Measuring on-the-job stress accurately.

Measuring job stress is difficult but there are some useful generic tools available. A New Zealand study using one such tool revealed high levels of stress in a regional women's health service. But the tool could be developed further by including items particular to New Zealand workpalces.

GLASS mercury thermometers have the habit of breaking and dispersing their contents. The potentially poisonous mercury runs about and defies efforts to pick it up. Measuring occupational stress is a bit like chasing mercury--it's both apparent and elusive. Is the job causing stress, or are stressed individuals poisoning the work environment? Finding the boundaries that exist between occupational and personal stress issues is difficult. (1) Like permeable membranes that allow substances to cross sides depending upon the amount of pressure exerted, occupational stress has the potential to cross over to other spheres of our lives, affecting what we think, feel and do, and the people we interact with. And, of course, stress can flow in the opposite direction, ie, from our personal lives to intrude on our work.

Finding and maintaining a balance between dysfunctional or "poisonous" stresses and the little stresses that are a normal and helpful part of everyday life is crucial to our wellbeing. If an individual, health professional is stressed, from whatever source, then the potential for spillover into patient care is real and needs to be dealt with. (2,3) Even small stressors can have a cumulative effect on the individual. When groups of people are involved in caring for patients, then this spillover from occupational stress can be multiplied: (4,5,6) a stressed individual can infect and negatively influence other people on the team. The recent introduction of the Health and Safety in Employment Amendment Act shows the Government's advisers have, perhaps belatedly, recognised some of the negative implications of occupational stress. (7)

Stress does involve very personal, elements. What is perceived as stress and how the person responds to that stress is reflective of personality, knowledge and support systems, so is deeply personal. (8,9) As well, stress means different things to different people on different days (like mercury, it's amorphous). What's more, it can be embarrassingly revealing--people feel diminished when they react negatively to stress, and many managerial, systems punish people who show stress symptoms, while rewarding those who seem oblivious to it. Accordingly, when studying a large group of people in their work environment, it is essential to guarantee confidentiality and anonymity.

The measuring tool, the job stress survey (3%) used in the research study (10) will be described. However, one of the prime objectives of this article is to raise questions around the measurement of job stress, and how this can be made more meaningful for New Zealand workplaces. In a small country with changing health environments and limited resources, a tool is required that provides local insights. Arguably, every workforce has its own idiosyncratic nature.

The study itself involved sending questionnaires, following approval from the ethics committee, to all staff (193) who had worked at a regional women's health service for a minimum of six months. The mailed package contained the JSS, the General Health Questionnaire (GHQ-12), demographic questions (including cultural. safety), shift work questions, and a blank page for "qualitative comment". Over 12,000 pieces of data were collected from the study but this article focuses only on the results of the JSS.

The Job Stress Survey

The JSS was chosen as it has "simplicity and face validity". (11) These are appealing features for busy staff, encouraging them to participate. Knowing that the JSS has been carefully engineered and tested is clearly important, and it is equally important that the toot is seen to have use to respondents (face validity being a real plus here), otherwise the strength of the study is likely to be diminished. (12)

In designing the JSS, job stress researchers Vagg and Spielberger, drew from their review of occupational stress measuring tools in the psychological literature from 1975-1996. They sought a questionnaire addressing generic, job-related stressor events. A recommendation (13) that both the intensity and frequency of job stressors become integral components of occupational stress measurement tools was honoured, with the JSS emerging as a tool for assessing both the perceived severity and the frequency of genetic work stressors that cause psychological strain. Occupational stress researcher Dewe conducted a study on the stress of New Zealand nurses in 1986. (14)

The JSS can be used to determine a "job stress index" and can also be used to measure "job pressure" and "lack of organisational support".

Each of these aspects can be examined at an individual level, or for a group as a whole. The JSS contains 30 items describing job-related stressor events. In applying the tool, the JSS asks the respondent to rate, on a nine-point scale, the perceived severity of each stressor event, by comparing it to a standard stressor, eg assignment of disagreeable duties, with a midpoint value of five. (15) The respondent is asked to compare each of the 30 items relative to this stressor.

The job stress index is calculated by multiplying the "severity rating", from 1 (no stress) to 9 (extremely stressful), by its "frequency rating", which is based on the number of days the stress occurred in the last six months, on a scale from 0 (did not occur) to 9 (occurred on nine or more days).

The job stress index result varies from 0 (no stress, or no days) to 81 (extremely stressful on 9 or more days). Therefore, low numbers mean Less stress, less often, while high numbers (maximum 81) mean high stress, very often.

The job stress index works on two levels: first, the result is an indicator of the perceived stress level for each item; and second, as a collective average of the 30 items surveyed. Each of these two measures of job stress can then be examined in order to look at a group as a whole.

For this study, job stress index scores were calculated and organised by occupational groupings. The occupational groups included (in order of numbers of staff): midwives; nurses; medical staff; therapists (social workers, physiotherapists, ultra-sonographers); support-aides; and clerical staff. The overall level of occupational stress experienced by the respondents in these groupings is shown in Table 1 (see above).

As can be seen from the table, the range of values is very large in almost every case. Either there was a huge difference in people's perceived levels of stress, or people were interpreting the questions and answers in very different ways, or both (the mercury effect?). As noted earlier, just one or two people in any group can affect the morale of the group, producing stress of varying degrees. (3)

Within the 30 items of job stress surveyed, the "job pressure index" and "lack of organisational support index" consist of 10 items each. These two sub-scales provide a more specific focus. The 10 stressors in the job pressure index reflect stressful aspects of the job's structure, design or duties. The 10 stressors in the lack of organisation support index reflect events involving other people or organisational policies or procedures, rather than specific aspects of the job itself.

The job pressure index sub-scale asks about such items in the workplace as:

* performing tasks not in job description;

* excessive paperwork;

* frequent interruptions;

* frequent changes from boring to demanding activities; and

* insufficient personal time, eg coffee breaks, lunch.

In contrast, the lack of organisational support index sub-scale looks outwards from the individual at, for example:

* fellow workers not doing their job;

* lack of recognition for good work;

* inadequate or poor quality equipment;

* lack of participation in policy-making decisions; and

* poor or inadequate supervision.

The highest scoring five responses (of the 30 possible) to the JSS items are shown in Table 2 (see p13). The five stressors identified are ranked in priority, according to the average scores for each professional group. It's evident that unacceptably high levels of stress were encountered regularly.

For the sake of brevity, the results for midwives, nurses and doctors are detailed for occupational groupings and comparison. All three groups cited inadequate or poor quality equipment, excessive paperwork, insufficient personal time, and frequent interruptions, as their top stressors. Three of these four stressors fall within the job pressure index.

Implications for practice

In 2004, especially with the emerging focus on primary health care and its underlying self-determining philosophies, it is crucial that patients receive equally therapeutic care, whether in hospital or the community. Health and well-being is only achievable through informed and responsive care in all health sectors. For nurses, both within hospitals and in the wider community, teamwork, effective communication (backed by technical support), and, ideally, emotional intelligence, interact to reduce stress. (4,16)

So, is the JSS useful? Perhaps the strength of the JSS is that it is a straightforward tool that units/areas can use in order to determine general issues affecting morale, thereby promoting discussion and effecting change. The survey served as a catalyst for changes at the regional women's health service. These changes included: extensive discussions; equipment being updated; management being made aware of the depth of concern felt by staff; the creation of a place for staff to have personal time; and coping intervention strategies were initiated. (18) Now, the challenge is to further develop the JSS so this tool is of increased relevance to health staff throughout the country.

The JSS does measure aspects of job stress. However, given the potential peculiarities of the New Zealand health system, other items could be surveyed concerning job stress here. Some examples of this are: difficulties with clients; interprofessional, conflict; professional self-doubt; role conflict; unqualified staff numbers; reduced time for service users; job security; concerns related to the particular client groups; and pay relativities. (19)

Research has shown that the most effective way of managing stress is to tackle the problem at several levels. (19) We need to accept that the mental health of staff is an important issue that should be integrated into each organisation's health and safety policy. Workplace stress should become as outmoded as smoking (or mercury thermometers) in hospitals.

The time has come to develop our own slant on generic tools, such as the JSS. Its authors acknowledge the limitations of the JSS and recognise that no generic measure of job stress can evaluate stressors unique to a particular work setting. They support additional items being constructed and administered to assess stressors that are idiosyncratic to a particular occupational group. (15) After all, the more we are able to hone in on the mercurial effects of stress, the better equipped we will be to develop, in our individual workplaces, meaningful stress management interventions.

Hospitals (and communities) are very complex and demanding health environments. Nurses' occupational stress needs to be addressed in order to deliver effective therapeutic patient care to both the individual and the community at large. It is contrary to our raison d'etre as health professionals to leave stress symptoms alone just because they are so hard to pick up, or to let the poisons of stress wreak havoc on or among us, with a resulting fallout on patient care.

Table 1: Job stress scores by occupation (for midwives, nurses
and doctors only). NB: For each index, no stress equals 0 and
maximum stress equals 81.

OCCUPATION    N       JOB STRESS          JOB PRESSURE
                      INDEX (JS-X)        INDEX (JP-X)

                      Median    Range     Median    Range

Midwifery     57      31        2-62      35        4-71
Nursing       22      23        9-39      23        5-57
Medicine      16      24        3-54      31        4-57

OCCUPATION    N       LACK OF SUPPORT
                        INDEX (LS-X)

                      Median    Range

Midwifery     57      24        2-65
Nursing       22      19        3-50
Medicine      16      15        0-60

Table 2: The five top most stressful job-related events. NB:
1st equals most stressful and 5th equals least stressful of the
top five stressors.

STRESSFUL JOB-RELATED EVENTS      PRIORITY RANKING 1-5 (JS-X)

                                  Midwifery     Nursing       Medicine
Inadequate or poor quality
equipment                         5th           1st           2nd

Excessive paperwork               4th           3rd           1st

Insufficient personal time
(eg coffee breaks, lunch)         1st           2nd           5th

Frequent interruptions            2nd           4th           3rd

Insufficient personnel to
handle an assignment              3rd

Experiencing negative attitudes
to the organisation                                           4th

Inadequate salary                               5th

References

(1) Cox, T., Griffiths, A. & Rial-Gonzalez (2005) Research on work-related stress. http://agency.osha.eu.int/publications/reports/stress/full.php3

(2) Leiter, M.P., Harvie, P. & Frizzell, C. (1998). The correspondence of patient satisfaction and nurse burnout. Social Science and Medicine; 47: 10, 1611-1617.

(3) Randle, J. (2003) Bullying in the nursing profession. Journal of Advanced Nursing; 43:4, 395-401.

(4) Humpel, N., Caputi, P. & Martin, C. (2003) The relationship between emotions and stress among mental health nurses. Australian and New Zealand Journal of Mental Health Nursing; 10, 55-60.

(5) Sitzia, J. & Wood, N. (1997) Patient satisfaction: a review of issues and concepts. Social Science and Medicine, 45:12, 1829-1843.

(6) Wheeler, H.H. (1997) Nurse occupational stress research 3: a model of stress for research. British Journal of Nursing, 6:16, 944-949.

(7) Scott-Howman, A. & Walls, C. (2003) Workplace Stress in New Zealand. Auckland: Thomson Brookers.

(8) Birch, L. (2001) Stress in midwifery practice: an empirical study. British Journal of Midwifery; 9:12, 730-734.

(9) Norbeck, J.S. (1985) Types and sources of social support for managing job stress in critical care nursing. Nursing Research; 34:4, 225-230.

(10) Brinkman, S.A. (2000) A Study into the causes and effects of occupational stress in a regional women's health service. Unpublished master's thesis for Victoria University of Wellington.

(11) O'Roark, A.M. (1995) Occupational stress and informed interventions. In Spielberger, C.D., Sarason, I.G., Brebner, J.M.T., Greenglass, E., Laungani, P. & O'Roark, A.M. (Eds.), Stress end emotion: Anxiety. Anger, and Curiosity; 15, 121-135. Washington, DC: Taylor & Francis

(12) Vagg, P.R. & Spielberger, C.D. (1998) Occupational stress: Measuring job pressure and organizational support in the workplace. Journal of Occupational Health Psychology, 3:4, 294 305.

(13) Dewe, P.J. (1989) Examining the nature of work stress: Individual evaluations or stressful experiences and coping. Human Relations; 42, 993-1013.

(14) Dewe, P.J. (1986) The causes and consequences of stress in nurses: A Report. Wellington: NZNA

(15) Spielberger, C.D. & Vagg, P.R (1998) Manual for the Job Stress Survey: Professional Manual. Florida: Psychological Assessment Resources.

(16) Jeanneau, M. & Armelius, K. (2000) Self-image and burnout in psychiatric staff. Journal of Psychiatric and Mental Health Nursing; 7, 399-406.

(17) Personal communications from regional women's health service staff, 2000-2004.

(18) Edwards, D. & Burnard, P. (2003) A systematic review of stress and stress management interventions for mental health nurses. Journal of Advanced Nursing; 42,2, 169-200.

This article was reviewed by Kai Tiaki Nursing New Zealand's editorial review committee in May 2004.

Anne Brinkman, RCpN, BA, BN, MA Appld (Nursing), is a lecturer at the School of Health Sciences, Massey University, Wellington Campus.

Brian Caughley, MSc, is a senior lecturer at the Institute of Food, Nutrition and Human Health, Massey University, Wellington Campus.