Occup. Med. Vbl. 49, No. 7, pp. 451-467, 1999
Copyright O 1999 Upplncott Wimams 4 Wilklra for SOM
Printed In Great Britain. All rights reserved
0962-7480/99
Study to evaluate the effectiveness
of stress management workshops
on response to general and
occupational measures of stress
R. J. L. Heron,* S. McKeown,11 J. A. Tomenson* and
E. L. Teasdale*
* Corporate Health & Safety, AstraZeneca; +Health Care Services,
Cheadle Royal Hospital, Cheadle, Cheshire, UK; *Epidemiology Unit, ICI
PLC, Northwich, Cheshire, UK
This study was designed to evaluate the effectiveness of stress management training
workshops within Zeneca Pharmaceuticals. The study was of cross-sectional design,
comparing groups of workshop attendees and non-attendees. In addition, self-rated
well-being scores of attendees were compared with results obtained pre-workshop
and 2-3 months after the workshop. Employees participating in the study were drawn
from the Manufacturing, Research and Development, Sales and Marketing sites of
Zeneca Pharmaceuticals located in Cheshire, United Kingdom. Three hundred and
ninety persons who had participated in stress management workshops since 1988
were matched for age, gender and department with an equal number of employees
who had not attended stress management workshops. Outcome measures included
self-rated well-being (as measured by the 3O-questtan General Health Questionnaire),
knowledge of company guidance on the management of stress in staff, and an
assessment of coping strategies. Subjects who had not attended a stress
management workshop were much more likely to have a poor understanding of the
principles of management of stress in staff [odds ratio (OR) = 8.3; 95% confidence
interval (Cl) = 3.3-21.3] and more likely to have poor coping skills (OR = 2.8;
Cl = 1.3-6.1). However, mean scores for the two measures were similar In attendees
and non-attendees. Self-rating of current well-being was strongly associated with the
life-events score, but not related to workshop attendance. The study Indicates that
stress management training workshops reduce the prevalence of employees with a
poor understanding of the principles of the management of stress in staff and with
poor coping strategies. An improvement in the self-rated well-being observed shortly
after the workshop was not sustained.
Key words: Evaluation; stress; training.
Occup. Med. Vol. 49, 451-457, 1999
Received 14 January 1999; acctpud in final form 8 AprU 1999
INTRODUCTION
Psychiatric health problems are common in the UK and
one study reported that one in seven adults of working
age had some sort of neurotic health problem in the week
prior to the interview.1 Stress related to work has been
increasingly cited as a cause of morbidity and is regarded
as a contributory factor to accidents, job dissatisfaction
and illnesses such as coronary heart disease, alcoholism
Correspondence to: R. J. L Heron, Global Health & Hygiene Manager,
Corporate Health and Safety, AstraZeneca Aldertey Park, AWertey Edge,
Macctesfleld, Cheshire, SK10 4TF, UK. Tel: (+44) 01625 512278; Fax:
(+44)01625 517824.
and hypertension.2 It has been estimated that 80 million
days costing £3.7 billion are lost from work each year.3
Recent legal case law relating to breaches of health and
safety obligations have caused employers to look more
closely at the issue of work-related stress.4
Research carried out for the UK Health and Safety
Executive (HSE) into work-related stress,5 has identified
contributory factors at home and work. In their guidance
for employers, the HSE suggests that organizations
adopt solutions in line with their particular company
style.6 They advise employers to raise awareness and to
take organizational approaches to stress management.
452 Occup. Med. Vol. 49, 1999
Training to enable staff to manage pressures is also
encouraged. Raising awareness of mental health issues
in the workplace is also advised in the 'Health of the
Nation' document 3
As a vehicle for implementing these recommendations,
stress management training programmes have a number
of potential advantages for employees and organizations.
They can be tailored to the needs of particular groups of
workers, and can contribute to the management of nonwork problems.5 However, such programmes have been
criticized because although some have shown short-term
improvements in physiological parameters such as systolic
blood pressure and muscle tension, and psychological
symptoms such as mood state and job satisfaction,7"10
they are usually not designed to eliminate or reduce
sources of stress, and they focus on coping strategies
or cure rather than primary prevention. A recent review
of stress management interventions acknowledged the
importance of assessing their effectiveness.11
Zeneca Pharmaceuticals started stress management
workshops in 1988. These form part of the overall strategy for managing stress in the business (Figure 1) and
have the following objectives:
• to raise awareness of what is meant by stress and to
help participants to recognize it in themselves and
others;
• to display a range of stress management skills and
• to show the impact of behavioural styles on individual
stress and that of work colleagues.
It has been a deliberate policy to cascade the workshops throughout the organization, starting at the top.
This was considered to be the best way to achieve a real
change in the attitude of management and employees to
stress. The first three workshops were attended by 90%
of the directorate. For most people attending a workshop, their own manager will have attended previously.
However, attendance is voluntary.
The idea behind the stress management workshop is
straightforward. It is to show people that stress is a
normal part of healthy life that can, however, get out of
control. It is intended to help people recognize, in oneself and others, when stress levels are getting too high
and to provide them with stress management skills to do
something about it before overload is reached. The stress
management workshop is not intended to be a counselling forum for people who are deemed to have stressrelated problems.
The workshop requires the active participation of the
attendee. Participants are asked to talk about the sources
of stress in their life in a private session with another
participant. A group session focuses on 'what stresses
me'. These activities are intended to demonstrate that
stress is a legitimate subject for discussion. Videos are
used to illustrate what happens when the warning signs
of stress are not spotted early enough, and to pinpoint the responsibility of the manager. In addition,
participants are introduced to various techniques of
relaxation.
The primary aim of this study was to evaluate the
effectiveness of the workshop in raising awareness of
stress management by assessing understanding of the key
principles outlined in a company guideline on the prevention of adverse effects of stress.12 A secondary aim
was to assess the coping skills of attendees and their selfassessed well-being.
Figure 1. Strategy for managing 3tress, mental hearth and organizational well-being in Zeneca Pharmaceuticals in the UK.
Health
Progressively worsening state of
health
> Improving health and _ _ —*• Good performance
well-being
Serious health problems
Depression
Anxiety
Well-being
Fulfilment
Development and Growth
Resources
Referral
Advice and
Counselling
Health Promotion
Training
-task
- assertiveness
- team building
- stress/life mgmrt
Work Organisation/
Functioning
job
- structure
people - number
- selection
- development
- performance
-reward
Agents
GP/Specialist
Occupational Health
-doctor
-nurse
- counsellor
External Agencies
Occupational Health
Human Resources
Training
Line Management
Human Resources
Senior Management
Line Management
t Stress Management Workshop
R. J. L Heron et a/.: Effectiveness of stress management workshops 453
MATERIALS AND METHODS
The study design was cross-sectional and included 452
UK employees of Zeneca Pharmaceuticals who had
attended Stress Management workshops as part of their
general development training between 1988 and 1996.
Three hundred and ninety persons were matched to
attendees by age, gender and department. A suitable
match could not be found for 62 attendees, but they
were included in the study in order to look at changes in
well-being scores since the stress management training.
A four-part questionnaire was mailed to all participants comprising:
1. the 30-question General Health Questionnaire
(GHQ30) used to compare self-rated stress/well-being
in the two groups;13
2. coping skills questions from the Occupational Stress
Indicator;14
3. questions assessing understanding of company guidance regarding management of stress in staff and
4. a modified life-events questionnaire.15
A GHQ30 score, a coping skills score (CSS) and a
managing stress in staff score (MSSS) were obtained by
giving equally spaced scores to the ordinal responses to
each question and summing the scores. The life events
questionnaire was scored using the supplied scoring
scale to give a life events score (LES).
GHQ30 scores were available for 249 of the workshop
attendees pre- and 2-3 months post- the stress management training.
STATISTICAL ANALYSIS
Univariate analysis of variance (ANOVA) was used to
investigate the effect on mean GHQ30, CSS and MSSS
of a range of factors including workshop attendance.
Analyses were performed for the matched subjects but
data from all subjects including the workshop attendees
who were not originally matched to non-attendees, were
also analyzed. The ANOVA model included terms for
workshop attendance, gender, number of staff managed,
LES and age. LES was incorporated in the models as a
five point score with the cut points given by the quintiles
of LES. This was done because of concerns about the
accuracy of some of the highest scores. The SAS package
was used to fit the ANOVA models.16
For some parameters, the normal error assumption of
the analysis of variance was not met, but non-parametric
analyses based on ranked data gave similar results and
are not presented. The means presented in thefiguresare
least squares means.17 These means correct for imbalance in the number of subjects in the different categories
when broken down by the factors present in the ANOVA
model.
In addition, subjects were categorized according to
whether their CSS and MSSS were below or equal to the
5th percentile of the whole group and whether their
GHQ30 score was greater than or equal to the 95th
percentile of the whole group. For each of these categorizations, the odds ratio for workshop attendance was
determined in order to see if attendance had resulted in a
reduction in the numbers of employees with poor coping
skills, poor skills in managing stress in staff and high selfrated well-being scores.
Rank correlation methods were used to assess the
relationship between the variables GHQ30, CSS, MSSS
and LES.
Changes in GHQ30 scores from pre- and postworkshop were tested using a Wilcoxon rank test, and rank
correlation methods were used to assess the relationship
between changes in GHQ30 scores, and the time elapsed
since workshop attendance.
RESULTS
Fully completed questionnaires were returned by 368
workshop attendees and 240 control subjects who had
not attended the workshop. A further 21 subjects
returned questionnaires which contained incomplete
data and were excluded. Twenty subjects had changed
circumstances since the matching was performed and
were no longer eligible, giving a response rate of 77%.
One hundred and sixty-six of the matched pairs completed questionnaires. The results of analyses of the 608
respondents are presented; the analyses of data from the
166 matched pairs gave similar results.
The attendee and non-attendee groups were well
matched in respect of age and gender, but there was a
large difference in the percentages of subjects who managed staff. Table 1 shows the attendee and non-attendee
groups broken down by the numbers of staff managed.
Only 34% of non-attendees managed staff compared
to 70% of attendees. The attendees who managed staff
were responsible for more staff than the non-attendee
managers.
Table 2 shows non-parametric correlations between
GHQ30, CSS, MSSS, LES and age. CSS and MSSS
were highly correlated (r=0.29; p< 0.001). GHQ30
was correlated with LES (r = 0.20; p < 0.001) and CSS
Table 1. Respondent numbers (%) according to workshop attendance and number of staff managed
Number of staff managed
Workshop
attendance
0
Non-attendee
Attendee
1-4
158 (65.8) 51 (21.3)
110 (29.9) 98 (26.6)
5-14
15+
26 (10.8) 5 (2.1)
117 (31.8) 43 (11.7)
Total
240
368
Table 2. Spearman (rank) correlations between the variables
GHQ30, CSS, MSSS, LES and age
GHQ30
CSS
MSSS
LES
Age
1.0
-0.12"
0.01
0.20"*
0.06
GHQ30
1.0
0.29"*
0.01
-0.08*
CSS
*p<0.05; "p-cn.01; "*p<0.001.
1.0
0.1
0.06
MSSS
1.0
-0.07
LES
1.0
Age
454
Occup. Med. Vol. 49, 1999
Figure 2. GHQ30 least squares means and standard errors broken down by workshop attendance, gender and life events score.
GHQ30
35 -t
30
20
16
10
N
Y
Attendance
F
M
Gender
(r= -0.12; p< 0.01). There was a just significant association between CSS and age.
Mean GHQ30 scores showed no dependence on
workshop attendance, but there was a significant linear
trend with LES (p< 0.001). The results are shown in
Figure 2.
There was a small increase in CSS in workshop
attendees, but it was not statistically significant (see
Figure 3). Female subjects achieved significantly higher
scores than male subjects (p< 0.001).
MSSS was dependent on workshop attendance (p<
0.01), gender (p<0.01) and a significant linear trend
with the number of staff managed (p < 0.05). The results
are shown in Figure 4.
Similar findings for GHQ30 and CSS were obtained
in the analysis of the data of matched subjects. However,
there were only 47 matched manager pairs and only the
linear trend in MSSS with number of staff managed
remained significant (p<0.01).
The analysis of subjects with GHQ30 results equal to
or higher than the 95th percentile showed that subjects
who had not attended the workshop were 1.5 [95% confidence interval (CI) = 0.7-3.2] times more likely to have
such a score. Subjects who had not attended the workshop were 2.8 (CI = 1.3-6.1) times more likely to have a
CSS below or equal to the 5th percentile and 8.3
(CI = 3.3-21.3) times more likely to have an MSSS
result below or equal to the 5th percentile. Similar results
were obtained in the analysis of matched pairs.
GHQ30 scores at the time of the workshop and 2-3
months later, were available for 249 of the workshop
attendees. GHQ30 scores had fallen by 2.4 units
I
II
III IV V
Life events score (quintiles)
(approximately 10%) at 2-3 months post-workshop
(p < 0.001) but were slightly higher (0.5 units) than the
pre-workshop level by the time of the cross-sectional
study. Changes in the GHQ30 score since the stress
management training were not related to the length of
the time interval between workshop attendance and the
cross-sectional study.
DISCUSSION
A prospective study design would have been the preferred choice to evaluate the effectiveness of the workshops, but a cross-sectional design was chosen to provide
more rapid feedback and for the secondary benefit of
obtaining information about employees who had not
attended the workshops.
The intention was to match workshop attendees to
non-attendees by age, gender and department. Matching
by department was chosen to eliminate departmental differences in attitudes to stress, which were thought to be
large. A weakness of the study is that attendees and
non-attendees were poorly matched on grade which is
known to be a key determinant of capabilities in the work
environment. Unfortunately it was not possible to find
sufficient matches if subjects were matched on both
department and grade. Because of the way the workshops had been cascaded through the organization and
the fact that they had come to be seen as an essential part
of management training, it was difficult to identify sufficient senior managers who had not attended a workshop.
Differences in response rates by workshop attendees
(86%) and non-attendees (65%) resulted in the low
R. J. L Heron et a/.: Effectiveness of stress management workshops
455
Figure 3. CSS least squares means and standard errors broken down by workshop attendance, gender and number of staff managed.
CSS
90
s^
80
70
60
50
40
30
20
10
i .I
N
Y
F
Attendance
J.J
0
M
1-4 5-14 15+
Number of staff managed
Gender
Figure 4. MSSS least squares and standard errors broken down by workshop attendance, gender and number of staff managed.
MSSS 25
I
•
*
•
20
15
! i" i
10
J
N
Y
Attendance
number of matched pairs with data and would have led
to 276 questionnaires being excluded from the analysis.
Because of the potential loss of study material, it was
decided to include all subjects in the analyses, including
F
M
Gender
1-4
5-14
15+
Number of staff managed
the workshop attendees who were not originally matched
to non-attendees. However, these analyses were supplemented by analyses of the smaller group of 166 matched
pairs.
456 Occup. Med. Vol. 49, 1999
The study suggests that non-attendees of the Stress
Management workshop were much more likely to have a
poor understanding of the principles of stress management and poor coping skills Qowest 5th percentile).
However, there was little difference in mean scores
between the attendee and non-attendee groups. A significant difference in MSSS was seen in the analysis of
all subjects, but the group of attendees who managed
staff were not well matched to the group of non-attendees
who managed staff. In the full study group, approximately
twice as many workshop attendees managed staff as
did non-attendees (70% vs. 34%). When the analysis of
MSSS was restricted to matched pairs of managers,
dependence upon workshop attendance was no longer
significant.
Coping skills were slightly higher in people who had
attended the workshops but the only significant effect
was the increased level in female staff. In a study of
occupational stress in female managers by Davidson and
Cooper,18 there was only one gender difference in
coping strategy, with male managers being less likely to
talk to someone they knew in order to relax.
Two subsets of coping skills questions were used to
derive a problem focus (PF) score and an emotion focus
(EF) score. Comparison data for the PF and EF scores
were available from a group of 18,520 non-managers
and a group of 2,454 managers in the retail, private
and public sectors.19 Managers and non-managers had
similar PF scores in the external survey (25.3 and 24.8,
respectively) compared to scores of 26.8 and 25.5 by
attendees and non-attendees, respectively, in this study.
Managers had lower EF scores than non-managers in the
external study (13.8 vs. 14.7), but there was little difference between attendees and non-attendees in the current
study (14.4 and 14.6, respectively).
The study group did not show any relationship
between workshop attendance and self-rated well-being.
This is unsurprising as the study population may have
attended the workshop at any time between 18 months
and eight years prior to the completion of the study
questionnaire. The GHQ tool used to assess self-rated
well-being largely reflects short-term influences on selfrated well-being. This would be consistent with the
observation that the strongest influence on self-rated
well-being was the presence of a recent adverse life-event
(e.g., bereavement).
In an earlier review of Zeneca's stress management workshops, short-term changes in self-rated wellbeing were seen.20 In this study, mean GHQ30 scores
for attendees fell by approximately 10% 2-3 months
after workshop attendance, when compared with preworkshop scores. However, the GHQ30 had returned to
pre-workshop level by the time of the cross-sectional
study. We were not able to adjust for life-events at
the time of workshop attendance or 2-3 months after
attendance.
In conclusion, subjects who had not attended a stress
management workshop were eight times more likely to
have a poor understanding of the principles of management of stress in staff and three times more likely to have
poor coping skills. However, mean scores for the two
measures were similar in attendees and non-attendees.
Self-rating of current well-being was strongly associated
with the life-events score, but not related to workshop
attendance.
The study indicates that the stress management training workshops reduce the prevalence of employees with a
poor understanding of the principles of the management
of stress in staff and with poor coping strategies. An
improvement in self-rated well-being observed shortly
after the workshop was not sustained.
Although the study has demonstrated relatively small
differences between attendees and non-attendees, there
is no doubt that employees have positively received the
stress management workshops.20 The management style
of the Company has changed dramatically over the last
decade and managers and employees are much more
sensitive to stress-related issues. In addition, the incidence of stress-related illnesses has declined significantly
in recent years. As noted earlier, the stress management
workshops are only part of the overall strategy for managing stress in the business and consequently it is difficult to quantify the benefits of the workshops in isolation.
A prospective study might have enabled a better quantification of the benefits of the workshop but the present
study has provided much useful information about stress
awareness and well-being across the organization.
We believe that different elements of the stress management workshop would be of value to other organizations as part of a more comprehensive stress management
strategy. Feedback indicates that the four types of skills
covered in the workshops (behavioural, physiological,
emotional and cognitive) are thought to be of real benefit
by the participants. In particular, participants have
found the development of cognitive skills to be extremely
useful and this has led to a greater emphasis on critical
thinking skills and rational emotive therapy. The workshops have also helped to identify wider training needs
such as assertiveness and balanced living. However, we
would recommend that other organizations should give
thought at the outset to how they will assess benefit to
the individual and the organization. Consideration
should be given to implementing the programme in a
way that permits the conduct of an intervention study,
ideally a randomized controlled trial.
NOTE
Since this article was received, Zeneca has merged with
Astra to form AstraZeneca. The information contained
in this paper is based on policies and practices in operation at Zeneca prior to this organizational change.
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