When job burnout was first described by Christina Maslach et al, it was specific to caring professionals. Eventually, it was found that it can occur in all occupations and across all demographics. Physician and nurse burnout has been the hot topic the last few years, though a recent meta-analysis pointed out that there’s little that can be concluded about physician burnout because of the level of variation in definition and measurement (a lot of people disagree with this).
Studies have found that pervasiveness of Electronic Medical Records plays a big role in physician burnout. This makes sense, as it can be connected to several of the known burnout antecedents, especially autonomy/control, but also unsatisfactory social interaction and values conflict.
Pay attention to the science-backed workplace mental health frameworks that are taking shape outside the US, like those in Canada, Europe, and Australia.
In the US, the messaging of vendors and consultants tends to drown out science. Last year, for example, data from a meta-analysis — which included more than 120,000 research subjects — showed that job strain (the combination of high demands and low control at work) may lead to clinically diagnosed depression. This is consistent with a lot of other research that points us toward employer strategies for the primary prevention of mental health problems. But psychosocial risk and primary prevention are missing-in-action when we look at mental health resources made available by US employee wellness professional organizations and their vendors/consultant partners, .
Mental health crises — just like physical health crises — are mission critical, but this doesn’t mean we can’t prevent them before they happen and, what’s more, aspire to create workplace environments in which employee well-being flourishes.
Canada’s “Standard for Psychological Health and Safety in the Workplace” is a compelling example of a social strategy to promote mental health in all its stages — emphasizing primary prevention. Find out more about Canada’s Standard and other science-backed workplace mental health strategies on the Jozito mental health resources hub.
Big thanks to the folks at Lumity, Inc. for inviting me to present the webinar “Wellness, Wellbeing, and Workforce Sustainability: 3 Routes to Employee Wellness and Optimal Performance.” If you missed it, check out the recording.
In this orderly mash-up, I present about 40 years of work in 33 minutes (plus Q&A). It has something for everyone — from the HR generalist who’s been assigned to wellness but may not know much about it, to veteran managers of comprehensive programs trying to figure out what does and doesn’t work. I cover
the premise of health risk costs and risk reduction;
the distinctions between wellness and wellbeing;
ROI vs. VOI;
typical wellness program components;
work, stress, and health;
Without being overly prescriptive, I offer my own interpretations of evidence and practices, some of which you’ll find immediately applicable and some of which will irk you to no end. This link, exclusively for my blog readers, takes you directly to the recording.
In 2015, Japan passed a law requiring businesses with 50 or more employees to offer workers an annual assessment — the “Stress Check” — which measures risk of stress and other mental health concerns based on three domains:
Psychosocial and other stressors in the work environment, including job demands, job control (autonomy), work intensity, and sense of purpose.
Mental and physical symptoms of stresslike irritability, exhaustion, difficulty concentrating, musculoskeletal discomfort, difficulty sleeping.
Social support, including connection with supervisors, co-workers, and loved ones.
The Japanese government recommends their 57-question assessment tool, theBrief Job Stress Questionnaire(BJSQ). Take a look at the English versionhere. Employers can use alternative questionnaires, but they’re required to include the same domains — workplace stressors, symptoms, and support.
The law — designed to helppreventstress in response to an epidemic of stress-related death and disease — mandates that
Employees are given the results of their Stress Check.
Employees found to be at high-risk for potentially harmful stress are referred to a physician.
Employers modify stressful work conditions (such as schedules, work location, or responsibilities) in collaboration with high-risk employees’ physicians.
Stress Check process (click to enlarge)
The law encourages employers to improve the workplace environment based on analysis of their group’s data. Specific interventions aren’t prescribed, although models and case studies are available.
The law prohibits release of employees’ data to employers without the employee’s permission, and it prohibits discrimination based on Stress Check participation or results. Though employers are required to offer the Stress Check, workers aren’t required to participate.
No one’s advocating a program like this outside Japan, but it should evoke dialog among wellbeing professionals and enlighten how we view job stress.
Japan — likemuch of Europe,Canada, and the US’sNIOSH— recognizes that job stress is rooted in workplace risk factors: lack of autonomy, role ambiguity, job insecurity, lack of social support, excessive demands, harsh environments, inadequate rewards, work/life conflict, and unfair treatment.
The Stress Check questionnaire draws on a growing body ofevidenceshowing that it does, indeed, identify people who are at high risk of mental health-related disability.
As for intervention… There’s a lot of experimentation to be done before we can definitively say what works. To date, evidence supports organizational change more than personal interventions to prevent worker stress.
Recently, a small initialstudyfailed to demonstrate positive outcomes for either the questionnaire alone or for workplace interventions alone. However, the researchers reported:
Combining the annual stress survey with improvement in the psychosocial work environment can effectively reduce psychological distress.
Like it or hate it, the Stress Check program is innovative. We’re reminded that innovation is not always technology driven. We need innovators to follow Japan’s example and take a fresh look at our job stress paradigms.
To understand what job crafting has to do with employee health and wellbeing, it’s important to understanding the inner workings of job stress and motivation.
In a previous post — “I’ve Seen the Future of Employee Wellbeing: It’s Name Is Job Crafting” — I explained how, in 2001, Amy Wrzesniewski and Jane Dutton proposed that employees tweak their job tasks, workplace social connections, and perspective about their role to gain a greater sense of purpose and meaning, potentially leading to better job performance.
Around that same time, in the Netherlands, Evangelia Demerouti, Arnold Bakker, and othersintroduced their model of Job Demands-Resources(JD-R), which has since been fine-tuned and validated as relevant to a full range of occupations and outcomes in countless studies around the world.
If you’re familiar with job stress research, you know that job stress has causes, and shouldn’t be dismissed as a choice employees make.
Forget trendy notions that “stress is good.” It’s wishful thinking based on cherry-picked evidence. If stress is so great, why aren’t employees demanding more of it?
Forty years of research has shown thatharmful job stress is a result of jobs that have low levels of autonomy and high demands.
Job Demands and Autonomy Are Linked to Health Problems
Over the years, jobautonomy(or control) has been defined different ways, but can be broadly understood as limited flexibility (for example, with the tasks of the job) and limited decisional latitude, meaning the employee isn’t permitted or encouraged to make decisions in their work or about their work.
Jobdemandsoriginally meant the psychological intensity of work, but ultimately can be understood to include workload, time pressure, and physical demands.
Robert Karasekintroduced the theory of demands and control in 1979. He and others have shown that jobs in which workers consistently encounter high job demands with low job control — the combination of which is called jobstrain— are linked to a variety of health issues, especially high blood pressure and cardiovascular disease, as well as depression, anxiety, burnout, and metabolic disorders. Reducing job strain can improve productivity.
Karasek later learned thatsocial support “buffers” the negative effects of high-strain jobs. Social support originally meant supervisors’ and co-workers’ support for performing job tasks, but can be understood in all of the many ways it’s been defined: Having a sense of “belongingness” at work; having co-workers who are empathetic and confidantes; having supervisors who take a genuine interest in the personal and professional lives of team members; and having a best friend at work.
In sum, high demands and low control are an unhealthy combo.(High demands andhighcontrol are not necessarily bad.)
Effort-Reward Imbalance Is Linked to Health Problems
Unhealthy job stress has been framed in other ways. Germany’sJohannes Siegrist foundthat work in which the required effortis disproportionately high compared to the jobrewards— effort-reward imbalance — leads to the same kinds of health problems that result from job strain. “Rewards,” here, doesn’t just mean financial compensation, but also career opportunities and level of esteem within the organization.
The effort-reward imbalance model reminds me of an encounter I once had with a business analyst who transferred to another department because she didn’t feel valued in the department she was hired into. When I asked her, “What would have made you feel more valued?” her answer was not “better pay” or “someone saying ‘good job’”…
“I just wanted someone to listen to my ideas,” she told me.
A worker who doesn’t feel valued (i.e. esteemed) by being “listened to” is likely to have a higher level of disengagement and health impairment. This offers a glimpse into how management style, job design, organizational culture, performance, turnover, health, and wellbeing are all interconnected.
Overtime, Job Insecurity, Injustice, and More…
Several other causes of job stress have been identified, and most of them can in some way fit into the demand-control and/or the effort-reward imbalance model:
• chronic overtime
• job insecurity
• work-life conflict
• role ambiguity (not being clear of what’s expected, receiving contradictory direction, duplication with other workers’ roles, or not understanding how the work fits into the overall organization — all of which are among the most common complaints I’ve heard from employees who report high job stress).
• organizational injustice (being treated unfairly, which at the extreme includes bullying and harassment)
• lower levels of status within the organization
• sustaining high levels of vigilance (e.g. first responders, air traffic controllers, etc.)
Back to Bakker
The overlaps between and the nuances of these job stress theories makes them difficult to understand and apply. That’s where Bakker and Demerouti’s Job Demands-Resources model comes in. While building on the existing theories and expanding upon them, it also provides a simpler way of making sense of job stress and motivation. I consider it a comprehensible and practical unifyingtheory.
JD-R posits that all job traits can be categorized as either demands or resources.
• Demandsrequire sustained effort from employees. They’re an expenditure of personal energy.
• Resourceshelp fuel progress toward work-related goals. They’re restorative, buffering the effects of job demands —and activating personal development.
I interpret JD-R to mean that Karasek’s “demands,” Siegrest’s “efforts,” as well as role ambiguity, job insecurity, injustice, tedium, and work-life conflict aredemands.
Job autonomy, social support, rewards, recognition, feedback, task variety, and training are examples ofresources.
Side note: If you’re familiar withEdward Deci and Richard Ryan’s self-determination theory— popularized in the Daniel Pink bestseller,Drive— which tells us that motivation and flourishing depend onautonomy,competence, andrelatedness(i.e. social connection), you may recognize that job resources generally can be matched to the components of self-determination.
• Demandsregulate job stress.
• Resourcesregulate job motivation and engagement.
• And the two forces may act upon each other.
That’s enough theory for now. What I’ve come to appreciate about JD-R is how, according to research by Bakker and others, it serves as a foundation for a practical application: job crafting.
JD-R takes job crafting beyond meaning and purpose — which has received most of the public attention — and ties it directly into health and wellbeing.
I’ll spell this out further in a future post, and also draw the important distinction between positive and negative job demands. I’ll share what research shows about the effectiveness of job crafting interventions for improving employee wellbeing, work engagement, absenteeism, performance, and productivity. And I’ll offer evidence-based tips on how you can prime your organization for job crafting.
If you can find some downtime (or some treadmill time?), listen to “Dealing With Burnout” the Wisconsin Public Radio Morning Show. One of the guests wasMonique Valcour PhD CPCC, who has a gift for articulating, in super-practical terms, the connection between work and wellbeing. Monique explains what burnout really is, and delivers keen insight when the first caller makes a reference to the role of autonomy in addressing his own burnout. She talks about burnout as an “interpersonal phenomenon” and notes the supportive effects of mindfulness and emotional intelligence. And she provides practical tips for workplace leaders.
By the way, not only is it essential for us wellness professionals to address the burnout that occurs amongst employees, but I’m observing that it’s increasingly common within HR, Employee Benefits, and Employee Wellness teams. So if you don’t feel the need to learn about burnout for your organization, learn about it as an act of compassion for yourself.
Our major wellness conferences will connect their attendees with nonprofit (or under-resourced) employers in their host cities to model wellbeing interventions for employees who otherwise might not have access.
It may be too late for employee wellness professionals to adjust their plans for holiday-season programs this year, but now is an ideal time to rethink the holiday stress programs we typically offer.
Every December, wellness program managers promote programs about managing “holiday stress.” These commonly take the form of lunch-and-learns or communication campaigns. They have the usual catchy titles like Holiday Stress Less and Take the Hassle Out of the Holidays.
The holiday season is stressful for many employees — no doubt about it. And it’s distinct from other sources of stress in the workplace in that the conditions that cause holiday stress can, indeed, be modified with behavioral approaches.
But I suspect that our holiday stress programs add to employee stress. They contribute to a culture that considers stress the primary mental state in which we experience the holidays and, as such, comprise a self-fulfilling prophecy.
May I suggest a new approach to promoting mental health during the holidays, even if some of the content may be the same? Let’s offer programs that promote happiness and joy, rather than just trying to remediate stress. Next year, instead of teaching people to manage holiday stress, why not teach them how to nurture their holiday happiness? Why not publish newsletter articles like “How to Share Holiday Joy”?
Instead of “5 Tips for Managing Your Holiday To-Do List,” how about “101 Reasons to Enjoy a Holiday Vacation”? Rather than “Balancing the Burdens of Work/Life During the Holidays,” how about “Focus on Family this Holiday Season!”
[Originally posted by Bob Merberg in May 2010 on the In TEWN blog.]
The Robert Wood Johnson Foundation, as well as the Harvard T.H. Chan School of Public Health and National Public Radio, may have given a boost last week to advocates of employee wellbeing. Here, I refer to what I consider authentic wellbeing — based on workers’ exposure to harmful job conditions and environments — not the store-bought imitation based on wellness websites, apps, incentives, and medicalized interventions.
To promote the findings of their Workplace Health poll of 1,601 workers, these sponsoring organizations waged a publicity blitz that brought the “healthy work” perspective to a broad new audience. A Health in the American Workplace panel, streamed live on the web, served as a centerpiece of the campaign.
Workers’ Views on Jobs and Health
Poll results, according to panelists, revealed that many workers view their jobs as impediments to their wellbeing.
43% said their job has a negative impact on their stress level
28% said their job undermines their eating habits
27% reported that their job interfered with the ability to get a good night’s sleep
22% said their job has a negative impact on their weight.
Panelist Marjorie Paloma, director of RWJF, explained how job stress and health are influenced by workplace policies:
If you think about the stress a person feels whether because of their day to day work routines, or the stress they feel because of caring for a loved one while working a full time job, or workers who feel as if they have to go into work despite being sick…These are all stressors that influence health.
Succinctly describing the relationship between behaviors and the environment, Paloma stated:
The choices we make are as good as the choices we have.
She summarized this position with the catchy phrase:
Health shapes work, and work shapes health.
“Human Resource Failures”
Harvard Business School professor John Quelch described how workforce management and the intensification of work have been shown to influence health. Quelch bemoaned…
…the sheer overload that comes from downsizing and outsourcing and asking someone to do two jobs when previously they had to do one.
He cited an often overlooked source of stress:
It can also come from job ambiguity — the requirements of the job are not being clearly articulated by supervisors.
Quelch characterized these workforce management patterns as “fundamental human resource failures.”
Gloria Sorensen, from Harvard Chan, cited her team’s studies of health care workers, whose job conditions have been linked to health problems:
Risk of injury or musculoskeletal pain or accidents on the job increase…when we look at harassment on the job, inadequate staffing, bullying at work, high job demands, lack of control, and poor supervisor support.
Sorensen went on to say that these job conditions also have been linked to fatigue, sleep problems, and risk of obesity. She concluded…
The point is these conditions of work are critical when we look at a range of health outcomes for workers.
The panelists’ remarks revealed mixed feelings about conventional worksite wellness programs that focus on behavior change. The poll results showed that only half of workers have access to wellness programs, which at times the panelists, such as Harvard’s Robert Blendon, seemed to cite as an indictment of employers:
Almost half of people who work are at a workplace that has no workplace health program.…People go to work every day, and this is something they read about in a magazine, but they don’t see in their own job.
On the other hand, Paloma remarked…
Worksite wellness is insufficient if it’s not going hand in hand with efforts to improve the health of communities.
Blendon, director of the poll, said that the findings changed his mind about stress. He led an uncomfortable laugh at the expense of conventional stress management strategies, and noted…
Employers should have some responsibility for lowering the level of stress.
NPR’s Joe Neel, the panel’s moderator, summarized…
It’s all about conditions of the workplace and stress.
Kudos to Harvard Chan’s Sorensen, who introduces the audience to the study of job stress in San Francisco transit operators, in which changing the work — such as modifying schedules, training, staffing changes, and equipment upgrades — succeeded in reducing worker stress, whereas, according to Sorensen, previous efforts to change the workers (for example, with stress management programs) failed. For the curious: The research Sorensen cited has been incorporated into an in-depth analysis of stress prevention for bus drivers, available from the International Labour Organization.
The disconnect between the “healthy work” approach and the behavior change emphasis in the panel’s videos, if anything, highlights the need for an acceleration of credible worker health research, which is exactly what NIOSH’s Total Worker Health initiative has set out to do .
In the interim, watch the full one-hour panel here:
You look to your job not only for income and benefits, but also for purpose, social interaction, and daily routine. These influence your health, and the loss of them — or the threat of losing them — can suck the life right out of you.
Every day, millions of Americans either look for work or go to work. Their success at finding and/or maintaining a decent job with good benefits will, to a large degree, determine their current and future health.
Job loss, long periods of unemployment, and job insecurity have all been linked to deteriorating health. Yet, even companies that profess to support employee well-being have been known to contradict themselves by executing mass layoffs as a first line of financial defense rather than a last resort.
The Netflix exec who masterminded the vaunted slide deck about the company’s do-or-die culture boasted about the workers she’d laid off and fired. After being let go in 2015, she “doesn’t like to talk about it.”
Of course, layoffs aren’t the only source of unemployment and job insecurity…
Workers get fired due to performance problems.
Businesses go belly-up.
Some employers foster job insecurity as an ill-fated method to drive productivity.
But mass layoffs — regardless of whether they are euphemistically called reductions-in-force, redundancies, right-sizing, down-sizing, or all-around-the-town-sizing — are responsible for the majority of job loss that is out of workers’ control.
Job Loss and Health
Compared to employed workers, people who have recently lost a job are…
According to Gallup, Americans who have been unemployed for a year or more are more likely to be obese than those unemployed for a shorter time. The obesity rate rises from 22.8%, among those who have been jobless for less than three weeks, to 32.7% among those unemployed for a year or more. Those who have been jobless for more than 26 weeks are twice as likely to have high blood pressure and high cholesterol compared to people who have been unemployed for shorter periods.
Gallup also found that 20% of people unemployed for a year or more suffer from depression — about twice the prevalence compared to people unemployed for less than six weeks.
The Robert Wood Johnson Foundation points to several pathways from unemployment to deteriorating health:
Reduced income, which leads to inadequate nutrition, shelter, and health care.
Increased stress and limited access to the physical, mental, and social activity that are underpinnings of well-being.
Increased likelihood of engaging in unhealthy behaviors, like alcohol consumption, smoking, and drug use.
Job Insecurity and Health
The jury is still out on whether job insecurity — the threat of involuntary job loss — causes measurable declines in health status, but plenty of studies suggest a connection.
Job insecurity harms health, even more than unemployment.
One of the largest investigations of job insecurity and health analyzed data from more than 174,000 workers who were studied for nearly 10 years. It found that workers with job insecurity were 20% more likely to experience life-threatening heart disease compared to others who felt their jobs were a lock.
Job insecurity can lead to unhealthful behaviors like smoking, a Canadian analysis concluded, and avoidance of healthy behaviors like exercise and taking needed vacation and sick time off. It may even increase the risk of work-related injury and illness.
The relationship between job insecurity and health may depend on job type, economic conditions — how readily a laid off worker can land a new job — and workers’ attitudes about their employment and health. Case studies suggest that availability of social support and services for laid off workers may be differentiators for wellbeing.
Honeywell CEO Dave Cote doesn’t have a perfect record when it comes to worker well-being, but his decision to favor furloughs over layoffs during the Great Recession serves as a Harvard Business School case study on how to maintain competitive edge during economic downturns and recoveries. Cote’s process should be required reading for execs who succumb to arguments that layoffs are inevitable.
The benefits of using layoffs to manage costs during a recession didn’t make economic sense…
For workers in America, if you worked at a company like General Electric it’s more like you get a month’s salary and go. They lock the doors on the day you are fired. At Nokia there were people who knew they were going to be laid off in six months and were able to stay at Nokia with a Nokia email address with the Nokia laptop and spend time applying for new things, and Nokia helped them.
— Ari Tulla, laid off Nokia employee, now co-founder and CEO of BetterDoctor (quoted by BBC)
In a separate post, we’ll explore what we know about the relationship of health and on-demand or “gig” economy jobs, like Uber drivers, Airbnb hosts, Postmates couriers, and TaskRabbit taskers.
[If you’d like to comment on this post, please head on over to the LinkedIn version.]
Half of What I Know About Employee Health
I Learned from Concussion
Concussion is a movie about employee health as much as it’s about anything.
In the movie, the National Football League goes to great lengths to cover up the harm it allows to be inflicted on its players. The league is motivated by fear of liability and its unquenchable thirst for ever-increasing revenue.
Medical examiner Bennett Omalu, MD, a trained neuropathologist played in the movie by Will Smith, determines that several ex-players who died of unnatural causes suffered from chronic traumatic encephalopathy — CTE. The disease is characterized by long-term damage to specific sections of the brain, where tau proteins surround and choke off brain cells. The damage affects memory, agitation, and anger, and leads to dementia and, reportedly, Alzheimer’s disease. Brain studies were conducted on numerous players who died, including several who committed suicide. Ann McKee, a neuropathologist at Boston University’s CTE Center, reported in 2013 that she’d examined the brains of 46 former football players and found CTE in 45 of them.
Professional football players are employees of their respective teams, and the NFL serves as a sort of trade association for its member teams. For years, the NFL deflected blame for CTE, sometimes onto the players themselves. They pointed their finger to substance abuse (including steroids and alcohol), past history of concussion, and genetics. They downplayed the role of concussion, insisting that “mild traumatic brain injuries are not serious” and that players could safely return to the same game after suffering a concussion.
Ultimately, the NFL agreed to pay $765 million dollars in a settlement with more than 4,500 retired players who sued the league for concealing the issue. Speaking about the settlement, NFL Commissioner Roger Goodell said, “There was no admission of guilt. There was no recognition that anything was caused by football.”
The settlement included a provision that the NFL would never again compensate players or their families for CTE, which is why, as one example, the family of hall of famer Frank Gifford, diagnosed with CTE post-mortem in November 2015, cannot take action against the NFL.
Joe’s brain cloud and black brain mass, which viewers are led to believe result from job strain, are the stuff of satire. But is there really a chance that average workers exposed to prolonged job stress suffer brain damage — structural changes in brain tissue with accompanying symptoms?
Yes, there is.
Repetitive stimulation of the amygdala — a result of prolonged job stress — releases chemicals to the medial prefrontal cortex and may cause thinning of the cortex, enlargement of the amygdala and, consequently, a cycle of deteriorating stress modulation, cognitive symptoms, and impaired fine motor function.
In 2014, Ivanka Savic, MD, PhD of Sweden’s Karolinska Institute, published a study that used brain MRIs and showed that prolonged job stress — which included chronic overtime and a cycle of distorted perceptions regarding job demands, abilities, and control — leads to structural changes in the brain.
Compared to the MRIs of demographically matched control subjects, the patients who reported debilitating job stress — and exhibited burnout symptoms like impaired memory and concentration, sleeplessness, achiness, fatigue, and emotional exhaustion — showed abnormalities in the parts of the brain involved with the processing and perception of stress, specifically the prefrontal cortex and the cortex (which were abnormally thin) and the amygdala (abnormally large). These findings were consistent with Savic’s hypothesis that “repeated, chronic stress could lead to damage of the brain areas which modulate stress perception, leading to a vicious cycle with impaired ability to cope with stress.” The MRI findings were supported by documentation of reduced fine-motor skills and emotional regulation in the stressed group compared to the control subjects.
Finally, Dr. Savic concluded, “This condition needs to be considered as a stress illness, whose sufferers deserve proper and swift treatment.”
While a worker suffering from stress-related ailments may feel, as they go about their business, like they metaphorically are banging their head against a wall, the analogy between job-stress and football concussions is somewhat tenuous. Here are some ways the two phenomena differ:
The research on job-stress-related brain damage is still preliminary.
CTE is a result of smashed brains. Job-stress-related brain damage is more subtle, resulting from interactions between an individual’s job and their perceptions, and the resulting chemical activity in the brain.
There is no “cover-up” of job-stress-related brain damage that we know of — if for no other reason than most employers don’t know about it.
Job-stress-related brain damage has not been linked to behaviors that are as aberrant as those linked to repeated football concussions, nor has it been linked to death (though job stress has been found to be a significant risk factor for cardiovascular disease and death).
But there are some similarities, too:
Football concussions cause brain damage. Prolonged job stress also appears — based on preliminary research — to cause brain damage.
Just as football’s CTE was originally blamed on players (their drug use, history of previous head injury, or genetics), job stress in the United States has commonly been accepted to be solely a consequence of employee perception and coping skills, with employers turning a blind eye to their own role in creating job conditions that cause stress. Instead of empowering you with more control over your workflow, your employer adds a resilience program to your to-do list. In the absence of a broader preventive strategy, resilience programs are for job stress what football helmets are for concussions: Tools to help you endure more pain.
NFL players and everyday workers — as well as the enterprises that employ them — will benefit from having these neurological conditions identified and treated as early and effectively as possible.
Ultimately, symptoms of job-stress-related brain damage may prove to be less severe than CTE. But its burden to society — in terms of economics, well-being, and productivity — may be far greater simply due to the vastly larger population at risk.
It may be hard to get your brain around abstract models of stress, especially when they don’t line up with the usual fright-or-flight illustrations or seem remediable by the relaxation tips commonly sold as solutions. But if we care about workers, and how employers may be able to help them, we can’t ignore the harmful effects of effort-reward imbalance.
Think back to Psych 101 and you’ll remember that most human transactions are based on our expectation of an even exchange, or social reciprocity. It’s like an unwritten contract. We’re hard-wired for evenhandedness, and when we get — or believe we’ve gotten — a raw deal, we suffer from physical and emotional stress.
In the workplace, employees trade their currency — effort — for the employer’s currency, rewards, which include:
job security and prospects for promotion
respect and prestige within the organization
The balance — or imbalance — of effort and reward may be influenced by an employee’s motivational style, especially for employees who are intrinsically driven to overextend their effort independent of rewards, often to fulfill their underlying longing for approval. This surfaces as “overcommitment” in the effort-reward imbalance model.
When physical and or mental job effort outweigh the reward — or employees perceive the balance to be out of whack — the result is chronic stress and, over time, the physical and mental problems that stress can lead to.
This understanding of work stress was first conceptualized by medical sociologist Johannes Siegrist.
The model of effort rewards imbalance claims that lack of reciprocity between costs and gains (i.e., high-cost/low-gain conditions), define a state of emotional distress with special propensity to autonomic arousal and associated strain reactions.
Siegrist’s theory was put to the test in Britain’s classic “Whitehall II Study,” which followed more than 10,000 civil service workers for 11 years. Results showed that effort-reward imbalance led to increased risk of cardiovascular disease, as well as declines in overall physical and mental health. Study subjects who were lower on the organizational chart and those with less workplace social support had the highest levels of risk among those with effort-reward imbalance. Since then, research has shown even more pronounced effects of effort-reward imbalance, especially on the risk of heart disease and depression — based on rigorous studies of employees in a wide range of occupations working in countries across the globe.
The Whitehall researchers, led by social determinants of health pioneer Sir Michael Marmot, felt their results showed that cardiovascular disease and other stress-related illnesses could be prevented by improving work conditions. Their work led to a campaign to encourage employers to:
Improve rewards by recognizing good job performance
Encourage job-skill and professional development
Foster social support at the workplace
Siegrist has proposed additional solutions:
Leadership development among supervisors, emphasizing the importance of esteem, recognition and appropriate feedback.
Building upon non-monetary rewards, like flexible work options, more effectively matching job status to achievements, and fostering job security.
Effort-reward imbalance is one of the two most influential frameworks for understanding job stress, alongside the demand-control model of job strain. In fact — despite our preoccupation with other models that push accountability for stress solely on workers — regarding both demand-control and effort-reward imbalance, Siegrist wrote in 2014:
Empirical evidence on their health-adverse effects is far broader than is currently the case for any other stress-theoretical model related to work and employment.
Ultimately, most elements of the psychosocial work environment can be plugged into one or both of these models.
Whether effort-reward imbalance is a product of employee perception or actual work conditions remains a topic of debate. Most likely, both play a role. Certainly, job demands and job control have been validated as causes of cardiovascular disease and high blood pressure, in contrast to trendy notions that stress is a mindset or is a good thing and that employees are on their own to address it. The role of personal interventions is to help employees with problem-solving skills that can help them advocate for themselves, assess their level of effort as objectively as possible and, in some cases, moderate overcommitment. Stress management and resilience programs may play a supporting role.
The workplace demons that threaten employee health include long work hours, job insecurity, low job control, high job demands, shift work, effort/reward imbalances, role ambiguity, work-family conflict, inadequate workplace social support, and unfair treatment. These can be bucketed in various ways, but whatever you call them, they are the work conditions — controllable by employers — that research has consistently shown to influence employee health and well-being.
Now, along comes a study out of Stanford University that not only endeavors to quantify the burden — in terms of health outcomes, cost, and mortality — of these demons (what the researchers called “stressors” and I sometimes refer to as the workplace determinants of health), but also puts it into context relative to other, more commonly recognized, health issues.
Spoiler alert: More than 120,000 deaths per year and approximately 5% to 8% of annual healthcare costs may be attributable to how U.S. companies manage their workforce, according to this analysis. The mortality rate for these stressors, plus another the researchers found to have significant impact — lack of health insurance — was on par with the fourth and fifth largest causes of death in the U.S.: heart disease and accidents. It was greater than mortality resulting from diabetes, Alzheimer’s, or influenza.
Exposure to the following stressors was found to be more harmful than secondhand tobacco smoke:
Lack of health insurance
Low organizational justice (fairness)
High job demands
And — again, using secondhand smoke as a benchmark — the conditions that had a greater affect on mortality are:
Low job control
Long work hours
Lack of health insurance
The Stanford researchers concluded,
Employers may not make appropriate decisions concerning workplace management if they are unaware of the link between management decisions and employee health and healthcare costs. Our analysis suggests that for such organizations, paying attention to the structure of the workplace and the associated job stressors experienced by their employees may be a fruitful way to reduce unnecessary healthcare costs.
But they acknowledge that employers may have limited motivation to address these issues if, indeed, they’re not on the hook for the costs of health care — for example, in the cases of employees who have been laid off or who are not offered health insurance. The study didn’t delve into associations between stress and productivity.
The analysis was conducted by Joel Goh, Jeffrey Pfeffer, and Stefanos A. Zenios and published in Management Science. Goh is now on the faculty of Harvard Business School.
The researchers are conservative yet insightful in their expectations regarding the implications of their work:
While we stop short of claiming that employer decisions have a definite effect on these outcomes and costs, denying the possibility of an effect is not prudent either. Analyzing how employers affect health outcomes and costs through the workplace decisions they make is incredibly important if we are to more fully understand the landscape of health and well-being.
And what of our current approach to employee well-being, with its slaphappy embrace of screenings, health risk assessments, health coaching, apps, wearables and incentives? How does it jibe with the real determinants of worker health? Not very well, according to study co-author Jeffrey Pfeffer. In his YouTube interview for the Stanford Graduate School of Business, he says,
Employers worry mostly about individual decisions: eating, exercise, smoking, drinking…things like that. Or about policy issues like how we pay for health care. A lot of their excess health care costs come from what happens to people every day in the work environment… Things that employers could fix, if they wanted to.
Job strain is a particularly insidious form of stress that goes far beyond overflowing inboxes or tight deadlines. It is characterized primarily by organizational environments and job structure in which employees have high levels of demands placed on them and limited control over those demands (that is, low “decisional latitude”). This is the demand-control model that was originally described and measured by Robert Karasek. Other organizational and job-related factors that contribute to unhealthy job-related stress are effort-rewards imbalances, long work hours (sometimes including long commutes), job insecurity, and lack of social support on the job. Some researchers have categorized all of these stressors as job strain, others differentiate them. But most agree that these stressors — all related to organizations and job design and not to individual behavior — lead to negative health outcomes.
How unhealthy is job strain?
Job strain has been linked to hypertension and to heart disease. This is not a simple matter of people who have other risk factors, like pre-existing hypertension or what used to be called Type A personality, being drawn to stressful jobs. Research suggests a causal relationship between job strain and both hypertension and cardiovascular disease. (Some studies also have linked job strain to depression, musculoskeletal disorders, dyslipidemia, physical inactivity, obesity, and adverse birth outcomes.)
Blue collar workers are more prone to the effects of job strain compared to white collar workers, but no one is immune.
Not every study of job strain has confirmed this relationship, but most have. A 10-year prospective study of 22,086 female health professionals, published in 2012, revealed that women with active jobs (high demand, high control) and high levels of job strain (high demand, low control) were 38% more likely to experience a cardiovascular disease event (such as heart attack or diagnosis of atherosclerosis) compared to women reporting low job strain. During the study, there were 170 myocardial infarctions, 163 ischemic strokes, 440 coronary revascularizations, and 52 cardiovascular-disease-related deaths, reaffirming that cardiovascular disease is a major concern for employers and for public health.
A Finnish study of 812 employees, followed for more than 25 years, found that employees with high demands at work and low job control had a 2.2-fold increased cardiovascular mortality risk — independent of other risk factors — compared to their colleagues with low job strain.
Earlier this year, an Israeli study confirmed a link between job burnout and coronary heart disease. Job burnout was defined as physical, cognitive, and emotional exhaustion that results from stress at work. Factors contributing to burnout included most of those typically associated with job strain or job stress: heavy workload, lack of control over job situations, lack of emotional support, and long work hours. Over the course of the study, 8,838 male and female employees were followed for an average of 3.4 years. Each subject was measured for burnout, which, as it turned out, was associated with a 40% increased risk of developing heart disease. Of greatest concern, the 20% of participants with the highest burnout scores had a 79% increased risk of heart disease.
A British study of 6,014 workers, followed for an average of 11 years, found that three to four hours of overtime per day is associated with a 1.6-fold increase in coronary heart disease risk, independent of other risk factors. (More about overtime in a future post.)
Countless research studies have demonstrated the relationship between job strain and health.
Unlike many other countries (again…especially Scandinavian countries), American employers continue to insist on offering employees behaviorally based stress management programs, such as relaxation programs and time management seminars, rather than trying to address the program where the employer actually has the most control: the structure of the organization and the jobs within it.
Even the National Institute for Occupational Safety and Health declares, “Working conditions play a primary role in causing job stress” and it advises,
As a general rule, actions to reduce job stress should give top priority to organizational change to improve working conditions.
Check out the NIOSH page for some ideas about the type of organizational change that is needed.
Emphasis on the organization’s role, rather than the employee’s role, may have applications beyond stress. Fitness challenges, biggest loser contests, tobacco-free campuses, incentives, health risk assessments, coaching, health screenings, yoga classes, and even culture-of-health have limited potential to evoke meaningful population health improvement…as long as the roots of the problem persist.
[A version of this post was first published on Bob Merberg’s Health Shifting blog on December 20, 2014]