Spangler, Nancy W. PhD; Koesten, Joy PhD; Fox, Michael H. ScD; Radel, Jeff PhD
Stress and depression are strongly associated with higher medical costs for employers.1 Researchers have explored issues related to perceptions about stressors, neurochemical and hormonal reactions that make up the stress response, the role of emotions, and a wide range of health conditions related to distress, yet stress continues to be associated with ill effects, including heart disease, cancer, pain, delayed wound healing, and depression.2–4 Mild depression seems to be influenced by life stressors and is particularly costly to employers because of its high prevalence and high aggregate productivity loss.5
Excessive stress may result in difficulty managing emotions, focusing attention, making decisions, and thinking clearly or objectively.6 Acute and chronic stressors also seem to have a negative influence on reward and motivation circuits of the brain.7 Heightened circuit reactivity in these systems affects subsequent cravings for relief of the associated arousal (eg, through smoking, drinking, drugs, gambling, or excessive working). Workers who use these types of coping strategies can be very challenging to employers, as the physical and behavioral effects frequently spill over to the workplace through reduced work performance (for both the distressed individual and the person's coworkers), increased absence, and disability.8
Researchers in neuroscience and child development have observed that some individuals are far more resilient to adverse and distressing circumstances than others and that resilience to stressors is modifiable.9,10 Resilience generally describes characteristics or capacities enabling individuals to recover from adversity and use available resources adaptively. Resilient individuals tend to have a positive outlook, are hopeful, view change as a challenge, and have secure emotional attachment to others. They are likely to have a sense of humor, are action-oriented with an internal locus of control, have a sense of personal competence, take opportunities for physical replenishment, are able to express needs and engage support of others, and are able to self-soothe and manage emotions and impulses.9,11,12 Inherent to the resilience construct is the idea that an individual's mindset and behaviors change through positive adaptation to adverse or distressing events or circumstances. Research suggests that individual resilience may be modifiable, and changes may affect individuals at a cellular and genetic level.9
Organizations also vary in terms of collective resilience. In both individuals and organizations, the capacity to develop new adaptive capabilities to weather future storms makes the resilience construct distinct.13 Positive organizational scholarship (POS) suggests that resilience at the organizational level may be enhanced through concerted efforts at discovering and enhancing organizational strengths and positive dynamics.14–17 An outgrowth of positive psychology, POS seeks to understand the factors that enable adaptive capacities and potential positive outcomes in organizational systems.
Research has documented effectiveness of interventions related to managing stress at both the individual and organizational levels. Individual-level interventions help individuals change circumstances creating distress, alter perceptions about stressors, and/or manage the corresponding physiological or emotional or both responses.18 At the organizational level, two theoretical models are common in workplace stress research: the Demand–Control–Support model19 and the Effort–Reward Imbalance model.20 The Demand–Control–Support model suggests that work is distressing when an individual has high job demands but inadequate decision-making authority (low control). Job demands include factors such as volume of work and time constraints. The original Demand–Control model was modified to reflect that social support from one's supervisor or colleagues might moderate stressors' effects. The Effort–Reward Imbalance model places emphasis on rewards rather than on control of work, proposing that work is a contractual reciprocal exchange of rewards for individual effort. Rewards include financial remuneration, self-esteem, status, or security/career opportunities. Jobs requiring high effort for little reward violate this basic social exchange and elicit stress responses with mental and physical health consequences.
Studies have generally supported these organizational-level models,18,21,22 yet little is documented on how regularly these models are incorporated in practical use in workplaces. In light of recent economic challenges and worker layoffs, employers may be limited in ways they can address stress by reducing demands, increasing decision latitude, or enhancing financial remuneration. In addition, little is documented on the use or effectiveness of resilience-related interventions.
In 2010, surveys of workplace health and benefits professionals found that more than 60% of workplaces were offering stress management or resilience education or both at the individual level.23,24 The nature of the resources, however, was unclear, and the surveys did not ask about organization-level interventions. Additional research to determine the scope and detail of employer approaches seemed warranted.
The purpose of this study was to systematically record the interventions and organizational approaches that employers use related to workplace stress and resilience, along with perceptions held by managers responsible for employee health and performance about the effectiveness of these approaches.
Grounded theory was used for sampling and data analysis. Grounded theory is an inquiry process that generates systematic analysis based on emerging observations, data-to-data comparison, and comparison of data to existing theories.25–27A qualitative design was used to gather narratives about approaches to stress and resilience organizations use and workplace professionals find most valuable.
Setting and Sample
The study protocol was approved by the institutional review board at the University of Kansas Medical Center. A purposeful sample of workplace professionals was developed through collaborations with the Mid-America Coalition on Health Care, Disability Management Employer Coalition, Employee Assistance Roundtable, Partnership for Workplace Mental Health, and Blue Cross Blue Shield of Kansas City.
Participants were recruited through e-mail or phone follow-up or both after printed information was received in advance regarding the study purpose, procedures, and privacy precautions. They were intentionally recruited from managers of human resources, benefits, employee assistance programs (EAPs), disability management benefits, and health promotion programs, because numerous disciplines address workplace mental health and work performance. Participants provided verbal informed consent. No incentives for participation were provided.
Discussions and Interviews
Over a 5-month period, eight small group discussions (two in Kansas City, five in Minneapolis, and one by phone) and 16 individual telephone interviews were conducted. Each was semistructured and typically lasted 60 to 90 minutes. The study was designed to encourage discussion and reflection among employers about workplace stress and resilience. Discussion questions focused on participants' perceived organizational strengths, which allowed solution-based frameworks to emerge following tenets of POS. When positive frameworks are used to study patterns of excellence in organizations and the processes that create these patterns, more dynamic, creative, and transformative thoughts and actions result.28,29
Initial questions were open-ended, beginning with a question such as, “What do you believe are your organization's greatest strengths in the way you prevent stress or help your employees with coping or resilience building skills?” The discussions were conversational in nature, allowing reflection and interaction among participants. Probing questions were used to explore concepts as they emerged from the discussion and to clarify meaning, following grounded theory methodology. This is in contrast to focus group studies that use a specific question set consistently with each group.
Examples of probes included the following: “Have you had a peak experience, something that stands out, as a result of this approach?” “Do you explicitly use the terms stress and resilience in your programs and communication?” “Could we explore how your employee assistance program and human resources work together to help resolve employee–supervisor conflicts when someone is returning to work?” “Can you tell me more about how you have shifted from process measures for EAP toward outcome measures?”
The discussion groups or interviews were audiorecorded and transcribed in a modified verbatim format to ensure accurate portrayal of participants' narratives and to allow reflection upon meaning. Three discussion groups were not recorded at the request of one or more participants to protect privacy. During unrecorded discussions, a member of each group served as a scribe to summarize the discussion in written notes.
Initial interview and focus group transcripts were coded line by line (open coding) to identify words and phrases used frequently in similar or contrasting contexts. In interviews and in focus groups, comments by each individual were considered individual units of analysis, or incidents, for coding purposes. Words and phrases representing similar concepts were grouped together into categories. Using the constant comparative method,30 incident to incident were systematically compared and then incidents to properties of a category. Categories were modified through the analysis process as the properties, dimensions, and relationships between concepts became apparent.25 For example, properties such as transparent communications, emphasizing values and ethics, and supportive culture were integrated under the category of Preventing Stress. Likewise, process for referrals, interdisciplinary return-to-work planning, and establishing familiarity were part of Actively Intervening. As variables recurred consistently in the data, coding became selective and focused on core concepts and properties with explanatory power for the emerging patterns.
Interviews with additional individuals or previous participants occurred by phone until the conceptual categories reached a level of saturation that represented a pattern of regularity and repetition in the categories, with no new properties or dimensions emerging and ideas about the developing model–theory consistent. Theoretical sampling and data collection ended at this point. Theoretical coding (sorting ideas and hypotheses progressively generated in memos and comparing them to the data) was used to develop a theory and model explaining how these concepts are operating in effective approaches to workplace stress and resilience.
After a framework conceptualizing how employers were addressing stress and resilience emerged, the resulting model was grounded in accordance with other research by making comparisons to additional research literatures. Comparing participants' narratives along dimensions of the coding categories and the conditions in which various phenomena occurred aided in discovery of patterns (commonalities and exceptions) in the employers' perceptions.31
Memoing encouraged a reflective progression during coding to note consistencies and conflicts observed in the data as it accumulated, to determine areas of additional questioning needed to saturate all of the categories, and to help in discovering patterns and relationships between concepts in the analysis and theory development. 26 Other methods included examining meaning behind frequently used words, words used in striking ways, or those used with emotional emphasis, as well as diagramming to put the various conceptual categories together in an overall schema.27
The research team made a conscious effort to focus on participants' narratives and to place previous literature reviews in the background, allowing a model to emerge from the data.30 Steps taken to reduce bias and ensure quality and trustworthiness of the research are summarized in Table 1.
The participant sample included 12 men and 34 women ranging from 27 to 62 years of age (mean age, 50 years). Participants had been with their current employer from 2 to 29 years (mean length of service, 12 years). In total, 46 individuals from 40 businesses or organizations employing more than 1.3 million employees participated in the study. The mean number of employees per organization was 31,800 (excluding two outliers at the extremes of the range of 350 to 120,000 employees). Professional roles of participants and information about industries represented are summarized in Tables 2 and 3.
Three main approaches effective in addressing workplace stress and resilience emerged in discussions, summarized in Fig. 1. These include (1) preventing distress and building resilience; (2) providing information, resources, and benefits for employees; and (3) actively intervening with troubled employees. These approaches are represented by a pyramid in Fig. 1 to illustrate the proportions of employees affected by each approach. The labeling taxonomy for the approaches uses commonly understood terms to encourage interdisciplinary dialogue.
Participants' perceptions of their organization's strengths are summarized in the following sections, followed by the systemic role of trust that emerged across all three categories.
Preventing Distress and Building Resilience
Three subthemes emerged around approaches related to preventing distress and building resilience: use of values, ethics, and missions; workplace cultures and practices; and strong communication that guides behavior.
Role of Values, Ethics, and Missions as Symbols and Guideposts for Behavior
A common strength of organizations that participants perceived was their organizations' commitment to values, ethics, or missions, which provided symbols and guideposts (ie, organizational rules) for employee behaviors. Organizational policies were well aligned with missions and communicated thoroughly.
Many participants were able to recite their core values or mission statements verbatim, and some indicated that senior leaders were newly identified as responsible for ensuring that people-oriented values were followed. Some mentioned that their organizations' Web sites contained clear guidelines that employees had developed together outlining specific behaviors for treating one another respectfully. Organization's ethics guidelines and grievance processes helped to reduce employee distress in instances in which ethics were violated. One participant shared:
One of the really remarkable things about the employer where I'm at now is that they incorporate how people treat each other, people's behavior, in their ethics requirements, and people are held accountable for treating each other well including how management treats the employees. So you don't see things I've seen in other organizations where people are getting yelled at by managers or they're not being treated fairly, because they could just pick up the ethics hotline and report it, and it gets investigated. We have generations of families there.
Organizational missions were described as helpful in tying individual workers' roles to the larger purpose of the organization. Individual role clarity was enhanced through training, mentoring, and performance review processes that encouraged frequent interaction and clarification of expectations in multiple directions—supervisor to employee, employee to supervisor, and among workers and supervisors within work units.
Adequate attention to person-job fit and training programs focusing on career development were described as helpful to employees for understanding how a current role fits into a long-term career trajectory, and for enhancing individuals' sense of meaning and identity from their work. One participant saw furthering people's career opportunities as a key responsibility that is beneficial to the organization.
You should be in a role now as much by choice as possible.... [But] the workplace is fluid, it's capricious, it can be quite unpredictable.... It's good for you to have a narrative that's empowering, that makes sense of it and also puts [your career] in sequence-–I'm doing this call center job now, and it's helping me learn something about the public, and it's got a regular schedule, and my kids are young, and in three years when they're all in grammar school, this is what I'm going to do next.
Workplace Culture and Practices
The concept of a career trajectory was common among participants from organizations with long-standing and paternalistic histories and was described as part of the organizational culture. A participant in one of these environments said that their tradition of providing opportunities to fulfill career ambitions and aspirations was one of her company's greatest strengths. She felt that this was helping build a strong supportive culture “department by department,” win national awards, and “recruit the best and the brightest.”
Paternalistic organizations were sometimes described as having family-like cultures. Family-like workplaces tended to encourage a strong work ethic and loyalty to the organization without an expectation for working excessive hours. Participants from organizations with family-like cultures suggested that their organizations have lower levels of absence and disability and that workers in these cultures viewed being gone from work as “letting their teammates down.”
There was frequent discussion of changes occurring among all organizations, but participants suggested that change occurred more gradually in older, more established organizations or in organizations where original family members retained key leadership positions. Cultural practices as simple as free lunch were mentioned by individuals from two separate organizations. One participant said that the free lunch her family-owned employer still provided was a benefit she valued because it reduced distress from daily time conflicts. “I don't have to pack a lunch. I just throw myself in the car, and lunch will be there when I need it.” Another mentioned that when their traditional free lunch ended, it represented what was lost when the company went public and became “much more focused on productivity, much more focused on efficiency. It exists to make a significant profit, as opposed to make a profit and also be an environment that is nurturing and very much a community.”
Representatives from older, established organizations and those from newer companies with workforces more diverse in terms of age and ethnicity said that culture was a major key to health behavior change. Many organizations assess work culture through surveying worker attitudes and perceptions, and these cultural assessments sometimes identified that trust in managers was lacking. This issue then became an emphasis primarily for executive leaders to address. Numerous participants, like the following, described key executive leaders as highly important in setting an example of the work tone or a culture of health and life balance.
Our chair of the firm had meetings on Monday mornings with all his direct reports and at one point, this was years ago as part of developing the culture, he would say, “How was your weekend? What'd you do over the weekend?' ‘Well, I got ABC client and we're ready to go.' ‘But, no, what did you do with your family? And what'd you do in the community?' These are smart people, so it didn't take too many weeks for them to be ready with some answers.
Several participants said that employee feedback led them to attempt to make the workplace “more fun,” with times for more casual social interaction and social connectedness, or “to celebrate what we've done.” Participants mentioned also celebrating the diversity of their employee population through affinity groups, bringing together people with common interests.
Even when probing questions were aimed at finding greater detail about particular intervention, support, or case management approaches, participants shared that it was really their culture and relationships that made a difference. “We just have a very strong work ethic ... and people want to be at work.” “They're on a team ... and they want to be pulling their own weight.”
Although participants mentioned these aspects of employee culture and climate as organizational strengths in preventing distress, many viewed these efforts as outside of their own area of responsibility. Employee engagement, mentioned as a common measure of work climate and culture, was also described as an overall assessment of stress prevention efforts, although efforts were “owned” by senior leaders or the Human Resources department and outside of most participants' domain and scope of practice.
Many participants volunteered that regular and clear communication was their organization's greatest strength in reducing distress, particularly following the economic downturn of 2008 and resulting layoffs for many. Communication was seen as imperative to the overall goal of building a thriving culture of healthy employees and a financially successful business.
We've been on the consistent message for two and a half years.... I think taking that unknown or the uncertainty out of the situation, for all of us, has positive impact to coming to work and what we're going to do each day.
Transparency about organizational changes was seen as vital. “People just want to know” was a frequent theme. “Sometimes the stress people experience is fear of the unknown and their concern for what's happening to co-workers.” Treating individuals respectfully, transparently, and as generously as possible during downsizings reassured both the person leaving and the employees remaining with the organization. One company prepared for their reductions by providing an internal outplacement program an entire year before severances occurred and included stress management and meditation sessions led by their internal EAP.
Another company communicated frequently with employees about their creative restructuring of operations to avoid downsizing and their generous relocation packages. Sixty percent of affected employees took advantage of the relocation offer. A top company executive personally welcomed the employees to their new office in another state across the country on the first day of work. Electronic and in-person communications encouraged employees to use an internal assessment tool designed to help them recognize common emotional reactions associated with transitions and helped familiarize them with supportive resources available to them.
The concept of “face-to-face” communication, even when provided virtually through technology, was mentioned consistently as being helpful in preventing distress. The importance of having a chief executive officer or top leader “give face time” at predictable recurring time points was emphasized as a positive factor.
One employer provided a multiyear communication training program for all departments. The program addressed principles acknowledging the emotional and cognitive sides of communication. It was credited with markedly improving managers' relationships and their willingness to work toward common goals rather than competing.
A commonality in comments about communication was an example of positive relational behaviors—leaders modeling calm rational interactions, clear communication of policies, and manager–employee discussions in regular interactive performance reviews for enhancing role clarity.
Providing Screenings, Information, Benefits, and Resources
The second approach that emerged from the data centered on providing screenings, information, benefits, and resources. Nearly all participants had employed health risk appraisals, many with stress-related questions, a few assessed for depression and anxiety, and a few included resilience-focused questions. There seemed to be high variability in how health risk appraisal questions were constructed.
Health risk appraisal reports invited people to join coaching or intervention programs. Data comparison related to risk and program outcomes was described as difficult even within a single organization, as information is typically housed within a health plan or among other various vendors to protect employee privacy. A few participants lauded the value of data warehouses or analytic partners to allow comparisons of data from different areas of the organization, to understand their populations' multiple and overlapping health risks, and to help in making decisions about benefit and program design. “We did a deep dive into determining pharmacy utilization and comorbidities and discovered the mental health pieces of other chronic diseases. It was there, we just weren't looking at it yet,” shared one participant.
One organization used an assessment that helped employees anticipate how changes in life events (such as military deployment, returning to school, having children) might affect work and then steered them to supportive information and services. This tool gave information on how to talk with managers about such changes, facilitating potentially difficult conversations and allowing adjustments to occur more smoothly.
Nearly all participants mentioned EAPs or behavioral health benefits or both. All provided access to some kind of information about stressors, the stress response, and coping skills through their health plans or through health promotion, EAP, or Work–Life programs. Some specifically indicated that they provided programs or resources to help employees understand the concept of personal resilience, the potential for growth following adverse and challenging experiences, and the importance of developing cognitive and physical reserves. Many were providing innovative and flexible ways of providing access to this information for family members of employees.
Increased use of technology was described as expanding proactive outreach for mental health screening and follow-up by some organizations. Participants said that on-line health education webinars were preferred “even if the live presenter is just down the hall.” In some locations, events are video recorded and placed on a company intranet for 10 days, and employees may call in to a “warm body” to get personal questions answered about the topic. Training sessions educate managers about the benefits of such approaches for the employer organization so these managers will then encourage employees to take advantage of the resources.
A number of participants, however, suggested that the programs went beyond individual outcomes. “The idea is not to have a little health and wellness department that is available.... but more to help shape the organization.” Others shared that individual-level education programs had limitations for effecting major organizational change. Managers living out the teachings had the greatest effect. By demonstrating through example that physical and emotional replenishment requires managers attending to people's needs, they began including strategies like scheduling “walk-and-talks” instead of long meetings in conference rooms. One participant said that after years of attention to individual and team resilience “it's part of our DNA.”
Actively Intervening With Troubled Employees
The third approach that emerged from the data centered on actively intervening with troubled employees. Participants described that a growing area of practice was to help supervisors manage employees who struggle with chronic distress. Actively intervening with these “troubled employees” took on two main forms: disease management and absence/disability prevention and management.
Disease Management Programs
These strategies are provided by some employers, typically through health plans or other vendors, to proactively reach out to and help workers cope with a chronic illness that may be challenging to understand and manage, such as diabetes, heart disease, or depression. Layering stress-related coping strategies on top of the education about the illness itself was viewed as a natural extension of the health management process.
Others suggested that participation in disease management programs for specific conditions was historically low in their population, and they were finding greater success with more proactive case management through EAP or disability management or both, rather than through health plans, for individuals with chronic conditions. These participants suggested that internal approaches may better address comorbid conditions, contextual issues of the workplace, and the employee's functional abilities in addition to the clinical treatment needs typically addressed by external disease management programs.
Absence and Disability Prevention and Management
Another emerging area of practice described by participants involves mental health professionals helping employees and managers with complex work relationships in earlier stages to prevent excessive absences or disability leaves. For example, an employee with a work performance problem complicated by difficulty tolerating distressing situations may revert to ineffective behavior patterns learned through early childhood and cultural interactions. The mental health professional consults with the manager or the employee or both and coaches them on effective ways of resolving conflicts or negotiating work roles.
Participants stated that these active intervention approaches could involve personnel from HR, EAP, case management, risk management personnel, or all of these, and these teams worked actively on interdisciplinary case reviews and prompt cross-referrals. One participant said, “Part of the strategy is to jump in as early as I can and ... talk about return to work and setting the stage for it.” Mental health and rehabilitation specialists also described helping employees navigate the health care system, facilitating quality behavioral health care practices, and providing input on benefit design that removes barriers to care.
One study participant, a disability manager, gave a poignant description of a series of interdisciplinary trainings among her staff and occupational medicine staff in motivational interviewing, an approach involving facilitated discussion around ambivalence to change.33 The experience released this participant from the paper-pushing role she had assumed, and “gave her permission to focus on the human elements” with clients. The participant felt that the training freed her to help her clients better manage stressful aspects of their lives as she had been trained originally, rather than simply ensuring that clients got certain benefits.
Another participant said that becoming more proactive with trainings and consultations with managers was helping to uncover troubled managers, especially those new to management and supervision who were sometimes uncomfortable with the role or lacked interaction skills. A coaching strategy helped reduce distress for both managers and the employees they supervised. This person said that the coaching helped reduce unnecessary disability claims related to distressing work relationships.
Core Category of Trust
Across all three categories of approaches participants described, a concept of building trust in relationships and organizational structures recurred regularly and was considered a core category of the analysis. A core category within the coded data is one that has the greatest explanatory relevance in developing a coherent framework or theoretical model.26,27
An example of trust in preventing stress came in discussions of cultural practices, such as regular communication with leaders.
People can ask any question they want, once a month. So people start to trust in top management because he's been transparent with them. They may not always like the message, but at least they can trust that it's probably true.
Participants shared that effective screening and intervention programs require trust, time, and structures encouraging interdisciplinary collaboration to be effective. One participant described a sense of trust when developing an innovative life-coaching pilot in conjunction with a respected nursing department manager who was “someone you'd take a bullet for.”
Participants who described high satisfaction with internally managed EAPs attributed the strength to depth of knowledge an internal manager develops about the organization over time. Yet, participants who were pleased with external EAP arrangements attributed their success to long-standing, trusting relationships; thus, the consistent factor seems to be trust rather than an internal or external service delivery design.
The purpose of the study was to understand the kinds of approaches organizations used in relation to workplace stress and resilience and beliefs about effectiveness of these approaches. Unique aspects of the study included its strengths-based focus and its recruitment of participants from among managers across multiple disciplines responsible for the health and work abilities of the workforce.
Grounded theory analysis of participant narratives identified strengths in three main approaches to addressing stressors and supporting resilience. In addition to describing the kinds of approaches used in relation to workplace stress, participants offered valuable information about why their approaches may be effective. This information may contribute to theory refinement and additional theory building related to workplace stress and resilience.
For example, in relation to the two major workplace stress theories, participants' perceived strengths contained little related to job redesign that might increase employee decision latitudes or reduce demands of work as might be expected in the Demands–Control–Support theory,34 although some mentioned flexible scheduling to reduce work–life imbalance. Participants frequently described opportunities for job training, mentoring, and career progression as strengths supporting self-efficacy. These practices could be considered rewards under the Effort–Reward imbalance theory.20
Participant discussion consistently focused on strengths in their organizations' culture, connectedness, and relationships. The effectiveness described in participant examples may be more fully explained by theories related to POS, organizational systems, and personal well-being.
Positive organizational scholarship researchers attempt to understand organizational strengths and positive dynamics to explain optimal individual and organizational outcomes.16 The study participants emphasized strengths in collective processes for enhancing respect, civility, and ethical coworker interaction, for continually aligning stated values, missions, and roles, and for creating connectedness. These become pragmatic practices both for enabling resilient adaptive capacity with employees effectively handling work challenges and for enhancing worker engagement.
Participants described numerous examples of relationship building through consistent leader communication, affinity groups, EAP consults with managers, and disability case manager interactions to resolve work conflicts and help troubled individuals. Heaphy and Dutton35 show that positive work relationships act to enhance affiliative needs and provide a sense of meaning. Spreitzer and Sonenshein15 suggest that this sense of meaning is rooted in intrinsic motivation. Motivation from within, in contrast to external rewards, allows individuals to gain a sense of vitality from work and to retain a proactive behavioral orientation, even when task demands become challenging, through the desire to make a difference.
Heaphy and Dutton35 also point out that physiological research related to work has largely focused on markers of stress and strain, and there has been little study on the physiology of positive social interactions and relationships. Their systematic review of studies comparing interactions of social connection and relationship measures with cardiovascular, immune, and neuroendocrine measures suggests that positive work connections and relationships alone affect healthy physiological resourcefulness and responsiveness, regardless of stressful experiences. In addition to studies of physiology, neuroscience research may also inform an understanding of how the supportive organizational cultures and social relationships described by participants may reduce distress through the development of trust and rule-guided behavior.
Researchers examining the neuroscience of trust suggest that early development of social–emotional behaviors in family units may influence patterns of relational interaction and emotion regulation in other settings later in life.36–38 For example, early trusting relationships encourage empathy, an unconscious perception of another person's emotional state, and relational styles of interaction and communication.39 Excessive aggression or the sudden inability to speak may also stem from early and unconscious emotion regulation patterns based on distrust. Disengagement and defensive withdrawal may cause valuable information that could drive positive organizational change to be lost.40
Researchers examining rule-guided behavior suggest that rules such as those described by participants related to ethics and values serve a priming role in the brain helping to facilitate desired behaviors through automatic cognitive constructs or ways of thinking.41 Thus, conscious behaviors, as well as automatic responses, are facilitated by rules, and they are encoded into memory for guiding daily activities and emotional responses.42 Specificity of rules enables recall and future behavioral application. The explicit ethics and values statements and policies serve as rules that may narrow employee behaviors, shape the work culture, and contribute to development of trust in enduring organizational structures and practices, as participants described.
Scholars of social and organizational systems suggest that these structures and practices, repeated in patterns and routines over time, become institutionalized and engender a sense of continuity. Straus43 labeled this collective interaction negotiated order. Organizational systems models suggest that changes in one part of a complex system have powerful effects on other areas,44 thus explaining how supportive workplace cultures affect positive organizational outcomes. Participants who shared strengths in preventing stress through strong leadership, communication, and workplace relationships also described positive outcomes in work engagement, teamwork ethics, and financial performance. Organizations that incorporate early identification and intervention for individuals with stress-related difficulties, especially by supporting those with supervisor conflicts, report particularly positive systemic outcomes affecting multiple areas, such as high work-unit production and low disability rates. Systems research encourages looking beyond narrow theories of cause and effect to the highly complex, quickly changing, and interacting factors within workplaces, building on the composite of individual and organizational structures that are best studied together and understood as inseparable.45–47
Social connectedness and a sense of meaning through work may be explained by studies of well-being. The well-being construct has generally been described in terms of positive emotions (ie, happiness) and life satisfaction.48–50 Essential components of well-being include strong social relationships and attainment of what is valued by the individual, typically in terms of work, family, and health49 and through mastery experiences, personal growth, and life purpose.50,51 Our findings suggest that organizations providing opportunities for social bonds, emphasizing job training, role alignment, and career progression, and encouraging constructively working out conflicts, increase the likelihood of personal well-being, which may help buffer the effects of stress and strains.
The study findings suggest practical implications for senior leaders and for interdisciplinary professionals responsible for health- and disability-related benefits and programs.
For Senior Leaders
Chief executive officers and other top leaders are the literal and figurative faces of the organization, setting the stage for a culture of trust in relationships, hope for enduring organizational structures, and vision for the workforce. Although corporate leaders of the past tended to follow hierarchical bureaucratic models of management,52 current workplace environments point to the need for leaders to assume new roles and identities in response to changing relational interactions, societal changes, and shifts in patterns of working to be optimally effective.53–55
Leaders should provide structured and predictable opportunities for communication both in person and through technology.56,57 Technology-enhanced communication (telephone and e-mail) is effective for interactions once a personal relationship is developed, but complex or highly emotional situations typically require face-to-face interaction as supported by organizational communication research.58,59
Study participants described engagement efforts as being “owned” by executive leadership, managed by human resources, and separate from health-related efforts. Research suggests, however, that engagement and mental well-being are indeed related concepts.60 Leader acknowledgment of this connection, and inclusion of health-related managers in engagement efforts, is important.
Relational and interpersonal roles may be difficult for executives accustomed to more transactional and instrumental leadership roles. Top organizational leaders often struggle with stressors and may feel the need for their own emotional support and resources. Executive coaching (through EAP or outside consultants) is a resource for supporting leaders in these new roles.61
Coaching and preventive resources may also be helpful for managers and supervisors at the work-unit level to support day-to-day work.55,62 Team members who struggle with challenges but work out conflicts constructively build greater capacity for the learning and innovation required in uncertain business environments.56,57 Additional study of and attention to factors that enhance communication and social dynamics may be helpful.63
For Managers of Health-Related Programs and Benefits
The study findings suggest that managers over areas such as EAP, work–life, wellness, health benefits, occupational health, and disability management need a full understanding of and participation in the organization's structure (values, mission, policies, practices, and culture). Managers should build strong relationships with program vendors to enhance goal alignment and vendors' understanding of the unique cultures, traditions, and practices of their organization.
Participants who described providing stress management interventions frequently emphasized exercise, which has an evidence base as a stress-coping skill and for enhancing physiological resilience.64–66 Other evidence-based interventions included conflict management,67 motivational interviewing,68 and cognitive restructuring of negative thinking, a component of cognitive–behavioral therapy–based stress management interventions.69 Electronic delivery of intervention was also mentioned, which is effective for delivery of cognitive–behavioral therapy interventions.70
Individual components for resilience-focused interventions included (1) opportunities for individual or collective reflection or both through dialogue or writing or both about experiences, personal identity, abilities to persevere through adversity, and commitment to future desired states;71–74 (2) support and opportunities for developing relational communication and emotion regulation;42 (3) resources and structures for health and lifestyle habits (relaxation, exercise, and nutrition) that generate physical and emotional reserves for times of challenge and that support periods of recovery and replenishment;75 (4) perceived organizational support;58 and (5) self-efficacy and mastery experiences, particularly skill development in the context of meaningful work.76
A number of study participants were trained in clinical fields. Managers should recognize that clinical training often emphasizes individual-level intervention and proximal deficit-based measures (such as disease symptoms, risk factors, or disability levels) rather than positive and more distal individual metrics (including employee engagement, well-being, satisfaction, and trust in leaders) and organizational measures (attendance, employee retention, work production, and financial performance). Supplemental training in population health management and systems-based approaches may be valuable.
Strengths and Limitations
This study involved participants from a variety of professional roles and industries, and this broad pool of experiences and perspectives provides strength for our conclusions. Participants expressed that they found the interactive process to be an effective way to learn from one another. The strengths-based approach used in the study elicited rich discussion and numerous detailed examples.
Study limitations include cautions when generalizing the current findings to other organizations. Participants in these discussions were drawn from some of the largest employers in the United States. Future studies with representatives from small- to medium-sized companies would be valuable for learning differences in the ways smaller organizations and their managers approach workplace stress and resilience building. The preponderance of women managers in the study sample seems to reflect the target population for the study because 67% to 80% of HR managers, psychologists, counselors, and social workers are women,77 yet future studies comparing potential differences in perceptions based on gender and age may be useful. Perceptions of executive leaders and of managers and supervisors in operational areas would also be valuable, particularly those with larger numbers of union employees.
In a special issue of the Journal of Organizational Behavior, Bakker and Schaufeli,78 discussed that positive organizational behavior is an effective strategy for workplaces to shift away from the prevailing four Ds approach (damage, disease, disorder, and dysfunction) toward emphasis on positive traits, states, and behaviors of engaged employees. Our findings support the need for organizational leaders to attend to the role of positive social and emotional aspects in the workplace and on the importance of tying these factors to individual coping skills, resilience to stress, health, well-being, and organizational outcomes. Employees at risk of, struggling with, or deeply troubled and disabled by stress-related illness are an organizational reality. The well-being of these individuals can affect organizational outcomes. Preparing leaders and professionals with the skills necessary to address all aspects of the health continuum effectively, as early as possible, and with an understanding of systemic effects, is essential to ensure long-term organizational health and stability.
The authors thank the anonymous employer representatives who participated in this study and shared their perceptions, as well as the organizational collaborators who helped recruit participants and who offered input through various stages of the study. These collaborators include Sally Baehni (Mid-America Coalition on HealthCare), Marcia Caruthers (Disability Management Employer Coalition), Clare Miller (Partnership for Workplace Mental Health), and Teresa Gerard (Blue Cross Blue Shield of Kansas City) Additionally, appreciation for their guidance goes to Jacque Carpenter (Saint Luke's Nursing School) and Lisa Mische Lawson and Dory Sabata (both from University of Kansas Medical Center).
1. Goetzel RZ, Anderson DR, Whitmer RW, Ozminkowski RJ, Dunn RL, Wasserman J. The relationship between modifiable health risks and health care expenditures. An analysis of the multi-employer HERO health risk and cost database. The Health Enhancement Research Organization (HERO) Research Committee. J Occup Environ Med. 1998;40:843–854.
2. Vale S. Psychosocial stress and cardiovascular diseases. Postgrad Med J. 2005;81:429–435.
3. Lutgendorf SK, Sood AK, Antoni MH. Host factors and cancer progression: biobehavioral signaling pathways and interventions. J Clin Oncol. 2010;28:4094–4099.
4. McEwen B. Protection and damage from acute and chronic stress: allostasis and allostatic overload and relevance to the pathophysiology of psychiatric disorders. Ann N Y Acad Sci. 2004;1032:1–7.
5. Allen H, Hyworon B, Colombi A. Using self-reports of symptom severity to measure and manage workplace depression. J Occup Environ Med. 2010;52:363–374.
6. McCraty R, Tomasino D. Emotional stress, positive emotions, and psychophysiological coherence. In: Arnetz B, Ekman R, eds. Stress in Health and Disease. Weinheim, Germany: Wiley-VCH; 2006:342–364.
7. Soderpalm B, Soderpalm A. Stress and addiction. In: Arnetz B, Ekman R, eds. Stress in Health and Disease. Weinheim, Germany: Wiley-VCH; 2006:384–400.
9. Charney DS, Manji HK. Life stress, genes, and depression: multiple pathways lead to increased risk and new opportunities for intervention. Sci STKE. 2004;2004:re5.
10. Rutter M. Implications of resilience concepts for scientific understanding. Ann N Y Acad Sci. 2006;1094:1–12.
11. Campbell-Sills L, Cohan SL, Stein MB. Relationship of resilience to personality, coping, and psychiatric symptoms in young adults. Behav Res Ther. 2006;44:585–599.
12. Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18:76–82.
13. Sutcliffe KM, Vogus TJ. Organizing for resilience. In: Cameron KS, Dutton JE, Quinn RE, eds. Positive Organizational Scholarship. San Francisco, CA: Berrett-Koehler Publishers Inc; 2003:94–110.
14. Weick K, Sutcliffe K. Mindfulness and the quality of organizational attention. Organ Sci. 2006;17:514–524.
15. Spreitzer G, Sonenshein S. Positive deviance and extraordinary organizing. In: Cameron K, Dutton J, Quinn R eds. Positive Organizational Scholarship: Foundations of a New Discipline. San Francisco, CA: Berrett-Kohler; 2003:207–224.
16. Cameron KS, Dutton JE, Quinn RE, eds. Positive Organizational Scholarship: Foundations of a New Discipline. San Francisco, CA: Berrett-Koehler Publishers; 2003.
17. Norris FH, Stevens SP, Pfefferbaum B, Wyche KF, Pfefferbaum RL. Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. Am J Community Psychol. 2008;41:127–150.
18. Quick J, Quick J, Nelson D, Hurrell J Jr. Preventive Stress Management in Organizations. Washington, DC: American Psychological Association; 1997.
19. Karasek RA, Theorell T. Healthy Work: Stress, Productivity, and the Reconstruction of Working Life. New York: Basic Books; 1990.
20. Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occcup Health Psychol. 1996;1:27–41.
21. Biron C, Brun JP, Ivers H, Cooper CL. At work but ill: psychosocial work environment and well-being determinants of presenteeism propensity. J Public Ment Health. 2006;5:26–37.
22. Biron C, Cooper C, Bond F. Mediators and moderators of organisational interventions to prevent occupational stress. In: Cartwright S, Cooper CL, eds. Oxford Handbook of Organizational Wellbeing. Oxford: Oxford University Press; 2008:441–465.
23. Integrated Benefits Institute. More Than Health Promotion: How Employers Manage Health and Productivity. San Francisco, CA: Integrated Benefits Institute; 2010.
25. Charmaz K. Grounded theory: objectivist and constructivist methods. In: Denzin N, Lincoln Y, eds. Handbook of Qualitative Research. 2nd ed. Thousand Oaks, CA: Sage Publications; 2000:509–536.
26. Glaser B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago, IL: Aldine Publishing Company; 1967.
27. Corbin J, Strauss A. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Los Angeles, CA: Sage Publications; 2008.
28. Sekerka L, Fredrickson B. Establishing positive emotional climates to advance organizational transformation. In: Ashkanasy NA, Cooper CL, eds. Research Companion to Emotion in Organizations. Northampton, MA: Edward Elgar Publishing; 2008:531–545.
29. Fredrickson B. The role of positive emotions in positive psychology: the Broaden-and-Build Theory of positive emotions. Am Psychol. 2001;56:218–226.
30. Glaser B. Theoretical Sensitivity: Advances in the Methodology of Grounded Theory. Mill Valley, CA: The Sociology Press; 1978.
31. Goulding C. Grounded Theory: A Practical Guide for Management, Business, and Market Researchers. Los Angeles, CA: Sage Publications; 2002.
32. Cohen DJ, Crabtree BF. Evaluative criteria for qualitative research in health care: controversies and recommendations. Ann Fam Med. 2008;6:331–339.
33. Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change. New York: Guilford Press; 2002.
34. Van Der Doef M, Maes S. The Job Demand–Control–(Support) Model and psychological well-being: a review of 20 years of empirical research. Work Stress. 1999;13:87–114.
35. Heaphy E, Dutton J. Positive social interactions and the human body at work: linking organizations and physiology. Acad Manage Rev. 2008;33:137–162.
36. Decety J, Cacioppo J, eds. The Handbook of Social Neuroscience. New York: Oxford University Press; 2010.
37. Insel TR. The challenge of translation in social neuroscience: a review of oxytocin, vasopressin, and affiliative behavior. Neuron. 2010;65:768–779.
38. Schore A. Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Ment Health J. 2001;22:7–66.
39. Carter C, Harris J, Porges S. Neural and evolutionary perspectives on empathy. In: Decety J, Ickes W, eds. The Social Neuroscience of Empathy. Cambridge, MA: MIT Press; 2009;169–182.
40. Argyris C. Overcoming Organization Defenses: Facilitating Organizational Learning. Boston, MA: Allyn and Bacon; 1990.
41. Bunge S, Wallis J, eds. The Neuroscience of Rule-Guided Behavior. New York: Oxford University Press; 2007.
42. Mauss I, Bunge S, Gross J. Culture and automatic emotion regulation. In: Ismer S, Jung S, Kronast S, Scheve CV, Vandekerckhove M, eds. Regulating Emotions. London: Blackwell Publishing; 2008;39–60.
43. Strauss A. Continual Permutations of Action. New York: Walter de Gruyter; 1993.
44. Katz D, Kahn R. Organization and the systems concept. In: Corman S, Banks S, Bantz C, Mayer M, eds. Foundations of Organizational Communication. 2nd ed. White Plains, NY: Longman Publishers; 1994.
45. Katz D, Kahn R. The Social Psychology of Organizations. 2nd ed. New York: John Wiley & Sons; 1978.
46. Giddens A. The Constitution of Society: Outline of the Theory of Structuration. Berkeley, CA: University of California Press; 1984.
47. Giddens A. Conversations With Anthony Giddens: Making Sense of Modernity. Cambridge: Polity Press; 1998.
48. Ryan R, Deci EA. On happiness and human potentials: a review of research on hedonic and eudaimonic well-being. Rev Psychol. 2001;52:141–166.
49. Diener E, Suh E, Lucas R, Smith H. Subjective well-being: three decades of progress. Psychologic Bull. 1999;125:276–302.
50. Ryff C, Keyes C. The structure of psychological well-being revisited. J Pers Soc Psychol. 1995;69:719–727.
51. Harter JK, Schmidt FL, Keyes CL. Well-being in the workplace and its relationship to business outcomes: a review of the Gallup studies. In: Keyes CL, Haidt J, eds. Flourishing: The Positive Person and the Good Life. Washington, DC: American Psychological Association; 2002:205–224.
52. Weber M. The Theory of Social and Economic Organization. London: Collier Macmillan Publishers; 1947.
53. Weick K. An introduction to organizing. In: Corman S, Banks S, Bantz C, Mayer M, eds. Foundations of Organizational Communication. 2nd ed. White Plains, NY: Longman Publishers; 1995:142–151.
54. Fairclough N. Language and Power. 2nd ed. London: Longman; 2001.
55. Boyatzis R, Smith M, Blaize N. Developing sustainable leaders through coaching and compassion. Acad Manag J Lear Educ. 2006;1:8–24.
56. Edmondson A, Nembhard I. Product development and learning in project teams: the challenges are the benefits. J Prod Innov Manag. 2009;26:123–138.
57. Senge P. The Necessary Revolution: How Individuals and Organizations Are Working Together to Create a Sustainable World. New York: Doubleday; 2008.
58. Stamper C, Johlke M. The impact of perceived organizational support on the relationship between boundary spanner role stress and work outcomes. J Manag. 2003;29:569–588.
59. Maznevski M, Chudoba K. Bridging space over time: global virtual team dynamics and effectiveness. Organ Sci. 2000;11:473–492.
60. Schaufeli W, Bakker A. Utrecht Work Engagement Scale. Utrecht, the Netherlands: Utrecht University, Occupational Health Psychology Unit; 2003.
61. Peltier B. The Psychology of Executive Coaching: Theory and Application. 2nd ed. New York: Taylor and Francis Group; 2010.
62. Weick K, Quinn R. Organizational change and development. Annu Rev Psychol. 1999;50:361–386.
63. Argyris C. Good communication that blocks learning. Harv Bus Rev. July–August 1994:1–7.
64. Rostad F, Long B. Exercise as a coping strategy for stress: a review. Int J Sport Psychol. 1996;27:197–222.
65. Southwick SM, Vythilingam M, Charney DS. The psychobiology of depression and resilience to stress: implications for prevention and treatment. Annu Rev Clin Psychol. 2005;1:255–291.
66. Cotman C, Berchtold N, Christie L. Exercise builds brain health: key roles of growth factor cascades and inflammation. Trends Neurosci. 2007;30:464–472.
67. Alper S, Tjosvold D, Law K. Conflict management, efficacy, and performance in organizational teams. Pers Psychol. 2000;53:625–642.
68. Miller WR, Rose GS. Toward a theory of motivational interviewing. Am Psychol. 2009;64:527–537.
69. van der Klink JJ, Blonk RW, Schene AH, van Dijk FJ. The benefits of interventions for work-related stress. Am J Public Health. 2001;91:270–276.
70. Grime PR. Computerized cognitive behavioural therapy at work: a randomized controlled trial in employees with recent stress-related absenteeism. Occup Med (Lond). 2004;54:353–359.
71. Roberts L, Dutton J. Exploring Positive Identities and Organizations: Building a Theoretical and Research Foundation. New York: Psychology Press; 2009.
72. Pennebaker J. Writing about emotional experiences as a therapeutic process. Psychol Sci. 1997;8:162–165.
73. Seligman ME, Steen T, Park N, Peterson C. Positive psychology progress: empirical validation of interventions. Am Psychol. 2005;60:410–421.
74. Christensen C. Identity, personal projects and happiness: self construction in everyday action. J Occup Sci. 2000;7:98–107.
75. Hawkley L, Berntson G, Engeland C, Marucha P, Masi C, Cacioppo J. Stress, aging, and resilience: can accrued wear and tear be slowed? Can Psychol. 2005;46:115–125.
76. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall; 1986.
77. US Department of Health & Human Services Substance Abuse and Mental Health Services Administration. Women in the Labor Force: A Databook (2010 edition). Labor force statistics from the current population survey 2010. Available at: http://www.bls.gov/cps/wlftable11-2010.htm
. Accessed November 1, 2010.
78. Bakker A, Schaufeli W. Positive organizational behavior: engaged employees in flourishing organizations. J Organ Behav. 2008;29:147–154.