SLR Course Paper - Analyzing and Visualizing Data
REVIEW
Reducing work related psychological ill health and sickness absence: a systematic literature review S Michie, S Williams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Occup Environ Med 2003;60:3–9
A literature review revealed the following: key work factors associated with psychological ill health and sickness absence in staff were long hours worked, work overload and pressure, and the effects of these on personal lives; lack of control over work; lack of participation in decision making; poor social support; and unclear management and work role. There was some evidence that sickness absence was associated with poor management style. Successful interventions that improved psychological health and levels of sickness absence used training and organisational approaches to increase participation in decision making and problem solving, increase support and feedback, and improve communication. It is concluded that many of the work related variables associated with high levels of psychological ill health are potentially amenable to change. This is shown in intervention studies that have successfully improved psychological health and reduced sickness absence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
L evels of ill health, both physical and psycho- logical, and associated sickness absence are high among those working in health care in
the UK.1 2 This problem is not unique to the UK.3
Poor psychological health and sickness absence are likely to lead to problems for patients in that both the quantity and quality of patient care may be diminished. Because most health care is provided by staff working in teams, ill health and sickness absence in any one individual is likely to cause increased work and stress for other staff.
Several explanations have been put forward for this high level of ill health, including the nature of the work, organisational changes, and the large amounts and pressure of work.
4 A comparison across UK hospitals in the public sector found that rates of psychological ill health varied from 17% to 33%, with lower rates in hospitals charac- terised by smaller size, greater cooperation, better communication, more performance monitoring, a stronger emphasis on training, and allowing staff more control and flexibility in their work.
5 This supports the notion that organisational factors may contribute to the level of psychological ill health experienced by staff.
To tackle the problem of work related psycho- logical ill health, evidence is needed about the work factors associated with psychological ill health and sickness absence, and about interven- tions that have been implemented successfully to
prevent or reduce psychological ill health and
sickness absence. The primary focus of this
review is the association between work factors
and psychological ill health among health care
staff. However, because of the paucity of evidence
in health care, 1 evidence was reviewed across all
work settings, although presented separately for
health care workers where appropriate.
METHODS Our review method was based on that used by the
NHS Centre for Reviews and Dissemination.6 This
method involves a systematic examination of
selected databases using a variety of strategies,
including keywords and subject headings. It
allows the integration of quantitative data across
studies, where they have similar outcome meas-
ures, and the summary of findings where
methods used are diverse.
Identification of papers Four electronic databases were used: Medline
(1987–99), PsychInfo (1987–99), Embase (1991–
99), and the Cochrane Controlled Trials Register
(1987–99). Relevant papers up to and including
1997 were selected from a larger study. 1 The
search strategy in the larger study was of MeSH
key words and text words in each of three catego-
ries: work factors; staff; and ill health/
absenteeism/economic consequences. The search
included all types of employment and all devel-
oped countries but was limited to abstracts in
English. Secondary references were chosen from
the primary paper references and by contacting
academics researching this area. Psychological ill
health included measures of anxiety, depression,
emotional exhaustion, and psychological distress
(“stress” was excluded since it is a mediating
hypothetical construct rather than an outcome
measure of psychological ill health). For the pur-
pose of this review, papers from 1998 and 1999
were identified using the same search strategy,
but excluding physical ill health and economic
consequences.
Selection criteria Abstracts were selected for retrieval of the paper if
they were judged to include data about both work
factors and psychological ill health or absentee-
ism. Dissertations were excluded, as were studies
of very specific staff groups or settings, work pat-
terns (for example, shift working), or events (for
example, violence). All abstracts were selected
independently by two researchers (three re-
searchers were involved in this activity). The per-
centage of abstracts for which two researchers
agreed about inclusion and exclusion varied
See end of article for authors’ affiliations . . . . . . . . . . . . . . . . . . . . . . .
Dr S Michie, Reader in Clinical Health Psychology, Centre for Outcomes Research and Effectiveness, Department of Psychology, University College London, Gower Street, London WC1E 6BT, UK; s.michie@ucl.ac.uk
Accepted 14 May 2002 . . . . . . . . . . . . . . . . . . . . . . .
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between 80% and 90%. Disagreements were resolved by
discussion.
Information extraction Information from papers was extracted and coded within the
following categories: study aim, study design, type of study
population (for example, occupational group), sampling strat-
egy, sample size and response rate, demographic characteris-
tics, type of intervention, type of study measure, main
outcomes, and summary of results.
Further selection criteria Coded papers excluded from the review were studies with:
volunteer or inadequately described sample; response rate of
less than 60%; no standardised measures of psychological
outcome.
RESULTS Of the studies identified as part of the larger study,1 40 were
selected for this study (34 associations and six interventions).
A further nine studies meeting the above selection criteria
were identified in the period 1998–99, all of associations. No
studies were found in the Cochrane Controlled Trials Register.
The results are summarised in tables 1–4.
Because these studies were diverse in terms of outcomes
and measures used to assess these outcomes, a meta-analysis
was not appropriate.
Associations with work The results are presented in three groups: health care workers
in the UK, health care workers in other developed countries,
and non-health care workers. This enabled an assessment of
whether associations between work factors and psychological
ill health are similar across sector and country.
Health care In the UK, factors associated with psychological ill health in
doctors, from junior to senior grades, are long hours worked,9
high workload and pressure of work,7 16 11 and lack of role
clarity12 (table 1). Pressure of work has also been found to be
associated with poor mental health in dentists.10 In family
doctors, the issues were interruptions during and outside sur-
gery hours and patient demands.16
Among UK nurses, the most frequently reported source of psychological ill health was workload pressures.17 Distress in student nurses has been caused by low involvement in decision making and use of skills, and low social support at work.13 In a study of health care workers across job type, bul- lying was found to be prevalent, carried out mainly by manag- ers and associated with both anxiety and depression.14 Of the two studies addressing sickness absence, one found a negative association with job demands,13 while the other found no association with control over work.15
Similar factors are associated with psychological ill health in health care workers in the rest of Europe, the USA, and Australia (table 2). The one study of doctors found an associ- ation between work control and social support and psycho- logical distress.22 Among nurses, lack of co-worker support,24 27 job influence,26 and organisational climate and role ambiguity28 were associated with psychological distress. Among other hospital workers, work overload and pressure, role ambiguity, lack of control over work, and lack of participation in decision making were all found to be associated with distress.18 20 25
Sickness absence was associated with work pressures and lack of training,23 unsupportive management style,21 role ambiguity, tolerance of absenteeism, and low pay.19
Beyond health care The picture among non-health care workers in Europe and the
USA was similar to that of health care workers (table 3). The
Table 1 Summary of observational studies of associations between work factors and ill health: health care workers in UK
Study Design Participants Response rate Work factors Outcomes Results
Agius et al, 19967
Cross sectional 375 consultant doctors
75% Work demands Emotional exhaustion (MBI)
High academic work demands associated with low emotional exhaustion (r=−0.14, p<0.05)
Baglioni et al, 19908
Cross sectional 475 senior nurses 80% Workload Mental health (CCEI) No association
Baldwin et al, 19979
Longitudinal 142 junior doctors 95% Long hours Psychological distress (GHQ-28)
No association overall; association with somatic symptoms, r=0.24
Cooper et al, 198810
Cross sectional 484 dentists 85% Time pressures, pay stressors and technical problems
Mental health (CCEI) Time pressures, pay stressors and technical problems associated with poor mental health (respective Bs=0.24, 0.20, 0.12; F=20.54, p<0.001)
Deary et al, 199611
Cross sectional 333 consultant doctors
67% Clinical workload Psychological distress (GHQ-28), emotional exhaustion (MBI)
High clinical workload associated with emotional exhaustion (χ2 for model=30.31, p=0.11, satisfactory fit)
Heyworth et al, 199312
Cross sectional 201 trainee and consultant doctors
72% Task clarity, supportive communication
Depression (CES-D) Task clarity and supportive communication associated with lower depression (r=−0.51 and −0.36 respectively, p=0.0001)
Parkes, 198213 Experimental 164 student nurses 97% Job demand, discretion, social support
Anxiety (GHQ), depression (CCEI), sickness absence
Anxiety and depression associated with low job discretion and job support (r=−0.30 and −0.35 for anxiety and −0.26 and −0.36 for depression) and job demand was negatively associated with sickness absence (r=−0.24)
Quine, 199914 Cross sectional 1100 health care workers
70% Bullying Anxiety, depression (HADS)
Bullying associated with higher anxiety (30% v 9%, p<0.001) and depression (8% v 1%, p<0.001)
Rees and Cooper, 199215
Cross sectional 1176 health care workers
67% Control over work (OSI)
Sickness absence No association
Sutherland and Cooper, 199316
Cross sectional 917 family doctors 61% Job demands Anxiety, depression and somatic anxiety (CCEI)
Associations with anxiety (beta=0.17) depression (beta=0.28) and somatic anxiety (beta=0.23)
Tyler and Cushway, 199217
Cross sectional 72 nurses 60% Workload, conflict, social support
Psychological distress (GHQ 28)
GHQ predicted by managing the workload (beta=0.32)
4 Michie, Williams
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key work factors associated with psychological ill health were:
work overload and pressure31 34 36 39–40 41 47 48; conflicting de-
mands47; lack of control over work and lack of participation in
decision making34 36 37 39 40 46–48; poor social support at
work31 33 35 38 39 41 47 48; unclear management and work
role29 30 41 34 38; interpersonal conflict42 46; and conflict between
work and family demands.46 Long hours were found to be
associated with depression in women, but not in men.44
Sickness absence was negatively associated with high job
demand,45 and positively associated with monotonous work,
not learning new skills and low control over work,36 37 45 and
non-participation at work.43
Evaluated interventions Six intervention studies met our methodological criteria
(table 4). Three were randomised controlled trials,49 50 52 three
were conducted in the USA,50 51 54 one in the UK,53 and two in
Scandinavia.49 52 Three were of health care workers.50 52 54 Five
were training programmes offered as part of the working day
and one was an organisational intervention.53
Skills to mobilise support at work and to participate in
problem solving and decision making were taught to care staff
of people with mental ill health or mental disability in a ran-
domised controlled trial.50 Groups of 20 had six sessions of 4–5
hours training over two months, and were trained to train
those in their workplace. Compared to those in the control
group, the intervention group reported more supportive feed-
back, more ability to cope, and better work team functioning
and climate. Among those most at risk of leaving, those
undergoing the training reported reduced depression. The
second randomised controlled trial compared receiving
support, advice, and feedback from a psychologist with having
the passive presence of the same psychologist at staff meetings
in a geriatric hospital facing organisational change.52 Staff
were taught skills of stress management, and how to partici-
pate in, and control, their work. The intervention was an hour
a fortnight during the 10 weeks before, and the 10 weeks after,
the organisational change. There was a significant difference
between groups, with a decrease of stress hormone levels in
the intervention group.
Staff of a psychiatric hospital were taught verbal and non-
verbal communication and empathy skills. 54 Groups of 6–8 had
eight hour weekly sessions for four weeks involving infor-
mation, videos, modelling, and role playing. Compared to a
matched control group, the intervention group showed
reduced staff resignations and sick leave, although no statisti-
cal tests are reported.
Among physically inactive employees of an insurance com-
pany, a randomised controlled trial found stress management
training and aerobic exercise interventions had mixed
Table 2 Summary of observational studies of associations between work factors and ill health: health care workers in developed countries beyond the UK
Study Country Design Participants Response rate Work factors Outcomes Results
Arsenault et al, 199118
Canada Cross sectional 760 hospital workers
Not reported
Professional latitude, clinical demands, workload problems, role difficulties
Mental strain including depression (Cobb) and anxiety (STAI)
Low professional latitude (F=12.7, p<0.001) and high workload problems (F=4.5, p<0.04) and role difficulties (F=31.6, p<0.001) associated with mental strain
Brooke and Price, 198919
USA Cross sectional 425 hospital workers
74% Routinisation, centralisation, pay, reward policy, role ambiguity, conflict, overload, organisational tolerance of absenteeism
Absenteeism High role ambiguity and tolerance of absenteeism, low pay and low centralisation predicted absenteeism (structural coefficients 0.21, p<0.001; 0.27, p<0.001; −0.11, p<0.05; −0.19, p<0.02, respectively)
Estryn-Behar et al, 199020
France Cross sectional 1505 female hospital workers
90% Mental load, insufficient training, time pressure
Psychological distress (GHQ-12)
Mental load and time pressure associated with psychological distress (ORs 2.9 and 2.2)
Gray-Toft and Anderson, 198521
USA Experimental 159 nurses Not reported
Open, supportive supervisory style
Absenteeism Open supportive supervisory style associated with lower absenteeism (relevant statistics not presented)
Johnson et al, 199522
USA Longitudinal 581 doctors 86% Job demands, work control, social support
Psychological distress (GHQ-20)
Work control and social support negatively associated with psychological distress (B=−0.44, p=0.05 and B=−0.46, p=0.05)
Landeweerd and Boumans, 199423
NetherlandsCross sectional 561 nurses 96% Work pressure, job complexity, feedback, autonomy, promotion/training
Absence frequency Work pressures associated with absence frequency (B=0.12) and promotion/training negatively associated (B=−0.12)
Marshall & Barnett, 199224
USA Cross sectional 362 female nurses and social workers
Not reported
Work related support, job overload
Psychological distress (SCL-90-R) and emotional well-being (Rand Corporation)
Co-worker support associated with emotional wellbeing (B=−0.20, p<0.01)
Martin, 198425
USA Cross sectional 95 and 140 hospital workers
63% and 70%
Work overload and ambiguity, participation in decision making
Psychological distress (GHQ-12)
Work factors associated with distress (canonical correlations=0.53 and 0.41, p<0.001)
Petterson et al, 199526
Sweden Cross sectional 2568 nurses 76% Job influence Emotional exhaustion (MBI)
Job influence negatively associated with emotional exhaustion (p<0.001)
Pisarski et al, 199827
Australia Cross sectional 172 nurses, aged 21–40 years
Not reported
Social support Psychological distress (GHQ-12)
Co-worker social support directly associated with distress and mediates association with supervisor social support (path coefficients <0.001)
Revicki and May, 198928
USA Cross sectional 232 nurses 77% Organisational climate, supervisor behaviour, role ambiguity, social support
Depression (Rand corporation)
The association of organisational climate and role ambiguity with depression is mediated by stress
Reducing work related psychological ill health and sickness absence 5
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Table 3 Summary of observational studies of associations between work factors and ill health: non-health care workers
Study Country Design Participants Response rate Work factors Outcomes Results
Bacharach et al, 199129 USA Cross sectional 430 public sector engineers
79% Role conflict, time pressure Emotional exhaustion (MBI) High role conflict (B=0.24) associated with emotional exhaustion
Carayon et al, 199530 USA Prospective 148 public sector office workers
71% Job demands, content and control, social support, task clarity and job future ambiguity
Worker strain, including anxiety and depression (McNair)
Predictors of worker strain at one and two years were task clarity and job future ambiguity
Driscoll et al, 199531 USA Cross sectional 4900 public sector workers
70% Job demands, control and social support Anxiety and depression (NIOSH Generic Job Stress Questionnaire)
High demand and low support associated with anxiety (ORs 1.46 and 2.01) and depression (ORs 2.02 and 1.69)
Ferrie et al, 199832 UK Prospective 10308 public sector workers
80% Job insecurity Psychological distress (GHQ-30)
Non-significant association
Frese, 199933 Germany Longitudinal 90 male blue collar workers
35–66% Work intensity, uncertainty, organisational problems, environmental problems, social pressure, social support
Anxiety, depression Social pressure and support associated with anxiety/depression (r=0.21/0.20 and −0.21/−0.27)
Frone et al, 199534 USA Longitudinal 795 employed adults
67% Work pressure, lack of autonomy, role ambiguity
Depression (CES-D) Work pressure, lack of autonomy, role ambiguity all associated with depression (Bs=0.10, p<0.01; 0.19, p<0.001; 0.18, p<0.001, respectively)
Fusilier et al, 198735 USA Cross sectional 312 police officers and fire fighters
65% Role conflict and ambiguity, social support
Depression (Caplan) Low social support associated with depression (B=−0.24, p<0.01)
Karasek, 1979: Study 136
Sweden Longitudinal 1896 working males 92% and 85% Decision latitude and job demands Depression (amended from American Health Survey), absenteeism
Decision latitude negatively associated with depression and absenteeism (OR=−1.29, p<0.05 and −1.44, p<0.01). Job demands associated with depression (OR=1.45, p<0.001)
Study 2 USA Cross sectional 911 working males 76% As above As above Decision latitude negatively associated with depression and absenteeism (OR=−1.41, p<0.01 and –2.04, p<0.001); job demands associated with depression (OR=1.20, p<0.05)
Karasek, 199037 Sweden Cross sectional 8504 white collar workers
87% Changes in control over work Depression and absenteeism Decreased control associated with depression (p<0.01) and with absenteeism in men (p<0.01) but not women
LaRocco et al, 198038 USA Cross sectional 636 male workers Not reported Supervisor support, participation, future ambiguity, under-utilisation, workload, role conflict
Anxiety and depression (Cobb and Kasl)
Supervisor support buffers the adverse effect of low participation on depression (p<0.1, significant ) and of future ambiguity on anxiety (p<0.01)
Niedhammer et al, 199839
France Prospective 11552 92% Psychological demands, decision latitude and social support
Depression (CES-D) High psychological demand, low decision latitude and social support associated with subsequent depression. For men, OR of 1.8, 1.4 and 1.6 respectively and for women, OR of 1.4, 1.4 and 1.3 respectively.
Payne and Fletcher, 198340
UK Cross sectional 148 teachers 74% Workload demands, discretion Anxiety and depression (CCEI) Association with workload demands (betas=0.117 for anxiety and 0.176 for depression) and negative association with discretion (betas=−0.222 for anxiety and –0.121 for depression)
Reifman et al, 199141 USA Cross sectional and longitudinal
200 married, professional women
>90% Social support at work , control over work, role ambiguity, workload
Depression (SCL-90) Cross sectionally, association with social support at work (r=0.37), role ambiguity (r=0.35) and workload (r=0.29). No associations one year later
Romanov et al, 199642 Finland Prospective 15530 employees Not reported Conflict at work Psychiatric morbidity (hospital discharge registry)
Positive association (RR 2.18, CI95 1.34, 3.54)
Rubenowitz et al, 198343
Sweden Cross sectional 25 departments of 5 companies. Numbers not reported
85–90% Perceived participation (individual, group, representative)
Absenteeism Negative association for individual participation (r=−0.53)
Shields, 199944 Canada Prospective 3830 working population
80% Long working hours Depression (Composite International Diagnostic Interview)
>35 hours per week associated with depression in women (OR=2.2) but not men
Smulders and Nijuis, 199945
The Netherlands Cross sectional and prospective
1755 male public sector workers
70% Job control and job demands Absence rate and absence frequency
Cross sectionally, job control associated with low absence frequency (beta=0.10, p<0.01) and job demand associated with low absence rate (beta=−0.08, p<0.05)
Sparks and Cooper, 199946
UK Cross sectional 7099 from 13 occupations
Not reported Work control, career achievement, organisational climate, job factors, home/work interface, work relationships
Mental health (OSI) All associated (r=0.22 to −0.28, p<0.001)
Stansfeld et al, 199547 UK Cross sectional 10314 public sector employees
73% Job variety and skill use, control, social support, work pace, conflicting demands
Psychological distress (GHQ-30)
All significantly associated (intertile trend p values < 0.001)
Stansfeld et al, 199848 UK Prospective 7372 public sector workers
72% Job demands, decision latitude, social support and effort-reward imbalance
Psychological functioning (SF-36)
Low support and effort-reward imbalance associated with poor psychological functioning (OR=1.2 for men and 1.4 for women; 1.8 for men and 2.3 for women respectively). In men, low decision latitude (OR=1.2) and in women, high job demand (OR=2.0) were associated with poor psychological functioning
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effects.49 After three sessions a week for 10 weeks, stress man-
agement training resulted in improved perceived coping abil-
ity but no change in physical or psychological health. Aerobic
exercise resulted in improved feelings of wellbeing and
decreased complaints of muscle pain.
Employees of a fire department underwent one of seven
training programmes emphasising one or more aspect of
stress management: physiological processes, coping with
people, or interpersonal awareness processes. 51 Weekly ses-
sions for 8–10 people were run over 42 weeks. There was no
control group. Compared to baseline, there were reductions in
depression, anxiety, psychological strain, and emotional
exhaustion immediately after the programme. There was a
further reduction in psychological strain and emotional
exhaustion at 9–16 months follow up.
A structural intervention for local authority staff on long
term sickness absence was effective in reducing sickness
absence. Referral to occupational health services was triggered
after two or three months absence, rather than at six months
which was the practice before the intervention. The average
duration of sickness absence reduced from 40 to 25 weeks
before resumption of work and from 72 to 53 weeks for those
staff who left employment for medical reasons. The authors
describe large financial savings but no statistical tests are
reported. 53
DISCUSSION This systematic review of a large number of studies covers a
wide range of employment sectors in the developed world and
summarises those studies that use rigorous methods. The
studies show that, while levels of psychological ill health are
higher in health care than in non-health care workers,5 the
associations between work factors and psychological ill health
are similar. They are also similar across continents. This
suggests that a generic approach to reducing work related
psychological ill health may be appropriate.
The most common work factors associated with psychologi-
cal ill health were work demand (long hours, workload, and
pressure), lack of control over work, and poor support from
managers. These were also associated with sickness absence.
The findings of this review, summarised in tables 1–4, are
consistent with the demand-control model of job strain. 36
Interventions aimed at changing these workplace factors
reduced psychological ill health.
This review highlights limitations in the research identified.
The studies that have been carried out are limited in the ques-
tions addressed and in the study designs used. Since most
studies are cross sectional, causal relations cannot be shown.
It may be that the associations found reflect a tendency for
more vulnerable people to choose work in caring roles or other
types of job which are well represented in published research
studies. The question of what aspects of work lead to ill health
and sickness absence can only be addressed by longitudinal
studies that are able to investigate the causal relations
between work factors and health outcomes and by ran-
domised controlled trials of interventions. A longitudinal
study that directly addressed the nature of the relation found
a causal relation between psychological stress and psychoso-
matic complaints. 55
There are several practical implications suggested by the
studies of association in this review, for both employment
Table 4 Summary of studies of interventions
Study Participants Design Response rate Intervention Outcomes Results
Gronningsaeter et al, 199249
76 physically inactive Norwegian insurance workers
Stratified RCT 72% 6 sessions aerobic exercise per week for 10 weeks or 3 sessions stress management training per week for 10 weeks
Anxiety (STAI) and health complaints
No association of either intervention with anxiety. Aerobic exercise associated with reduced health complaints (F=3.4, p=0.07 compared to controls, and F=4.8, p<0.05 compared to stress management intervention)
Heaney et al, 199550
1375 US residential care workers
Cluster RCT 62% 6 × 4 hour sessions over 9 weeks to teach skills to enhance social support and problem solving
Depression (SCL-90R)
For those most at risk of leaving their jobs, R2=0.41, p<0.01
Kagan et al, 199551
373 US fire department workers
Randomised, uncontrolled
Not reported
42 weeks of 7 psycho-educational programmes, 6 weeks each
Anxiety, depression, psychological strain, emotional burnout
Compared to baseline, F=52.3, 42.2, 29.1, 10.6 respectively; p<0.001 for all. At 9–16 month follow up, F=4.8 (p<0.05), 8.7 (p<0.01), 21.4 (p<0.001), 45.2 (p<0.001) respectively
Lokk and Arnetz, 199752
26 Swedish hospital ward workers
RCT 93% 20 weekly 1 hour stress management sessions
Stress hormone (prolactin) level
Change scores: Intervention group −0.58 Control group +1.85 F=7.3, p<0.01
Malcolm et al, 199353
604 UK long term sick local government workers
Observational 100% Early referral to Occupational Health
Duration of sickness absence (weeks)
25 weeks in intervention period compared to 40 in control period
Smoot and Gonzales, 199554
65 US hospital workers
Matched controlled
90% 4 weekly 8 hour sessions of communication training
Sick leave (hours) in 6 months after compared to 6 months before
% change: −28.2 in experimental group, −6.4 in control group
Main messages
• Key work factors associated with psychological ill health and sickness absence in staff are long hours worked, work overload and pressure, and the effects of these on personal lives; lack of control over work; lack of participation in decision making; poor social support; and unclear management and work role.
• There is some evidence that sickness absence is associated with poor management style.
• Successful interventions that improve psychological health and levels of sickness absence use training and organisa- tional approaches to increase participation in decision making and problem solving, increase support and feedback, and improve communication.
Reducing work related psychological ill health and sickness absence 7
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practices and management style. Intervention studies, how-
ever, have focused mainly on staff training. There is a need for
future studies to evaluate interventions based on employment
practices and management style. This would represent
primary prevention, reducing sources of psychological ill
health, rather than secondary prevention, training individuals
who are already experiencing work related stress, to be more
robust in the face of such pressures. Only one of the interven-
tion studies included an economic evaluation: such evalua-
tions are important in facilitating employers to make
decisions about whether or not to implement interventions.
Future research should adhere to minimum scientific
standards absent in many of the studies reviewed, such as
adequate design, sufficiently large samples, and valid outcome
measures. Lessons that are learnt from rigorously evaluated
interventions can then be applied more generally.
ACKNOWLEDGEMENTS We are grateful to Shriti Pattani for help with literature searching and to Frédérique Cooper for help with preparing this manuscript.
. . . . . . . . . . . . . . . . . . . . . Authors’ affiliations S Michie, Reader in Clinical Health Psychology, Centre for Outcomes Research and Effectiveness, Department of Psychology, University College London, Gower Street, London WC1E 6BT, UK S Williams, Consultant in Occupational Medicine, Royal Free Hampstead NHS Trust, London NW3 2QG, UK
REFERENCES 1 Williams S, Michie S, Pattani S. Improving the health of the NHS
workforce. London: The Nuffield Trust, 1998. 2 Confederation of British Industry. Managing absence: in sickness and
in health. London: CBI, 1997. 3 Whitley TW, Allison Jr EJ, Gallery ME, et al. Work related stress and
depression among practicing emergency physicians: an international study. Ann Emerg Med 1994;23:1068–71.
4 Cox T, Griffiths A. The nature and measurement of work stress: theory and practice. In: Wilson, JR, Corlett E, Nigel E, et al, eds. Evaluation of human work: a practical ergonomics methodology, 2nd edn. London: Taylor & Francis, 1995:783–803.
5 Wall TD, Bolden RI, Borrill CS, et al. Minor psychiatric disorder in NHS trust staff: occupational and gender differences. Br J Psychiatry 1997;171:519–23.
6 University of York. Understanding systematic reviews of research on effectiveness. CDR report 4. York: NHS Centre for Reviews and Dissemination, 1996.
7 Agius RM, Blenkin H, Deary IJ, et al. Survey of perceived stress and work demands of consultant doctors. Occup Environ Med 1996;53:217–24.
8 Baglioni Jr AJ, Cooper CL, Hingley P. Job stress, mental health and job satisfaction among UK senior nurses. Stress Medicine 1990;6:9–20.
9 Baldwin PJ, Dodd M, Wrate RM. Young doctors’ health—I. How do working conditions affect attitudes, health and performance. Soc Sci Med 1997;45:35–40.
10 Cooper CL, Watts J, Baglioni Jr AJ, et al. Occupational stress amongst general practice dentists. J Occup Psychol 1988;61:163–74.
11 Deary IJ, Blenkin H, Agius RM, et al. Models of job-related stress and personal achievement among consultant doctors. Br J Psychol 1996;87:3–29.
12 Heyworth J, Whitley, TS, Allison Jr EJ, et al. Correlates of work-related stress amongst consultants and senior registrars in accident and emergency medicine. Arch Emerg Med 1993;10:279–88.
13 Parkes KR. Occupational stress among student nurses: a natural experiment. J Appl Psychol 1982;67:784–96.
14 Quine L. Workplace bullying in NHS community trust: staff questionnaire study. BMJ 1999;318:228–32.
15 Rees D, Cooper CL. Occupational stress in health service workers in the UK. Stress Medicine 1992;8:79–90.
16 Sutherland VJ, Cooper CL. Identifying distress among general practitioners: predictors of psychological ill health and job dissatisfaction. Soc Sci Med 1993;37:575–81.
17 Tyler P, Cushway D. Stress, coping and mental well-being in hospital nurses. Stress Medicine 1992;8:91–8.
18 Arsenault A, Dolan SL, Van Ameringen MR. Stress and mental strain in hospital work: exploring the relationship beyond personality. Journal of Organisational Behaviour 1991;12:483–93.
19 Brooke PP, Price JL. The determinants of employees absenteeism: an empirical test of a causal model. J Occup Psychol 1989;62:1–19.
20 Estryn-Behar M, Kaminski J, Peigne E, et al. Stress at work and mental health status among female hospital workers. Br J Ind Med 1990;47:20–8.
21 Gray-Toft PA, Anderson JG. Organisational stress in the hospital: development of a model for diagnosis and prediction. Health Serv Res 1985;19:753–74.
22 Johnson JV, Stewart W, Hall EM, et al. The psychosocial work environment of physicians. J Occup Environ Med 1995;37:1151–9.
23 Landeweerd JA, Boumans NPG. The effect of work dimensions and need for autonomy on nurses’ work satisfaction and health. J Occup Organ Psychol 1994;67:207–17.
24 Marshall NL, Barnett RC. Work-related support among women in caregiving occupations. J Community Psychol 1992;20:6–42.
25 Martin TN. Role stress and inability to leave as predictors of mental health. Human Relations 1984;37:969–83.
26 Petterson IL, Arnetz BB, Arnetz JE. Predictors of job satisfaction and job influence: results from a national sample of Swedish nurses. Psychother Psychosom 1995;64:9–19.
27 Pisarski A, Bohle P, Callan VJ. Effects of coping strategies, social support and work-nonwork conflict on shift worker’s health. Scand J Work Environ Health 1998;241:41–145.
28 Revicki DA, May HJ. Organisational characteristics, occupational stress, and mental health in nurses. Behav Med 1989;15:30–6.
29 Bacharach SB, Bamberger P, Conley S. Work-home conflict among nurses and engineers: mediating the impact of role stress on burnout and satisfaction at work. Journal of Organisational Behaviour 1991;12:39–53.
30 Carayon P, Yang C, Lim S. Examining the relationship between job design and worker strain over time in a sample of office workers. Ergonomics 1995;38:1199–211.
31 Driscoll RJ, Worthington KA, Hurrell Jr JJ. Workplace assault: an emerging job stressor. Consulting Psychology Journal: Practice and Research 1995;47:205–12.
32 Ferrie JE, Shipley MJ, Marmot MG, et al. An uncertain future: the health effects of threats to employment security in white-collar men and women. Am J Public Health 1998;88:1030–6.
33 Frese M. Social support as a moderator of the relationship between work stressors and psychological dysfunctioning: a longitudinal study with objective measures. J Occup Health Psychol 1999;3:179–92.
34 Frone MR, Russell M, Cooper ML. Job stressors, job involvement and employee health: a test of identity theory. J Occup Psychol 1995;68:1–11.
35 Fusilier MR, Ganster DC, Mayes BT. Effects of social support, role stress, and locus of control on health. Journal of Management 1987;13:517–28.
36 Karasek Jr RA. Job demands, job decision latitude, and mental strain: implications for job redesign. Adm Sci Q 1979;24:285–311.
37 Karasek R. Lower health risk with increased job control among white collar workers. Journal of Organisational Behaviour 1990;11:171–85.
38 LaRocco JM, House JS, French Jr JRP. Social support, occupational stress, and health. J Health Soc Behav 1980;21:202–18.
39 Niedhammer I, Goldberg M, Leclerc A, et al. Psychosocial factors at work and subsequent depressive symptoms in the Gazel cohort. Scand J Work Environ Health 1998;24:197–205.
40 Payne R, Fletcher BC. Job demands, supports, and constraints as predictors of psychological strain among schoolteachers. Journal of Vocational Behaviour 1983;22:136–47.
41 Reifman A, Biernat M, Lang EL. Stress, social support, and health in married professional women with small children. Psychology of Women Quarterly 1991;15:431–45.
42 Romanov K, Appelberg K, Honkasalo M, et al. Recent interpersonal conflict at work and psychiatric morbidity: a prospective study of 15,530 employees aged 24–64. J Psychosom Res 1996;40:169–76.
43 Rubenowitz S, Norrgren F, Tannenbaum AS. Some social psychological effects of direct and indirect participation in ten Swedish companies. Organisation Studies 1983;4:243–59.
44 Shields M. Long working hours and health. Health Reports 1999;11:33–48.
45 Smulders PGW, Nijhuis, FJN. The job demands-job control model and absence behaviour: results of a 3-year longitudinal study. Work and Stress 1999;13:115–31.
46 Sparks K, Cooper CL. Occupational differences in the work-strain relationship: towards the use of situation-specific models. Journal of Occupational Organizational Psychology 1999;72:219–29.
47 Stansfeld SA, North FM, White I, et al. Work characteristics and psychiatric disorder in civil servants in London. J Epidemiol Community Health 1995;49:48–53.
48 Stansfeld SA, Bosma H, Hemingway H, et al. Psychosocial work characteristics and social support as predictors of SF-36 health functioning: the Whitehall II study. Psychosom Med 1998;60:247–55.
Policy implications
• Many of the work related variables associated with high levels of psychological ill health are potentially amenable to change.
• More evaluations of interventions are required, based on randomised or longitudinal research designs.
• Interventions for which evidence of effectiveness exists should be piloted and evaluated across different work settings.
8 Michie, Williams
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49 Gronningsaeter H, Hytten K, Skauli G, et al. Improved health and coping by physical exercise or cognitive behavioural stress management training in a work environment. Psychology and Health 1992;7:147–63.
50 Heany CA, Price RH, Refferty J. Increasing coping resources at work: a field experiment to increase social support, improve work team functioning, and enhance employee mental health. Journal of Organisational Behaviour 1995;16:335–52.
51 Kagan NI, Kagan H, Watson MG. Stress reduction in the workplace: the effectiveness of psychoeducational programs. Journal of Counselling Psychology 1995;42:71–8.
52 Lokk J, Arnetz B. Psychophysiological concomitants of organisational change in health care personnel: effects of a controlled intervention study. Psychother Psychosom 1997;66:74–7.
53 Malcolm RM, Harrison J, Forster H. Effects of changing the pattern of referrals in a local authority. Occup Med 1993;43:211–15.
54 Smoot SL Gonzales JL. Cost-effective communication skills training for state hospital employees. Psychiatr Serv 1995;46:819–22.
55 Frese M. Stress at work and psychosomatic complaints: a causal interpretation. J Appl Psychol 1985;70:314–28.
ECHO ................................................................................................................ Air pollution study confirms concerns over childhood rickets
A study in India has shown that young children living in areas of high air pollution are in danger of developing rickets.
Two groups of age matched infants and toddlers were compared for serum vitamin D metabolites, cal- cium, alkaline phosphatase (AP), and parathormone (PTH) concentrations. One group lived in a central location in Delhi and the other on the outskirts of the city, where air pollution is much lower.
Children from the city centre had significantly lower mean serum total 25-hydroxyvitamin D (25(OH)D)—an indictor of vitamin D status—than children from the outskirts (12.4 ng/ml v 27.1 ng/ml). Their mean serum AP and PTH concentrations were significantly higher, and the inverse relations between 25(OH)D and AP, PTH were also significant. Three children had serum total 25(OH)D low enough to indicate rickets, and nine more below adequate amounts. All children from the outskirts had adequate 25(OH)D. Mean haze score was significantly less at the city centre (2.1 against 2.7).
Each group included 34 children aged 9–24 months with similar home conditions, diet, family income, and time spent outside. Blood was taken from 26 children from the city centre and 31 from the outskirts. Haze scores measured at ground level three times daily (0900, 1200, 1600) during February 2000 were taken as a marker for UVB radiation.
Concerns are growing that increasing air pollution from industry and motor vehicles blocks out UVB radiation and children’s ability to make vitamin D naturally, leading to rickets.
m Archives of Disease in Childhood 2002;87:111–113.
Please visit the Occupational and Environmental Medicine website [www. occenvmed.com] for link to this full article.
Reducing work related psychological ill health and sickness absence 9
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