EXPOSURE TO STRESS

Occupational Hazards 

in Hospitals

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

Exposure to Stress

Occupational Hazards in Hospitals

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health
ii

This document is in the public domain and may 

be freely copied or reprinted.

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Safety and Health (NIOSH). In addition, citations to 

Web sites external to NIOSH do not constitute NIOSH 

endorsement of the sponsoring organizations or their 

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DHHS (NIOSH) Publication No. 2008–136

July 2008

Safer • Healthier • PeopleTM
iii

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

What causes occupational stress? . . . . . . . . . . . . . . . 1

What are the potential adverse health effects

of occupational stress? . . . . . . . . . . . . . . . . . . . . . 3

How can stress be controlled in the workplace? . . . . 4

Case reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

More information about occupational stress . . . . . . . 10

1

Exposure to Stress

Introduction

Occupational stress has been a long-standing concern 

of the health care industry. Studies indicate that 

health care workers have higher rates of substance abuse 

and suicide than other professions and elevated rates of 

depression and anxiety linked to job stress. In addition 

to psychological distress, other outcomes of job stress 

include burnout, absenteeism, employee intent to leave, 

reduced patient satisfaction, and diagnosis and treatment errors.

The purpose of this brochure is to

# identify the sources of occupational stress,

# identify the adverse health effects of occupational 

stress, and

# recommend work practices to reduce occupational 

stress.

What causes occupational stress? 

The National Institute for Occupational Safety and 

Health (NIOSH) defines occupational stress as “the 

harmful physical and emotional responses that occur 

when the requirements of the job do not match the capabilities, resources, or needs of the worker.”

The following workplace factors (job stressors) can result in stress: 

# Job or task demands (work overload, lack of task 

control, role ambiguity)
2

# Organizational factors (poor interpersonal relations, unfair management practices) 

# Financial and economic factors

# Conflict between work and family roles and responsibilities

# Training and career development issues (lack of 

opportunity for growth or promotion)

# Poor organizational climate (lack of management 

commitment to core values, conflicting communication styles, etc.) 

Stressors common in health care settings include the 

following: 

# Inadequate staffing levels

# Long work hours

# Shift work

# Role ambiguity 

# Exposure to infectious and hazardous substances 

Stressors vary among health care occupations and even 

within occupations, depending on the task being performed. 

In general, studies of nurses have found the following 

factors to be linked with stress: 

# Work overload

# Time pressure

# Lack of social support at work (especially from supervisors, head nurses, and higher management)

# Exposure to infectious diseases 

# Needlestick injuries

# Exposure to work-related violence or threats

# Sleep deprivation
3

# Role ambiguity and conflict

# Understaffing

# Career development issues

# Dealing with difficult or seriously ill patients

Among physicians, the following factors are associated 

with stress:

# Long hours

# Excessive workload

# Dealing with death and dying

# Interpersonal conflicts with other staff

# Patient expectations

# Threat of malpractice litigation 

The quality of patient care provided by a hospital may 

also affect health care worker stress. Beliefs about 

whether the institution provides high quality care may 

influence the perceived stress of job pressures and 

workload because higher quality care maybe reflected in 

greater support and availability of resources.

What are the potential adverse health 

effects of occupational stress? 

Stress may be associated with the following types of reactions:

# Psychological (irritability, job dissatisfaction, depression)

# Behavioral (sleep problems, absenteeism)

# Physical (headache, upset stomach, changes in 

blood pressure) 

An acute traumatic event could cause post traumatic 

stress disorder (PTSD). Not every traumatized person 

develops full-blown or even minor PTSD. 
4

Although individual factors (such as coping strategies) 

and social resources can modify the reaction to occupational stressors to some degree, working conditions can 

play a major role in placing workers at risk for developing health problems.

How can stress be controlled in the 

workplace? 

As a general rule, actions to reduce job stress should 

give top priority to organizational changes that improve 

working conditions. But even the most conscientious 

efforts to improve working conditions are unlikely to 

eliminate stress completely for all workers. For this reason, a combination of organizational change and stress 

management is often the most successful approach for 

reducing stress at work.

Organizational Change Intervention

The most effective way of reducing occupational stress is 

to eliminate the stressors by redesigning jobs or making 

organizational changes. Organizations should take the 

following measures:

# Ensure that the workload is in line with workers’ 

capabilities and resources

# Clearly define workers’ roles and responsibilities

# Give workers opportunities to participate in decisions and actions affecting their jobs

# Improve communication

# Reduce uncertainty about career development and 

future employment prospects

# Provide opportunities for social interaction among 

workers
5

The most commonly implemented organizational interventions in health care settings include

# team processes,

# multidisciplinary health care teams, and

# multi-component interventions.

Team process or worker participatory methods give 

workers opportunities to participate in decisions and 

actions affecting their jobs. Workers receive clear information about their tasks and role in the department. 

Team-based approaches to redesign patient care delivery 

systems or to provide care (e.g., team nursing), have 

been successful in improving job satisfaction and reducing turnover, absenteeism, and job stress.

Multidisciplinary health care teams (e.g., composed 

of doctors, nurses, managers, pharmacists, psychologists, 

etc.) have become increasingly common in acute, longterm, and primary care settings. Teams can accomplish 

the following: 

# Allow services to be delivered efficiently, without 

sacrificing quality 

# Save time (a team can perform activities concurrently that one worker would need to provide sequentially)

# Promote innovation by exchanging ideas 

# Integrate and link information in ways that individuals cannot

Multicomponent interventions are broad-based and 

may include

# risk assessment,

# intervention techniques, and

# education.
6

Successful organizational stress interventions have several things in common: 

# Involving workers at all stages of the intervention

# Providing workers with the authority to develop, 

implement, and evaluate the intervention

# Significant commitment from top management 

and buy-in from middle management

# An organizational culture that supports stress interventions

# Periodic evaluations of the stress intervention

Without these components (in particular, management support) it is not likely that the intervention 

will succeed. 

Stress Management Intervention

Occupational stress interventions can focus either on 

organizational change or the worker. Worker-focused 

interventions often consist of stress management techniques such as the following:

# Training in coping strategies

# Progressive relaxation

# Biofeedback 

# Cognitive-behavioral techniques 

# Time management

# Interpersonal skills

Another type of intervention that has shown promise 

for reducing stress among health care workers is innovative coping, or the development and application by 

workers of strategies like changes in work methods or 

skill development to reduce excessive demands. 
7

The goal of these techniques is to help the worker deal 

more effectively with occupational stress. Workerfocused interventions have been the most common 

form of stress reduction in U.S. workplaces. Although 

worker interventions can help workers deal with stress 

more effectively, they do not remove the sources of 

workplace stress, and thus may lose effectiveness over 

time. 

Mental health support intervention may be needed in 

the event of a significant event at a health care organization [see Case 2]. 

Case Reports

Case 1

Researchers evaluated a participative intervention program at an acute care hospital [Bourbonnais et. al 2006]. 

A baseline (initial) risk evaluation was conducted at an 

acute care “experimental” hospital and a similar size 

acute care “control” hospital using a 30 minute telephone 

interview with employees to obtain answers pertaining to 

psychological demands, reward at work, social support, 

psychological distress, burnout and sleeping problems. 

Similar stress indices were measured at both the experimental and control hospitals.

A participative intervention program was then implemented at the experimental hospital. This program used 

a participative problem solving process including an intervention team of employees led by an external moderator. 

The intervention team held regularly scheduled meetings 

over several months to identify adverse working conditions and recommended solutions ranked according to 
8

priority and feasibility. Hospital management assisted the 

intervention team with implementation of several of the 

recommendations.

One year after the intervention, the telephone survey 

was repeated at both hospitals and there was a significant 

reduction in sleeping problems and work-related burnout 

in the hospital with the intervention team versus the control hospital.

Case 2

The 2003 outbreak of Severe Acute Respiratory 

Syndrome (SARS) in Hong Kong, Singapore, and 

Toronto, Canada led to psychological impacts and increased stress in the health care profession. In Toronto, 

43% of the cases were health care workers; 3 of the infected workers died. The SARS outbreak substantially 

changed working conditions and the perception of 

personal danger. In Toronto, modifications of infection 

control procedures and public health recommendations 

changed day to day, increasing uncertainty. Outpatient 

clinics were closed, surgeries cancelled, nonessential 

staff told to stay home, use of masks, gloves, and gowns 

were mandatory, and thousands of people were quarantined. Interpersonal isolation was high as staff members were discouraged from interacting with colleagues 

outside of the hospital, staff meetings were cancelled, 

and eating and drinking, which require removing a face 

mask, were done alone or outside the hospital. 

The infected and quarantined health care workers

# experienced interpersonal isolation, 

# expressed concern about the infectious risk to 

staff caring for them,

# expressed fear about the potential lethality of the 

illness, and 
9

# expressed anger because their risk of infectious 

exposure had not been recognized earlier. 

Medical residents working during the SARS outbreak at 

a teaching hospital expressed anxiety over

# variability of available information, 

# perceived poor communications, and 

# the balance between personal safety and duty-tocare.

Health care workers who experience a significant event 

such as SARS, will benefit from timely communication of 

relevent information. Efforts to overcome interpersonal 

isolation should include effective risk communications using emails, Web sites, and video and audio conferencing.

Conclusions

Health care occupations have long been known to be 

highly stressful and associated with higher rates of 

psychological distress than many other occupations. 

Health care workers are exposed to a number of stressors, ranging from work overload, time pressures, and 

lack of role clarity to dealing with infectious diseases 

and difficult and ill, helpless patients. Such stressors can 

lead to physical and psychological symptoms, absenteeism, turnover, and medical errors. However, the literature points to both organizational and worker-focused 

interventions that can successfully reduce stress among 

health care workers. Although organizational interventions (because they address the sources of stress) are 

preferred, interventions that combine worker and organizational components may have the broadest appeal as 

they provide both long-term prevention and short-term 

treatment components.
10

More Information about

Occupational Stress

# Visit the NIOSH Job Stress topic page: www.cdc.

gov/niosh/topics/stress/

# To locate a psychologist or consultant in your area, 

visit the American Psychological Association Web site: 

www.apahelpcenter.org/ or phone 1–800–964–2000

# For more information about post traumatic stress 

syndrome, visit the National Institute of Mental 

Health Web site: www.nimh.nih.gov/health/topics

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occupational safety and health topics, contact NIOSH atTo receive NIOSH documents or more information about 

 (1–800–232–4636)

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v

or visit the NIOSH Web site at www.cdc.gov/nios

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 by visiting www.cdc.gov/niosh/eNews.

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