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Teresa Mendonça McIntyre University of Minho, Portugal EAOHP Conference, Maia, 2004

DEVELOPING OCCUPATIONAL STRESS RESEARCH IN A SOUTHERN EUROPEAN COUNTRY: A CASE STUDY ON PORTUGUESE HEALTH PROFESSIONALS. Teresa Mendonça McIntyre University of Minho, Portugal EAOHP Conference, Maia, 2004. SUMMARY. From Health Psychology to OHP The need for OHP in Portugal

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Teresa Mendonça McIntyre University of Minho, Portugal EAOHP Conference, Maia, 2004

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  1. DEVELOPING OCCUPATIONAL STRESS RESEARCH IN A SOUTHERN EUROPEAN COUNTRY: A CASE STUDY ON PORTUGUESE HEALTH PROFESSIONALS Teresa Mendonça McIntyre University of Minho, Portugal EAOHP Conference, Maia, 2004

  2. SUMMARY • From Health Psychology to OHP • The need for OHP in Portugal • Occupational stress as a case study for OHP in Portugal. • Developing a line of research in Occupational stress in the health professions • Describing and defining the problem • Applying Western Explanatory models: Do they work? • Future directions

  3. FROM HEALTH PSYCHOLOGY TO OCCUPATIONAL HEALTH PSYCHOLOGY WHAT IS OCCUPATIONAL HEALTH PSYCHOLOGY? “OHP concerns the application of psychology to improving the quality of work life, and to protecting and promoting the safety, health and well-being of workers” (NIOSH, 2000, p. 2). “OHP is the application of psychology to occupational health (and safety)” European Academy of Occupational Health Psychology, Cox, Baldursson & Rial-González, 2000

  4. WHAT IS OCCUPATIONAL HEALTH PSYCHOLOGY?Quick, 1999 ORGANIZATIONAL FRAMEWORK HEALTH PSYCHOLOGY PUBLIC HEALTH OCCUPATIONAL HEALTH PSYCHOLOGY PREVENTIVE MEDICINE

  5. FROM HP TO OHP • Health Protection AND Health Promotion • Individual ANDorganizational focus • Socio-Cognitive-Behavioral AND Organizational-Ecological Models • Clinically-based interventions AND systemic-policy-culturally oriented interventions

  6. THE NEED FOR OHP IN PORTUGAL EU Directives • Directive 89/31 which defines the general principles for the identification and prevention of risks at work. Hierarchy of prevention: • Prevent risks • Deal with risks at the point of origin • Adjust work to the individual • Replace the dangerous for the safe • Give priority to collective measures of protection in relationship to individual measures.

  7. THE NEED FOR OHP IN PORTUGAL Statistics on work, safety and health in Portugal are inconsistent or unreliable • Portugal has one of the highest rates of work accidents in Europe (construction) • Daily about 500.000 people miss work for medical or unknown reasons (Min. Labor, 2004). • Portuguese report high levels of stress (??); 40% (Eurostat, 2004) • Portuguese women take 3 times more sleep medication than the European average. (Infarmed, 2003)

  8. OCCUPATIONAL STRESS AS A CASE STUDY FOROHP IN PORTUGAL Developing a line of research: • Stress is a central theme in both HP and OHP (e.g. Journal Work & Stress) • Focus on the Health professions • Direct request from professionals and services • High risk professions • Political/organizational changes • Funding available • General stress theories/models (Lazarus)

  9. Stress as a Stimulus (Pressure, Sources of Stress) Stress as a Response (Strain) Stress as a Mediational Process(Transaction) Occupational stress STIMULUS STRESS RESPONSE

  10. 1. DESCRIBING ANDDEFINING THE PROBLEM • Characterise Portuguese health professionals in terms of sources of stress (Stress as stimulus) • Characterise Portuguese health professionals in terms of stress responses • Some mediational processes (coping , social support)

  11. STUDY 1-CHARACTERIZATION OF STRESS IN PORTUGUESE HEALTH PROFESSIONALS FROM HEALTH CENTERS IN THE NORTHERN REGION(McIntyre, McIntyre & Silvério, 2000). SAMPLE • 114 PHYSICIANS, 125 NURSES, 129 ADMIN. STAFF (N=368) • 52 health centers (response rates from 62-85%) • FEMALE : 75%; MALE : 25% • AVERAGE AGE: 44.7 years • NUMBER OF YEARS IN THE PROFESSION: 20 • NUMBER OF YEARS IN PLACE OF WORK: 14.5 INSTRUMENTS • Brief Personal Survey (McIntyre, McIntyre & Silvério, 1995) • Sociodemographic and professional form • List of sources of stress (McIntyre, McIntyre, & Silvério, 1999)

  12. CHARACTERIZATION OF STRESS IN PORTUGUESE HEALTH PROFESSIONALS FROM HEALTH CENTERS (McIntyre, McIntyre & Silvério, 2000) MAIN SOURCES OF STRESS (RANKING) 1.WORK OVERLOAD 2. EXCESSIVE NUMBER OF PATIENTS 3. POOR PHYSICAL AND TECHNICAL CONDITIONS 4. EXCESSIVE DEMANDS FROM PATIENTS AND THEIR FAMILIES 5. INABILITY TO RESPOND TO PATIENT DEMANDS

  13. Administrative Staff ROUTINE LACK OF AUTONOMY HIERARCHICAL DEMANDS LACK OF OPPORTUNUTIES FOR PROMOTION Physicians PATIENT OVERLOAD Nurses RISKS TO OWN HEALTH STUDY 1SOURCES OF STRESS: GROUP COMPARISONS

  14. CHARACTERIZATION OF STRESS IN PORTUGUESE HEALTH PROFESSIONALS FROM HEALTH CENTERS (McIntyre, McIntyre & Silvério, 2000) MAIN STRESS RESPONSES (BPS) (High Denial) • 1. PHYSICAL COMPLAINTS • 2. PRESSURE/OVERLOAD • 3. ANGER/FRUSTRATION • 4. ANXIETY • 5. GUILT Negative correlations between stress and job satisfaction (r range -.18 to -.23)

  15. STUDY 1GROUP COMPARISONS MAIN STRESS RESPONSES (BPS) • No significant differences between the three professional groups EXCEPTION: ANGER/FRUSTRATION • Physicians report higher values than nurses and administrative staff.

  16. MAIN COPING RESOURCES (BPS) 1. Social Support 2. Coping Confidence 3.Existential/Spiritual Resources GROUP COMPARISONS Physicians lower Social Support Coping Confidence Existential/Spiritual Resources STUDY 1CHARACTERIZATION OF STRESS IN PORTUGUESE HEALTH PROFESSIONALS FROM HEALTH CENTERS (McIntyre, McIntyre & Silvério, 2000)

  17. STUDY 2STRESS AND COPING : VARIATIONS WITH TYPE OF SERVICEMcIntyre, McIntyre & Silvério, 1999 • relationship between coping resources and stress responses • variations in perception of stressors with the work context SAMPLE 118 Nurses (74% female) chronic care (internal medicine, rehab.) n=62 acute care (intensive care, emergency) n=56

  18. STUDY 2STRESS AND COPING STRESS-COPING RELATIONSHIP Significant negative correlations (r range -.26 to -.59)

  19. GAINS/PROBLEMS ++ • Determine that the sources of stress found are not different from those reported in literature • Confirm predicted relationships -- • Difficulty in determining the extent of the problem in comparison to other European countries. • High denial; How to best measure stress?

  20. STUDY 3OBJECTIVE VERSUS SUBJECTIVE STRESS RESPONSESMcIntyre et al., 2003 • High denial • How to measure stress? • Psychological perspective (transactional model) - inside-out • Perceived stress versus distress 1. What is the relationship between self-report and objective indicators of stress? 2. What is the relative importance of psychosocial variables in predicting self-report and objective indicators of stress?

  21. STUDY 3OBJECTIVE VERSUS SUBJECTIVE STRESS RESPONSESMcIntyre et al., 2003 SAMPLE • 86 professionals, 42 nurses, 13 administrators, 18 auxiliary staff and 7 other professionals. • Gender: 80% F and 20% M. • Average age: 40.4 years (SD= 9.44) • Average of 17 years in their profession (SD = 9.4) • GHQ-12 equal or greater than 3

  22. STUDY 3OBJECTIVE VERSUS SUBJECTIVE STRESS RESPONSESMcIntyre et al., 2003 Psychosocial Measures: • Perceived Coping and Sources of Stress Ranking List (McIntyre, McIntyre & Silverio, 1998) • Portuguese version of the General Health Questionnaire 12 (Goldberg, 1992; McIntyre, McIntyre & Redondo, 1999) • Portuguese version of the Job Descriptive Index and Job in General Scale (Balzer et al., 1997; McIntyre, McIntyre, Silverio, Iglesias & Godinho, 1999) • Portuguese version of the Brief Personal Survey (Mauger, 1994; McIntyre, McIntyre & Silverio, 1995) • Portuguese version of the Interpersonal Behavior Survey (Mauger & Adkinson, 1980; McIntyre, 1985) • Portuguese version of the Ways of Coping Questionnaire (Coyne, Aldwin & Lazarus, 1981; McIntyre, McIntyre & Redondo, 1999)

  23. STUDY 3OBJECTIVE VERSUS SUBJECTIVE STRESS RESPONSESMcIntyre et al., 2003 • Clinical Measures: • Cortisol. • Psychophysiological Measures: • Heart Rate • Blood Pressure; • Skin Conductance Level (SCL) • Electromyography (EMG) Temporalis and Frontalis muscles

  24. STUDY 3OBJECTIVE VERSUS SUBJECTIVE STRESS RESPONSESMcIntyre et al., 2003 Laboratory Induced Stress Protocol (11 events) • Baseline • Selection of stressful event at work (to recall later) • Relaxation tape • Recall of stress event at work • Spontaneous relaxation • Mental task • Baseline

  25. OBJECTIVE VERSUS SUBJECTIVE STRESS RESPONSESSUMMARY OF RESULTS • Cortisol and and Diastolic Blood Pressureat all 11 stress protocolevents (r Range: .23 to .36) • Denial and Diastolic BP at relaxation tape events (r range .27 to .36). • Anger and Heart Rate at Events 2 (choice stress sit.), E9 (end relax), E11 (end mental task) (r range = .22 to .25). • Guilt and Diastolic BP at 5 events (choice stress sit., relax and end mental task) (r range: -.22 to -.24). • Pressure/overload and HR at end of protocol, r = .25. • SUDS at the end of spontaneous relaxation (Event 9) and SCL at all stress protocol events (r range: .22 to .27)

  26. OBJECTIVE VERSUS SUBJECTIVE STRESS RESPONSES PSYCHOSOCIAL PREDICTORS • Social Support and HR at 3 events (stress situation recall) (R2Change range: .05 to .09; sr range: -.24 to -.30) • General Coping and HR (stress sit. Recall)(R2Change=. .08; sr = - .26) • General Aggressiveness and HR at end of spontaneous relaxation (R2Change=.08; sr = .24) • Social Support and SCL at baseline and all stress protocol events (R2Change range: .08 to .12; sr range: .32 to .38)

  27. OBJECTIVE VERSUS SUBJECTIVE STRESS RESPONSES CONCLUSIONS • Include both subjective and objective measures of stress, especially HR and SCL • Include social support and interpersonal behavior in future models since they best predicted both objective and subjective stress responses

  28. STUDY 4A STRESS AUDIT IN A PORTUGUESE HOSPITAL(McIntyre, McIntyre, Araújo-Soares, Figueiredo & Johnston, 2000) SAMPLE • 705 health professionals of both sexes • 104 physicians, 312 nurses, 74 administrative staff, 185 auxiliary staff and 30 diagnostic technicians • 533 women and 172 men • AVERAGE AGE: 38.9 • NUMBER OF YEARS IN THE PROFESSION: 14.8 • .

  29. STUDY 4A STRESS AUDIT IN A PORTUGUESE HOSPITAL -GHQ-12

  30. STUDY 4A STRESS AUDIT IN A PORTUGUESE HOSPITAL DEMOGRAPHIC AND PROFESSIONAL PREDICTORS OF STRESS • age • education • work load • night shift work • years in the profession

  31. STUDY 5A STRESS AUDIT IN A PORTUGUESE LEAN PRODUCTION COMPANYSalgado, McIntyre et al., 2003 • Sample:representative sample of the company workers (N=451 – 25-30% of the total number of employees). • Gender: 23.7% males; 76.3% females. • Structure:74.8% direct workers; 25.2% indirect workers • Age: x=31 (minimum:18; maximum: 56)

  32. Clinically Significant Symptoms Percent YES (clinical group) 52.8% NO 47.2% STUDY 5A STRESS AUDIT IN A PORTUGUESE LEAN PRODUCTION COMPANYSalgado, McIntyre et al., 2003

  33. Comparison of stress symptoms between Portuguese company and hospital • Prevalence of occupational stress symptoms • Hospital: 38.9% • Company: 52.8%

  34. WHY?

  35. PORTUGUESE ORGANIZATIONAL CULTURE • Stress generating culture? • Authoritarian management • Highly hierarchical • Low worker involvement/participation • Lack of team work • Product oriented • Low reward

  36. Applying Western Explanatory models: Do they work?

  37. MAIN THEORETICAL MODELS OF OCCUPATIONAL STRESS • The Person-Environment Fit Model(e.g. French, Caplan & Harrison, 1982) • The Vitamin Model(Warr, 1987) • The Demand-Control Model and the Demand-Control-Support Model(Karasek, 1979; Johnson & Hall, 1988) • The Effort-reward Imbalance Model(Peter & Siegrist, 1997)

  38. The Demand-Control Model(Karasek, 1979)

  39. CROSS-CULTURAL VALIDATION Second European Survey on the Working Environment -(Paoli, 1992) • Measures of demand, control and social support in 16.000 workers in 12 European countries • Four clusters: • Northern (Denmark, Germany, the Netherlands, Great Britain) • Middle (Belgium and Luxemburg) • Southern (Spain, Portugal France, Italy and Ireland) • Isolated Southern (Greece) • Cultural and economic factors explained clusters in terms of job characteristics

  40. CROSS-CULTURAL VALIDATION EUROTEACH study (Verhoeven, Maes, Kraaij & Joekes, 2003) • Test of the JDCS model in 2796 teachers of 13 European countries • Outcomes: Burnout, somatic complaints and job dissatisfaction • Three regions (South, West, East): • The JDCS model explains the most variance in Western Europe (25-46%), followed by Southern Europe (21 to 38%) and Eastern Europe (13 to 34%) • The JDCS model seems to suffer from a Western bias

  41. STUDY 6 - A TEST OF THE DEMAND-CONTROL AND DEMAND-CONTROL-SUPPORT MODELS IN A SAMPLE OF PORTUGUESE HEALTH PROFESSIONALS IN A HOSPITAL CONTEXTMcIntyre, 2002 • SAMPLE • stratified random sample of professionals in the Northern Region who work in central hospitals (N = 1276) • four professional groups: 156 physicians, 877 nurses, 85 diagnostic technicians and 158 administrative staff. • Average age 38 (SD = 10.5) • 75% female, 25% male • average 15 years in the profession (SD = 9.99)

  42. STUDY 6 - A TEST OF THE DEMAND-CONTROL AND DEMAND-CONTROL-SUPPORT MODELS Research questions: 1.To what extent are the dimensions Demand (D) and Control (C) able to predict the stress responses of these health professionals? 2. To what extent does the variable Control act as a moderator of the impact of Demand on the stress responses (Interaction effects), as predicted in the model? 3. To what extent does Social Support add to the explanatory power of the model and acts as a moderator of the proposed relationships? 4. Do these models have the same explanatory power for the four professional groups or does their usefulness vary according to the professional group and how?

  43. STUDY 6 - A TEST OF THE DEMAND-CONTROL AND DEMAND-CONTROL-SUPPORT MODELS VARIABLES PREDICTORS Demand(D) -performance or not of night shift work. Control (C) -(Organisational Climate Questionnaire, McIntyre, McIntyre & Silvério, 1998) Participation - the extent that the health professional participates in decision-making, in activity and program evaluation and attention given to one’s opinions Autonomy - the extent that professionals are autonomous in their jobs and their degree of responsibility

  44. STUDY 6 - A TEST OF THE DEMAND-CONTROL AND DEMAND-CONTROL-SUPPORT MODELS VARIABLES PREDICTORS (cont.) Social Support - (Brief Personal Survey) availability of social support in terms of emotional support. OUTCOMES (Brief Personal Survey, McIntyre, McIntyre & Silvério, 1995) - Physical Distress - Anxiety - Anger/frustration - Depression

  45. STUDY 6 - TEST OF THE DEMAND-CONTROL MODEL (N = 1276)

  46. STUDY 4 - A TEST OF THE DEMAND-CONTROL-SUPPORT MODEL (N = 1276)

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