting inadequate beneﬁts; (b) unfair job arrangements may be accepted for a certain period of one’s occupational trajectory for strategic reasons; by doing so employees tend to improve their chances for career promotion at a later stage; (c) a speciﬁc personal pattern of coping with demands and of eliciting rewards characterized by overcommitment may prevent people from accurately assessing cost–gain relations. ‘Overcommitment’ deﬁnes a set of attitudes, behaviors, and emotions reﬂecting excessive striving in combination with a strong desire for being approved and esteemed (Siegrist 1996). At the psychological level, experience of eﬀort–reward imbalance is often paralleled by feelings of impaired self-worth or self-esteem.
2.4 Empirical Evidence
Evidence of impaired health due to exposure to stressors that are deﬁned by the concepts described is growing rapidly. In particular, a number of well-designed prospective social-epidemiological studies found moderately elevated relative risks (two-to threefold) of incident CHD in economically active middle-aged men and women who were suﬀering from high demand/low control or eﬀort–reward imbalance. Other health eﬀects observed in prospective and cross-sectional studies concern distinct cardiovascular risk factors, gastrointestinal symptoms, mild psychiatric disorders, poor subjective health, and musculo-skeletal disorders. In addition, rates of absenteeism are elevated (Marmot et al. 1999). There is also evidence of changes in physiological patterns, release of stress hormones, and altered immune competence following stressful experience at work. Taken together, the burden of illness that can be attributed, at least in part, to exposure to an adverse psychosocial work environment turns out to be impressive. While further research is needed to address important issues, practical implications of this new evidence deserve special attention.
3. Practical Implications And Future Directions
Overall, worksite health promotion activities are realized with little concern about scientiﬁc advances obtained in the ﬁeld of occupational stress research. Eventually, this may change in the future as all three models described in the last paragraph (as well as additional models not mentioned in detail, for summary see Cooper 1998) provide a rationale for evidence-based preventive activity. Person–environment ﬁt theory concludes that work demands need to be tailored according to the worker’s abilities. This involves both speciﬁc measures of organizational development and person development. Moreover, organizational interventions must suit the needs of aﬀected individuals that are closely linked to the work role (e.g., motivation, learning, satisfaction; Edwards et al. 1998). In the demand–support–control model, special emphasis is put on autonomy, skill discretion, and personal growth. Measures of work reorganization include job enlargement, job enrichment, skill training, enhanced participation, and teamwork (Karasek and Theorell 1990). Practical implications of the eﬀort–reward imbalance model concern the development of compensatory wage systems, the provision of models of gain sharing, and the strengthening of nonmonetary gratiﬁcations. Moreover, ways of improving promotional opportunities and job security need to be explored. Supplementary measures are interpersonal training and skill development, in particular leadership behavior.
Clearly, the power of economic life and the constraints of globalization limit the options and range of worksite health promotion measures. Moreover, such measures are diﬃcult to apply to medium-sized and small enterprises where the majority of the workforce in advanced societies is employed. Finally, it must be stated that many instrumental activities that qualify as work are no longer conﬁned to the conventional type of workplace located within an enterprise or organization, particularly with the advent of advanced communications technology (Cooper 1998).
3.1 Future Challenges For Research
There are at least three obvious future directions for occupational stress research. First, the theoretical concepts of stressful experience at work discussed need to be examined in a comparative perspective, with emphasis on their potential overlap or cumulative eﬀects. For instance, recent studies found independent statistical prediction of the demand–control and the eﬀort–reward imbalance model when tested simultaneously (Marmot et al. 1999). Moreover, the estimation of health risk was considerably improved when based on combined information derived from both models.
A second direction of research addresses the link or interface between work and nonwork settings, in particular work and family. In advanced societies work and family have been identiﬁed as the two most central domains, especially so in midlife. Therefore, stress-enhancing and stress-buﬀering experiences in these two domains signiﬁcantly contribute to personal health and well-being. This interface is conceptualized in terms of spillover, compensation, or cumulation. Spillover refers to the transfer of experience and behavior from one domain to the other. For instance, work overload or shiftwork schedules may have negative eﬀects on family life. Alternatively, experience of competence and success at work can have beneﬁcial eﬀects on marital life and relationships between parents and children (Kohn and Schooler 1983). Compensation represents eﬀorts to reduce stressful experience in one domain by improving satisfaction in another domain. For instance, leisure and family activities are enhanced to the extent that decreasing involvement in a stressful work environment is feasible. Compensation often occurs in terms of resource management in a stressful situation. In conceptual terms, there is some overlap between the buﬀering model of social support and compensation processes (House 1981). Cumulation refers to the fact that the critical components of stressful psychosocial experience, such as lack of control or eﬀort–reward imbalance, generalize across core life domains. For instance, disease vulnerability may be highest among people with insecure, badly paid, eﬀortful jobs who also live in a family arrangement that oﬀers little emotional and material satisfaction. It is desirable to extend the theoretical models discussed, both conceptually and operationally, to life domains other than work.
A third direction of research concerns intervention studies. The implementation and evaluation of theorybased intervention is a promising area for creating new knowledge although it is admitted that established methodological principles of scientiﬁc trials cannot be fully met. Recent theory-based intervention studies have documented favorable health eﬀects (Cooper 1998, Karasek and Theorell 1990, Siegrist 1996, see Occupational Health). In view of the importance of work for health, it is well justiﬁed to advance the ﬁeld of occupational stress both at the science and policy level.
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