Occupational stress and itsconsequences

Implications for health policy andmanagement

Ali Mohammad MosadeghradHealth Management and Economics Research Centre, School of HealthManagement and Information Sciences, Tehran University of Medical

Sciences, Tehran, Iran

AbstractPurpose – This study aims to identify the status of occupational stress among a sample of hospitalemployees in Iran. It further intended to reveal the harmful effects of occupational stress on employees’health and well-being.Design/methodology/approach – The study used a cross-sectional research design. A validatedquestionnaire was used to collect data from hospital employees.Findings – Job-related, working environment, interpersonal and organisational factors were related tooccupational stress. One-fourth of employees rated their occupational stress high. The major sources ofoccupational stress were inadequate pay, inequality at work, too much work, staff shortage, poorrecognition and promotion, time pressure, job insecurity and lack of management support. High levelsof occupational stress have been linked to an increased risk of physical injuries, cardiovascular disease,high blood pressure, depression and increases in negative personal behaviours such as anger, anxietyand irritability. Occupational stress was positively associated with employees’ turnover intentions.Research limitations/implications – The findings of this study are not generalisable to the widerpopulation of hospital employees in Iran due to the small sample size. Thus, future research shouldinvolve additional samples.Practical implications – The study has practical relevance for designing and implementingstrategies to decrease occupational stress among hospital employees.Originality/value – This article contributes to health care theory and practise by identifying factorscontributing to employees’ occupational stress and examining the association between occupationalstress and two important employee outcomes – health status and turnover intention.

Keywords Human resource management, Stress, Hospitals, Employees, Occupational stress

Paper type Research paper

IntroductionHealth care, with excessive workload, difficult working conditions, dealing withdifficult patients, uncertainty concerning treatment of patients and numerousoccupational health and safety hazards is essentially a stressful profession. Severalresearchers have tried to identify sources of stress among health care employees.

The author would like to thank all the hospital employees who participated in the study. Theauthor is also grateful to the editor and anonymous LHS reviewers for their constructivecomments and guidance for improving this paper.

The current issue and full text archive of this journal is available atwww.emeraldinsight.com/1751-1879.htm

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Received 20 July 2013Revised 2 November 2013Accepted 13 January 2014

Leadership in Health ServicesVol. 27 No. 3, 2014pp. 224-239© Emerald Group Publishing Limited1751-1879DOI 10.1108/LHS-07-2013-0032

Job related, individual, organisational and environmental factors influenceemployees’ stress. The job itself including duties, responsibilities, heavy workload,variations in workload, role ambiguity and role conflict can be a source of stress foremployees (McGowan, 2001; Michie and Williams, 2003; and Robinson et al., 2003). Theworking environment such as resources shortage, problems with colleagues and poormanagement styles can be stressful (Flanagan, 2006; Isikhan et al., 2004; and Steinhardtet al., 2003). Organisational policies such as long work hours, inadequate training, jobinsecurity, inadequate salary and lack of career prospects can also be stressful (McCannet al., 2009; Mosadeghrad, 2013; and Schmitz et al., 2000). Socio-demographic predictorsof occupational stress include:

• gender (Cheng et al., 2001);• educational level (Golubic et al., 2009);• tenure (Chiang and Chang, 2012); and• race (Mitchell et al., 2001).

Finally, personality characteristics have an influence on an individual’s ability to copewith occupational stressors (Oginska-Bulik, 2006).

Occupational stress causes adverse outcomes for both employees and organisations.Occupational stressors are serious threats to the health and well-being of health careemployees. Occupational stress may cause physical, mental and social illness forhealthcare professionals. It is associated with the following:

• chronic fatigue (Van der Ploeg and Kleber, 2003);• disordered eating (King et al., 2009);• headaches (Schaubroeck and Fink, 1998);• increased blood pressure (Melamed et al., 2001);• increased risk of cardiovascular diseases (Espnes and Byrne, 2008); and• musculoskeletal pains (Eriksen et al., 2003).

Occupational stress may also cause psychological distress such as:• emotional exhaustion (Coffey and Coleman, 2001; and Imai et al., 2004);• mood disturbance (Healy and McKay, 2000);• sleeping problems (Piko, 1999);• lack of concentration (Shapiro et al., 2005);• depression (Cho et al., 2008);• anxiety (Bussing and Hoge, 2004); and• suicidal ideation (O’connor et al., 2000).

On the organisational level, occupational stress is linked to employee performance (AbuAl Rub, 2004). Stress decreases attention, concentration and decision-making andjudgement skills (Shapiro et al., 2005). A strong inverse relationship was found betweenoccupational stress and employees’ quality of working life (Machin et al., 2004; andMosadeghrad et al., 2011), morale (Machin et al., 2004), motivation (de Jonge et al., 2001),job satisfaction (Flanagan and Flanagan, 2002; Grunfeld et al., 2000; and Redfern et al.,

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2002) and organisational commitment (Khatibi et al., 2009; and Lambert and Paoline,2008). Occupational stress also may lead to increased burnout and physical, mental andemotional exhaustion (Spickard et al., 2002), absenteeism (Eriksen et al., 2003; andMachin et al., 2004) and intention to leave workplace (Chou-Kang et al., 2005;and Mosadeghrad, 2013). Occupational stress is also negatively related to quality of caredue to loss of compassion for patients and increased incidences of mistakes and practiceerrors (Engström et al., 2006; Teng et al., 2010).

A conceptual framework aiming to explain the impact of occupational stress onemployees’ outcome is expressed graphically at Figure 1. There is a variety ofjob-related, interpersonal, organisational and working environment factors influence aperson’s level of occupational stress. As shown, the relationship between occupationalstress and employees’ outcomes is moderated by individual and socio-cultural factors.

MethodologyPurpose and objectivesThe purpose of this paper is fourfold: first, to assess the occupational stress level inhospital employees in Isfahan, Iran; second, to reveal factors that influence hospitalemployees’ occupational stress; third, to identify stress-related physical and mentalproblems of hospital employees; and fourth, to examine the relationships betweenoccupational stress and employees’ turnover intention.

DesignThe study utilised cross-sectional, descriptive and correlational design and surveymethod.

Setting and sampleHospital care in Iran is provided by government-financed Ministry of Health hospitals(MOH), the social security organisation-affiliated hospitals (SSO) and private hospitals.

Figure 1.Conceptual framework ofrelationships betweenoccupational stress andemployee outcomes

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The study was carried out at six hospitals, three MOH (two educational and onenon-educational) one SSO and two private hospitals. The six hospitals of the study wereselected to represent the three dominant hospital care systems in Iran. Seven hundredand forty employees were selected for this research after a pilot study by using thefollowing formula (N � 2411, d � 0.03, z � 1.96 and s � 0.50). Employees who had lessthan six-months working experience were excluded from this study.

n �Nz2s2

Nd2 � z2s2

InstrumentA literature review was conducted to identify the occupational stress questions (Frenchet al., 2000; McVicar, 2003; McGowan, 2001 and Michie and Williams, 2003). From eachstudy, a list of questions was created. Using a Delphi technique, the organisationalbehaviour and management experts’ opinions were used in completing this list. Factoranalysis was used to group questions into certain dimensions. These included stressrelated to job, work environment, organisational policies and interpersonal relations(Table I). Content and face validity were established by a panel of management expertsand hospital staff.

A pilot study was undertaken to test the relevance and clarity of the questions and torefine them as needed to avoid misunderstandings. A small sample of 40 randomlyselected hospital employees who were not included in the sample received thequestionnaires. The questionnaires were found to be understandable and acceptable.Cronbach’s alpha was computed for each scale using the SPSS-11 statistical package.The reliability coefficient was 0.82 for occupational stress questionnaire (Table II).Turnover intention was measured using a single item: “To what extent do you want toleave this organisation, if you find another job opportunity?”

Table I.Definition of job stressors

Job stressors Definition

Job-related stressors Anything related to duties, responsibilities andorganisational role that produces adverseconsequences for an individual such asworkload, time pressure and decision latitude

Work environment-related stressors Anything related to an organisationalenvironment that produces adverseconsequences for an individual such asinappropriate working condition, inadequateequipment and hazardous situation

Organisational policies-related stressors Anything related to organisational policies thatproduces adverse consequences for an individualsuch as inadequate pay, poor promotionprospects, job insecurity and deficient leadership

Interpersonal relations-related stressors Anything related to interpersonal relationshipsthat produces adverse consequences for anindividual such as bullying and harassmentbehaviour from managers, co-workers andcustomers

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Data collectionThe sampling method was stratified as random sampling. Employees from variousdepartments of the hospitals participated in the survey. Informed consent was obtainedfrom all subjects following receipt of information on the purpose of the study,assurances of anonymity and confidentiality. Respondents were asked to rate theintensity of 30 common occupational stressors using a five-point scale (very low, low,medium, high, very high).

Data analysisAll data were analyzed using the statistical package for the social sciences (SPSS 11). Tonormalise the Likert scale on 1- 5 scales for each domain of occupational stressquestionnaire, the sum of raw scores of items in each domain was divided by thenumbers of items in each domain, and for overall occupational stress, the sum of rawscores of items were divided by 30. The possible justified scores were varied between 1and 5. Scores of 2 or lower on the total scale indicate very low, scores between 2 and 2.75indicate low, scores between 2.76 and 3.50 indicate moderate, scores between 3.51 and4.25 indicate high and scores of 4.26 or higher indicate very high occupational stress.

The differences between groups were tested with the chi-square, independent t-test,Mann–Whitney and Kruskal–Wallis tests. Then, the relationship between occupationalstress and its five dimensions was investigated by calculating Pearson’s correlationcoefficients. Regression analysis was used to identify the most important predictordomains in occupational stress. The significance level was set at p � 0.05.

ResultsSix hundred and eight employees filled out the questionnaires (82.2 per cent). More thanhalf of the participants were females (54.3 per cent) and over three-fourths (80.6 per cent)were married. The majority had bachelor’s degree (45.4 per cent). More than half of theemployees (58.4 per cent) had an incomes of � 3 million Rials (poverty line in Iran in2008); 48.7 per cent of employees had permanent employment (Table III).

The average employee age was 34.53 years (SD � 8.28) with the youngest aged 21years and the oldest 60 years. The majority of the respondents were aged 20-30 years(34.4 per cent), followed by 31-40 years (32.6 per cent). Employees had worked anaverage of 10.8 years (SD � 8.07) in their career, with a minimum of 1 year and amaximum of 32 years.

The mean score of employees’ occupational stress was 3.14 compared with thepossible range from 1.10 to 4.63 (Table IV). Overall, 26 per cent of hospital employeesreported that their job was very or extremely stressful. The major sources ofoccupational stress were inadequate pay (3.79), inequality at work (3.75), insufficientregular breaks at work (3.71), too much work (3.67), staff shortages (3.62), poor

Table II.Internal consistencyanalysis

Job stressors Item numbers Number of items Cronbach’s alpha

Job-related stressors 1-12 12 0.78Work environment-related stressors 13-15 3 0.71Organisational policies-related stressors 16-25 10 0.88Interpersonal relations-related stressors 26-30 5 0.81Overall job stress 1-30 30 0.82

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recognition and promotion (3.61), time pressure (3.60), job insecurity (3.58) and poormanagement support (3.48).

Employees scored a mean of 2.88 and 2.73 on a five-point scale for role ambiguity androle conflict, respectively, as occupational stressors. While 21.2 per cent of employeesfound role ambiguity (unclear job description) a source of stress, 41.1 per cent ofemployees saw role contradiction (unclear role expectations) stressful.

The Kruskal–Wallis test revealed that the total occupational stress scores wasdiffered among six hospitals (chi-square � 22.195, df � 5, p � 0.00). Employees’

Table III.Percentage of participants

and the mean score oftheir job stress

Demographicparameters Per cent of sample

Job stressMean SD

GenderMale 45.7 3.10 0.65Female 54.3 3.18 0.68Marital statusSingle 19.4 3.21 0.60Married 80.6 3.12 0.69EducationIlliterate 0.7 2.67 0.58Under diploma 14 2.85 0.53Diploma 19.9 3.07 0.58Post-diploma 15.8 3.16 0.60Bachelor’s degree 45.4 3.24 0.69Master’s degree or GP 3.6 3.28 0.68Doctoral degree 0.7 3.31 0.52Area of workManagerial and clerical 12.0 2.97 0.62Ancillary or logistic 19.4 3.01 0.60Diagnostic 17.1 3.11 0.60Therapeutic 51.5 3.24 0.71Age (years)20-30 34.4 3.15 0.6731-40 32.6 3.20 0.7141-50 29.1 3.12 0.63� 50 3.9 2.73 0.58Tenure (years)1-5 32.9 3.16 0.706-10 26 3.19 0.7111-15 15.1 3.14 0.6816-20 11.2 2.11 0.6521-25 7.6 3.09 0.5926-30 6.9 3.08 0.54� 30 0.3 2.82 0.60Type of employmentTemporary 51.3 3.20 0.70Permanent 48.7 3.08 0.66Received wages� RLS3,000,000 58.4 3.16 0.66� RLS3,000,000 41.6 3.12 0.69

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occupational stress in public hospitals was less than private and semi-public hospitals(Table IV). The differences between values of employees’ occupational stress in thesehospitals were statistically significant (p � 0.001).

The employee’s occupational stress in therapeutic (clinical) and diagnosticdepartments was higher than ancillary and administrative departments. A statisticalsignificant association was seen between employees’ occupational stress and their areaof work or specialty (p � 0.001). Nurses and physicians showed the highest levels ofoccupational stress. The mean score of employees’ occupational stress in the psychiatryward (4.07), internal medicine (3.91), orthopaedics (3.62), surgery (3.55), obstetrics (3.53),admission (3.44), ICU (3.43), paediatrics (3.42), cardiology (3.35), operation room (3.38),accident and casualty department (3.27), physiotherapy (3.26), coronary care unit (3.21)and laboratory department (3.03) was high. Employees experienced low occupationalstress in non-specialised and clinical environments such as library (2.32), secretariat(2.73) and administrative office (2.82).

As Table V shows, employees reported more occupational stress than managers.However, the differences between values were not statistically significant (t � �0.137and p � 0.891).

High levels of occupational stress have been linked to an increased risk of physicalinjuries; cardiovascular disease; high blood pressure; depression; and increases innegative personal behaviours, such as anger, anxiety and irritability (Table VI). Femaleemployees experienced more job stress-related physical and mental problems than theirmale colleagues (r, p � 0.02). Overall, 257 employees (42.3 per cent) had to use workstress-related leave. Employees’ work stress-related leave was, on average, 7.77 days(total, 1997 days).

Table IV.The mean of employees’job stress in differenthospitals (on a five-pointscale)

Job stress dimensions

Publichospitals

Semi-publichospitals

Privatehospitals Overall

Mean SD Mean SD Mean SD Mean SD

Job-related stress 3.05 0.79 3.36 0.81 3.13 0.77 3.12 0.73Interpersonal relations 2.92 0.94 3.11 0.94 2.72 0.83 3.06 0.92Work environment 3.15 0.96 3.25 0.93 3.26 0.98 3.20 0.83Organisationalpolicies 3.06 0.76 3.38 0.65 3.23 0.70 3.16 0.73Overall job stress 3.07 0.70 3.30 0.60 3.15 0.66 3.14 0.67

Table V.The mean of employeesand managers’ job stress(on a five-point scale)

Job stress dimensionsManagers Employees

p-valueMean SD Mean SD

Job-related stress 3.11 0.82 3.13 0.78 0.76Interpersonal relations 3.20 0.89 3.15 0.92 0.29Work environment 2.99 0.92 3.08 0.95 0.90Organisationalpolicies 3.18 0.65 3.20 0.74 0.61Overall job stress 3.12 0.68 3.15 0.68 0.73

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Occupational stressors such as too much work, hazardous situation, lack of abilities todo the job, staff shortages, time pressure, lack of training, inadequate resources andinappropriate working conditions were related to staff physical injuries. Low decisionlatitude, role contradiction, conflict in the workplace, discrimination at work, jobinsecurity, lack of management support and bullying and harassing behaviour fromcustomers were related to staff psychological illness (e.g. depression).

There was strong correlation between the occupational stress of employees and theirgender (r � 0.134 and p � 0.001), age (r � �0.131 and p � 0.002), tenure (r � �0.110 andp � 0.008), graduation level (r � �0.125 and p � 0.002), their place of work (r � �0.179and p � 0.001) and type of employment: permanent or contract employment (r � �0.085and p � 0.04).

Female employees reported higher occupational stress than their male colleagues.Women because of their responsibilities at both home and workplace are facing doublestress. Men and women experienced different stressors at work. While insufficient paywas the main stressor for male employees, female employees complained more aboutdiscrimination at work, too much work (quantity burden) and insufficient regularbreaks at work. Female employees reported more occupational stress resulting fromorganisational policies and interpersonal relations than their male counterparts (p �0.01). Nevertheless, men used more work stress-related leave than women (nine vs sevendays a year).

There is a meaningful difference in stress among various ages. Occupational stresswas higher in younger employees. Occupational stress peaked at ages 31-40, with about30.3 per cent of hospital personnel in this age range reporting high occupational stress.Older employees with more years of experience had less occupational stress than theiryounger colleagues. Regarding marital status, although the average occupational stressamong single employees was higher than the married ones according to Mann–Whitneytest, there was no meaningful difference (p � 0.665).

Calculations of Spearmen’s ratios revealed the strongest correlation between totaloccupational stress and occupational stressors related to organisational policies,job-related, interpersonal relations and work environment. As Table VII shows, thisrelationship was statistically significant in all cases (p � 0.001).

Correlation analysis revealed that occupational stressors such as low decisionlatitude (0.680), given responsibility without the authority to take decisions (0.666), jobinsecurity (0.635), bullying and harassment behaviour from managers (0.631),discrimination at work (0.623), poor management support (0.616), inadequate equipment

Table VI.Employee job-related

problems in studyhospitals

Job stressors Percentage

Anxiety 27.3Headache (migraine) 26.15Anger 23.5Back pain 21.7Gastrointestinal problems 19.9Irritability 18.1Depression 17.4Foot pain 13.3Cardiovascular disease 7.7

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(0.615), bullying and harassment behaviour from co-workers (0.608), conflictingdemands (0.590), job identity (0.542), lack of recognition and promotion prospects(0.541), role ambiguity (0.537), bullying and harassment behaviour from customers(0.494), role contradiction (0.479) and policies and regulations (0.329) had more effect onemployees’ occupational stress.

Multiple regression analysis was used to assess the impact of independentorganisational, job-related and individual variables upon self-reported stress(dependent variable). Job-related factors explained the largest amount of the variance inemployee occupational stress (80.2 per cent), followed by organisational factors,interpersonal relations and work environment. With regard to job-related factors, timepressure explained the largest amount of the variance, followed by conflicting demands,needing more consciousness for doing tasks (quality burden), lack of coordinationbetween the job and employee abilities and too much responsibility. Employees’characteristics explained a smaller amount of variation in occupational stress.

DiscussionThe occupational stress of Iranian hospital employees who participated in this surveywas at a medium level, mainly because of inadequate salaries, inequality at work,excessive workload, staff shortage, poor promotion, job insecurity and poormanagement support. These findings are consistent with other studies’ that foundIranian hospital employees face moderate (Faraji et al., 2012; and Sharif et al., 2011) orhigh occupational stress (Ghasemi et al., 2011; Tabatabaei et al., 2012). They alsoreported increased staff shortage, heavy workload, low pay and job insecurity as themain stressors for Iranian hospital employees.

High levels of occupational stress were associated with poor health and increasedturnover intention. Occupational stress caused physical and mental problems forhospital employees. Heavy workload, hazardous situation, staff shortages, lack oftraining and inadequate resources were related to employees’ physical injuries. Lowdecision latitude, role contradiction, conflicting demands, job insecurity and poormanagement support caused psychological distress for employees.

Employees were more likely than managers to report job-related stress. They weremore dissatisfied with the salaries, benefits and workload. The current study showedthat female employees are more vulnerable to the effects of occupational stress on healththan their male colleagues. While men experienced higher job demand and role-relatedstressors, women reported higher occupational stress related to organisational policiesand interpersonal relations.

Table VII.Inter-correlations betweenjob stress

Job stressors 1 2 3 4 5

1. Overall job stress �2. Stress related to the job 0.776** �3. Stress related to human relations 0.835** 0.607** �4. Stress related to work environment 0.715** 0.535** 0.547** �5. Stress related to organisational policies 0.869** 0.620** 0.677** 0.531**6. Intention to leave the organisation 0.254** 0.187** 0.155** 0.113** 0.246**

Note: ** Correlation is significant at the 0.01 level (two-tailed)

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At present, Iran is subject to the United Nations, the USA and the EuropeanUnion economic sanctions. The imposed sanctions directly or indirectly affecteconomic activity, employment status and quality of life of Iranian people.Economic restrictions had contributed to shortages of staff and resources. Hospitalemployees in this study complained about staff shortages, too much work and jobinsecurity.

Employees working in semi-public hospitals reported higher level of occupationalstress as compared to employees working in public and private hospitals. They facehigh duty-related stressors. Semi-public hospitals provide free health care services tosocial security-insured patients. Consequently, the demand for services in thesehospitals is very high. The findings also showed that all four dimensions of occupationalstress are inter-related. Therefore, it can be concluded that an increase in duty and workenvironment-related stress can result in more interpersonal tensions. Tankha (2006)similarly found that hospital employees in private hospitals experienced moreoccupational stress than employees in public hospitals.

Stress scores were significantly higher for employees in clinical departments. Nursesand physicians in psychiatric, internal medicine, orthopaedics, surgery and obstetricswards experienced more occupational stress and were more likely to leave theirpositions than the staff in other departments. These findings support the assumptionthat nursing and medicine are stressful occupations, and nurses and physicians aremore prone to a high degree of stress and burnout than other staff in health care settings.Occupational stressors in nursing and medicine include excessive workloads, staffshortage, irregular working hours, dealing with patients, uncertainty concerningtreatment of patients, conflict with other colleagues, dealing with death and dyingpeople and concerns about technical knowledge and skills (McGowan, 2001; Robinsonet al., 2003; and Sharif et al., 2011).

Dissatisfaction with remuneration was a major source of distress for Iranian hospitalemployees. Lack of benefit and reward is an increasing source of frustration andcontributes to employees’ turnover. The findings of this study revealed that employees’income was associated with their intentions to quit. Similarly, other studies found thatpay and benefits were the major determinants of occupational stress and turnoverintention (Ernst et al., 2004).

Heavy workload and inadequate staff to cover duties were the most significantassociated factors of stress for Iranian hospital employees. Several studies havehighlighted work overloads and time pressure as significant contributors to work stressamong health care professionals (Al-Aameri, 2003; Grunfeld et al., 2000). An excessiveworkload increases job tension and decreases job satisfaction, which, in turn, increasesthe likelihood of turnover (Aiken et al., 2002; and Strachota et al., 2003). Inadequatestaffing also inversely influence the quality of provided health care services and patientoutcomes (Whitman et al., 2002).

Unfairness and inequality at work (lack of organisational justice) were alsoreported as main occupational stressors among hospital employees in this study.Findings from the study showed that treating people unfairly could result in a seriesof negative or stress-related reactions that increase the risk of poor physical andmental health. These findings are consistent with those findings of McCann et al.,2009 and Wilkinson, 2005.

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Job insecurity was found in this study as a factor that negatively influencesoccupational stress of hospital employees. Job insecurity threatened employees in theprivate sector more than those in the public sector. Because private hospitals areprofit-oriented, there is redundancy resulting from over staffing. This is in contradictionwith the findings of Ogunjimi et al.’s (2009) study that found public sector employees areless satisfied with their job security.

The current study showed that promotion opportunities were another significantpredictor of occupational stress among study participants. Life-long learning,professional growth and advancement promote employees’ job satisfaction, and enablecontinued provision of high-quality health care services (Donner and Wheeler, 2001). Itis therefore recommended that managers provide equal promotion opportunities foremployees. Managers should promote employees to key positions and increase theirinvolvement in decision-making (AbuAlrub and AL-Zaru, 2008).

Poor professional relationship and lack of social support at the workplace wereimportant predictors of occupational stress among Iranian hospital employees. Socialsupport, supportive relationships with colleagues and group cohesion reduce theoccurrence and the impact of job stress (Piko, 1999; and Steinhardt et al., 2003).Education, training and emphasising teamwork help improve cooperation amongprofessionals in health care organisations.

The findings revealed that organisational policies had the strongest correlation withemployee occupational stress. Structural and organisational changes such asrestructuring, downsizing, right sizing and re-engineering can result in a change in thenature of work for many employees and eventually their lay-off or relocation. Theseorganisational changes may result in excessive work demands, time pressure and roleconflicts, which cause stress for employees (Giga et al., 2003).

Developing a supportive social environment and applying corporate wellnessprogrammes improve employees’ job satisfaction and reduce occupational stress.An emphasis on staff health and safety, education and training, managers’ andemployees’ cohesion and recognition and rewards have a positive impact onemployees’ quality of work life and well-being. Corporate wellness programmespromote the adoption of organisational practices and personal behaviour conduciveto maintaining or improving employee physiological, mental and social well-being(Ho, 1997). Improving management systems and structures, assuring employeeautonomy and participation, enhancing work environment, providing necessaryeducation and training and demonstrating value to employees could reduceemployees’ occupational stress. Jobs should be designed in ways that providemeaning, motivation and opportunities for employees to use their skills. Employees’workload should be in line with their capabilities and resources. Employees’ rolesand responsibilities should be clearly defined. Necessary education and trainingshould be provided for employees to be able to do their duties effectively. Theyshould be given opportunities to participate in decisions and actions affecting theirjobs. Workplace discrimination should be minimised and preferably eliminated.Work environment and working procedures should be optimised.

In addition to applying organisational policies and strategies to improve employees’quality of working life, employees should use personal strategies to enhance theirself-controlling skills to cope with job stress. Preventive stress managementprogrammes should be available for hospital employees.

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Conclusion and implications for managementThis study makes several distinct contributions. First, using a cross-sectional approach,the level of employees’ occupational stress among a group of hospital employees inIranian hospitals was examined. Second, factors contributing to employees’occupational stress were identified. Third, the impact of occupational stress onemployees’ health status was investigated. Fourth, the relationship betweenoccupational stress and employees’ turnover intention was examined.

Hospital employees reported moderate levels of job-related stress. Factors that mayinfluence the level of employees’ occupational stress were demographic variables ofgender, age, tenure, graduation level, place of work, type of employment, type of hospitaland the four subscales of occupational stressors, as indicted in Table I. Occupationalstressors related to job itself, organisational policies, interpersonal relations and workenvironment were the best predictors of occupational stress among hospital employees.Occupational stress was associated with poor physical and mental health and increasedturnover intention.

There are several practical implications that can be derived from the findings. Thefindings alert health care managers to become more knowledgeable about occupationalstress, the risk factors, mechanisms and effects. Because occupational stress is animportant determinant of employees’ retention, it is very important to reduce it byapplying the right human resources polices. The most occupational stressors forhospital employees found in this study were inadequate pay, inequality at work, toomuch work, staff shortages, poor promotion prospects, time pressure, job insecurity andpoor management support.

Hospital managers must apply appropriate policies and strategies to prevent andreduce these occupational stressors. Such stress management programmes can decreasethe level of employees’ occupational stress by increasing their satisfaction with policies,work conditions, compensation and promotion. Besides, there are many strategies forcoping with occupational stress that employees should adopt to cope with stress easilyand effectively. Physical activity, meditation, healthy lifestyle and time managementcan help employees to cope with their occupational stress.

Limitations and implications for future researchThe findings should be interpreted with caution, as the participants were hospitalemployees from a particular province of Iran and do not represent all hospital employeesin this country. More research in this area is needed before generalizing the studyfindings. More studies that involve hospital employees from other countries wouldenrich the literature on occupational stress among hospital employees, which could, inturn, generate strategies to improve the global retention of hospital employees. Futureresearch also needs to explore the effects of variables that were not measured in thisstudy, which can also directly or indirectly influence feelings of occupational stress,such as external environmental factors.

ReferencesAbu Al Rub, R.F. (2004), “Job stress, job performance, and social support among hospital nurses”,

Journal of Nursing Scholarship, Vol. 36 No. 1, pp. 73-78.

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Abu Al Rub, R.F. and AL-Zaru, I.M. (2008), “Job stress, recognition, job performance and intentionto stay at work among Jordanian hospital nurses”, Journal of Nursing Management, Vol. 16No. 3, pp. 227-236.

Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J. and Silber, J.H. (2002), “Hospital nurse staffingand patient mortality, nurse burnout, and job dissatisfaction”, Journal of the AmericanMedical Association, Vol. 288 No. 16, pp. 1987-1993.

Al-Aameri, A.S. (2003), “Source of job stress for nurses in public hospitals”, Saudi Medical Journal,Vol. 24 No. 11, pp. 1183-1187.

Bussing, A. and Hoge, T. (2004), “Aggression and violence against home care workers”, Journal ofOccupational Health Psychology, Vol. 9 No. 3, pp. 206-219.

Cheng, Y., Guo, Y.L. and Yeh, W.Y. (2001), “A national survey of psychosocial job stressors andtheir implications for health among working people in Taiwan”, International Archives ofOccupational and Environmental Health, Vol. 74 No. 7, pp. 495-504.

Chiang, Y.M. and Chang, Y. (2012), “Stress, depression, and intention to leave among nurses indifferent medical units: implications for healthcare management/nursing practice”, HealthPolicy, Vol. 108 Nos 2/3, pp. 149-157.

Cho, J.J., Kim, J.Y., Chang, S.J., Fiedler, N., Koh, S.B., Crabtree, B.F., Kang, D.M., Kim, Y.K. andChoi, Y.H. (2008), “Occupational stress and depression in Korean employees”, InternationalArchives of Occupational and Environmental Health, Vol. 82 No. 1, pp. 47-57.

Chou-Kang, C., Chi-Sheng, C., Chieh-Peng, L. and Ching Yun, H. (2005), “Understanding hospitalemployee job stress and turnover intentions in a practical setting: the moderating role oflocus of control”, The Journal of Management Development, Vol. 24 No. 10, pp. 837-855.

Coffey, M. and Coleman, M. (2001), “The relationship between support and stress in forensiccommunity mental health nursing”, Journal of Advanced Nursing, Vol. 34 No. 3,pp. 397-407.

de Jonge, J., Dormann, C., Janssen, P.P.M., Dollard, M.F., Landweerd, J.A. and Nijhuis, F.J.N. (2001),“Testing reciprocal relationships between job characteristics and psychological well-being:a cross-lagged structural equation model”, Journal of Occupational and OrganizationalPsychology, Vol. 74 No. 1, pp. 29-46.

Donner, G.J. and Wheeler, M.M. (2001), “Career planning and development for nurses: the time hascome”, International Nursing Review, Vol. 48 No. 2, pp. 79-85.

Engström, M., Ljunggren, B., Lindqvist, R. and Carlsson, M. (2006), “Staff satisfaction with work,perceived quality of care and stress in elderly care: psychometric assessments andassociations”, Journal of Nursing Management, Vol. 14 No. 4, pp. 318-328.

Eriksen, W., Bruusgaard, D. and Knardahl, S. (2003), “Work factors as predictors of sicknessabsence: a three month prospective study of nurses’ aides”, Occupational andEnvironmental Medicine, Vol. 60 No. 4, pp. 271-278.

Ernst, M.E., Messmer, P.R., Franco, M. and Gonzalez, J.L. (2004), “Nurses’ job satisfaction, stress,and recognition in a paediatric setting”, Pediatric Nursing, Vol. 30 No. 3, pp. 219-227.

Espnes, G.A. and Byrne, D.G., (2008), “Occupational stress and cardiovascular disease”, Stressand Health, Vol. 24 No. 3, pp. 231-238.

Faraji, O., Valiee, S., Moridi, G., Ramazani, A.A. and Rezaei-Farimani, M. (2012), “The relationshipbetween job characteristics and job stress in nurses of Kurdistan University hospitals”,Nursing Research, Vol. 2012 No. 7, pp. 54-63.

Flanagan, N.A. (2006), “Testing the relationship between job stress and satisfaction in correctionalnurses”, Nursing Research, Vol. 55 No. 5, pp. 316-327.

LHS27,3

236

Flanagan, N.A. and Flanagan, T.J. (2002), “An analysis of the relationship between job satisfactionand job stress in correctional nurses”, Research in Nursing and Health, Vol. 25 No. 4,pp. 282-294.

French, S.E., Lenton, R., Walters, V. and Eyles, J. (2000), “An empirical evaluation of an expandednursing stress scale”, Journal of Nursing Measurement, Vol. 8 No. 2, pp. 161-178.

Ghasemi, M., Ghahremani, Z., Vahedian, A. and Ghorbani, F. (2011), “Job stress among Zanjanuniversity hospitals’ nurses”, Scientific Journal of Gorgan Nursing and Obstetrics Faculty,Vol. 8 No. 1, pp. 42-51.

Giga, S.I., Cooper, C. and Faragher, B. (2003), “The development of a framework for acomprehensive approach to stress management interventions at work”, InternationalJournal of Stress Management, Vol. 10 No. 4, pp. 280-296.

Golubic, R., Milosevic, M., Knezevic, B. and Mustajbegovic, J. (2009), “Work-related stress,education and work ability among hospital nurses”, Journal of Advanced Nursing, Vol. 65No. 10, pp. 2056-2066.

Grunfeld, E, Whelan, T.J., Zitzelsberger, L., Willan, A.R., Montesanto, B., Evans, W.K. (2000),“Cancer care workers in Ontario: prevalence of burnout, job stress and job satisfaction”,Canadian Medical Association Journal, Vol. 163 No. 2, pp. 166-169.

Healy, C.M. and McKay, M.F. (2000), “Nursing stress: the effects of coping strategies and jobsatisfaction in a sample of Australian nurses”, Journal of Advanced Nursing, Vol. 31 No. 3,pp. 681-688.

Ho, J.T.S. (1997), “Corporate wellness programmes in Singapore: effect on stress, satisfaction andabsenteeism”, Journal of Managerial Psychology, Vol. 12 No. 3, pp. 177-189.

Imai, H., Nakao, H., Tsuchiya, M., Kuroda, Y. and Katoh, T. (2004), “Burnout and workenvironments of public health nurses involved in mental health care”, OccupationalEnvironmental Medicine, Vol. 61 No. 9, pp. 764-768.

Isikhan, V., Comez, T. and Danis, M.Z. (2004), “Job stress and coping strategies in health careprofessionals working with cancer patients”, European Journal of Oncology Nursing, Vol. 8No. 3, pp. 234-244.

Khatibi, A., Asadi, H. and Hamidi, M., (2009), “The relationship between job stress andorganizational commitment in national olympic and paralympic academy”, World Journalof Sport Sciences, Vol. 2 No. 4, pp. 272-278.

King, K.A., Vidourek, R., Schwiebert, M. (2009), “Disordered eating and job stress among nurses”,Journal of Nursing Management Vol. 17 No. 7, pp. 861-869.

Lambert, E. and Paoline, E.A. (2008), “The influence of individual, job and organizationalcharacteristics on correctional staff job stress, job satisfaction and organizationalcommitment”, Criminal Justice Review, Vol. 33 No. 4, pp. 541-564.

McCann, L., Hughes, C.M., Adair, C.G. and Cardwell, C. (2009), “Assessing job satisfaction andstress among pharmacists in Northern Ireland”, Pharmacy World & Science, Vol. 31 No. 2,pp. 188-194.

McGowan, B. (2001), “Self-reported stress and its effects on nurses”, Nursing Standard, Vol. 15No. 42, pp. 33-38.

McVicar, A. (2003), “Workplace stress in nursing: a literature review”, Journal of AdvancedNursing, Vol. 44 No. 6, pp. 633-642.

Machin, M.A., Fogarty, G.J. and Albion, M.J. (2004), “The relationship of work support and workdemands to individual outcomes and absenteeism of rural nurses”, International Journal ofRural Psychology, Vol. 4 No. 1, pp. 1-13.

237

Occupationalstress and itsconsequences

Melamed, S., Fried, Y. and Froom, P. (2001), “The interactive effect of chronic exposure to noiseand job complexity on changes in blood pressure and job satisfaction: a longitudinal studyof industrial employees”, Journal of Occupational Health Psychology, Vol. 6 No. 3,pp. 182-195.

Michie, S. and Williams, S. (2003), “Reducing work related psychological ill health and sicknessabsence: a systematic literature review”, Occupational and Environmental Medicine, Vol. 60No. 1, pp. 3-9.

Mitchell, O., MacKenzie, D.L., Gover, A.G. and Styve, G.J. (2001), “The influences of personalbackground on perceptions of juvenile correctional environments”, Journal of CriminalJustice, Vol. 29 No. 1, pp. 67-76.

Mosadeghrad, A.M. (2013), “Occupational stress and turnover intention: implications for nursingmanagement”, International Journal of Health Policy and Management, Vol. 1 No. 2,pp. 179-186.

Mosadeghrad, A.M., Ferlie, E. and Rosenberg, D. (2011), “A study of relationship between jobstress, quality of working life and turnover intention among hospital employees”, HealthServices Management Research Journal, Vol. 24 No. 4, pp. 170-181.

O’connor, D.B., O’connor, R.C., White, B.L. and Bundred, P.E. (2000), “The effect of job strain onBritish general practitioners’ mental health”, Journal of Mental Health, Vol. 9 No. 6,pp. 637-654.

Oginska-Bulik, N. (2006), “Occupational stress and its consequences in healthcare professionals:the role of type D personality”, International Journal of Occupational Medicine andEnvironmental Health, Vol. 19 No. 2, pp. 113-122.

Ogunjimi, L.O., Ajibola, C.A. and Akah, L.U. (2009), “Comparative analysis of stressors on jobperformance of public and private health workers in Calabar, Nigeria”, International NGOJournal, Vol. 4 No. 4, pp. 97-103.

Piko, B. (1999), “Work-related stress among nurses: a challenge for health care institutions”,Journal of the Royal Society for the Promotion of Health, Vol. 119 No. 3, pp. 156-162.

Redfern, S., Hannan, S., Norman, I. and Martin, F. (2002), “Work satisfaction, stress, quality of careand morale of older people in a nursing home”, Health and Social Care in the Community,Vol. 10 No. 6, pp. 512-517.

Robinson, J.R., Clements, K. and Land, C. (2003), “Workplace stress among psychiatric nurses”,Journal of Psychosocial Nursing & Mental Health Services, Vol. 41 No. 4, pp. 32-42.

Schaubroeck, J. and Fink, L.S. (1998), “Facilitating and inhibiting effects of job control and socialsupport on stress outcomes and role behavior: a contingency model”, Journal ofOrganizational Behavior, Vol. 19 No. 2, 167-195.

Schmitz, N., Neumann, W. and Opperman, R. (2000), “Stress, burnout and locus of control inGerman nurses”, International Journal of Nursing Studies, Vol. 37 No. 2, pp. 95-99.

Shapiro, S.L., Astin, J.A., Bishop, S.R. and Cordova, M. (2005), “Mindfulness-based stressreduction for health care professionals: results from a randomized trial. InternationalJournal of Stress Management”, Vol. 12 No. 2, pp. 164-176.

Sharif, F., Rad, F. and Gholamzadeh, S. (2011), “Sources of occupational stress and copingstrategies among nurses who are working in admission and emergency department inhospitals affiliated to Shiraz University of Medical Sciences, Iran”, Iranian Journal ofNursing and Midwifery Research, Vol. 16 No. 10, pp. 42-47.

Spickard, A., Gabbe, S. and Christensen, J. (2002), “Mid-career burnout in generalist andspecialist physicians”, Journal of the American Medical Association, Vol. 288 No. 12,pp. 1447-1450.

LHS27,3

238

Steinhardt, M.A, Dolbier, C.L., Gottlieb, N.H. and McCalister, K.T. (2003), “The relationshipbetween hardiness, supervisor support, group cohesion, and job stress as predictors of jobsatisfaction”, American Journal of Health Promotion, Vol. 17 No. 6, pp. 382-389.

Strachota, E., Normandin, P., O’Brien, N., Clary, M. and Krukow, B. (2003), “Reasons registerednurses leave or change employment status”, Journal of Nursing Administration, Vol. 33No. 2, pp. 111-117.

Tabatabaei, H.R., Chobineh, A.R. and Barzideh, M. (2012), “The relationship between occupationalstress and general health of nurses”, Occupatioanl Medicine, Vol. 4 No. 3, pp. 17-27.

Tankha, G. (2006), “A comparative study of role stress in government and private hospitalnurses”, Journal of Health Management, Vol. 8 No. 1, pp. 11-22.

Teng, C.I., Hsiao, F.J. and Chou, T.A. (2010), “Nurse-perceived time pressure and patient-perceivedcare quality”, Journal of Nursing Management, Vol. 18 No. 3, pp. 275-284.

Van der Ploeg, E. and Kleber, R.J. (2003), “Acute and chronic job stressors among ambulancepersonnel: predictors of health symptoms”, Occupational and Environmental Medicine,Vol. 60 No. 1, pp. 40-46.

Whitman, G.R., Kim, Y., Davidson, L.J., Wolf, G.A. and Wang, S.L. (2002), “The impact of staffingon patient outcomes across specialty units”, Journal of Nursing Administration, Vol. 32No. 12, pp. 633-639.

Wilkinson, R. (2005), The Impact of Inequality: How to Make Sick Societies Healthier, The NewPress, New York, NY.

Further readingMelin, B., Lundberg, U. (1997), “A bio psychosocial approach to work-stress and musculoskeletal

disorders”, Journal of Psychophysiology, Vol. 11 No. 3, pp. 238-247.

Corresponding authorAli Mohammad Mosadeghrad can be contacted at: mosadeghrad@gmail.com

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