Professional Resilience Program
System Resilience Building
Introduction
This paper provides a brief assimilation of the available literature regarding stress
and its association with working in organisational systems, as relevant to the
resilience of Neurodevelopmental Behavioural Paediatricians (NBP’s). While there is
a small and growing literature on stress and resilience specifically discussing
physicians, there is limited evidence-based literature on how work systems generate
stress generally, and less as it relates specifically to physicians.
This paper focuses broadly on stressors in organisational work contexts. The
rationale for this is simple. Individual stress cannot be understood in isolation to the
environmental context in which it develops. Environmental stressors interact with and
impact upon personal stress, and create contextual precursors to the emergence of
specific forms of stress such as burnout, secondary traumatic stress, and
compassion fatigue. Specific approaches for building and maintaining resilience
through individual and interpersonal strategies will be the subject of a separate paper.
Physicians belong to a range of professions that fall under the broad category of
helping professions. These are professions with the primary task of addressing a
person’s physical, psychological, and emotional well-being. It has been broadly
recognised that work in the helping professions involves particular stresses, or ‘costs
of caring’ (Malasch 1982).
NBP’s hold specialist roles in the medical diagnosis and treatment of
neurodevelopmental and behavioural conditions in children. However, during
consultations NBP’s routinely deal with the psychological and emotional responses of
caregivers to both the issues of the children themselves, and caregiver’s reactions to
diagnosis and treatment. This is work is often psychologically and emotional
demanding of the NBP. Patients, managers or colleagues may not adequately
understand this aspect of the NBP’s role. It also requires a range of psychological
and interpersonal skills that may not have been fully provided for in training, nor may
there be adequate supervisory and other support available in their work context. This
situation creates ‘role ambiguity’, that is, uncertainty about the expectations,
behaviours, and consequences associated with a particular role (Kahn et al. 1964).
Role ambiguity is known to be a significant stressor in organisational contexts.
Research Summary: Organisational sources of of stress
General
Cox and colleagues (2000, 2007) have undertaken literature reviews of
organisational sources of stress in a broad range of organisations. Early workplace
stress research focused on the individual, and specifically on how individuals adjust
to their role in their work environments, and individual differences in the process of
adaptation and coping (Gardell 1982).
More recently, there has been a shift (Johnson & Hall 1996) from understanding how
individual’s cope with stress, to an interest in how management of work and design
of work environments are sources of individual’s stress (Cox et al., 2000).
Organisational systems have been identified in the literature as sources of significant
psychosocial hazards that generate stress related illness in individuals (Cox et al.,
2007). However, organisational level interventions are the least common form of
stress interventions (Cox et al., 2007).
Cox and colleagues (2000) reviews of the literature on the psychosocial hazards of
organisational systems highlights ten categories These are summarised below in
Table 1.
TABLE 1
Work Context
Organisational culture and function



Role
Career development
Decision latitude/control










Interpersonal relationships at work



Home work interface

Work environment and work equipment 

Task design
Workload/workplace
Work schedule










Hazards
Poor communication
Low levels of support for problem-solving
and personal development
Lack of definition of organisational
objectives
Role ambiguity and role conflict
Responsibility for people.
Career stagnation and uncertainty
Under-or over-promotion
Poor pay
Job insecurity
Low social value to work.
Low participation in decision-making
Lack of control over work (control
particularly in the form of participation
Is also a context and wider organisational
issue.
Social or physical isolation
Poor relationships with superiors
Interpersonal conflict, lack of social
support.
Conflicting demands of work and home,
low support at home, dual career
problems.
Problems regarding the reliability
availability, suitability and maintenance
or repair of both equipment and facilities.
Lack of variety or short work cycles
Fragmented or meaningless work
Under-use of skills
High level of uncertainty.
Work overload or underload
Lack of control over pacing
High levels of time pressure.
Shift working
Inflexible work schedules
Unpredictable hours, long or unsocial
hours.
A recent review of literature on mental health in the workplace of (Harvey et. al.
2014) found similar results to Cox and colleagues (2000): the majority of the
literature on workplace mental health focused on a few specific aspects of a role that
may influence mental health outcomes. In an effort to expand this, Harvey and
colleagues sought to expand consideration of factors affecting individual’s mental
health at the level of work teams, organisational structure and processes, and
home/work conflict. They found risk and protective factors summarised below in
Table 2.
TABLE 2
Job Design






Team Factors



Organisational

Factors






Work/Home Conflict
Individual Factors






Job demands
Control of in the work environment
Available resources
Level of work engagement
Characteristics of the job
Exposure to trauma
Support from colleagues and managers,
Quality of interpersonal relationships
Effective leadership and availability of manager training
Changes to the organisation,
Support from the organisation as a whole
Recognising and rewarding work,
How justice is perceived in an organisation,
Psychosocial climate of safety
Positive organisational climate,
Safe physical environment
Degree to which conflicting demands from home, including
significant life events, interfere with work
Genetics
Personality
Early life events
Cognitive and behavioural patterns
Mental health history
Lifestyle factors and coping style.
The evidence reviewed suggested that the interaction of these factors is complex.
Hence, a focus on single risk factors (eg individual factors) in isolation is unlikely to
promote resilience and mental health. For example, Bober & Regehr (2006) did not
find that engaging in any coping strategy recommended for reducing distress had an
impact on immediate symptoms. They cautioned that over-focusing on the use of
individual coping strategies might imply that those who feel stressed may not be
balancing life and work adequately and may not be making effective use of leisure,
self-care. This can have the effect of ‘blaming the victim’. They suggest that the
solution to compassion fatigue and vicarious trauma may be more structural than
individual and emphasise that organisations must be actively involved in limiting the
exposure to stressors on individual practitioners.
Occupational Stress in Health Care Professions
One literature review (Michie & Williams in 2002), indicated that key work factors
associated with psychological distress and sickness absence in staff were long hours
worked, work overload and pressure, and the effects of these on personal lives,
interpersonal conflict, and conflict between work and family demands.
Several explanations have been put forward in the literature for the high levels of
psychological stress in the health care environment, including the nature of the work,
organisational changes, and the large amounts and pressure of work (Cox 1995).
Commonly identified sources of stress are workload, patient care, interpersonal
relationships with colleagues, and bureaucratic-political constraints (Bailey 1985).
In a comparison of public sector hospitals in the UK, Wall (1997) found lower rates of
psychological stress and ill-health in hospitals that were of smaller size, had greater
cooperation, better communication, more performance monitoring, a stronger
emphasis on training, and allowed staff more control and flexibility in their work. This
supports the notion that organisational factors may contribute to the level of
psychological stress experienced by staff.
Organisational-level interventions
Organisational-level interventions identifying three distinct sets of objectives have
been adopted by organisations in the management of occupational stress (Cox et al.,
1990; Dollard & Winefield 1998). Objectives include:
1. Prevention (control of hazards and exposure to hazards by design and
training to reduce likelihood of those workers experiencing stress;
2. Timely reaction (based on management and group problem solving); and
3. Rehabilitation (offering support to help workers cope with and recover from
problems which exist) (Cox et al., 2000).
Cox and colleagues (2000) suggest that the reduction of stress through the
elimination and control of stressors or hazards appears to be the most promising
area for intervention. This is often achieved through adoption of a problem-solving
approach as a form of risk management. This is reflected by Murphy and colleagues
(1992), who conclude, “job redesign and organisational change remain the preferred
approaches to stress management because they focus on reducing or eliminating the
sources of the problem in the work environment”.
Van der Hek & Plomp (1997) also concluded that “there is some evidence that
organisation-wide-approaches show the best results on individual, individualorganisational interface and organisational parameters (outcome measures); these
comprehensive programs have a strong impact on the entire organisation, and
require the full support of management”.
Many reviews have found that most stress management techniques are individual
focused, and attempt to change the individual as opposed to the organisation. For
example, Murphy and colleagues (1984) reviewed thirteen published and
unpublished studies on personal stress management. Of the 32 outcome measures
used in the thirteen studies, 27 related to the individual and only 3 to the
organisation. Williamson (1994) found that out of 24 evaluative studies of stress
interventions, 21 focused on the individual, and only 3 focused on change at
organisational level. Another review (Marine et al., 2009) on preventing occupational
stress in health care workers included 19 studies, 13 on which were focused on
person-directed interventions and 6 on interventions that focused on the
organisation.
The general absence of literature on stress management interventions that focus on
the organisation reflects a generalised gap in the literature. It is unlikely that
individual directed interventions will lead to a long term reduction in stress amongst
employees unless organisational procedures are also in place to reduce or prevent
environmental stressors (Kenny, 2005).
Current research evaluating stress management interventions has identified key
variables related to support for the implementation of interventions. Variables include
the nature of managerial control for those interventions, and those affected by them,
employee readiness for and acceptance for the need for change, their motivation and
their willingness and ability to participate, their role in the decision-making process,
the resources available to support change, and the quality of social relations and
trust within the organisation (Cox et al., 2007; Nielsen et al., 2007; Nytro et al., 1998;
Nytro et al., 2000; Taris et al., 2003).
Discussion
It is clear that DBP’s are at risk of manifold forms of work related stress. Building
professional resilience is necessary to protect against this, support personal
wellbeing, enhance professional satisfaction, and maximise patient care. It is
important to note that most of the interventions that address workplace stress,
especially in the helping professions, devolves to ‘self-care’ strategies and practices.
The literature indicates that most interventions target the individual and not the
organisation, and few evaluation studies have been conducted to test the
effectiveness of such interventions. The available literature suggests that
organisational interventions that aim to reduce or control the hazards within the
workplace are most effective, and indicates that an approach that combines
interventions that target the organisation as well as the individual represent the best
approach.
Recommendations
This project has the opportunity to begin with both organisation and individual in
mind. While organisational interventions are more difficult to initiate, they have a
clear role in support the wellbeing of NDP’s.
In this context it is worthwhile to consider the following:
Specifically
1. Raise awareness with members regarding organisational impacts of stress as
part of this project
2. Create a clear focus on the organisational components of occupational stress
at the conference, and its connection to DBP burnout, compassion fatigue,
and vicarious trauma
3. Discuss establishing and developing collaborative partnerships with other
medical and allied health professionals on the topic of work-related stress
generally, and the particulars of burnout, compassion fatigue, and vicarious
trauma in relation to NBP’s
4. Consider how individual or group based interventions might become part of
organisational interventions
5. Begin liaising and raising awareness with administrators and managers on
the topic of the organisational origins of occupational stress and its varieties
within different roles. Create clear connections between work productivity,
professional support, patient satisfaction, and organisational action to reduce
occupational stress.
Generally
1. Seek opportunities for NBP participation in organisational level decisions
2. Ensure senior NBP staff engage in resilience training and mental health
promotion
3. Promote leadership training among the NBP membership
4. Provide training programs for leaders and supervisors including workplace
mental health education
5. Promote NBP peer group facilitation training
6. Schedule regular team and peer supervision group meetings (see Mick
O’Keefe’s article).
7. Ensure that change is managed in an inclusive manner with open and
realistic communication
Change
Support of senior management is critical in any attempt to establish interventions at
an organisation level. Organisational change requires leadership. Leadership may
not begin with senior management, but they may be influenced by it.
Following Kotter (2006), effective organisational change initiatives require several
stages:
1.
2.
3.
4.
5.
6.
7.
8.
Establish a sense of urgency
Form a powerful guiding coalition
Create a vision
Communicate the vision
Empower other to act on the vision
Plan for a create short term wins
Consolidate improvements
Institutionalise new approaches
Kotter identifies specific actions and barriers at each stage. Establishing a sense of
urgency requires raising awareness of the impacts of stress and its sequela (burnout,
compassion fatigue, vicarious trauma) for DBP and other professionals is a
prerequisite to initiating a change process. Linking work productivity, professional
support, patient satisfaction, and organisational action to reduce occupational stress
is critical. Collaborating with other professionals is necessary to establish leadership
and a guiding coalition from a wide cross-section of professionals and staff in the
organisation.
Glossary
Definitions of useful constructs in relation to the purposes of the PRP and this paper
are provided below.
General Constructs
Stress is a state of psycho-physical and emotional strain resulting from adverse or
demanding circumstances. Lazarus and Folkman (1984) conceptualise stress as a
relationship between a person and the environment that is appraised by the person
as being taxing or exceeding his or her resources and endangering his or her
wellbeing.
Occupational stress has been defined by many researchers (eg Cox, 1978;
Cummings & Cooper, 1979; Quick & Quick, 1984) as arising from work demands or
expectations that are beyond an individual’s skills, abilities and coping strategies,
and that has negative mental and physical health consequences. Stressors, the
major sources of occupational stress have been divided into seven categories: work
control; job-intrinsic factors such as work overload and lack of job variety;
interpersonal relationships; career development (under- or over-promotion);
organisational climate; and home–work interface (Sparks & Cooper, 1999).
Burnout is the accumulative result of chronic occupational stress (Burke &
Richardson, 2000; Cordes & Dougherty, 1993; Moore, 2000; Schaufeli & Enzmann,
1998; Wisniewski & Gargiulo, 1997). The chronic stresses that may lead to burnout
include qualitative and quantitative overload, role conflict and ambiguity, lack of
participation and lack of social support (Shirom, Melamed, Toker, Berliner, &
Shapira, 2005).
Coping When a person appraises a situation as potentially stressful, they then
assess their own resources for dealing with it, or their ability to cope. Coping under
stress involves an active, adaptive process in which an individual employs strategies
to manage a specific environment. Inadequate coping is conceptualised as occurring
when an individual perceives a failure in dealing with the situation, thus resulting in
stress (Biggam, Power, & Macdonald, 1997). Lazarus and Folkman (1984) consider
that there are two primary functions of coping: dealing with the problem that is
causing the distress (problem-focused coping) and regulating the emotional reaction
caused by the situation (emotion-focused coping). Problem-focused coping involves
activities that focus on directly changing elements of the stressful situation—for
example, focusing on the task at hand, goal-setting, information gathering, and
problem-solving. Emotion-focused coping involves techniques to modify one’s
internal reactions to the stressful situation such as, distancing, denial, seeking social
support, self-control, accepting responsibility and positive reappraisal.
Resilience describes the capacity of an individual to cope well and survive stressful
environments (for review see Kaplan, 1999; Masten, Best, & Garmezy, 1990).
Resilience is understood broadly as a protective factor in relation to stress due to the
potential for human adaptation to stress. Early work on resilience was concerned
with the individual. More recently, the term has been applied to the links between
individuals, organisations structures, and cultures.
Specific Stress Constructs Relevant to NBP’s.
In the helping professions, particular kinds of stress resulting from the ‘people work’
have been divided into three constructs; compassion fatigue, burnout, and vicarious
trauma. Compassion fatigue and vicarious trauma are more likely to be experienced
by those in the helping professions. These terms have particular applicability to role
of NBP’s.
Burnout can be experienced by anyone experiencing high job pressures, as a result
of low job satisfaction, high work demands powerless (see above).
Compassion fatigue refers to significant emotional and physical depletion
experienced by physicians from continuous acts of caring as part of their professional
role.
Vicarious trauma (Pearlman & Saakvitne 1995) or secondary traumatic stress
defined by Pearlman and Saakvitne (1995, p. 31), as the "negative effects of caring
about and caring for others". Vicarious trauma is not the same as burnout, although
burnout may be exacerbated by it.