5. Evaluate Progress. Results presented in one year's HFI profile
can be compared with the results of future employee profiles to
develop a clear measurement of progress. Study after study
indicates that a reduction in employee and corporate stress,
followed by an increase in both job satisfaction and employee
wellness, should lead to a decrease in the following areas:
Medical claims and accidents, illness, turnover and
absenteeism, theft, sabotage, and poor productivity. Such
decreases should be reflected in improved employee morale,
better organizational efficiency, and higher corporate gains.

6. Prevention. Finally, the HFI can be used to identify potential
stress-related loss areas before they cause any significant
level of loss.

II. WORK ENVIRONMENT SCALE (WES)

Dr. Rudolf Moos developed the Work Environment Scale in order to
assess the quality of worklife and stress levels in many types of work
units. The WES is described in depth elsewhere (e.g., Moos, 1981).

Some key features of this organizational climate survey are described
below.

The standard WES consists of 90 items that make up 10 subscales.
Normative data have been collected for over 1,400 employees from
general work groups and over 1,600 employees from a variety of health
care work groups. Test-retest reliability coefficients (one month
interval) are all in an acceptable range, varying from a low of .69 to
a high of .83, depending on the subscale.

WES Subscales

The 10 WES subscales assess 3 underlying dimensions of organizational
functioning: The Relationships dimension, the Personal Growth
dimension, and the System Maintenance and System Change dimensions.
The subscales that comprise each dimension are described in Table 3.3.

Inspection of Table 3.3 reveals that the WES subscales can be used to
assess organizational stress levels and major organizational
stressors. For example, the Work Pressure subscale assesses the
experience of workplace stress and tension. Examples of items on this
subscale include: "There is constant pressure to keep working.";
“People cannot afford to relax."; "It is very hard to keep up with
your work load."; "There always seems to be an urgency about
everything." The Involvement subscale is also an excellent measure of

58



instrument is administered as it is a function of the psychometric
qualities of the instrument. Such variations in testing or measuring
as enthusiasm of the tester, motivation of the respondents, and even
room characteristics such as temperature and humidity can all affect
reliability coefficients. Reliability is most usefully conceptualized
as a set of statistical, and situational conditions which affect the
error in the stability of data gathered by a given instrument (French
and Kaufman, 1983).

Validity. On the other hand, validity is the accuracy with which a
measurement instrument or procedure measures what it was intended to
measure. It is possible to have a highly reliable instrument that is
measuring the wrong impact or outcome. Validity only can be
determined by obtaining independent measures of the same impact or
outcome and comparing the results (Campbell and Fiske, 1959; Green and
Lewis, 1986; Windsor et al., 1984).

Measures of Stress

In the stress field, it is a much easier task to provide general
criteria for measurements than it is to suggest specific variables
that should be chosen. Before providing suggestions for the selection
of specific measures of stress at both the individual and
organizational level, it may be instructive to look briefly at why
this process is so complex.

First, no satisfactory definition of stress or specific goals and
objectives for stress identification and reduction were proposed in
Healthy People: The Surgeon General's Report on Health Promotion and
Disease Prevention (USDHEW, 1979), or in Promoting Health/Preventing
Disease: Objectives for the Nation (USDHHS, 1980b). The Institute of
Medicine (IOM) of the National Academy of Sciences subsequently
completed a status report on the relationship of stress to health
(Elliott and Eisdorfer, 1982). On the basis of this comprehensive
task force report, it was decided that it was not feasible to get a
concensus on a general definition of stress. Instead, a conceptual
model for the study of stress was proposed. In this model, the stress
concept was divided into four major domains: 1) stressors or sources
of stress, 2) reactions, 3) consequences, and 4) mediators.

The model and each of the four domains of variables is discussed in
detail in the IOM Report. In principle, variables should be looked at
in each of the domains. This would provide the most complete
perspective on the nature of stress-related problems and the dynamics
of intervention program process, impact, and outcomes. However, in
practice this generally is not feasible as most stress management
programs rarely have large budgets for research and evaluation.
Therefore, a great amount of selectivity must be used in choosing
variables. The following discussion will focus on measures of sources
of stress and reactions to stress since these have been studied most
carefully and are feasible to measure in low budget programs.

125



positions like waiters and waitresses also showed a high response
rate, though their steward was much less experienced and helpful. On
the other hand, we simply were not getting back surveys from the "back
of the house" members of the union. This problem affected our returns
both in the food and beverage department and in the housekeeping
department of the hotel.

It soon became clear that we faced two large problems with the "back
of the house" employees. First, they were hardly strangers to poor
working conditions or to stress, but they were skeptical about the
usefulness of a questionnaire. They already knew all they needed to
know about what was bothering them. Second, we had underestimated the
number of Spanish-speaking employees, particularly among the housemen
and maid staff. We had originally offered to produce a Spanish
version of the questionnaire, but the union staff assured us that this
would not be necessary except for 6 to 12 employees. Our subsequent
interactions led us to feel that we might have lost more than a dozen
employees to a language barrier.

Faced with these two obstacles we were still determined to fulfill our
promise of an assessment for all classes of hourly employees at the
hotel. To overcome the skepticism of the housekeeping and dishwashing
staff, we decided we needed to speak with them personally about why
the survey could be useful to them. With the aid of a few shop
stewards, we began to spend time at the employee cafeteria during
afternoon shift changes and breaks. We would introduce ourselves to a
maid or houseman, give them a questionnaire (if they had not yet
received one), and generally lobby for the usefulness of filling it
out. We also recruited Spanish-speaking stewards to introduce us and
to convey our message to a group of Hispanic workers. Often, these
members would bring the questionnaire home and have their sons or
daughters help to translate the questions. While this kind of
personal interaction helped tremendously to increase returns, it
required extensive time and labor, as well as being a little
anxiety-provoking (we never knew how a security guard or manager would
react to our presence in the hotel). Toward the end of the collection
period, we were also aided by a banquet waitress who was taking
part-time courses in psychology and took an interest in our project.

Our unorthodox style of data collection raises two difficult issues.
First, we may have appeared to be union representatives to prospective
respondents. This appearance could have biased our actual respondents
to be more pro-union and less pro-management. However, in our
presentation of surveys to employees, we emphasized that all types of
replies were valuable, not simply negative ones. Second, our
clandestine invasion of the cafeteria was not altogether ethical and
we would certainly not recommend this technique as a standard data
collection procedure.

22


conditions, terms of employment, or the skills and practices of
management. Stress programs for such workplaces will have to deal
with these issues.

In this context, a program teaching workers only coping (but not
change) skills could be construed, variously, as incomplete (leaving
out strategies to change workplace conditions rather than workers),
incompetent (unaware of workplace realities), biased (systematically .
Placing the burden of change on the employee rather than on the
employer), and/or illegal (making workers "correct" conditions that
are the employer's responsibility). Of course, the validity of these
charges depends on the specific situation... and the perspective of
the observer. But, the validity of such charges would not depend on
the intentions of the practitioner nor on the excellence of the
program in teaching coping skills.

The point here is that each workplace must be approached as a complex
“society” with a variety of subcultures each having its own
perceptions and interests with respect to what stress means, what
Problems it poses and who should act to deal with it. And that our
efforts to help must take a systems perspective of the full reality of
that workplace/society.

Are S Viewed As "Helpers" In The Work 2

My experience is that many in the helping professions (not just stress
practitioners) have an image of themselves and their practice that is
considerably different from the way they are viewed by many workers on
the lower ranks of workplace hierarchies. This discrepancy impairs
communication, increases interpersonal distance, and reduces the
effectiveness of persons and programs. Two stereotyped comments may
help to illuminate the cross cultural problems involved:

The professional: "My purpose is to help people, to do good. Of
course, I also want to do well, but I've a right to it, earned with
years of expensive study. My field is constantly improving because of
our commitment to quality, and we police ourselves pretty well. By
and large, people get what they earn; merit pays. I like winners and
I work to think like one. I"11 help those who try."

The blue collar worker: “I turn to professionals only when I have to,
when there's sickness or legal trouble or some kind of problem. If
you get a good one, that's ok but most of them... you just take a
chance they can help. If not you're probably out of luck, because
they stick up for each other. They make more money in less time than
anybody I ever knew. (I work hard but I'1l never make that kind of
money, not from working.) People like that don't know much about life
around here and I guess they don't think much of people like us."

157



in force (RIF) and the corporate secretary who is a solo parent with
young children deserve a better analysis of their stress situations
than is possible if we do not help them recognize the issues.

We all share a responsibility to design programs that allow and help
workers to develop a realistic understanding of all the elements
contributing to a stressful situation. How do we best help program
participants link their individual concerns to the complex nature of
the world we live in if we collude, even unintentionally, with evasion
of critical sources of stress?

How Do We Ident. 2 ealing With Stress?

One way to classify the strategies for dealing with stress is to
identify them by the kind of change that is their primary objective:
“personal” strategies attempt to make changes in the individual,
"interpersonal" strategies would change the relationships between
individuals, and "external" strategies aim to change aspects of the
environmental or organizational situation. Most of our current stress
programs focus almost exclusively on coping skills and thus target
"personal" changes first and foremost. Some attention is given to the
"interpersonal" area but "external" change is rarely even mentioned .
Moreover, we usually deal with change strategies for individuals to
effect and give little attention to collaborative efforts.

To be sure, individual self-change seems to be the handiest place to
start dealing with stress. But, it seems to me that changes in
individuals occur more readily and with greater effect when there are
also supportive changes taking place with others and in the general
situation; and, that the interaction of these efforts is highly
synergistic. In view of the difficulty that our current programs are
having in achieving sustained improvements, we cannot afford to
neglect whole categories of strategies and the need to use all three
categories interactively.

Moreover, our choices of which strategies we teach program
participants have psychological, legal and "political" implications
that many of us may not intend; some of these issues will be examined
below.

How Can W f-Blami:

My experience is that an extremely high percentage of our program
participants tend to blame themselves in some fundamental way for the
problems they are experiencing. ("If only I had listened to...If I
had been a more serious student...If I just hadn't...If I were
smarter...etc....then I wouldn't be in this fix.") This self-blame
undermines self-esteem and can block learning and change.

152



DISCLAIMER

The opinions, findings, and conclusions expressed herein are
not necessarily those of the National Institute for
Occupational Safety and Health, nor does mention of company
names or products constitute endorsement by the National
Institute for Occupational Safety and Health.

NIOSH Project Officers: Lawrence R. Murphy, Ph.D.
Theodore F. Schoenborn

DHHS (NIOSH) Publication No. 87-111

ili



within one worksite population. Two or more groups are randomized to
systematically varied combinations of program elements, and multiple
measurements are obtained. Each group receives a different mix of
stress management interventions (e.g., group A, relaxation training
alone; group B, relaxation training plus biofeedback; group C,
biofeedback training alone; group D, no program). Such designs have
been used in the evaluation of several stress management programs
(Murphy, 1984; McLeroy, et al., 1984).

Selectio valuation Measure:

The selection of specific measures both of individual and of
organizational characteristics is a critical step in program
evaluation. Making decisions about what to measure is often neither
simple nor straightforward. There is a large increase in the number
of potential, relevant, variables when one moves from the field of
basic research to that of program evaluation. Furthermore, the
selection of variables and measurement strategies in the stress field
is particularly difficult since there is a very large pool or
potential measures to choose from. Two general criteria, relevance

and feasibility always should be considered in the selection of
measures,

Relevance. Relevance is the first factor that should be considered in
the selection of measures. A measure can be considered relevant to
the extent that it either measures directly a specific object of
interest or behavioral objective or provides a good approximation of
it.

The selection of a particular measure or set of measures should
reflect a balance between the major objects of interest of the
sponsors and recipients of the program and evaluation, the standards
of acceptability that they are willing to apply to those objects, and
the criteria of ethical and scientific merit that can be applied to
the objects. The objects of interest may be one or more elements of
process, impact, or outcome as shown in Figure 3.

The issue of relevance often is decided in the needs assessment and
objective setting phases of a program. The specific objectives of
programs often largely determine what is measured. When objectives
are poorly conceived and loosely stated, they provide little guidance
for the selection of measures. Thus, time and money can be wasted by
placing emphasis on the detailed measurement of variables that have
little relevance to goals and objectives. However, if program
objectives are well developed and clearly stated they usually direct
attention to the general factors and sometimes the specific variables
of greatest importance. Therefore, the precise statement of
objectives is critical to the selection of the variables to measure
and monitor in programs.

121



PART II
STRESS MANAGEMENT PROGRAMS

Part II describes various aspects of stress management from the design
of programs, to the creation and maintenance of such programs, and the
measurement and evaluation of their effectiveness.

Chapter 4 contains a review and evaluation of stress management
programs based on published literature and direct contacts with
providers. Drs. Rosch and Pellitier note that such programs have been
broadly defined to include a range of activities from lectures,
symposia, and workshops lasting a few hours to in-depth training
sessions that may run several weeks. A variety of techniques have
been used including biofeedback, muscle relaxation, meditation, and
assorted cognitive strategies. These techniques have been helpful in
reducing individual levels of stress, but training schemes and
evaluation protocols have not been standardized sufficiently to allow
for accurate comparison among techniques. Rosch and Pellitier note
the need to accurately assess stressors in the work environment and
ultimately to devise strategies that remove or alter work stressors.

In Chapter 5, Dr. Adams presents a context for understanding worksite
stress management. He describes characteristics of an "ideal" program
in terms of conceptualizing, planning, setting goals, developing
system support, and acquiring resources. Dr. Adams argues that
comprehensive stress management must focus on both the individual and
the organization to have its greatest impact. He also suggests common
errors to avoid, program maintenance and evaluation, and the issue of
referring workers to outside agencies for treatment.

Drs, Stainbrook and Green tackle the difficult and often neglected
topic of program evaluation in Chapter 6. They provide a model for
planning and evaluating worksite stress management training (and other
health promotion programs) that is tied to the 1990 Health Objectives
for the Nation. They also discuss levels of evaluation research,
types of evaluation designs, selection of outcome measures, and
reliability/validity issues. The chapter ends with a discussion of
confidentiality and informed consent in worksite evaluation research.

Chapter 7 contains a description of stress management from the
perspective of a practitioner. Mr. Martin discusses current practices
in the field and identifies some underlying questions about stress
management. Next, he describes activities in developing a stress
program for the Graphic Arts International Union. Using client-driven
strategies in training workshops, he identifies and proposes solutions
to stress problems. The process-oriented nature of the effort and the
content of the workshops are described in detail. Mr. Martin
concludes by offering ideas to improve the content and delivery of
stress management training.

67



8 ss To ces Too Limited

My impression is that occupational stress programs are mostly
available to the relatively affluent; this has two consequences I
would like to see more widely examined. First, because we know that
there is as much, if not more, stress for those further down the
occupational ladder, access to stress programs must be improved if we
hope to increase individual and organizational outcomes like health
and productivity and to decrease those like accidents, and alcohol,
drug and mental health disorders in the workplace.

Second, our approaches to designing and implementing stress programs
seem skewed in both overt and less obvious ways. For example,
existing programs place moderate to heavy reliance on pencil and paper
exercises that are most useful to people who are used to working with
written, standard English. Or, the language or imagery of the print
and audiovisual materials used in the program may significantly
miscarry with participants from some socio-cultural group. Such
sensibilities are directly related to the self-identified stressors
that significantly affect many people. Educational programs in both
the academic and vocational spheres have already learned the necessity
for recognizing and respecting such issues in seeking to be effective.

jo Our rams Have Limi ional Utilit

We who see stress as a significant issue and would help others deal
with it have both the opportunities and drawbacks that accompany the
initial stages of any important effort; there is adventure in being a
pioneer but there are no roadmaps on how to proceed. We need not be
defensive about the fact that our efforts are initial, exploratory,
and experimental; but, it would help to be clear about where we are
and how far we've gotten. For example, most psychotherapists require
months of hour-long individual interventions to secure individual
change, so half-day stress workshops can hardly be faulted for not
being able to make 12 to 30 people “all better" or "all effective".
As we acknowledge that our current efforts have limited functional
utility we will be able to identify and specify what we can do that
works in helping others secure changes that they need to deal with the
stresses in their lives. As professionals, we need, at least, to
build research/evaluation efforts into our program presentations.

SELF-IMAGE
Is Stress More Than "Health Promotion"?

In the marketplace of programs, stress is becoming a subject within
health promotion, included in the list of other topics with nutrition,
exercise, and the like. If stress were simply a matter of individual
coping skills, this conceptual structure would be reasonable. But, in
many stress situations, the appropriate change objective is to

155



health as well as economic benefits of health promotion programs with

an emphasis on stress since it is such a pervasive concern. This type
of information is being developed at:

1. The University of Texas Center for Health Promotion, Research
and Development (McLeroy, et al, 1984).

2. UCLA under the auspices of Jonathan Fielding and U.S. Corporate
Health Management to determine efficacy of hypertension
control, smoking cessation, and stress management and, to a
lesser extent, physical fitness and weight reduction (Fielding,
1984).

3. The 3 year Corporate Health Promotion Research Project of the
University of California School of Medicine in San Francisco

and 13 major corporations to determine the most promising areas
of research (Pelletier, 1983).

In addition, the American Institute of Stress continually monitors and
reports on activities in this area in the United States and abroad.
Criteria for efficacy of stress reduction interventions should include
assessment of such parameters as:

1. Decreased health costs
2. Decreased absenteeism
3. Decreased employee turnover
4. Increased productivity
5. Self-report indicators of
(a) better quality of life
(b) improved employee interrelationship
(c) improved ability to cope with stress
(a) improved relations with the organization

The Johnson and Johnson Live for Life program offers stress management
as well as information on lifestyle activities such as eating,
exercise, and smoking which can be successfully promoted at the work
setting (Arnold, 1981). Some 25,000 employees are involved in active
programs at 40 separate locations throughout the United States, Puerto
Rico, and Europe. It was expected that by the end of 1985, that this
would have been extended to all 75,000 employees worldwide. Employee
participation is voluntary and services are provided free of charge.
On entry a “health screen" allows individuals to examine how healthy
their current lifestyles are. Following this, the concept of the
program is explained in depth and a variety of action programs are
offered to assist with smoking cessation, stress management, exercise,
nutrition, weight control, and general health knowledge. These are
all integrated closely with established medical programs such as
hypertension detection and control and other employee assistance
activities. A two year epidemiologic study was designed to evaluate
the success of the program using several criteria which were evaluated
annually. These included biometric observations such as blood
pressure, body fat, weight, estimated maximum oxygen uptake, and blood

79



The First S Assessment

With the assessment now a tangible project, we developed a research
strategy that would blend the application of the OSEG with a larger
systems outlook (see Table 1.2). As Table 1.2 indicates, the first
step of the research strategy was to contact labor and management
representatives. After contacting labor representatives, we wrote a
lengthy letter to the general manager of the hotel. We offered a list
of reasons for our choice of his particular hotel as a focus of our
assessment including its proximity to Yale, its highly professional
staff, its blend of autonomy with support from a world wide
corporation, its competition with other downtown hotels, and its
established union work force. The letter went on to describe the
mechanics of the assessment (interviews and a survey), our financial
needs (none), and our strong commitment to a labor-management
collaboration. To assure him that we were interested in a balanced
collaboration and to underscore our bipartisanship, we indicated that
the same letter had been sent to the two organizers for the union. We
expressed from the outset that we were working under contract for the
National Institute for Occupational Safety and Health, and that our
purpose was to involve labor and management in a collaborative and
comprehensive assessment of stress.

During this time, we also made direct efforts to contact someone in
the parent corporation, such as a medical director or human resources
officer, who might be supportive of our proposed assessment. We hoped
their approval might lead to a "top down" decision to collaborate in
the hotel stress assessment. Unfortunately, and characteristic of many
service corporations (see Singer et al., 1986), there was no such
sympathetic figure to be found in this organization. Our
conversations with health representatives of the corporation made it
clear to us that stress programs or interventions, particularly at the
level of non-salaried employees, were a low priority. After two weeks
without a reply from the hotel's general manager, we began to leave
messages with his secretary. Though he never returned our phone
calls, we did finally receive a one paragraph note approximately three
weeks later. The note explained that due to renovations, changes in
management, and upcoming contract negotiations, the hotel
administration would not find it possible to participate with us in
this project. At this point, we kept to our original commitment to
follow through on our agreement with the union, even though the
assessment would not become a shared project between management and
labor.

As a structure for our assessment, we returned to the four principles
of systems theory listed earlier. The first systems principle, the
hierarchical organization of work stress, would allow us to divide the
hotel up into increasing levels of complexity. Each level, and each
subsystem within it, could then be assessed for its contribution to
employee stress. Accordingly, we would need to design questions that

12



prior studies have been summarized in three recent reports (Chen,
1984; McLeroy, et al., 1984; and Murphy, 1984). The dependent
variables that were measured most frequently in the 19 prior stress
Management programs reviewed by McLeroy et al. (1984) are presented in
below:

Variable Frequency

Anxiety (trait=5, state=1)
Muscle tension

Stress symptoms

Perceived job stress
Blood pressure

Hand temperature

Job satisfaction

WWPUUUA

Of these seven variables, four (anxiety, stress symptoms, perceived
job stress, and job satisfaction) are subjective measures that depend
entirely on self-reports. The three other variables (muscle tension,
blood pressure, and hand temperature) all can be measured objectively
by independent observers with monitoring equipment. Typically, it is
preferable to choose variables that can be measured objectively.
However, the other general criteria that were discussed previously,
namely, relevance and feasibility also should be given careful
consideration, as well as two other factors, sensitivity and
representativeness.

Sensitivity to Change. An additional issue that should be considered
is the likelihood of effecting reductions in the levels of the impact
and outcome indicators through the types of programs being offered.
The results of the stress management studies reviewed by Murphy (1984)
and McLeroy et al. (1984), suggest that most of these variables are
sensitive and can be reduced acutely by relatively low-cost programs.
However, the long-term health implications of these changes and the
cost-benefit and cost-effectiveness of most stress management programs
have not been studied.

There are other variables that would be relevant outcome measures for
some stress management programs and would allow better cost-benefit
and cost-effectiveness estimates than most of the previously discussed
measures. These include absenteeism, turnover, health services
expenditures, health insurance claims, and disability and workers'
compensation payments. To date, very little study of these variables
has been done in relation to stress management programs. The issues
of cost-benefit and cost-effectiveness analysis will be considered in
the next section.

130



level, ethical issues also should be considered at the organizational
level. Ethical issues in organizational research have been treated in
two recent publications (Mirvis and Seashore, 1979; Evaluation
Research Society, 1980).

Informed Consent. Prominent among the principles that should guide
evaluators is that of informed consent. The principle of informed
consent requires that an evaluator secure in advance of the study
agreement of all participants in an investigation. This consent is
obtained after the potential participants have learned about the
nature of the investigation. The issue of informed consent has been
addressed previously (ADAMHA, 1975; APA, 1973).

Informed consent has been defined as:

The knowing consent of an individual or his/her legally
authorized representative, so situated as to be able to exercise
free power of choice without undue inducement or any element of
force, fraud, deceit, duress, or other forms of constraint or
coercion (ADAMHA, 1975).

Several basic elements of information necessary to informed consent
are:

o A clear explanation of the program, its objectives, and
procedures. Identification of any procedures that are
experimental.

o An explanation of any risks or discomfort that might occur.
o A description of the benefits that might occur.
o An offer to answer any questions about the procedures.

o A statement that participants are free to withdraw from the
program at any time without reprisals.

o An offer to help individuals find alternative services should
they wish to withdraw from the study.

Three useful references on the topic of ethics in research are,

Ethical Principles in the Conduct of Research with Human Participants
(APA, 1973), and the ADAMHA Guide for the Protection of Human Subjects
(ADAMHA, 1975), and the reports of the President's Commission for the
Study of Ethical Problems in Medicine and Biomedical Research (1981).

136



Document Associates, Inc.
211 East 43rd Street

New York, NY 10017
212/682-0730

Contact: Gary Crowdus

Educational Activities, Inc.
P.O. Box 392

Freeport, NY 11520
516/223-4666 (New York)
800/645-3739 (outside New York)

Edupac, Inc.

231 Norfolk Street
Walpole, MA 02081
617/668-7746

Contact: Carol Perry

Fitness Publications

P.O. Box 178554

San Diego, CA 92117

714/569-6581

Contact: Thomas A. Murphy; Dianne Murphy

Human Relations Media

175 Tompkins Avenue
Pleasantville, NY 10570
914/769-7496 (New York)
800/431-2050 (outside New York)
Contact: Bruce Holmes

Human Sciences Press

72 Fifth Avenue

New York, NY 10011
212/243-6000

Contact: Barbara Perrin

International Film Bureau, Inc.
332 South Michigan Avenue
Chicago, IL 60604
312/427-4545

Contact: Eriel Reimers

181



programs, cited improved morale, better quality of life, greater
inducement for recruiting, less employee turnover, and better
employee-management relationships as additional benefits. Johnson &
Johnson's wellness program "Live For Life" far exceeded predicted and
hoped for cost savings and also created a greater "sense of community”
among the employees as well as between the company and its employees
(Brown, 1981).

CAUSES AND NATURE OF STRESS AT THE WORKSITE

Job stress can have many roots and causes. Some of these are
environmental and arise from annoying physical problems at work such
as crowding, noise and air pollution, and possible exposure to
potentially hazardous substances. Others may relate to the nature of
the occupation, The common denominator here is often being placed in a
situation which demands considerable responsibility without
commensurate authority or decision making capability or not being able
to express your true feelings and get things off your chest. Dull,
dead-end, assembly line type of work, or having a job which does not
permit full use of one's talents and potential or where constant
deadlines do not permit enough time to get the job done to one's
satisfaction may prove particularly stressful for large groups of
individuals in middle management positions.

Stress at work can also be due to the individual's own personality, a
good example being the executive with Type A behavior who is
continually frustrated by self imposed unrealistic goals that are
inflexibly pursued. Such individuals may themselves be vectors of
stress at work as their aggressive and sometimes hostile behavior
produces adverse repercussions on co-workers and customers. More
often, it is not the individual or the job per se but rather a
mismatch between the two in terms of basic goals, needs, and values
that causes continuing problems. Stress at work may also have its
real roots outside the workplace because of family or financial
problems which lead to alcoholism, depression, or anxiety that affect
activities and performance on the job. Some common factors that
contribute to job stress are (Rosch, 1984b):

Inadequate time to complete the job to one's satisfaction.

Lack of clear job description or chain of command.

Absence of recognition or reward for good job performance.

Inability or lack of opportunity to voice complaints.

Lots of responsibilities but little authority or

decision-making capability.

Inability to work with superiors, co-workers, or subordinates

because of basic differences in goals and values.

Lack of control or pride over the finished product.

o Job insecurity due to pressures from within or possibility of
takeover or merger.

o Prejudice and bigotry due to age, sex, race, or religion.

eoo0000

°

°

74



Quality of Employment Survey (1977). Ann Arbor, Michigan: Survey
Research Center.

Schwartz, G.E. (1981). A systems analysis of psychobiology and behavior

therapy: Implications for behavioral medicine. Psychotherapy and
Psychosomatics, 36, 159-184.

Schwartz, G.E. (1982a). Testing the biopsychosocial model: The ultimate

challenge facing behavioral medicine? Journal of Consulting and
Clinical Psychology, 50, 1040-1053.

Schwartz, G.E. (1982b). Disregulation theory and disease: Applications
to the repression/cerebral disconnection/cardiovascular disorder

hypothesis. International Review of Applied Psychology, 32,
95-118.

Singer, J.A., Neale, M.S. and Schwartz, G.E. (1986). Conflicting
Perspectives on labor and management definitions of stress: A systems
approach to their resolution. In Cataldo, M. and Coates, T. (Eds.)

Health and Industry: A Behavorial Medicine Perspective. New York:
Wiley.

Strand, R. (1983). A systems paradigm of organizational adaptations to
the social environment. Academy of Management Review, 8, 91-97.

von Bertalanffy, L. (1968). General Systems Theory. New York:
Braziller.

29



stressful situations. As such, every training program offered by the
training staff of most organizations is conceivably a stress
management program to the extent that it helps people to do their work
more effectively and with less hassle. Thus, embedding the stress
management training course in the context of training in the
organization is important. If it is offered as something entirely
separate from other training programs, it will not serve the
participants as effectively as if it is seen as a central part of the
training.

By the same token, in many organizations, there are many staff
services available to employees that are of relevance to the stress
management training and these connections should be made for the
participants. Included would be Employee Assistance Programs, other
counseling programs, medical department services (if there is an
interest in prevention), emergency personal services programs, Human
Resources programs, and so on. Every service offered to employees is
conceivably of some relevance to a comprehensive stress management
training program, and care should be taken to establish and nurture
the relationships among these services as the stress management
training proceeds. If one or more of these services becomes alienated
or turns against the stress management program, the program's
credibility will suffer.

System Response

One effective framework for assessing the effectiveness of stress
Management suggests three levels of response. The first two levels,
(1) avoiding or removing stress and (2) coping effectively with
stress, are focused on adjusting the stress levels individuals are
experiencing. The third level, building and protecting health, has to
do with developing the individuals' capacities (reserves) to withstand
the rigors of working in a stressful environment. It should be
obvious that there are many facets to each of these three levels which
individuals need to be taught in a comprehensive stress management
training program. What is often less obvious are ways the system can
respond on each of these three levels to cut down on the amount of
unnecessary stress generated and to encourage individuals to look
after their health and well-being. Some system level ideas follow.

Removal or Avoidance of Stressors: The organization can help to avoid
creating a lot of episodic stress for its members by ensuring
effective communications about necessary changes and taking other
steps to minimize the amount of surprise and uncertainty (novelty) so
often associated with complex change processes in organizations.
Further, the organization can encourage face to face work groups to
identify the stressful habits or norms affecting their work and to
take steps to alter these norms. Thirdly, different styles of
decision making and policy formulation may be necessary. Finally,
organizations can often take the heat off, at least temporarily, by
rotational work assignments.

104



Non-Work Factors

Workers clearly do not leave their family and personal problems behind
when they go to work nor do they typically forget job problems upon
returning home, Nearly all models of job stress, in fact, acknowledge
non-work factors and their potential interaction with work in
affecting health outcomes. However, very few studies have attempted
to examine the respective health effects of job and
extra-organizational stressors (Bhagat, McQuaid, Lindholm, and
Segovis, 1985). While some investigators have incorporated generic
stressful life events scales into job stress surveys, these scales
provide only rough indications of social, familial and financial
stressors. It is quite clear that greater attention needs to be paid
to these kind of factors. Interpersonal, marital, financial, and
child-rearing stressors as well as other non-work situations can
exacerbate existing job stressors to promote acute stress reactions.
Alternatively, the absence of such extra-organizational problems may
make a less than satisfactory job situation more tolerable (less
stressful) and can impede the development of stress reactions.

Buffer Factors

A number of factors are known to weaken the stressor-acute reaction
link and, therefore, reduce the occurrence of ill-health outcomes.
Such factors are generally referred to as buffers. One of the
earliest buffer variables examined in job stress research was social
support. House and Wells (1978) showed that workers who report high
levels of social support have fewer health complaints than comparably
stressed workers with low social support. The source of support also
appears to be important. Social support from one's supervisor or
spouse was found by House and Wells (1978) to be more effective than
support from co-workers or from friends or relatives. Support was
also found to buffer the effects of stress on some health conditions
(e.g., neurosis and ulcers) more than on others (e.g., angina). More
recent research (Thoits, 1982) has confirmed the protective role of
social support on worker health.

Another potent buffer is coping. A great deal of literature on stress
coping exists but little of this knowledge has been included in
occupational stress/health formulations until recently. Lazarus and
colleagues (Cohen and Lazarus, 1979; Folkman and Lazarus, 1980) have
indicated that coping is not a trait or disposition but is a
continuous, transactional process which is modified by experience
within and between stressful episodes. Further, a specific coping
strategy which can serve to alleviate stress in one situation may be
maladaptive in other situations (Cohen and Lazarus, 1979).

Pearlin and Schooler (1978) believe that the coping responses people

use are a function of the social and psychological resources at their
disposal. Social supports and psychological resources (e.g., mastery

37



My belief is that this is a subtle but pivotal issue for most people,
After all, we are dealing with affective not cognitive concerns where
the specifics have great significance to the men and women involved.

So, why not use stress assessment instruments for general distribution
or for introductory workshops? My sense is that, until program
participants have made a conscious, informed decision relatively free
of self-blaming to deal with stress in a manner different than they
were before, and have begun to identify and accept their own concerns
as significant, they are more likely to have their perception of their
stressors invalidated by not having these particular stressors appear
on the printed list of questions than they are to appreciate the
sampling subtlety involved. There are useful stress assessment
instruments available; I prefer to introduce them to people who are
actively working to improve their stress situation rather than to use
them as a warning or awareness tool for "beginners".

Use Adult Educa iscovery Techniques

Learning to deal with stress is learning to deal differently with
life. Clearly, there is no single starting point, no specific path
that will work for everyone, not even for many. We each have
individual concerns and awareness, varying goals and priorities, and
different strengths and resources, including learning styles. Also,
our clients will choose their own change strategies almost regardless
of the value of our professional advice or the dramatic quality of our
exhortations. Significant change in emotionally charged areas will
rarely result simply from rational planning and cognitive instruction
even when we are technically right about what others should do and how
they should do it.

So, it appears clear to me that stress programs will be most
successful to the extent they are individualized, experiential in
training design, and approach the participant as a self-directed
learner while enhancing his/her capability to function in that manner.

My experience in learning to use such adult education approaches is
that vastly more is involved than learning some new "techniques" or
organizing learning activities in a different way. In addition to
learning new practices, I was -- and still am — required to
reconsider my role in facilitating other people's learning, to
reevaluate my expectations about what can be accomplished and who is
responsible for what in the learning process, to become aware of my
behavior and learners’ behaviors in new ways, and to change some of my
own "teaching" practices that would be accepted, indeed, taken for
granted in most instructional programs focussed on cognitive learning.

167



this nursing group in order to get a finer understanding of the
organizational stressors that were impacting this group.

Eighteen nurses completed the OMS. The following stressors were
identified: (1) Nurses were overworked and responsible for too many
tasks; (2) poor communication existed between this work group and the
other work units in the hospital; (3) nurses were chronically worried
about job security; (4) unsafe equipment was being used; and (5)
management talked down to employees, failed to give sufficient
feedback, and did not compliment employees who did their jobs well.
The data from the OMS supported the initial results from the HFI. It
was also discovered that this high risk nursing department was
engaging in a number of acts of negligence within the hospital that
could eventually lead to a medical malpractice loss. Hospital
administration studied the OMS results and quickly set out to correct
the organizational stressors that were identified.

V. INDIRECT MEASURES

Some companies might not have access to organizational stress surveys
for a number of reasons, one being financial. For these companies,
there are a number of indirect measures of stress that can be used to
identify high risk work groups.

Insurance claims data are often related to organizational stress
(Jones and DuBois, 1985). Companies can analyze workers' compensation
costs, medical costs, and the frequency and severity of accidents in
order to determine if there are more losses than usual or more losses
compared to similar types of companies. Other indirect measures
include turnover and productivity data. Ideally, this data can be
analyzed across time and by different work groups in order to identify
an aberrant pattern of losses that can be linked back to job stress.
Corrective actions could then be taken.

CONCLUSION

This chapter described a number of instruments that can be used to
assess organizational stress. ‘These instruments are cost-efficient,
brief, and can be used in nearly any type of work setting. They can
be administered and scored by nonprofessional personnel, who, with a
bit of training, can also deliver basic interpretive information to
key decision makers within a company.

Other stress inventories like the Stress Map (Jaffe and Scott, 1985),
the Stress Audit (Miller and Smith, 1983) and the Stress Management
Questionnaire (Peterson and Lawrence, 1983) exist, but too little
validity data has accumulated to warrant detailed descriptions in this
chapter. By the same token, inventories like the Job Descriptive
Index (Smith, Kendall, and Hulin, 1969) have a proven track record,

63



We Identify The es 0 S88?

Stress is a significant issue and an increasing problem; as the rate
of change in the world increases, individuals experience more and more
stress. In the "right" circumstances for the "right" person, almost
anything could be a source of stress. How should we categorize the
varieties of internal and external experience that can be stressful?
Clearly we cannot list everything but, how do we avoid omitting
stressors of significance to the people with whom we work?

Part of my concern about this issue arises from my sense that there
are at least two categories of stressors that many programs fail to
adequately address: background stressors and stigmatized stressors.

We live in a time of high and increasing background levels in our
personal and work stress situations; there is a lot happening that
affects our sense of well-being. Because stress is a cumulative
process, "background stressors" such as international tensions,
socio-economic pressures, high unemployment, intergroup tensions,
racial and sexual discrimination, objective concerns about aging, and
the like form a baseline stress arousal level to which day to day job,
family and individual stress adds. My guess is that we give these
background stressors short shrift because we know relatively less
about how to help people with these legitimate concerns.

The second category, stigmatized stressors, originate in taboo issues
that many individuals either prefer not to think about or reasonably
hesitate to raise in any but the safest or most intimate contexts,
which only rarely will include relatively brief, occupational stress
programs.

And, if these issues are difficult for participants to discuss, they
are no less problematic for the practitioner. There may be many
reasons why an external consultant, hired only to conduct a half-day
stress workshop for a company, does not raise such volatile issues as,
say, the labor-management climate, the effect of corporate work norms,
or how to reduce the stress of sexual harassment. But we know that
continuing evasion of such issues will further neither individual
growth nor corporate productivity, and the existence of substantial
hidden issues in a workshop undermines its effectiveness and can
produce considerable stress for the workshop leader.

My concern is not only that certain categories of stressors are
omitted from consideration and that, when they are left out, our
efforts lose relevance, effectiveness, and, ultimately, acceptance.
My concern is also that we may frequently fail to validate individual
participants' stressors. Think back on the questions you've been
asked during a workshop and recall how often people are, in effect,
inquiring, "Is this issue that bothers me a genuine source of
stress? Is my situation actually difficult or am I just not
adequate?" The government worker whose agency faces a reduction

151



conditions interacts with the worker and results in an acute
disruption of psychological or behavioral homeostasis. ‘These acute
reactions or disruptions, if prolonged, are thought to lead to a
variety of illnesses. As shown in Figure 1, the most commonly
researched of these job stress-related illnesses have been
hypertension, coronary heart disease, alcoholism and mental illness.

MODEL OF JOB STRESS AND HEALTH

INDIVIDUAL
FACTORS

JOB STRESSORS PERSONALITY TRAITS
SSOR: ‘STAGE OF CAREER
—=———| _ DEVELOPMENT

J0B/TASK DEMANOS
ret ACUTE REACTIONS
* SONTAOL PSYCHOLOGICAL

AFFECT i ILLNESS 1
ORGANIZATIONAL sop oissatisraction | #
«ROLE DEMANDS HYPERTENSION |
© MANAGEMENT PHYSIOLOGICAL cH L.

HEART RATE “1 /| acconousm [7

STYLES 7
° CAREEA/SECURITY BLOOD PRESSURE MENTAL ILLNESS} #
‘© INTERPERSONAL

RELATIONS, 1 BEHAVIORAL

SLEEP PROBLEMS L..!

x

NON—WORK SUBSTANCE USE/ i
Cee omarion FACTORS BUFFER FACTORS | AGUSt i
@ HEAT/COLO
—

FINANCIAL STATUS P=] SOCIAL SUPPORT
FAMILY SITUATION [~] COPING i

a

eee eee e mmm nh nnn nnn n nw nee dnn — cone enn nee n nen nee

Figure 2.1. Model of Job Stress and Health

Job Stressors.and Their Consequences

That various job conditions can produce psychological, physiological,
and behavioral reactions in workers has been well documented (see
Baker, 1985; Holt, 1982; and Hurrell and Colligan, 1982 for reviews).
In general, these conditions or stressors fall into three very broad
categories: Job/Task Demands, Organizational Factors, and Physical
Conditions. Examples of common stressors in each category are
discussed below.

Job/Task Demands. Workload is a feature of occupations that is easily
recognized as "stressful" and has therefore received substantial
empirical attention. Working excessive hours or holding down more
than one job (or both), for example, has been associated with coronary

33



Jones, J.W., and DuBois, D. (1985). The Human Factors Surveys:

Background and Interpretation Guide. St. Paul, MN: The St. Paul

Insurance Companies, 1-33.

Maslach, C. (1982). Burnout: The Cost of Caring. Englewood Cliffs,
New Jersey, 1-192.

Maslach, C., and Jackson, S.E. (1979). Burned-out cops and their
families. Psychology Today, 12 (12), 59-62.

Maslach, C. and Jackson, S.E. (1981). The Maslach Burnout Inventory.
Palo Alto, CA: Consulting Psychologist Press.

Maslach, C., and Pines, A. (1977). The burnout syndrome in the
day care setting. Child Care Quarterly, 6, 100-113.

Miller, L. H. and Smith, A. D. (1983). Stress Audit. Boston, Mass:
Biobehavioral Associates.

Moos, R. H. (1981). Work Environment Scale Manual. Palo Alto, CA:
Consulting Psychologist Press, Inc.

National Council on Compensation Insurance (1985). Emotional stress
in_the workplace: New legal rights in the eighties. New York:

National Council on Compensation Insurance.

Peterson, J. C. and Lawrence, H. (1983). Stress Management
Questionnaire. Tucson, Arizona: James J. Peterson.

Smith, P.C., Kendall, L.M., and Hulin, C.L. (1969). The Measurement

of Satisfaction in Work and Retirement. Chicago: Rand-McNally.
Wetzel, J. (1976). Dependence upon unsustaining environments as an
antecedent variable of depression. Doctoral dissertation, George

Warren Brown School of Social Work Washington University, St. Louis,
MO, 1976; Dissertation Abstracts International, 37, 5361.

Wetzel, J. (1978). Depression and dependence upon unsustaining
environments. Clinical Social Work Journal, 6, 75-89.

66



Coping Effectively with Unavoidable Stressors: The organization can
help its members cope with stressors on a day to day basis if it
encourages the use of effective problem solving techniques, rather
than letting expedience or internal political dynamics "solve" the
problems which inevitably arise. Second, employee education is
increasingly necessary. In addition to making stress management
training available to employees, organizations should identify the
specific interpersonal skills needed by its members and make sure that
training in these skills is readily available. Third, rather than
just removing stress "casualties" from the organization after they
have burned out, organizations need to be providing competent,
confidential counseling and referral services for those who have
problems, and they need to reach these people before their problems
become overwhelming.

Building and Protecting Health: Organizations can help their members
protect themselves by encouraging and supporting good individual
self-management practices. This support needs to be manifested
through such things as quiet rooms and relaxation instruction;
exercise facilities and instruction; and the availability of healthful
foods in cafeterias and vending machines. Verbal support of the
program, without these tangible manifestations of that support are
merely platitudes which employees quickly see through. Finally, task
forces can be created (with real tasks and authority!), to further
develop long term protection against the kinds of stress which arise
when organizational units are overly differentiated from each other
and/or often in conflict with each other.

In summary, a good, comprehensive, preventive approach to stress
management requires that both individuals and the organization at
large assume specific responsibilities. Neither must be allowed to
abdicate these responsibilities. The illustrations given above apply
to most organizations. Each organization needs to develop its own
unique responses to stress on each level.

SUMMARY

This chapter closes by returning to the questions raised in the
opening paragraphs. Perhaps the most important question to answer is
"what results do you want to create?" Many training programs are so
busily focused on the process of training and the "latest" techniques
that this question isn't even asked, let alone clearly answered.

There are at least three categories of focus or orientation which have
a bearing on this question of desired results. First, should the
program have an individual focus or will it include systemic issues
such as management procedures and corporate habit patterns. Programs
which include this systemic focus are most likely to have a sustained
positive impact. Without this systemic focus, the most that can be
done is to teach people how to protect themselves from their own
working environments!

105



I have felt the considerable impatience of some workshop participants
and organizational policy makers with our inability to "cure" stress;
I understand the pressure that exists to exercise professional
responsibility by using our expertise to diagnose problems and to
prescribe a regimen that helps. Yet, my experience is that we are
rarely able to obtain significant and lasting changes in the stress
situation of persons or organizations and institutions simply by
directive techniques. Such changes occur only when the principal
actors have great ownership of the idea, a personal investment in the
outcomes, and sufficient skill and resources. We cannot and need not
"give" these to our clients. But, we can support their efforts and
help them obtain skills needed to learn from and change their
situation.

Take A Systems Approach

Stress is a complex dynamic simultaneously involving each person at a
number of levels including being an ethnic group member, a family
member, a worker, an individual, a spiritual being, and a
constellation of bio-physical processes. Thus a systems approach is
required to change stress situations; e.g. a multi-level scope of
effort is required, the change objectives must be derived from a
data-based analysis of the current situation and a coordinated
strategy for starting and completing the project must be agreed to by
all the major stakeholders involved.

Joint Labor Managemen: rts

I have two, interrelated reasons for suggesting that, to the maximum
extent possible, we should undertake our pilot, experimental,
developmental, and research projects in worksites with the active
involvement of both management and labor representatives. One reason
is that I believe this situation contains the best potential for
successful projects and useful outcomes and the second is that I
believe this situation reflects significant values for stress work.

My experience in working with organizations and groups on both action
and research projects is that the more my clients are clear about the
outcomes they want and committed to achieving results, the more
effective my work can be. In practice, this means that there is a
body of people in the client system who are interested in the project,
stay current with and support it, lending assistance and/or follow up
in both formal and informal roles. I get clearer data about what help
people want, what is possible, how best to implement ideas in that
specific situation/climate, greater interest in my suggestions and
participation, better feedback on my actions, and there is more
likelihood that my work will be useful. I believe this clarity and
involvement are most likely to occur in a workplace where labor and
management have a mutually respectful relationship and where there is
a high level of worker participation in the local union,

170



Given the range and complexity of many of these personal factors that
may increase the likelihood of work-related stress, there is no easy
way to define and isolate individuals' susceptibility. Thus, several
different approaches should be used to identify the type and severity
of stress producing factors at the individual level.

When the purpose is to screen a relatively large number of employees
who are functioning reasonably well, self-report inventories may be
used. A number of life events scales are available which allow
estimates to be made of the amount of stress that persons are under.
Some of these scales are reviewed by Jenkins et al. (1984). Also, an
instrument is available to measure more proximal and frequently
occurring daily hassles (Kanner et al., 1981).

Since the specific types and general pattern of major life changes and
hassles that can occur at work may differ greatly for different
occupations and companies, questions may need to be specifically
tailored. Often this will require the development and use of semi- or
unstructured techniques. Martin (1983) has reported on the use of
semi-structural techniques in obtaining data on stress in the graphic
arts industry. The advantage of these techniques are their
flexibility and ability to provide details on specific problems that
are sources of stress to employees on particular jobs.

Baseline information on physical health habits can be collected
conveniently and relatively expensively through the use of
self-report, health-risk appraisals. Information on the availability
and characteristics of a large number of health risk appraisals has
been summarized in a recent publication (Green and Lewis, 1986).
Details and a discussion of the prospects for the use of health hazard
appraisals are provided in a recent technical report (Breslow et al.,
1985).

Reactions to Stress. Sources of stress have been implicated in
psychological, behavioral, and physiological/biochemical changes.
There is strong empirical documentation and a voluminous literature on
short-term reactions to sources of stress (Cincirpini et al., 1984;
Stainbrook and Green, 1983). However, while it has been suggested
that stress contributes to long-term mental and physical health
problems the strength of the relationship between individual stressors
or collective indices of stress and these health status indicators is
not strong (Baker, 1985; Kasl, 1980, 1984).

128



French, J.R.P. Jr., Israel, J. and Aas, D. (1960). An experiment in
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French, J.R.P., Jr. and Caplan, R.D. 91972). Organizational stress
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New York: AMACOM, 30-66. .

Friedman, M.D., Rosenmann, R.D. and Carroll, V. (1958). Changes in
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House, J. (1974). Occupational stress and coronary heart disease: A
review and theoretical integration. Journal of Health and Social
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House, J. and Wells, J.A. (1978). Occupational stress, social
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Reducing Occupational Stress. DHHS(NIOSH) Publication No. 78-140,
Washington, DC: U.S. Government Printing Office.

Hurrell, J.J. Jr. and Colligan, M.J. (1982). Psychological job

stress. -In W.N. Rom (Ed.) Environmental and Occupational Medicine.
Boston: Little Brown. 425-30.

Ivancevich, J.M., Matteson, M.J. and Preston, C. (1982). Occupational
stress, Type A behavior and physical well being. Academy of
Management Journal, 25, 373-391.

Ivancevich, J.M. and Matteson, M.T. (1984). A Type A person-work
environment interaction model for examining occupational stress
consequences. Human Relations, 37(7), 491-513.

Jackson, S. and Schuler, R. (1985). A meta-analysis and conceptual
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settings. Organizational Behavior and Human Decision, 36, 16-28.

Jenkins, C.D. (1971). Psychologic and social precursors of coronary
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Kahn, R.L., Wolfe, D.M., Quinn, R.P., Snoek, J.D., and Rosenthal, R.A.
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43



to some 75 questions designed to measure anxiety, depression,
hostility, ability to express emotions, Type A behavior with various
aspects of perceived job stress. A computerized printout is generated
which provides insight into whether the problems arise because of the
nature of working conditions, as opposed to personality, or behavioral
characteristics, or a mismatch between the two.

While we have seen that some simple stress reduction techniques may
provide across the board benefits, stress management techniques
ideally should be matched with the requirements of the organization
and the population being served. In some instances, emphasis may need
to be placed on problems such as job security or career management.
For maximum effectiveness, workers should ideally play an active role
in program selection, design, and evaluation. Progress is more apt to
be made by beginning starting with a small focused intervention
program for a specific target group that allows evaluation of efficacy
and costs. This can be enlarged in stepwise fashion as results
indicate the need for various modifications or greater emphasis in
specific areas. This approach seems preferable to instituting a large
multifaceted smorgasbord of services. Existing facilities should be
utilized whenever possible, and this can usually be accomplished with
respect to exercise or fitness programs. On the other hand, it may
sometimes be more efficient and economical to take advantage of
existing community based exercise programs such as those offered by
local YMCA facilities. These often provide other counselling services
with respect to diet, nutrition, smoking cessation, hypertension
detection, and management of low back problems. It is particularly
important that any program provide built-in evaluation techniques to
assess the efficacy of the intervention. This requires the
participation of randomized control groups and long term follow-up
assessment.

Companies can best embark on such programs by learning from the
experience of others, particularly organizations of similar size and
demographics that have instituted successful programs. An useful
resource in such information gathering is the newly formed National
Health Network which maintains a current computerized database
accessible to businesses, through a toll free number (1-800-322-1234),
for locating health promotion services available in their respective
geographical location,

87



Levels.

Sociocultural

Organizational

Work Setting

Interpersonal

Psychological

Biological

Physical/
Environmental

TABLE 1.1 PA’

Stressors

Racism; Sexism
Ecological shifts
Economic downturns
Political changes
Military crises

Hiring policies

Plant closings

Layoffs, Relocation,

Automation, Market
shifts, Retraining

Organizational priorities

Task (time, speed,
autonomy, creativity)

Supervision

Co-workers

Ergonomics

Participation in decision
making

Divorce, Separation
Marital discord
Conflict, family/friend
Death, illness in family
Intergenerational conflict

Legal/financial difficulties

Early parenthood

Neurosis, Mental illness

Disturbance of Affect,
Cognition or Behavior

Ineffective coping skills

Poor self-image

Poor communication

Addictive behavior

Disease, Disability
Sleep, Appetite

disturbance
Chemical dependency
Biochemical imbalance
Pregnancy

Poor air, climate

Noise exposure

Toxic substance exposure
Poor lighting

Radiation exposure

Poor equipment design
Bad architecture

Grass roots organizing

NA RI [ALUAT: R:
Intervention:
Formal nformal
Elections
Lobbying/political Petitions
action

Public education
Trade associations

Corporate decision

Reorganization

New management model

Management consultant
inservice/retraining

Supervisor meetings
Health/safety meetings
Union grievance
Employee involvement
Quality circles

Job redesign
Inservice training

Legal/financial services
Leave of absence
Counseting, Psychotherapy
Insurance plans

Family therapy
Loans/Credit unions

Day care

Employee assistance
(referral/in house)

Counseling, Psychotherapy

Medication

Supervisory training

Stress Management

Workshop

Preplacement screening
Counseling

Medical treatment
Health education
Employee assistance
Maternity leave

Protective clothing/
equipment

Climate control

Health/safety committee

Interior decoration

Muzak

Union grievance

Demonstrations
Migration
Spouse employment.

Social activities
Contests; Incentives
Manager involvement &
ties with workers
Continuing education
Moonlighting

Slow down/speed up
Redefine tasks

Support of other workers
Sabotage, theft

Quit, change jobs

Seek social support/
advice

Seek legal/financial
assistance

Self-help groups

Vacation/sick days

Child care

Seek support from
friends, family, church

Self-help groups/books

Self-medication

Recreation, leisure

Sexual activity

“Mental health" days

Change sleep/wake habits
Bag lunch
Self-medication
Cosmetics

Diets, exercise

Consult physician

Own equipment, decoration

Walkman, radio

Consult personal
physician

Letters of complaint



CONTRIBUTORS
PREFACE

PaRT I

Chapter 1

Chapter 2

Chapter 3

PART II

Chapter 4

Chapter 5

Chapter 6

Chapter 7

PART III

CONTENTS

STRESS IN ORGANIZATIONAL SETTINGS

The Nuts and Bolts of Assessing Occupational
Stress: A Collaborative Effort With Labor
Jefferson A. Singer, Michael S. Neale,

and Gary E. Schwartz

An Overview of Organizational Stress and Health
Joseph J. Hurrell, Jr.

A Review of Organizational Stress Assessment
Instruments
John W. Jones and David DuBois

STRESS MANAGEMENT PROGRAMS

Designing Workplace Stress Management Programs
Paul Rosch and Kenneth Pelletier

Creating and Maintaining Comprehensive Stress
Management Training
John Adams

Measurement and Evaluation Methods for
Worksite Stress Management
Gene Stainbrook and Lawrence Green

Worker Stress: A Practitioner's Perspective
Eugene V. Martin

RESOURCE GUIDE

Training Materials, Products and Equipment

iv

vii

3-29

31-45

47-66

67

69-91

93-107

109-147

149-172

173-190



We who provide stress services didn't create this situation but I
think we sometimes unwittingly contribute to it. Our assertions about
"...taking personal responsibility" are likely to significantly
reinforce this victim self-blaming for many program participants and
undermines the skill-learning processes we propose. Our almost
exclusive focus on individual self change as the strategy for dealing
with stress also conveys a powerful message to many that "If you were
only better, you wouldn't have all this stress." We may mean "better"
in terms of skill; we may be heard to mean “a better person".

There are two ways in which I would like to have more effective skills
for helping people reduce such self—blame so they can increase their
clarity about their stress situation and how to improve it. First, I
would like to be better able to help workshop participants identify
"external" stressors and collaborative change strategies without their
feeling overwhelmed. Second, I wish we had better techniques for
empowerment and building self-esteem that could be used with small
groups and general audiences.

Are hod, ten Incongruent Wit! Ob, ?

Stress is a consequence of the perception of change; yet, our programs
would have participants initiate additional change to modify some
aspect of their stress situation. My impression is that we rarely
advise participants that stress programs are stressful, nor do we
obtain their informed consent before involving them in potentially
stressful activities. I believe we could build more supportive and
recuperative measures into the stress program itself.

Moreover, the changes we seek to help people make are rarely
superficial or trivial to accomplish. Typically, our programs'
participants want complex, interrelated changes in all three strategy
areas. Such changes usually take time and the development of a
variety of skills. Also required are the belief that change is
possible, a commitment to staying with the learning/change process,
and the adaptation of general learnings to one's own situation.

These factors indicate the need for self-directed learning, for
workshop dynamics based on peer-consultation, for "discovery"
techniques, and for us to take "facilitative" rather than "expert"
roles. We are needed to help people become empowered at self care, to
build on what they already know how to do, as they add skills that
they choose from needs that they have assessed. Do we often think
that we have to change -- rather than help them examine -- their
priorities and lifestyle choices?

153



Organizational strategies which have potential for preventing or
reducing stress include quality circles, which bring bench-level
workers into the decision-making process, worker representation on
health and safety committees, more extensive training programs for
workers whose jobs are being altered by the introduction of new
technology, alteration of communication channels within an
organization, and creation of more psychologically humane evaluation
systems to replace ones that are either archaic or ones that monitor
employee performance in a Big Brother fashion (e.g., computer
monitoring of keystrokes). These interventions, however, have not
been subjected to rigorous scientific evaluation, perhaps owing to
some of the problems mentioned earlier. Evaluation schemes for such
interventions should include an element of cost/benefit in addition to
assessments of worker satisfaction, job stressors, performance,
absenteeism, and health status.

The foregoing sections have described a growing knowledge base on
occupational stress and health. Though the area is complex, and much
additional research is needed, it is quite clear that organizations
can no longer afford to ignore the human and organizational costs of
stress. Instead, it has become increasingly mandatory for
organizations to understand and endeavor to deal with it.

40



amelioration. The purpose of this session was to formulate the
participants' conclusions for presentation to the industry's union and
management leadership.

Results

Individual interviews proved a successful means for creating initial
awareness and interest in the topic of stress among the industry's
leaders. None of those who were asked declined to be interviewed,
even several who objected to the project. (One manager said it was a
waste of money because "stress cannot be studied scientifically"; a
union officer believed the project defamed workers by implication.
“Our people aren't crazy.") Virtually all verified that they would
not initially have attended a meeting called to discuss the topic.

The most intriguing single finding was the almost unanimous agreement
that stress is a significant issue in the industry, But each of the
union and management leaders also believed that he or she was
virtually the only one who would “admit” it.

One union staff member initially denied that there was any significant
stress and, some time later in the interview, paused abruptly while
talking about another topic, sat quietly for a moment, and then said,
“You know, as we've been talking, I've been remembering the people I
worked with when I was a shop steward. And, as I see their faces, I
remember the specific problems and concerns they had. I can't believe
I told you there was no stress.”

The manager of a plant operating around the clock, seven days a week
also initially denied that stress was a problem. "Oh no, we've got
good working relations here." Later in the interview he said that
several times a week he would go out on the plant roof where he could
privately hold onto a chimney and scream "to relieve some tension".

Although the industry's leaders believe the problem is significant,
they believe themselves to be isolated in this perception and view the
issue of stress as stigmatizing and as an unavoidable aspect of work.
They are individually hopeful that unions and management could work
together on the issue, at least initially, but, anticipate that stress
raises difficult issues and, potentially, significant differences in
vested interests, so far as those interests are now recognized.

The original plan to feedback the results of the interviews to the
advisory panels and then reinterview their members were not
implemented; adequate funding was not available and other activities
in the SHAPE program had higher priority.

In the absence of models for large scale, comprehensive stress
programs that can deal with workplace issues, and given the absence of

164



concluded that “despite methodological problems inherent in some of
the previous evaluations, the data suggest that stress reduction
programs at the worksite are effective in reducing both physiological
and psychological indications of stress" (McLeroy, Green, Mullen and
Foshee, 1984). They also emphasized that stress management programs
must address both individual and collective stress management
techniques, as well as modifying the stressful aspects of the work
environment including business policies and corporate culture.

There are numerous anecdotal reports that suggest benefits. Several
years ago, the PA Medical Corporation claimed a 14% decline in
absenteeism due to their stress reduction program (Everly and Girdano,
1980). Kenecott Copper credited a whopping 75% decrease in "sickness
and accident costs" to their stress reduction efforts (Egdahl and
Walsh, 1980). At Transco, much of the company's profit rise was
considered to be a direct consequence of stress reduction programs
(Everly and Girdano, 1980). Such enthusiastic claims have naturally
spurred other corporations on to investigate the desirability of
introducing or adding stress reduction programs as an additional
employee benefit.

While our purpose here is to review and evaluate formal stress
reduction programs per se, it is perhaps more practical to study
efficacy within the context of broader employee assistance programs.
Many such efforts really represent stress reduction techniques
although they fall under other headings such as exercise, counselling
on alcoholism, and substance abuse, marital problems, and diet, all of
which have important stress related implications. The mere
establishment of an employee assistance program may in itself have
important stress reduction benefits since it provides pertinent
resources for the worker, as well as tangible evidence of management's
interest and dedication to personal welfare. One study suggests that
10% of all employees have significant serious personal problems
(Pelletier, 1984), while another indicates that employee assistance
Programs, by improving or resolving such difficulties, have achieved
an average 80% rehabilitation rate among participants (Berry, 1981).
In terms of over-all employee assistance programs which do not
necessarily employ specific stress reduction strategies cited
previously, there appears to be little question of benefit to all
parties concerned. Kimberly Clark reported a 70% reduction in on the
job accidents with their employee assistance program (Dedmon, 1980).
At General Motors, there was a 40% decrease in lost time and a 60%
decrease in sickness and accident benefit payments. On the job
accidents decreased by 50% and so did grievances. The cost
effectiveness of each dollar invested was significant with at least a
3-1 return (Stessin, 1977). Equitable Life Assurance Society
estimated $ 5.52 (Manuso, 1984) and Kenecott Copper $6.00 (Berry,
1981) saved for every dollar spent on their programs. Other less
quantifiable benefits were also cited. The Chief Executive officer of
Tenneco, which purports to have the "Cadillac" of corporate wellness

73



psychologists conducted group meetings to answer any questions and
teach additional briefer forms of relaxation that might be utilized
throughout the work day.

All four groups, including controls, showed improvement after 5 1/2
months. However, those who were members of the meditation-relaxation
groups reported significantly greater symptom reduction than controls
as measured by the SCL-90-R. Compliance was greatest in the
standardized meditation group (81%) as compared to 76% with the
"Relaxation Response" and 63% for the progressive muscular relaxation
group. When those subjects who were still practicing their techniques
at the conclusion of the study were compared with non-practicers, the
therapeutic benefits were even more pronounced despite only occasional
use.

The SCL-90-R scores for employees were compared with those of
comparison groups previously studied including normals and psychiatric
out-patients. The initial scores fell midway between those of
psychiatric out-patients and normals on entry into the program.
However, at the end of 5 1/2 months, the scores for the
meditation-relaxation groups fell in the middle of the normal range
and the summarization scale was significantly below normal. In
contrast, the New York Telephone control group still ranged
significantly above the non-patient normal average value. The
progressive muscle relaxation group did not differ significantly from
controls in terms of symptom reduction but most meditation groups
did. Those subjects who stopped practicing generally did so within
the first three months. Those who continued, often switched from
frequent to occasional practicing, but significant improvement was
still apparent.

In another study conducted in the corporate offices of the Converse
Rubber Company (Peters, Benson and Porter, 1977a), 126 volunteers
participated in a program designed to study the effects of two fifteen
minute relaxation breaks during the work day. One third of the group
had two or three instructional sessions in the relaxation response,
another third simply relaxed without focusing on anything specific, or
listened to music, and a final group received no special instruction.
The efficacy of the program was assessed by self report of physical
and mental symptoms including level of energy, improved concentration,
overall efficiency, problem solving ability, and time lost due to
illness. On each of these indices, the relaxation response group
showed the greatest benefits. The control group reported least
improvement, and the daily relaxation break without specific training
showed intermediate gains. Of interest was the notation that specific
relaxation training instructions also appeared to result in
significant reductions in blood pressure (Peters, Benson and Peters,
1977b). The results of such studies are encouraging since they
suggest that positive benefits can result from relatively simple,
brief, easy to learn techniques that are inexpensive, do not require

82



STRESS MANAGEMENT IN WORK SETTINGS

EDITORS

Lawrence R. Murphy

Applied Psychology and Ergonomics Branch
Division of Biomedical and Behavioral Science

and
Theodore F. Schoenborn

Technical Information Branch
Division of Standards Development and Technology Transfer

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Centers for Disease Control
National Institute for Occupational Safety and Health

May, 1987


program. A third purpose is often to assess the cost-benefit ratio or
the cost-effectiveness of the program. A list of general reasons for
evaluation adapted from prior summaries (Rossi and Freeman, 1982;
Shortell and Richardson 1978; and Weiss, 1972) is displayed below:

o To determine how effective a program has been in achieving its
goals.

o To examine how efficient a program has been in achieving its
goals.

o To determine the success of a program with different target
groups.

o To study the cost-benefit of a program.

o To determine the cost-effectiveness of a program.

o To justify past or projected expenditures.

o To gain greater control over a program.

o To determine future courses of action.

o To contribute to the fields of applied and basic knowledge.

The priority given to particular reasons for evaluation usually
depends on the perspective of the program sponsor. For example,
executives may be concerned primarily with outcomes and costs, program
managers may be interested in program utilization and impact, and
participants may be primarily concerned with their own personal
interests and satisfaction.

Program Planning

The first stage in the development of a stress management program is
planning and the first step in planning is the assessment of needs.
The care with which a program is planned often determines the quality
of the evaluation that can be done. Ideally, considerations of
measurement and evaluation should be an integral part of the planning
process.

Three basic steps should be used in the planning and determination of
the scope and specific direction of stress management programs. These
steps are (1) conducting a needs assessment, (2) establishing
priorities, and (3) specifying, goals and objectives. Each of these
steps will be discussed briefly.

110



Association for the Advancement of Health Education
1900 Association Drive

Reston, VA 22091

703/476-3440

Provides catalogs, brochures, fact sheets, newsletters, films
and books.

Behavioral Consultants, Ltd.
P.O. Box 30536

Seattle, WA 98103
206/789-5500

Provides self-help manual, audiocassette, and conducts
programs.

Biofeedback Institute of Los Angeles
6399 Wilshire Blvd.

Los Angeles, CA 90048

213/933-9451

Provides information on the design and manufacture of
physiological equipment.

Blue Cross and Blue Shield Associations
676 St. Clair Street

Chicago, I1 60611

312/440-6000

Provides brochures and booklets on a wide range of health
topics at no charge.

Boston Women’s Health Book Collective
P.O. Box 192

West Somerville, MA 02144
617/924-0271

Provides brochure, fact sheet, books, information packet,
posters; also conducts programs.

185



These analyses can provide valuable information to program managers
and policy makers in a variety of ways. Some of their major uses are
summarized below:

o To account for the use of public and private funds

o To compare the efficiency of the operation

o To compare the cost of alternative services or programs
o To determine allocation or reallocate of resources.

In some cases government organizations are the primary source of funds
for prevention programs. In most cases, the costs of stress
management programs have been borne by individual companies. Cost
analysis can answer questions regarding the efficient use of resources
and the optimum size of a program, etc. Cost analysis also can be
used to compare alternative methods of providing services or

programs. With cost data on alternate methods for providing
prevention services, the analysis seeks to identify the least costly
program alternative that can accomplish the desired objective.
Information on the costs and effectiveness of alternative programs or
methods within a program can help program managers to modify or

improve the process of the program or to reallocate resources to
alternative programs.

Gost-benefit Analysis. Cost-benefit analysis reduces all outcomes to
monetary terms. This allows the direct comparison of programs with
different outcomes. In order to conduct cost-benefit analyses several
things must be known. First, it must be possible to estimate the
effectiveness of the programs. This step requires estimating the
reduction in morbidity and mortality; calculating the direct cost of
the treatment or other services that may be averted; figuring the
indirect value of income which would be lost if the person continued
to exhibit certain problems; and estimating the money saved through
the reduction of the problems. Second, the operational costs of
running the program must be determined. Third, a monetary value must
be placed on the expected outcomes. When information is available on
two or more programs, cost-benefit data allows comparisons between
programs. Given the right set of conditions, the use of cost-benefit
analysis is very useful. However, in many disease prevention/health
promotion programs there is insufficient information available to
carry out this type of analysis. Methods and procedures for
conducting cost-benefit analyses have been discussed in detail (Green
and Lewis, 1986; Rossi and Freeman, 1982; Shepard and Thompson, 1979).

133



representing the industry locally. The members of the three advisory
panels of influential labor and management leaders were queried on
three aspects of job stress in the industry:

The Current Situation: Is job stress a significant issue in the
industry? What causes it? What is the nature of it? How do
labor and management view it?

The Preferred Situation: What are desirable goals for long range
improvement? What next steps would be useful? What will affect
labor-management cooperation dealing with stress?

This Project: What do labor and management representatives need
to know about stress? What questions would you like this project
to answer? What would you, personally, like to know about stress?

Participants for the workshops were nominated by the advisory panel
members in their respective cities and were invited by letter from the
SHAPE office. The participant lists were formed by the Director of
the Graphic Arts Institute in each city; these Institutes are jointly
trusteed, training facilities operated by labor and management to
provide the highly skilled workers needed for the local industry. The
15 to 20 participants in each city were selected to comprise a
five-way cross section of the industry: some of the advisory panel
members made up the union and the management contingents; three groups
of workers came from the preparatory, the press and the
bookbinding/finishing components of the industry.

Six workshops were conducted in each city, arranged as three pairs of
workshops held on consecutive days with some two weeks between the
pairs. Participants were asked to commit themselves to attending all
six in their invitation. The workshops were held in the facilities of
the Graphic Arts Institutes. In one city the workshop was held in a
classroom; in the other, the tables were arranged between two
commercial presses (not then in operation!).

Workshop I, a three-hour evening session was largely devoted to two
topics, reviewing the project's origins, plans, and intentions, the
expectations of and for participants; and an introductory review of
the dynamics and consequences of the stress reaction. The purpose was
to clarify the project as intended, recruit wholehearted
participation, modify plans as initially required, and begin with some
shared understanding of basic stress facts.

Workshop II, another three-hour session, was held the following
night. Participants worked in plenary and in small groups to plan how
they would study and observe, in themselves and among colleagues, the
existence, process, and effects of stress in their respective
workplaces. The purpose was for each participant-researcher to

162



Kenneth Pelletier

California Health and Medical Education
P.O. Box 13063

Oakland, California 94661

Paul Rosch

President, American Institute for Stress
124 Park Avenue

Yonkers, New York 10703

Gary E. Schwartz

Department of Psychology

Yale University

P.O. Box 11A, Yale Station

New Haven, Connecticut 06520-7447

Jefferson A. Singer

Department of Psychology

Yale University

P.O. Box 11A, Yale Station

New Haven, Connecticut 06520-7447

Gene Stainbrook

Center for Health Promotion Research and Development
The University of Texas Health Science Center at Houston
P.O. Box 20036

Houston, Texas 77225

iv



Needs Assessment. The first step in program planning should be to
conduct a needs assessment. While the importance of thorough needs
assessments to the success of programs often has been emphasized, it
still remains a weak component of most programs. The rationale and
methods of needs assessments have been detailed by many writers
(French and Kaufman, 1983; Rossi and Freeman, 1982; Siegel et al.,
1977; Warheit et al., 1977). This topic is treated specifically as it
relates to health education and health promotion programs by Green et
al. (1980); Parkinson et al. (1982); and Green and Lewis (1986); and
as it relates more to mental health programs by Siegel et al. (1977);
and Warheit et al. (1977).

The purpose of a needs assessment is to identify and document the type
and severity of problems in particular populations. Six objectives of
needs assessments have been identified by Green et al. (1980). These
are presented in below they apply to worksite programs:

1. To determine the subjective concerns with quality of life in
the employee population and with productivity in the employer
population.

2. To verify and clarify these concerns with analyses of existing
business and social indicators and other available information
sources.

3. To document the status of the employee and employer groups in
relation to those priority concerns for which there is a health
component or cause,

4, To make explicit the rationale for the selection of priority
problems.

5. To use the documentation and rationale to justify the further
expenditure of resources for the selected problems.

6. Ultimately, to use the documentation and rationale as the bases
on which to set objectives and to evaluate the program in
cost-effectiveness or benefit terms.

Several strategies are available to determine the type and extent of
problems that exist in particular jobs and work settings. Initial
steps of a needs assessment include a social or economic diagnosis, an
epidemiological diagnosis, and a behavioral diagnosis (Green et al.,
1980). The first assesses data on social or economic problems of the
company or employees. The epidemiological diagnosis assesses data on
the presence of work-related problems, and on the incidence and
prevalence of physical and mental health problems contributing to the

111



Rann ii ee = =£_e= Si iE RecninnEeen
\
8

A final related point is that our assessment reached workers whose
stressors are seldom documented by corporate stress management
programs. We allowed the opinions of maids, laundry workers, and
dishwashers about what makes their work stressful to enter the stress
literature alongside the air traffic controllers’ and executives'
complaints. For this data, we are grateful to the senior organizer,
who was adamant about our inclusion of the "back of the house."

Since the assessment, the Food and Allied Services and Trades
(F.A.S.T.) department of the AFL-CIO has requested copies of the OSEG,
questionnaires, and results. They have plans to apply the assessment
strategy to some organizing campaigns in non-union hotels. In fact,
at a recent convention of hotel union organizers, they presented our
model as potential organizing strategy, while one of the organizers
with whom we worked listened in the audience. He assured us it
sounded better in description than it looked while we were doing it.

27



Elkin, A. (1984). STRESSCARE, INC., 1000 Northern Blvd., Great Neck,
NY 11021.

Everly, G.S. and Girdano, D.A. (1980). The Stress Mess Solution; The
Causes and Cures of Stress on the Job, Robert J. Brady, Bowie, MD.

Fielding, J.B. (1984). Corporate Health Management, Reading, MA:
Addison-Wesley.

Friedman, M., Thoresen, C.E., Gill, J.J., Powell, L.H. (1984).
Alteration of Type A behavior and reduction of cardiac recurrences in

post myocardial infarction patients, American Heart Journal, 108,
237-248.

Haynes, S.G., and Lacroix, A.Z. (1985). Job stress--Who feels it
most? Powerlessness at work. Paper presented at the American Heart
Association's Twelfth Science Writers Forum, Monterey, CA.

Holmes, T.H. and Rahe, R.H. (1967). The social readjustment rating
scale, Journal of Psychosomatic Research, 11, 213-218.

Jacobson, E.J. (1929). Progressive Relaxation, University of Chicago
Press, Chicago.

Jenkins, C.D., Rosenman, R.H. and Friedman, M. (1967). Development of
an objective psychological test for determination of the coronary

prone behavior pattern in employed man, Journal Chronic Diseases 20,
371-379.

Joint National Committee on Detection, Evaluation, and Treatment of
High Blood Pressure. (1984) Report. U.S. Department of Health and
Human Services, (NIOSH publication no. 84-1088), Washington, DC.

Kanner, A.D., Coyne, J.C., Schaefer, and Lazarus, R.S. (1981).
Comparison of two modes of stress measurement: Daily hassles and
uplifts versus major life events, Journal of Behavavioral Medicine, 4,
1-39.

Karasek, R.A., Jr. (1979). Job demands, job decision, latitude and
mental strain: Implications for job redesign, Administrative Science
Quarterly, 24, 285-308.

Karasek, R.A., et al. (1981). Job decision latitude, job demands and
cardiovascular disease: A prospective study of Swedish men, erican
Journal of Public Health, 71, 694-705.

Kobasa, S. and Maddi, S. (1979). Psychological hardiness, Journal of
Occupational Medicine, 21, 595-598.

Lafferty, J.C. (1983, 1984 revisions). Human Synergistics, 39189
Plymouth Road, Plymouth, MI 48170.

89



information that directly affects behavior. As a result, a plan for
changing inappropriate or self defeating thinking and behavior
patterns can be formulated.

Levels 4(a) ("Management Practices Audit") and 4(b) ("Supervisory
Practices Audit") focus on managerial and supervisory behavior. This
measures some 15 management skill areas and 12 styles both by self
report as well as by 4 or 5 anonymous close co-workers reports. Such
confidential feedback about management methods has been found to
facilitate significant positive change. The Human Synergistics
program has been in existence for approximately 15 years with minor
modifications. The company indicates that efficacy can be validated
and that in addition to improved efficiency at work there are distinct
health benefits. Cost effectiveness is more difficult to prove and
the major value of this program would appear to be targeted to middle
management or executive personnel.

The Institute for Labor and Mental Health has developed an
Occupational Stress Group that uses trained shop stewards to conduct a
highly structured twelve week course in the workplace. This is
designed to increase the worker's sense of power or ability to
influence working conditions and to promote a greater sense of
camaraderie and self trust. A major result has been a more "focused
anger" directed at specific work problems that attempts to rectify
discrepancies. It is claimed that this increases productivity,
reduces problems related to alcoholism and emotional outbursts or

random anger at home (Behavior Today, 1985).

Another newly formed company, STRESSCARE, offers a prepackaged
multi-dimensional approach to stress management for corporations
(Elkin, 1984). This program contains a variety of techniques as shown
in Figure 4.1. Preliminary reports on general applicability, cost
effectiveness, compliance, and efficacy are favorable.

FUTURE DIRECTIONS

Clearly, management, labor unions, and various occupational
organizations have become increasingly aware of the importance of job
stress and are expressing increasing interest in programs to reduce
its causes or combat its effects. Rapidly rising worker compensation
claims for all sorts of job stress as well as increasing payroll costs
for health related insurance and expenses will undoubtedly accelerate
this trend. Detailed analysis of specific occupational stress related
problems have been noted in a variety of surveys including stress and
burn-out in the schools, operating railroad engineers, law enforcement
officials, air traffic controllers, editors, and graphic arts design
personnel. Such studies may be particularly useful in formulating
specifically targeted programs.

84



On the other hand, a major hotel in our area was having serious
problems with stress. As the union representative described the
situation at this hotel, we began to realize that labor-management
interactions had grown tremendously in sophistication. The
employee-manager relationship,was no longer a shopfloor phenomenon,
but was dictated by multinational corporate decisions that cut across
each level of the OSEG hierarchy. The hotel was part of a large
corporate chain that had recently been taken over by an even larger
conglomerate. Its policies were dictated by the chain's international
headquarters, which prescribed as much standardization and time
accountability as possible. The consequences of this standardization
at the managerial level included expectations of company loyalty,
little room for informal or flexible arrangements within a given
hotel's policies, and extensive managerial rotation (to help train
Managers to be interchangeable as needed).

The hotel in question, we were told, had been run in a rather
disorganized and informal manner for most of the nine years it had
been open. A year previously, with the hotel in the red, the
international headquarters had sent in a new management team drawn
from other hotels in the chain. The stated purpose of this new
management was to get the hotel back into shape and to standardize its
practices and routines in line with more successful chains. Even
though it was the best situated and equipped of the three major
downtown hotels, it had not yet fulfilled its earning promise. Under
a new general manager, who had taken up residence in the hotel, this
corps of “outsiders” had initiated sweeping changes in hotel policy
and organization, most notably staff reductions and new work
schedules, The union, organized shortly after the hotel opened,
reacted quite negatively to the management changes. Members believed
their performance was judged unfairly by a group of strangers, and
that inefficiency at the hotel was due to management's abuse of
perquisites and lavish after-hour parties. Union members resented the
new stricter policies instituted by management and also feared further
lay-offs due to a push for higher productivity.

While these changes were occurring at the hotel, contract negotiations
for all three downtown hotels were fast approaching. The union had
managed to arrange the three locals’ contract expiration dates to
overlap within the same week. Reflecting a sophistication equal to
that of management, the union's organizing effort for these new
contracts would involve a three-pronged strategy. At the highest
level, the union would go after the parent corporations that owned the
hotels. This would mean research into the larger social policies and
activities of each corporation. Key company leaders would become the
focus of letter-writing campaigns, demonstrations when they spoke in
public, and visits from politicians sympathetic to the union. This
“corporate campaign" would also challenge the public image of civic
commitment these companies projected to the city. Newspaper
advertisements and rallies would question the depth of their



VDTs. Some specific signs of technostress include headaches from
VDT use, fear of radiation exposure, eye irritation and fatigue,
muscle aches and pains, and emotional discomfort and stress.
(Employees who do not use VDTs are excluded from any analysis with
this scale.) Sample items include: "Do you get headaches from
VDT use?"; "Do your eyes become irritated and fatigued from VDT
use?7"; and "Does working on a VDT cause you any emotional
discomfort or stress?"

Distortion. This scale identifies the percentage of employees who
are truthful with their responses. It identifies the number of
employees who attempt to "fake good" or "fake bad" on the Human
Factors Inventory.

Interpreting HFI Scale Scores

The HFI takes approximately 30 minutes to complete. It is given to
all company employees. Participation is both anonymous and
voluntary. The HFI survey results are then computer scored and
compared to the national norm. An organizational "stress quotient" is
computed for each company. This comparison allows companies to
determine if their employees are above or below a national average in
terms of their stress reactions and coping skills. The inventory also

indicates in which jobs or departments employees are experiencing the
most stress.

The major findings of the Human Factors Inventory are derived from
analyzing the survey data on three levels: 1) Overall results for
each scale for all company employees combined; 2) analyses by employee
subgroups (e.g., job titles, departments, locations, demographic
variables); and 3) response frequencies for individual items. HFI
percentile scores ranging from 0 to 100 are plotted for each
subscale. Higher scores mean greater risk. The following guidelines
are used when interpreting all subscales:

Percentile Description Range

0 - 20%
Very Low Risk. The average employee is coping better than 80% or

more of the employees represented in the norms. This is probably
due to better coping skills and less exposure to stressful
situations.

21 - 40%

Low Risk. The typical employee is coping better than 60 to 79% of
the employees in the normative sample.

53



PERIODICALS

Center (5 issues/year)

Information on health promotion activities around the country and
resource materials (i.e., books, tapes, and other health education
publications and where to order). Each issue contains a special
section on workplace interventions. Subscription includes
“associate membership" for one year, discounts on other NCHE
publications, and invitations to NCHE seminars and conferences.
Cost: $40/year.

National Center for Health Education (NCHE)
30 East 29th Street
New York, NY 10016

Employee Health and Fitness (Monthly newsletter)

Information on organizational health promotion programs,
interviews with program personnel, question and answer section,
and notice of upcoming conferences including costs and where to
register. Each issue highlights new publications in worksite
health promotion and provides ordering information. Cost:
$98/year.

American Health Consultants, Inc.
67 Peachtree Park Drive, NE.
Atlanta, GA 30309

Practical Stress Management (Monthly Newsletter)

Short summaries of current research findings related to stress and
stress management. Information on conferences of interest is also
provided. Cost: $35/year.

American Institute of Stress, Inc.
124 Park Avenue
Yonkers, New York 10703

Your Health & Fitness (Bi-monthly magazine)

Topics include various aspects of health, includes addresses for
more information about most articles. Space is also available for
news from individual companies. Cost: $9/year.

Curriculum Innovations, Inc.

3500 Western Avenue
Highland Park, IL 60035

174



It is also possible, with such support, for the stress management
training program to actively consider how the culture of the
organization is both an asset and a liability to effective stress
management. For example, if one of the elements of the organization's
culture which people identify as stressful is that no one ever gives
any performance feedback except when mistakes are made, there is
little hope of engendering more positive performance feedback without
the active involvement of senior managers.

When solid support from management is lacking, the nature of the
stress management training is necessarily different. Rather than
including a systems perspective on how to respond to the stressors in
the working environment, one must focus the training primarily on
teaching the participants to protect themselves from their own
organizations!

One of the most effective ways to elicit top management support is to
present a statistical summary of the costs of unaddressed stress.
Such summaries are relatively easy to construct, as national health
Statistics are readily available from the Center for Disease Control,
plus many of the popular books on stress and health published over the
past 10 years. One can also easily access the trend in the
organization's health care payments for the last several years in most
organizations. In some cases, more specific stress related health
care costs are available within the organization (turnover and
absenteeism rates, prevalence of hypertension, etc.). With a little
more digging, the hidden overhead costs for replacing personnel can be
estimated with some accuracy. The figure usually comes out to be
close to the average salary plus benefits for the position being
filled. When one begins to develop such estimates, the magnitude of
unaddressed stress becomes evident, and the impetus for developing a
high impact stress management training program grows.

Another consideration in engendering system support for the intended
stress management training program is in relating the program to other
training seminars already available to members of the organization.

It can be argued that any training seminar which helps people do their
work better with less tension is a "stress management" training
program. With this perspective, aligning the stress management
training program with these other programs becomes an obvious thing to
do. With a broad sense of integration across the spectrum of training
resources available, all of the programs will benefit and have greater
impact.

Ensuring that the program is conducted by people with adequate
resources is also of utmost importance. Stress management training is
quite different from other kinds of training programs, which are
generally based on a single discipline such as social psychology.
Stress management training, on the other hand, necessarily is highly
multi—disciplinary, drawing on such diverse fields as psychology,

97



Metropolitan Life Insurance Company
Health and Safety Education Div.
One Madison Avenue

New York, NY 10010

212/578-5014

Provides educational materials and conducts programs for
industry and business,

National Center for Health Education
30 East 29th Street
New York, NY 10010

Provides educational materials, newsletters, and journals
covering a wide range of health topics.

National Clearinghouse for Mental Health Information
Public Inquiries Section

5600 Fishers Lane

Rockville, MD 20857

Provides catalogue of federal government publications dealing
with mental health.

National Health Information Clearinghouse
P.O. Box 1133

Washington, D.C. 20013-1133
703/522-2590 (Virginia)

800/336-4797 (outside Virginia)

Offers referrals to other health information organizations,
government agencies, self-help groups, and voluntary
associations.

National Institute for Occupational Safety and Health (NIOSH)
Robert A. Taft Laboratories

4676 Columbia Parkway

Cincinnati, OH 45226

513/533-8323

Offers information on current occupational safety and health
research, reprints of technical reports and selected journal
articles, and referrals to other agencies for additional
information.

188



PART III

RESOURCE CUIDE

Training Materials, Products, and Equipment

This part provides information on resources available for stress
Management programs at the worksites. Information is presented in
five sections corresponding to periodicals, books, video cassettes and

film media, training material sources, and miscellaneous
agencies/groups.

The resources listed in this part, though not exhaustive, should
provide interested parties with a range of contacts through which
additional information on stress management can be acquired.

173



o Unpleasant environmental conditions because of smoking,
crowding, noise and air pollution, exposure to toxic chemicals
or carcinogens, or commuting difficulties.

o Concerns related to responsibility for employees.

o Not being able to utilize personal talents or abilities
effectively or to full potential.

o The FUD factor — fear, uncertainty, doubt.

Most formal stress reduction programs concentrate on using various
methods to reduce physiologic and somatic responses to stress by the
use of meditation, progressive muscular relaxation, biofeedback, yoga,
exercise, or similar interventions and combinations. Obviously, the
ability to identify sources of stress and eliminate or mitigate them,
provides a more effective approach to the problem. Coordinating such
efforts with instruction in behavioral modification providing coping
skills, assertiveness training or taking advantage of other aspects of
an overall employee assistance program that deals with other
psychosocial problems would appear to represent the most effective and
comprehensive approach. It is important to keep each of these
multifaceted aspects in mind when attempting to construct or evaluate
stress management training programs for industry. As noted
previously, many stress reduction efforts offered by corporations are
not identified formally as such but are included as part of larger
company policies, programs, and benefits. A comprehensive analysis of
the problem that acknowledges all the above pertinent variables has
been developed by Schwartz and co-workers at the Department of
Psychology at Yale University (Neale, Singer, Schwartz and Schwartz,
1982). This is summarized in the form of an occupational stress
evaluation grid which analyzes and categorizes stressors from such
varying viewpoints and highlights strategies which have been developed
to deal with them. (See Table 1.1, p. 5)

STRESS MANAGEMENT TRAINING PROGRAMS AT THE WORKSITE

As part of this review, we attempted to identify, categorize, and
evaluate stress management training programs offered to workers. This
required reviewing the literature supplemented by a series of written
and telephone inquiries based on various leads and prior contacts.
There were few new programs identified and very little additional
information relative to new long term results or controlled studies.
There was a general absence of criteria for assessing the efficacy of
any such intervention. Most efforts consisted primarily of
educational programs designed to acquaint workers with the role of
stress in health, and illness, sources and causes of stress, nature of
stress related symptoms, and diagrams illustrating stress reduction
techniques. In a few instances there were also lectures, symposia, or
workshops lasting from several hours to several days. Such programs
were usually implemented at the worksite or at conference centers, and
hotels, occasionally in the form of a “retreat.” In larger
organizations tend to be administered by company personnel, and/or

75



heart disease (CHD) morbidity and mortality (House 1974; Jenkins,
1971; Theorell and Rahe, 1972). Studies showing a correlation between
workload and serum cholesterol levels (French and Caplan, 1972;
Friedman, Rosenman and Carroll, 1958) also seem to suggest a
CHD/workload relationship.

Recent evidence, however, has suggested that the amount of work does
not seem to be as critical to health as the control the worker has
over the work rate and related work processes. Karasek et al. (1979,
1982), for example, have used large scale data bases to examine the
relationship between workload, work pace and degree of worker
control. Their findings indicate that workers in jobs with higher
workload and pacing demands, and lower control over these demands,
have increased risk of coronary heart disease, higher blood pressure,
and smoke more than employees in jobs without these characteristics.

Shift work is another job demand thought to have health and safety
consequences. There is substantial converging evidence that night and
rotating shift schedules, in particular, can lead to sleep disorders,
gastrointestinal disorders, emotional disturbances, and increased risk
of occupational injury (Rutenfranz, Colquhoun, Knauth and Ghata, 1977;
Tasto, Colligan, Skjei and Polly, 1978; Smith, Colligan, Frockt and
Tasto, 1979). The primary mechanism responsible for these effects
appears to be disruption of biological rhythms resulting in
physiological and biochemical disturbances. Shift work also has
behavioral effects that can impact health, including altered sleeping
patterns, increased alcohol and tobacco use, and altered eating habits
(Rutenfranz, et al., 1977).

Organizational Factors. Numerous job stress studies have examined the
psychological and physical effects of roles within work
organizations. These studies were given original impetus by an
investigation conducted in the early 1960s by Robert Kahn and his
colleagues at the Institute for Social Research at the University of
Michigan. In this nationwide survey, Kahn et al. (1964) found that
men who experienced role ambiguity (i.e., lack of clarity about
objectives associated with the work role, expectations concerning the
work role and about the scope and responsibilities of the job)
experienced low self-confidence, higher job related tension and lower
job satisfaction. Likewise, workers who experienced role conflict
(i.e., conflicting job demands) were found to experience more job
related tension and to report less job satisfaction. A recent
meta-analysis of 96 studies (Jackson and Schuler, 1985) has not only
confirmed these relationships between role conflict, ambiguity and
affective reactions, but has suggested that these role stressors are
also related to absence and poor job performance. Role ambiguity and
conflict have also been shown to be related to psychological responses
such as increased heart rate and blood pressure (Caplan and Jones,
1975; French and Caplan, 1972; Ivancevich, Matteson and Preston, 1982).

34



American Heart Association
National Center

7320 Greenville Avenue
Dallas, TX 75231
214/750-5300

Provides educational material in the form of brochures,

catalogs, directory, fact sheet. Also offers training for
staff and volunteers.

American Institute of Stress, Inc.
124 Park Avenue

Yonkers, NY 10703

914/963-1200

Provides materials and conducts free workshops and symposia.

American Public Health Association
1015 15th Street, NW

Washington, DC 20005

202/789-5600

Provides catalogs, brochures, fact sheets, and newsletters.

American Red Cross

National Headquarters
17th & D Streets, NW
Washington, DC 20006

Provides stress management instructor courses, self-help
classes, brochures, films, videocassettes, slide-tape
presentations, textbooks, workbooks, and information kits.
Also offers training for volunteers and paraprofessionals.

APPLE (A Positive Plan for Lifestyle Enrichment)
Metropolitan Medical Center

900 South Eighth Street

Minneapolis, MN 55404

612/347-4655

Provides materials.and conducts programs in Upper Midwest area
for business, industry, and government organizations. Also
provides brochure and newsletter.

184



CHAPTER 3
A REVIEW OF ORGANIZATIONAL STRESS ASSESSMENT INSTRUMENTS

John W. Jones and David DuBois

Legal researchers are concluding that managers can no longer choose to
recognize and deal with the sources and symptoms of stress on the job
-- it has become a legal obligation (Ivancevich, Matteson, and
Richards, 1985). Organizational stress surveys can be used to provide
management with information on both the levels and sources of employee
stress. Stress surveys that can be employed in organizational
settings are reviewed in this chapter.

THE COST OF OCCUPATIONAL STRESS

Stress is a costly business expense, affecting both employee health
and company profits. However, companies can reduce stress and its
effects through comprehensive work site stress management programs.

Consider these stress facts gleaned from various safety and insurance
industry research (Jones, 1985):

o In 1982, the total cost of work-related accidents in the U.S.
alone was $32 billion.

o The causes of about 75-85 percent of all industrial accidents
are accident susceptibility factors (e.g., fatigue, poor
concentration, inattentiveness).

© Psychological or psychosomatic problems contribute to over 60
percent of long-term employee disability cases.

o About 11 percent of all occupational disease claims are for
workplace stress.

With regard to the last statistic, three forms of work stress claims
have been delineated (National Council on Compensation Insurance,
1985). A physical-mental claim occurs when a physical injury results
in a mental disability, such as a phobic fear of heights after falling
from a scaffold and breaking a leg. Mental-physical claims happen if
mental stress results in a physical injury, such as when constant
deadline pressures, coupled with overwork, culminates in a heart
attack. Lastly, mental-mental claims occur when mental stress causes
mental disability. An example would be sexual harassment that leads
an office worker to have anxiety attacks.

Legal suits for job-related stress likely will increase in the future
because:

1. Research suggests a relationship between stress and
injury/illness.

2. Many state workers' compensation laws specify compensation for
injuries, both physical and mental, resulting from job stress.

47



of the study should be made. When research is a major emphasis the
main threats to the validity of the conclusions that might be drawn
from the design must be considered (Cook and Campbell, 1979; Green and
Lewis, 1986). A sound choice of designs also requires recognition of
the practical, ethical, and financial constraints on the conduct of
the study. For example, issues of informed consent and denial of
services to control groups put constraints on many potential
evaluation activities.

There are some basic procedures that can always be used. Other very
elaborate designs can be used only when logistics are favorable and
substantial funding is available. By adding successive elements to
the basic procedures, it is possible to increase progressively the
level of internal validity or rigor and also the level of external
validity or generality. Elements of evaluation designs will be
discussed in the next section.

Six different evaluation designs are listed below. These designs
increase in complexity and cost of implementation from 1-6. The
historical and inventory approaches are basically bookkeeping
techniques, the comparative and controlled comparison approaches allow
effectiveness estimates, and the controlled experimental and
full-blown evaluative research project allow causal inferences and
generalizations to be made with maximum assurance. Examples of
worksite based health programs that were evaluated through the
inventory and other approaches may be found in Green and Lewis (1986)
and Parkinson et al. (1982).

1. Historical, Record Keeping Approach

2. Inventory Approach

3. Comparative Approach

4. Controlled Comparison, or Quasi-experimental Approach

5. Controlled Experimental Approach

6. Full-Blown Evaluative Research Project
Historical Approach. When an evaluator sets up a continuous
record-keeping procedure to accumulate data and then periodically
charts the data to determine if change is occurring, a historical
standard of acceptability has been applied. The frequency of data
collection depends on how often the events that are being recorded
occur. This very basic approach generates data that can be presented

in charts and graphs to demonstrate how the program is doing.
Collecting and charting data in this way provides periodic benchmarks

119



effectiveness. Sample items include: "I am very satisfied with
my job."; "This company is well managed."; "I am paid adequately
for what I do."; and "We have a good team relationship in my

department."
Organizational Stress. This scale assesses employees' perceptions

of organizational stress. This scale identifies whether
departments have unacceptable levels of organizational tension.
Some general signs of organizational stress that are measured by
this scale include poor productivity, interpersonal conflicts,
departmental tension, excessive absenteeism, accidents and
mistakes, and a perception that employees are distressed.
Employee dishonesty, waste and on-the-job alcohol and drug misuse
are also assessed. Sample items include: "My department is
understaffed."; "There is more absenteeism and tardiness in my
department than usual."; and "Staff turnover is high in my
department."

Stressful Life Changes. This scale measures the amount of
stressful life changes that employees have experienced in the past
12 months. Examples of stressful life changes that are assessed
include taking on debts; an illness, injury, or death of a loved
one; and major changes in job duties at work. This scale provides
a measure of personal stress. Most companies request a stress
survey that can differentiate between job stress and personal
stress.

Life and Health Risks. This scale measures lifestyles and health
habits that increase the risk for unnecessary injuries, illnesses,
and premature deaths among employees. Examples of such risks
include lack of exercise and relaxation, unsafe driving practices,
poor nutrition and weight control, smoking, alcohol abuse, and so
on. Sample items include: "I get a thorough physical examination
each year."; "I try to prevent work stress by exercising and
participating in recreational activities."; and "I get
approximately eight hours sleep at least four nights a week."

Accident Risks. This scale measures four human factors that
contribute to accidents and errors. The four factors are: (1) An
inability to cope with stress; (2) Poor safety attitudes; (3) A
tendency to worry about job performance, and (4) An inability to
Manage time Sample items include: "Are you always safety
conscious? "Do you feel hurried or rushed to complete deadlines
at work?"; and "Do you feel fatigued during the workday."

Technostress. Countless employees have claimed that working with
Video Display Terminals (VDTs) is an adverse experience. Many
employees are wary of the potential health hazards of VDTs. This
wariness leads to unnecessary stress. This scale measures how
much "technostress" is experienced by employees who work with

52



5 Formative evaluation of health promotion programs (1983).
6 On the subject of sampling. (1984).

7 Aids to evaluation: Computers and consultants (1984).

8 Health risk assessment in health program evaluation (1984).
9 Measurement Issues: Reliability and validity (1985).

10 Qualitative Methods in Program Evaluation (1986).

Subscription to Baseline is free and single copies of many of the back
issues can still be obtained at no charge. The editors are planning
to publish two more issues after which all issues will be updated and
edited as a manual or book. Correspondence regarding this publication
should be addressed to:

Editors, Baseline

Health Services Research Center
The University of North Carolina
Chase Hall 132-A

Chapel Hill, North Carolina 27514
Telephone (919) 966-5011

French, J.F. and Kaufman, N.J. (Eds.). (1983). Handbook for
Prevention Evaluation: Prevention Evaluation Guidelines. DHHS
Publication No. (ADM) 83-1145. U.S. Government Printing Office,
Washington, DC 20402

This is a well written manual which is practical, provides details
and covers most of the basic issues in program evaluation. It was
developed specifically as a guide for evaluators of primary
prevention programs for mental health and substance abuse
Problems. Thus, many of the concerns and examples are highly
relevant to issues in stress management programs.

The Handbook has been available at no charge from the National
Clearinghouse for Drug Abuse Information. The address is:

National Clearinghouse for Drug Abuse Information
P.O. Box 416

Kensington, MD 20795

If it is no longer available from the Clearinghouse, it can be
purchased from the Superintendent of Documents. The
identification number is 0-410-948. The address is:

Superintendent of Documents

U.S. Government Printing Office
Washington, DC 20402

140



3. More employees are prompted to file stress claims because they
believe in the stress-loss connection and know that fellow
employees have received workers’ compensation for it.

4. Finally, lawyers, judges and physicians are becoming more
familiar with this type of claim. It is more easily diagnosed
and more often used to receive legal and monetary restitution.

Hence, it becomes imperative that companies begin to understand,
assess, and remedy excessive levels of occupational stress.

But what is stress? By definition, stress is the adverse emotional
and physical reactions employees have to any source of pressure in
their environment. These stress reactions negatively affect personal
health and organizational effectiveness and often create losses (see
Table 3.1).

TABLE 3.1 THE PERSONAL AND ORGANIZATIONAL EFFECTS
OF OCCUPATIONAL STRESSES

Personal
Alcohol abuse Anxiety
Drug abuse Psychosomatic diseases
Emotional instability Eating disorders
Lack of self-control Boredom
Fatigue Mental illness
Marital problems Suicide
Depression Health breakdowns
Insomnia (cardiovascular, etc.)
Insecurity Irresponsibility
Frustration Violence

Organizational

Accidents Inflated health-care costs
Thefts Unpreparedness

Reduced productivity Lack of creativity

High turnover Increased sick leave
Increased errors Premature retirement
Absenteeism Organizational breakdown
Disability payments Disloyalty

Sabotage Job dissatisfaction
Damage and waste Poor decisions
Replacement costs Antagonistic group action

48



in terms of appraisal of threatening situations. Very often, it is
not the external event itself, but rather the individual's perception
of it that causes problems. Gognitive training is designed to assist
individuals in learning how to reappraise stressful situations by
logic and reasoning rather than emotional reactions that have been
ingrained by past habits. Often this involves emphasis on developing
improvement of self esteem and personal worth.

Physical Fitness

Physical fitness is far and away the most popular method utilized to
deal with stress in the workplace. This may take varied forms ranging
from lunch hour or other company sponsored walking and jogging groups,
aerobic dancing or exercise classes, or encouraging the use of
community or in-house fitness facilities where specialized muscle
pbuilding equipment is available. Proponents of jogging claim that
regular running dissipates the build up of stress related hormones and
provides a period of quiet time for personal reflection, free from the
intrusion of usual external noxious stimuli. Some enthusiasts believe
that the repetitive sound of footsteps facilitates the induction of a
meditative state or that this particular aerobic activity induces a"
spiritual high" by the release of small brain peptides such as the
endorphins. In general, physical fitness programs require
comparatively little expenditure of funds or specialized personnel and
can be adapted to a variety of situations and occupational resources.

Reduction of psychosocial stress in the form of counseling services,
weight reduction, cigarette smoking, alcohol and substance abuse, and
financial and family problems are also benefits provided by many
corporations or unions. Other employee programs which sharply reduce
costs for legal assistance, medical and dental care, drug treatment,
or by providing expanded insurance coverage are also offered. The
increasing use of flex-time, in which personnel have more flexibility
in determining working hours, and making baby sitting services
available for working parents with preschool children are other types
of stress reduction benefits. In addition to reducing workers'
anxiety and expenses, they also improve employee company relationships
by fostering a sense of caring and concern.

EVALUATION OF STRESS MANAGEMENT PROGRAMS

Both because of their heterogeneity and rather imprecise parameters of
efficacy, as well as lack of control groups, proof of the success of
stress management training intervention is difficult to obtain. There
is little additional information that can be added to the excellent
reviews by Murphy (Murphy, 1984) and the Yale — NIOSH Occupational
Stress Project (Neale, et al., 1982), and several comprehensive and
informative studies recently published (Fielding, 1984; O'Donnell and
Ainsworth, 1984; Quick and Quick, 1984). However, there are presently
several ongoing programs to develop and systematically evaluate the

78



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Egdahl, R. and Walsh, D. (1980). Mental Wellness Programs for
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Beehr, V.A. and Newman, J.E. (1978). Job stress, employee health, and
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Bhagat, R., McQuaid, S.J., Lindholm, H., and Segovis, J. (1985).
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Caplan, R.D., Cobb, S., French, J.R.P., Jr., Van Harrison, R. and

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Caplan, R.D., Naidu, L.K., and Tripathi, R.C. (1984). Coping and

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Caplan, R.D. and Jones, K.W. (1975). Effects of work load, role
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4l



Representativeness. Another issue that should be looked at carefully
in the selection of measures is that of representativeness.
Representativeness is a term that typically is applied to the type of
sampling techniques that are used, but it also applies in the
selection and use of measures. Measurements of some variables have
limited clinical significance unless they are representative, or
sample important domains of the environment and individual behavior.
Sometimes increasing the representativeness of measures requires
substituting informal data collection techniques for more formal or
standardized measures. This means that some reliability may have to
be sacrificed. However, there can be significant gains in validity.

Standardized psychometric scales often are given only to persons
before and after programs. While they are useful for general
screening purposes, they often do not provide accurate data on the
frequency and intensity of moods or symptoms at work and do not
reflect how much they interfere with work performance. Since most
standardized scales cannot be given frequently or during work, they
should be or supplemented by less formal but more frequently
administered measurement techniques such as daily stress logs. The
use of daily stress logs or diaries allow employees to record sources
of stress and their reactions to them both at work and at home.
Persons also can rate the severity of symptoms and estimate the amount
of work time lost for specific stressors and their reactions. This
allows rough estimates of the costs of stressors and stress reactions
and thus provides a baseline against which the cost effectiveness of
programs can be calculated (Manuso, 1983, 1984).

While physiologic variables often can be measured with a high degree
of accuracy and precision, they frequently are not representative.
Thus, their utility as clinical predictors of impact and outcome is
highly limited, For example, blood-pressure level often is used as a
dependent variable in stress management programs. Usually, blood
pressure is measured only in a clinic and not in the work
environment. The measures in the clinic may not accurately reflect
the blood pressures at work and may be less predictive of hypertension
(Sokolow et al., 1980; Pickering et al., 1982). Failure to obtain
representative measures may result in false positives or false
negatives —- both diagnostic errors -- and inaccurate estimates of
Program effectiveness. Thus, while stress management programs may
lead to reductions in pressures taken in the clinic they may have
little impact on the pressures during work. Many of the stress
management training studies on treatment of essential hypertension
have been criticized for their failure to demonstrate the
generalizability of blood pressure lowering. The representativeness
of blood pressure measurements can be improved by training individuals
to take their own blood pressures in home and work settings and
through the use of automatic-monitoring devices (e.g., Bertera and
Cuthie, 1984; Pickering et al., 1982).

131



At the aggregate level, one or more of five standards of acceptability
may be used. A basic description and examples of each of these
follows (Green, 1974).

Historical Standards. Current program outcomes are compared to prior
program results for comparable persons during a similar time period.
For example, if last years' stress management program yielded a 20%
reduction in stress-related complaints and symptoms in selected
participants, a historical standard of acceptability can be obtained
by comparing the results of subsequent programs with last year's 20%
reduction.

Normative Standards. Current program effects are sometimes compared
with the levels of performance or achievement against regional,
national, or international standards. For example, if the object of
interest were decreased stress-related symptoms, a suitable standard
of acceptability could be a 30% decrease in symptoms reported by
employees participating in that program. If this has been shown to be
a typical rate of decrease in other stress management programs in
industry, it could then be considered a normative standard of
acceptability.

Theoretical Standards. Program outcomes can be compared to a
theoretical level expected if everything were to go exactly as
planned, A theoretical standard is often based on the results of
previous research in which interventions have been tested in
controlled laboratory or clinical situations. For example, if a
demonstration stress management program, conducted by a
university-based team of behavioral scientists using state-of-the-art
methods yielded a 50% reduction in stress-related symptoms in a group
of management level employees, this could serve as the theoretical
standard of acceptability for application of the same stress
management methods in the "real world" with other management groups
and possibly other employee groups.

Absolute Standards. Program outcomes are sometimes compared to the
highest possible level attainable. Whereas theoretical standards are
based on the premise that everything will go as planned, absolute
standards are often even more unrealistic and may never be possible to
attain. For example, a 100% reduction of stress-related symptoms
among employees, an example of an absolute standard, is neither
realistic nor feasible, and probably even undesirable.

Negotiated Standards. Program criteria usually emerge from the
compromise and negotiation of several possible standards. A
negotiated standard is frequently an average of the preceding
standards of acceptability. For example, if other stress management
programs yield a 30% reduction of stress-related symptoms (normative),
historical standards for this company are approximately 20%, the
theoretical symptom reduction for your population is 50%, and the

115



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124


Some of the psychological, behavioral, and psychosomatic problems that
commonly have been associated with stress are presented in below:

Psychological Behavioral Psychosomatic
Anxiety Smoking High blood

pressure
Depression Alcohol use Tachycardia
Anger Drug use Headaches
Low job Disturbed Ulcers
satisfaction relationships

Low self-esteem Violent behavior Sleep problems

Several different psychometric instruments have been used to assess
the levels of stress-related psychological symptoms in populations of
workers. The Symptom Checklist 90 or SCL-90R often has been used and
has scales for anxiety, depression, and anger and is a good general
screening instrument (Derogatis, 1975). Anxiety frequently has been
measured with the Spielberger State-Trait Anxiety Scale (Spielberger
et al., 1968). This instrument, particularly the state component of
the scale has been found to be a sensitive indicator of stress in
non-clinical and work populations. Many self-report schedules can be
used to measure job-satisfaction. Jenkins et al. (1984) have reviewed
those instruments most commonly used to measure job satisfaction.
Self-esteem also can be measured with a number of different
questionnaires (Gilberts, 1983).

Behaviors that may be stress related can be screened with health
hazard appraisals or with instruments designed to obtain extensive
information on the specific behaviors, e.g., surveys of smoking,
alcohol use, and drug use, etc. Data on disturbed relationships and
violent or aggressive behavior can be collected through interviews
with the employee, fellow workers, and family members, and sometimes
through observations.

Information on many psychosomatic problems can be collected with
self-report instruments like the SCL-90R or more informal checklists.
If resources are available, the validity of self-report information
can be checked through medical record searches. Also, in the case of
tachycardia and high blood pressure direct measurements can be made.

It also can be helpful in the selection of measures to examine

carefully the indicators of stress that have been used in prior stress
Management programs. The impact and outcome measures used in many

129



SERVICE DELIVERY
Are Our Programs Oversold or Ov Ambitious Efforts

I would like to see a greater contrast between the way consumer
commodities are sold and the way that professional stress programs are
marketed. Sometimes it seems that many stress programs are marketed
like the products of fast food franchises, with promises of easy
appetizing answers served up in quick fixes. Of course, many program
sponsors are more careful with their language and stay within the
hyperbole that is accepted for selling management training programs.
But generally, I am uneasy that the language of "stress management"
marketing efforts frequently implies results that are not achievable
given the time and resources available. Consequently, stress programs
are seen as a passing, largely past, fad in many circles, or -at best-
as one component in health/fitness education, even while carefully
research is adding weight to the issue.

The other side of this coin is the well intentioned effort to include
too much. My experience is that many of us are frustrated by the
contrast between program participants' needs and the results we can
achieve in the time available to us. Apparently I am not alone in
feeling a strong pressure to cram, to plan to do more than is
realistic which, in turn, can make me try to rush the pace of learning
activities, and thus turn experiential exercises into exhortatory
lectures. I think that when this happens, learning is reduced, not
increased, and program participants experience even more stress.

Gan Stress Programs Have Negative Side Effects?

The stress response directly links individual personal experience to
changes in group dynamics and institutional effectiveness. I am
concerned that programs seeking to change the way people operate in
these influential activities can be expected to have potential side
effects. For example, I have already identified my concern that our
programs will increase some participants' stress (even though we may
decide that this effect is an acceptable consequence when the workshop
significantly increases most participants’ skills for dealing with
stress).

But, what about other possibilities? Does the victim-blaming effect,
when it occurs, reduce participant self-esteem or otherwise impair
learning? To what extent does the selection of instructional approach
affect individual empowerment? What are the specific consequences
when organizational practices are a major source of distress and we
provide a workshop to get individuals to change themselves instead?
As professionals, we need to investigate the answers to questions like
these, and to make necessary trade-offs consciously. And, when there
are risks of significant consequence, we should have the informed
consent of program participants before we proceed.

154



Professionals delivering stress programs and services must expect to
work with diverse groups of people and will require considerable
cross-cultural skills and sensitivities to be able to function
effectively. "Workers" here meanS all people who earn their living
regardless of the nature of the work they do or the social status
their work has. The case study described in the next section
illustrates some of the points raised in the previous section and
offers some observations and learnings from the experience.

THE JOB STRESS PROJECT: A CASE STUDY
Background

The Job Stress Project grew out of efforts by the Graphic Arts
International Union (GAIU) to develop a safety and health education
program for its membership, a cross section of the more than one
million men and women who work in the U.S. and Canadian printing and
publishing industry. GAIU began this five year curriculum development
and pilot testing project in 1979 with a survey of interests and
concerns about safety and health expressed by a sample of workers,
local union leaders, and employer representatives. This survey
identified "mental health in the workplace" as a major concern and a
unit on job stress was developed and became one of the eight 3-hour
sessions that now make up the course, Safety and Health Awareness and
Action Program for Employees and Employers (SHAPE). During the pilot
testing of SHAPE, and in subsequent presentations, participants
requested that more time and attention be given to the topic of job
stress and asked for more specifics about what could be done about
stress within their industry.

At that time, the issue of job stress was a new one for both labor and
management decision-makers. Neither labor, GAIU and other unions, nor
management, the Printing Industry Association (PIA), had adopted
policy statements or undertaken action specifically addressing job
stress as an industry-wide problem. There was no industry-specific
assessment of the stress situation, no clear sense of how the
industry's policymakers--both labor and management—- viewed the
situation: Did they see stress as a significant issue? What
information about stress and its effects would they need to have to
make policy and take action to improve the stress situation? And, what
would foster joint labor-management consideration of the issue?

Of course, there were a variety of efforts related to stress —- such
as employee assistance programs —- that were initiated by various
local unions and/or employers. But, these programs, however valuable,
did not add up to anything like a comprehensive stress program
applicable to the industry as a whole and adequate to the problems
that seemed present. Neither existing programs nor professional
guidelines offered the SHAPE staff much help answering the questions

158



CONTRIBUTORS

John Adams

Eartheart Enterprises

2000 15th Street North, Suite 103
Arlington, Virginia 22201

David DuBois

Department of Psychology
University of Minnesota
Minneapolis, Minnesota 55455

Lawrence Green

Center for Health Promotion Research and Development
The University of Texas Health Science Center at Houston
P.O. Box 20036

Houston, Texas 77225

Joseph J. Hurrell, Jr.

Motivation and Stress Research Section

Applied Psychology and Ergonomics Branch

Division of Biomedical and Behavioral Science

National Institute for Occupational Safety and Health (NIOSH)
4676 Columbia Parkway

Cincinnati, Ohio 45226

John W. Jones

Industrial Psychology Section
Risk Management Services Division
The St. Paul Companies

385 Washington Street

St. Paul, Minnesota 55102

Gene Martin

Gene Martin Inc.

6812 Sixth Street, N.W.
Washington, DC 20012

Michael S. Neale

Department of Psychology

Yale University

P.O. Box 11A, Yale Station

New Haven, Connecticut 06520-7447

iii



Stainbrook, G.L. and Green, L.W. (1983). Role of psychosocial stress
in cardiovascular disease. Houston Heart Bulletin, 3, 1-8.

Tesh, S.N. (1983, November). The Politics of Stress: The Case of
Traffic Control. Paper presented at the American Public Health
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U.S. Department of Health Education and Welfare. (1978a).
Occupational Stress: o. the cupational
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Government Printing Office.

U.S. Department of Health Education and Welfare. (1978b). Reducing
Occupational Stress: Proceedings of a Conference. (DHEW, NIOSH
Publication No. 78-140). Washington, DC: U.S. Government Printing
Office.

U.S. Department of Health Education and Welfare. (1979). Healthy

People; The Surgeon Generals Report on Health Promotion and Disease
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U.S. Government Printing Office.

U.S. Department of Health and Human Services. (1980a). New

Developments in Occupational Stress: Proceedings of a Conference.
(DHEW, NIOSH Publication No. 81-102). Washington, DC: U.S.
Government Printing Office.

U.S. Department of Health and Human Services. (1980b). Promoting

Health/ Preventing Disease: Objectives for the Nation. (1981
0-349-256). Washington, DC: U.S. Government Printing Office.

Warheit, G.J., Bell, R.A., and Schwab, J.J. (1977). Needs Assessment
Approaches: Concepts and Methods. Washington, DC: National
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Weinstein, M.C., and Stason, W.B. (1977). Foundations of
cost-effectiveness analysis of health and medical practices. New
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Weiss, C.H. (1972). Evaluation Research. Englewood Cliffs, CA:
Prentice Hall Inc.

Windle, C., Rosen, B.M., Goldsmith, H.F., and Shambaugh, J.P. (1975).
A demographic system for comparative assessment of "needs" for mental
health services. Evaluation, 2(2), 73-76.

Windsor, R.A., Baranowski, T., Clark, N., and Cutter, G. (1984).
Evaluation of Health Promotion and Education Programs. Palo Alto,
CA: Mayfield Publishing Company.

147



REFERENCES

Adams, J. (1981). Planning for comprehensive stress management. In
J. Marshall and C. L. Cooper (Eds). Co with .
Aldershot, U.K.: Gower, pp. 55-76.

Adams, J., Quigley, E., and Schmithorst, J.(1983). Health and stress

management education in three federal agencies, lealth and
Human Resources Administration, 6, 100-128.

Adams, J., Quigley, E., and Schmithorst J. (1984). Improving the
health and stress management of federal workers, In Warrick, D. D.
(Ed). orary organization development: Current thinking and
applications. Glenview: Scott, Forseman and Co., pp. 389-307.

Fritz, R. (1984). The path of least resistance. Salem, MA: DMA, Inc.

Griffen, D., Everly, G., and Fuhrman, C. (1982). Designing an
effective stress management training program. Training/HRD September,

pp. 44-47.
Loughary, J.W., and Hopson, B. (1979). Producing workshops, seminars
and short courses. Chicago: Follett Publishing Co.
McCauley, M., and Bellingham, R. (1984). Planning the AT&T
communications total life concept (TLC) program. unpublished ms.

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Barad, C. (1979) Study of burnout among social security
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DC: Social Security Administration.

Brady, C., Kinnaird, K., and Friedrich, W. (1980). Job satisfaction

and perception of social climate in a mental health facility. Texas
Research Institute of Mental Sciences, Houston, TX.

Bromet, E. and Moos, R. (1977). Environmental resources and the
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and Social Behavior, 18, 326-335.

Burdick, C. and Jones, J.W. (1985). The impact of stress surveys on
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MN: The St. Paul Insurance Companies.

Caplan, R. D., Cobbs, S., French, J. R. P., Jr, Van Harrison, R. and
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Holahan, C.J. and Moos, R. (198la). Development and validation of
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Holahan, C. J. and Moos, R. (1981b). Social support and adjustment:
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Jaffe, D., and Scott, C.D. (1985). The Stress Map: A comprehensive
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Jones, J.W. (1983). The Human Factors Inventory. St. Paul, MN: The

St. Paul Insurance Companies.

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Jones, J.W. (1985). Corporate Stress Management. The Risk Report, 7,
1-8.

65



can pinpoint the overall level of company stress, levels of stress in
selected work groups (e.g., departments, job types), and the major
organizational stressors that are causing the employee stress.

The major purpose of this chapter is to review organizational stress
assessment instruments that can be employed in business settings. The
review is not intended to be comprehensive, Instead, this chapter
focuses on a few key stress inventories that were specifically
designed for work settings and that have ample evidence of validity.
In addition, all of the instruments reviewed have been successfully
tested in a wide variety of companies.

This review is geared toward practitioners who want to gain a better
perspective on how to select, administer, score and interpret
organizational stress surveys. Four different assessment tools are
reviewed.

I. HUMAN FACTORS INVENTORY (HFI)

The Human Factors Inventory (HFI) is a 162-item organizational climate
survey (Jones, 1983; Jones and DuBois, 1985). The HFI is used by
businesses to assess various forms of occupational stress.

The HFI has the following six scales: Job Stress, Job
Dissatisfaction, Organizational Stress, Stressful Life Events, Life
and Health Risks, and Accident Risks. Test-retest reliability
coefficients (one-week interval) for these six scales are .91, .90,
-89, .89, .88, and .87, respectively. Each of these scales is briefly
described below. In addition, two speciality scales -- the
Technostress Scale and the Distortion Scale -- are also briefly
described below. Norms exist based on over 100,000 employees
representing hundreds of different companies and job types.

Job Stress. This scale identifies the average level of job stress
that employees are experiencing at an individual level. General
signs of job stress include feelings of frustration, boredom,
irritability, nervousness and "burn-out" at work. Physical signs
of job stress include headaches, stomach upset, backaches, chest
pains, chronic fatigue, and sleep difficulties. Employees who
score in the higher risk ranges are also less productive, they
have higher rates of illness and absenteeism, and they often think
about leaving the company. Finally, they feel that work-related
pressure contributes to tension in their family. Sample items
include: "I experience too much pressure on my job."; "I have
lost efficiency on my job."; and "I feel burned out on my job."

Job Dissatisfaction. This scale assesses how dissatisfied
employees are with various aspects of their job. Dissatisfaction
with the following areas is assessed: Job, pay, promotional
opportunities, co-worker relationships and overall management

sl



Inside Out: A Self-Te Manua: ofeedback
E. Peper and E.A. Williams. New York: Plenum Press, 1981, 431
pp., $25.00.

A detailed self-teaching manual on how to use biofeedback
equipment and evaluate progress of the learner. A solid
background is provided on biofeedback and mind-body awareness
techniques. Data recording protocols are provided.

Managing Stress: A Businessperson's Guide
G.E. Yates. New York: AMACOM, 1979, 165 pp., $12.95.

A very readable book which covers all aspects of stress and
Stress reduction with a focus on managers. Topics include
understanding and recognizing stress, stress/health
relationships, positive and negative stress, and stress
assessment and stress management exercises.

EY ess: uide for fessiona
bs. Numerof. Rockville, MD: Aspen Systems Corp., 1983, 350 pp.,
25.00.

Based upon a study of health administrators, physicians, and
nurses, the book contains a good description of stress and its
health effects. Fully 87 pages are devoted to stress
reduction including organizational change, quality circles,
and individual coping techniques.

Mental Wellness i3_fo loyees

W.B. Goldbeck. Boston, MA: Center for Industry and Health Care,
1980, 230 pp., $12.

The book is a collection of papers from an invitational
conference dealing with conceptual and logistical issues
surrounding mental wellness programs in work settings.

lational Conference on Health Prot rams _in Occupational
Settings Set of 11 background papers for an invitational
conference sponsored by the Office of Disease Prevention and
Health Promotion, 1979, $23.

Topics include current worksite programs for stress
management, smoking cessation, weight and nutrition,
hypertension, and cost effectiveness. (Seven of the papers
appeared in Public Health Reports, Vol. 95(2), Mar/Apr 1980;
Also, many were updated and published in Managing Health
Promotion in the Workplace. R. Parkinson and Associates, Palo
Alto, CA: Mayfield Publishing Company, 1982, 314 pp., $24.95.

176



important to establish the image that the stress response is a normal,
biological response, and that it is natural. Everyone in the
organization is subject to the adverse consequences of excessive
stress. And finally, wherever possible, spouses of employees should
be invited to participate. If a participant concludes during the
stress management training that s/he needs to make some fundamental
life style changes, there is a much greater chance s/he will succeed
if this conclusion is reached in the presence of the spouse.

Following the completion of a comprehensive stress management program,
people often feel the need for more specific or focused training
experiences to follow up. If there is a broad array of programs
available within the organization, their relationship to reducing
stress should be made clear. It is often helpful also to have a
listing of specialized programs available in the community.

Another important programmatic feature is the establishment of
individual plans for action. If people are going to make use of what
they learn in any training program, they need to take some specific
steps with their new learnings within two or three days of the end of
the training. It is therefore important that participants be guided
into a specific project area to work on first (one should adopt a one
step at a time mentality), and then to identify the specific action
steps they will begin taking within the next few days. The likelihood
of positive, lasting impact of the training will be further increased
if the individual action plans include a review of one's support
network and a determination of how specific other people can operate
in ways to guarantee the participant's success in her/his action plans.

Next, feedback loops need to be established to deal with themes or
issues which emerge from the stress management training at the
managerial or policy level of the organization. Invariably, many of
the things which participants identify as being their primary
stressors have to do with the careless implementation of changes and
the existence of shared "bad habits" within the organization. Many
such unnecessary stressors can be alleviated if there is a mechanism
created (e.g. a stress reduction task force) to address them on an
organization wide basis.

A final programmatic issue has to do with the creation of follow up
booster sessions for participants six months to a year after their
initial training. People inevitably will experience some frustrations
and loss of momentum even after the best possible training efforts,
and follow up sessions can often address problems of motivation and
get people back on the track. People will respond most favorably to
these follow up sessions if they see that "management" is doing
something procedurally about stress in the organization. If they
learned in their original training that a few simple changes within
the system could alleviate a lot of the stress they experience, and

102



At the same time that we were struggling to obtain returns, the
organizer for the hotel was pushing stewards to hand out and collect a
one page survey about the contract proposals. This survey increased
the demands and confusion among union members another notch.

Sometimes rank-and-file employees would ask, upon presentation of the
survey, if the questionnaire came from the "union." Their question
clearly implied that they saw themselves and the "union" as separate
entities, even though the entire bargaining unit were members. It
also expressed a certain psychological distance between the paid
staff, shop stewards, and the rank-and-file members.

In long moments while we waited for an employee to enter the
cafeteria, we fantasized about how different the operation could have
been if management had provided us with an identified space in the
hotel. Employees could have dropped in throughout the day.
Similarly, we would reflect on how much richer the assessment would
have been if we had been allowed to follow a maid or bellman through
the course of a workday.

Results of the Survey

Since we wanted to produce results that would be ready when contract
talks began, we suspended the data collection approximately two weeks
before the contract expired. Considering the chaotic conditions of
the survey collection, the return rate (42%) was respectable.

Table 1.4 presents the demographics of the sample, broken down by
department. It is not the purpose of this chapter to review the
results of the assessment, but we will point out one or two of the
most relevant findings. The major question we examined through the
survey was whether stressors at different levels of the OSEG would be
correlated in different and systematic ways with employees' perceived
well-being. More precisely, could we demonstrate that during a time
of union organizing around management practices (i.e., a period of
Management changeover and contract negotiations), reported
psychological and physical discomfort would be most related to the
organizational level, as opposed to all the other levels of the OSEG
we were able to sample?

In order to answer this question, we factor analyzed the questionnaire
into subscales that corresponded to different levels of the hotel
OSEG. The names of the subscales that emerged from the factor
analyses are listed at their appropriate level in column 3 of

Table 1.3. As one might note, the subscales of most interest to our
predictions were "satisfaction with management policies" and
"dissatisfaction with management practices." If we were to regress
these two scales (along with the other subscales) on the positive and
negative emotion subscales, we would expect them to emerge the
strongest predictors of subjective well-being. By and large, the
multiple regressions showed this result. The strongest predictors of

23


OSEG Levels:

TABLE 1.3

SSESSME)

Sample Stressors:

Sociocultural

Organizational

Work Setting:
Interpersonal

Job
Characteristics

Physical
Environment

Family/Social

Individual:
Psychological

Biological

OF AN URBAI

Gender or race discrimination
Economic downturn/recession

Seasonal business cycle

National labor relations climate

Corporate ownership/structure

Labor negotiations

Staffing and hiring policies

Layoff/reclassification
Management ethos

Multiple supervision

Management style/competence
Work group structure/norms

"Outsiders"

Unpredictable scheduling

Conflicting demands
Time pressure

High demands/additional duties

Low decision latitude

Inadequate supplies/equipment

Heavy lifting and pushing

Climate extremes
Poor ventilation
Hazardous situations

Poor recreational facilities

Poor quality food
Uncomfortable positions

Schedule interference

Child care responsibilities

Financial difficulties

Dual-career or blended families

Emotional experience of work

Mood/memory changes
Career/job expectations

Lack of control/helplessness

Motivation

Substance use/abuse
Tension/pain
Sleep difficulties
Digestive problems
Hypertension

19

Subscale Labels:

JOB SECURITY
SATISFACTION WITH
MANAGEMENT POLICY
SATISFACTION WITH
MANAGEMENT PRACTICE
COST-CUTTING

UPPER MANAGEMENT
POSTIVIE

UPPER MANAGEMENT
NEGATIVE

LOWER MANAGEMENT

CO-WORKER RELATIONS

SCHEDULING

JOB OVERLOAD
AUTONOMY
EXTERNAL CONTROL

PHYSICAL DEMANDS

POSITIVE EMOTION
NEGATIVE EMOTION

MUSCLE TENSION AND
PAIN
SLEEP DISTURBANCE



Second, should the program have a single focus (e.g. relaxation
techniques) or be as comprehensive as possible? It should be clear
from the foregoing that stress is a complex process and that
individuals need to establish their own self-tailored response
repertoires. Any given focus will work for some and not for others.
The broader the focus, the better able people will be to develop a
response repertoire that is effective.

Third, should the program reinforce our reactive-responsive
programming reacting to the environment and responding to external
pressures -- placing the locus of control outside the individual, who
never finishes reacting and responding; or should it emphasize the
development of a more creative orientation —- placing the locus of
control within the individual, who learns to establish clear pictures
of the desired life and then operates in ways to realize the results.
It is the contention of this chapter that to be truly effective,
stress management training programs must foster the emergence of a
more creative consciousness than most of us have developed so far.

Stress management training today is often just another training
program offered widely in organizations. It CAN have a major effect
on individual life orientation and choice making AND on system culture
and functioning. The impact a stress management program will have is
largely a function of how clearly one answers the question "What
results to you want?"

106



peer, professional, and public pressures to deal with the issue, it is
hardly surprising that the institutional leaders of the industry
generally have no agenda for action.

The workshops proved to be educationally effective, productive for
stress assessment purposes, and a useful process for initiating joint
labor-management activity.

As an exploratory effort, the project was useful. As a stress
consciousness raising process, it produced results and showed
promise. However, as the initial step in a self-generating, sustained
dynamic to develop an industry-wide stress services program, it proved
insufficient.

The project elicited data about stress, shows the potential for
involving workers as researchers and for using research as an
empowerment process. It provides a foundation that can be built on to
get both leadership and rank-and-file attention and involvement with
stress issues. It operated as a mutual labor-management effort
without compromising the collective bargaining process.

The project planners underestimated the time, attention and resources
that this effort would require so that reasonable threshold levels of
results were not achieved and key questions remain unanswered about
the project as a way to begin a larger, more comprehensive program.

Consequently, the project is only of academic and intellectual
interest.

IDEAS TOWARD IMPROVEMENT

Many times when I read formal papers, I suspect that a report of the
author's speculations after doing the work could be more useful and
interesting to me than the more certain, formal conclusions. In this
section I identify some suggestions, speculations about improving
stress programs and related professional practices derived both from
my experiences and other people's work. I have not attempted to
identify formal research that would justify or invalidate these
specific conclusions although I know there are general findings that
provide mixed support for these ideas. For me, these conclusions
represent working hypothesis that merit discussion and testing.

CONTENT/PROCESS
e Physical Aspe eS s Response

Many people, men especially, seem to think of stress as though it is
the consequence of inadequate emotional control. In this view,
experiencing stress indicates at least weakness in the individual,
perhaps even mental illness. Because of this, I started including in
introductory workshops a brief, but detailed, description of the

165



Model Desirable Behaviors

One method that I use to improve my workshop designs and facilitation
is to require myself to model the most essential behaviors that I
understand the program participants to want. The difficulties I then
encounter help me appreciate what, specifically, the participants face
and provide me with an assessment of what assistance and support from
me might be useful to them. Of course, there are other advantages of
modelling behaviors: the workshop outcomes are clearer; participants
have a standard of comparison for their own skills; and the learning
experience has greater sensory richness.

Some of the behaviors that I attempt to model in stress programs seem
to be generic; the following are illustrative: being a learner; being
open to others' experience of gender, "race", age, and the like; and
maintaining and acting in collaborative and equal-status
relationships. Because we are still learning how to improve stress
situations, I openly approach each workshop or consultation as an
opportunity to learn from participants or clients about what works for
them, from them, My experience is that people are generally pleased
to cooperate and many report they find this approach helpful in a
variety of ways: they are reassured that their experience is an
appropriate source of learning and has wider applicability, that an
authority figure sees them as capable of making significant change,
and that they retain control of the pace and direction of any changes.

Because human experience is such a rich source of useful learning and
because interpersonal conflict and intergroup tensions are important
factors in so many stress situations, I openly explore with program
participants the variations in their experience due to individual
differences such as gender, "race", and age. My experience is that
people are interested in each other's experience and can derive
important insights for themselves from personal sharing especially
when a safe, non-defensive climate is created and maintained .

Stress demonstrates the general, subtle, yet pervasive ways in which
we influence each other. Specifically, it shows that there are
important, tangible effects on each of us if we do not feel connected
to and included with others in a valued and supported manner. Yet our
society places great emphasis on being individual and on solitary
accomplishment and rarely affirms cooperative effort and
interdependence. So I work to create and maintain collaborative and
equal-status relationships with all persons involved in a stress
workshop.

Specifically, in a workshop, this means a myriad of specific behaviors
like: taking time to have everyone present introduced; openly
identifying my interests and objectives and asking others about
theirs; reviewing the proposed agenda and contracting on time
matters; adopting an empathetic perspective toward any participant's

168



The concept of action research is especially useful as a paradigm for
exploration, a way to learn what is required to accomplish desired
ends when there is little or no useful precedent that would support
the more conventional approach of preplanning the whole process.

Moreover, action research offers a natural way to integrate action
steps and research components in mutually supportive roles. Research
can help answer essential questions and action tests the
predictability of research-based theory.

I have found an action research model very useful for designing and
carrying out stress projects because the relative newness of the field
usually requires exploratory efforts (rather than standard
approaches). Moreover, the action research approach can be viewed as
an "action learning" model for how we can derive learnings about how
to deal with stress situations that have wider applicability than the
immediate project from which they come.

The case study described earlier is one example of an action research
approach and illustrates some of the major features of this conceptual
structure for organizing interventions intended simultaneously to
achieve practical results, increase knowledge, and foster learning.

As a practitioner, I would like to know what works and how to get
specific results more elegantly. Aside from measuring cognitive
learnings in workshops, there seem to be few inexpensive, readily
applicable techniques for assessing the behavioral and attitudinal
changes that are achieved. So I would like to see a larger and more
accessible body of evaluative techniques that can give me the feedback
I need. Similarly, I imagine that researchers also can benefit from
increased linkage to programs that will permit not only evaluation,
but also experimentation with evaluative methodology.

My impression is that there is too little such linkage between
research and action projects dealing with stress. Action programs
(such as brief work- shops for employees) are too often ad hoc, short-
term efforts for which there are no stated change expectations.
Researchers can appear to be more driven by their methodological
concerns than by any sensitivity to client/consultant issues and
relationships. Certainly, funding is not readily available for
either. And, there are additional factors that contribute to this
problem. I do not believe this will be an easy area in which to make
improvements but I am convinced that it is urgently necessary for us
to bring these inherently related processes into greater coordination.

172



producing strain in the homeostatic mechanisms. Although he used the
term somewhat casually, it is clear that Cannon, like Selye, conceived
of stress as involving physical as well as emotional stimuli (Mason,
1975).

More recently, Richard Lazarus and his colleagues added immensely to
the study of stress by describing in specific terms how one's
perceptions of objective events determine their health valence (see
Lazarus and Folkman, 1984).

Cognitive appraisal is described by Lazarus as an intrapsychic process
which translates objective events into stressful experiences. The
importance of this formulation lies in its recognition that subjective
factors can play a much larger role in the experience of stress than
objective conditions. Indeed, any given objective event can at once
be perceived positively by one person and negatively by another ("One
person's meat is another person's poison").

The study of occupational stress (as opposed to other sources of
stress) was given tremendous impetus in the early 1970s by the
establishment of the National Institute for Occupational Safety and
Health (NIOSH) by Public Law 96-596 (Occupational Safety and Health
Act of 1970). The stated goal of this agency is to assure safe and
healthful working conditions for America's working men and women,
NIOSH is the principal Federal agency in the United States engaged in
research aimed at the recognition and control of job related hazards.
That behavioral and motivational factors had an important bearing on
the attainment of this objective was clearly acknowledged in certain
research provisions of the OSHAct (1970). For example, Sections
20(a)(1) and 20(a)(4) explicitly directed NIOSH to include
psychological, behavioral, and motivational factors in researching
problems of worker safety and health, and in developing remedial
approaches for offsetting such problems. Job conditions were broadly
interpreted to include those of a psychological nature, consisting of
undue task demands, work conditions or work regimens which apart from,
or combined with, exposures to physical and chemical hazards may
degrade worker physical or mental health (Cohen and Margolis, 1973).
Since its inception, NIOSH has not only sponsored but conducted a
large number of research studies which have helped to shape the course
of job stress research in the United States.

A MODEL OF JOB STRESS AND HEALTH

Over the past twelve years, a paradigm of stress was developed by
research psychologists at NIOSH to guide efforts at examining the
relationship between working conditions and health consequences (see
Figure 1). This model builds upon frameworks proposed by Caplan,
Cobb, French, Harrison and Pinneau (1975), Cooper and Marshall (1976),
and House (1974). In it, job stress is viewed as a situation in which
some working condition (called a stressor) or combination of

32



Wellness at W :_A Report o1 d_ Fitness Programs for
loyees of Bu: d_ Indust.

R.M. Cunningham, Jr. Chicago, IL: Blue Cross and Blue Shield

Associations, 1982, 137 pp., $7.95.

Overview of the wellness movement, including examples of
worksite programs. Hints on starting a program, prepayment
plans and other resources, and an eye toward the future are
offered along with references and fitness resources.

Worksite Health Promotion: Examples of Programs That Work

Worksite Health Promotion: A Bibliography of Selected Books
and Resources

Wo: mn ; Some Questions and Answers to Hel
Ge d

Request the above publications free of charge from:

Office of Disease Prevention and Health Promotion
Public Health Service

Department of Health and Human Services
Washington, DC 20201

VIDEOCASSETTES AND FILM MEDIA
“Danger Zone: Stress"

A 13 minute color film/video providing an introduction to stress
Management using humor to help managers, employees, and their
families to (1) identify stressors and the symptoms of overload,
(2) understand the causes of stress, and (3) practice physical
and mental solutions to stress.

Cost: 16mm $430.00
Videocassette $430.00
Rental $90.00
Preview $25.00

Visucom Productions, Inc.
P.O. Box 5472

Redwood City, CA 94063
(415) 364-5566

178



Figure 6.1

Figure 1. Structure and logical relationships of the Objectives for the Nation in
disease prevention and health promotion

Processes of Objectives for Surgeon
Strategies change intermediate outcomes General's
(immediate objectives) Report
Heaith Organizing Access to
services —> | resources => | preventive —_—
service:
$ Healthy
Heath /}— —~—-__~_] Predisposing t 1 People
Ed Health (Surgeon
tien ~ promation => | Enabling —> | Behavioral -_ bencat's
seem ee 4 Reinforcing enhancement goal for
1990)
Heath [a
protection Regulating Environmental
"> | environment —* | changes _
Improved heatth Increased public Reduced Health
services, resources and professional tisk factor status
and activity ‘awareness objectives (46) objectives (56)
objectives (46) objectives (42) ,
L rere \ 4
Process objectives Impact objectives Outcome objectives

From Green, Wilson, and Bauer, 1983, p. 19

117


Masi and Teems (1983) reported on the development of an evaluation
system designed to assess the effectiveness of the Employee Counseling
Service (ECS) at the U.S. Department of Health and Human Services.
They noted that the issue of confidentiality was the most critical in
the development of the evaluation system. Every data collection form
and procedure had to be closely examined for its compliance with all
privacy and confidentiality regulations.

There often is a delicate balance between protecting individual rights
and privacy and protecting the best interests of companies. This
issue will become more controversial as greater emphasis is placed on
screening, risk reduction, and cost containment.

Debate continues over whether employers should have direct access to
the medical records and health information on individual employees.
Benefits to employers include better selection and placement of
employees, an improved ability to spot unusual occurrences of illness
and environmental risks, and more efficient targeting of resources at
high risk problems. Critics accept that the above practices may
benefit many employees, but they also argue that access to such
information can lead to unfair hiring and discriminatory promotion and
termination practices.

It is essential that issues of confidentiality be considered at each
step in the development of an evaluation plan. Although strict
adherence to the principle of confidentiality may place many obstacles
in the way of data collection, this can be weighed carefully against

the total loss of credibility of the program if data is accessed
unethically.

138



TRAINING MATERIAL SOURCES

The organizations below offer a variety of training materials such as
audio/audiovisual cassettes, films/filmstrips, workbooks, brochures,
etc. Items as well as prices change frequently in response to the
advent of new materials on the market. Most companies publish current
catalogs of their items and many offer guidelines to program personnel
who need to evaluate equipment and materials for possible adoption.

BMA Audio Cassettes

200 Park Avenue South

New York, NY 10003
212/674-1900 (New York)
800/221-3966 (outside New York)
Contact: Leo Stronger

Barr Films

P.O. Box 5667

Pasadena, CA 91107

213/793-6153 (California) (call collect)
800/423-4483 (outside California)
Contact: Helen Lee

Care Video Productions
P.O. Box 45132
Westlake, OH 44145
216/835-5872

Churchill Films

662 North Robertson Boulevard
Los Angeles, CA 90069-9990
213/657-5110

Current Affairs

P.O. Box 426

346 Ethan Allen Highway
Ridgefield, CT 06877
203/431-0421

Contact: Joseph P. Burke

Disney Educational Media

500 South Buena Vista Street
Burbank, CA 91521
213/840-1726 (California)
Contact: Hilda Weiss

180



$50,000 to over $100,000 had recently been filed. Item analyses of
the HFI stress scales helped to identify a number of organizational
stressors (e.g., poor communications, ineffective management,
understaffing) that the hospital administration was willing to correct
now that a connection between high departmental stress and risk for
medical malpractice was established. Moreover, the hospital
administrators admitted that they were "suspicious" about these high
risk departments, yet they did not know where to begin to remedy the
situation. Administration was now receptive to a number of different
work site stress management programs.

Another finding showed that employees in the general services
department at the hospital (i.e., housekeeping, laundry, maintenance)
had extremely high personal stress scores, as measured by the HFI
Stressful Life Changes scale. This same department also had nearly
$100,000 in workers' compensation losses for the year preceding the
stress assessment. This finding prompted the hospital to implement an
Employee Assistance Program (EAP) that provides opportunities for
professional counseling to chronically distressed employees and their
families. This case study documents how the HFI can be used in a
hospital setting to control losses. A summary of some of the other
ways in which the HFI has been used in industry is provided below:

1. Focus Efforts. Employee groups at greatest risk of having
stress-related accidents, injuries, or illnesses are
identified. Some possible solutions to their situation are
provided. Companies can then direct their training and
development dollars to where the need is greatest.

2. Pinpoint Strengths and Weaknesses. Companies get a clear
picture of how well the employees and managers are coping with
stress compared to a national norm group. Companies can
determine whether certain jobs or departments experience more
or less stress than others. They can see if important human
factors, such as job stress and employee wellness, cause their
employees to be more susceptible to accidents, illness, poor
productivity, and premature death.

3. Create Awareness. Just by administering the HFI, employees
feel management is interested in improving the quality of their
work life. In turn, employees become more motivated to manage
stress and seek wellness in their lives.

4. Employee Involvement. The HFI opens up an invaluable
communication channel between all levels of employees and
management. Such employee involvement leads to improved
morale, especially when employees see that their input helped
to facilitate the implementation of work site stress management
training programs.

57



Details about programs and sefvices should include the times and
Places, and the frequency, intensity, and duration of activities.
Information also should be provided on the type of personnel or staff
involved in the programs. Objectives for impacts and outcomes often
are expressed in terms of expected changes in knowledge, attitudes,
behaviors, and physiological or biochemical changes. Facts provided
on impact and outcome objectives should include specifics on the
amount of change expected, the time when the change is projected to
occur, and the expected duration or durability of the change.

An important factor in setting behavioral objectives is the choice of
quantifiable outcome measures (Green et al., 1980; Sechrest and Cohen,
1980). It often is necessary for evaluators to spend time with
program planners in the early stages of the program development to
assist them in articulating objectives that are clear, specific, and
measurable. Skilled evaluators with a knowledge of the stress field
can help in the selection of impact and outcome objectives that meet
these requirements.

Most objectives are stated in terms of the "average" change that is
expected to occur in the target group. Sometimes it also is useful to
complement the statement of objectives for groups by specifying a set
of objectives for individuals. The technique of Goa] Attainment
Scaling (Kiresuk, 1973) allows goals and objectives to be tailored for
individuals. It uses relative rather than absolute measures and
allows the progress of individuals to be tracked against their own
baselines on a number of variables and thus provides a personalized
profile. The results of individuals then can be summed to provide a
composite estimate of the program impact.

Standards of Acceptability in Program Evaluation

An important early step in planning an evaluation is to consider and
decide upon standards of acceptability. In evaluating a program, an
object of interest, (usually an impact or outcome measure based on a
Program objective), is compared to a standard of acceptability. The
method of determining whether the object of interest has met a
predetermined standard depends on the standard of acceptability
selected. Different standards exist against which program effects can
be judged. There are both individual and aggregate or group standards.

At the individual level, the acceptable standard of change may be
personally defined or defined by professionals. For example, an
individual may wish to lower diastolic blood pressure by 5 mmHg
without drugs; or the doctor may recommend that a patient must lower
diastolic blood pressure by 5 mmHg or must take medications. In
either case, the target level of change can be set for the individual
and the actual change, within certain time limits, can be evaluated
against the personalized standard of acceptability. Also, the
technique of goal attainment scaling may be a useful adjunct in
establishing individual standards.

114



outside consultants. In some instances vendors offer packaged
programs that utilize slides, descriptive material, case histories and
audio cassettes. Most commercial programs attempt to provide
participants with individual stress profiles based upon responses to
self report questionnaires, standardized psychological assessment
instruments, or the use of a standard or modified Holmes-Rahe Rating
Scale. On occasion a specially constructed questionnaire was designed
to focus on a particular occupation or worksite. Stress management
training was usually provided in the form of meditative or autogenic
techniques to induce general relaxation, and to a lesser extent,
behavioral and cognitive approaches. In some instances, biofeedback
services were available. Encouraging jogging, aerobic exercises and
dancing and participation in sports represented the most common
approach.

Physiologic Techniques

Most standardized stress management programs utilize procedures
designed to assist the individual in dealing with environmental
demands that cannot be avoided. One example is progressive muscular
relaxation which is achieved by contracting and then relaxing various
muscle groups in the body in a systematic fashion. The goal here is
to produce a level of deep muscular relaxation. The original
technique described by Jacobson (Jacobson, 1929) has been modified in
many ways so that attention is also directed to accompanying such
exercises with relaxing thoughts and images, as well as a tranquil
breathing pattern. Other forms which include Autogenic Training
(Luthe, 1969) place a greater emphasis on sensations such as limb
warmth or heaviness to achieve this effect and many use visual imagery
in conjunction with physical relaxation.

A variety of meditative measures are frequently employed. These range
from specific Eastern techniques to the simplified "Relaxation
Response" (Benson, 1975), which utilizes a repetitive deep breathing
pattern and associated focus on a word or phrase with each
expiration. It has been suggested that this induces a suppression of
arousal responses somewhat antithetical to the “fight or flight"
reactions. Practicing individuals seem more adept at resisting
intrusive stressful thoughts or unpleasant external stimuli throughout
the day as well as during the procedure. In rare instances,
transcendental or Siddha meditation or yoga have been taught and
utilized. A brief technique, known as the "Quieting Response"
(Stroebel, 1982) consists of a combination of deep breathing and
muscular relaxation combined with visual imagery for ten or fifteen
seconds. It is easy to learn and can be used several times a day,
especially when stressful situations are anticipated or encountered.

In sites where biofeedback training is available, individuals learn to

develop self control over a number of physiological activities
previously thought to be entirely involuntary. The most frequent

76



positive emotion at work were employees' feelings about upper
management and its workplace policies (i.e., did management provide
good training, treat employees like experts, and make efforts to
improve employees' worklife?). The strongest predictor of employees’
negative emotion at work was their dissatisfaction with managements’
practices (including understaffing, lack of promotions, and unfair
pay). No other subscale, including those that looked at job demands,
physical environment, job security, and even scheduling, showed the
same relationship to union members' emotions at work. Whether the
relationship of management's policies and practices to perceived
stress was particular to these hotel workers at a special moment in
their work history, and whether our finding would generalize to other
hotel workers (or other workers) are crucial questions. While the
circumstantial evidence is compelling, we cannot conclude from these
regressions that the organizing drive or the new management's policies
caused the hotel workers to link their dissatisfaction to
organizational factors.

On the other hand, these findings confirmed in an objective and
quantitative way what we had already heard in our interviews and
observed at the contract proposal meetings. The descriptive
statistics on the survey showed that employees felt stressed by both
job demands and management practices (working fast, skipping breaks,
and having little control in the workplace). The inferential
statistics revealed that at this particular juncture of rising tension
over contract negotiations, their emotional well-being was more linked
to feelings about management than any other aspect of the worksite.
These results validated the organizers' and shop stewards' impressions
about the employees' experience of the hotel climate. At the same
time, the findings also gave them feedback that their efforts to
intensify this climate may have worked.

The Impact of the Assessment

Our stress assessment, like the OSEG it employed, ended up with an
influence on many different levels of the hotel's system. Most
immediately and pragmatically, it actually played a role for the union
in negotiations, During a discussion of the need for more employee
input, the union negotiating committee raised the fact that they had
some strong survey results about management practices and stress. The
hotel negotiating committee expressed surprise that the survey had
been completed after their initial refusal to participate (we were
sure they knew all about us in the cafeteria). This exchange was
linked to others at the bargaining table that eventually produced new
contract language about monthly employee participation meetings
between shop stewards and upper management of the hotel. Management
has subsequently expressed interest in the results of the study and
even raised the possibility of a collaborative follow-up. This
development is probably the most gratifying of all, since it holds out
the opportunity that we could perform a truly comprehensive

25


not likely to be particularly useful in the long run. A stress
program which is based mostly on the creative orientation is more
likely to have a lasting impact on participants than is one based
solely on the Reactive-Responsive orientation. (For a detailed
development of these orientations, see Fritz, 1984.)

Comprehensive stress management programs must focus on both the
individual and the system (Adams, 1981). On the individual level,
there needs to be an external focus on avoiding or removing
unnecessary stressors and on coping effectively with those stressors
which are unavoidable (or the individual chooses not to avoid). In
addition there needs to be an internal focus on health protection and
enhancement and on attitudinal orientation as suggested in the
previous paragraph.

These same considerations (removal, coping, health protection) also
must be considered on the systems or organizational level. What can
be done within the organizational system to remove or avoid inducing
unnecessary stressors? In general, the answer to this question has to
do with minimizing novelty (surprise, uncertainty) associated with the
introduction of necessary changes and modifying stress provoking
organizational norms. What can the organization be doing to equip
members to handle necessary stressors effectively (e.g. effective
problem solving, availability of training courses)? And finally, in
what ways other than the stress management training programs can the
organization encourage good health habits?

In summary, the "ideal" stress management program receives managerial
support across the organization. There is a feedback loop created in
which systems-oriented ideas for reducing the number of unnecessary
stressors and for coping effectively with the necessary ones are
encouraged and taken seriously. The training programs themselves
encourage and foster the creative orientation referred to above in
which individual organization members learn to operate from the
fundamental choices to be creative and to have full and vibrant health.

AN IDEAL WORKSITE STRESS MANAGEMENT TRAINING PROGRAM
Conceptualizing the Program

Clear, understood, and accepted goals are an essential starting point
for an effective stress management training program. When the goals
of any training program are unclear, the program results are bound to
be diluted. Griffen, et. al. (1982) have suggested six criteria for
setting goals for an effective stress management training program:

1. Make the goals as specific as possible

2. Make the goals measurable

3. Ensure that the goals are realistic/attainable

4. Include both individual and organizational benefits

95



with labor sponsorship, the data we obtained were somewhat skewed
toward stressors in the work setting, organization, and physical
environment. While we did assess some personal, emotional, and
physical variables, we learned little of home life and lifestyle
patterns that might increase or complicate an individual's stress.

With these reservations stated, this chapter presents the mechanics of
how to assess workplace stress using the OSEG. It provides a hands-on
account of how to (and how not to) do an assessment of occupational
stress in collaboration with a union. Our focus will be on such
traditional community and organizational psychology issues as entry,
the consultant's role, establishing trust and allies, group dynamics,
organizational structure, reciprocity, and follow-up. The actual data
of the assessment will be summarized briefly, but are reported
extensively elsewhere (Neale, Singer, and Schwartz, 1987).

Throughout, we emphasize that the OSEG assessment procedure involves a
combination of qualitative and quantitative information. Both
one-on-one interviews and organization-wide surveys are employed.
Additionally, since the OSEG grows out of a systems perspective, it is
only one part of a larger assessment strategy that draws on systems
principles of hierarchy of levels, dynamic process, differentiated
input and output, and feedback (Miller, 1978). Each of these
principles will be discussed at length in the course of our
description of the actual assessment.

PUTTING THE OSEG INTO ACTION: AN ASSESSMENT OF A HOTEL
DURING CONTRACT NEGOTIATIONS

To pursue an assessment of occupational stress that would involve
labor and management, we felt it necessary to begin with a unionized
work force. Consultants on occupational stress have traditionally
worked with managerial level employees or with nonunionized
populations (Huszczo, Wiggins, and Currie, 1984; Singer, Neale,
Schwartz, and Schwartz, 1986). Accordingly, these consultants' stress
Programs and assessments in work settings have tended to neglect
organizational and workplace stressors of most concern to unions.
Hired by management and not necessarily with employees’ previous
approval, these consultants may seek to perform a fair and
participative assessment with extensive employee feedback about
stressors and responses. Still, the employees’ attitudes toward this
type of intervention may often be guarded, particularly if the results
suggest changes in personal lifestyle, but not in organizational
conditions.

By working with a union on our assessment, we could address some of
the problems faced by the management-employed stress consultant.
First, we reasoned that the structural organization offered by a labor
union would assure us of employees' prior approval of and subsequent
involvement in the assessment. Union input into the content and
format of the assessment would necessarily include organizational



training techniques utilize frontalis muscle tension, fingertip
temperature, and electrodermal response. Special electronic sensors
located at appropriate anatomical sites generate a signal that is
converted into electrical activity. This input is then transformed
into either an auditory or visual cue which varies correspondingly
with the degree of activity. By receiving such information on a
continuing basis, individuals quickly become aware of body processes
which were previously unknown and can recognize stimuli or feelings
which produce consistent changes in a certain direction. By
repetitive training and reinforcement of measures which reduce muscle
tension or raise fingertip temperatures, a state of relaxation can be
induced (Brown, 1977). In clinical practice, patients with tension
headaches or Raynaud's disease have been successfully taught to abort
attacks by reducing muscle tension or warming their fingertips as soon
as early warning signs appear. Similarly, many other stress related
symptoms can be reduced by successfully learning and practicing
strategies. Biofeedback does require specialized equipment and
trained personnel and generally requires individualized instruction.
Consequently, it is not as cost effective as meditation, muscular
relaxation or autogenic training which can be taught to groups of
individuals.

Gognitive Training

Behavioral modification is another method used to reduce exaggerated
or inappropriate responses to stress, One example is assertiveness
training-which is designed to provide individuals with more effective
control over their activities. This approach emphasizes the
development of appropriate assertive techniques to facilitate
communication of personal needs and requirements. It is particularly
useful in dealing with difficult interpersonal relationships, such as
a need for change in job assignment since it reduces the anger and
anxiety often associated with such situations. Other behavioral
techniques are directed towards improving skills and communication,
time management, and assistance in career development to more fully
utilize potential skills and talents. In clinical practice, reduction
of Type A coronary prone behavior has been reported to be the most
effective method of preventing recurrent heart attacks (Friedman, et
al., 1984). Increased use of techniques to reduce coronary prone
behavior can be anticipated as soon as training programs and
methodologies become standardized. However, this requires specially
trained personnel and outside of one or two research efforts, no
formal programs are available in training programs in this technique.
In general, behavioral modification utilizes role playing,
observation, self report feedback, and other behavioral therapy
techniques and can be effectively taught in a group setting.

Improving cognitive skills may also provide important stress reduction

benefits. This approach is based on the assumption that harmful
stress responses often result from the individual's past experiences

77



highly trained personnel or specialized equipment, and can be adapted
to almost any work setting. However, long term follow-up is required
to demonstrate sustained improvement and such data is not readily
available.

Mullen at the University of Texas recently presented an overview of
the evaluation of health promotion programs in a discussion paper for
the United Way Trust (Mullen, 1985). Among the programs reviewed were
those at Pioneer Hi-Bred International, Quaker Oats, and the
innovative and highly successful program of the Mendocino United
School District. Healthy People in Unhealthy Places: Stress and
Fitness at Work (Pelletier, 1984) is based on a two year study of over
160 corporate programs and profiles the effective programs at Xerox,
Johnson & Johnson, IBM, and Scherer Brothers Lumber Company. Both of
these sources provide useful information on program design,
incentives, development, and evaluation.

A variety of outside vendors also offer stress management training
programs for workers that may be delivered on site or at other
locations. These generally provide psychologists or specially trained
personnel to instruct employees in the various stress reduction
techniques noted above. However, evaluating their efficacy is
hampered because of lack of control groups, absence of long term
follow-up and inadequate assessment criteria. One innovative approach
which attempts to focus on job related stress due to incompatibility
between the individual's goals and behavior and work requirements is
offered by Human Synergistics (Lafferty, 1983, 1984 revisions). Level
1 ("Life Styles Inventory: Self Description") provides detailed
information about behavior by means of a lifestyle inventory. This
involves completing a self description questionnaire revealing
thinking patterns which characterize personality and lifestyle and
whether such activities are productive or destructive.

The results develop a profile that rates and compares concern for
people and satisfaction, concern for people and security, concern for
task and security, and concern for task and satisfaction. At Level 2
("Life Styles Inventory: Description by Others") the same lifestyle
inventory is completed by 6 or 7 other close friends or co-workers
whose opinion would be respected in describing these same aspects of
the individual's behavior and attitude. The resulting composite
profile helps to identify the way others perceive your attitude. The
similarities and differences that exist between the results of Level 1
and Level 2 evaluation provide important insights into understanding
the effects your behavior has on other people.

Level 3 ("Concept of Self Index") offers an in-depth psychological
inquiry into the major influences that cause observable behavior.
This provides basic information on factors such as self esteem,
motivations, misconceptions, and fundamental ways of processing

83



PART I

STRESS IN ORGANIZATIONAL SETTINGS

The chapters in Part I provide a background on the nature and sources
of organizational stress, relationships of perceived stress to worker
health and well-being, and strategies for measuring stressors and
strains in organizational settings. In Chapter 1, Drs. Singer, Neale
and Schwartz present a case study of a stress evaluation conducted in
a complex work setting. They use a systems approach to assess
occupational stress and describe key elements of the assessment
process. The chapter is a careful chronology of events surrounding
the conduct of stress assessment in a work setting. Notable actions
that facilitated the assessment process and pitfalls to avoid are
succinctly described. The perceived effects of the study at different
levels in the organization are also described.

Chapter 2 is an overview of occupational stress and health. Dr.
Hurrell points out that the stress/health relationship is not a simple
one but is moderated by a number of variables, including subjective
appraisals of objective conditions, extra-organizational factors,
personality traits, and buffer factors. Acknowledging these
complexities, a number of stressful job elements and work routines
that can impact worker health are identified and discussed.

In the final chapter, Drs. Jones and DuBois describe and evaluate
organizational stress assessment instruments. The chapter examines
four stress inventories that were designed for use in work settings
and have ample evidence of validity and reliability: the Human
Factors Inventory, the Work Environment Scale, the Maslach Burnout
Inventory, and the Organizational Management Survey.



Setting Priorities. A second step in the program planning process
that is critical to subsequent evaluation is setting the priorities
among needs to be addressed. Several formal methods exist for
clarifying and prioritizing needs. One of these is multi-attribute
utility analysis, which is based on a decision theoretic approach to
evaluation (Edwards, et al., 1975).

This approach allows the formal explication and ranking of the
objectives of different groups. Each group first defines and ranks
its objectives and provides information on those that it considers
most useful. Then through the use of Bayesian statistics, the choices
are analyzed and reported back to the groups. On this basis, the
priorities are reordered. The process of providing information,
linking objectives to inferences, and reordering objectives is
continued until the groups have taken into account their diverse
views. The decision theoretic approach is especially useful when the
different stakeholders hold sharply conflicting views and the pool of
potential objectives is beyond informal reconciliation.

Goals and Objectives. When the main problems and priorities have been
defined, the next step is to develop formally the program goals and
objectives. A statement of clear and concise objectives is critical
both to the implementation and to subsequent evaluation of the program
(McLeroy et al., 1984). It is almost axiomatic that evaluation cannot

be conducted objectively unless adequate objectives have been
developed.

Methods of specifying goals and objectives have been addressed for
many years in educational and service programs (Green et al., 1980;
Mager, 1962; Rossi and Freeman, 1982; and Weiss, 1972). The basic
purpose of goals is to provide the general direction or orientation of
the program and that of objectives to map out the specific procedures
and methods. Thus, goals typically are stated in general terms while
objectives provide details. The amount of detail provided in

objectives often sets limits on the quality of evaluation that can be
done.

Objectives should be developed both at the program level and at the
individual level. At the program level, objectives should specify who
{the target population) will change or will receive how much of what
health program, behavior or services; and, by when (the expected date
or elapsed time required for measurement of the impact or outcome of
the services). The specification of the characteristics of the target
population and the program should be very routine but often
insufficient details are given. Minimal information about target
groups should include basic demographics; age, sex, level of
education, income levels, and job types, etc. In worksite programs,
facts about the specific characteristics of work also should be
provided.

113



TABLE 4.1. Preliminary findings from Johnson & Johnson's
Live for Life Program.

Percent Change
Baseline ~ One Year

Treatment Control

Health Screen Measure (N=737) [=68'
Fitness

Aerobic Calories (/Kg/Week) 43% *% 6%
Weight Control

% Above Ideal Weight —1% ** 6%
Smoking Cessation

% Current Smokers -15% * - 4%
Stress Management

General Well Being 5% ** 2%

% With Elevated Blood —32% - 9%

Pressure (140/90)
Employee Attitudes

Self-Reported Sick Days -9% * 14%

Satisfaction With 3% xx - 7%

Working Conditions

Satisfaction With 1% ** - 3%

Personal Relations At Work

Ability to Handle Job Strain 0% ** - 2%

Job Involvement 2% 0%

Commitment to the Organization 0% - 2%

Job Self-Esteem 0% * - 2%

Satisfaction With -1% - 3%

Growth Opportunities

Significant at the 5% level.
Significant at the 1% level.

aK

81



CHAPTER 6

MEASUREMENT AND EVALUATION METHODS FOR WORKSITE
STRESS MANAGEMENT PROGRAMS

Gene L. Stainbrook and Lawrence W. Green

INTRODUCTION

This review summarizes the main features of the cumulative development
of measurement and evaluation in stress management programs in working
settings.

Definitions of Measurement and Evaluation

Evaluation has been defined variously. Jemelka and Borich (1979)
defined it as a process for decision making, Nutt (1981) as a measure
of the degree to which objectives have been achieved, and Green (1974)
as the comparison of an object of interest against a standard of
acceptability. In contrast to basic research, evaluation implies and
requires from the onset criteria and procedures for making judgments
of merit, value, or worth (Scriven, 1967). Measurement represents the
systematic application of procedures for assessing quantities and
qualities, whether for purposes of planning or of evaluation.

Purposes of Evaluation and Measurement

As a systematic endeavor, evaluation serves two general purposes. One
purpose is to assess the impact or effectiveness of products and
services in achieving pre-determined objectives. A second purpose is
to assess the efficiency of products and services in bringing about
any change, but more commonly in achieving pre-established

objectives. The assessment of effectiveness requires the detection of
a change or effect compared with some absolute criterion or standard.
In contrast, the assessment of efficiency requires the detection of
change relative to some comparable product or service. Other
applications of measurement, besides evaluation, include the
assessment of employee needs, experiences, and interests prior to
their recruitment into a program.

A common purpose of most program evaluations is to determine
effectiveness; specifically whether the program objectives are being
met. A second common purpose is to determine the efficiency or
comparative effectiveness of two or more programs or methods within a

Note: The authors are indebted to Richard A. McCuan, M.S.,
Pre-doctoral Fellow, Chris Lovato, Ph.D., Faculty Associate, and
Patricia Mullen, Dr. P.H., Associate Director, Center for Health
Promotion Research and Development, The University of Texas Health
Science Center at Houston,

109



CHAPTER 5

CREATING AND MAINTAINING COMPREHENSIVE
STRESS MANAGEMENT TRAINING

John D. Adams

This chapter begins by establishing a philosophical basis for
comprehensive stress management training which encourages each
individual to become more self responsible and self determining, and
suggests that the overall program must focus on dynamics within the
organization as well as within the individual. It then goes on to
describe an ideal program in relation to planning, goal setting,
developing system support, and the technologies and resources needed.
Ongoing program maintenance is discussed in relation to program
evaluation processes, its relationship to other existing programs, and
the need for the system itself to respond to issues identified in the
program. The chapter does not provide specific instruction in stress
management techniques or specific substantive information relative to
stress management techniques.

INTRODUCTION

There is little doubt that stress management training has, over the
past few years, become the most popular form of training available in
American organizations. It's popularity is likely to continue, as
people recognize that they are under more stress than is good for
them, and that there are specific things they can do to combat the
effects of excessive stress.

Whenever a training topic becomes popular, large numbers of full and
part time trainers begin to offer the training as a part of their
repertoire. Often, the result is that the topic becomes just another
program from the training department. When this happens, the training
program generally has little impact. It is likely that with
increasing popularity, the quantity of stress training programs
increases and the quality and impact of such training decreases in
proportion. At this point, most of those employed as trainers in
America have at least a "stress module" in their repertoire, while
those trained in health protection and health care are just beginning
to join in on the training ventures.

Another related problem is that most trainers keep themselves too busy
conducting training programs to do any serious follow up impact
studies on their work. Thus, at this point, relatively little is
known about the relative impact of various approaches to conducting
stress management training.

One of the basic questions which should be asked of a suggested stress

training program is "what is the true purpose of the training?"
Often, these programs are created in organizations as palliatives or

93



Sterling Educational Films
241 East 34th Street

New York, NY 10016
212/683-6300

Trainex Corporation

12601 Industry Street

Garden Grove, CA 92641
800/472-2479 (California)
800/854-2485 (outside California)

DITIO! ES 'ORMATIO!
Ye es:

- Biofeedback Therapists

- Counselors

- Exercise Equipment

- Exercise & Physical Fitness Programs
- Holistic Practitioners

~ Hospitals

- Management Consultants

- Mental Health Centers

- Motivational & Self Improvement Training
- Psychologists

~ Social Service Organizations

Libraries

Health Services Directory
A. Kruza, 1981

Medical and Health Information Directory
Gale Research Co., 1980

National and Local Agencies

American Health Foundation

Mahoney Institute for Health Maintenance
320 East 43rd Street

New York, NY 10017

212/953-1900

Provides materials and conducts programs for employers and
employee groups.

183



Dale Carnegie & Associates, Inc.
1475 Franklin Avenue

Garden City, NY 11530
516/248-5100

Provides courses in self-improvement areas such as "Effective
Speaking and Human Relations." Fees based on services provided.

-

Center for Health Promotion and Education
Centers for Disease Control

1600 Clifton Road

Atlanta, Georgia 30333

404/329-3158

Provides information on health risk appraisals and other
health promotion activities in work settings.

Clearinghouse on Business Coalitions for Health Action
1615 H Street, NW, Suite 526

Washington, DC 20062

202/463-5970

Publishes newsletter and directory of business coalitions,
schedules meetings, and provides a speaker's bureau.

Conscious Living Foundation
P.O. Box 513

Manhattan, KS 66502
913/539-2449

Provides catalog, brochure, books, audiocassettes, biofeedback
equipment and conducts programs.

Consumer Information Center
Pueblo, CO 81009
303/544-5277 x370

Provides catalog, brochure, and newsletter.
Five Valleys
Health Information Clearinghouse
235 East Pine Street, No. 4
Missoula, MT 59802
800/332-5759 (Montana)

Provides catalog, brochure, newsletter, and conducts programs.

186



10.

TABLE 3.3.--WES Subscales and Dimensions Descriptions
RELATIONSHIP DIMENSIONS

Involvement - the extent to which employees are concerned
about and committed to their jobs

Peer Cohesion - the extent to which employees are friendly and
supportive of one another

Supervisor Support - the extent to which management is
supportive of employees and encourages employees to be
supportive of one another

PERSONAL GROWTH DIMENSIONS

Autonomy - the extent to which employees are encouraged to be
self-sufficient and to make their own decisions.

Task Orientation - the degree of emphasis on good planning,
efficiency, and getting the job done.

Work Pressure - the degree to which the press of work and time
urgency dominate the job milieu

SYSTEM MAINTENANCE AND SYSTEM CHANGE DIMENSIONS
Clarity - the extent to which employees know what to expect in
their daily routine and how explicitly rules and policies are

communicated

Control - the extent to which management uses rules and
pressures to keep employees under control

Innovation - the degree of emphasis on variety, change, and
new approaches

Physical Comfort - the extent to which the physical
surroundings contribute to a pleasant work environment.

59



fell into one of four categorits: Falls and trips, lifting strains,
lacerations, and miscellaneous (e.g., smashed finger, infection of
unknown origin, hematoma from dropping cabinet on foot, etc.). All
injuries required medical care and time off from work. All of these
occupationally-injured employees completed the HFI to further test the
hypothesis that employees who get injured at work experience more job
stress and dissatisfaction than their co-workers.

Obtained results supported the hypothesis. Statistical analyses
showed that the injured employees, on the average, experienced higher
levels of job stress, job dissatisfaction, and organizational stress
compared to a control group of over 1,000 co-workers (p<.01). In
addition, the injured employees encountered more stressful life
changes during the past 12 months compared to the control group
(p<.01). These findings support the hypothesis that employee stress
is related to more on-the-job accidents and injuries.

A second part of this study examined the stress levels of a group of
workers who engage in a high level of wellness behaviors. From the
theory of stress, it is expected that employees who engage in the
regular use of stress management techniques and maintain healthy
lifestyles (i.e., regular exercise, good nutrition, strong social
support network, etc.) will be more resistant or hardy when exposed to
normal or high levels of stressors.

To assess the sensitivity of the HFI to measure groups with high
levels of wellness behaviors and expected low levels of distress, 80
practitioners of the Transcendental Meditation Program were surveyed
with the HFI and compared both with the norm group and with the
injured employees. As expected, the meditating group displayed
significantly lower levels of job and organizational stress than
either the norm group or the injured workers (p<.01).

Also, their scores on the Accident Risks, Job Dissatisfaction, and
Life and Health Risks scales were significantly lower than the other
groups (p<.01 in all cases). The scores on the Stressful Life Changes
scale showed no significant differences, indicating that the level of
life stressors were similar. The lower levels of stress reactivities
measured by the Job and Organizational Stress scales can be presumed
to be due to the increased level of stress coping skills rather than a
lower level of stressors.

The relationship between HFI scores and levels of chronic back pain
was assessed with 518 hospital employees in another validity study.
Employees indicated how often they experience distressing backaches
and pains. Back pain and injury is a leading cause of workers'
compensation claims. Obtained results show that approximately 21% of
all employees experience high rates of backaches and pains. Only 13%
of employees reported that they "never" experienced back pain (see
Table 3.2).

55



sources of data (before a new data collection step was initiated) to
confirm that we understood their commumications and that our next step
in the assessment conveyed their concerns.

First Gontact with Hotel Employees

In a follow-up meeting with both organizers for the hotel, we laid out
the basic components of the assessment. We wanted to interview
representative employees from each department of the hotel. These
interviews would provide us with a detailed sense of those stressors
unique to specific jobs or departments in the hotel as well as
information about stressors shared by all members of the hotel staff.
Based upon this information, we would develop a survey for general
distribution that would cover the diverse stressors raised in the
interviews. At the same time, each survey would have additional
questions aimed at the specific concerns of each department. We would
analyze the results of the survey and prepare a written report in time
for use in contract negotiations.

In order to choose a sample of union members for interviews and also
to make sure the employees were interested in such an assessment, we
requested a meeting with shop stewards from the different hotel
departments. We cannot overestimate the importance of shop stewards
to the success or failure of any attempted collaboration with labor.
Shop stewards serve as ombudsmen, organizers, union officials, and
psychotherapists. They are the conduit through which any outsider
will reach a rank-and-file member. Consequently, a union's
organization is only as good as its shop steward structure. In times
of contract negotiations, shop stewards oversee contract proposal
meetings and election of the negotiating committee. During strikes,
shop stewards become picket captains and administrators of picket pay
and strike funds.

All this noted, we should point out that the main goal and main
headache for the organizer with whom we worked was to strengthen the
shop steward structure at the hotel before the contract negotiations
began. Our first meeting with the shop stewards conveyed to us the
extent of the task that lay before them. Four of the eight stewards
made it to the meeting. One steward's son had just been fired for
stealing from a cash box and she interrupted our presentation
intermittently to argue with the organizer about his handling of the
incident. On top of this, since the meeting was held in the hotel,
one or another steward was summoned away for minutes at time. The
scene itself was quite comic, given the diverse outfits of the union
members (bellman coats, chef's hats, waitress aprons, and housekeeping
uniforms) and the half-Spanish, half-English yelling match between the
steward and the organizer. Still, the shop stewards present could not
overemphasize the stress they had experienced at the hotel under the
new management. They were very much in favor of whatever efforts we
could offer to provide concrete evidence of this problem. They

15



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45



Diagram A.

The Distress Cycle

Employees are exposed to many stressors. Those who have coping deficiencies rather
than coping skills become distressed. Chronic distress, in turn, leads to social and
financial costs — accidents, injuries, turnover and poor productivity. But it doesn’t stop
there. These symptoms of distress become, themselves, stressors, and the distress cycle

develops.

ir ~ YY
coping
losses
es
NG eres

deficiencies


lipid values. Behavioral benefits in terms of smoking, alcohol use,
physical activity, nutrition, job performance, and interpersonal
relations were also recorded. Attitudinal alterations were assessed
in terms of sense of general well being, job satisfaction, company
relationships, quality of life in the workplace, and improved health
attitudes. Four divisions received the complete "Live for Life"
program, while 5 served as controls, offering only the health screen
to their employees. Approximately 4,000 employees were involved in
the epidemiologic study group. Unfortunately, a randomized,
prospective control trial was not attempted since the educational
program facilities for lifestyle improvement were available to all
workers. Thus it would have been impossible to keep individuals
randomly assigned to a control group from escaping the effects of this
intervention. Random assignment of company sites was also not
possible.

Preliminary findings on the cohort of employees which did complete
both the baseline and one year health screen did suggest an ability to
achieve significant and meaningful improvement as indicated by the
figures cited in Table 4.1 (Wilbur, 1981). Obviously, programs such
as Live for Life require a major commitment on the part of the
employer as well as personnel, equipment, and other resources
frequently not available to many organizations. Control Data has
spent “well over $10 million” in its six year Stay Well program in
which 50,000 employees nationwide are offered classes on coping with
stress, nutrition, etc. However, benefits and savings are difficult
to quantify or accurately estimate and that very question bothered the
Director of Health Services. In a recent New York Times article
(Mirvis, 1985), he was quoted as saying, "Businesses don't know what
the return is on any of their employee benefits. What's the return on
an extra week of vacation? So why hold wellness programs to such a
test?"

However, stress management techniques that can be utilized in almost
any industrial setting have also been studied and determined to
provide significant benefits. One such program was conducted at the
New York Telephone Company for some 160 volunteers who reported high
stress (Carrington, et al., 1980). On entry, the subjects completed
form A of the 16 personality factor inventory, the SCL-90-R
(Derogatis, 1981), and a pretreatment attitude compliance
questionnaire. The same instruments were used to measure progress at
the end of 6 weeks and again at 5 1/2 months. Thirty-eight subjects
were assigned to one of three treatment groups utilizing clinically
standardized meditation, Benson's Relaxation Response, and progressive
muscular relaxation. A control group of 40 received no specific
instruction. The techniques were taught through audio taped
instructions with supplementary reading material which the
participants reviewed at home. The techniques were practiced twice
daily for 15 to 20 minutes and at the end of 2 weeks specially trained

80



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Prospects for a Healthier America. (pp. 9-19). Washington, DC:
U.S.DHHS, Office of Disease Prevention and Health Promotion.

Kiresuk, T. (1973). Goal attainment scaling at a county mental health
service. Evaluation, 1(1), 12-18.

Lerner, M., and Shore, L. (1982). Occupational stress and labor

organizing: The work of the Institute for Labor and Mental Health.
Socialist Review, 12, 121-139.

144



Methods of Ensu:; Gor - Several general methods can be
used to help protect the privacy of individuals. These include
establishing policies stipulating that only evaluators will have
access to information on individuals; sending the results of
screenings and risk assessments to private physicians or employees’
homes; and contracting with outside organizations to provide employers
only with aggregate information. The success of these methods depends
on the degree of confidence that employees have in them. However,
providing only aggregate data precludes further analysis at the
individual level.

To provide continued access to individual data and still protect
privacy, several other methods have been developed. Often a master
list of names along with code numbers is set up. The master list is
kept in a secure location and all data forms are identified only by
the code number. This method has been used successfully in the past
but has some limitations. Such records could be subpoenaed as a part
of a legal proceeding. As there is no complete guarantee of
anonymity, employees may distort responses to questions about alcohol
and drug use and other behaviors that may be strongly incriminating or
socially unpopular.

Another way to protect anonymity and possibly reduce response bias on
sensitive questions is the use of random response techniques. This
approach protects the anonymity of the question rather than the
respondent. In one of the simplest models, two questions are
presented--the sensitive question and an innocuous question for which
the probability of response is already known. Respondents are asked
to chose a question by flipping a coin, and then to respond without
letting the interviewer know which question is being answered. Given
prior knowledge of the probabilities of question selection and
responses to the innocuous question, the proportions of group
responses to the sensitive question can be estimated reasonably
accurately. A limitation of the random response techniques is that
they require large sample sizes since the obtained variance is a
function of the proportion of the sample responding to the sensitive
question rather than the entire sample (French, 1979; Fox and Tracy,
1980).

The success of worksite based hypertension programs depends critically
on steps taken to ensure confidentiality and job security. Such
measures can range from excluding management from the premises during
screening and treatment to preventing the release of patient records
without the written consent of the employee. This guarantees that
only program sponsors and health care personnel know which employees
are hypertensive and are familiar with their progress in therapy
(Alderman, 1984).

137



humanitarian spirit. How could these companies have civic pride if
they didn't treat their own employees well? The final prong of the
union strategy, and always the most important, was the willingness of
the three locals to stand by each other and take to the streets. Paid
staff and shop stewards at each hotel would be responsible for
building a strong committee structure that would define contract
proposals, elect a negotiating committee, and, if necessary, form the
nucleus of picket captains.

Once he finished his description of how all these elaborate forces
would come into play within the next nine months, the union
representative suggested where our assessment might fit into this
scenario. The paid union staff for the three hotels consisted of two
full time organizers and a part time clerical worker. The senior
organizer of the two was also covering hotels in the neighboring state
for another staffer who was helping out at a significant strike in Las
Vegas. Our project might keep the union in the minds of the membership
as the other organizer struggled to lay the groundwork for a committee
structure at the three hotels. As long as we did not make many time
demands on either organizer, we could aid in the educative process
necessary to the contract negotiations. Our assessment might help
employees to articulate dissatisfactions and demands that they might
later express during the contract proposal meetings. Additionally, we
might be able to document quantitatively the effect of top level
corporate decisions as they trickled down and affected the individual
employee. Perhaps, the information we collected could be used during
negotiations either through the media or to support requests for
better contract language at the bargaining table. The union
representative did not, however, express much confidence in these
possibilities.

Our assessment had already begun with this 1 1/2 hour meeting. In
terms of the OSEG, we were operating at the highest social/political
level. Our assessment of a union work force's occupational stress was
to take place on the battleground of a modern union-management
struggle. The players were no longer a bunch of immigrant workers and
a grizzled boss, who had come off the boat only a few years earlier
than the workers. Instead, the bosses were unidentified corporate
decisionmakers, who relied on computer projections and
standardization. The workers were led by college-educated, full-time
organizers who orchestrated contract negotiation drives like commando
assaults. It became very clear to us that a major goal would be to
document how these higher level strategies (which were only then
commencing) would produce specific effects on employees' lives and
perceptions at the time of our full-scale assessment.

10



APPENDIX
Evaluation Resources

Several U.S. Government publications and privately subsidized
publications on evaluation are available free or at relatively low
costs. Several of these are listed and briefly described. The
resource guide developed by Zapka et al. (1982) is a good place to
start as it provides a relatively large number of annotated references
on evaluation.

Locating Resources for Evaluation:

Zapka, J., Schwartz, R., and Giloth, B. (1982). Locating Resources
for Evaluation. Chicago: American Hospital Association.

This is a useful resource guide, written primarily for persons
working in the health education and health promotion fields. It
provides annotated references on evaluation methods for health
education and health promotion programs. References are provided
in four topic areas: 1) Evaluation design and implementation, 2)
data sources, 3) evaluation instruments, and 4) evaluation
management. In addition to listing references, brief discussions
of each of the four areas are provided.

The publication is currently available at no cost from:

Center for Health Promotion
American Hospital Association
840 North Lake Shore Drive
Chicago, IL 60611

Baseline is a publication provided by the Health Services Research
Center of the University of North Carolina at Chapel Hill with
support from the W.K. Kellogg Foundation of Battle Creek,
Michigan. The Kellogg Foundation's national demonstration program
in health promotion/disease prevention gives special emphasis to
careful program evaluation.

To date, ten issues of Baseline have been published. Most of the
issues are four to five pages in length and provide clear and
succinct discussions of basic issues in health promotion program
evaluation. The editors for this series are G.H. DeFriese, and
W.L. Beery. The titles for each publication are:

1 Background Information (1982).

2 Cost-benefit and cost-effectiveness analysis for health
promotion programs (1982).

3 Choosing an evaluation strategy (1983).

4 Goal-oriented evaluation as a program management tool (1983).

139



41 - 60%

Average Risk. The average employee is coping just as well as the
average employee represented in the norms. The typical employee
in this group is no worse or no better than the typical employee
from the normative sample. That is, scores in this range mean
that employees have both coping skills and coping deficiencies.

61 - 80%

High Risk. Scores in this range mean that there are opportunities
to reduce stressors and improve coping skills. That is, the
typical employee is coping worse than 61 to 80% of the normative
sample employees. Interventions are needed for these employee
groups.

81 - 100%

Very High Risk. Active interventions are definitely needed for
these employee groups, The average employee is coping worse than
81 - 100% of the employees represented in the norms. This is
probably due to poorer coping skills and more exposure to
stressful situations.

In brief, work groups with percentile scores greater than 50 are
experiencing above average levels of stress. Groups with percentile
scores less than 50 are experiencing below average levels of stress.

A score of 60 or more indicates critically higher levels of stress and
should serve as a warning to companies that worksite stress management
programs are definitely needed.

Validity

A test or survey is valid when it predicts those behaviors and
outcomes that it was designed to predict. A number of validation
studies have been conducted with the HFI (Jones and DuBois, 1985). A
selection of five of these are presented briefly below.

In one study, 150 employed college students completed the HFI and made
anonymous admissions of accidents, injuries and illnesses. Results
showed that higher scores on the HFI (higher scores mean more stress
and poorer coping skills) significantly correlated (p<.05) with higher
rates of on-the-job accidents, minor injuries, major injuries, minor
illnesses, major illnesses, and days of work missed due to injury
and/or illness. Higher HFI scores were also associated with more
frequent use of medical facilities. Finally, higher HFI scores were
associated with poorer productivity and tendencies to look for a new
job. This study was replicated with over 6,000 employees who
represented hundreds of different job titles.

Forty-two employees who reported on-the-job injuries to an

occupational nurse participated in another validity study. All
employees worked for the same company. Reported injuries typically

54



ACKNOWLEDGEMENTS

The editors are indebted to Sheila Saalfeld for assembling information
presented in the Resource Guide and to Connie Kidd and Nadine

Dickerson for their technical assistance in preparing revisions of
this document.

vi



Organizational Stress and Preventive Management
J.C. Quick and J.D. Quick. New York: McGraw-Hill Book Co., 346
pp, $14.95.

A excellent textbook on organizational stress designed for
college level courses, It is a thorough, readable discussion
of stress and stress reduction with a focus on organizational
Practices and preventive management principles.

rinciples and Practice ess it
R.L. Woolfolk and P.M. Lehrer, (Eds.) New York, NY: Guilford
Publications, Inc., 1984, 477 pp., $35.

A detailed examination of relaxation, meditation, yogic
therapy, hypnosis, biofeedback and cognitive approaches to

stress management. Underlying principles for the techniques
are also offered.

esource Guide o: cupatio

E. Boostrom & I. Jillson-Boostrom. Rockville, MD: Work & Mental
Health Research Section, 1984.

The publication contains names and addresses of individual
experts, organizations, publications and audiovisual
materials, and a list of research projects which are sources
of information on occupational stress.

Stress Management: A Comprehensive Guide to Wellness
E.A. Charlesworth and R.G. Nathan, 1982. Houston, Texas:
Biobehavioral Press, 517 pp., $19.95.

A self-help book containing stress education information and a
wide range of stress management training techniques. An
"Inside to Self-Help Groups" is provided as an appendix to the
book. Occupational stress is not a major focus of the book.

ought: elings: The Art of Cognitive Stress Vv.
M. McKay, M. Davis, and P. Fanning, 1981. Richmond, California:
New Harbinger Publications, 218 pp., $11.50.

This workbook describes cognitive techniques for stress
reduction and stress management. Background information on
stress is presented followed by detailed coping exercises.
Occupational factors contributing to stress are not treated
specifically.

177



physiology of the stress response, the range of anatomical structures
involved and some initial consequences. In this presentation, I point
out that it is not necessary to remember any of these specific details
to recognize that: the stress response is a physical fact (not "just"
a set of feelings), that it is involuntary, that it has widespread
effects throughout the body, and that its consequences are
simultaneously physical, mental, and behavioral.

Of course, this cognitive information will not, by itself, modify
highly socialized values about "strength", improve popular attitudes
toward mental illness or change participants’ behaviors of self-care.
But it does appear to command attention, to be persuasive in making
stress "real", to be required information for understanding stress,
and to validate the importance of learning more about stress and of
dealing with it.

Validate The Stressors Presented

Of necessity, we deal with stressors in categories, either very
general ones like “objective” or “subjective” stressors, or more
specific issues, like "problems with my children" or “lack of
appreciation from my supervisor". Stress assessment instruments also
must deal in categories, using representative examples to cover the
range of potential individual concerns. I have become concerned about
some effects of discussing stressor categories and, as one result,
have decided, tentatively, not to use stress assessment instruments in
introductory workshops.

My concern arose as I worked with an increasingly wide range of
people. I became aware of a pattern that had no apparent relation to
the education or social status of workshop participants: when
participants were asked to discuss the major stressors in their lives
some would identify a very specific, obviously stressful situation and
ask whether that could be a source of stress.

This frequent phenomenon puzzled me because I have never met an adult
who needed a definition of stress or lacked an answer to the question
“What are the major sources of stress in your life?" So what were
these people really asking? The conclusion that makes most sense to
me is that these people needed to have validation of their concerns,
to be assured that their stress is significant stress. This
validation appears to be a prerequisite for many people learning how
to deal with stress; it is as though they were choosing between two
conclusions: "This should not be an issue, the problem is some flaw in
me, and because this is my fault, I'm stuck with having the problem
because I'm not a better person." or "This is a real problem, so there
might be something that can be done about it, something that I can do
about it.”

166



attacks (Rosenman, et al., 1964, 1970). The relationship of such
"male" type behavior is best assessed by a standardized and structured
personal interview conducted by trained personnel (Rosenman, 1978).
This requirement makes large scale surveys time consuming and
expensive. As a consequence, a variety of questionnaires such as the
Jenkins Activity Survey (Jenkins, 1967) and the Bortner Rating Scale
(Bortner, 1969) have often been used to uncover coronary prone
behavior to improve cost effectiveness and can be used in the
industrial setting for screening.

Finally, it seems quite apparent that the nature of stress in modern
society can result from not only major life change events or
exaggerated and inappropriate behavioral syndromes but also a host of
minor irritating hassles that occur repeatedly on a daily basis.
Examples are getting stuck in a traffic jam on the way to or from
work, arguments with co-workers, customers, relatives, friends, etc. —
or even a broken shoelace. These can also be measured by means of a
“Hassle Index" (Kanner, et al., 1981) which can also forecast adverse
health consequences. The amazing thing is that despite the crudity of
all these approaches, the Holmes-Rahe Scale, Type A coronary prone
behavior evaluation, and the Hassle Index all seem able to forecast
with some accuracy the development of subsequent illness. The 467
item computer scored Stress Vector Analysis attempts to incorporate
and correlate information obtained from these and other stress
measuring scales to provide a profile of stress that displays its
relative sources of origin and mechanisms of expression (Staats,
1982). Further developments would appear to offer greater promise by
refining combinations of such test approaches or by measuring
psychophysiologic responses to standardized emotional challenges.
Proof of the efficacy of stress management programs is difficult to
obtain. There are a variety of reasons for this. A major problem in
gathering information is that stress reduction efforts are often
components of a larger employee assistance program that includes or
emphasizes such activities as jogging, aerobic exercise, counseling on
nutrition, alcoholism, substance abuse, or family problems. While
such ancillary services also may come under the general heading of
stress reduction measures, it is difficult to dissect out the specific
contribution of a stress reduction intervention, per se. Meditation,
progressive muscular relaxation, biofeedback, assertiveness training,
behavioral modification and other stress reduction strategies may
provide benefits but they cannot be isolated and identified as such.
In addition, relatively few stress reduction programs have been
constructed so as to permit adequate evaluation of efficacy. Criteria
cited are often diminished absenteeism, improved productivity,
improved relations or better quality of life in the workplace.
However, these are usually influenced by other confounding factors or
by virtue of their self report nature are not susceptible to
scientific scrutiny. Nevertheless after an extensive analysis of
stress programs in 1984, Green and his colleagues at the Center for
Health Promotion Research and Development at the University of Texas

72



TABLE 1.4 RESPONSE RATES AND DEMOGRAPHICS OF HOTEL SAMPLE

Total hotel staff
Unionized employees

Response rate (hotel)

Response rate (by department)

Banquet
Engineering
Food and Beverage
Front Desk
Housekeeping
Respondent characteristics
Age: Mean= 37.7 years
S.D.= 13.45
Sex: Male 43%
Female 57%
Education: Mean = 12 years
S.D. 3.40
Race: White 68%
Black 21%
Hispanic 10%
Asian 1%
Marital status: Married
Single
Divorced/Separated
Widowed
Children None
One
Two

Job Tenure:

Tenure at hotel:

Three or more

Mean = 5.80 years

S8.D.= 4.80
Mean = 5.78 years
S.D. 3.43

24

240 (approx.)
196

82/196 (42%)

12/25 (48%)
2/7 (29%)
33/82 (40%)
14/32 (44%)
21/57 (37%)

43%
37%
19%

41%

9%
23%
27%


stress was considered to be the greatest factor leading to adverse
health habits (American Association of Family Physicians, 1979).

Surveys suggest that 75-90% of visits to primary care physicians are
due to stress-related problems such as backache, headache, insomnia,
anxiety, depression, chest pain, hypertension, gastrointestinal, and
dermatologic complaints, etc. (Stroebel, 1982). The ability of
stress to cause emotional and somatic symptoms or contribute to
various disease syndromes has long been appreciated but mechanisms
of action have only recently begun to be clarified. A pertinent
example is the stressful Type A coronary prone behavior pattern now
acknowledged to be as predictive as any other known risk factor for
coronary heart disease (Coronary-Prone Behavior Review Panel,

1981). Furthermore, reducing coronary prone behavior currently
represents the most successful strategy for preventing recurrent
heart attacks (Friedman, et al., 1984). The role of stress in
hypertension is attested to by the latest National Heart, Lung, and
Blood Institute's recommendations for the treatment of hypertension
(Joint National Committee on Detection, Evaluation, and Treatment of
High Blood Pressure, 1984). These new guidelines urge that
non-pharmacologic measures be employed as the initial treatment for
hypertension or be instituted as adjuvant measures in any
therapeutic regimen. While weight reduction and salt restriction
fall into this category, their efficacy is rather limited. To a
considerable extent therefore, these new recommendations really
reflect a growing acknowledgement of the importance of stress and
efficacy of stress reduction strategies such as meditation,
progressive muscular relaxation, or specific biofeedback techniques
in treating hypertension. Clearly, industry has also shown great
interest in this approach. A recent survey of 160 corporations
indicated "stress management" programs to be the first priority
(Pelletier, 1984). There were four times as many projects in this
category as the next largest segments, physical fitness, and
non-drug treatment of hypertension. At the present time a three
year program is underway between the University of California School
of Medicine, Bank of America, and several major corporations in
California to develop and evaluate behavioral approaches to reduce
stress and hypertension (Pelletier, 1983).

Anecdotal reports supported by preliminary research data implicate
psychosocial stress as an important factor in the development and
course of various malignancies as well as infections ranging from
the common cold to herpes. Verification of the validity of such
relationships has now come from the rapidly emerging field of
psychoneuroimmunology (Ader, 1981), clearly confirming the ability
of stress to reduce immune system defenses against cancer, as well
as bacterial and viral infections. Increased gastrointestinal,
secretory and motility patterns in response to stress allow insight
into the pathogenesis of conditions such as peptic ulcer and colitis
characterized by such abnormalities. Similarly, the facilitative
effects of stress on a variety of allergic phenomena that affect the

70



CHAPTER 7
WORKER STRESS: A PRACTITIONER'S PERSPECTIVE

Eugene V. Martin

In the past, when workers -- whether manual, office, managerial, or
professional -- have organized associations, unions, or clubs to
provide mutual occupational assistance, they have traditionally paid
attention to issues affecting their working conditions as well as to
job security and salary. Yet, it is only in recent years that stress
has surfaced as an issue affecting workers at every level and in every
occupation. Even though intuitive awareness of stress in the
workplace is virtually universal, the definitions and formal concepts
of "stress" are still tentative and evolving. Hopefully, those of us
who are concerned with workers and their stress problems can expect to
see considerable evolution of programs and practices as these groups
become more aware of the additional dimension that stress adds to
traditional workplace concerns and as we all come to better understand
what helps and what is needed.

This paper, addressed to those who work on stress problems, consists
of observations derived from my efforts to design, implement, and
evaluate stress education, action, and research projects. As I have
tried to learn from others and from my own experience, these ideas and
assumptions have seemed useful and important. They are offered here
as hypotheses intended to stimulate discussion and further
experimentation that will give us a fuller understanding of stress in
the workplace and how we can identify effective ways to help workers
deal with it.

The paper has three sections. In Section I, I raise questions about
prevailing practices I think we should be addressing. These questions
focus on the content and process of current stress programs, the way
we are delivering services and dealing with clients, and, more
generally, on the field and how we see ourselves. Section II is a
brief case study of one project I worked on and some observations and
learnings from that experience. In Section III, I offer some
suggestions for or about possible next steps and invite more
collaborative action.

CURRENT PRACTICES
CONTENT/PROCESS

What Should The Emphasis On Self-Responsibility Be?

I have found that many stress programs tell their participants
implicitly — and often explicitly -- that, "The stress lies in you
and your reactions, not in your job (or other, external factors)." In

149



under a variety of validation strategies (Maslach and Jackson, 1981).
For instance, Barad (1979) found that larger caseloads were
significantly correlated with more intense feeling of burnout among
Social Security employees.

Case Studies

The MBI was administered to 130 police families in order to better
understand the impact of job stress on family life (Maslach and
Jackson, 1979). Both police officers and their spouses completed the
MBI. Analyses showed that high burnout scores were associated with
more domestic strain. The ability to link job stress to marital
problems provided the justification to implement a variety of work
site stress management programs.

The MBI was also given to 83 child care workers in order to understand
some of the sources of job stress (Maslach and Pines, 1977). Results
showed that higher burnout scores were related to higher staff-child
ratios and longer hours of direct contact with children. Conversely,
lower burnout scores were associated with the use of relaxation
breaks, regular staff meetings, and good team relationships. Hence,
the MBI was used to identify major stressors and stress "buffers,"
respectively. Corrective steps were then taken to eliminate the
organizational stressors.

IV. ORGANIZATIONAL MANAGEMENT SURVEY (OMS)

The Organizational Management Survey (OMS) is a 43-item instrument
designed to identify a variety of organizational stressors in the
workplace (Jones, 1984). The OMS is used by companies to identify the
most prevalent organizational stressors that exist in a work group.
Management can use the OMS in order to reduce or eliminate stressful
job elements. Unlike the three previous stress surveys, the OMS
yields item scores, not scale scores.

The OMS is typically not given to all employees within a work
organization. Organizational stress surveys like the HFI, WES, and
MBI are given first. These comprehensive measures of occupational
stress can then be used to identify highly stressed work groups within
companies. The OMS can then be used to identify the exact type of
organizational stressors that are operative within the distressed work
groups. An example of this strategy is presented in the following
case study.

Case Study

The HFI was administered within a large hospital to over 800 employees
representing approximately 30 departments. The HFI scores identified
the Surgical Nursing Department as being one of the most stressed
clinical medicine departments in the hospital. The OMS was given to

62



Though these stressors were specific to discrete tasks within each
department, an overarching theme of dissatisfaction with
labor-management relations repeatedly surfaced. This theme was
symbolized by complaints one might first dismiss as rather minor.
First, every representative mentioned the poor quality of food served
by the cafeteria. Since employees of the hotel were not allowed to
leave the hotel during their shifts, many relied on the cafeteria for
both meals and social life. The menu was dictated by whatever had
been left over from the various functions catered by the banquet
department. Second, the new management had removed the television
from the cafeteria with the explanation that it had led to prolonged
breaks and wasted work time. The food and, to an even greater extent,
the abducted television, summed up in a powerful (if not visceral)
way, the employees’ sense that management treated them like children
or, even worse, robots. The other impression communicated by
interview participants was that workers could see an improvement in
the hotel's quality and efficiency, but were asking themselves, at
what or whose expense? Each could think of co-workers who had
recently been laid off or who had had their hours cut, while a large
dining room, closed ostensibly for renovations, lay dark and empty in
the middle of the hotel.

The second portion of the interview consisted of an oral
administration of a pilot version of our stress questionnaire, divided
into the OSEG levels previously discussed. In addition to the items
we had created, we drew questions from the "Quality of Employment
Survey” (1977), the "Office Workers: Health and Well-being Survey”
(Gordon, Stellman, and Snow, 1982), and the "CWA Local 1180 Stress
Questionnaire” (Love, 1983). The list of items ranged from the
temperature in the restaurant kitchens to the level of competition
with other hotels in the city.

We found this trial run of our eventual questionnaire extremely
helpful. We learned how to reword certain items to make them clearer
and more neutral. Additionally, we were able to delete questions that
were uniformly irrelevant across the departments of the hotel. Most
importantly, we realized that to assess both stressors and responses
to stressors in the same survey would be too demanding on employees'
time. To satisfy properly the different levels of the OSEG, from
physical environment through work demands on up to organizational
factors, we had already created a 10 page questionnaire. For this
reason, we decided to restrict our initial efforts to the study of
stressors and not employee responses to the stressors. With the
contract expiration date drawing closer, we agreed to limit our
subsequent assessment efforts to the patterns of stressors we could
identify (Steps 1-7). We could then take up employees' characteristic
responses to stressors in a subsequent assessment. Though this
decision was necessary, it troubled us to know that we might raise
employees' awareness of problems at the hotel without also raising

17



Various management styles, such as the allowance of little or no
participation in decision making, lack of effective consultation,
restrictions on behavior, etc, are organizational features that also
have been viewed as potentially stressful (see Beehr and Newman,
1978). Of these, lack of participation in decision making has
received the most research attention. Early field studies
demonstrated that greater participation in decision making led to
greater job satisfaction, lower turnover, better
supervisor-subordinate relationships, and increased productivity (Coch
and French, 1948; French, Israel and Aas, 1960). Moreover, in a
nationally representative sample of nearly 1,500 workers,
nonparticipation at work was found to be significantly related not
only to low self-esteem and low job satisfaction but to overall poor
physical health, escapist drinking, depressed mood and absenteeism
(Margolis, Kroes and Quinn, 1974).

Factors related to career development have also been linked to health
consequences. These include overpromotion, underpromotion, status
incongruence, lack of job security, fear of redundancy, obsolescence
or early retirement (see Beehr and Newman, 1978). One of the most
potent of these stressors appears to be ambiguity about one's job
future. For instance, uncertainty about continued employment has been
found to be related to low job satisfaction, low life satisfaction,
low self esteem, escapist drinking and overall poor physical health
(Margolis et al, 1974).

Relationships at work with one's colleagues, supervisors and
subordinates have been identified as sources of job stress (see
Davidson and Cooper, 1981; Beehr and Newman, 1978). For example, the
most common sources of stress for a sample of 5,000 managers included
inadequate support by supervisors, ineffective performance by
supervisors, and conflict and ambiguity about what's expected (Pearse,
1977).

Physical Conditions. Adverse environmental conditions appear to be
associated with health disorders in a synergistic way by exacerbating
the overall job demands placed’ on employees, thus lowering worker
tolerance to other stressors and decreasing worker motivation.
Conditions like excessive noise, heat or cold, poor ventilation,
inadequate lighting and ergonomic design deficiencies have been
associated with employee physical and psychological health complaints
and with attitudinal and behavioral problems (Caplan et al., 1975;
Cooper and Marshall, 1976). It is also no coincidence that outbreaks
of mass psychogenic illness typically occur in workplaces which
employees view as physically uncomfortable (Colligan and Murphy, 1979).

35



2) Individual interviews were to be conducted with the members of
these three groups to determine their awareness of, interest in,
and views on stress and stress issues within the industry. Also,
each Project Advisory Group's members nominated the participants
for a stress workshop series conducted in that city.

3) A series of six workshops was to be held over a one month
period in each of the project's site cities; the participants made
up a five-way cross section of the industry in that city
(consisting of representatives from each of the three major
production areas, from the union, and from management). The
six,three-hour workshops had dual objectives: to test an
experiential approach to educating workers about stress and how to
deal with it, and,simultaneously, to involve these participants as
researchers to help identify work-specific information about the
extent, nature, and effects of stress and the action needed to
foster both performance and satisfaction in their respective
workplaces.

4) The original project plan was to reinterview the industry
leadership about their reactions to the ideas surfaced among the
leadership as a whole, their peers, and obtained from the workshop
participants, their constituents. Actually, this step was never
taken because the available funding would not reach to this effort
and federal support for this kind of inquiry became unavailable at

that time.
Action Research Strategy

The action research model provided the strategy for simultaneously
starting both efforts, the effort to assess the stress situation and
the effort to initiate useful, planned change in that situation. The
strategy consisted of identifying key figures in the industry's "power
structure" in each city, and at the national level, and interviewing
them about their perceptions of the situation and what is required for
action. Because there was no acknowledged stress problem to start
with, it is extremely unlikely that the industry's top leadership
would have attended a meeting on the subject. But none of them
refused the request for an interview, and the interview allowed them
to informally explore the subject of stress while providing the
interviewer with clear information about what would be required to
increase their individual and collective interest.

The action research model differs significantly from other research
models which appear to rely heavily upon outside researchers who come
into a workplace setting to measure, tabulate, and report on
phenomena—-all too often without even the informed consent of the
workers being studied, let alone the active participation of the
research subjects. In this project, the ongoing participation of the

160



Table 3.2. Relationship Between HFI Scores and Chronic Back Pain.

Pain Frequency Sample Size Percent of Total
Never 69 13.3%
Rarely 181 34.9%
Sometimes 161 31.1%
Often 83 16.0%
Always 24 4.6%
TOTAL 518 100.0%

The relationship of HFI job stress scores to frequency of back pain is
presented in Table 3.2. A very strong relationship between stress and
backpain is documented. That is, employees who report higher levels
of job stress also report significantly more back pain. In fact, the
employees (N = 24) who report that they "always" experience back pain
also suffer from critically high levels of job stress (i.e., Job
Stress = 90th percentile).

Finally, the HFI was administered in 17 hospitals. Stress scores were
compared to a number of hospital loss indices. Statistically
significant results (p<.05 in all cases) showed that hospital
departments that had higher stress levels had higher rates of
turnover, employee injuries, worker's compensation claims, and risk
for medical malpractice compared to the hospital departments with
lower stress. In addition, a very strong relationship was obtained
between HFI stress scores and frequency of back pain, thus replicating
Study Four.

The results of these validity studies indicate that companies that use
the HFI to assess corporate stress can be assured that higher HFI
scores indicate a higher risk for loss due to accidents, injuries,
illnesses, medical claims, poor productivity, turnover, and acts of
negligence. Stress management training, at both the level of the
individual employee and the organization, should lead to lower rates
of stress-related accidents and losses,

Gase Study

This case study describes how the HFI was used to control losses in
the hospital industry. Approximately 1,500 employees from a
southeastern hospital anonymously completed the HFI on company time.
These employees represented over 40 hospital departments. Analyses
revealed that three clinical medicine departments (e.g., surgical
nursing, anesthesia, and pharmacy) exhibited critically high levels of
stress on the HFI Job Stress, Job Dissatisfaction, and Organizational
Stress scales. Analysis of these departments' insurance loss
statistics revealed that a number of malpractice claims ranging from

56



With the questionnaire set, the next major hurdle was its distribution
to the approximately 200 hourly employees of the hotel. At a meeting
with the organizers, we saw clearly how protective they were of the
time of both stewards and rank-and-file members. With the
negotiations looming, there would be many requests for meetings,
rallies, and votes. The organizers did not want to increase this
load. The significance of management's nonparticipation weighed
heavily at this point. Without management approval, the possibility
of group administration or any use of work time was out of the
question. We considered a mailing, but the union's poor return rates
for their own surveys through the mail ruled out that option. Also,
the union's lists of addresses and phone numbers for members was
neither up-to-date nor complete. Finally, we decided to distribute
the questionnaires at the contract proposal meetings and that each
questionnaire would have a stamped envelope attached. In this way we
could be sure that we, or a steward, had made personal contact with
anyone who received a questionnaire. If respondents did not want to
mail the questionnaire back, they could pass it on to the steward from
their department. We stapled a cover letter to each questionnaire
describing our research group and assuring confidentiality of
responses. If an employee did not attend the meetings, the shop

Stewards were to keep track and present them with a questionnaire at a
later date.

The contract proposal meetings were held in three large assemblies to
overlap with each of the three shifts. Not only did we distribute the
questionnaires, but we gained an invaluable check on the value of our
survey and of our assessment up to that point. Perhaps of greatest
interest, we could see the same union strategy first articulated to us
by the international representative now laid out for the rank-and-file
members by the junior organizer. At each of the meetings, the
organizer made a brief speech about how the hotel unions represented
an exception to the national trend of givebacks and union-busting. He
outlined the same three-pronged (corporate—community-committee)
strategy that was used in the Las Vegas hotel workers strike and by
clerical workers at Yale to win certification of their union.

Finally, he pointed out the need for active participation of the
rank-and-file members in a contract proposal committee, an organizing
committee, and a negotiating committee. With these structures in
Place, he felt certain they could obtain reasonable advances without
(though, if necessary, with) a strike.

Over the course of the three proposal meetings, the familiar triad of
wages, benefits, and working conditions was often raised, but it was
clear that the last dominated the first two (with the exception of
repeated requests for better sick day and disability provisions).
Concern about working conditions emerged in many different ways; over—
and under-staffing, misallocation of hotel resources, poor meals,
uniform costs, scheduling, arbitrary decisions by management, extreme
variation of temperature in the hotel lobby, etc. In the midst of

20



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(Ed.) Perspectives of Curriculum Evaluation, AERA Monograph Series on
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#82-1058, Cincinnati, Ohio.

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90



BOOKS

al Approach to the Manage: of Stress
H.R. Beech, L.E. Burns, and B.F. Sheffield. New York: John Wiley
& Sons, 1982, 132 pp., $29.95.

An overview of behavioral approaches for reducing tension and
anxiety. Occupational stress is discussed in a short section.

iofeedback: Clin: ications in Behavioral Medic
D.S. Olton and A.R. Noonberg. Englewood Cliffs, New Jersey:
Prentice-Hall, 1980, 437 pp., $24.95.

A scholarly exposition of principles and practices of
biofeedback beginning with a discussion of feedback
mechanisms, operant and classical conditioning, and the
biological bases of behavior. Detailed accounts of the use of
biofeedback in a variety of clinical situations are also
included.

Controlling Stress and Tension: A Holistic Approach
D. Girdano and G. Everly. New Jersey: Prentice-Hall, Inc., 1979,
242 pp., $7.95

An excellent textbook which provides a detailed analysis of
stress and its effects on the individual. Assessment
exercises allow the reader to chart a Stress Profile. Ways to
reduce stressful aspects of one's Profile are offered.

oping W: ess At Work
J. Marshall and C.L. Cooper (Eds.) Aldershot, Hunts, England:
Gower Publishing Co. Ltd. 1981, 236 pp., $35.50.

A collection of case studies from industrial settings which
describe coping with stress through worker training, health
promotion, counseling, and work environment change tactics.
The book provides perspective on stress coping from academics,
occupational health physicians, stress consultants, and health
care/human resource workers in work settings.

From Burnout to Balance
D.T. Jaffe, and C.D. Scott New York: McGraw-Hill Paperbacks,
1984, 209 pp, $8.95.

A workbook geared to improve awareness of stress and burnout
containing self-report instruments for evaluating stress
levels of stress The book lends itself to adaptation by
program staff educating and enabling employee self—evaluation.

175



Cohen, A. and Margolis, B. (1973). Initial psychological research

related to the Occupational Safety and Health Act of 1970. American
Psychologist, 28, 600-606. :
Colligan, M.J. and Murphy, L.R. (1979). Mass psychogenic illness in

organizations: An overview. Journal of Occupational Psychology, 52,
77-90.

Cooper, C.L. and Marshall, J. (1976). Occupational sources of
stress: a review of the literature relating to coronary heart disease
and mental i11 health, Journal of Occupational Psychology, 49, 11-28.

Cooper, T., Detre, T., Weiss, S.M., Bristow, J.D., Carleton, R.,
Dustan, H.P., Elliot, R.S., Feinleib, M., Jesse, M.J., Klocke, F.J.,
Schwartz, G.E., Shields, J.M., and Stallones, R.A. (1981).
Coronary-prone behavior and coronary heart disease: A critical
review. Circulation, 63, 1200-1215.

Davidson, M.J. and Cooper, C.L. (1981). A model of occupational
stress. Journal of Occupational Medicine, 23(8), 564-570.

Dembroski, T.M., MacDougall, J.M., Shields, J.L., Pettito, J. and
Lushine, R. (1978). Components of the Type A coronary-prone behavior
pattern and cardiovascular responses to psychomotor performance

challenge. Journal of Behavioral Medicine, 1, 159-176.

Dewe, P., Guest, D. and Williams, R. (1979). Methods of coping with
work-related stress. In C. MacKay and T. Cox (Eds.) Responses to
Stress; Occupational Aspects. Guilford, Surrey: IPC Science and
Technology Press, Ltd., pp. 69-84.

DHHS (1979). alt) eople, the su: ' on health
promotion and disease prevention. DHHS (PHS) Publication No.

79-55071. Washington DC: US Government Printing Office.

DHHS (1980). Promo eventing disease: Objectives for the
Nation. DHHS, PHS, Washington, DC: US Government Printing Office.

Felton, B.J., Revenson, T.A., and Hinrichsen, G.A. (1984). Stress and
coping in the explanation of psychological adjustment among

chronically ill adults. Social Science and Medicine, 18, 889-898.

Fleishman, J.A. (1984). Personality characteristics and coping
patterns. Journal of Health and Social Behavior, 25, 229-244.

Folkman, S. and Lazarus, R.S. (1980). An analysis of coping in a
middle-aged community sample. Journal of Health and Social Behavior,
21, 219-239.

42



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85


“Employee Stress Education"

A 17 minute program which teaches employees to define stress,
assess stress in their work, and better cope with stress.
Cost: Videocassette $295.00

International Human Factors Institute
Risk Management Services Division

St. Paul Insurance Companies

385 Washington Street

St. Paul, MN 55102

"Managing Stress to Prevent Worker Accidents"

A 14 minute program which teaches employees to understand and
control stress-related accidents. The stress/accident cycle is
described along with strategies for reducing stress-related
losses.

Cost: Videocassette $295.00

International Human Factors Institute
Risk Management Services Division
St. Paul Insurance Companies

385 Washington Street

St. Paul, MN 55102

“Stress Management: A Positive Strategy”

Five 30 minute color cassettes, narrated by George Coe, are
designed for managers at all levels. Consists of video
counseling by well-known experts in the stress management field,
interspersed with dramatic vignettes portraying realistic stress
situations that confront managers everywhere. Includes leader's
manual and participants’ handbooks.

Cost: 5 Videocassettes $4450
Rental $500/month
Manual & Handbook $19.00 to $29.50 ea

Time/Life Video
Box 666 Time & Life Building
New York, NY 10019

179



Analysis of WES profiles revealed that Work Group A differed from Work
Group B on a number of different dimensions. Work Group A, the low
stress staff, felt committed to their jobs, were friendly and
supportive of one another, and thought that the facility management
was supportive and helpful. Group A staff felt that there was a
strong emphasis on good planning and efficiency and little work
pressure. The Group A staff reported that they knew what to expect in
their daily routine and that rules and policies were clearly
communicated. Finally, this staff perceived a better than average
degree of autonomy and self-sufficiency in their jobs, and they
reported that their facility was above average in physical
attractiveness and convenience.

Conversely, the staff members in Work Group B perceived a
significantly different work environment as revealed by the WES. They
reported low involvement, poor communications, and a lack of peer
cohesion and supervisor support. This staff perceived an emphasis on
autonomy and self-sufficiency, yet Work Pressure scores revealed
excessive pressure to keep up with an ever-increasing workload.
Furthermore, the staff perceived their workplace as being poorly
organized and inefficient, and they were unclear about expectations,
rules, and procedures. Comparing and contrasting the WES profiles in
this case study indicates that improving the work environment of Work
Group B may be an effective first step toward improving employee
morale.

III. MASLACH BURNOUT INVENTORY (MBI)

The Maslach Burnout Inventory (MBI) measures staff "burnout," a
syndrome of emotional exhaustion and cynicism that occurs frequently
among chronically distressed "people workers" (Maslach, 1982). Hence,
the MBI is appropriate for use with police officers, counselors,
teachers, nurses, social workers, psychiatrists, psychologists,
attorneys, physicians, and agency administrators. The MBI is
thoroughly described elsewhere (e.g., Maslach and Jackson, 1981).

The MBI consists of three regular subscales and a fourth optional
subscale. The four subscales are:

1. The 9-item Emotional Exhaustion subscale (e.g., "I feel
emotionally drained from my work.");

2. The 5-item Depersonalization subscale (e.g., "I feel I treat some
recipients as if they were impersonal '‘objects'.");

3. The 8-item Personal Accomplishment subscale (e.g., "I feel I'm
positively influencing other people's lives through my work.");

4. The 3-item, optional, Personal Involvement subscale (e.g., I feel
I'm personally involved with my recipients’ problems.")

These four subscales are scored separately. They have been proven
highly reliable and have been validated against numerous criteria

61



A recent New York Times (Mirvis, 1985) article cited preliminary
results during the first year of a 5 year $4.3 million study of some
85,000 Federal employees and Hawaii residents eligible for Medicaid,
who were simply provided access to short-term psychotherapy for stress
related problems. The result was a 37% reduction in total medical
bills which saved almost $16 million in medical and health claims.

The cost of a mental health program offered by Blue Cross/Blue Shield
of Arizona to employees of some 1,200 companies in Phoenix and Tucson
was not disclosed, but the manager of the project insists that
“reduced health care claims will ‘more than make up' the costs." His
analysis of claims further suggested that half of a company's medical
expenses come from just 10% of the employees.

The American Telephone and Telegraph Company stafted its Total Life
Concept program in 1982 in anticipation of mounting stress with the
impending divestiture of the Bell Companies, offering classes on
stress control, nutrition, and exercise. The results were so
rewarding that the courses are now offered at five AT&T locations with
plans to extend it nationwide. The program manager indicated, "we
expect a $2.00 return for every $1.00 invested."

An ongoing study of some 6.7 million federal workers‘ health claims
over the past decade similarly revealed that while those seeking
mental health treatment initially had higher medical expenses, after
five years, the costs were lower than those who did not, even though
the patients were older. In fact, patients 55 years and over who
received such stress reduction assistance showed the greatest decrease
in hospital charges.

New York State now offers a new "crisis intervention visits" program
for “persons struggling with a sudden stressful situation." Insurance
provides $60 per visit for up to three visits, up to $48 for the next
ten visits, and up to $40 for the next twenty visits. The
Commissioner of the New York State Department of Civil Service
predicted that the program would "save the state $200 million in
absenteeism and medical claims over three years."

Obviously, the most effective approach would be to identify sources of
job stress and remove them wherever possible. The subject has been
explored at length in Healthy People in Unhealthy Places (Pelletier,
1984) which, as previously noted, should provide a valuable resource
for organizations interested in reducing stressful working

conditions. As indicated, job stress may also frequently result from
problems that have their origin in the worker's personality, attitude,
and goals and more frequently an incompatibility with these and the
job requirements.

Analysis and differentiation of such sources of stress can be

approached by using an inexpensive simple questionnaire offered by the
American Institute of Stress. This utilizes and correlates responses

86



which the labels or numbers are assigned to objects. In program
evaluation, measurement refers to the systematic procedures applied to
the objective quantification of needs, processes, impacts, and
outcomes.

Levels of Measurement. An understanding of levels of measurement is
necessary to determine how the various forms of measurement set limits
on the statistical procedures that can be used in the data analysis.

By convention, there are four levels of measurement: nominal, ordinal,
interval, and ratio. The nominal level is considered the lowest,
ordinal and interval intermediate, and ratio the highest. These four
levels of measurement along with their definitions, and a summary of
some of the statistical tests that can be applied at each level are
presented in Table 6.1. A number of books provide detailed
discussions of levels of measurement and their characteristics (Green
and Lewis, 1986; Siegel, 1956; Windsor et al., 1984).

From a technical perspective, it is preferable to select data
collection techniques that allow the ratio, or highest, level of
measurement to be used. This maximizes the ability to distinguish
between background noise or variance and specific treatment effects.
Higher levels also permit use of a wider range of statistical tests
and more powerful statistical procedures in the data analyses. Using
sophisticated statistical tests enhances the likelihood of detecting
Pprogram-specific effects and distinguishing them from non-program
effects.

Regardless of how creatively designed, well controlled, and smoothly
executed an evaluation design is, it is only as good as the measures
from which data are derived. Inappropriate and inadequate or "noisy"
measures will impair and can totally compromise the quality of the
most elaborate and expensive evaluation. Thus, careful attention
should be given to measurement instruments and techniques.

Reliability and Validity

Accuracy in measurement is traditionally viewed as a combination of
two separate issues, reliability and validity (Bernstein, 1976).

Reliability. As generally used, reliability refers to the extent to
which an instrument is consistent. It is important, however, to
distinguish clearly between reliability as relative freedom from error
and stability.

Reliability coefficients are affected by the variance of the scores
upon which the correlation coefficient is based, and the reliability
of an instrument typically increases with the homogeneity of scores.
However, a reliability coefficient is as much a function of the
population being assessed and the conditions under which the

123



Sources of Stress. Sources of stress and potential solutions to
stress-related problems have been identified at both the
organizational and individual levels. Sources of stress at the
organizational level can be divided broadly into categories of
Physical and psychosocial stressors.

Organizational Level. Different types of physical stressors have been
studied carefully in the laboratory and have been identified in work
settings. They have been discussed in many reviews (USDHEW, 1978a, b;
USDHHS, 1980a; Holt, 1982; Neale et al., 1983).

Holt has listed five categories of physical properties of working
environments that can be sources of stress. These are 1) physical
hazards, chronic dangers, 2) pollution, less immediate dangers, 3)
extremes of heat, cold, humidity, and pressure, etc., 4) noise, and 5)
bad man-machine design. Shift work is another physical property of
jobs that may be a source of stress for many workers.

Most of these sources of physical stress can be measured objectively,
and with a high degree of reliability and validity. In some cases,
standards exist which can be used in the regulation of the levels of
some of these stressors. However, individual tolerances vary widely,
so the performance of employees should be observed, and subjective,
self-reports of workers about the aversiveness of these factors should
be obtained. Given the initial differences in tolerances among
individuals for potential sources of physical stress, and differential
abilities to adapt, multiple sources of input must be obtained to
establish the degree of stressfulness of these physical factors.

Over the past 20 years, much progress has been made in identifying
sources of psychosocial stress in work environments. A number of
Properties of system design and job content appear related both to job
satisfaction and to health (Elliott and Eisdorfer, 1982). Those that
have been studied most carefully include the following:

0. Quantitative overload: too much to do, excessive time
pressure, or repetitious work flow in combination with
one-sided job demands and superficial attention.

o. Qualitative underload: too narrow and one-sided job content,
lack of stimulus variation, no demands on creativity or problem
solving, and low opportunities for social interaction.

o. Lack of control: especially in relation to pace of work and
working methods.

o. Lack of social support: inadequate social networks with fellow
workers and lack of support from supervisors.

126



REFERENCES

Derogatis, L.R. (1975). SCL-90-R. Baltimore: Clinical
Psychometric Research.

French, J.R.P., Rodgers, W. and Cobb, S. (1974). Adjustment as person—
environment fit. In G.V. Coelho, D.A. Hamburg and J.E. Adams (Eds.),

Coping and Adaptation. New York: Basic, 316-333.
Gordon, G.C., Stellman, J.M., and Snow, B.R. (1982). Offi St

Health and Well-Being Survey. School of Public Health, Columbia
University.

Harrison, R.V. (1978). Person-Environment fit and job stress. In C.L.
Cooper and R. Payne (Eds.) Stress at Work. London: Wiley.

Huszczo, G.E., Wiggins, J.G., and Currie, J.S. (1984). The
relationship

between psychology and organized labor: Past, present, and future.
American Psychologist, 39, 7-15.

Kahn, R.L., Wolfe, D.M., Quinn, R.P., and Snoek, J.D. (1964).
Organizational Stress: Studies in Role Conflict and Ambiguity. New
York: Wiley.

Karasek, R.A. (1979). Job demands, job decision latitude, and mental
strain: Implications for job redesign. Administrative Science
Quarterly, 24, 285-307.

Leigh, H. and Reiser, M.F. (1980). The Patient: Biological,
Psychological, and Social Dimensions of Medical Practice. New York:
Plenum.

Love, M. (1983). Communications Workers of America Local 1180 Stress
Questionnaire. CWA Local 1180, 225 Broadway, New York, New York.

Miller, J.G. (1978). Living Systems. New York: McGraw Hill.

Neale, M.S., Singer, J.A., and Schwartz, G.E., and Schwartz, J.I.
(1982). Conflicting perspectives on stress reduction in occupational
settings: A systems approach to their resolution. Report to the
National Institute for Occupational Safety and Health (NIOSH) P.O.
82-1058, Cincinnati, OH.

Neale, M.S., Singer, J.A., and Schwartz, G.E. (1987). Assessing
Occupational Stress in a Hotel During a Period of Contract
Negotiations. In A. Riley, S. Zaccaro, and R. Rosen (Eds.)
Occupational Stress d_Or; al Effectiveness. New York:
Praeger.

28



that workers were posing: What are the levels and sources of distress
in our industry? What abatement action and educational programs will
be most useful and relevant to workers from the shop floor to the
executive penthouse? What steps will increase awareness of stress
issues and encourage management and union leaders to deal with the
prevailing stress situation? What practical help can “stress
management" courses offer individuals beyond relaxation techniques and
sermons on lifestyles?

The Job Stress Project was conceived to achieve several objectives
simultaneously: to assess the stress situation in the graphic
communications industry; to identify next steps necessary to improve
the current situation; to increase the leadership's awareness of
stress issues and needed action; and, to increase the SHAPE program's
ability to support stress evaluation, planning and action. The
project received financial and intellectual support from Elliot
Liebow, then Chief of the Center for Work and Mental Health, National
Institute of Mental Health, Department of Health and Human Services.

Project Plan

The Job Stress Project was designed with the long range goal of
improving the industry's stress situation and the specific purpose of
encouraging action to that end. The basic premise of the project was
that the people responsible for action needed answers to two
questions: What is the current job stress situation in the industry
and what can be done about it? Accordingly, the planned outcomes were
to: 1) identify the stress information needs of workers, union
leaders, and managers; 2) assess and call attention to the job stress
situation in the industry as perceived by workers, union, and
management; 3) test the feasibility of labor-management cooperation in
dealing with job stress; 4) provide labor and management policymakers
with relevant options for action based on workers, union, and
management views; 5) increase the GAIU's capacity to plan and
implement activities that help people deal with both industry-specific
and general job stress situations; and, 6) increase the number of
persons actively dealing with the industry's stress situation.

The action research paradigm —- an ongoing replication of cycles of
evaluation, planning, and action -- offers a strategy for acting and
for learning; so the project was structured as action research to
simultaneously initiate improvements in the stress situation while
learning from the process how to improve future efforts.

1) To test joint participation from the outset, a Project Advisory
Group composed of the industry's labor and management leaders was
to be established in each of the two cities designated as project
sites; a third, National Advisory Group was also established in
Washington, D.C. made up of elected officers of GAIU, corporate
representatives, and PIA (Printing Industries of America)
officials.

159



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682 Prospect Avenue
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203/233-2658

Contact: Mark Wertheim

McGraw-Hill/CRM Films
110 15th Street

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714/453-5000
Contact: Tom Allred

PBS Video

475 L'Enfant Plaza, SW

Washington, DC 20024

202/488-5220 (Washington metropolitan area)
800/424-7963 (outside Washington, DC)

Pyramid Film and Video

Box 1048

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213/828-7577 (California)
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Contact: Teresa Morrissey

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182



Systems theory (von Bertalanffy, 1968; Miller, 1978) posits a
hierarchical organization of biological, psychological, and social
systems, or levels, each possessing unique resources, demands, and
constraints. These systems are interrelated such that disharmony or
change at one level of the hierarchy almost inevitably influences
behavior at other levels. With respect to the work setting, the most
obvious interaction takes place between an individual and the
organization. In the literature on stress, French, Rogers, and Cobb
(1974), Kahn, Wolfe, Quinn, and Snoek (1964), and Harrison (1978) have
described this interaction as an issue of "person-environment fit."
However, a systems orientation would also include other levels at
which the fit of demands and resources might be out of balance (i.e.,
a specific work group and its physical setting, management policies
and the entire organization, the organization and its relationship to
other organizations in its particular industry, etc.). A systems
assessment concerns itself with individual perceptions of strain, but

also looks at pressures and changes in work groups and organizations
over time.

In this view, exclusively corporate or labor definitions of
occupational stress place a narrow focus on selected levels of the
systems hierarchy. The corporate stress reduction effort might be
successful at helping the employee to exercise but, if it does nothing
about toxic fumes in the physical environment, it may make little
difference. Similarly, a union representative who wins a reduction of
overtime hours for an employee and then stands by while he or she uses
the new free time to increase his/her drinking, also does a partial
job.

To promote comprehensive and collaborative assessments of occupational
stress by corporations and unions, we proposed a systems-driven
assessment device, the Occupational Stress Evaluation Grid (OSEG) (see
Table 1.1). The OSEG is a seven-by-three matrix that orders stressors
and responses to stressors in a hierarchy going from physical
dimensions to sociocultural levels of analysis. It enables us to plot
the types of stressors operating at each level of the system, as
perceived by those involved, and the impact of various stress
reducers. Additionally, by separating interventions into formal and
informal categories, the OSEG allows us to gauge the amount of
personal and organizational control inherent in each of these
potential adaptive reactions.

The remainder of this chapter describes our first attempt to test the
practical utility of the OSEG as an assessment instrument in a work
setting. While we had hoped that our assessment would serve as a
starting point for labor-management collaboration in battling stress
across each level of the OSEG's hierarchy, our initial effort was
limited by pending contract negotiations and the inevitable
constraints of field research. Due to management's refusal to
participate in our project and our decision to pursue an assessment



An Evaluation Han Education Programs ess
Management:

I0X Assessment Associates of Los Angeles, California, through a
contract with the Centers for Disease Control in Atlanta, has
produced a series of seven Evaluation Handbooks for Health
Education Programs. One handbook deals specifically with the
topic of Stress.

This handbook has a brief introductory section on basic
considerations in health education program evaluation. It also
provides examples of a large number of both standardized and
non-standardized, self-report type questionnaires in the
Appendix. Data collection instruments appropriate both for
children and adults are provided. The wide range of measurement
instruments introduced and described in this handbook should be
useful to all educators and others who place a major emphasis on
cognitive and affective changes in their stress management
Programs.

Limitations. The manual does not provide examples of behavioral
and physiological/biochemical measures. Another limitation of the
manual is that information on the reliability and validity of many
of the questionnaires had not yet been obtained when it was
published.

All of the uation Handbooks for lucation Programs are
available from the National Technical Information Service. The
order number for the Handbook on Stress Management is PB 84-171735
Al8, and the price is $31.00.

Correspondence regarding this publication should be addressed to:
National Technical Information Service

U.S. Department of Commerce
Springfield, VA 22161

141



these workshops, participants are urged to believe that they are the
sole creators of any stress they experience and that they have the
power and capacity to control or eliminate "their stress".

Certainly, some stress is “internally generated", a function of the
individual's values and emotional dynamics, or it is the immediate
consequence of that person's voluntary behavior. And, we know that
some effective psychotherapies put great emphasis on the acceptance of
self-responsibility as a requisite for individual change. But, I
believe that this position is blaming the victim, often inaccurately
and usually dysfunctionally. Responsibility for stress is more
complex a matter, "You cause your stress" is, at best, only a partial
truth that leaves out important aspects of the issue, and there is
real harm to people as a result.

The assertion that "people cause their own stress" ignores, for
example, the body of research demonstrating that workers with little
control over job demands will have greater stress than those with more
control over events. And, that assertion obscures distinctions
between the kinds of stressors that can be controlled by the
individual and those that lie well beyond the control of the specific
individual or the range of individual capacities to mediate stress
effects. My concern is not about theoretical inaccuracy; the
strategies for dealing with stressors beyond individual control can be
quite different from what works with stressors that are controllable.
The participants in our programs need accurate, balanced statements
from us, especially about the interactions of individual perceptions
with external reality.

Consider, for example, the cases of an autoworker who loses her job in
a plant closing, a manager who is fired when his company is purchased
by another, or an executive whose subordinate commits suicide. These
people are experiencing major stressors, yet, in these cases, say,
they are not essentially responsible for causing their situations. We
know that it is virtually certain that they will experience feelings
of guilt, and we know they must begin to understand the limits of
their own responsibility before they can accurately assess and
effectively deal with their respective situations. What is the effect
of telling these three that all stress they experience is their

fault? Any workshop that ignores the reality of external power may
well be undermining its participants' efforts to develop realistic
coping and change skills.

Blaming the victim for the problem is often unfair; blaming the stress

victim is also often highly counterproductive in securing needed
changes.

150



eliminate the stressor, not to adjust to it. The strategy for making
required changes then provides both a defining context and necessary
elements for coping and, when needed, for increasing coping skills.
If we limit “stress programs" to what can be called “health
promotion", we may omit important issues about stress and create
problems for practitioners as well as participants.

Consider, for example, stress due to racial/sexual discrimination in
employment. The range of "remedies", depending on a myriad of
factors, might involve elements of private and public protest,
self-help, governmental assistance, and legal action. These
activities paradoxically can provide the individual with more support
and additional resources while increasing the need for personal help
and greater resources. Moreover, such activities provide a context
for the individual's life, defining the ends and values of adjustment,
the goals and means for coping.

The practitioner who tries to teach internal coping when external
change is required may be judged by others to be expressing a position
of hostility and/or opposition to needed changes. Specifically, the
consultant hired by management to conduct a stress workshop may well
be viewed as anti-worker and/or anti~labor if he or she presents
stress as originating in the individual solely without reference to
working conditions, rules and th equality of supervision; the
Practitioner's actual motives and attitudes will be moot.

How Do W W: ess As A Workplace 2

Stress practitioners recognize that stress is not simply about
psychological concerns, that the stress response integrates mind, body
and behavior. Then many of us attempt to use stress programs in the
workplace as though we were conducting value-free efforts that should
be welcomed by everyone. But stress is a contentious issue,
especially in the workplace. Should not stress programs intended for
workplace use recognize and be designed to deal with essential issues,
such as safety and health and the quality of management for example?

Stress creates safety and health hazards. National policy expressed
in federal law requires employers to provide a safe and healthy
workplace. Both employers and employees have specified rights and
responsibilities that are supposed to be enforced by the Occupational
Safety and Health Administration and the courts. In recent years, in
a growing list of states, the courts have awarded settlements and/or
worker's compensation to employees for the effects of stress on the
job and knowledgable observers expect such litigation to grow
rapidly. Similarly, further research can be expected to more directly
link specific supervisory practices with needless stress and certain
work rules with unnecessarily decreasing worker control, thereby
increasing stress. So, actionable stressors may occur in working

156



Karasek, R.A., Schwartz, J., and Theorell, T. (1982). Job
Character tion, and Coro’ a: sease, Final Report
on contract No. R-01-0H00906. Cincinnati, Ohio: NIOSH.

Kobasa, S.C., Maddi, S.R., Puccetti, M.C. and Zola, M.C. (1985).
Effectiveness of hardiness, exercise and social support as resources
against illness. Journal of Psychosomatic Research, 29(5), 525-533.

Kobasa, S.C., Maddi, S.R., and Puccetti, M.C. (1982). Personality and
exercise as buffers in the stress-illness relationship. Journal of
Behavioral Medicine, 5(4), 391-404.

Kobasa, S.C., Maddi, S.R., Courington, S. (1981). Personality and
constitution as mediators in the stress-illness relationship. Journal
of Health and Social Behavior, 22, 368-378.

Krause, N. and Stryker, S. (1984). Stress and well-being: The
buffering role of locus of control beliefs. Social Science and
Medicine, 18, 783-790.

Lazarus, R.S. and Folkman, S. (1984). Stress appraisal and coping.
New York: Springer Publishing Company.

Lovallo, W.R. and Pishkin, V.A. (1980). Psychophysiological
comparison of Type A and B men exposed to failure and uncontrollable
noise. Psychophysiology, 17(1), 29-36.

Mason, J.W. (1975). A historical view of the stress field: Part I.
Journal of Human Stress, 1, 6-12.

Margolis, B., Kroes, W.H. and Quinn, R.P. (1974). Job stress: An

unlisted occupational hazard. Journal of Occupational Medicine, 16,
659-661.

Murphy, L.R. (1984). Occupational stress management: A review and
appraisal. Journal of Occupational Psychology, 57, 1-15.

NCCI (1984). National Council on Compensation Insurance Media Release
(May 7, 1984) Deerfield Beach Florida.

NCCI (1985). Emotional Stress in the Workplace-New Legal Rights in
the Eighties. Deerfield Beach, Florida: National Council on
Compensation Insurance.

Neale, M.S., Singer, J.A., Schwartz, G.E. and Schwartz, J. (1982).
Conflicting perspectives on stress reduction in occupational

settings: A systems approach to their resolution. Report to NIOSH on
P.O. 82-1058, Cincinnati, Ohio.

44



CHAPTER 1

THE NUIS AND BOLTS OF ASSESSING OCCUPATIONAL STRESS:
A COLLABORATIVE EFFORT WITH LABOR

Jefferson A. Singer, Michael S. Neale, and Gary E. Schwartz

A few years back we conducted an extensive mail and telephone survey
of occupational stress reduction programs for non-managerial employees
(Neale, Singer, Schwartz and Schwartz, 1982; Singer, Neale, Schwartz,
and Schwartz, 1986). In the process we learned that corporate and
labor definitions of occupational stress were widely divergent.
Stress, according to our corporate respondents, was primarily a
question of maladaptive personal lifestyles and poor
“person-environment fits." Alternatively, labor representatives
portrayed stress as the product of organizational conditions that
promoted loss of control, work overload, or underload.

In practice, these definitions often led management and labor to take
quite separate paths in stress reduction programs. The corporate
approach placed responsibility for managing stress on the individual,
who was encouraged to relax, exercise, diet, and modify "Type A"
behavioral patterns. Virtually all of these corporate stress
management programs were linked to medical departments or to
organization-wide health promotion campaigns, reflecting additional
corporate priorities to reduce health care costs and to improve
productivity. Labor's response to stress emphasized strong health and
safety contract language and active health and safety committees to
enforce written agreements, Any effort, including organizing,
grievance procedures, or employee involvement, that effectively
increased the worker's control and autonomy at the shopfloor or office
level was considered a stress reduction strategy.

In our summary of these findings, we emphasized that the term "stress"
had become part of a political rhetoric that allowed each camp, labor
or management, to choose a meaning which was friendly to its cause.

We highlighted some maverick companies and unions that had crossed
“enemy lines" to develop stress reduction programs that included both
personal and organizational approaches within the same intervention.
Finally, we proposed a systems perspective, drawn from our research
and clinical work in biofeedback and psychophysiology (Schwartz,
1982a, 1982b), as a potential integration of these diverse definitions
of stress.

We gratefully acknowledge the support of the officers, staff and
members of the Hotel Employees and Restaurant Employees Union (Local
217), specifically John Wilhelm, Henry Tamasin, and Rob Traber, whose
assistance made this assessment possible.



and self-esteem) are what people draw upon in developing coping
strategies. Research has shown that these resources vary by sex,
educational level, and income:such that men appear to have more
psychological resources than women and use them to develop more
effective coping responses. In the same way, the better educated and
the more affluent possess more resources and a wider range of coping
alternatives (Pearlin and Schooler, 1978).

What is more important, aside from what people actually do to cope
with stress, is the relative effectiveness of coping responses.
Pearlin and Schooler (1978) considered a coping response effective if
it buffered the relationship between stressors and strains. The
authors concluded that no single coping response was strikingly
protective across life and work areas, but that having a larger and
more varied coping repertoire was effective in reducing
stressor/strain relationships. In this regard, the effectiveness of
problem-focused vs. emotion-focused coping for buffering ill-health
seemed to be a function of the controllability of the stressor, coping
of any type being relatively ineffective in situations beyond the
individual's control (Caplan, Naidu, and Tripathi, 1984; Felton,
Revenson, and Hinrichsen, 1984; Fleishman, 1984; Krause and Stryker,
1984).

Particularly important in the present context was Pearlin and
Schooler's finding that while various coping responses were effective
in the areas of marriage, child-rearing, and household finances,
coping was strikingly ineffective when applied to occupational
problems. The authors suggested that the resistance of occupation to
coping may be due to the impersonal nature of work and the lack of
worker control over stressors.

Evidence from other recent studies suggests that some coping behaviors
which workers use actually increase distress. Parasuraman and Cleek
(1984) identified adaptive and maladaptive coping responses used in
work settings. They found that adaptive coping responses (planning,
organizing, and prioritizing assignments, enlisting the support of
others) had no buffering effects on felt-stress or job satisfaction
but were associated with elevated trait anxiety. Maladaptive coping
(working harder, making unrealistic promises, avoiding supervision)
contributed to felt stress and job organizational tenure, indicating
that experience on the job did not necessarily lead to better stress
coping skills (Dewe, Guest, and Williams, 1982).

It is clear from the foregoing that the coping responses which workers
use may increase, decrease, or have no effect on stressor/health
relationships. Those which increase or decrease stress reactions need
to be factored into job stress assessment instruments to increase
ecological validity and "fine tune" descriptions of stressor/health
relationships. Coping behaviors which have no buffering effect
provide insights into the types of stress reduction strategies which
are likely to be successful.

38



Relevance, however, is a highly subjective factor and depends on the
views of major shareholders or stakeholders in the program. The issue
of the relevance of measures has been analyzed in terms of the
different needs and priorities of administrators, researchers and
clinical perspective (Green et al., 1980).

Often, there are several identifiable groups, sometimes with
conflicting views, who have an interest in program design and
outcomes. In the case of stress management programs, management,
labor unions, clinical practitioners, and researchers or evaluators,
all have different interests and sets of priorities. Therefore, what
is relevant to one group may be much less relevant to another.
Failure to consider the relevance of measures for different groups
affected by a program can seriously compromise the program outcomes
and usefulness of the evaluation results.

Thus, in addition to the scrutiny of program objectives, it is
sometimes important for evaluators to distance themselves from the
major assumptions of the program sponsors and to analyze the
theoretical or conceptual framework and the particular biases that
guided the program development. A critical analysis of the
theoretical framework, and political-economic rationale for a program
can suggest additional variables that may not have been specified in
the objectives. These may be highly relevant when considered in a
broader social and ethical framework.

Feasibility. Feasibility refers to the practical issues of making
measurements and obtaining data. Some of the basic factors that
affect feasibility are access to the data, technical expertise
(ability to make measures), cost of making the measurements
(equipment, personnel and timecosts to company and employees), and
ability to track participants over time. All these factors need to be
given some consideration in selecting measures. Feasibility should
not, however, be equated with appropriateness of measurement.
Unfortunately, in many stress management programs, measures have been
chosen primarily because they are inexpensive and easy to use.

Changes in these variables may have very little clinical, economic, or
scientific significance.

Technical Features

In addition to the previously discussed general criteria, there also
are several technical features of measurement techniques that should
be considered. Three important criteria are level of measurement,
reliability, and validity.

Measurement, by definition, is the assignment of labels or numbers to
objects, events, or persons according to specified rules.
Measurements require first, specification of the objects to be
measured, second, the labels or numbers to use, and third the rules by

122



promised to produce for us a. list of 12 names of rank-and-file
employees who could familiarize us with the workings and the
particular stressors of each department. The most experienced
steward, the head bellman, also indicated he would explain our project
to the absent stewards and obtain the necessary names from them.

At this point we began to understand a warning the senior organizer
had given to us about our assessment. He cautioned us that it would
be easy for our assessment to become an evaluation of life in "the
front of the house” of the hotel, meaning the bellmen, front desk
clerks, waitresses, and bartenders. These individuals were usually
the more articulate and often college—educated employees of the

hotel. For our assessment to be valid and helpful to him, we needed
to reach the “back of the house” in equal numbers (housekeepers,
housemen, dishwashers, laundry workers, busboys). His point raises a
larger issue in any assessment of a work organization. Each workplace
has a subculture with its own class system and norms. If an
assessment fails to account for this culture in the construction of
its instruments, the result will most likely be skewed and

inaccurate. We faced this problem with Spanish-speaking employees, as
will be described later on.

As we waited for the stewards to produce a list of names, we realized
that our assessment faced a long road ahead. The steward structure
was by no means as organized as we had hoped (nor, you can bet, as the
organizer had hoped). Practically, this meant that every step in our
assessment strategy would take more time and effort on our part than
we had anticipated. Additionally, it left the organizer little time
to work with us in designing or implementing our project.

The Interview Process

With a list of employees finally in hand, we began the interview
Process (following along on Table 1.2, we were now up to Step 4). Our
goal here was to perform a diagnostic occupational history, using our
12 union representatives to convey the general conditions of their
particular departments (Step 5). In the first portion of the
interview we recorded their previous work experience and the types of
jobs they had performed at the hotel. We then asked each interviewee
to take us step-by-step through a typical day and a particularly
stressful day in their department. Their accounts were strikingly
detailed and vivid; one laundry worker even drew a picture of the
laundry room and narrow corridors to convey how much difficulty she
had with her linen carts. A front desk clerk described how her
responsibility for paperwork and finances (shift sheet, mail logs,
events of the day, bank vault, outlet checks) conflicted with her
interactions with guests at the counter. A pastry chef's assistant
discussed the monotony and effort involved in rolling dough and
spreading jam daily for 1000 turnovers.

16

ce



First Contact with the Paid Staff of the Hotel Union

To follow up our first meeting, we arranged a meeting with the two
organizers for the three downtown hotels. The object of this meeting
was to present our project to them and, if they were interested, to
confirm that we would do an assessment of the hotel named by the
international representative at our prior meeting. We ended up
meeting only with the senior organizer since the other organizer, who
was directly responsible for servicing the hotel in question, was
involved in a member's grievance hearing. His absence foreshadowed
just how tightly his time would be scheduled during our assessment
efforts. The senior organizer re-emphasized much of what we had
previously heard about the corporate style of management at the hotel
and the excesses of past managers. He made it clearer that the
organizing campaign for the contract would not be centrally focused on
wages, but rather on working conditions. The employees would present
their demands in the context of "dignity and justice on the job."
What they wanted most was respect from the new managers and
recognition of their professionalism.

The senior organizer also offered us a first glimpse of specific
stressors we might want to investigate at the hotel. Besides the
difficulty with management, he felt we might look for evidence of
short-staffing, abrupt schedule changes, and lack of information about
policy changes. At the response level, he pointed out that hotel
employees tended toward alcohol and substance abuse (partly due to the
subculture of parties and extravagance that a hotel breeds). While he
presented the hotel employees as basically a good union membership, he
mentioned it would help him if he could learn more about what the
union members saw as positive benefits to being in the union. This

knowledge could be extended to organizing drives for non-union hotel
employees.

Since he seemed willing to let us do the assessment, we raised the
issue of soliciting management's collaboration. Without much
hesitation he agreed to this, but for reasons we had not expected. He
was so convinced that management would refuse our request that he saw
their refusal as an organizing opportunity. He could promote the
union as willing to aid health professionals in helping the
membership, while the hotel management didn't seem to care. When
questioned about what he would do if they did agree, he replied that
conditions were so stressful at the hotel that the management would
still be forced to make concessions. If they didn't change conditions
once the stressors had been identified, they would look even worse
than if they hadn't participated in the assessment; which is why, he
pointed out, they would never accept our offer in the first place ——
they had no interest in making changes that might upset their
standardization.

11



PREFACE

Since the mid-1970s, a growing number of studies have evaluated the
merits of prescriptive, relaxation-based stress control methods as
applied in work settings. Collectively labeled stress management,
methods like muscle relaxation, meditation, biofeedback, and cognitive
strategies have been taught to workers as a means of reducing
psychophysiological and subjective distress. Such strategies have
focused exclusively on providing the individual worker with skills for
recognizing and coping with stress in a health promotion context.
Accordingly, stress management is usually offered to healthy,
asymptomatic workers as a preventive measure. Workers exhibiting
acute stress reactions or organizations where apparent stress problems
exist have not been the usual targets for stress management.

The purpose of this publication is to summarize scientific evidence
and to review conceptual and practical issues relating to worksite
stress management. It is a collection of original contributions that
address current issues and problems in the field. The chapters aim to
provide a context within which stress management programs can be
developed, implemented, evaluated, and maintained in work settings.
As such, it seeks to offer guidance, not guidelines.

The intended audience of this publication is best described by their
classification into "user" groups: (1) those who ultimately make the
decision to offer employees a stress reduction program (or rather to
take some action with respect to employee stress, be it a program or
not), (2) those who have responsibility for deciding what type of
action will be taken, its' scope, essential ingredients, and operating
characteristics, and (3) those who actually implement the action,
whether in-house personnel or an outside individual or group. Each of
these "user" groups will find information in this publication relevant
to their respective needs.

The document is divided into three parts. Part I contains three
chapters that deal with organizational stress and its assessment.
Part II contains four chapters that describe aspects of stress
management as applied in work settings. Part III is a collection of
resources for training materials, products, and equipment.

Two themes that run throughout this publication should be acknowledged
here. First and foremost is that stress management, as currently
defined, has a limited role in reducing organizational stress because
no effort is made to remove or reduce sources of stress at work.
Focusing on the individual as the prime target for organizational
intervention creates a dilemma of "blaming the victim." A more
appropriate application of stress management would be as a complement
to job redesign or organizational change interventions.

vil



Limiting Conditions. Often the access to medical records and
insurance claims forms is limited; the benefits of health programs
cannot be defined easily in concrete terms; and even when outcomes can
be clearly defined and measured, and usually it is difficult to place
dollar amounts on them. In the case of stress, the epidemiologic
evidence linking specific sources of stress to particular long-term
effects or outcomes is not very strong. The best case has been made
for its association with elevated blood pressure. While there is
evidence that stress management programs can have short-term impacts
on blood-pressure and other physiologic variables, there are few
long-term data. Thus, their effect on morbidity and mortality is not
known.

Another complication is that ethical problems may arise in the use of
cost-benefit analyses. For example, when employee preferences are
weighted heavily in the calculation of value, more persons may be
willing to pay for and/or use personal time to attend weight loss
classes rather than to participate in smoking cessation and alcohol
treatment programs. This presents a problem in decision making
because the likelihood of success and potential payoffs of the latter
are greater. Also, when earnings are used to calculate the indirect
costs of absenteeism and lower productivity related to symptoms of
stress, those with the highest incomes such as top management and
Professionals will be assigned a higher value than clerical and blue
collar workers. Typically, most stress management programs have been
offered first to management and possibly later to clerical and blue
collar workers, Thus, cost-benefit or pay-off projections already
have been operating in decisions about allocation of resources.

Given the number of limitations in conducting cost-benefit analyses of
most health promotion programs, it has been suggested that
cost-effectiveness analyses may be more appropriate for most of these
programs at their current stage of development and cost-benefit
analysis should be limited to valuation of immediate outcomes (Green
and Lewis, 1986).

Gost Effectiveness. In contrast to cost-benefit analysis,
cost-effectiveness analysis does not require that program impacts or
outcomes be reduced to monetary terms. Instead, the respective costs
of a number of alternative strategies or programs for achieving a
desired end are compared. Therefore, cost-effectiveness analysis
generally is an easier approach to use in health promotion program
evaluation. Its main limitation is that it does not allow the
comparison of programs with different outcomes.

There are four basic steps in most cost-effectiveness analyses: 1)

definition of program objectives; 2) computation of the program's net
monetary costs; 3) definition of program outcomes; and 4) conduct of a
sensitivity analysis. As this process has been discussed in detail by

134



social or economic problems in the specific employee population or
firm. Another method consists of making comparisons between rates of
problem indicators in different work populations.

Comparative data from sources such as the National Center for Health
Statistics, the National Institute for Occupational Safety and Health,
other agencies of the Department of Health and Human Services, local
and state health departments, and other planning agencies are useful
in documenting a particular worksite problem. Also, social indicators
for particular occupations and communities can be used (Attkisson et
al., 1978; Sheldon and Parke, 1975). Soliciting employee views
through small group techniques like the Nominal Group Technique
(Delbecq, et al., 1971) and the Delphi Technique (Dalkey and Helmer,
1969) also may be helpful.

The use of direct archival data from company records or files provides
another source of information. Data on attendance, rates of accidents
and injuries, and use of mental and physical health services are
useful in establishing program needs. Data from records on use of
services, however, must be used cautiously as a basis for an
epidemiological diagnosis. Often strong biases exist in the use of
services by subgroups of employees and in the reporting of service use
(Attkisson et al., 1978). When used alone for epidemiological
diagnosis, this information could seriously distort the needs
assessment. Use of services does provide a good measure of behaviors
associated with health problems, however, and therefore contributes to
the behavioral diagnosis.

Key informant surveys can be used to collect information from
employees known to have knowledge about problems and needed services.
This method can provide valuable insights on both behavior and the
next step following behavioral diagnosis—-the educational diagnosis.
This method provides a more balanced perspective when views are
obtained from sectors of the company likely to have contrasting views,
such as management and labor (Neale et al., 1983; Martin, 1983).

After establishing the presence of specific behavioral problems, the
next major step of a needs assessment is to determine the interest and
willingness of employees in the target population to use certain
services or to participate in particular programs. This is often
accomplished through surveys of employees’ prior experiences, current
attitudes, and future intentions. As was the case for identifying
behavioral problems, techniques such as employee sample surveys, key
informant surveys, and the Nominal Group Technique can be useful in
determining the interest of employees in specific services or
programs. There is no simple formula or ideal way to carry out needs
assessments. Perhaps, the best overall strategy for conducting a
needs assessment is to use multiple sources for data collection and
the method of triangulation to reach final conclusions (Attkisson et
al., 1978; Campbell and Fiske, 1959).

112



CHAPTER 4
DESIGNING WORKSITE STRESS MANAGEMENT PROGRAMS
Paul J. Rosch and Kenneth R. Pelletier
Increased interest in stress management training programs delivered
in the workplace has accelerated because of:
o Recognition that job stress represents a significant and growing
health problem as well as a mounting major expense for American

industry.

° Increasing understanding of the mechanisms of actions that link
stress with various illness syndromes and somatic complaints.

° Improved methodologies for identifying and evaluating stress in
the workplace.

° Improved implementation and validation of various stress
reduction techniques.

o

Evidence that stress management training programs are not only
cost effective for corporations but also increase employee
satisfaction and relationships with management, and improve
quality of life in the workplace.

Health care costs in 1984 consumed almost 11% of the gross national
product (American Medical News, 1985). Heart disease, cancer,
strokes, and accidents are major contributors and are increasingly
being linked to stressful lifestyles and behaviors or inappropriate
coping responses to stress. Job stress has been estimated to cost
American industry $150 billion dollars annually as assessed by
absenteeism, diminished productivity, compensation claims, health
insurance and direct medical expenses (Manuso, 1984). Put into
perspective, that's more than 15 times the price tag for all strikes
combined. Over 500 million work days are lost each year due to
illness or disability, 93 million because of back problems, and 26
million are attributed to cardiovascular complaints associated with
coronary heart disease and hypertension. The Metropolitan Life
Insurance Company in 1984 indicated that an average of one million
workers are absent on any given work day largely due to stress
related disorders. Some estimates suggest that up to 25% of payroll
expenses may be health related. The Xerox Corporation estimates
that it costs approximately one to one and a half million dollars to
replace a top executive and $200,000-$500,000 for senior managers at
lower echelons (Rosch, 1984a). In addition to the major illness
categories cited, a variety of other stress related behaviors also
take their toll. Alcoholic employees and smokers exhibit twice as
much absenteeism. A recent American Association of Family
Physicians' study of six occupational groups confirmed that job

69



this clamor of dissatisfaction, the organizer skillfully returned each
group's attention back to the management's lack of respect for and
obvious underestimation of the union's strength.

At the beginning of each meeting, one of our investigators made a
short speech to explain the survey, urging the audience to fill it out
and mail it to the union. The organizer and one of our interviewees
also spoke briefly in favor of the project. In all, we handed out 100
questionnaires in the course of that day and another 150 through shop
stewards' efforts in the weeks following the contract proposal
meetings.

Listening to the organizer train the stewards and rank-and-file
members in the same program we had heard described by the
international representative and the senior organizer, we realized our
assessment had taken on a purpose different from, but not incongruent
with, our original goal. We were about to provide the union with
quantifiable feedback about the effectiveness of their organizing. In
other words, if the organizer's committee structure and message took
hold, the dominant stressor identified by our respondents should be
the employees' relationship with management. According to the hotel
OSEG (Table 1.3), our assessment should locate the greatest stress at
the work setting/interpersonal level and, above that, at the
organizational level (see Table 1.3 column 2, for specifics of these
levels).

Before any analyses could be performed, we had the imposing task of
retrieving a respectable number of questionnaires. Management's
non-involvement had hindered distribution of surveys, but the effect
was much worse for survey collection. In the beginning, we were
completely dependent on the overextended organizer and shop stewards
to prod and remind members to complete and return questionnaires.
Shop stewards varied greatly in their commitment to the distribution
and collection of questionnaires. When a shop steward failed to pass
out our surveys or gave them out without explanation or follow-up, we
could be set back for several days or weeks. Finally, another steward
would carry the ball for the less helpful one and we would begin to
see returns. Sometimes, the nature of the department itself
influenced the number of respondents. Educational background,
language differences, amount of satisfaction in a department, and
relationships with superiors all influenced the rate of response in a
given work group.

Here is where the senior organizer's warning about the “back of the
house" and the "front of the house" was particularly salient. The
front desk department responded most enthusiastically, due most likely
to their higher educational level and to the head bellman's
effectiveness as a steward. Also, their returns indicated they
perceived themselves as extremely stressed due to high demands,
understaffing, and lack of supervision. The other "up front"

21



McLeroy, K.R., Green, L.W., Mullen, P.D., and Foshee, V. (1984).
Assessing the effects of health promotion in worksites: A review of
stress program evaluations. Health Education Quarterly, 11, 379-401.

Mager, R.F. (1962). Preparing Educational Objectives. Palo Alto, CA:
Fearon.
Manuso, J. (1983). Occupatio: Psychology. New York:

Praeger Press.

Manuso, J. (1984). Management of individual stressors. In
M.O'Donnell, and T. Ainsworth (Eds.). Health Promotion in the
Workplace. New York: John Wiley and Sons.

Martin, E.V. (1983). Describing Usefulness of Labor-Management
ive to Designing Job-Stress Reduc: si

the Graphic Arts/Communications Industry. (NIOSH Order No. 82-1966).

Cincinnati: National Institute for Occupational Safety and Health.

Masi, D.A., and Teems, L. (1983). Employee Counseling Services
Evaluation System: Design, issues and conclusions. Evaluation and
Program Planning, 6, 1-6.

Mirvis, P.H., and Seashore, S.E. (1979). Being ethical in
organizational research. American Psychologist, 34, 766-780.

Murphy, L.R. (1984). Occupational stress management: A review and
appraisal. Journal of Occupational Psychology, 57, 1-15.

Neale, M.S., Singer, J.A., Schwartz, G.E., and Schwartz, J. (1983).
Cor e S on Stress Reduction in 0 1

A ‘stems A ach to the . Cincinnati:
National Institute for Occupational Safety and Health.

Nutt, P.C. (1981). Evaluation Concepts and Methods: Shaping Policy
for the Health Administrator. New York: SP Medical and Scientific
Books.

Parkinson, R.S., Green, L.W., McGill, A., Erikson, M., and Ware, B

et al. (1982). Managing Health Promotion in the Workplace:
Guidelines for Implementation and Evaluation. Palo Alto: Mayfield
Publishing Company.

”

Pickering, T.G., Harshfield, G.A., Kleinert, H.D., and Laragh, J.
(1982). Ambulatory monitoring in the evaluation of blood pressure in
patients with borderline hypertension and the role of the defense

reflex. Clinical and Experimental Hypertension, 4, 675-693.

145



aspects of stress not often studied in the workplace. Second, we
could make an effort to redress the imbalance in psychological
services provided to unions, as compared to corporations. An alliance
between a union and psychologists on the issue of occupational stress
might offer a small step in building better faith between the two
groups (see Huszczo et al., 1984). These two opportunities convinced
us of the desirability of collaboration with a union and the need to
follow through on that collaboration, regardless of management's
decision to work with us or not. In other words, if we could get a
union to agree to work with us on an assessment of stress we would
perform the assessment, even if it did not fit our ideal plans for how
the OSEG should be implemented.

Our one stipulation was that we would not work with a union unwilling
to collaborate with management in the assessment. Joint
collaboration, we felt, would provide us with access to all employees,
credibility with both salaried and hourly staff, and a better overview
of the setting. While a collaborative effort might raise concerns
among respondents about potential uses of our assessment findings, we
felt that the potential for setting-wide feedback and multilevel
interventions far outweighed these issues. We also realized that such
a collaboration would be difficult to accomplish in most settings,
given the traditional adversarial relationship of labor and
Management. Any union we contacted would have to play down their side
of this antagonism for the collaborative assessment to work. By the
same token, management would need to take a role equal to the union in
both the assessment and dissemination of results.

The above explanation is important since it dictated what our point of
entry would be (with whom we would first meet) and what our ultimate
goals were (not just to test the OSEG, but to build better ties
between psychologists and labor). With this agenda laid out, we
considered settings that would fit our OSEG framework and that
possessed unionized work forces. Hospitals, schools, and hotels all
seemed like appropriate choices due to their relatively self-contained
nature and variety of occupational and organizational levels. With
aid from some community contacts, we settled upon the hotel industry
and set up an appointment with an international representative of a
large hotel workers' union.

First Contact with the Union

In a meeting to prepare for our initial discussion with union
representatives, we outlined what we wanted to accomplish and what we
felt we had to offer to the union. From our perspective, we wanted to
show that stress was not a unitary concept with clear cut effects. By
dividing the hotel into levels of the OSEG, we hoped to demonstrate
that stressors at different levels of the grid would produce discrete
patterns of stress and well-being. If this hypothesis were confirmed,
it would present a strong case against generic stress management



Cook, T.D., and Campbell, D.T. (1979). Quasi-experimentation: Design
and Analysis Issues for Field Settings. Skokie, IL: Rand McNally.

Dalkey, N.C. and Helmer, 0. (1969). The Delphi Method: An
Experimental Study of Group opinion. Santa Monica, CA: Rand

Corporation.

Delbecq, A.L., and Van de Ven, A.H. (1971). A group process model for
problem identification and program planning. Journal of Applied
Behavioral Science, 7, 466-492.

Derogatis, L.R. (1975). e_$' tom Che —| SCL-90-R
Baltimore: Clinical Psychometrics Research.

Edwards, W., Guttentag, M., and Snapper, K. (1975). A decision
theoretic approach to evaluation research. In E. Struening and M.

Guttentag (Eds.). Handbook of Evaluation Research, Vol. 1. (pp.
139-182). Beverly Hills, CA: Sage Publications.

Elliott, G.R., and Eisdorfer, C. (1982). Stress and Health. New
York: Springer.

Evaluation Research Society. (1980). Standards for Program
Evaluation. Washington, DC: Evaluation Research Society.

French, J.F., and Kaufman, N.J. (1983). Handbook for Prevention

Evaluation: Prevention Evaluation Guidelines. (DHHS Publication No.
ADM 83-1145). Washington, DC: U.S. Government Printing Office.

French, J.F. (1979). Randomized response: A method for increasing
the privacy of individual responses to surveys. Current Trends in
Drug Research, I. Rockville, MD: National Institute on Drug Abuse.

Fox, J.A., and Tracy, P.E. (1980). The randomized response approach
and its applicability to criminal justice research and evaluation.
Evaluation Review.

Gilberts, R. (1983). The evaluation of self-esteem. Family and
Community Health, 6(2), 29-49.

Green, L.W. (1974). Towards cost-benefit evaluations of health

education. Health Education Monographs, 1, (Suppl.), 34-36.

Green, L.W., Kreuter, M.D., Deeds, S., and Partridge, K.B. (1980).

Health Education Planning: A Diagnostic Approach. Palo Alto, CA:
Mayfield Publishing Co.

Green, L.W., and Lewis, F.M. (1986). Measurement and Evaluation in

Health Education and Health Promotion. Palo Alto, CA: Mayfield
Publishing Company.

143



Government Printing Office
Superintendent of Documents
Washington, DC 20402

All federal government publications can be ordered from this
source.

Guidance Associates
Communications Park, Box 3000
Mount Kisco, NY 10549
914/666-4100 (New York)

Provides catalog and videocassettes.

Health and Risk Evaluation Program
Loma Linda University, School of Health
Loma Linda, CA 92350

714/824-4594

Provides brochure and conducts programs.

International Human Factors Institute
St. Paul Insurance Companies

385 Washington Street

St. Paul, Minnesota 55102
612/221-8107

Offers a number of corporate stress management programs
designed to reduce stress-related losses (e.g., accidents,
illnesses). Also conducts job stress assessments and provides
feedback to organizations regarding ways to reduce
stress-related losses.

International Institute of Stress
2900 Boul. Edouard Montpetit
Montreal, Canada H3C 3J7
514/343-6379

Provides brochure, quarterly journal, and conducts programs.

187



assessment. A jointly-sponsored project would allow us to look at
employees' lifestyles and health habits. We could also have access to
more employees, including supervisors and upper management. In this
way, we could avoid the more polemical aspects (falling into a good
guy - bad guy mind-set) that are inevitable when one works for only
one side of a dispute.

The political flavor of our assessment and our role as assessors needs
further thought and discussion. Working with shop stewards and union
organizers, our analysis of the conditions at the hotel was, without
question, biased. Still, the actual questionnaire data offered a more
independent test of our initial biases. One could argue that only
ardent union supporters answered the questionnaire, but an examination
of open-ended responses left us fairly confident that the sample was a
fair cross-section of opinion at the hotel. A more probing question
might be whether we should have allowed ourselves to become part of a
conscious strategy to organize the union work force. We believe there
are three arguments in favor of our decision to do so. First, we saw
our role for the union as functionally equivalent to that of a stress
consultant for management. The stress consultant, who asks questions
about diet and exercise and offers training in relaxation, promulgates
a certain "management" conception of what stress is and how it should
be treated. In the same vein, we asked questions about job
characteristics, organizational policies, and working conditions.
These questions encouraged employees to conceive of organizational
stressors that they might not have considered previously. The fact
that our approach seems unorthodox and politically-slanted may be more
a statement about the lack of labor-oriented stress consultants than
an indictment of our method.

Second, unions have agendas just as corporations do. No manager would
hire a stress consultant who did not promise to improve the
productivity and lower the health costs of employees. Similarly, a
stress consultant for labor must offer a tangible service that will
add to organizing efforts by unions during membership drives or
contract negotiations. The bottom line for the union is how this
project will help or hinder the advantage the union seeks in
solidarity or negotiation.

Third, our project with the union allowed us to look at an area that
is extremely under-researched in psychology - namely, strikes and
their impact on employees and settings. We were able to trace an
organizing campaign from its inception nine months before contract
negotiations to the actual day of the strike deadline. Our
conversations with organizers and shop stewards permitted us a more
subtle understanding of the attributions employees make about working
conditions and stressors during a period of contract negotiations.

26



contribution; using small taskgroups as a basic design element;
incorporating consensual decision procedures and allowing adequate
time to use them; explaining the rationale for each and every activity
as part of giving the group directions; and respecting participants’
needs that lie outside the workshop; to name but a few. My experience
is that actions like these are rarely commented on by participants but
that their cumulative effect is profound and can set the stage for
dramatic and effective learning.

SERVICE DELIVERY

Ethical Marketing Requires Client Education

Most people are used to educational programs which identify the
correct answers and best ways to proceed. Many of our prospective
clients believe that competent professionals will have a "cure" for
stress, I take it as my responsibility to determine whether this is
the case and I believe I am protecting my own interests when I clarify
with the client what can and cannot be done at the level of effort
being considered.

In addition to overestimating what can be achieved, some clients may
want a stress (coping skills) workshop as a way to deal with what I
would consider an organizational or personnel issue or as an attempt
to circumvent the collective bargaining process. Sometimes the
solution the client wants to buy doesn't match my view of the

problem. Again, I actively seek to clarify these issues because I
cannot afford to be identified as a provider of ultimately ineffective
services, And, as a person seeking to reduce human distress, I am
unwilling to act in any way that impairs the collective bargaining
Process. In my experience, it is usually necessary for the
practitioner to take the initiative to clarify the outcomes the client
seeks, say, by sponsoring a workshop and what other expectations the
client may have about the content or approach to be taken. Depending
on the complexity of these expectations, I have found that I may need
to gather data about the situation which will be fed back to the
prospective client, The process of contracting to provide stress
services to or through an organization may need to be an educational
or planning intervention in its own right.

e Client-Driv: ategies

I have felt the considerable impatience of some workshop participants
and organizational policy makers with our inability to "cure" stress;
I understand the pressure that exists to exercise professional
responsibility by using our expertise to diagnose problems and to use
client-driven strategies.

169



National Mental Health Association
1800 North Kent Street

Arlington, VA 22209

703/528-6405

Provides catalog, self=instruction packets, and special
publications dealing with mental health topics.

Office of Disease Prevention and Health Promotion
Worksite Health Promotion Initiative

Department of Health and Human Services

Public Health Service

Mary E. Switzer Building, Room 2132

330 C Street SW

Washington, DC 20201

202/472-5370

Provides information about health promotion activities in work
and nonwork settings and coordinates all federal activities in
this area. A list of publications is available free of charge.

President's Council on Physical Fitness & Sports
Room 7103, Judiciary Plaza

450 Fifth Street, SW

Washington, DC 20001

Provides information and catalogue of publications.

Sagamore Institute

National Humanistic Education Center
110 Spring Street

Saratoga Springs, NY 12866
518/587-8770

Offers referrals to other programs, conducts workshops,
provides brochure, catalog, and speakers bureau.

Stress Control, Inc.
P.O. Box 592
Hillsboro, OR 97123
503/642-4433

Provides brochure and newsletter at no cost.

189



DEVELOPING READINESS FOR STRESS MANAGEMENT TRAINING

Assess position of top management

Areas of concern clearly identified

Coordinate with relevant departments (medical, HRD, etc.)
Identify what the progrém is meant to accomplish
Identify needed training resources

Anticipate and address criticisms

Develop means of assessing impact

Identify target population

Determine course content and focus

Select program title with desired effect

Check out the instructors

eoo0o0o00 00000

OVERCOMING RESISTANCE TO STRESS MANAGEMENT PROGRAMS

o Gather data on cost effectiveness

o Cultivate a clear understanding that the stress
response is a natural biological response, not a
characterological weakness or an indicator of
poor mental health

o Establish that stress management training is for
prevention, and that it is neither treatment nor a
form of therapy

o Demonstrate that it is a lot more than a single
technique (such as relaxation)

In a similar vein, McCauley and Bellingham (1984) have developed a
list of pitfalls to avoid in their health promotion work at the New
York Telephone Company.

COMMON ERRORS TO AVOID

© FRAGMENTATION: unrelated and unintegrated programs
o ACTIVITIES: creating diverse activities without articulating
desired results
o ILLNESS FOCUS: a successful program will focus on establishing
and maintaining well-being
o LACK OF INVOLVEMENT: the more people involved in some way with
program development and conduct, the more excitement and
enthusiasm
UNAPPLIED KNOWLEDGE: facts don't change behavior; teachable
skills are the tools for success
INDIVIDUAL FOCUS: if the organization's culture is not
addressed, impact is limited
EMPHASIS ON START UP: a successful program must be based on a
long term view

°

°

°

99



REFERENCES

Alderman, M.H. (1984). Worksite treatment of hypertension. In J.D.
Matarazzo, S.M. Weiss, J.A. Herd, N.E. Miller, and S.M. Weiss (Eds.).

Behavioral Health: A Handbook of Health Enhancement and Disease
Prevention. New York: John Wiley and Sons.

Ahlbom, A., Karasek, R., and Theorell, T. (1977). Psychosocial
occupational demands and risk for cardiovascular death. (Swedish)
Lakantidningen, 77, 4243-4245.

Alcohol, Drug Abuse, and Mental Health Administration. (1975). The

ADAMHA Guide for the Protection of Human Subjects (Rev. ed.).
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American Psychological Association. (1973), Ethical Principles in the
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Psychological Association.

Attkisson, C.C., Hargreaves, W.A., and Horowitz, M.J. (Eds.) (1978).
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Baker, D.B. (1985). The study of stress at work. Annual Review of
Public Health, 6, 367-381.

Bernstein, I.N. (1976). Validity Issues in Evaluative Research.
Beverly Hills, CA: Sage Publications.

Bertera, R.L. and Cuthie, J.C. (1984). Blood pressure self-monitoring
in the workplace. Journal of Occupational Medicine, 26, 183-188.

Breslow, L. et al. (1985). s) or Update Project: Final
Report. Atlanta: U.S. Department of Health and Human Services,
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Campbell, D.T., and Fiske, D.W. (1959). Convergent and discriminant
validation by the multitrait-multimethod matrix. Psychological
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Chen, M.S. (1984). Proving the effects of health promotion in

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1Q, 235-245.

Cincirpini, P.M., Hook, J.D., Mendes de Leon, C.F., and Pritchard,

W.S. (1984). A Review of Cardiovascular, Electromyographic,
Electrodermal, and Respiratory Measures of Psychological Stress.
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Occupational Safety and Health.

142



Rosch, P.J. (1984b). The health effects of job stress, Business and
Health, May 1984, pp. 5-8.

Rosenman, R.H., Friedman, M., Straus, R., Wurm, M., et al. (1964). A
predictive study of coronary heart disease. The Western Collaborative

Group Study, Journal of the American Medical Association, 189, 15-22.

Rosenman, R.H., Friedman, M., Straus, R., Jenkins, C.D., et al.
(1970). Coronary heart disease in Western Collaborative Group Study:
A follow-up experience of 41/2 years, Journal of Chronic Diseases,

23, 173-190.

Rosenman R.H. (1978). The interview method of assessment of the
coronary-prone behavior pattern, in Coronary-Prone Behavior (T.E.
Dembroski, S.M. Weiss, J.L. Shields, S.G. Haynes Eds.), New York:
Springer-Verlag, pp. 55-69.

San Francisco Examiner (1981). January 9, Section B, p. S.

Staats, T.E. (1982). The Stress Vector Analysis. MEDICOMP, INC.,
1805 Line Avenue, Shreveport, LA 71101.

Stessin, L. (1977). When an employer insists, New York Times,
April 3, p. 9.

Stroebel C.F. (1982). The Quieting Reflex. New York: G. P. Putnam.

Wilbur, C.S. (1981). Director, Live for Life Program, Johnson &
Johnson, Personal correspondence.

91



programs that apply the same set of interventions to any group of
employees without a systematic assessment of their actual stressors.
Since unions were not sponsors of these “fix-all" programs in the
first place, we knew our interest in this question would not be a
selling point to entice the hotel union's involvement.

Our second major goal was to bridge the gap between labor and
management definitions of stress through a collaborative stress
assessment. With labor and management involved, both lifestyle and
organizational aspects of stress would be covered. Since much of any
union's organizing is accomplished through an adversarial relationship
with management, collaboration did not promise to be much of an
enticement either (we later saw the union take creative advantage of
our interest in collaboration). A third goal, to produce a case study
of stress assessment for this manual, might give the union some free
publicity, but we were so vague about who would see the manual that we
could not make this possibility sound very compelling.

There was, of course, another much more practical goal, and this one
offered common ground. We could quantify for the union complaints of
poor conditions, overwork, or arbitrary supervision. At the same
time, our interviews and surveys would serve an educational purpose;
individuals would be asked to think about problems or conflicts at
work that they might have previously left unnoticed or reluctantly
accepted. In the name of the union (and potentially of management as
well), we might raise employee consciousness about what they deserve
or should expect from bosses, fellow employees, and themselves at work
(and we would do this all for free). While it might not be helpful to
raise employees' awareness of stressors without offering alternatives
to reduce them, we felt comfortable that the union structure could
turn our findings into a vehicle for organizational change. Moreover,
our very presence would provide concrete evidence to union members of
the union's interest in their welfare. Even if we could tell the
union leadership nothing new about their workplace, we could function
as an effective organizing tool in the union's effort to solidify its
ranks. Acknowledging our potential to become a political vehicle for
the union, we reasoned this might be our best offer, especially since
our other selling points might not be immediately attractive.

At the start of our meeting, the hotel union representative made it
clear that health and safety issues were not a major bargaining
concern in an era where unions face take-backs and work force
reductions. No major time or labor could be diverted from organizing
efforts around wages, benefits, and job security in order to help us
with our stress project. He underscored this point with a story about
a previous research group that had done a stress questionnaire with
his union. After investing many hours of shop stewards' time, the
union had never heard a word about the results. They had felt used
and were naturally a bit wary of any new project.



physiology, anatomy, nutrition, endocrinology, systems theory,
sociology, and so on. The trainer needs to be able to communicate the
interrelationships of very complex information in language which is
easily understood by the participants. Further, the trainer must know
the currently acceptable tenets in each of these diverse fields, in
order to debunk the plethora of media-mythologies and fads. And
finally, if external trainers are used, there need to be some direct
forms of internal staff involvement created to handle the likely needs
for follow ups arising from the training.

The creation of a comprehensive stress management training program may
necessitate the coordination of several different expert resources, if
a single person with the broad range of knowledge and skills required
is not available. There may also be personnel in the organization who
have developed specialized expertise in certain relevant areas who
might often be overlooked (e.g., a secretary who has learned an
extensive amount about nutrition and would like to share her ideas).
It is essential that the lead trainers be role models for the client
population. One of the fastest ways to kill a stress management
training program is to have it taught by someone who obviously is a
poor stress manager! One is never "finished" in his or her
development of stress management skills, but in order to have
credibility, one must be seriously "in process" and be able to be
articulate about what s/he is doing about his or her own stress.

Yet another factor in establishing and maintaining support for the
program has to do with effective overall planning. Griffen, et al.
(1982) have outlined a useful progression of planning steps, suggested
means for assessing the systems readiness for stress management
training, and outlined a strategy for working with resistance to the
program. Their suggestions are presented in the following lists:

STEPS IN PLANNING A STRESS MANAGEMENT PROGRAM

Assess and measure each employee's stress level

Assess present adaptive and maladaptive coping strategies
Determine the major stressors in the workplace

Explain what stress is

Explain the personal health implications

Identify individuals’ symptoms of excessive stress
Identify personal causes of stress

Describe various stress management strategies

Develop personalized action plans

e©oo0o0g 000

(For more details on the planning points listed above, see Adams,
1981, Adams, et. al., 1983, and Adams, et. al., 1984).

98



Takin' Charge

St. Paul-Ramsey Medical Center
640 Jackson Street

St. Paul, MN 55101
612/221-3479

Provides brochure, newsletter, and conducts programs.

YMCA and YWCA
Contact your local branch

Offer information and programs on stress management and other
health promotion topics.

190



then see that the powers that be in the system do not respond to their
suggestions, any attempts to do follow up "booster sessions" will most
likely result only in a great deal of cynicism.

ON-GOING PROGRAM MAINTENANCE
Evaluation

One of the most frequently overlooked aspects of most training which
is conducted in the United States today is evaluation. Most programs
do have some sort of satisfaction measure taken at the conclusion of
the training which is of the "did the dogs like the dog food?"
variety. Course evaluations of this sort have some usefulness to the
training staff relative to specific techniques or design features
used, but after several programs, most trainers see the same pluses
and minuses over and over again and are more likely to rationalize the
reasons for the minuses and generally ignore the results of the
evaluation.

Of greater importance to the overall success of a comprehensive stress
management training program is a form of evaluation which is seldom
undertaken by training departments -- an evaluation of the actual
impact of the training on the lives of the participants. For example,
after six months, how many have sustained significant changes in their
life styles? How many have lowered their blood pressure or lost
weight or stopped smoking or continued to practice the relaxation
habits they have learned. Have absenteeism and turnover been
reduced? Has morale increased? More difficult to get at and even
more important to measure is the degree to which the person has
altered her/his attitudes and expectations about stress and her/his
ability to respond effectively. Impact measures such as these need to
be tied to the original objectives of the course and need to be
measured prior to the training to provide some basis for comparison at
some point after the training.

Over the course of the program, as several courses have been offered
and the impact evaluations begin to accumulate, those responsible for
the stress management training will note patterns in the long term
responses to their program, which they can consider in redesigning and
continually refining the program. While it is nice to get "high
marks" on course reaction forms, the true test of the effectiveness of
stress management training can only be measured in terms of how people
are thinking and acting differently a significant period of time after
the course has ended.

Context of Other Programs

A major segment of the stress management repertoire that is taught in
a comprehensive program introduces the notion of behavioral and
interpersonal skills as being necessary to make effective responses in

103



against which to compare both previous and future program efforts.
The rates of problem indicators can be plotted against program inputs
over time and be presented as time-series graphs or frequency polygons.

Inventory Approach. Source data cannot be collected continuously. An
evaluator must collect data at specific intervals and compile them at
specific points in time--at least at the beginning and end of the
program. Target dates for interim assessments can be set, expected
outcome levels must be identified, and observations made or sample
surveys performed. For some type of programs, the critical
measurement points have been standardized (e.g., smoking cessation at
11/2, 3, 6, and 12 months). These intervals also would be applicable
to most stress management programs.

Comparative Approach. The standard of comparison can be the results
of programs completed in other settings. It is therefore necessary
that the evaluator identify similar programs carried out in other
settings and then borrow or buy the standardized instruments for
collecting data. Comparative evaluations between companies also can
be done if standardized methods and procedures are adopted. Thus, use
of standardized procedures allows comparisons both of results obtained
in other settings and with future results in the same company. Data
from a particular program also can be compared with national data.
Again, such normative comparisons are greatly facilitated if
standardized instruments are used for data collection whenever
possible.

Controlled Comparison _ rime: ach. When the
evaluator identifies a population for comparison that is similar to
the target population but is not receiving a stress management
program, the quasi-experimental design is applied. The historical or
inventory method is then applied both to the target population and to
the comparison population, which are then periodically compared. This
approach reduces some of the threats to internal validity that weaken
the two prior designs.

Controlled Experimental Approach. This approach is comparable to the
clinical trial in medical research. The evaluator establishes a
formal procedure for randomly selecting the persons within the study
population who will participate in the experimental stress management
program and those who will not, a control group. Use of this approach
requires a situation in which it is possible to deny the program to
some individuals. The evaluator collects identical data at similar
intervals in both the experimental and control groups and tracks their
progress over time.

Full-blown Evaluative Research Project. This approach is not feasible
for most worksite based stress management programs. In this design
the strategies from the controlled experimental approach are applied

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yet their focus is on employee satisfaction, not organizational
stress. Still other instruments, like the ones developed by the
Institute for Social Research at the University of Michigan (Caplan,
Cobb, French, Van Harrison, and Pinneau, 1975) and used in many
studies of occupational stress, do not lend themselves to use by those
unfamiliar with psychometric theory.

The purpose of this chapter was to describe a few key stress
inventories that are valid and have a history of successful business
applications, Readers must be warned that accurately assessing
employees’ stress reactions and organizational stressors is the first
step in controlling stress-related losses. The critical step is the
implementation of a comprehensive work site stress management program
to control or actually prevent stress-related losses. Such a program
should teach management how to correct organizational stressors, and
employees how to improve their stress coping skills.

64



skin and lung have assisted us in understanding the role of emotions
in dermatologic, allergic, chronic pulmonary obstructive disease and
asthma. Further understanding of the nature of stressful stimuli that
can provoke such responses increasingly implicates work-related
problems as a potent factor.

Of particular interest has been recent research linking stressful
working conditions with an increased incidence of coronary heart
disease in certain occupational groups (Karasek, et al., 1981).
Common denominators in such situations appear to be lack of control,
increased responsibility without commensurate authority, and inability
to express emotions in the workplace (Karasek, 1979). Many
occupations that fall into this category primarily involve females.
More and more women also are subjected to further stress because of
increasing migration into a male dominated work force that does not
fulfill the promise of the Equal Rights amendment or the women's
liberation movement. This appears to be of particular importance
since certain subsets of working females seem to be exhibiting more
and more male Type A coronary prone behavior and a concomitant
substantial increase in heart attacks or are in occupations that have
high demand and low control. (Haynes and Lacroix, 1985). One recent
study at Stanford University indicated that four times as many women
MBAs than male controls seek psychological counselling and have more
frequent functional stress related complaints (San Francisco Examiner,
1985).

Conversely, it appears likely that "positive" stressful stimuli and
emotions confer health enhancement benefits. The availability of
strong social support networks, pride of accomplishment, a sense of
being in control, enjoying what you are doing, being able to get
things "off your chest" all seem to fall into this category (Kobasa
and Maddi, 1979). Such observations also have relevance for job
stress reduction program goals.

Even if we were to agree that stress and particularly stress at work
can cause significant illness, is it possible to develop techniques to
identify or quantify it to enable us to predict and hopefully prevent
such harmful consequences? While current methodologies are admittedly
crude, the answer would appear to be a resounding yes. Perhaps the
most well known and popular stress appraisal instrument is the
Holmes-Rahe Social Readjustment Rating Scale (Holmes and Rahe, 1967).
This technique which has undergone several modifications, rates some
43 life change events in order of magnitude ranging from loss of a
spouse at the top with a value of 100 to getting a traffic ticket at
the bottom with a score of 11. By merely totalling the score of items
experienced in the preceding 6 to 12 months, it is possible to predict
with some accuracy the likelihood of future illness and to some extent
its severity. As indicated previously, identification and measurement
of stressful Type A coronary prone behavior has also been found to be
significantly predictive for the subsequent development of heart

71



10.

11.

12.

13.

14,

15.

16.

17.

TABLE 1.2 OVERALL ASSESSMENT AND RESEARCH STRATEGY

Contact labor and management representatives for potential collaboration.
Define work units and organizational structure. Outline demographics.

Identify representatives within work units for interview.

- Develop work history interview format. Select relevant survey items.

Interview work unit representatives about work experiences. Administer
trial survey.

Feedback of results to work unit representatives for verification.
Finalize stressor survey based on interview data and representative input.
Contact employees and survey organization about work-related stressors.

Feedback of results to the entire organization.

Devise a stress response survey specific to work units and to identified
stressors.

. Survey work units about responses to work-related stressors.

Feedback of results to work units.
Compile stressor-response results and formulate profile of organization.

Identify stressful event for organization, using management and labor
assistance.

Survey work units about stressors and responses related to stressful
event, again using instruments specific to work units and identified
stressors.

Feedback of results to work units and organization.

Devise interventions at work group level to deal with stressful events,
based on survey responses.

Identify another stressful event for organization, this time implementing
intervention strategy.

Survey work units about response to stressful event and effectiveness of
intervention strategy.

Feedback of results to work units and organization.
Compare stressors-responses to both stressful events.

Attempt to establish this research-intervention strategy as an ongoing
organization process, with individuals trained to implement it.

13



develop a plan that would be both realistic and comfortable for him or
her to implement; sector-groups met to help each other, but no one was
asked to modify his or her plans to fit with others’.

In the following two weeks, participants carried out their data
collection plans. Some had opted to interview coworkers, others to
observe. Some chose to openly collect and record data about critical
incidents, interviewee comments, personal observations, and the like;
others chose to collect and record their findings unobtrusively. Some
developed specific questions, topics for lunch table discussion, or
checklists of issues; others prepared for a more informal process.

Workshop III was again a three hour session, held on a Friday night,
and devoted entirely to participants' reports of their experiences,
the data they had collected and the conclusions about stress
conditions they had drawn. The purpose was to develop a detailed
assessment of the stress situation in the industry as reflected by the
worksites they had sampled.

Workshop IV occupied the better part of the next day, and was devoted
to strategies for dealing with stress. “Samplers” were presented to
simulate the ways that the popular coping techniques are taught, from
relaxation exercises to assertiveness training. Strategies for
interpersonal change and for "external" change (in
environmental/institutional conditions) were introduced in addition to
the usual, self change strategies; the discussion topics included
brief reviews of contract provisions that affect stress conditions and
some techniques for social change. The purpose of this workshop was
to introduce participants to the wide spectrum of approaches to
eliminating stressors, reducing effects, or recovering from strain.

In the following 10 to 12 days, participants were asked to consider
the applicability of these approaches and to look for opportunities
that would test their utility on the job or at home. Of course,
participants had only been introduced to a sampling of tools, so the
question posed to them was not "Which of these tools will work in your
situation?" but rather, “Which do you think merit a further look,
possibly a try?"

Workshop V was another three-hour, weeknight session focussed on
participants' observations about strategies/tools for dealing with
stress and their possible relevance to the workplace and to workers'
lives. The purpose of this workshop was to assess which approaches to
stress seemed relevant for the industry, which seemed inappropriate,
and what more might be useful.

Workshop VI concluded the workshop series the following evening with a

three hour discussion of the participants’ conclusions about stress
conditions in the industry and their recommendations for its

163



TECHNOLOGIES, RESOURCES AND STRATEGIC QUESTIONS

Once the above points have been taken into consideration, there are
still a number of more specific points which need to be included in
the development of the stress management training program.

PREWORK: Some form of prework, such as having participants complete
some stress level assessments and/or a health risk appraisal can be a
very valuable component of the program. In addition to saving time in
the program itself, participants are stimulated to begin thinking
about their experiences of stress as a result of responding to such
diagnostic questionnaires.

BALANCE: There needs to be a balance established in the training
among lecture, reading, activities, instrumentation, and audio-visual
presentations. While trainers vary in their preferences, an overload
of any of these design possibilities will diminish the impact of the
program, as will the total absence of any of them.

PRACTICING WHAT YOU PREACH: If one is going to lead a training group
in yoga exercises, one should first be a regular yoga practitioner.
If one is going to teach meditation techniques, one should be a
regular meditator. And so on.

SELF-DIRECTED PACKAGES: There are a great many self guided or self
directed stress management packages in the marketplace and, in
general, that is where they should remain. The only usefulness they
have is to supplement group training activities. When these packages
are made available in lieu of training, they are generally not used
well and are a waste of money.

NUTRITION: Many stress management training programs overlook the
importance of nutrition. Healthful meals and breaks can easily be
provided in most instances. Material needs to be made available
explicating the interactions of blood sugar, fats, salt, fiber, water
soluble vitamins and stress.

LOCATION: Off-site locations are preferable whenever feasible.
Programs conducted on site have a great deal more difficulty holding
the participants’ attention. Many participants' experiences of the
training become fragmented by coffee break visits to the office and
the "inevitable" emergencies which arise.

COMPOSITION: The initial groups generally must be heterogeneous, but
succeeding groups should be made up of teams whenever possible. This
allows for the resolution of stressful shared bad habits such as poor
communications, sweeping disagreements under the rug, providing only
negative performance feedback, and so on.

100



their awareness of solutions to these stressors. We took some comfort
that the union leaders were using their organizing campaign to address
practical solutions to many of the concerns raised by our interviewees.

The interviews were conducted in the union hall and lasted 2-3 hours.
Though we paid $10 per interview, we had a difficult time pinning down
the 12 representatives to meet with us. Much of this difficulty had
to do with the odd scheduling shifts that are part of hotel work.

Some of their reluctance and spotty attendance might also be
attributed to the awkwardness of the task or to unfamiliarity with the
union office.

Union members' unfamiliarity with the location of the union office
could be interpreted in two ways. Either the union's shop steward
structure was so effective, rank-and-file members had no cause to go
the office, or the union's organization was not as firmly entrenched
as we had thought. In a sense, both possibilities were true; it
simply depended on the effectiveness of each department's shop
steward. Still, the union office was housed in the third floor of a
dentist's office on a leafy, almost suburban street two miles from the
hotel. The primary reason was the cost of downtown rents, but we came
to feel the extent of its inconvenience for members was costly as well.

The Stress Survey

With the interviews completed, we generated a new OSEG tailored to
stressors present at the hotel (See Table 1.3, columns 1 and 2).
Based on the organization of the new OSEG, we produced a stress survey
specifically for the hotel (Step 6). This effort provided our first
output to the union members. We went back to the shop stewards and
asked them to read and fill out the survey. We wanted to know if we
had listened well and picked up on the main concerns faced by
employees in the hotel. Their feedback helped us to clarify wording
once more and to shorten the questionnaire even further. The head
bellman proved to be extremely helpful again in making sure all the
Stewards completed the pilot survey and returned it to us.

The final questionnaire covered the organizational, work setting
(interpersonal, job characteristics, and physical environment), and
individual (psychological and biological) levels of the OSEG. Among
the work setting items, we embedded 20 of Karasek's (1979) questions
concerning the level of demands and control attached to a particular
job. For our psychological and physical items, we used a list of
emotions in a typical day at work and a list of physical symptoms from
the Symptom Checklist 90 (Derogatis, 1975). As mentioned earlier, we
added an additional page of questions (color-coded by department) that
focused on stressors specific to each department of the hotel. We
hoped these questions would help differentiate patterns of stressors
unique to work groups across the hotel. The questionnaire ran 10
pages and took between 15 to 30 minutes to complete.

18



Employees continually confront various pressures or "stressors." They
experience stress if unable to effectively cope with such stressors as
poor management, lack of job security, work overload, unclear
communications, excessive deadline pressure, unrealistic expectations,
insufficient pay, and uncertainty about job duties and
responsibilities. a

BREAKING THE DISTRESS CYCLE

The major goal of work site stress management programs is to help
companies interrupt what is called the distress cycle. Diagram A
illustrates how this damaging cycle evolves. Research by the St. Paul
Insurance Company has shown that there are two basic approaches to
breaking the distress cycle. One is to identify and to modify the
stressors. The other is to increase an employee's ability to cope
with stress. Both methods can be used individually or in combination.

For example, organizational stressors can be identified and
corrected. Consider one production unit with a very high stress
level, a high number of accidents, and low productivity. Results of
an organizational stress survey showed that poorly defined job
responsibilities caused stress in the unit members. After each
person's job was analyzed and defined, production increased and
accidents were reduced, The stress survey also revealed other
stressors which needed controlling, including poor communications,
undefined pay raise systems, and employee drug abuse (Jones, 1985).

The second way to break the distress cycle -- increasing the ability
to cope -- consists of the more commonly known stress management
techniques. These include physical fitness programs, relaxation
techniques, assertiveness training, biofeedback, weight loss, drug
and/or alcohol rehabilitation, and periodic physical examinations.
These techniques are not intended to alter stressors, but to increase
an individual's ability to cope with stressors in his/her environment.

THE ASSESSMENT OF ORGANIZATIONAL STRESS

To better control stress-related losses in industry, companies must
periodically use organizational stress surveys which assess: (1)
Employees' physical, mental, and emotional reactions to a stressful
work environment; (2) the corporate stressors which cause stressful,
pressured work environments; and (3) the corporate, and employee,
coping skills and resources that can serve as "stress buffers."

Research at The St. Paul Insurance Company (Burdick and Jones, 1985)
indicates that companies are more likely to implement work site stress
management programs once they learn, through an organizational stress
assessment, that their employees are indeed experiencing exceptionally
high levels of occupational stress. Ideally, the stress assessment

49



5. Elicit the support and endorsement of top management
6. Focus on attitudinal adjustments, modifications of behavior,
skills to be acquired.

The absence of clear goals, or desired results, is probably the most
frequent cause of low impact stress training. The above criteria
should provide the program initiator with sufficient guidance to
undertake a highly successful program.

One should note at this point that the second criterion is that goals
should be measurable. This is essential to the establishment of an
effective evaluation process. In fact, if the evaluation of the
impact of the program is to be useful, it must be designed at this
point, prior to the conduct of the program.

Once the goals are clear, they can be broken down into specific
program objectives. The format for establishing goal related

objectives advanced by Loughary and Hopson (1979), outlined below, is
a very useful one.

GOALS OBJECTIVES
KNOWLEDGE SKILLS ATTITUDES
Review present Understand Able to identify It's necessary
responses to framework for own warning for me to take
stress stress mgt. warning signals responsibility
of excessive for my own
stress well being
ETC. EITC. EITC. ETC.

Acquiring System Support

If one can negotiate the key goals of the program with top management,
and then identify the specific objectives associated with each, the
design and development of the program usually fall nicely into place.
When this goal/objective setting step is rushed or overlooked, the
design and development phases generally take much longer and the
resulting program is generally lacking in focus.

As has been stated, top level support is crucial for a stress
Management program to have lasting impact on the participants and on
the organization. With this support, feedback loops can be created by
means of which the "system" can respond to ideas and issues which
emerge during the course of the training.

96



CHAPTER 2
AN OVERVIEW OF ORGANIZATIONAL STRESS AND HEALTH

Joseph J. Hurrell, Jr.

Americans in increasing numbers are claiming that stress in the
workplace has caused them some form of disability. A recent study by
the National Council on Compensation Insurance (NCCI, 1984) indicated
that claims involving mental disorders caused by stress accounted for
nearly 11% of all occupational claims between 1980 and 1982.
Moreover, claims in which stress causes a physical disability are now
recognized in all compensation jurisdictions except Ohio (NCCI,
1985). Despite this increased recognition by the legal, medical and
insurance communities, stress for many (even those in the scientific

community) is a complex and nebulous construct implying numerous
events and processes.

Occupational stress as a field of inquiry examining job conditions and
their health and performance consequences is a relatively new research
domain crystallizing in the early 1970's. Its conceptual roots,
however, can be traced to the early animal research of Hans Selye
(1936) and Walter Cannon's (1929) work on the physiological
concomitants of emotion. In the early 1930's Selye (1936) discovered
that a wide variety of noxious stimuli (which he later referred to as
stressors), such as exposure to temperature extremes, physical injury,
and injection of toxic substances evoked an identical pattern of
physiological changes in his laboratory animals. In each case, the
cortex of the adrenal gland became enlarged, the thymus and other
lymphatic structures became involuted and deep bleeding ulcers
developed in the stomach and intestines. These effects were
"non-specific" in that they occurred regardless of the nature of the
insult and were superimposed upon any specific effects associated with
the individual agents, Some years later, Selye (1946) described this
somatic response as the General Adaptation Syndrome (GAS) and defined
stress as the non-specific response of the body to any demand made
upon it. His mention of “nervous stimuli" among the "stressor" agents
capable of eliciting the GAS had an energizing effect on those working
in the field of psychosomatic medicine.

Cannon (1914, 1929) had earlier laid the scientific groundwork for an
understanding of how various emotional states affect physiological
functions and disease states by describing the “fight or flight"
response. This response, evoked by potentially dangerous situations,
included elevated heart rate and blood pressure, a redistribution of
blood flow to the brain and major muscle groups and away from distal
body parts, and a decrease in vegetative functions. Perhaps equally
important, Cannon (1932, 1935) pioneered the concept of physiological
homeostasis and developed the use of an engineering concept of stress
and strain in a physiological context. In particular, Cannon (1935)
proposed the notion of critical stress levels which were capable of

31



For me, helpful stress programs are based on some intrinsic values
such as: people can change and grow, learning from their own
experience; people can identify their own interests and needs; people
can learn to work together to satisfy mutual needs; and the like.
When workers organize in mutual efforts to deal with critical issues
in their lives, they are taking important steps to improve their
stress situation because they are simultaneously increasing their
personal support systems and affirming values that support self-care.
These steps support both personal and social change.

Look Into The Action Research Approach

The action research or action learning approach appears to me to be a
first candidate to consider in designing stress programs, This
approach provides a structured way to work collaboratively with
clients in tailor-fitting the project to the specific needs and
realities of the audiences involved, while supporting the application
and assessment of models for problem solving. It organizes the
collection and progressive application of data about the situation and
efforts to change. And, it integrates action steps and research
components in mutually supportive roles.

The most frequently used formal structure for planning and managing
projects calls for a sequence of milestones for preplanned tasks. By
contrast, an action-research project consists of three stages that are
repeated until project objectives are achieved; task requirements are
re(identified) as the project proceeds. The three stages are
assessment, preparation, and action.

Initially, the project starts with an assessment of current state:
what is the current situation, who is involved, what resources are
available, what would the optimal, changed situation look like, which
options for "next-step" action appear indicated, what likely
consequences can now be identified,...? The assessment phase can be
considered as making an informed choice about how to begin or how to
proceed with the next step.

Preparation consists of moving from the choice of steps-to-be-taken to
readiness to act. Resources may need to be obtained, support rallied,
allies informed, staff trained, and the like. The action step is
intended to produce a preplanned outcome that supports achievement of
the project's objectives. The action step, completed, is followed by
assessment again. Did the action produce what was hoped for? Where
are we now? And so the project proceeds, organically, in response to
changes in both the situation and refinements in understanding what
helps.

171



several authors (Green and Lewis, 1986; Rossi and Freeman, 1982;
Shepard and Thompson, 1979), it will be discussed only briefly in this
chapter. The processes of setting specific objectives and selecting
measurable outcomes have been discussed in an earlier section, so will
not be dealt with here. Steps two and four will be considered briefly.

Computation of the monetary costs of programs requires that costs to
both sponsors and participants be considered. Sponsor costs include
staff, space, materials, telephone, postage, etc. Participant costs
often include time, transportation, child care, etc. Potential
indirect or side effects with associated costs also should be
considered. For example, exercise programs carry a small risk of
injury that can be estimated from experience. If a program results in
such costs they should be included in the calculations. This
procedure is sometimes called “risk-benefit analysis."

The final step of a cost-effectiveness analysis is to rum a
sensitivity analysis. The purpose of this procedure is to vary the
basic assumptions, e.g., participation rates, compliance rates, etc.,
and to figure the worst as well as the best possible cases. This
process is discussed in detail by Shepard and Thompson (1979).

Confidentiality. The confidentiality of information in worksite
health promotion programs should be given careful attention (Alderman,
1984; French and Kaufman, 1981; Kiefhaber and Goldbeck, 1984). In all
worksite based preventive medicine and health promotion programs
confidentiality and job security and sensitive issues. Data from
insurance claims, medical examinations, employee assistance programs,
mental health programs, and health risk assessments are subject to
many uses. Some of these may not be in the best interests of
employees. Both individual employees and union leaders have expressed
concern about the possible misuses of health data made available to
employers. There is fear that such information could secretly be used
in decisions about job assignment, promotion, or termination. Certain
diagnostic labels present more problems than others. For example,
drug abuse, alcoholism, and epilepsy, and are feared to be grounds for
not hiring, denying promotions, and forcing early retirement or even
dismissal.

The acceptance and success of some worksite based screening and
intervention programs has depended on the degree to which
confidentiality and job security were guaranteed (Alderman, 1984; Masi
and Teems, 1983). If guarantees of confidentiality are not provided
often programs will not be accepted.

Research and evaluation activities should be guided by high integrity
and a strong respect for human dignity. Thus, evaluators should not
engage in activities which compromise or infringe on individual
rights. In addition to the considerations of ethics at the individual

135



would assess the individual performing his/her work within a setting
(physical environment), as part of a work group (interpersonal
environment), which represented one component or subsystem in the
hotel (organization). The hotel, in turn, was subject to local,
national, and international market forces and to a variety of social,
and political influences (Strand, 1983). Second, we sought to assess
the dynamic process of stress in the workplace. Alterations in the
organization (such as new management or contract negotiations) should
lead to variation in levels of the OSEG at which stress is reported.
Depending on particular factors salient in a workplace at a given
time, employees’ perceptions of stressors would actually sway from
individual or job specific causes to organizational ones and back
again.

Since the union leadership sought to capitalize on employees’ apparent
dissatisfaction with new management, we were curious at which levels
employees would report the greatest stressors. If the union leaders'
strategy proved effective, employees of the hotel at this time would
increasingly view upper level management and treatment by the
organization as significant stressors, perhaps even more so than the
conditions of their work. Later, if we were to do a follow-up
assessment after the contract was settled and organizing efforts
reduced, we might find a shift away from an emphasis on management as
a stressor. The dynamic concept of stress argues for repeated
assessments over different moments in an organization's history. The
number and location of stressors reported by employees might fluctuate
not only with contract timetables, but even more frequently with peak
and off seasons. Single administrations of stress surveys might
encourage respondents to perform an averaging process that would mask
temporal variation in their perception of stressors.

At all times during our assessment, we would attempt to differentiate
moments when we provided input to the hotel's system or collected
output from it. In other words, any questions or surveys we presented
to the hotel would need to be understood as information we were
offering to the employees about what issues seemed important or worth
discussion. Similarly, their replies to our inquiries would be an
opportunity for union members to inform us about what they,
themselves, thought to be of actual relevance or importance. This
distinction between input and output would also allow us to monitor
how our questions might influence or shape employees’ responses. To
safeguard against this bias, we split the interview segment of our
assessment into two parts. The first task of the interview involved
employees' open-ended descriptions of "a typical day at work." Once
interviewees had described their perceptions of the hotel in their own
words, they answered items we had written.

Finally, we sought to apply the systems principle of feedback to the

actual creation of our assessment instruments and strategies. This
would mean, as Table II indicates, we would return to our original

14



employee stress. This subscale determines if employees are concerned
about and committed to their jobs (low stress) or if workers are
apathetic about and uncommitted to their jobs (high stress). Examples
of items on this subscale include: "There's not much group spirit; A
lot of people seem to be just putting in time; It's hard to get people
to do any extra work; Few people ever volunteer."

The WES also can be used to assess organizational stressors and stress
buffers. For example, management can be considered a stress buffer if
favorable scores are obtained on the Supervisor Support subscale, and
as a stressor if unfavorable scores are obtained on this subscale.
Similar interpretations can be made with the Peer Cohesion, Task
Orientation, Clarity, Control, and Physical Comfort subscales.

Validity

Moos (1981) reviews a number of validity studies conducted on the
WES. Holahan and Moos (1981 a, b) found that a number of WES
subscales were related to complaints of depression and psychosomatic
symptoms in a representative sample of men and women workers. Brady,
Kinnaird, and Friedrich (1980) found a relationship between perceived
work environment, as measured by the WES, and job satisfaction among
staff members of a mental health center. More specifically, employees
who saw their work settings as more oriented toward involvement,
cohesion, support, autonomy, and innovation showed greater
satisfaction with their jobs.

Wetzel (1976, 1978) found that WES scores were associated with
clinical measures of depression. Moos (1981) reviewed a number of
studies (e.g., Bromet and Moos, 1977) that related WES scores to
recovery rates among working alcoholics. Relapsed alcoholics had
lower scores (i.e., more stress) on both the Work Pressure and the
Physical Comfort subscales than the recovered patients.

Case Study

There are a number of practical applications for the WES as described
by Moos (1981). A major use is to compare various subgroups of
employees in order to assess their stress levels and determine some of
the possible sources of their stress.

In this case study, the WES profile of 35 staff members in a
residential care setting for older people (Work Group A) was compared
to the profile of 42 staff members in a community mental health center
(Work Group B). Work Group A was known to be relatively satisfied
with their jobs, as evidenced by turnover rates that were much lower
than that of other long-term care settings. Work Group B was known to
have a morale problem.

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While knowledge of previously used variables and the impact of
programs on these indicators is useful, these variables should not be
tacitly chosen in subsequent studies. Frequently, systematic biases
exist in the ways that program objectives are set and measures are
selected. For example, most of the programs reviewed by McLeroy et
al., and Murphy strongly reflect the biases of clinicians, behavioral
researchers, and management. Most of these programs might best be
termed symptom-reduction programs. In many cases, the variables that
are measured are not relevant to participants. Furthermore, the
exclusive emphasis of these programs on the reductions of physiologic
reactions to stressors and stress-related symptoms has recently come
under criticism from organized labor. The primary complaint has been
that the exclusive emphasis on individuals represents a strong
psychological bias and avoids management responsibility for
environmental factors. It is pointed out that in most cases no
attempts are made to identify and minimize sources of stress in the
workplace (Lerner and Shore, 1982; Neale et al., 1983; Tesh, 1983).

The preference for physiological indices reflects other biases.
First, many of the measures have been standard measures in
laboratory-based research; thus, they have an aura of credibility or
scientific merit. Second, most of them can be measured with physical
techniques and expressed as interval or ratio measures. Third, most
of the measures are highly reactive and are subject to being reduced
with short-term interventions. Therefore, the chances of getting a
positive effect are good which increases the chances for publication
of the findings. The relationship of short-term reactions to
stressors to longer-term, outcome measures has not been firmly
established. The findings thus may be of interest and may serve a
purpose in a narrow research or academic context but may have little
practical, clinical, or administrative meaning outside these contexts.

2) wvaluatio:

Cost-Benefit and Cost-Effectiveness. Cost-benefit analysis and
cost-effectiveness analysis are logical extensions of evaluation
research. The procedures are based on the assumption that judgments
about either costs or benefits of programs cannot be made without
relating them to each other. In order for the value or merit of a
program to be determined either in dollar amounts (cost-benefit
analysis) or in relation to available alternatives (cost-effectiveness
analysis) there must be some evaluative evidence, i.e., impact or
outcome results (Weiss, 1972; Rossi and Freeman, 1982; French and
Kaufman, 1981).

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absolute standard is complete reduction of symptoms (100%), then a
negotiated standard could be 35%. That is a weighted average of the
other standards that gives greater weight to historical and normative
standards than to theoretical and absolute standards.

Model for Planning Program Evaluations

A model that can be used to assist in the planning and evaluation of
worksite health promotion and stress management programs is presented
in Figure 6.1 This model was developed to help conceptualize the
overall plan and main strategies for achieving and evaluating progress
toward the objectives for the nation in disease prevention and health
promotion (Green, et al., 1983). In the model, three levels of
objective—-process, impact, and outcome--are specified. There are
levels of evaluation that correspond to these three levels of
objectives.

Evaluation models, monitoring systems, and specific data collection
techniques, for each of these levels must be selected and implemented
in order to track progress toward the final or outcome objectives. In
subsequent sections, levels of evaluation, general evaluation models,
and measurement methods appropriate for stress-reduction and
management programs in worksettings will be discussed.

Evaluation efforts can be focused on one or several levels of program
objectives. By convention there are three basic levels of
evaluation. These are process, impact, and outcome, and each one is
treated briefly in the following discussion.

Process Evaluation. In process evaluation, the object of interest is
professional or management practice and the delivery of services. The
standard of acceptability is appropriate conduct of practice. Common
methods of evaluation include quality assurance mechanisms such as
peer review, audit, accreditation, certification, and government or
administrative surveillance. Informal and formal feedback from
service providers and participants also are used.

Impact Evaluation. Impact evaluation typically focuses on the
immediate effects of the program on knowledge, attitudes, and behavior
of participants. This evaluation is concerned, then, with the more
immediate, short-term, goals of the program. Knowledge, attitudes,
and other predisposing, enabling, and reinforcing factors influence
behavior that relates to reduced exposure to risks, reduced delay in
use of preventive health services, and decreased lead time in
diagnosing and treating disease. The most widely comparable standard
of acceptability against which to evaluate an impact is
cost-effectiveness because it uses a common metric in the numerator
(dollars) and a common denominator (unit of impact) (Green et al.,
1980).

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Qutcome Evaluation. In the outcome evaluation of preventive medicine
programs the main objects of interest usually are morbidity and
mortality. In the case of morbidity, the years of productive life and
length of survival following detection and the treatment of the
conditions also are important variables. Stress management program
outcomes also may be expressed in terms of work-related variables.
Stated in their most succinct form, the standards of acceptability are
cost/benefit estimates, where the benefits may be stated in company
savings or profits, or stated in their most humanistic form, improved
quality of life of workers.

Currently, improved evaluation of stress management programs is needed
at all three of these levels. Unfortunately, generally accepted
eriteria and standards do not exist against which to judge the
qualifications of providers. Also, standards for assessing the
methods and procedures of programs have not been developed. Thus,
considerable work needs to be carried out to strengthen the

measurement of process and to obtain consensus on the standards of
acceptability.

A substantial amount of work has been done in the assessment of the
impact, i.e., short-term effects, of programs (Murphy, 1984; McLeroy
et al., 1984). Nevertheless, several problematic issues plague
evaluation at this level. Some of these will be discussed at greater
length in the section on measurement. The relationship of the
short-term effects have not been related clearly to more long-term
indicators. Very little work has been done on estimating
cost-benefits and cost-effectiveness. Improved measurement and
documentation of impact on knowledge, attitudes, and beliefs, and
especially behavioral and environmental changes related to outcomes is
necessary. Thus, more work on impact evaluation is needed.

Both scientific and financial barriers limit the likelihood of good
outcome evaluation of stress management programs in the near future.
The evidence linking particular sources of environmental stress and
personal coping behaviors to short- and long-term indicators of work
performance and health is not strong. Also, very few reports on good
comparative short-range or impact studies have been published.
Finally, clinical trials large enough to link stress and stress
reduction interventions to work performance, and especially to
morbidity and mortality, would be expensive. No funding mechanism has
offered to support such costly, large-scale, long-term studies.

Evaluation Designs

Many designs are available for use in program evaluation. The most
appropriate design depends on the logistical circumstances of the
program and the available resources. The decision to use a specific
design for evaluation should be based on several considerations. An
estimation both of practical importance and potential scientific value

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The second theme is that conceptual issues are as important as
logistical ones in determining program success. Considerable effort
should be expended at the outset to define the purpose of the program,
delineate organizational and individual goals, acquire organizational
support, and integrate the program with existing occupational safety
and health efforts. In this way, the foundation is laid for a more
stable and holistic program for controlling organizational stress.

The present collection of papers aims to shift the ‘mind-set’ away
from prescriptive, brief stress workshops and toward more
comprehensive actions that target the organization and the individual
worker as intervention points for stress reduction.

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as one time efforts. They are the "thing to do", or it is felt that
management has done its "bit for humanity” in offering stress courses
—- and therefore, they need not worry further about the unnecessarily
stressful environment they have created. My findings (Adams, et. al.,
1983, 1984) about these kinds of training efforts have been that
people are forced to protect themselves from their organizations. In
six month post-training follow up studies, for example, I have found
consistently that people will be getting more exercise, eating better,
relaxing more, and so on, while feeling less satisfied and fulfilled
at work and less supported on the job. When this finding is explored
further, one finds that the stress training taught people to see
clearly how minor managerial adjustments could reduce the level of
unnecessary stress in the working environment. When they make
suggestions, however, they are told to mind their own business or are
ignored.

A large proportion of stress programs are sold by the trainers to
their companies, and are offered as this year's "trick". When this is
the case, the programs are most often not thought through carefully,
but are merely added to the trainer's repertoire. Such programs
generally have little if any long range effect.

If a stress management program is to have a strong impact on both
health and performance, it needs to be conceived in and built on the
clear purpose to make the system (organization) less unnecessarily
stress provoking while at the same time enhancing individuals’
abilities to cope and to thrive.

There are two basic life orientations, and the one which predominates
in the individuals offering the program will have a major impact on
how the program is conducted and whether or not it is effective in the
long run. One of these, the Reactive-Responsive orientation, places
the locus of control outside the individual as s/he reacts to stimuli
from the environment and responds as effectively as possible to the
constraints s/he faces. Programs based on this orientation will teach
a lot of techniques for managing stress, but will contain the implicit
message that stress comes from the environment and “you'll just have
to make the best of it". Participants are not likely to derive long
term benefits from such an approach. Rather, the approach will
ultimately reinforce their feelings of powerlessness to cope
effectively with a "hostile" environment.

The other is the Creative orientation, which views each individual as
being the predominant creative force in her/his own life. Programs
based on this orientation will focus on the underlying patterns in
each person's consciousness which are the major determinants of what
the person is getting from life. It will also teach participants how
to develop creative orientations within themselves. Basic to this
orientation is the individual's fundamental choice to be healthy. If
an individual does not make this choice, stress management tricks are

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Moderating Factors

As alluded to earlier, there are a number of personal and situational
characteristics that seem to lead to differences in the way
individuals exposed to the same work context perceive and/or react to
the situation. These “moderators” are depicted in Figure 1 in the
blocks labeled "Individual Factors,” "Non-Work Factors," and "Buffer
Factors," and are discussed separately below.

Individual Factors. The most widely discussed personal characteristic
contributing to stress at work has been the coronary prone Type A
behavior pattern characterized by intense striving for achievement,
competitiveness, time urgency, excessive drive and over commitment to
vocation or profession. In the past decade alone, many investigators
have reported the Type A pattern to be independently associated with
coronary artery disease. There is also extensive evidence that Type A
persons show more severe and widespread coronary arteriosclerosis on
coronary arteriography (Cooper et al., 1981). While static
measurements have shown no differences in heart rate and blood
pressure between Type A's and their opposite Type B personality type,
Type A's upon exposure to various laboratory stressors, have been
shown to exhibit more pronounced cardiovascular responses (Dembroski,
MacDougall, Shields, Pettito, Lushine, 1978; Lovallo and Pishkin,
1980). Such findings have suggested to a number of authors (e.g.,
Ivancevich and Matterson, 1984) that an interaction between various

job stressors and type A characteristics may produce reactions which
ultimately lead to heart disease,

The hardy personality style is another individual characteristic
thought to mediate the stressor illness relationship (Kobasa, Maddi
and Courington, 1981). Hardy persons are believed to possess various
beliefs and tendencies that are very useful in coping with stressors.
These include tendencies toward optimistic appraisals of events and
decisive actions in coping (Kobasa, Maddi, and Puccetti, 1982; Kobasa,
Maddi Pucetta and Zola, 1985). Hardy persons have been found to
report less illness in the face of stressors in both a retrospective
and prospective study of executives (see Kobasa et al, 1985).

Stage of career development, while little studied, may also affect the
stressor illness relationship. Extensive work experience, for
example, may moderate worker response to negative events at work
(Wanous, 1973). Indeed, several studies (e.g., O'Reilly and Roberts,
1975) have shown a positive correlation between age and work
satisfaction. This has been interpreted to indicate that worker
expectations of what is to be derived from work activity decrease with
experience in the working world. Conversely, however, older workers
may be more vulnerable to certain physical and mental job demands.

36



population being studied was actively solicited, encouraged, and
supported from the inception to the conclusion of the effort.

It was hoped that by involving workers (including management workers)
as action researchers, the study or project would be more likely to
produce insights into the stress situation in the industry, more
likely to identify practical remedies, and more likely to result in
"ownership" of the findings thereby increasing commitment to take
action to improve the stress situation. Moreover, by this approach,
the external researcher/change agent would model the behaviors needed
to create and extend the collaborative, integrative, and mutually
supportive structures that are needed for stress-ameliorative changes.

This action research project used the series of experiential,
equal-status workshops simultaneously as a research and instructional
mechanism both because of GAIU's experience and the researcher's
approach and concerns (indicated by the preceding sections of this
Paper). The SHAPE staff and the Vice President in charge of SHAPE had
already concluded that: 1) Prevailing approaches to "stress
management” were inadequate and often objectionable because little or
no emphasis was placed on the action needed to bring about
environmental and organizational change, 2) Such approaches tend to
“blame the victim" by focussing largely on the individual's ability,
or lack of ability to handle work situations. Then, when the worker
reacts in a less than adaptive manner to the presence of stressors in
the environment, he or she is blamed for the inability to function
properly and bears all the burden for change.

To get a fresh, less limited perspective on the situation the
researcher and the Union wanted to look through the eyes of those who
make up and lead the industry; to carry out an assessment, those in
the industry would both need to know about and, therefore, learn about
stress. This suggested the sequence of workshops which were conducted.

Interviews and Workshops

The Job Stress Project's primary activities consisted of forming the
advisory panels, interviewing panel members, recruiting the workshop
participants, and conducting the workshops.

The national-level advisory panel was made up of all the nationally
elected officers of Graphic Arts International Union (GAIU) together
with representatives from the Printing Industries Association (PIA)
who were suggested by GAIU; PIA interviewees added additional names to
the list. Similarly, the presidents of GAIU Local Unions 289 in
Detroit and 285 in Washington were asked to form advisory panels

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Several of these organizational characteristics appear to interact
synergistically to impair mental and physical health. For example,
Swedish workers with high work loads and low control over the work
were found to have higher rates of morbidity and mortality than
workers with moderate loads and higher control over the work situation
(Ahlbom et al., 1977; Karasek, 1979; 1981). The high-load,
low-control workers showed more symptoms of excessive fatigue and
depression, and higher rates of cardiovascular disease and overall
mortality.

Besides the fact that these four job dimensions have been linked
through epidemiologic studies to mental and physical health problems,
another advantage in their use is that they can be measured both
objectively and subjectively. Most assembly line or production jobs,
and many blue collar jobs, can be rated independently by outside
observers for characteristics of overload and underload and level of
control, Thus, rough “objective indices" of the stressfulness and the
relative risk for health problems of different occupations can be
developed. However, since the demands of many jobs are dynamic rather
than static, these general indices should be supplemented with surveys
of the ratings of employees in specific companies on these job
characteristics.

Other potential sources of psychosocial stress in work settings are
role related factors such as role-ambiguity, conflict, and strain.
Poor person-environment fit (PE-fit) is an additional possible source
of stress. While these measures have been used frequently in the
past, information on them can be collected only through subjective,
self-reports. Thus, job types cannot be classified independently in
terms of these factors. Furthermore, while these factors have been
associated with conditions such as job dissatisfaction, they have not
been found to be strongly predictive of mental or physical illness.
Despite recent criticisms of the utility of these variables in stress
research (Baker, 1985; Kasl, 1984), they still may be useful if their
limitations are recognized. Jenkins et al. (1984) have provided a
review and discussion of many of the available instruments to measure
role-related factors and person-environment fit. This review provides

a brief description of the scales and information on their reliability
and validity.

Individual Level. Potential sources of stress also can be identified
at the individual level through the study of personal characteristics
and patterns of social interaction. Personal factors that may
increase the likelihood of stress at work include, anxious-tense
personality, low self-esteem, Type A personality, poor communication
skills, poor assertiveness skills, and minor and major forms of
psychopathology that interfere with technical work performance and
social interactions. Factors outside of work that may increase the
likelihood of job stress include alcohol and other drug problems, poor
nutrition and lack of exercise, financial and legal problems, and
social and family problems.

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PREVENTIVE: If the program develops a "touchy-feely" reputation, it
won't last long. It is imperative that stress management training
programs be clearly seen by organizational members as being rooted in
an illness prevention and health promotion context.

REFERRALS: It is very important that stress management trainers be
able to make knowledgable referrals for specific conditions beyond the
scope of the training (e.g. alcoholism) both inside and outside the
organization. From time to time, people will appear in stress
management training who are experiencing possibly stress related
conditions such as chronic anxiety, recurring headaches, hypertension,
and so on, seeking an easy "cure", It should be clear that stress
management training is not the place to treat chronic situations such
as these even if they are stress related. It is important for the
program leader to either be well versed in identifying problems which
need referral or have access to such a person, so that appropriate
referrals can be made.

PROGRAMMATIC CONSIDERATIONS

There are also some additional considerations having to do with
program decisions which need to be spelled out. A comprehensive
stress management training program, one which offers participants a
broad array of options to follow (as in a "cafeteria"), needs to be of
substantial length. A two day program is just about the minimum
amount of time that must be devoted to such a program —- with three to
five day programs having demonstrably higher impact. It also is
imperative that such programs be offered on company time, and that
participants be given release from their normal duties to attend. If
this is not done, employees quickly develop the idea that the
organization isn't really serious about the program. It should also
be obvious that conducting the program after normal working hours or
on weekends, so as not to lose employee time at work is more than a
little antithetical to the underlying message of the program.

When the desired comprehensive program cannot be offered all at once,
there are some advantages to offering it a module at a time (e.g. for
half a day at a time over a period of several weeks). This model
allows for participants to go into some depth in each area of
training, plus it presents an opportunity to do homework practices
between each session, with reportbacks on progress. The shortcoming
is that participation falls off, as people have "emergencies" arising
in their work. (It is incredible how often participants in this
format find that they have too many stressful things going on in their
work to complete the stress course!)

Another programmatic concern is whom to invite to participate. Too
often, these programs are made available to management only, while the
highest stress levels are most likely experienced by clerical staff,
the first line supervisors and their workers. Relatedly, it is

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JOB STRESS REDUCTION

Despite the complexities in job stress research, the merits of both
individual-oriented, and to a lesser extent, work environment-oriented
approaches to reduce stress have been explored. Given the conceptual
framework emphasizing the subjective element of stress presented
earlier, it is not surprising to find that most stress reduction
studies in the literature have focused on the individual rather than
the organization and have used individual-oriented outcome measures to
assess program success. Such studies have clearly supported the
efficacy of various types of stress management training in reducing
psychophysiological and self-report signs of stress (Murphy, 1984).
These techniques, applied in work settings, have a distinctive
preventive flavor with an emphasis on imparting training skills to
symptom-free workers. Accordingly, stress management is considered a
health promotion activity rather than a strategy to relieve stress
problems in troubled workers. Stress management has an important
place in job stress reduction efforts because it addresses the issue
of individual differences in the perception of events as stressful and
can be useful in reducing reactions to work and nonwork stressors that
interact with individual characteristics to produce health
consequences.

While studies of individual-centered stress management approaches have
steadily increased over the past 10 years, efforts to reduce or
eliminate the sources of stress in work settings remain relatively
sparse in the published literature. Reasons for this discrepancy seem
straightforward: individual-oriented strategies are easy to
implement, can be evaluated in the short term, do not require
disruptions in production schedules or organizational structure, and
fit nicely with managements' view of stress as an individual-worker
problem (Neale et al 1982). Individual strategies also ride the
coattails of the expanding interest among employers in health
promotion/disease prevention programs which focus exclusively on
individual lifestyle/behavioral change to improve health (DHHS, 1979,
1980; Parkinson, 1982).

At the same time, organizational change approaches require an
accurate, valid assessment of work factors which generate undue
stress, and an extensive knowledge of the dynamics of change processes
in social organizations (e.g., Alderfer, 1976) so that potentially
undesirable outcomes can be minimized. At the same time,
organizational change strategies can be expensive and disruptive
interventions, making them less palatable to management.

Nevertheless, job redesign and organizational change approaches focus
on reducing or eliminating the sources of stress at work and, hence,
are preferred solutions.

39