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Free Essays - Health Essays

Is stress related to cardiovascular morbidity in the workplace?

Introduction

Stress in the workplace is a commonly underrated phenomenon. This essay seeks to explore its causes, frequency, its governing legislation, possible remedies and treatment.

To put the problem in perspective, the Health and Safety Executive (2004) currently estimates that about 500,000 people in the UK experience workplace related stress at a level that they believe is making them ill and in the region of 5 million people feel either very or extremely stressed by their work. This can be translated into a cost of about 4 billion a year in terms of costs to the UK economy.

What is stress?

It is a common consideration that we all believe that we actually know what stress is and that we can all recognise it. It is actually not easy to define and harder still to quantify.

Crampton (et al. 1995) differentiates between two types of stress - the psychological stress and the biological (or physical) stress. Although the two varieties are indeed similar, they do have fundamental differences. (Cheng et al 2000).

The biological stresses are agents such as hunger and cold, which are not what we are specifically considering in this essay. The psychological sequelae of stress are legion and, dependant on the exact nature of the stimulus, may comprise many different potential responses. (Alterman et al. 1994)

For some definitions of psychological stress we can turn to Hans Selye, whose pioneering work went a long way to defining the field. One of his basic definitions of stress was "the non-specific response of the body to any demands made upon it" (1956).

Crampton (et al. 1995) took this definition further by extending the definition to include an internal state or reaction to anything we consciously or unconsciously perceive as a threat, either real or imagined. Selye went on to help us further with his comments that stress has the ability to evoke a number of different emotions and feelings including - amongst others - fear, sadness conflict, hurt, anger, inadequacy, guilt, frustration, loneliness, pressure or confusion.

We must not, however, lose sight of the fact that a number of sources remind us that stress is not a universally negative emotion. Apter, who is more usually associated for is work on reversal theory, points out that it is a commonly held belief that people can live longer if they avoid stress in their lives. He reminds us that stress adaptation has evolved over biological time scales to confer an evolutionary advantage. Those organisms that adapt and cope with stress tend to evolve and flourish better than those who don't. (Apter 2001). He refers to stress as the spice of life and suggests that some people need a degree of stress in their lives if they are to function well. There are people who appear to thrive on stress and the only situation that he suggests that we would not experience stress is death.

While the original definition of stress (Selye) was basically a biological description and the Crampton definition was a psychological one, we can look to workers such as Shattner (2003) who defines the various possible responses to various stressors and Mussleman (et al 1998) elucidates still further with the concepts of positive and negative elements to stress.

Legislation governing stress in the workplace

In the context of this essay, stress is defined by the Health and Safety Executive as:

"The adverse reaction people have to excessive pressure or other types of demand placed on them".

This is interesting, not only because it defines stress in a completely negative (adverse) way, but because it then goes on to add:

Pressure is part and parcel of all work and helps to keep us motivated . But excessive pressure can lead to stress which undermines performance, is costly to employers and can make people ill.

This is in line with Apter's comments (above) but draws the distinction that, in this definition, stress is excessive pressure and in this article, we will continue to use this definition for our purposes.

In order to explore our topic further, we must consider some of the recent literature on the subject. It is probably useful to start by considering the legislation on the subject by The Health and Safety Executive. We have already considered, and have adopted, their working definition of stress in the workplace. The consequences of stress in the workplace can be very varied and include high sickness absence and staff turnover together with poor staff performance. (Pickering. 2001)

The Health and Safety Executive set a series of Management Standards which currently should to be met by employers. It is not yet enforceable in law, but the intention is soon to make it so. It is not appropriate to consider all of the Standards in detail, but in general terms, they cover areas of workload, patterns and environment, how much say the employee has in their own working conditions together with the support that the employee has when actually doing their job. The employer also has a responsibility to try to avoid workplace conflict and to deal with unacceptable behaviour. (Theorell et al. 1996)

The Health and Safety Executive makes a number of recommendations to minimise the potential for workplace related stress including clearly delineating the role of the employee and to actively and positively manage chance in the workplace.

Literature relating to the morbidity associated with stress in the workplace

Susan Mayor ( 2001) is an advocate of counselling for workplace related stress. She points to studies that show a 50% reduction in stress levels after counselling courses. In her analysis of a number of papers that look at the issue of stress in the workplace, she found that symptoms and stress levels fell to normal levels for more than 50% of clients in over 60% of the papers analysed and, as a direct consequence of this reduction, a number of studies found accompanying improvements in criteria such as job satisfaction, commitment and work-related functioning. The authors also make the very pertinent observation that stress in the workplace can not only affect the worker, but may also have a knock-on effect on the worker's spouse and family.

We should consider whether stress in the workplace actually does have any demonstrable physical effects on an employee's health. The paper by Everson (et al. 1997) considered the effects of workplace related stress on the cardiovascular system. The study assessed the association between self-reported stress levels at work and the progression of atherosclerotic processes within the body (as assessed by ultrasound).

The group followed up a cohort of nearly 600 men over a 4 year period. The results were rather startling. In the group that had already present atherosclerotic changes at the beginning of the study, those who reported high stress levels had 46% greater atherosclerotic progression than the low-stress group. The author's conclusions were unusually strongly worded for a medical paper:

Psychological stress plays an important part in the illness and premature death associated with cardiovascular disease.

The paper gives the results and appropriate discussion in great detail, and defers to the diathesis-stress model for an explanation of the findings (Manuck et al. 1990). The paper also found a positive relationship between increased systolic reactivity during a physical stress test and high levels of self-reported stress in the workplace.

Taking this particular study a stage further, Truelsen (et al. 2003) looked at the increased risk of cerebro-vascular accident in association with workplace related stress. It is a commonly held belief that too much stress can give you a stroke. (Schnall et al. 1994). This was a huge study involving over 13,000 people over a 13 year follow up. The authors reported that the risk of a fatal stroke in the highly stressed group was nearly double that of the low stress group. Interestingly, the risk for non-fatal strokes was not increased. The authors comment that there is a commonly found relationship between stress and other factors such as smoking (House et al. 1990) and alcohol (Macko et al.1996) which may, in themselves, be precipitating factors.

Everson (et al.2001) considered the possibility of socio-economic factors, as workers from lower socio-economic backgrounds were statistically more likely to suffer a cerebro-vascular accident. It has been postulated that this may be a reflection of the fact that better educated workers may actually be in better control of the stresses associated with their jobs (Lynch et al.1997)

Both of these studies are in a similar vein to the Sokejima (1998) study, which sought to find out if there was a correlation between long working hours and myocardial infarction. This study was conceived after the results of the Uehata (1991) study were published which found that two thirds of the cases of sudden death admitted to a hospital in Japan were working more than 60 hours a week. The reason why a Japanese study is important in this regard is due to the fact that the Japanese have an unusually low morbidity and mortality from myocardial infarction. (Robertson et al.1977). these results are therefore very significant.

The results of the study were very interesting, as there was a relationship between working hours (stress) and the rate of myocardial infarction, but it was not quite as expected (Siegrist. 1996)

Although there was a definite correlation with overlong working hours (>60 hours), there was also a distinct increase in incidence if the working hours suddenly dropped (if the work was seasonal). The authors suggest that this second phenomenon may be explained by the stress caused by financial hardship associated with a reduced wage packet. (Morris et al. 1994)

Kageyama (et al.1997) have suggested that increased working hours are associated with increased sympathetic tone and decreased vagal tone and that this may be the mechanism for increased blood pressure and increased rates of myocardial infarction.

These findings are broadly in line with the findings in the Kivimaki (et al 2001) study - the first major study to compare the mortality of the two major stress models (Bosma et al. 1998). The major finding of this study was a twofold increase in the myocardial infarction death rate when there was a high job strain high effort reward imbalance. Both of these factors were found to be related to a high cholesterol and BMI, which are both predictors of cardiovascular disease (Vrijkotte et al. 1999)

Discussion

In this essay we have considered the morbidity associated with stress in the workplace, the evidence for it and the Health and Safety Executive guidelines intended to combat it. From the evidence that we have presented, there seems little doubt that there is a marked association between both cardiovascular disease, cerebro-vascular disease and chronic stress. The whole situation was summed up and evaluated in a very well written article by John Macleod in the BMJ (2002), where he discussed the findings of the studies that we have considered in this essay. The sum total of the evidence appears to be that those people in jobs where the rewards do not appear to match the effort, and those in jobs that have little autonomy, have an increased risk of cardiovascular disease. For reasons that are not completely clear, both groups of workers tend to have a raised cholesterol and a higher than average BMI. (Davey Smith et al. 1997). It is thought that this may be mediated by some form of neuro-endocrine mechanism.

Macleod makes the very valid point that is the bane of many epidemiological studies, and that is that it is vital to distinguish between the true causal factors of an outcome and those factors that are simply associated with that particular outcome. The first group obviously are susceptible to direct intervention strategies whereas the second group clearly are not. (Macleod et al. 2001).

By way of illustration he quotes Shaw's A Dr's Dilemma

It is easy to prove that the wearing of tall hats and the carrying of umbrellas enlarges the chest, prolongs life, and confers comparative immunity from disease; for the statistics show that the classes which use these articles are bigger, healthier, and live longer than the class which never dreams of possessing such things.

He comments that the effects on morbidity may simply be a reflection of other, related factors, such as the fact that it is those very workers who work long hours who happen to be stressed and have myocardial infarctions where the causal mechanism may actually be something like their poor socio-economic status that makes them work the long hours in the first place, and it is the poor socio-economic status rather than the stress that may be the cause of the morbidity.(Phillips et al. 1991).

This is clearly vital to the arguments, as if stress is not the root cause of the morbidity, treating stress will not reduce the morbidity any more than the redistribution of the umbrellas and tall hats would change immunity to disease.

Until this issue can be properly answered, it is clearly important, for the well being of all concerned to endeavour to reduce the stress levels in the workplace as an industrial relations exercise. From the Public Health perspective, Macleod remarks that, in his opinion, it is more likely that any improvement in cardiovascular morbidity will come from the improvements in material conditions of the socio-economic deprived than simply by reducing their stress.

Methodology

Having decided on the topic and title, appropriate papers were sought at the local post-graduate centre and University library using their library-based search programmes. The papers were assimilated, ranked for relevance and then incorporated into the narrative of this essay. The references for all papers quoted are in the reference section.

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