Causes and Cures of Stress in Organizations
© 1993, David S. Walonick, Ph.D.
Job stress in organizations is widespread. About half of all American workers feel the pressures of job-related stress. Extensive research shows that excessive job stress can adversely affect the emotional and physical health of workers. The result is decreased productivity, less satisfied, and less healthy workers. This paper will first discuss the symptoms and causes of stress, and then explore ways in which managers might reduce stress in themselves and their subordinates.
Definition of Stress
Stress is an imprecise term. It is usually defined in terms of the internal and external conditions that create stressful situations, and the symptoms that people experience when they are stressed. McGrath (1976) proposed a definition based on the conditions necessary for stress.
So there is a potential for stress when an environmental situation is perceived as presenting a demand that threatens to exceed the person's capabilities and resources for meeting it, under conditions where he expects a substantial differential in the rewards and costs from meeting the demand versus not meeting it. (p. 1,352)
McGrath's definition implies that the degree of stress is correlated with a persons perceived inability to deal with an environmental demand. This would lead to the conclusion that a person's level of stress depends on their self-perceived abilities and self-confidence. Stress is correlated with a person's fear of failure.
Arnold and Feldman (1986) define stress as "the reactions of individuals to new or threatening factors in their work environment." (p. 459) Since our work environments often contain new situations, this definition suggests that stress in inevitable. This definition also highlights the fact that reactions to stressful situations are individualized, and can result in emotional, perceptual, behavioral, and physiological changes.
Williams and Huber (1986) define stress as "a psychological and physical reaction to prolonged internal and/or environmental conditions in which and individual's adaptive capabilities are overextended." (p. 243) They argue that stress is an adaptive response to a conscious or unconscious threat. Like McGrath, they point out that stress is a result of a "perceived" threat, and is not necessarily related to actual environmental conditions. The amount of stress that is produced by a given situation depends upon one's perception of the situation, not the situation itself. In other words, stress is a relativistic phenomena.
In Gestalt Therapy Verbatim (Real People Press, 1969) Perls proposes a more general definition, where stress is a manifestation of thinking about the future. Anxiety is created by focusing attention away from the "here and now". It is created by expectations of the future--the tension between the now and the later. According to Perls, there is no difference between good stress and bad stress. They are both created by thinking about the future. When anxiety finds an outlet, we say that the stress was motivating; when it doesn't, we call it debilitating.
French, Kast, and Rosenzweig (1985) also emphasized the idea that stress itself is not necessarily bad. "The term stress can be considered neutral with the words distress and eustress used for designating bad and good effects." (p. 707) They propose a model that defines an optimum range of stress in terms of its effect on performance. Stress levels that exceed an optimum level result in decreased performance and eventual burnout. Stress levels below a minimum level result in decreased performance and "rust-out".
Symptoms of Stress
Selye (1946) was the first to describe the phases that the body goes through in response to a threat. The general adaptation syndrome model states that the body passes through three stages. The first stage is an alarm reaction. The body prepares for a potential emergency. Digestion slows down, the heart beats faster, blood vessels dilate, blood pressure rises, and breathing becomes rapid and deep. All bodily systems work together to provide maximum energy for fight or flight. The second stage is resistance. If the stress continues, the body builds up a tolerance to its effects. The body becomes habituated to the effects of the stressor, however, the bodies adaptive energies are being used as a shield against the stressor. The third stage is exhaustion. When the body's adaptive energies are depleted, the symptoms of the alarm reaction reappear, and the stress manifests itself as an illness, such as ulcers, heart ailments, and high blood pressure. During the first or second stages, the removal of the stressor will eliminate the symptoms.
Ivancevich and Matteson (1980) point out that during the early days of our evolution, we needed the fight-or-flight response for our survival. "The problem we encounter today is that the human nervous system still responds the same way to environmental stressors, although the environment is radically different. The tigers are gone and with them the appropriateness of the fight-or-flight response." (p. 10)
Reitz (1987) writes that individuals in modern society often substitute other psychological reactions for flight-or-flight. Substitutions for fighting include negativism, expression of boredom, dissatisfaction, irritability, anger over unimportant matters, and feelings of persecution. Substitutions for fleeing include apathy, resignation, fantasy, forgetfulness, inability to concentrate, procrastination, and inability to make decisions. (p. 239)
Short-term stress has served a useful purpose in our survival. Long-term stress, however, involves increasingly higher levels of prolonged and uninterrupted stress. The body adapts to the stress by gradually adjusting its baseline to higher and higher levels. For example, workers in stressful jobs often show an increased "resting" heart rate. Pelletier (1977) believes that the deleterious effects of stress are created only by unrelieved long-term stress. Albrecht (1979) also believes that the effects of stress are cumulative in nature. Ulcers do not just happen overnight in a high stress situation; they are generally the result of long extended exposure to stress. "The health breakdown is simply the logical conclusion of a self-induced disease development over a period of 10 to 20 years." (p. 119)
Job stress can have a substantial negative effect on physical and emotional health. Williams and Huber (1986) provide a comprehensive list of the symptoms of stress. These are: "constant fatigue, low energy level, recurring headaches, gastrointestinal disorders, chronically bad breath, sweaty hands or feet, dizziness, high blood pressure, pounding heart, constant inner tension, inability to sleep, temper outbursts, hyperventilation, moodiness, irritability and restlessness, inability to concentrate, increased aggression, compulsive eating, chronic worrying, anxiety or apprehensiveness, inability to relax, growing feelings of inadequacy, increase in defensiveness, dependence on tranquilizers, excessive use of alcohol, and excessive smoking." (p. 246) Furthermore, job stress can make people more susceptible to major illnesses. High stress managers are twice as prone to heart attacks as low stress managers. (Rosenman and Friedman, 1971)
Excessive job-related stress is not a small or isolated problem. Over one-third of all American workers thought about quitting their jobs in 1990. One-third believe they will burn-out in the near future, and one-third feel that job stress is the single greatest source of stress in their lives. Nearly three-fourths of all workers feel that job stress lowers their productivity, and they experience health problems as a consequence. (Lawless, 1991, 1992) Furthermore, this is not exclusively a United States phenomena. A Japanese poll conducted by the Health and Welfare Ministry in 1988 indicated that 45 percent of workers felt stress from their jobs. (Asahi News Service, 1990)
Recent studies have found evidence of dangerous physical changes attributed to prolonged stress. One New York study reported a twenty gram increase in heart muscles of those suffering from job stress. There was a significant "thickening of the heart's left ventricle, or chamber, a condition that often precedes coronary heart disease and heart attacks." (Pieper, C., 1990) Omni magazine (March, 1991) wrote about a series of experiments with rats to examine the physiological effects of prolonged stress. The researchers found that there was actually a loss of neurons in the hippocampus section of their brains. The article concluded with a warning that there is some evidence of a similar neuron loss occurs in humans.
Many researchers have studied the effects of stress on performance. McGrath (1978) reported that mild to moderate amounts of stress enables people to perform some tasks more effectively. The rationale is that improved performance can be attributed to increased arousal. However, if the stressor continues, it eventually takes its toll, and results in decreased performance and deleterious health consequences. Furthermore, workers are aware of the toll that stress has had on their own performances. Half of all workers say that job stress reduces their productivity. (Lawless, 1992)
Causes of Stress
Stressors can be divided into those that arise from within an individual (internal), and those that are attributable to the environment (external). Internal conflicts, non-specific fears, fears of inadequacy, and guilt feelings are examples of stressors that do not depend on the environment. Internal sources of stress can arise from an individual's perceptions of an environmental threat, even if no such danger actually exists. Environmental stressors are external conditions beyond an individual's control. Bhagat (1983) has reported that work performance can be seriously impaired by external stressors. There are many aspects of organizational life that can become external stressors. These include issues of structure, management's use of authority, monotony, a lack of opportunity for advancement, excessive responsibilities, ambiguous demands, value conflicts, and unrealistic work loads. A person's non-working life (e.g., family, friends, health, and financial situations) can also contain stressors that negatively impact job performance.
Albrecht (1979) argues that nearly all stressors are emotionally induced. These are based on peoples' expectations, or ". . . the belief that something terrible is about to happen." (p. 83) Thus, emotionally induced stress arises from one's imagination. Albrecht believes that our society's number one health problem is anxiety, and that emotionally induced stress can be classified into four categories: 1) time stress, 2) anticipatory stress, 3) situational stress, and 4) encounter stress. Time stress is always created by a real or imaginary deadline. Anticipatory stress is created when a person perceives that an upcoming event will be unpleasant. Situational stress can occur when a person is in an unpleasant situation, and they worry about what will happen next. Encounter stress is created by contact with other people (both pleasant and unpleasant).
Many situations in organizational life can be stressful. These include: 1) problems with the physical environment, such as poor lighting or excessive nose, 2) problems with the quality of work such, as lack of diversity, an excessive pace, or too little work, 3) role ambiguities or conflicts in responsibilities, 4) relationships with supervisors, peers, and subordinates, and 5) career development stressors, such as lack of job security, perceived obsolescence, and inadequate advancement.
Adverse working conditions, such as excessive noise, extreme temperatures, or overcrowding, can be a source of job-related stress. (McGrath, 1978). Reitz (1987) reports that workers on "swing shifts" experience more stress than other workers. Orth-Gomer (1986) concludes that when three shifts are used to provide around-the-clock production, major disturbances in people may be unavoidable. One source of environmental stress ignored in the organizational literature is non-natural electromagnetic radiation. Becker (1990) reports that the two most prominent effects of electromagnetic radiation are stress and cancers. Modern offices are filled with electronic devices that produce high levels of radiation. These include computers, video monitors, typewriters, fluorescent lights, clocks, copying machines, faxes, electric pencil sharpeners, and a host of other electronic devices. Human sensitivity to electomagnetic fields is well-documented, and the design of future office equipment will most likely involve a consideration of emitted radiation.
Arnold and Feldman (1986) emphasize the deleterious effects of role ambiguity, conflict, overload and underload. Role ambiguity is often the result of mergers, acquisitions and restructuring, where employees are unsure of their new job responsibilities. Role conflict has been categorized into two types: intersender and intrasender. (Kahn, et al., 1964) Intersender role conflict can occur when worker's perceive that two different sources are generating incompatible demands or expectations. Intrasender role conflict can arise when worker's perceive conflicting demands from the same source. Overload is frequently created by excessive time pressures, where stress increases as a deadline approaches, and then rapidly subsides. Underload is the result of an insufficient quantity, or an inadequate variety of work. Both overload and underload can result in low self-esteem and stress related symptoms, however, underload has also been associated with passivity and general feelings of apathy. (Katz and Kahn, 1978)
Poor interpersonal relationships are also a common source of stress in organizations. Arnold and Feldman (1986) cite three types of interpersonal relationships that can evoke a stress reaction: 1) too much prolonged contact with other people, 2) too much contact with people from other departments, and 3) an unfriendly or hostile organizational climate.
Personal factors are often a source of stress. These include career related concerns, such as job security and advancement, as well as financial and family concerns. Holmes and Rahe (1967) constructed a scale of forty-three life events, and rated them according to the amount of stress they produce. The most notable feature of their instrument is that many positive life changes (i.e., marriage, Christmas, vacations, etc.) are substantial sources of stress. Generally, stress appears to be a result of any change in one's daily routine.
French, Kast, and Rosenzweig (1985) believe that any situation that requires a behavioral adjustment is a source of stress. However, a situation that is stressful for one person might not be stressful for another. Older workers seem to be less strongly affected by stressful situations. (Parasuraman and Alutto, 1984) Individuals with high self-esteem and a tolerance for ambiguity are less prone to stress-related illnesses. (Arnold and Feldman, 1986). There is also considerable evidence that a person's susceptibility to stress is dependent on their personality types. Type A personalities (those that seek out fast-paced, challenging situations) often react to stress with hostility and anger, while Type B personalities seem to be have an immunity to the same stressors (Albrecht, 1979; Friedman and Rosenman, 1974; Matthews, 1982; Organ, 1979).
Several studies have found that individual's who believe they have control over their own fate (internals), perceive less stress in their work than those who believe their future is determined by other factors (externals). Genmill and Heisler (1972) reported that "internals" had more job satisfaction and perceived their jobs as less stressful than "externals". They also found that a managers perceived stress was unrelated to education, length of time in their career, or their level in the hierarchy. Another study looked at managers of businesses in a community that had recently been destroyed by a hurricane. (Anderson, Hellriegel, and Slocum, 1977). These researchers found that "internals" experienced less stress from the catastrophe, and that their perceived locus of control was a more important factor than their insurance coverage, the amount of the loss, or the duration that the company was out of business. Lawless (1992) reports that ". . . job stress is a consequence of two key ingredients: a high level of job demands and little control over one's work." (p. 4)
Some studies have reported that males seem to be more prone to stress-related illness than females. Men report more ulcers and have a higher rate of heart attacks than women (Albrecht, 1979). Other studies have found no differences. Friedman and Rosenman (1974) found that Type A women suffered from cardiovascular diseases and heart attacks as often as their male counterparts. Women in managerial positions suffer heart attacks at the same rate as men in similar positions. (Albrecht, 1979) In a recent study, Lawless (1992) reported that women suffered fifteen percent more stress related illnesses than men. They also thought about quitting their jobs more often, and reported a higher incidence of burnout. Lawless proposed that this is the result of unequal pay scales and a failure of organizations to adopt policies sensitive to family issues. As more women enter the work force, the effects on their health are becoming increasingly apparent. It may be that past differences between males and females are the result of their experience in the work force, and unrelated to gender per se.
Lawless (1991) identified the five most common causes of worker stress: 1) too much rigidity in how to do a job, 2) substantial cuts in employee benefits, 3) a merger, acquisition, or change of ownership, 4) requiring frequent overtime, and 5) reducing the size of the work force. Over forty percent of the work force experienced one or more stress-related illnesses as a result of these five stressors. Single or divorced employees, union employees, women, and hourly workers reported greater stress levels, and a higher likelihood of "burning out". (p.6-8) In a follow-up study, Lawless (1992) found similar results except that there was no significant difference between married and unmarried workers. However single women with children were more likely to burn out than married women with children. "Single parenthood compounds the stress women face in juggling work and child care responsibilities, especially when overtime hours are required." (p. 11)
The current recession is, to some degree, responsible for increased stress in America's work force. "Private sector workers feel more pressure to prove their value because of the recession." (Lawless, 1992, p. 6) Nearly half of all workers and supervisors blame the recession for higher stress levels and lower productivity. Both are being asked to achieve higher goals with a reduced work force. Supervisors reported slightly more stress than workers, however, they were no more likely to experience job burn out. Lawless proposed that supervisors' higher salaries and more having more control over their jobs, partially counteracted the negative effects of stress. Employees who earned less than $25,000 reported less stress, but they were more likely to burn out because they had less control over their work. Over half of the college graduates in this income category reported feeling burned out.
Mangers of organizations have a dual perspective of stress. They need to be aware of their own stress levels, as well as those of their subordinates. Most of the literature focuses on ways of reducing stress. However, a more appropriate approach might be to examine ways of optimizing stress. French, Kast, and Rosenzweig (1985) state that the challenge is to minimize distress and maintain eustress. They point out that the conditions of organizational life create a series of paradoxes, that demonstrate the need for balance and equilibrium.
1. Uncertainty can lead to distress, but so can certainty or overcontrol.
2. Pressure can lead to distress, but so can limbo or lack of contact.
3. Responsibility can lead to distress, but so can lack of responsibility or insignificance.
4. Performance evaluation can lead to distress, but so can lack of feedback concerning performance.
5. Role ambiguity can lead to distress, but so can job descriptions that constrain individuality. (p. 708)
The role of management becomes one of maintaining an appropriate level of stress by providing an optimal environment, and "by doing a good job in areas such as performance planning, role analysis, work redesign/job enrichment, continuing feedback, ecological considerations, and interpersonal skills training." (p. 709)
There are essentially three strategies for dealing with stress in organizations (Jick and Payne, 1980): 1) treat the symptoms, 2) change the person, and 3) remove the cause of the stress. When a person is already suffering from the effects of stress, the first priority is to treat the symptoms. This includes both the identification of those suffering from excessive stress, as well as providing health-care and psychological counseling services. The second approach is to help individuals build stress management skills to make them less vulnerable to its effects. Examples would be teaching employees time management and relaxation techniques, or suggesting changes to one's diet or exercise. The third approach is to eliminate or reduce the environmental situation that is creating the stress. This would involve reducing environmental stressors such as noise and pollution, or modifying production schedules and work-loads.
Many modern organizations view the management of stress as a personal matter. An effort to monitor employee stress levels would be considered an invasion of privacy. However, Lawless (1991) found that nine out of ten employees felt that it was the employers responsibility to reduce worker stress and provide a health plan that covers stress illnesses. She emphasized that "employees have no doubt that stress-related illnesses and disability should be taken seriously. Employees expect substantive action by their employer and hold their employer financially responsible for the consequences of job stress." (p. 12)
Lawless (1991) reported that four different employer programs were effective in reducing job burn out, where the percent of people reporting burn out was reduced by half. Furthermore, when these programs were offered, there were also half as many stress related illnesses. They are: 1) supportive work and family policies, 2) effective management communication, 3) health insurance coverage for mental illness and chemical dependency, and 4) flexible scheduling of work hours. This study also reported that the success rate for treating stress related disabilities was considerably less than the average for all disabilities, and that the average cost to treat stress related conditions was $1,925 (both successful and unsuccessful).
Managers can take active steps to minimize undesirable stress in themselves and their subordinates. Williams and Huber (1986) suggest five managerial actions that can be used to reduce stress in workers.
1. Clarifying task assignments, responsibility, authority, and criteria for performance evaluation.
2. Introducing consideration for people into one's leadership style.
3. Delegating more effectively and increasing individual autonomy where the situation warrants it.
4. Clarifying goals and decision criteria.
5. Setting and enforcing policies for mandatory vacations and reasonable working hours. (p. 252)
Establishing one's priorities (i.e., value clarification) is an important step in the reduction of stress. The demands of many managerial positions cause the neglect of other areas of one's life, such as family, friends, recreation, and religion. This neglect creates stress, which in turn affects job performance and health. Value clarification is linked to time management, since we generally allocate our time according to our priorities. By setting personal priorities, managers and subordinates can reduce this source of stress. It is typically the first step in any stress reduction program.
Many sources of stress in organizations cannot be changed. These might include situations like a prolonged recessionary period, new competitors, or an unanticipated crisis. Organizational members generally have little control over these kinds of stressors, and they can create extended periods of high-stress situations. People who adjust to these stressors generally use a form of perceptual adaptation, where they modify the way in which they perceive the situation.
Other sources of stress in organizations can be changed. One particularly effective way for managers to minimize employee stress is to clarify ambiguities, such as job assignments and responsibilities. (Arnold and Feldman, 1986) Employee stress is directly related to the amount of uncertainty in their tasks, expectations, and roles. Managers can encourage employees to search for more information when they are given unfamiliar tasks, or when they are uncertain of their roles. Another way to reduce employee stress is to incorporate time management techniques, as well as setting realistic time schedules for the completion of projects.
There are many other successful ways of dealing with stress. These include stress reduction workshops, tranquilizers, biofeedback, meditation, self-hypnosis, and a variety of other techniques designed to relax an individual. Programs that teach tolerance for ambiguity often report positive effects. One of the most promising is a health maintenance program that stresses the necessity of proper diet, exercise and sleep.
Social support systems seem to be extremely effective in preventing or relieving the deleterious effects of stress. Friends and family can provide a nurturing environment that builds self-esteem, and makes one less susceptible to stress. One study found that government white-collar workers who received support from their supervisors, peers, and subordinates experienced fewer physical symptoms of stress. (Katz and Kahn, 1978) Managers can create nurturing and supportive environments to help minimize job-related stress.
Albrecht (1979) hypothesized that there are eight relatively "universal" factors that come into play when evaluating the balance between stress and reward (job satisfaction) in organizations. These are: 1) workload, 2) physical variables, 3) job status, 4) accountability, 5) task variety, 6) human contact, 7) physical challenge, and 8) mental challenge. Each individual has a "comfort zone" for the eight factors. The goal of management is to find the "comfort zone" for each employee that results in optimal performance without producing undesirable side effects. Albrecht's taxonomy is important because it recognizes the necessity of balance. For example, Taylorism stresses the ideas of maximum output, minimal task variety, and continuous supervision. The predicted effect of these imbalances would be stress and a reduction in job satisfaction. Perhaps many of today's organizational problems with worker stress are the result of the effective application of Taylorism.
The social climate of an organization is often viewed as a cause of stress. However, social climate is a relativistic concept, and "the social climate of an organization is whatever most of the people think it is." (Albrecht, 1979, p. 167) There are three factors that need to be examined when evaluating social climate. The first is the degree to which employees identify with or alienate themselves from the organization. Employee attitude surveys are an effective method of measuring this factor. Identification can be measured through employees pride in membership, and the extent to which they take initiative and offer constructive suggestions. Alienation can be detected by examining whether members openly criticize the organization, or the degree to which they oppose change. The second factor of organizational climate is the degree to which labor and management are polarized. One of the most effective ways of dealing with this problem is to make all levels of management more visible and accessible. Employees are less likely to criticize management who they see on a regular basis. The goal is to change to perception from "they" (the managers) to "we" (the members of the organization). The third factor is the perceived social norms of the organization. Social norms are abstract organizational values, such as trust, fairness, and respect. Interviews and questionnaires can be used to ascertain organizational social norms, but corrective action involves setting up management programs that clarify organizational values, and may involve replacing certain managers when necessary.
Quick and Quick (1984) suggest several diagnostic procedures for determining stress levels in organizations. Interviews allow in-depth probing, but they are time consuming and depend primarily on the listening skills of the interviewer. Questionnaires have the advantage of being able to process higher volumes of data, but they often lose the "flavor" or feel of the responses. Observational techniques (both medical and behavioral) can be either quantitative or qualitative. Quantitative techniques might involve gathering company records, such as the rates of absenteeism, tardiness, turnover, and production. Qualitative techniques involve observing workers for signs of stress-related behavior.
Job engineering and job redesign are recent concepts that attempt to minimize job-related stress. Job engineering takes into account the values and needs of the worker, as well as the production objectives of the organization. (Albrecht, 1979) It involves a six-step cyclical process, beginning with defining the job objectives. This initial step makes statements about "accomplishing something of recognized value." (p. 159) The second step is to define the job conditions. This step specifies the physical, social, and psychological characteristics of the job. The third step is to define the job processes, equipment, and materials. Processes are often presented in a flow chart to show the sequence of operations. The fourth step is to re-evaluate the design from the perspective of the worker, the goal being to achieve a balance between job satisfaction and performance. The fifth step is to test the job design. Employees often experience problems not anticipated by job engineers. The evaluation should look at the "total combination of person, equipment, materials, processes, and surroundings as an integrated whole, and you must measure both productivity and employee satisfaction before you can say the job is well designed." (p. 162) The sixth step involves the ongoing re-evaluation and redesign of the job. Employee attitudes and values change, and new technology provides alternatives to the status quo. Job engineering attempts to be sensitive to these changes, and to modify job descriptions as necessary.
Sevelius (1986) describes his experience implementing a wellness education program at a large manufacturing plant. Several successful techniques were used. Booklets on specific health subjects were place in "Take one" bins conveniently located around the plant. The booklets were positively received and increased employees awareness and knowledge. Campaigns were undertaken to highlight the specific themes in the booklets. Group lectures were tried and found to be ineffective because less than ten percent of the employees attended them. In addition, the lectures were video taped, but employees did not take the time to view them. Medical examinations generally did not reveal hidden illnesses, however, they were found to be of considerable value because they gave employees the opportunity of individual medical counseling. Sevelius suggests that peer support systems might also be successful in the workplace.
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This paper explores the impact of organizational attributes on client engagement within substance abuse treatment. Previous research has identified organizational features, including small size, accreditation, and workplace practices that impact client engagement (Broome, Flynn, Knight, & Simpson, 2007). The current study sought to explore how aspects of the work environment impact client engagement. The sample included 89 programs located in 9 states across the U.S. Work environment measures included counselor perceptions of stress, burnout, and work satisfaction at each program, while engagement measures included client ratings of participation, counseling rapport, and treatment satisfaction. Using multiple regression, tests of moderation and mediation revealed that staff stress negatively predicted client participation in treatment. Burnout was related to stress, but was not related to participation. Two additional organizational measures – workload and influence – moderated the positive relationship between staff stress and burnout. Implications for drug treatment programs are discussed.
Keywords: drug treatment, organizational attributes, client engagement, stress, burnout, satisfaction
The TCU Treatment Process Model (Simpson, 2004) and supporting empirical studies (Simpson & Joe, 1993, 2004) document that early engagement and the development of therapeutic relationships is an integral component of effective drug abuse treatment. While client factors such as problem severity and readiness for treatment impact client participation (Simpson, 2004), other factors, including organizational health also contribute to the therapeutic process (Simpson et al., 1997). Organizational features (e.g., small size, accreditation) and staff perceptions of the workplace (e.g., better climate, more collaborative workplace practices, and higher staff efficacy) are associated with higher client engagement (Broome, Flynn, Knight, & Simpson, 2007; Greener, Joe, Simpson, Rowan-Szal, & Lehman, 2007). While newer versions of the TCU Treatment Process model depict organizational factors as important (Simpson, 2008), the ways in which organizational factors interact as they affect client outcomes are not specified.
The current study extends this research by exploring the impact of organization-level stress, burnout, and satisfaction on client engagement within outpatient substance treatment programs. Because the focus is on organizations and how variations in contextual factors affect an organization’s ability to engage clients, the unit of analysis is the program. In the sections that follow, literature on burnout, satisfaction, and stress is reviewed. While most of the relevant research has been conducted with health service organizations and has implications for the field of substance abuse treatment, the intent of this study is to examine how these specific aspects of organizational functioning impact client engagement specifically within substance abuse treatment settings. Burnout and satisfaction have been shown to influence client engagement (e.g., Garman, Corrigan, & Morris, 2002; Killaspy et al., 2009), and staff stress has been linked to both burnout and satisfaction (Cummins, 1990; Spielberger & Reheiser, 1995). Further exploring these relationships and their impact on client engagement in these settings will begin to inform the role that organizational factors play in treatment process and identify possible organizational implications.
1.1. Staff burnout, satisfaction, and stress
Burnout describes the overall condition of emotional exhaustion due to an overload in demands, including emotional and interpersonal stressors (Boswell, Olson-Buchanan, & LePine, 2004; Iverson, Olekalns, & Erwin, 1998), higher caseloads (Broome, Knight, Edwards, & Flynn, 2009), and inadequate resources (Garland, 2004; Garner, Knight, & Simpson, 2007). Burnout has been shown to affect physical health, mental health, and job performance including turnover, staff absenteeism, and intentions to quit (Belcastro, Gold, & Grant, 1982; Cherniss, 1992; Elman & Dowd, 1997; Kahill, 1988). It is especially salient in human service organizations (Pines & Aronson, 1988) and specifically in substance abuse treatment where clients are apt to deny and minimize their problems (Elman & Dowd, 1997; Farmer, 1995).
Adverse effects of burnout on staff can extend to client engagement. Leiter, Harvie, & Frizzell (1998) found that patients under the care of nurses who reported more emotional exhaustion and expressed an intention to quit were less satisfied with the care they received. Garman et al. (2002) examined team burnout among treatment staff at a psycho-social rehabilitation facility and found higher burnout was predictive of lower client satisfaction. While this relationship is seen in related fields including nursing and health services, the degree to which burnout affects client outcomes in drug abuse treatment organizations is unknown.
While sometimes considered as conceptually opposite of burnout, staff satisfaction is a distinct construct, comprising beliefs, attitudes, and behaviors towards one’s job (Weiss, 2002). Staff satisfaction has been linked to higher levels of job performance including commitment, job retention, and job attendance (Bannister & Griffeth, 1986; Locke, 1976). Given that higher staff turnover is associated with higher client dropout rates and difficulty bonding with counselors (Hiatt, Sampson, & Baird, 1997), staff satisfaction has implications for client engagement. For instance, studies in the field of nursing and community mental health organizations found that when staff reported higher satisfaction and fewer conflicts with clients, clients reported higher satisfaction (Daub, 2005; Weisman & Nathanson, 1985) and were more engaged with treatment (Killaspy et al., 2009). Similar to burnout, the relationship between staff satisfaction and client outcomes has been documented in health service organizations but has not yet been examined within the context of drug abuse treatment.
Organizational stress is defined as the level of environmental demand that can disrupt or enhance an individual’s physiological or psychological state and change the normal mode of functioning (Schuler, 1980). Environmental demands include time pressures, increases in work load, and lack of organizational resources (Bhagat & Allie, 1989). Stress has been shown to adversely affect organizations wherein staff who report higher levels of stress have lower job satisfaction, increased turnover, increased absenteeism, and lower productivity (e.g., Cummins, 1990; Spielberger & Reheiser, 1995). But while stress has been cited as one cause of burnout and dissatisfaction among staff, it has not yet been shown to directly affect client outcomes. The lack of empirical evidence for a direct staff stress-client engagement link could indicate a more complex set of relationships among stress, burnout, and satisfaction.
While stress has not been linked to client outcomes, stress has been associated with both burnout and satisfaction, two staff attributes hypothesized to mediate the stress-client outcome relationship. Iverson et al. (1998) examined role stress (when a task must be reconciled due to conflicting requirements or through role ambiguity when a task requires clarification and additional information) and found that stress predicted increased burnout among healthcare workers. This stress-burnout relationship is particularly salient in social service agencies where turnover rates are higher, workloads overextend the staff, and staff report high levels of stress and burnout (Johnson, Brems, Mills, Neal, & Houlihan, 2006). Indeed, stress has been found to be a significant predictor of counselor burnout in corrections-based drug treatment organizations (Garner et al., 2007).
Similar patterns exist for the relationship between stress and job satisfaction. Bhagat and Allie (1989) found that high organizational stress was a significant predictor of lower ratings of work, co-worker, and supervisor satisfaction among staff. Similarly, higher role ambiguity (one component of job stress) was a significant predictor of lower job satisfaction within social service organizations (Pasupuleti, Allen, Lambert, & Cluse-Tolar, 2009). Overall, staff who report a stress-filled work environment also report dissatisfaction with their job. Consequently, exploration of how organizational stress affects client engagement should include tests of meditational effects of burnout and satisfaction.
1.2.1. Moderating influences on stress and burnout
As the literature demonstrates, a highly stressful environment cultivates higher burnout. This relationship between stress and burnout has been shown to be influenced by several staff and client attributes, including self-efficacy, influence, and workload. Bandura’s behavior change theory (1997) states that people with high self-efficacy (i.e., belief that they can perform a task well) will view difficult tasks as a challenge, carry out more challenging tasks, set higher goals, and achieve them (Bandura, 1997; Schwarzer, 1992). Self-efficacy moderates the relationship between stress and burnout, serving as a protective buffer against the negative effects of stress (Schwarzer & Hallum, 2008). For example, job strain can lead to burnout, but when stress is high, those with high self-efficacy reported less burnout (Borucki, 1987; Schwarzer & Hallum, 2008). Thus efficacy appears to moderate how employees respond to stressful environments.
Similar to self-efficacy, staff influence has been cited as an important component of how individuals cope with stress. According to Johnson and colleagues (2006), stress levels decrease when employees have opportunities to provide input towards changes that affected them directly. In their work, staff influence was found to attenuate the high levels of stress as a result of changes in the workplace. Another potential moderator, workload (i.e., caseload and proportion of clients with severe problems) can also impact the relationship between stress and burnout (Killaspy et al., 2009). Among hospital employees, higher caseloads are associated with increased emotional exhaustion, depersonalization, and decreased personal accomplishment (Iverson et al., 1998). Within drug treatment organizations, larger caseloads are associated with higher staff burnout (Broome et al., 2009). Because higher caseloads place increased demands on staff, caseload may also impact the relationship between burnout and stress.
Client severity, a second component of workload, also has implications for how staff respond to stress. Staff stress can lead to burnout which in turn leads to complications with clients, including increased premature dropout (Bowen & Twemlow, 1978; Garland, 2004). However, the severity of clients’ problems can also adversely affect the staff (Beck, 1987; Farber & Heifetz, 1982). The client to staff component of this bidirectional relationship has been largely overlooked. Working with clients who have major social problems (Beck, 1987) and clients who are unappreciative or hostile towards staff is thought to exacerbate burnout among staff (Farber & Heifetz, 1982). Given that clients with dual diagnoses of mental health and substance abuse have increased severity and needs and may add increased challenges to treatment, a stronger relationship between stress and burnout may exist in organizations that treat higher proportions of these high-severity clients.
As the literature indicates, organizations in which perceptions of self-efficacy and influence are higher and perceptions of workload are lower may exhibit weaker positive relationships between stress and burnout. In this study, these moderation effects are examined to further understand what contributes to burnout at the organizational level. Burnout holds many implications for the entire organization, with over half of the staff at drug abuse treatment organizations reporting high levels of burnout as indicated by depersonalization and emotional exhaustion (Farmer, 1995). Examining the antecedents of burnout are particularly salient for this field.
The current study tested two hypotheses that together address the process through which staff experiences (within substance abuse treatment programs) impact client engagement. The first focuses on organizational factors impacting client engagement whereas the second focuses on organizational factors impacting how organizations respond to stress. Hypothesis one states that there is a negative relationship between organizational stress and better client engagement, and that this relationship is mediated by organizational burnout and satisfaction. Specifically, programs with high levels of stress will also have high levels of burnout, and programs high in burnout will have lower client engagement. An identical pattern was expected for staff satisfaction. Substance abuse treatment programs with high levels of stress but high levels of satisfaction are expected to have higher client engagement ratings. Hypothesis two states that specific organizational characteristics, including workload, influence, efficacy, and client severity will moderate the relationship between stress and burnout at the organizational level. In particular, when high levels of stress combine with greater workloads (i.e., higher caseloads or higher proportion of severe problem clients), programs will experience higher burnout among staff. However, other organizational factors, including influence and efficacy, will weaken this relationship.
2. Materials and methods
Data were collected from 115 Outpatient Drug-Free (ODF) treatment programs from 9 states (Florida, Idaho, Illinois, Louisiana, Ohio, Oregon, Texas, Washington, and Wisconsin) in 2004 and 2005 as part of the Treatment Costs and Organizational Monitoring (TCOM) project. The data comprises an initial assessment of organizational structure and the first of three annual surveys of clinical staff, clients, and costs. All measures used in this study were collected during the first year of the project. With the assistance of Addiction Technology Transfer Centers (ATTCs; including the Southern Coast ATTC, Great Lakes ATTC, Gulf Coast ATTC, and Northwest Frontier ATTC), the programs selected for this project represent the major types of ODF treatment for adults in diverse geographic locations across the United States.
The study included 89 programs, representing 86% of those eligible. Twenty-one of the 115 programs did not provide data. Eleven of these 21 programs were ineligible for the first annual data collection as three were undergoing reorganization, six closed between the time of the initial assessment and first annual survey administration, and two were being rebuilt after Hurricane Katrina. Ten programs withdrew from the study. Because this study examined client outcomes, program directors were included in the analyses if they saw clients. After removing those who did not see clients, five programs were removed from the analyses for having less than three responses, because three or more responses were necessary for a valid program measure.
Most of the programs provided a mix of regular and intensive care (63%) followed by 24% of programs offering regular outpatient care (less than six hours of structured programming per week) and 16% offering intensive care (minimum of two hours of structured programming three days a week). All programs provided individual and group counseling sessions on-site, and most also provided a variety of wraparound services (see Knight, Edwards, & Flynn, 2010). On average, within the 89 programs, 4.9 staff (SD = 3.9, total of 445 across programs) and 52.63 clients (SD = 63.11, total of 5013 across programs) responded. The staff had a mean age of 47 years, were predominately White (76.33%), and female (61.81%). A majority were currently certified or licensed (66.44%), had over 5 years of experience in the field (62.22%), and held a bachelor’s degree or higher (73.5%). Clients were primarily white (67.53%) and male (64.61%) with a median age of 33. Clients who had been in treatment less than 30 days were removed from the mediation analyses, for a total of 3,285 clients, because they were deemed not to have been in treatment long enough to provide an accurate account of their experience in the program (Simpson, 1979; Simpson, 1981).
Program directors completed the Survey of Structure and Operations (SSO) upon enrollment in the project. This survey gathered information regarding general program characteristics, organizational relationships, clinical assessment and practices, services provided, staff and client characteristics, and recent changes. Directors from each program were then trained on staff and client data collection procedures, including recruitment and consent protocols. All staff with direct client contact completed the Survey of Organizational Functioning (SOF; Broome et al., 2007) which included the Organizational Readiness for Change (ORC; Lehman, Greener, & Simpson, 2002) instrument. This survey addressed perceptions of needs and pressures for change, general resources, staff attributes, organizational climate, job attitudes, and specific workplace practices. Clients completed the Client Evaluation of Self and Treatment (CEST; Joe, Broome, Rowan-Szal, & Simpson, 2002) which assessed their motivation for treatment, psychological and social functioning, and treatment experience. Individual responses were aggregated to form program level measures for each construct. All research methods and procedures were reviewed and approved by TCU’s Institutional Review Board.
2.2.1. Organizational factors
Five SOF scales were used to assess organizational factors: Burnout, Satisfaction, Influence, Efficacy, and Stress. Created primarily as program-level indicators (Lehman et al., 2002), individual level responses were transformed into program level measures by taking the average score for all staff at each program. Thus, the reliability coefficients for each item below refer to the program level. All ratings from the SOF and CEST used a Likert-type scale ranging from one to five in which one indicated “disagree strongly” and five indicated “agree strongly.” The composite scores were rescaled to range from 10 to 50. A higher score on all of the scales indicates a greater amount of the construct being measured.
Six items were used to measure burnout (α = .74, Knight, Broome, Edwards, & Flynn, 2011). These statements focused on issues of emotional exhaustion (e.g., “You feel depressed”) as well as issues of inefficacy (e.g., “You feel like you aren’t making a difference” and “You feel disillusioned and resentful”). Six items were used to measure job satisfaction (α = .78, Knight et al., 2011). The statements ranged from broad assessments (e.g., “You are satisfied with your present job”) to specific job elements (e.g., “You like the people you work with”). Six items were used to assess influence (α = .79, Lehman et al., 2002). These statements assessed the staff member’s general level of influence among their peers (e.g., “You often influence the decisions of other staff here”) as well as their own willingness to share information (e.g., “You frequently share your knowledge of counseling with other staff”). Five items addressed efficacy (α = .68, Lehman et al., 2002). The statements assessed the staff’s perception of their own skills (e.g., “You have the skills needed to conduct effective individual counseling”) as well as their own sense of effectiveness and self-assurance regarding their job (e.g., “You are effective and confident in doing your job”). Four items composed the measure of stress (α = .90, Lehman et al., 2002). These statements evaluated strain in the workplace (e.g., “You are under too many pressures to do your job effectively”), signs of stress including frustration (e.g., “Staff frustration is common here”), as well as a general assessment of stress in the workplace (e.g., “Staff members often show signs of stress and strain”).
2.2.2. Client engagement
Three CEST scales were used to assess client engagement: Treatment Satisfaction, Counselor Rapport, and Treatment Participation. Seven items were used to assess clients’ treatment satisfaction (α = .88, Joe et al., 2002). While the statements included a broad assessment of treatment satisfaction (e.g., “You are satisfied with this program”), specific aspects of treatment were also included (e.g., “You can get plenty of personal counseling at this program”). Counselor rapport (α = .96, Joe et al., 2002) comprised 13 items. The statements assessed specific counselor qualities (e.g., “Your counselor is well organized and prepared for each counseling session”) as well as the client’s relationship with the counselor (e.g., “You trust your counselor”). Twelve items were used to appraise client’s treatment participation (α = .92, Joe et al., 2002). These statements addressed the client’s overall engagement in the treatment sessions (e.g., “You always participate actively in your counseling sessions”) as well as attendance (e.g., “You always attend the counseling sessions scheduled for you”).
Workload was assessed in terms of caseload and client severity. Caseload was defined as the average number of clients per counselor. The scale ranged from one to five, where one indicated 1 to 10 clients and each increase on the scale indicated an increase by 10 clients. These were averaged across all staff at each program. Three measures from the CEST were used to evaluate client severity: Hostility, Depression, and Anxiety. These individual level measures were transformed to create a program level measure by taking the average score for all clients at each program. Eight items were used to evaluate client hostility (α = .91, Joe et al., 2002). The statements assessed general aggression (e.g., “You have urges to fight or hurt others” and “You feel a lot of anger inside you”) as well as specific hostile actions (e.g., “You have carried weapons, like knives or guns”). There were seven items that assessed client anxiety (α = .93, Joe et al., 2002). The statements included broad measures of tension and nervousness (e.g., “You feel tense or keyed-up”) as well as physical measures of anxiety (e.g., “You have trouble sleeping” and “You feel tightness or tension in your muscles”). Six measures were used to address client depression (α = .89, Joe et al., 2002). The statements evaluated general sadness (e.g., “You feel sad or depressed”) as well as specific characteristics of depression (e.g., “You feel hopeless about the future”).
Baron and Kenny’s (1986) test of mediation was used to test hypothesis one. For this part of the study, the mediation effect of burnout and satisfaction in the relationship between stress and client engagement were examined using regression analyses. A mediation effect is said to have occurred when the effect of the combined model of the independent variable and mediator variable on the dependent variable is more than the effect of the independent variable on the dependent variable. Burnout was examined first as a potential mediator in the relationship between stress and client engagement. The same set of regression analyses was used to examine satisfaction as a mediator.
Testing hypothesis two required a test of the potential moderating effect (Baron & Kenny, 1986) of client severity, caseload, influence, and efficacy on the relationship between stress and burnout. To test a moderation effect, the interaction effect between the independent variable and moderator variable must be significant. Each potential moderator was examined in a separate regression analysis examining the relationship between stress and burnout. Moderation allows one to see if the relationship between the independent variable and the dependent variable changes at different levels of the moderator variable.
A majority of the 89 programs were free-standing substance abuse centers (80.5%) providing both regular and intensive care to clients (64.4%). Most of the programs were in urban settings (43%) and were private, not for profit facilities (73.6%). Caseloads ranged from 3 to 80 clients with 25 clients as the median. On average, client engagement was high (M = 41.2, SD = 2.3), while problem severity was low (M = 24.95, SD = 3.17). For the staff, stress (M = 30.4, SD = 6.4) and burnout (M = 22.15, SD = 3.1) were low compared to efficacy (M = 40.6, SD = 3.9), influence (M = 36.9, SD = 4.17), and satisfaction (M = 40.3, SD = 4.2).
Hypothesis 1: Organizational Burnout, Stress, and Satisfaction Related to Client Engagement
Before conducting the mediation regression analyses, the three components of client engagement, treatment participation, treatment satisfaction, and counselor rapport, were regressed on stress in order to meet the first assumption of mediation analyses. According to Baron and Kenny (1986), this initial relationship between the independent variable and the dependent variable must be significant. Treatment participation was the only component of client engagement that was predicted by stress and was thus the only measure examined in the following mediation analyses. The first set of analyses examined the relationship of stress and burnout to treatment participation. The results indicated that stress predicted treatment participation, (R2 = .35, F (1, 88) = 11.97, p = .001, β = −.35, t = −2.23, p = .029, f2 = .54), as well as burnout, (R2 = .46, F (1, 88) = 75.34, p = .001, β = .33, t = 8.68, p = .001) but burnout was not a mediator of the stress and treatment participation relationship.
The second set of regression analyses examined the relationship of stress and satisfaction to treatment participation. Consistent with the findings for burnout, the relationship between stress and treatment participation was not mediated by satisfaction. The standardized regression coefficient between stress and client engagement did not decrease substantially when controlling for satisfaction. Similarly to burnout, satisfaction was not a significant predictor of treatment participation when controlling for stress, thus violating one condition of mediation. Stress was also not a significant predictor of satisfaction violating another condition of mediation.
Hypothesis 2: Moderators of the Burnout and Stress Relationship
For the second hypothesis, a set of regression analyses were run to test moderation. Satisfaction was not examined due to a lack of significant findings (above) and because the literature suggests burnout as potentially more influential. Burnout was regressed on the focal predictor, the moderator, and the interaction term to test the moderation hypotheses. To facilitate the illustration of significant interactions, stress (the focal predictor) and the significant moderator variables were categorized into high (one SD above the mean) and low (one SD below the mean) categories. Mean burnout scores by high and low levels of stress and each moderator are displayed in Table 1. Significant interactions were found for two moderators, as described below.
Predicted Values of Burnout from Moderation Regression Analyses
In regards to counselor attributes, the interaction term between stress and staff influence explained a significant amount of variance in job burnout (β = −1.87, t = −2.37, p = .02, R2 = .30, F(3, 85) = 2.8, p = .045, f2 = .43). As shown in Figure 1, when program staff report high levels of influence, ratings of burnout are lower compared to programs with low levels of influence when stress is high. However, when programs have low stress, ratings of burnout are similar across both levels of influence.
Moderating Effects of Influence and Number of Clients
The interaction term between stress and number of clients also explained a significant amount of variance in job burnout (β = −1.7, t = −2.63, p = .01, R2 = .31, F(3, 85) = 3.07, p = .03, f2 = .45). As number of clients increases by 10 clients (1 unit on the scale), the coefficient for stress decreases by .17. As Figure 1 shows, with fewer clients, the coefficient for stress is positive (as stress increases, burnout increases) whereas with more clients, the coefficient for stress is negative (as stress increases, burnout decreases).
The interaction term between stress and staff efficacy did not explain a significant amount of variance in job burnout (β = −.58, t = 1.79, ns, R2 = .064, F(3, 85) = 1.9, ns), nor did the interaction terms between stress and measures of client problem severity: client hostility (β = −.38, t = −.72, ns, R2 = .22, F(3, 85) = 1.39, ns), client depression (β = −1.05, t = −1.06, ns, R2 = .19, F(3, 85) = 1.05, ns), nor client anxiety (β = .798, t = 1.44, ns, R2 = .22, F(3, 85) = 1.39, ns).
This study is the first to examine the link between staff stress and client engagement within the field of substance abuse treatment. Findings indicate that within outpatient drug-free treatment programs, higher organizational stress is associated with lower client participation. Burnout is higher in high-stress organizations, and workload and staff influence moderate the stress – burnout relationship. Specifically, stress and burnout appear to be more strongly linked when caseloads are lower and opportunities for staff to influence program practices are few. A summary of these results can be found in Figure 2.
Contrary to the original hypothesis, the link between staff stress and client engagement was not mediated by either burnout or satisfaction. In the current study, staff stress was a positive predictor of burnout, as previous research has shown (Borucki, 1987; Garner et al., 2007; Iverson et al., 1998), but was not a predictor of staff satisfaction despite past research (Cummins, 1990; Spielberger & Reheiser, 1995). While other researchers have found that staff satisfaction positively predicts client engagement in related fields of nursing (Weisman & Nathanson, 1985) and mental health (Killaspy et al., 2009), and that burnout negatively predicts client engagement (Bowen & Twemlow, 1978; Leiter et al., 1998), relationships among these constructs were not significant in this sample of drug abuse treatment programs. These findings suggest that burnout and satisfaction at the program level may have indirect effects on client engagement. However, while the overall level of burnout and satisfaction at these programs did not relate to client engagement, the overall level of stress did.
The current study also found that the degree to which members of the organization perceive themselves as having influence can moderate the relationship between stress and staff burnout. When influence is higher within a program, stress is not related to burnout. However, when influence is low, higher stress is associated with higher burnout. Thus, influence serves as a buffer against burnout. Programs where staff report more knowledge sharing, influence in the decisions made by the program, and being viewed as a leader by their peers have lower organizational burnout even when stress was high.
Despite previous research that shows that both staff influence and efficacy provide a protective buffer against burnout at the individual level (Bhagat & Allie, 1989; Borucki, 1987; Johnson et al., 2006; Schwarzer & Hallum, 2008), the current study only found influence to be a significant moderator when examined at the organizational level. While influence describes the dynamics of counselor interactions, efficacy reflects the perceived ability of a counselor to successfully engage with clients. This notion is documented by Broome et al. (2007) establishing a link between efficacy and client engagement and suggests that within drug abuse treatment, efficacy may be a counselor-level factor that impacts client engagement rather than an organizational-level factor that impacts staff burnout. Future research should examine these issues further.
Workload was also a significant moderator in the relationship between stress and burnout. In substance abuse treatment programs where staff have smaller caseloads, higher stress is associated with higher burnout. However, in programs with larger caseloads, the positive relationship does not exist and instead, higher stress is associated with slightly lower burnout. This relationship between stress and burnout is supported by previous research (Broome et al., 2009; Iverson et al., 1998; Killaspy et al., 2009), and suggests that when caseloads are large, stress may act as a motivator and buffer against burnout. While Broome et al. (2009) found that burnout was positively associated with number of clients, the current study expands this relationship by examining stress. The increased stress that may arise from a large number of clients appears to invert the caseload and burnout relationship suggesting that increased stress does not necessarily lead to feelings of being overwhelmed and exhausted; instead, it may provide motivation to work harder as the stress is perceived as a “challenge’ rather than an obstacle. Research has shown that moderate amounts of stress can impact work outcomes, highlighting the complexity of this construct (Boswell et al., 2004). Perhaps larger caseloads are more common in larger programs where counselors may share the workload and have more resources available to them. Future research could examine perceived workload (Shirom, Nirel, & Vinokur, 2010), the percentage of criminal justice clients (Broome et al., 2009) and other client characteristics, as well as workplace practices to provide further insight into the stress and burnout relationship.
Due to the many facets of stress, some research has divided this construct into several components. Boswell et al. (2004) refer to ‘challenge’ and ‘hindrance’ related stress to distinguish between the positive and negative consequences of stress. This dichotomy is more clearly seen in the moderating effect of staff influence and workload. Individuals with high influence may perceive the stressful situation as an opportunity and challenge rather than a hindrance and disruption. Likewise, stress may be perceived as a ‘challenge’ associated with juggling multiple demands of larger caseloads, rather than a deterrent. Adding the variable perceived workload may capture how counselors perceive their caseloads and further illuminate the stress and burnout relationship. Distinguishing between these various components of stress may prove to be a fruitful endeavor for future research to fully capture the complexity of stress and its implications for both staff and clients.
Similar to stress, burnout is also a complex phenomenon, and past research has divided it into several components, including emotional exhaustion, depersonalization, and lower sense of personal accomplishment (Iverson et al., 1998). The burnout measurement in the current study captures these individual components in the six questions comprising the scale. However, the lack of agreement with the current study’s findings and previous findings (Bowen & Twemlow, 1978; Leiter et al., 1998) may point to the need to separate burnout into these three distinct components rather than examining burnout as a single element. Furthermore, staff with high burnout have been shown to have higher rates of turnover (Hiatt et al., 1997), and some may have already left the program and therefore were excluded in the current analysis. The data to divide burnout into several components is not available, but future research should consider expanding the burnout measure to include these distinct components.
Contrary to expectations, the interaction between client problem severity and staff stress did not account for an increase in staff burnout. The literature remains divided regarding the impact of client attributes on staff attributes (e.g., Beck, 1987; Farber & Heifetz, 1982; Schulz, Greenley, & Brown, 1995). Perhaps client severity directly influences staff stress (rather than burnout). Alternatively, previous research has shown that clients in drug abuse treatment are apt to deny or minimize their problems (Elman & Dowd, 1997; Farmer, 1995). It is possible that clients who would have scored high on problem severity did not respond to the survey or denied the severity of their problems. Furthermore, high burnout among the staff is associated with high client dropout (Bowen & Twemlow, 1978), suggesting that programs with high stress or burnout among staff may be at an increased risk for clients prematurely dropping out of treatment.
The current study has several limitations. First, measures were examined at one point in time, limiting the ability to make causal inferences or make conclusions about directionality. The factors cannot be said to cause changes in another factor as the relationship could be reciprocal. A longitudinal study of staff and clients could examine how staff attributes impact clients over time. For instance, grouping the programs into increasing, decreasing, or stable in regards to stress, burnout, and satisfaction across the data collection period and examining how different trends relate to similar patterns in client engagement would provide important insights into how organizational changes affect clients.
A second limitation involves generalizability due to exclusions in sampling. Clients who had been in treatment for less than 30 days were excluded from the analyses because they had not been in treatment long enough to answer the survey regarding treatment participation, counselor rapport, and treatment satisfaction. However, dropout rates are often highest in the first 30 days of treatment, ranging from 30 to 40% (Galanter & Kleber, 1999). Because this study only included clients in treatment for more than 30 days, engagement ratings are likely to be higher and problem severity lower among this sample compared to the population of all clients in treatment. Future research should extend this issue earlier and study program performance, examining how organizational stress and burnout impact retention during the critical first 30 days of treatment.
Finally, it is important to acknowledge that there are numerous other organizational and contextual factors that contribute to the stress-burnout relationship, beyond those captured within this study. The impact of economic factors, including counselor compensation and consistency of program funding can have profound effects on perceived stress, particularly when job security is uncertain (Graber et al., 2008; Sharp, 2008). While highly relevant, such measures were not included in the current study.
Despite these limitations, the current study expands research regarding predictors of client engagement by documenting a link between organizational stress and client participation in substance abuse treatment, and identifying important factors that affect the relationship between stress and burnout among counselors. These findings suggest that in their efforts to improve client participation, program managers may want to focus efforts on identifying underlying sources of organizational stress. Furthermore, cultivating a workplace culture where staff members feel influential – where their insights are sought and their views are heard – may serve to diminish the stress-burnout relationship. With implications for both clients and staff, organizational stress may indeed be a crucial element of the treatment process.
The authors would like to thank the Gulf Coast, Great Lakes, Northwest Frontier, and South Coast Addiction Technology Training Centers (ATTCs) for their assistance with recruitment and training. We would also like to thank staff at the individual programs who participated in assessments and training in the TCOM Project.
This work was funded by the National Institute on Drug Abuse (Grant R01 DA014468). The interpretations and conclusions, however, do not necessarily represent the position of the NIDA, NIH, or Department of Health and Human Services. More information (including data collection instruments that can be downloaded without charge) is available on the Internet at www.ibr.tcu.edu, and electronic mail can be sent to ude.uct@rbi.
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