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Case Examples

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Jill, a 32-year-old Afghanistan War veteran

Jill had been experiencing PTSD symptoms for more than five years. She consistently avoided thoughts and images related to witnessing her fellow service members being hit by an improvised explosive device. This case example explains how Jill's therapist used a cognitive worksheet as a starting point for engaging in Socratic dialogue.

Tom, a 23-year-old Iraq War veteran

Several published CPT case examples exist in the literature but many find the one in this chapter to be especially helpful: 

Monson, C.M., Resick, P.A., & Rizvi, S.L. (2014). Posttraumatic stress disorder. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders (5th ed., pp. 80-113). New York, NY: Guilford Press. 

Philip, a 60-year-old who was in a traffic accident (PDF, 294KB)

This case example from the European Journal of Psychotraumatology details an assisted self-study application of cognitive therapy for PTSD. Philip developed PTSD and comorbid major depression following a traffic accident. He was treated in six sessions of cognitive therapy with self-study modules completed in between sessions.

Terry, a 42-year-old earthquake survivor

Terry consistently avoided thoughts and images related to witnessing the injuries and deaths of others during an earthquake. He began spending more time at work and filling his days with hobbies and activities. However, whenever he had free time, he would have unwanted intrusive thoughts about the earthquake. In addition, he was having increasingly distressing nightmares. This case example is followed by an excerpt from an in-session imaginal exposure with a different client.

Conditionally Recommended Treatments

Mike, a 32-year-old Iraq War veteran

Mike was a 32-year-old flight medic who had completed two tours in Iraq and discharged from the Army due to his posttraumatic stress disorder.

Eric, a 24-year-old Rwandan refugee living in Uganda (PDF, 28KB)

This document from the Common Language for Psychotherapy Procedures summarizes narrative exposure therapy and includes a case example about a Rwandan civil war refugee living in a Ugandan settlement. Eric had recurring intrusive images and nightmares of seeing his family be shot by armed rebels.

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Stress and Well-Being: A Systematic Case Study of Adolescents’ Experiences in a Mindfulness-Based Program

• Original Paper
• Published: 28 November 2020
• Volume 30 , pages 431–446, ( 2021 )

Cite this article

• Deborah L. Schussler   ORCID: orcid.org/0000-0001-5970-4326 1 ,
• Yoonkyung Oh 2 ,
• Julia Mahfouz 3 ,
• Joseph Levitan 4 ,
• Jennifer L. Frank 1 ,
• Patricia C. Broderick 1 ,
• Joy L. Mitra 1 ,
• Elaine Berrena 1 ,
• Kimberly Kohler 1 &
• Mark T. Greenberg 1  

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Research on mindfulness-based programs (MBPs) for adolescents suggests improvements in stress, emotion regulation, and ability to perform some cognitive tasks. However, there is little research examining the contextual factors impacting why specific students experience particular changes and the process by which these changes occur. Responding to the NIH call for “n-of-1 studies” that examine how individuals respond to interventions, we conducted a systematic case study, following an intervention trial (Learning to BREATHE), to investigate how individual students experienced an MBP. Specifically, we examined how students’ participation impacted their perceived stress and well-being and why students chose to implement practices in their daily lives. Students in health classes at two diverse high schools completed quantitative self-report measures (pre-, post-, follow-up), qualitative interviews, and open-ended survey questions. We analyzed self-report data to examine whether and to what extent student performance on measures of psychological functioning, stress, attention, and well-being changed before and after participation in an MBP. We analyzed qualitative data to investigate contextual information about why those changes may have occurred and why individuals chose to adopt or disregard mindfulness practices outside the classroom. Results suggest that, particularly for high-risk adolescents and those who integrated program practices into their daily lives, the intervention impacted internalizing symptoms, stress management, mindfulness, and emotion regulation. Mindful breathing was found to be a feasible practice easily incorporated into school routines. Contextual factors impacted practice uptake and program outcomes. Implications for practitioners aiming to help high school students manage stress are discussed.

Systematic case study provides nuanced data about how individuals respond to a mindfulness-based program (MBP).

High-risk adolescents received the most benefit from MBP participation.

Students who practiced were more likely to experience change across outcomes.

The MBP most impacted the way students responded to stress.

Mindful breathing may be the most accessible practice for students.

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Author Contributions

All authors contributed to the study conception and design. Qualitative data collection and analysis were performed by D.L.S., J.M., and J.L. Quantitative analysis was performed by Y.O., while J.L.M., E.B., and K.K. led the quantitative data collection. The first draft of the manuscript was written by D.L.S. and Y.O., and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

The project described was supported by Award Number R305A140113 from the Institute of Education Sciences (IES). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Institute of Education Sciences or the U.S. Department of Education.

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Deborah L. Schussler, Jennifer L. Frank, Patricia C. Broderick, Joy L. Mitra, Elaine Berrena, Kimberly Kohler & Mark T. Greenberg

University of Texas Health Science Center, Houston, TX, USA

Yoonkyung Oh

University of Colorado, Denver, CO, USA

Julia Mahfouz

McGill University, Montreal, QC, Canada

Joseph Levitan

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Correspondence to Deborah L. Schussler .

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In accordance with ethical obligations, P.C.B., developer of Learning to Breathe, is reporting a financial interest that may be affected by the research reported in the enclosed paper.

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This study was approved by the Human Research Ethics committee of Pennsylvania State University (Study 00000492; initial approval 2/24/2015).

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Schussler, D.L., Oh, Y., Mahfouz, J. et al. Stress and Well-Being: A Systematic Case Study of Adolescents’ Experiences in a Mindfulness-Based Program. J Child Fam Stud 30 , 431–446 (2021). https://doi.org/10.1007/s10826-020-01864-5

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Accepted : 08 November 2020

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DOI : https://doi.org/10.1007/s10826-020-01864-5

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Understanding stress management intervention success: A case study-based analysis of what works and why

--> Boulos, Marina Wasfy Aziz (2019) Understanding stress management intervention success: A case study-based analysis of what works and why. PhD thesis, University of Leeds.

This thesis investigates the process behind stress management interventions (SMIs). This includes the design, implementation and evaluation of interventions (both formative and summative), along with exploring the roles of involved stakeholders. Although there exists a plethora of studies around work-related stress across several disciplines, they are predominantly focused on the effects of stress on individuals, organisations and society, highlighting the various costs which are associated with it. However, studies on SMIs are less common, particularly ones with detailed accounts of the SMI process. As a result, this hinders our understanding of which SMIs work for whom in what context (Biron, 2012), making it difficult for forthcoming studies to benefit from the results. A multiple case study research, of a higher education institute (Russell University) and an Arm’s Length (ALMO) housing association (Bravo City Homes), was conducted to address what the literature has neglected. Specifically, it examined the various steps of the SMI process, highlighting the key roles of the involved stakeholders, while contrasting the effects that context had across two different sectors. This was done through forty semi-structured interviews with relevant stakeholders from both organisations to gain retrospective insight into the SMI processes, understand their role and what they perceived it to be, and to evaluate what helped and hindered the success of SMIs. It was found that giving each step of the research process sufficient attention from each of the relevant stakeholders was key. The lack of communication around who the relevant stakeholders were significantly hindered the interventions. Managers, in particular, were found to be crucial to SMI success by supporting the interventions and enhancing communication. Other stakeholders whose roles were found to be vital were Human Resources and trade unions, which have also been neglected in the literature.

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STRESS MANAGEMENT : A CASE STUDY OF PROFESSIONAL STUDENTS ON IMPACT OF MEDITATION & YOGA ON STRESS

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Article contents

Work, stress, coping, and stress management.

• Sharon Glazer Sharon Glazer University of Baltimore
• , and  Cong Liu Cong Liu Hofstra University
• https://doi.org/10.1093/acrefore/9780190236557.013.30
• Published online: 26 April 2017

Work stress refers to the process of job stressors, or stimuli in the workplace, leading to strains, or negative responses or reactions. Organizational development refers to a process in which problems or opportunities in the work environment are identified, plans are made to remediate or capitalize on the stimuli, action is taken, and subsequently the results of the plans and actions are evaluated. When organizational development strategies are used to assess work stress in the workplace, the actions employed are various stress management interventions. Two key factors tying work stress and organizational development are the role of the person and the role of the environment. In order to cope with work-related stressors and manage strains, organizations must be able to identify and differentiate between factors in the environment that are potential sources of stressors and how individuals perceive those factors. Primary stress management interventions focus on preventing stressors from even presenting, such as by clearly articulating workers’ roles and providing necessary resources for employees to perform their job. Secondary stress management interventions focus on a person’s appraisal of job stressors as a threat or challenge, and the person’s ability to cope with the stressors (presuming sufficient internal resources, such as a sense of meaningfulness in life, or external resources, such as social support from a supervisor). When coping is not successful, strains may develop. Tertiary stress management interventions attempt to remediate strains, by addressing the consequence itself (e.g., diabetes management) and/or the source of the strain (e.g., reducing workload). The person and/or the organization may be the targets of the intervention. The ultimate goal of stress management interventions is to minimize problems in the work environment, intensify aspects of the work environment that create a sense of a quality work context, enable people to cope with stressors that might arise, and provide tools for employees and organizations to manage strains that might develop despite all best efforts to create a healthy workplace.

• stress management
• organization development
• organizational interventions
• stress theories and frameworks

Introduction

Work stress is a generic term that refers to work-related stimuli (aka job stressors) that may lead to physical, behavioral, or psychological consequences (i.e., strains) that affect both the health and well-being of the employee and the organization. Not all stressors lead to strains, but all strains are a result of stressors, actual or perceived. Common terms often used interchangeably with work stress are occupational stress, job stress, and work-related stress. Terms used interchangeably with job stressors include work stressors, and as the specificity of the type of stressor might include psychosocial stressor (referring to the psychological experience of work demands that have a social component, e.g., conflict between two people; Hauke, Flintrop, Brun, & Rugulies, 2011 ), hindrance stressor (i.e., a stressor that prevents goal attainment; Cavanaugh, Boswell, Roehling, & Boudreau, 2000 ), and challenge stressor (i.e., a stressor that is difficult, but attainable and possibly rewarding to attain; Cavanaugh et al., 2000 ).

Stress in the workplace continues to be a highly pervasive problem, having both direct negative effects on individuals experiencing it and companies paying for it, and indirect costs vis à vis lost productivity (Dopkeen & DuBois, 2014 ). For example, U.K. public civil servants’ work-related stress rose from 10.8% in 2006 to 22.4% in 2013 and about one-third of the workforce has taken more than 20 days of leave due to stress-related ill-health, while well over 50% are present at work when ill (French, 2015 ). These findings are consistent with a report by the International Labor Organization (ILO, 2012 ), whereby 50% to 60% of all workdays are lost due to absence attributed to factors associated with work stress.

The prevalence of work-related stress is not diminishing despite improvements in technology and employment rates. The sources of stress, such as workload, seem to exacerbate with improvements in technology (Coovert & Thompson, 2003 ). Moreover, accessibility through mobile technology and virtual computer terminals is linking people to their work more than ever before (ILO, 2012 ; Tarafdar, Tu, Ragu-Nathan, & Ragu-Nathan, 2007 ). Evidence of this kind of mobility and flexibility is further reinforced in a June 2007 survey of 4,025 email users (over 13 years of age); AOL reported that four in ten survey respondents reported planning their vacations around email accessibility and 83% checked their emails at least once a day while away (McMahon, 2007 ). Ironically, despite these mounting work-related stressors and clear financial and performance outcomes, some individuals are reporting they are less “stressed,” but only because “stress has become the new normal” (Jayson, 2012 , para. 4).

This new normal is likely the source of psychological and physiological illness. Siegrist ( 2010 ) contends that conditions in the workplace, particularly psychosocial stressors that are perceived as unfavorable relationships with others and self, and an increasingly sedentary lifestyle (reinforced with desk jobs) are increasingly contributing to cardiovascular disease. These factors together justify a need to continue on the path of helping individuals recognize and cope with deleterious stressors in the work environment and, equally important, to find ways to help organizations prevent harmful stressors over which they have control, as well as implement policies or mechanisms to help employees deal with these stressors and subsequent strains. Along with a greater focus on mitigating environmental constraints are interventions that can be used to prevent anxiety, poor attitudes toward the workplace conditions and arrangements, and subsequent cardiovascular illness, absenteeism, and poor job performance (Siegrist, 2010 ).

Even the ILO has presented guidance on how the workplace can help prevent harmful job stressors (aka hindrance stressors) or at least help workers cope with them. Consistent with the view that well-being is not the absence of stressors or strains and with the view that positive psychology offers a lens for proactively preventing stressors, the ILO promotes increasing preventative risk assessments, interventions to prevent and control stressors, transparent organizational communication, worker involvement in decision-making, networks and mechanisms for workplace social support, awareness of how working and living conditions interact, safety, health, and well-being in the organization (ILO, n.d. ). The field of industrial and organizational (IO) psychology supports the ILO’s recommendations.

IO psychology views work stress as the process of a person’s interaction with multiple aspects of the work environment, job design, and work conditions in the organization. Interventions to manage work stress, therefore, focus on the psychosocial factors of the person and his or her relationships with others and the socio-technical factors related to the work environment and work processes. Viewing work stress from the lens of the person and the environment stems from Kurt Lewin’s ( 1936 ) work that stipulates a person’s state of mental health and behaviors are a function of the person within a specific environment or situation. Aspects of the work environment that affect individuals’ mental states and behaviors include organizational hierarchy, organizational climate (including processes, policies, practices, and reward structures), resources to support a person’s ability to fulfill job duties, and management structure (including leadership). Job design refers to each contributor’s tasks and responsibilities for fulfilling goals associated with the work role. Finally, working conditions refers not only to the physical environment, but also the interpersonal relationships with other contributors.

Each of the conditions that are identified in the work environment may be perceived as potentially harmful or a threat to the person or as an opportunity. When a stressor is perceived as a threat to attaining desired goals or outcomes, the stressor may be labeled as a hindrance stressor (e.g., LePine, Podsakoff, & Lepine, 2005 ). When the stressor is perceived as an opportunity to attain a desired goal or end state, it may be labeled as a challenge stressor. According to LePine and colleagues’ ( 2005 ), both challenge (e.g., time urgency, workload) and hindrance (e.g., hassles, role ambiguity, role conflict) stressors could lead to strains (as measured by “anxiety, depersonalization, depression, emotional exhaustion, frustration, health complaints, hostility, illness, physical symptoms, and tension” [p. 767]). However, challenge stressors positively relate with motivation and performance, whereas hindrance stressors negatively relate with motivation and performance. Moreover, motivation and strains partially mediate the relationship between hindrance and challenge stressors with performance.

Figure 1. Organizational development frameworks to guide identification of work stress and interventions.

In order to (1) minimize any potential negative effects from stressors, (2) increase coping skills to deal with stressors, or (3) manage strains, organizational practitioners or consultants will devise organizational interventions geared toward prevention, coping, and/or stress management. Ultimately, toxic factors in the work environment can have deleterious effects on a person’s physical and psychological well-being, as well as on an organization’s total health. It behooves management to take stock of the organization’s health, which includes the health and well-being of its employees, if the organization wishes to thrive and be profitable. According to Page and Vella-Brodrick’s ( 2009 ) model of employee well-being, employee well-being results from subjective well-being (i.e., life satisfaction and general positive or negative affect), workplace well-being (composed of job satisfaction and work-specific positive or negative affect), and psychological well-being (e.g., self-acceptance, positive social relations, mastery, purpose in life). Job stressors that become unbearable are likely to negatively affect workplace well-being and thus overall employee well-being. Because work stress is a major organizational pain point and organizations often employ organizational consultants to help identify and remediate pain points, the focus here is on organizational development (OD) frameworks; several work stress frameworks are presented that together signal areas where organizations might focus efforts for change in employee behaviors, attitudes, and performance, as well as the organization’s performance and climate. Work stress, interventions, and several OD and stress frameworks are depicted in Figure 1 .

The goals are: (1) to conceptually define and clarify terms associated with stress and stress management, particularly focusing on organizational factors that contribute to stress and stress management, and (2) to present research that informs current knowledge and practices on workplace stress management strategies. Stressors and strains will be defined, leading OD and work stress frameworks that are used to organize and help organizations make sense of the work environment and the organization’s responsibility in stress management will be explored, and stress management will be explained as an overarching thematic label; an area of study and practice that focuses on prevention (primary) interventions, coping (secondary) interventions, and managing strains (tertiary) interventions; as well as the label typically used to denote tertiary interventions. Suggestions for future research and implications toward becoming a healthy organization are presented.

Defining Stressors and Strains

Work-related stressors or job stressors can lead to different kinds of strains individuals and organizations might experience. Various types of stress management interventions, guided by OD and work stress frameworks, may be employed to prevent or cope with job stressors and manage strains that develop(ed).

A job stressor is a stimulus external to an employee and a result of an employee’s work conditions. Example job stressors include organizational constraints, workplace mistreatments (such as abusive supervision, workplace ostracism, incivility, bullying), role stressors, workload, work-family conflicts, errors or mistakes, examinations and evaluations, and lack of structure (Jex & Beehr, 1991 ; Liu, Spector, & Shi, 2007 ; Narayanan, Menon, & Spector, 1999 ). Although stressors may be categorized as hindrances and challenges, there is not yet sufficient information to be able to propose which stress management interventions would better serve to reduce those hindrance stressors or to reduce strain-producing challenge stressors while reinforcing engagement-producing challenge stressors.

Organizational Constraints

Organizational constraints may be hindrance stressors as they prevent employees from translating their motivation and ability into high-level job performance (Peters & O’Connor, 1980 ). Peters and O’Connor ( 1988 ) defined 11 categories of organizational constraints: (1) job-related information, (2) budgetary support, (3) required support, (4) materials and supplies, (5) required services and help from others, (6) task preparation, (7) time availability, (8) the work environment, (9) scheduling of activities, (10) transportation, and (11) job-relevant authority. The inhibiting effect of organizational constraints may be due to the lack of, inadequacy of, or poor quality of these categories.

Workplace Mistreatment

Workplace mistreatment presents a cluster of interpersonal variables, such as interpersonal conflict, bullying, incivility, and workplace ostracism (Hershcovis, 2011 ; Tepper & Henle, 2011 ). Typical workplace mistreatment behaviors include gossiping, rude comments, showing favoritism, yelling, lying, and ignoring other people at work (Tepper & Henle, 2011 ). These variables relate to employees’ psychological well-being, physical well-being, work attitudes (e.g., job satisfaction and organizational commitment), and turnover intention (e.g., Hershcovis, 2011 ; Spector & Jex, 1998 ). Some researchers differentiated the source of mistreatment, such as mistreatment from one’s supervisor versus mistreatment from one’s coworker (e.g., Bruk-Lee & Spector, 2006 ; Frone, 2000 ; Liu, Liu, Spector, & Shi, 2011 ).

Role Stressors

Role stressors are demands, constraints, or opportunities a person perceives to be associated, and thus expected, with his or her work role(s) across various situations. Three commonly studied role stressors are role ambiguity, role conflict, and role overload (Glazer & Beehr, 2005 ; Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964 ). Role ambiguity in the workplace occurs when an employee lacks clarity regarding what performance-related behaviors are expected of him or her. Role conflict refers to situations wherein an employee receives incompatible role requests from the same or different supervisors or the employee is asked to engage in work that impedes his or her performance in other work or nonwork roles or clashes with his or her values. Role overload refers to excessive demands and insufficient time (quantitative) or knowledge (qualitative) to complete the work. The construct is often used interchangeably with workload, though role overload focuses more on perceived expectations from others about one’s workload. These role stressors significantly relate to low job satisfaction, low organizational commitment, low job performance, high tension or anxiety, and high turnover intention (Abramis, 1994 ; Glazer & Beehr, 2005 ; Jackson & Schuler, 1985 ).

Excessive workload is one of the most salient stressors at work (e.g., Liu et al., 2007 ). There are two types of workload: quantitative and qualitative workload (LaRocco, Tetrick, & Meder, 1989 ; Parasuraman & Purohit, 2000 ). Quantitative workload refers to the excessive amount of work one has. In a summary of a Chartered Institute of Personnel & Development Report from 2006 , Dewe and Kompier ( 2008 ) noted that quantitative workload was one of the top three stressors workers experienced at work. Qualitative workload refers to the difficulty of work. Workload also differs by the type of the load. There are mental workload and physical workload (Dwyer & Ganster, 1991 ). Excessive physical workload may result in physical discomfort or illness. Excessive mental workload will cause psychological distress such as anxiety or frustration (Bowling & Kirkendall, 2012 ). Another factor affecting quantitative workload is interruptions (during the workday). Lin, Kain, and Fritz ( 2013 ) found that interruptions delay completion of job tasks, thus adding to the perception of workload.

Work-Family Conflict

Work-family conflict is a form of inter-role conflict in which demands from one’s work domain and one’s family domain are incompatible to some extent (Greenhaus & Beutell, 1985 ). Work can interfere with family (WIF) and/or family can interfere with work (FIW) due to time-related commitments to participating in one domain or another, incompatible behavioral expectations, or when strains in one domain carry over to the other (Greenhaus & Beutell, 1985 ). Work-family conflict significantly relates to work-related outcomes (e.g., job satisfaction, organizational commitment, turnover intention, burnout, absenteeism, job performance, job strains, career satisfaction, and organizational citizenship behaviors), family-related outcomes (e.g., marital satisfaction, family satisfaction, family-related performance, family-related strains), and domain-unspecific outcomes (e.g., life satisfaction, psychological strain, somatic or physical symptoms, depression, substance use or abuse, and anxiety; Amstad, Meier, Fasel, Elfering, & Semmer, 2011 ).

Individuals and organizations can experience work-related strains. Sometimes organizations will experience strains through the employee’s negative attitudes or strains, such as that a worker’s absence might yield lower production rates, which would roll up into an organizational metric of organizational performance. In the industrial and organizational (IO) psychology literature, organizational strains are mostly observed as macro-level indicators, such as health insurance costs, accident-free days, and pervasive problems with company morale. In contrast, individual strains, usually referred to as job strains, are internal to an employee. They are responses to work conditions and relate to health and well-being of employees. In other words, “job strains are adverse reactions employees have to job stressors” (Spector, Chen, & O’Connell, 2000 , p. 211). Job strains tend to fall into three categories: behavioral, physical, and psychological (Jex & Beehr, 1991 ).

Behavioral strains consist of actions that employees take in response to job stressors. Examples of behavioral strains include employees drinking alcohol in the workplace or intentionally calling in sick when they are not ill (Spector et al., 2000 ). Physical strains consist of health symptoms that are physiological in nature that employees contract in response to job stressors. Headaches and ulcers are examples of physical strains. Lastly, psychological strains are emotional reactions and attitudes that employees have in response to job stressors. Examples of psychological strains are job dissatisfaction, anxiety, and frustration (Spector et al., 2000 ). Interestingly, research studies that utilize self-report measures find that most job strains experienced by employees tend to be psychological strains (Spector et al., 2000 ).

Leading Frameworks

Organizations that are keen on identifying organizational pain points and remedying them through organizational campaigns or initiatives often discover the pain points are rooted in work-related stressors and strains and the initiatives have to focus on reducing workers’ stress and increasing a company’s profitability. Through organizational climate surveys, for example, companies discover that aspects of the organization’s environment, including its policies, practices, reward structures, procedures, and processes, as well as employees at all levels of the company, are contributing to the individual and organizational stress. Recent studies have even begun to examine team climates for eustress and distress assessed in terms of team members’ homogenous psychological experience of vigor, efficacy, dedication, and cynicism (e.g., Kożusznik, Rodriguez, & Peiro, 2015 ).

Each of the frameworks presented advances different aspects that need to be identified in order to understand the source and potential remedy for stressors and strains. In some models, the focus is on resources, in others on the interaction of the person and environment, and in still others on the role of the person in the workplace. Few frameworks directly examine the role of the organization, but the organization could use these frameworks to plan interventions that would minimize stressors, cope with existing stressors, and prevent and/or manage strains. One of the leading frameworks in work stress research that is used to guide organizational interventions is the person and environment (P-E) fit (French & Caplan, 1972 ). Its precursor is the University of Michigan Institute for Social Research’s (ISR) role stress model (Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964 ) and Lewin’s Field Theory. Several other theories have since evolved from the P-E fit framework, including Karasek and Theorell’s ( 1990 ), Karasek ( 1979 ) Job Demands-Control Model (JD-C), the transactional framework (Lazarus & Folkman, 1984 ), Conservation of Resources (COR) theory (Hobfoll, 1989 ), and Siegrist’s ( 1996 ) Effort-Reward Imbalance (ERI) Model.

Field Theory

The premise of Kahn et al.’s ( 1964 ) role stress theory is Lewin’s ( 1997 ) Field Theory. Lewin purported that behavior and mental events are a dynamic function of the whole person, including a person’s beliefs, values, abilities, needs, thoughts, and feelings, within a given situation (field or environment), as well as the way a person represents his or her understanding of the field and behaves in that space. Lewin explains that work-related strains are a result of individuals’ subjective perceptions of objective factors, such as work roles, relationships with others in the workplace, as well as personality indicators, and can be used to predict people’s reactions, including illness. Thus, to make changes to an organizational system, it is necessary to understand a field and try to move that field from the current state to the desired state. Making this move necessitates identifying mechanisms influencing individuals.

Role Stress Theory

Role stress theory mostly isolates the perspective a person has about his or her work-related responsibilities and expectations to determine how those perceptions relate with a person’s work-related strains. However, those relationships have been met with somewhat varied results, which Glazer and Beehr ( 2005 ) concluded might be a function of differences in culture, an environmental factor often neglected in research. Kahn et al.’s ( 1964 ) role stress theory, coupled with Lewin’s ( 1936 ) Field Theory, serves as the foundation for the P-E fit theory. Lewin ( 1936 ) wrote, “Every psychological event depends upon the state of the person and at the same time on the environment” (p. 12). Researchers of IO psychology have narrowed the environment to the organization or work team. This narrowed view of the organizational environment is evident in French and Caplan’s ( 1972 ) P-E fit framework.

Person-Environment Fit Theory

The P-E fit framework focuses on the extent to which there is congruence between the person and a given environment, such as the organization (Caplan, 1987 ; Edwards, 2008 ). For example, does the person have the necessary skills and abilities to fulfill an organization’s demands, or does the environment support a person’s desire for autonomy (i.e., do the values align?) or fulfill a person’s needs (i.e., a person’s needs are rewarded). Theoretically and empirically, the greater the person-organization fit, the greater a person’s job satisfaction and organizational commitment, the less a person’s turnover intention and work-related stress (see meta-analyses by Assouline & Meir, 1987 ; Kristof-Brown, Zimmerman, & Johnson, 2005 ; Verquer, Beehr, & Wagner, 2003 ).

Job Demands-Control/Support (JD-C/S) and Job Demands-Resources (JD-R) Model

Focusing more closely on concrete aspects of work demands and the extent to which a person perceives he or she has control or decision latitude over those demands, Karasek ( 1979 ) developed the JD-C model. Karasek and Theorell ( 1990 ) posited that high job demands under conditions of little decision latitude or control yield high strains, which have varied implications on the health of an organization (e.g., in terms of high turnover, employee ill-health, poor organizational performance). This theory was modified slightly to address not only control, but also other resources that could protect a person from unruly job demands, including support (aka JD-C/S, Johnson & Hall, 1988 ; and JD-R, Bakker, van Veldhoven, & Xanthopoulou, 2010 ). Whether focusing on control or resources, both they and job demands are said to reflect workplace characteristics, while control and resources also represent coping strategies or tools (Siegrist, 2010 ).

Despite the glut of research testing the JD-C and JD-R, results are somewhat mixed. Testing the interaction between job demands and control, Beehr, Glaser, Canali, and Wallwey ( 2001 ) did not find empirical support for the JD-C theory. However, Dawson, O’Brien, and Beehr ( 2016 ) found that high control and high support buffered against the independent deleterious effects of interpersonal conflict, role conflict, and organizational politics (demands that were categorized as hindrance stressors) on anxiety, as well as the effects of interpersonal conflict and organizational politics on physiological symptoms, but control and support did not moderate the effects between challenge stressors and strains. Coupled with Bakker, Demerouti, and Sanz-Vergel’s ( 2014 ) note that excessive job demands are a source of strain, but increased job resources are a source of engagement, Dawson et al.’s results suggest that when an organization identifies that demands are hindrances, it can create strategies for primary (preventative) stress management interventions and attempt to remove or reduce such work demands. If the demands are challenging, though manageable, but latitude to control the challenging stressors and support are insufficient, the organization could modify practices and train employees on adopting better strategies for meeting or coping (secondary stress management intervention) with the demands. Finally, if the organization can neither afford to modify the demands or the level of control and support, it will be necessary for the organization to develop stress management (tertiary) interventions to deal with the inevitable strains.

Conservation of Resources Theory

The idea that job resources reinforce engagement in work has been propagated in Hobfoll’s ( 1989 ) Conservation of Resources (COR) theory. COR theory also draws on the foundational premise that people’s mental health is a function of the person and the environment, forwarding that how people interpret their environment (including the societal context) affects their stress levels. Hobfoll focuses on resources such as objects, personal characteristics, conditions, or energies as particularly instrumental to minimizing strains. He asserts that people do whatever they can to protect their valued resources. Thus, strains develop when resources are threatened to be taken away, actually taken away, or when additional resources are not attainable after investing in the possibility of gaining more resources (Hobfoll, 2001 ). By extension, organizations can invest in activities that would minimize resource loss and create opportunities for resource gains and thus have direct implications for devising primary and secondary stress management interventions.

Transactional Framework

Lazarus and Folkman ( 1984 ) developed the widely studied transactional framework of stress. This framework holds as a key component the cognitive appraisal process. When individuals perceive factors in the work environment as a threat (i.e., primary appraisal), they will scan the available resources (external or internal to himself or herself) to cope with the stressors (i.e., secondary appraisal). If the coping resources provide minimal relief, strains develop. Until recently, little attention has been given to the cognitive appraisal associated with different work stressors (Dewe & Kompier, 2008 ; Liu & Li, 2017 ). In a study of Polish and Spanish social care service providers, stressors appraised as a threat related positively to burnout and less engagement, but stressors perceived as challenges yielded greater engagement and less burnout (Kożusznik, Rodriguez, & Peiro, 2012 ). Similarly, Dawson et al. ( 2016 ) found that even with support and control resources, hindrance demands were more strain-producing than challenge demands, suggesting that appraisal of the stressor is important. In fact, “many people respond well to challenging work” (Beehr et al., 2001 , p. 126). Kożusznik et al. ( 2012 ) recommend training employees to change the way they view work demands in order to increase engagement, considering that part of the problem may be about how the person appraises his or her environment and, thus, copes with the stressors.

Effort-Reward Imbalance

Siegrist’s ( 1996 ) Model of Effort-Reward Imbalance (ERI) focuses on the notion of social reciprocity, such that a person fulfills required work tasks in exchange for desired rewards (Siegrist, 2010 ). ERI sheds light on how an imbalance in a person’s expectations of an organization’s rewards (e.g., pay, bonus, sense of advancement and development, job security) in exchange for a person’s efforts, that is a break in one’s work contract, leads to negative responses, including long-term ill-health (Siegrist, 2010 ; Siegrist et al., 2014 ). In fact, prolonged perception of a work contract imbalance leads to adverse health, including immunological problems and inflammation, which contribute to cardiovascular disease (Siegrist, 2010 ). The model resembles the relational and interactional psychological contract theory in that it describes an employee’s perception of the terms of the relationship between the person and the workplace, including expectations of performance, job security, training and development opportunities, career progression, salary, and bonuses (Thomas, Au, & Ravlin, 2003 ). The psychological contract, like the ERI model, focuses on social exchange. Furthermore, the psychological contract, like stress theories, are influenced by cultural factors that shape how people interpret their environments (Glazer, 2008 ; Thomas et al., 2003 ). Violations of the psychological contract will negatively affect a person’s attitudes toward the workplace and subsequent health and well-being (Siegrist, 2010 ). To remediate strain, Siegrist ( 2010 ) focuses on both the person and the environment, recognizing that the organization is particularly responsible for changing unfavorable work conditions and the person is responsible for modifying his or her reactions to such conditions.

Stress Management Interventions: Primary, Secondary, and Tertiary

Remediation of work stress and organizational development interventions are about realigning the employee’s experiences in the workplace with factors in the environment, as well as closing the gap between the current environment and the desired environment. Work stress develops when an employee perceives the work demands to exceed the person’s resources to cope and thus threatens employee well-being (Dewe & Kompier, 2008 ). Likewise, an organization’s need to change arises when forces in the environment are creating a need to change in order to survive (see Figure 1 ). Lewin’s ( 1951 ) Force Field Analysis, the foundations of which are in Field Theory, is one of the first organizational development intervention tools presented in the social science literature. The concept behind Force Field Analysis is that in order to survive, organizations must adapt to environmental forces driving a need for organizational change and remove restraining forces that create obstacles to organizational change. In order to do this, management needs to delineate the current field in which the organization is functioning, understand the driving forces for change, identify and dampen or eliminate the restraining forces against change. Several models for analyses may be applied, but most approaches are variations of organizational climate surveys.

Through organizational surveys, workers provide management with a snapshot view of how they perceive aspects of their work environment. Thus, the view of the health of an organization is a function of several factors, chief among them employees’ views (i.e., the climate) about the workplace (Lewin, 1951 ). Indeed, French and Kahn ( 1962 ) posited that well-being depends on the extent to which properties of the person and properties of the environment align in terms of what a person requires and the resources available in a given environment. Therefore, only when properties of the person and properties of the environment are sufficiently understood can plans for change be developed and implemented targeting the environment (e.g., change reporting structures to relieve, and thus prevent future, communication stressors) and/or the person (e.g., providing more autonomy, vacation days, training on new technology). In short, climate survey findings can guide consultants about the emphasis for organizational interventions: before a problem arises aka stress prevention, e.g., carefully crafting job roles), when a problem is present, but steps are taken to mitigate their consequences (aka coping, e.g., providing social support groups), and/or once strains develop (aka. stress management, e.g., healthcare management policies).

For each of the primary (prevention), secondary (coping), and tertiary (stress management) techniques the target for intervention can be the entire workforce, a subset of the workforce, or a specific person. Interventions that target the entire workforce may be considered organizational interventions, as they have direct implications on the health of all individuals and consequently the health of the organization. Several interventions categorized as primary and secondary interventions may also be implemented after strains have developed and after it has been discerned that a person or the organization did not do enough to mitigate stressors or strains (see Figure 1 ). The designation of many of the interventions as belonging to one category or another may be viewed as merely a suggestion.

Primary Interventions (Preventative Stress Management)

Before individuals begin to perceive work-related stressors, organizations engage in stress prevention strategies, such as providing people with resources (e.g., computers, printers, desk space, information about the job role, organizational reporting structures) to do their jobs. However, sometimes the institutional structures and resources are insufficient or ambiguous. Scholars and practitioners have identified several preventative stress management strategies that may be implemented.

Planning and Time Management

When employees feel quantitatively overloaded, sometimes the remedy is improving the employees’ abilities to plan and manage their time (Quick, Quick, Nelson, & Hurrell, 2003 ). Planning is a future-oriented activity that focuses on conceptual and comprehensive work goals. Time management is a behavior that focuses on organizing, prioritizing, and scheduling work activities to achieve short-term goals. Given the purpose of time management, it is considered a primary intervention, as engaging in time management helps to prevent work tasks from mounting and becoming unmanageable, which would subsequently lead to adverse outcomes. Time management comprises three fundamental components: (1) establishing goals, (2) identifying and prioritizing tasks to fulfill the goals, and (3) scheduling and monitoring progress toward goal achievement (Peeters & Rutte, 2005 ). Workers who employ time management have less role ambiguity (Macan, Shahani, Dipboye, & Philips, 1990 ), psychological stress or strain (Adams & Jex, 1999 ; Jex & Elaqua, 1999 ; Macan et al., 1990 ), and greater job satisfaction (Macan, 1994 ). However, Macan ( 1994 ) did not find a relationship between time management and performance. Still, Claessens, van Eerde, Rutte, and Roe ( 2004 ) found that perceived control of time partially mediated the relationships between planning behavior (an indicator of time management), job autonomy, and workload on one hand, and job strains, job satisfaction, and job performance on the other hand. Moreover, Peeters and Rutte ( 2005 ) observed that teachers with high work demands and low autonomy experienced more burnout when they had poor time management skills.

Person-Organization Fit

Just as it is important for organizations to find the right person for the job and organization, so is it the responsibility of a person to choose to work at the right organization—an organization that fulfills the person’s needs and upholds the values important to the individual, as much as the person fulfills the organization’s needs and adapts to its values. When people fit their employing organizations they are setting themselves up for experiencing less strain-producing stressors (Kristof-Brown et al., 2005 ). In a meta-analysis of 62 person-job fit studies and 110 person-organization fit studies, Kristof-Brown et al. ( 2005 ) found that person-job fit had a negative correlation with indicators of job strain. In fact, a primary intervention of career counseling can help to reduce stress levels (Firth-Cozens, 2003 ).

Job Redesign

The Job Demands-Control/Support (JD-C/S), Job Demands-Resources (JD-R), and transactional models all suggest that factors in the work context require modifications in order to reduce potential ill-health and poor organizational performance. Drawing on Hackman and Oldham’s ( 1980 ) Job Characteristics Model, it is possible to assess with the Job Diagnostics Survey (JDS) the current state of work characteristics related to skill variety, task identity, task significance, autonomy, and feedback. Modifying those aspects would help create a sense of meaningfulness, sense of responsibility, and feeling of knowing how one is performing, which subsequently affects a person’s well-being as identified in assessments of motivation, satisfaction, improved performance, and reduced withdrawal intentions and behaviors. Extending this argument to the stress models, it can be deduced that reducing uncertainty or perceived unfairness that may be associated with a person’s perception of these work characteristics, as well as making changes to physical characteristics of the environment (e.g., lighting, seating, desk, air quality), nature of work (e.g., job responsibilities, roles, decision-making latitude), and organizational arrangements (e.g., reporting structure and feedback mechanisms), can help mitigate against numerous ill-health consequences and reduced organizational performance. In fact, Fried et al. ( 2013 ) showed that healthy patients of a medical clinic whose jobs were excessively low (i.e., monotonous) or excessively high (i.e., overstimulating) on job enrichment (as measured by the JDS) had greater abdominal obesity than those whose jobs were optimally enriched. By taking stock of employees’ perceptions of the current work situation, managers might think about ways to enhance employees’ coping toolkit, such as training on how to deal with difficult clients or creating stimulating opportunities when jobs have low levels of enrichment.

Participatory Action Research Interventions

Participatory action research (PAR) is an intervention wherein, through group discussions, employees help to identify and define problems in organizational structure, processes, policies, practices, and reward structures, as well as help to design, implement, and evaluate success of solutions. PAR is in itself an intervention, but its goal is to design interventions to eliminate or reduce work-related factors that are impeding performance and causing people to be unwell. An example of a successful primary intervention, utilizing principles of PAR and driven by the JD-C and JD-C/S stress frameworks is Health Circles (HCs; Aust & Ducki, 2004 ).

HCs, developed in Germany in the 1980s, were popular practices in industries, such as metal, steel, and chemical, and service. Similar to other problem-solving practices, such as quality circles, HCs were based on the assumptions that employees are the experts of their jobs. For this reason, to promote employee well-being, management and administrators solicited suggestions and ideas from the employees to improve occupational health, thereby increasing employees’ job control. HCs also promoted communication between managers and employees, which had a potential to increase social support. With more control and support, employees would experience less strains and better occupational well-being.

Employing the three-steps of (1) problem analysis (i.e., diagnosis or discovery through data generated from organizational records of absenteeism length, frequency, rate, and reason and employee survey), (2) HC meetings (6 to 10 meetings held over several months to brainstorm ideas to improve occupational safety and health concerns identified in the discovery phase), and (3) HC evaluation (to determine if desired changes were accomplished and if employees’ reports of stressors and strains changed after the course of 15 months), improvements were to be expected (Aust & Ducki, 2004 ). Aust and Ducki ( 2004 ) reviewed 11 studies presenting 81 health circles in 30 different organizations. Overall study participants had high satisfaction with the HCs practices. Most companies acted upon employees’ suggestions (e.g., improving driver’s seat and cab, reducing ticket sale during drive, team restructuring and job rotation to facilitate communication, hiring more employees during summer time, and supervisor training program to improve leadership and communication skills) to improve work conditions. Thus, HCs represent a successful theory-grounded intervention to routinely improve employees’ occupational health.

Physical Setting

The physical environment or physical workspace has an enormous impact on individuals’ well-being, attitudes, and interactions with others, as well as on the implications on innovation and well-being (Oksanen & Ståhle, 2013 ; Vischer, 2007 ). In a study of 74 new product development teams (total of 437 study respondents) in Western Europe, Chong, van Eerde, Rutte, and Chai ( 2012 ) found that when teams were faced with challenge time pressures, meaning the teams had a strong interest and desire in tackling complex, but engaging tasks, when they were working proximally close with one another, team communication improved. Chong et al. assert that their finding aligns with prior studies that have shown that physical proximity promotes increased awareness of other team members, greater tendency to initiate conversations, and greater team identification. However, they also found that when faced with hindrance time pressures, physical proximity related to low levels of team communication, but when hindrance time pressure was low, team proximity had an increasingly greater positive relationship with team communication.

In addition to considering the type of work demand teams must address, other physical workspace considerations include whether people need to work collaboratively and synchronously or independently and remotely (or a combination thereof). Consideration needs to be given to how company contributors would satisfy client needs through various modes of communication, such as email vs. telephone, and whether individuals who work by a window might need shading to block bright sunlight from glaring on their computer screens. Finally, people who have to use the telephone for extensive periods of time would benefit from earphones to prevent neck strains. Most physical stressors are rather simple to rectify. However, companies are often not aware of a problem until after a problem arises, such as when a person’s back is strained from trying to move heavy equipment. Companies then implement strategies to remediate the environmental stressor. With the help of human factors, and organizational and office design consultants, many of the physical barriers to optimal performance can be prevented (Rousseau & Aubé, 2010 ). In a study of 215 French-speaking Canadian healthcare employees, Rousseau and Aubé ( 2010 ) found that although supervisor instrumental support positively related with affective commitment to the organization, the relationship was even stronger for those who reported satisfaction with the ambient environment (i.e., temperature, lighting, sound, ventilation, and cleanliness).

Secondary Interventions (Coping)

Secondary interventions, also referred to as coping, focus on resources people can use to mitigate the risk of work-related illness or workplace injury. Resources may include properties related to social resources, behaviors, and cognitive structures. Each of these resource domains may be employed to cope with stressors. Monat and Lazarus ( 1991 ) summarize the definition of coping as “an individual’s efforts to master demands (or conditions of harm, threat, or challenge) that are appraised (or perceived) as exceeding or taxing his or her resources” (p. 5). To master demands requires use of the aforementioned resources. Secondary interventions help employees become aware of the psychological, physical, and behavioral responses that may occur from the stressors presented in their working environment. Secondary interventions help a person detect and attend to stressors and identify resources for and ways of mitigating job strains. Often, coping strategies are learned skills that have a cognitive foundation and serve important functions in improving people’s management of stressors (Lazarus & Folkman, 1991 ). Coping is effortful, but with practice it becomes easier to employ. This idea is the foundation for understanding the role of resilience in coping with stressors. However, “not all adaptive processes are coping. Coping is a subset of adaptational activities that involves effort and does not include everything that we do in relating to the environment” (Lazarus & Folkman, 1991 , p. 198). Furthermore, sometimes to cope with a stressor, a person may call upon social support sources to help with tangible materials or emotional comfort. People call upon support resources because they help to restructure how a person approaches or thinks about the stressor.

Most secondary interventions are aimed at helping the individual, though companies, as a policy, might require all employees to partake in training aimed at increasing employees’ awareness of and skills aimed at handling difficult situations vis à vis company channels (e.g., reporting on sexual harassment or discrimination). Furthermore, organizations might institute mentoring programs or work groups to address various work-related matters. These programs employ awareness-raising activities, stress-education, or skills training (cf., Bhagat, Segovis, & Nelson, 2012 ), which include development of skills in problem-solving, understanding emotion-focused coping, identifying and using social support, and enhancing capacity for resilience. The aim of these programs, therefore, is to help employees proactively review their perceptions of psychological, physical, and behavioral job-related strains, thereby extending their resilience, enabling them to form a personal plan to control stressors and practice coping skills (Cooper, Dewe, & O’Driscoll, 2011 ).

Often these stress management programs are instituted after an organization has observed excessive absenteeism and work-related performance problems and, therefore, are sometimes categorized as a tertiary stress management intervention or even a primary (prevention) intervention. However, the skills developed for coping with stressors also place the programs in secondary stress management interventions. Example programs that are categorized as tertiary or primary stress management interventions may also be secondary stress management interventions (see Figure 1 ), and these include lifestyle advice and planning, stress inoculation training, simple relaxation techniques, meditation, basic trainings in time management, anger management, problem-solving skills, and cognitive-behavioral therapy. Corporate wellness programs also fall under this category. In other words, some programs could be categorized as primary, secondary, or tertiary interventions depending upon when the employee (or organization) identifies the need to implement the program. For example, time management practices could be implemented as a means of preventing some stressors, as a way to cope with mounting stressors, or as a strategy to mitigate symptoms of excessive of stressors. Furthermore, these programs can be administered at the individual level or group level. As related to secondary interventions, these programs provide participants with opportunities to develop and practice skills to cognitively reappraise the stressor(s); to modify their perspectives about stressors; to take time out to breathe, stretch, meditate, relax, and/or exercise in an attempt to support better decision-making; to articulate concerns and call upon support resources; and to know how to say “no” to onslaughts of requests to complete tasks. Participants also learn how to proactively identify coping resources and solve problems.

According to Cooper, Dewe, and O’Driscoll ( 2001 ), secondary interventions are successful in helping employees modify or strengthen their ability to cope with the experience of stressors with the goal of mitigating the potential harm the job stressors may create. Secondary interventions focus on individuals’ transactions with the work environment and emphasize the fit between a person and his or her environment. However, researchers have pointed out that the underlying assumption of secondary interventions is that the responsibility for coping with the stressors of the environment lies within individuals (Quillian-Wolever & Wolever, 2003 ). If companies cannot prevent the stressors in the first place, then they are, in part, responsible for helping individuals develop coping strategies and informing employees about programs that would help them better cope with job stressors so that they are able to fulfill work assignments.

Stress management interventions that help people learn to cope with stressors focus mainly on the goals of enabling problem-resolution or expressing one’s emotions in a healthy manner. These goals are referred to as problem-focused coping and emotion-focused coping (Folkman & Lazarus, 1980 ; Pearlin & Schooler, 1978 ), and the person experiencing the stressors as potential threat is the agent for change and the recipient of the benefits of successful coping (Hobfoll, 1998 ). In addition to problem-focused and emotion-focused coping approaches, social support and resilience may be coping resources. There are many other sources for coping than there is room to present here (see e.g., Cartwright & Cooper, 2005 ); however, the current literature has primarily focused on these resources.

Problem-Focused Coping

Problem-focused or direct coping helps employees remove or reduce stressors in order to reduce their strain experiences (Bhagat et al., 2012 ). In problem-focused coping employees are responsible for working out a strategic plan in order to remove job stressors, such as setting up a set of goals and engaging in behaviors to meet these goals. Problem-focused coping is viewed as an adaptive response, though it can also be maladaptive if it creates more problems down the road, such as procrastinating getting work done or feigning illness to take time off from work. Adaptive problem-focused coping negatively relates to long-term job strains (Higgins & Endler, 1995 ). Discussion on problem-solving coping is framed from an adaptive perspective.

Problem-focused coping is featured as an extension of control, because engaging in problem-focused coping strategies requires a series of acts to keep job stressors under control (Bhagat et al., 2012 ). In the stress literature, there are generally two ways to categorize control: internal versus external locus of control, and primary versus secondary control. Locus of control refers to the extent to which people believe they have control over their own life (Rotter, 1966 ). People high in internal locus of control believe that they can control their own fate whereas people high in external locus of control believe that outside factors determine their life experience (Rotter, 1966 ). Generally, those with an external locus of control are less inclined to engage in problem-focused coping (Strentz & Auerbach, 1988 ). Primary control is the belief that people can directly influence their environment (Alloy & Abramson, 1979 ), and thus they are more likely to engage in problem-focused coping. However, when it is not feasible to exercise primary control, people search for secondary control, with which people try to adapt themselves into the objective environment (Rothbaum, Weisz, & Snyder, 1982 ).

Emotion-Focused Coping

Emotion-focused coping, sometimes referred to as palliative coping, helps employees reduce strains without the removal of job stressors. It involves cognitive or emotional efforts, such as talking about the stressor or distracting oneself from the stressor, in order to lessen emotional distress resulting from job stressors (Bhagat et al., 2012 ). Emotion-focused coping aims to reappraise and modify the perceptions of a situation or seek emotional support from friends or family. These methods do not include efforts to change the work situation or to remove the job stressors (Lazarus & Folkman, 1991 ). People tend to adopt emotion-focused coping strategies when they believe that little or nothing can be done to remove the threatening, harmful, and challenging stressors (Bhagat et al., 2012 ), such as when they are the only individuals to have the skills to get a project done or they are given increased responsibilities because of the unexpected departure of a colleague. Emotion-focused coping strategies include (1) reappraisal of the stressful situation, (2) talking to friends and receiving reassurance from them, (3) focusing on one’s strength rather than weakness, (4) optimistic comparison—comparing one’s situation to others’ or one’s past situation, (5) selective ignoring—paying less attention to the unpleasant aspects of one’s job and being more focused on the positive aspects of the job, (6) restrictive expectations—restricting one’s expectations on job satisfaction but paying more attention to monetary rewards, (7) avoidance coping—not thinking about the problem, leaving the situation, distracting oneself, or using alcohol or drugs (e.g., Billings & Moos, 1981 ).

Some emotion-focused coping strategies are maladaptive. For example, avoidance coping may lead to increased level of job strains in the long run (e.g., Parasuraman & Cleek, 1984 ). Furthermore, a person’s ability to cope with the imbalance of performing work to meet organizational expectations can take a toll on the person’s health, leading to physiological consequences such as cardiovascular disease, sleep disorders, gastrointestinal disorders, and diabetes (Fried et al., 2013 ; Siegrist, 2010 ; Toker, Shirom, Melamed, & Armon, 2012 ; Willert, Thulstrup, Hertz, & Bonde, 2010 ).

Comparing Coping Strategies across Cultures

Most coping research is conducted in individualistic, Western cultures wherein emotional control is emphasized and both problem-solving focused coping and primary control are preferred (Bhagat et al., 2010 ). However, in collectivistic cultures, emotion-focused coping and use of secondary control may be preferred and may not necessarily carry a negative evaluation (Bhagat et al., 2010 ). For example, African Americans are more likely to use emotion-focused coping than non–African Americans (Knight, Silverstein, McCallum, & Fox, 2000 ), and among women who experienced sexual harassment, Anglo American women were less likely to employ emotion focused coping (i.e., avoidance coping) than Turkish women and Hispanic American women, while Hispanic women used more denial than the other two groups (Wasti & Cortina, 2002 ).

Thus, whereas problem-focused coping is venerated in Western societies, emotion-focused coping may be more effective in reducing strains in collectivistic cultures, such as China, Japan, and India (Bhagat et al., 2010 ; Narayanan, Menon, & Spector, 1999 ; Selmer, 2002 ). Indeed, Swedish participants reported more problem-focused coping than did Chinese participants (Xiao, Ottosson, & Carlsson, 2013 ), American college students engaged in more problem-focused coping behaviors than did their Japanese counterparts (Ogawa, 2009 ), and Indian (vs. Canadian) students reported more emotion-focused coping, such as seeking social support and positive reappraisal (Sinha, Willson, & Watson, 2000 ). Moreover, Glazer, Stetz, and Izso ( 2004 ) found that internal locus of control was more predominant in individualistic cultures (United Kingdom and United States), whereas external locus of control was more predominant in communal cultures (Italy and Hungary). Also, internal locus of control was associated with less job stress, but more so for nurses in the United Kingdom and United States than Italy and Hungary. Taken together, adoption of coping strategies and their effectiveness differ significantly across cultures. The extent to which a coping strategy is perceived favorably and thus selected or not selected is not only a function of culture, but also a person’s sociocultural beliefs toward the coping strategy (Morimoto, Shimada, & Ozaki, 2013 ).

Social Support

Social support refers to the aid an entity gives to a person. The source of the support can be a single person, such as a supervisor, coworker, subordinate, family member, friend, or stranger, or an organization as represented by upper-level management representing organizational practices. The type of support can be instrumental or emotional. Instrumental support, including informational support, refers to that which is tangible, such as data to help someone make a decision or colleagues’ sick days so one does not lose vital pay while recovering from illness. Emotional support, including esteem support, refers to the psychological boost given to a person who needs to express emotions and feel empathy from others or to have his or her perspective validated. Beehr and Glazer ( 2001 ) present an overview of the role of social support on the stressor-strain relationship and arguments regarding the role of culture in shaping the utility of different sources and types of support.

Meaningfulness and Resilience

Meaningfulness reflects the extent to which people believe their lives are significant, purposeful, goal-directed, and fulfilling (Glazer, Kożusznik, Meyers, & Ganai, 2014 ). When faced with stressors, people who have a strong sense of meaning in life will also try to make sense of the stressors. Maintaining a positive outlook on life stressors helps to manage emotions, which is helpful in reducing strains, particularly when some stressors cannot be problem-solved (Lazarus & Folkman, 1991 ). Lazarus and Folkman ( 1991 ) emphasize that being able to reframe threatening situations can be just as important in an adaptation as efforts to control the stressors. Having a sense of meaningfulness motivates people to behave in ways that help them overcome stressors. Thus, meaningfulness is often used in the same breath as resilience, because people who are resilient are often protecting that which is meaningful.

Resilience is a personality state that can be fortified and enhanced through varied experiences. People who perceive their lives are meaningful are more likely to find ways to face adversity and are therefore more prone to intensifying their resiliency. When people demonstrate resilience to cope with noxious stressors, their ability to be resilient against other stressors strengthens because through the experience, they develop more competencies (Glazer et al., 2014 ). Thus, fitting with Hobfoll’s ( 1989 , 2001 ) COR theory, meaningfulness and resilience are psychological resources people attempt to conserve and protect, and employ when necessary for making sense of or coping with stressors.

Tertiary Interventions (Stress Management)

Stress management refers to interventions employed to treat and repair harmful repercussions of stressors that were not coped with sufficiently. As Lazarus and Folkman ( 1991 ) noted, not all stressors “are amenable to mastery” (p. 205). Stressors that are unmanageable and lead to strains require interventions to reverse or slow down those effects. Workplace interventions might focus on the person, the organization, or both. Unfortunately, instead of looking at the whole system to include the person and the workplace, most companies focus on the person. Such a focus should not be a surprise given the results of van der Klink, Blonk, Schene, and van Dijk’s ( 2001 ) meta-analysis of 48 experimental studies conducted between 1977 and 1996 . They found that of four types of tertiary interventions, the effect size for cognitive-behavioral interventions and multimodal programs (e.g., the combination of assertive training and time management) was moderate and the effect size for relaxation techniques was small in reducing psychological complaints, but not turnover intention related to work stress. However, the effects of (the five studies that used) organization-focused interventions were not significant. Similarly, Richardson and Rothstein’s ( 2008 ) meta-analytic study, including 36 experimental studies with 55 interventions, showed a larger effect size for cognitive-behavioral interventions than relaxation, organizational, multimodal, or alternative. However, like with van der Klink et al. ( 2001 ), Richardson and Rothstein ( 2008 ) cautioned that there were few organizational intervention studies included and the impact of interventions were determined on the basis of psychological outcomes and not physiological or organizational outcomes. Van der Klink et al. ( 2001 ) further expressed concern that organizational interventions target the workplace and that changes in the individual may take longer to observe than individual interventions aimed directly at the individual.

The long-term benefits of individual focused interventions are not yet clear either. Per Giga, Cooper, and Faragher ( 2003 ), the benefits of person-directed stress management programs will be short-lived if organizational factors to reduce stressors are not addressed too. Indeed, LaMontagne, Keegel, Louie, Ostry, and Landsbergis ( 2007 ), in their meta-analysis of 90 studies on stress management interventions published between 1990 and 2005 , revealed that in relation to interventions targeting organizations only, and interventions targeting individuals only, interventions targeting both organizations and individuals (i.e. the systems approach) had the most favorable positive effects on both the organizations and the individuals. Furthermore, the organization-level interventions were effective at both the individual and organization levels, but the individual-level interventions were effective only at the individual level.

Individual-Focused Stress Management

Individual-focused interventions concentrate on improving conditions for the individual, though counseling programs emphasize that the worker is in charge of reducing “stress,” whereas role-focused interventions emphasize activities that organizations can guide to actually reduce unnecessary noxious environmental factors.

Individual-Focused Stress Management: Employee Assistance Programs

When stress become sufficiently problematic (which is individually gauged or attended to by supportive others) in a worker’s life, employees may utilize the short-term counseling services or referral services Employee Assistance Programs (EAPs) provide. People who utilize the counseling services may engage in cognitive behavioral therapy aimed at changing the way people think about the stressors (e.g., as challenge opportunity over threat) and manage strains. Example topics that may be covered in these therapy sessions include time management and goal setting (prioritization), career planning and development, cognitive restructuring and mindfulness, relaxation, and anger management. In a study of healthcare workers and teachers who participated in a 2-day to 2.5-day comprehensive stress management training program (including 26 topics on identifying, coping with, and managing stressors and strains), Siu, Cooper, and Phillips ( 2013 ) found psychological and physical improvements were self-reported among the healthcare workers (for which there was no control group). However, comparing an intervention group of teachers to a control group of teachers, the extent of change was not as visible, though teachers in the intervention group engaged in more mastery recovery experiences (i.e., they purposefully chose to engage in challenging activities after work).

Individual-Focused Stress Management: Mindfulness

A popular therapy today is to train people to be more mindful, which involves helping people live in the present, reduce negative judgement of current and past experiences, and practicing patience (Birnie, Speca, & Carlson, 2010 ). Mindfulness programs usually include training on relaxation exercises, gentle yoga, and awareness of the body’s senses. In one study offered through the continuing education program at a Canadian university, 104 study participants took part in an 8-week, 90 minute per group (15–20 participants per) session mindfulness program (Birnie et al., 2010 ). In addition to body scanning, they also listened to lectures on incorporating mindfulness into one’s daily life and received a take-home booklet and compact discs that guided participants through the exercises studied in person. Two weeks after completing the program, participants’ mindfulness attendance and general positive moods increased, while physical, psychological, and behavioral strains decreased. In another study on a sample of U.K. government employees, study participants receiving three sessions of 2.5 to 3 hours each training on mindfulness, with the first two sessions occurring in consecutive weeks and the third occurring about three months later, Flaxman and Bond ( 2010 ) found that compared to the control group, the intervention group showed a decrease in distress levels from Time 1 (baseline) to Time 2 (three months after first two training sessions) and Time 1 to Time 3 (after final training session). Moreover, of the mindfulness intervention study participants who were clinically distressed, 69% experienced clinical improvement in their psychological health.

Individual-Focused Stress Management: Biofeedback/Imagery/Meditation/Deep Breathing

Biofeedback uses electronic equipment to inform users about how their body is responding to tension. With guidance from a therapist, individuals then learn to change their physiological responses so that their pulse normalizes and muscles relax (Norris, Fahrion, & Oikawa, 2007 ). The therapist’s guidance might include reminders for imagery, meditation, body scan relaxation, and deep breathing. Saunders, Driskell, Johnston, and Salas’s ( 1996 ) meta-analysis of 37 studies found that imagery helped reduce state and performance anxiety. Once people have been trained to relax, reminder triggers may be sent through smartphone push notifications (Villani et al., 2013 ).

Smartphone technology can also be used to support weight loss programs, smoking cessation programs, and medication or disease (e.g., diabetes) management compliance (Heron & Smyth, 2010 ; Kannampallil, Waicekauskas, Morrow, Kopren, & Fu, 2013 ). For example, smartphones could remind a person to take medications or test blood sugar levels or send messages about healthy behaviors and positive affirmations.

Individual-Focused Stress Management: Sleep/Rest/Respite

Workers today sleep less per night than adults did nearly 30 years ago (Luckhaupt, Tak, & Calvert, 2010 ; National Sleep Foundation, 2005 , 2013 ). In order to combat problems, such as increased anxiety and cardiovascular artery disease, associated with sleep deprivation and insufficient rest, it is imperative that people disconnect from their work at least one day per week or preferably for several weeks so that they are able to restore psychological health (Etzion, Eden, & Lapidot, 1998 ; Ragsdale, Beehr, Grebner, & Han, 2011 ). When college students engaged in relaxation-type activities, such as reading or watching television, over the weekend, they experienced less emotional exhaustion and greater general well-being than students who engaged in resources-consuming activities, such as house cleaning (Ragsdale et al., 2011 ). Additional research and future directions for research are reviewed and identified in the work of Sonnentag ( 2012 ). For example, she asks whether lack of ability to detach from work is problematic for people who find their work meaningful. In other words, are negative health consequences only among those who do not take pleasure in their work? Sonnetag also asks how teleworkers detach from their work when engaging in work from the home. Ironically, one of the ways that companies are trying to help with the challenges of high workload or increased need to be available to colleagues, clients, or vendors around the globe is by offering flexible work arrangements, whereby employees who can work from home are given the opportunity to do so. Companies that require global interactions 24-hours per day often employ this strategy, but is the solution also a source of strain (Glazer, Kożusznik, & Shargo, 2012 )?

Individual-Focused Stress Management: Role Analysis

Role analysis or role clarification aims to redefine, expressly identify, and align employees’ roles and responsibilities with their work goals. Through role negotiation, involved parties begin to develop a new formal or informal contract about expectations and define resources needed to fulfill those expectations. Glazer has used this approach in organizational consulting and, with one memorable client engagement, found that not only were the individuals whose roles required deeper re-evaluation happier at work (six months later), but so were their subordinates. Subordinates who once characterized the two partners as hostile and akin to a couple going through a bad divorce, later referred to them as a blissful pair. Schaubroeck, Ganster, Sime, and Ditman ( 1993 ) also found in a three-wave study over a two-year period that university employees’ reports of role clarity and greater satisfaction with their supervisor increased after a role clarification exercise of top managers’ roles and subordinates’ roles. However, the intervention did not have any impact on reported physical symptoms, absenteeism, or psychological well-being. Role analysis is categorized under individual-focused stress management intervention because it is usually implemented after individuals or teams begin to demonstrate poor performance and because the intervention typically focuses on a few individuals rather than an entire organization or group. In other words, the intervention treats the person’s symptoms by redefining the role so as to eliminate the stimulant causing the problem.

Organization-Focused Stress Management

At the organizational level, companies that face major declines in productivity and profitability or increased costs related to healthcare and disability might be motivated to reassess organizational factors that might be impinging on employees’ health and well-being. After all, without healthy workers, it is not possible to have a healthy organization. Companies may choose to implement practices and policies that are expected to help not only the employees, but also the organization with reduced costs associated with employee ill-health, such as medical insurance, disability payments, and unused office space. Example practices and policies that may be implemented include flexible work arrangements to ensure that employees are not on the streets in the middle of the night for work that can be done from anywhere (such as the home), diversity programs to reduce stress-induced animosity and prejudice toward others, providing only healthy food choices in cafeterias, mandating that all employees have physicals in order to receive reduced prices for insurance, company-wide closures or mandatory paid time off, and changes in organizational visioning.

Organization-Focused Stress Management: Organizational-Level Occupational Health Interventions

As with job design interventions that are implemented to remediate work characteristics that were a source of unnecessary or excessive stressors, so are organizational-level occupational health (OLOH) interventions. As with many of the interventions, its placement as a primary or tertiary stress management intervention may seem arbitrary, but when considering the goal and target of change, it is clear that the intervention is implemented in response to some ailing organizational issues that need to be reversed or stopped, and because it brings in the entire organization’s workforce to address the problems, it has been placed in this category. There are several more case studies than empirical studies on the topic of whole system organizational change efforts (see example case studies presented by the United Kingdom’s Health and Safety Executive). It is possible that lack of published empirical work is not so much due to lack of attempting to gather and evaluate the data for publication, but rather because the OLOH interventions themselves never made it to the intervention stage, the interventions failed (Biron, Gatrell, & Cooper, 2010 ), or the level of evaluation was not rigorous enough to get into empirical peer-review journals. Fortunately, case studies provide some indication of the opportunities and problems associated with OLOH interventions.

One case study regarding Cardiff and Value University Health Board revealed that through focus group meetings with members of a steering group (including high-level managers and supported by top management) and facilitated by a neutral, non-judgemental organizational health consultant, ideas for change were posted on newsprint, discussed, and areas in the organization needing change were identified. The intervention for giving voice to people who initially had little already had a positive effect on the organization, as absence decreased by 2.09% and 6.9% merely 12 and 18 months, respectively, after the intervention. Translated in financial terms, the 6.9% change was equivalent to a quarterly savings of £80,000 (Health & Safety Executive, n.d. ). Thus, focusing on the context of change and how people will be involved in the change process probably helped the organization realize improvements (Biron et al., 2010 ). In a recent and rare empirical study, employing both qualitative and quantitative data collection methods, Sørensen and Holman ( 2014 ) utilized PAR in order to plan and implement an OLOH intervention over the course of 14 months. Their study aimed to examine the effectiveness of the PAR process in reducing workers’ work-related and social or interpersonal-related stressors that derive from the workplace and improving psychological, behavioral, and physiological well-being across six Danish organizations. Based on group dialogue, 30 proposals for change were proposed, all of which could be categorized as either interventions to focus on relational factors (e.g., management feedback improvement, engagement) or work processes (e.g., reduced interruptions, workload, reinforcing creativity). Of the interventions that were implemented, results showed improvements on manager relationship quality and reduced burnout, but no changes with respect to work processes (i.e., workload and work pace) perhaps because the employees already had sufficient task control and variety. These findings support Dewe and Kompier’s ( 2008 ) position that occupational health can be reinforced through organizational policies that reinforce quality jobs and work experiences.

Organization-Focused Stress Management: Flexible Work Arrangements

Dewe and Kompier ( 2008 ), citing the work of Isles ( 2005 ), noted that concern over losing one’s job is a reason for why 40% of survey respondents indicated they work more hours than formally required. In an attempt to create balance and perceived fairness in one’s compensation for putting in extra work hours, employees will sometimes be legitimately or illegitimately absent. As companies become increasingly global, many people with desk jobs are finding themselves communicating with colleagues who are halfway around the globe and at all hours of the day or night (Glazer et al., 2012 ). To help minimize the strains associated with these stressors, companies might devise flexible work arrangements (FWA), though the type of FWA needs to be tailored to the cultural environment (Masuda et al., 2012 ). FWAs give employees some leverage to decide what would be the optimal work arrangement for them (e.g., part-time, flexible work hours, compressed work week, telecommuting). In other words, FWA provides employees with the choice of when to work, where to work (on-site or off-site), and how many hours to work in a day, week, or pay period (Kossek, Thompson, & Lautsch, 2015 ). However, not all employees of an organization have equal access to or equitable use of FWAs; workers in low-wage, hourly jobs are often beholden to being physically present during specific hours (Swanberg McKechnie, Ojha, & James, 2011 ). In a study of over 1,300 full-time hourly retail employees in the United States, Swanberg et al. ( 2011 ) showed that employees who have control over their work schedules and over their work hours were satisfied with their work schedules, perceived support from the supervisor, and work engagement.

Unfortunately, not all FWAs yield successful results for the individual or the organization. Being able to work from home or part-time can have problems too, as a person finds himself or herself working more hours from home than required. Sometimes telecommuting creates work-family conflict too as a person struggles to balance work and family obligations while working from home. Other drawbacks include reduced face-to-face contact between work colleagues and stakeholders, challenges shaping one’s career growth due to limited contact, perceived inequity if some have more flexibility than others, and ambiguity about work role processes for interacting with employees utilizing the FWA (Kossek et al., 2015 ). Organizations that institute FWAs must carefully weigh the benefits and drawbacks the flexibility may have on the employees using it or the employees affected by others using it, as well as the implications on the organization, including the vendors who are serving and clients served by the organization.

Organization-Focused Stress Management: Diversity Programs

Employees in the workplace might experience strain due to feelings of discrimination or prejudice. Organizational climates that do not promote diversity (in terms of age, religion, physical abilities, ethnicity, nationality, sex, and other characteristics) are breeding grounds for undesirable attitudes toward the workplace, lower performance, and greater turnover intention (Bergman, Palmieri, Drasgow, & Ormerod, 2012 ; Velez, Moradi, & Brewster, 2013 ). Management is thus advised to implement programs that reinforce the value and importance of diversity, as well as manage diversity to reduce conflict and feelings of prejudice. In fact, managers who attended a leadership training program reported higher multicultural competence in dealing with stressful situations (Chrobot-Mason & Leslie, 2012 ), and managers who persevered through challenges were more dedicated to coping with difficult diversity issues (Cilliers, 2011 ). Thus, diversity programs can help to reduce strains by directly reducing stressors associated with conflict linked to diversity in the workplace and by building managers’ resilience.

Organization-Focused Stress Management: Healthcare Management Policies

Over the past few years, organizations have adopted insurance plans that implement wellness programs for the sake of managing the increasing cost of healthcare that is believed to be a result of individuals’ not managing their own health, with regular check-ups and treatment. The wellness programs require all insured employees to visit a primary care provider, complete a health risk assessment, and engage in disease management activities as specified by a physician (e.g., see frequently asked questions regarding the State of Maryland’s Wellness Program). Companies believe that requiring compliance will reduce health problems, although there is no proof that such programs save money or that people would comply. One study that does, however, boast success, was a 12-week workplace health promotion program aimed at reducing Houston airport workers’ weight (Ebunlomo, Hare-Everline, Weber, & Rich, 2015 ). The program, which included 235 volunteer participants, was deemed a success, as there was a total weight loss of 345 pounds (or 1.5 lbs per person). Given such results in Houston, it is clear why some people are also skeptical over the likely success of wellness programs, particularly as there is no clear method for evaluating their efficacy (Sinnott & Vatz, 2015 ).

Moreover, for some, such a program is too paternalistic and intrusive, as well as punishes anyone who chooses not to actively participate in disease management programs (Sinnott & Vatz, 2015 ). The programs put the onus of change on the person, though it is a response to the high costs of ill-health. The programs neglect to consider the role of the organization in reducing the barriers to healthy lifestyle, such as cloaking exempt employment as simply needing to get the work done, when it usually means working significantly more hours than a standard workweek. In fact, workplace health promotion programs did not reduce presenteeism (i.e., people going to work while unwell thereby reducing their job performance) among those who suffered from physical pain (Cancelliere, Cassidy, Ammendolia, & Côte, 2011 ). However, supervisor education, worksite exercise, lifestyle intervention through email, midday respite from repetitive work, a global stress management program, changes in lighting, and telephone interventions helped to reduce presenteeism. Thus, emphasis needs to be placed on psychosocial aspects of the organization’s structure, including managers and overall organizational climate for on-site presence, that reinforces such behavior (Cancelliere et al., 2011 ). Moreover, wellness programs are only as good as the interventions to reduce work-related stressors and improve organizational resources to enable workers to improve their overall psychological and physical health.

Concluding Remarks

Future research.

One of the areas requiring more theoretical and practical attention is that of the utility of stress frameworks to guide organizational development change interventions. Although it has been proposed that the foundation for work stress management interventions is in organizational development, and even though scholars and practitioners of organization development were also founders of research programs that focused on employee health and well-being or work stress, there are few studies or other theoretical works that link the two bodies of literature.

A second area that requires additional attention is the efficacy of stress management interventions across cultures. In examining secondary stress management interventions (i.e., coping), some cross-cultural differences in findings were described; however, there is still a dearth of literature from different countries on the utility of different prevention, coping, and stress management strategies.

A third area that has been blossoming since the start of the 21st century is the topic of hindrance and challenge stressors and the implications of both on workers’ well-being and performance. More research is needed on this topic in several areas. First, there is little consistency by which researchers label a stressor as a hindrance or a challenge. Researchers sometimes take liberties with labels, but it is not the researchers who should label a stressor but the study participants themselves who should indicate if a stressor is a source of strain. Rodríguez, Kozusznik, and Peiró ( 2013 ) developed a measure in which respondents indicate whether a stressor is a challenge or a hindrance. Just as some people may perceive demands to be challenges that they savor and that result in a psychological state of eustress (Nelson & Simmons, 2003 ), others find them to be constraints that impede goal fulfillment and thus might experience distress. Likewise, some people might perceive ambiguity as a challenge that can be overcome and others as a constraint over which he or she has little control and few or no resources with which to cope. More research on validating the measurement of challenge vs. hindrance stressors, as well as eustress vs. distress, and savoring vs. coping, is warranted. Second, at what point are challenge stressors harmful? Just because people experiencing challenge stressors continue to perform well, it does not necessarily mean that they are healthy people. A great deal of stressors are intellectually stimulating, but excessive stimulation can also take a toll on one’s physiological well-being, as evident by the droves of professionals experiencing different kinds of diseases not experienced as much a few decades ago, such as obesity (Fried et al., 2013 ). Third, which stress management interventions would better serve to reduce hindrance stressors or to reduce strain that may result from challenge stressors while reinforcing engagement-producing challenge stressors?

A fourth area that requires additional attention is that of the flexible work arrangements (FWAs). One of the reasons companies have been willing to permit employees to work from home is not so much out of concern for the employee, but out of the company’s need for the focal person to be able to communicate with a colleague working from a geographic region when it is night or early morning for the focal person. Glazer, Kożusznik, and Shargo ( 2012 ) presented several areas for future research on this topic, noting that by participating on global virtual teams, workers face additional stressors, even while given flexibility of workplace and work time. As noted earlier, more research needs to be done on the extent to which people who take advantage of FWAs are advantaged in terms of detachment from work. Can people working from home detach? Are those who find their work invigorating also likely to experience ill-health by not detaching from work?

A fifth area worthy of further research attention is workplace wellness programing. According to Page and Vella-Brodrick ( 2009 ), “subjective and psychological well-being [are] key criteria for employee mental health” (p. 442), whereby mental health focuses on wellness, rather than the absence of illness. They assert that by fostering employee mental health, organizations are supporting performance and retention. Employee well-being can be supported by ensuring that jobs are interesting and meaningful, goals are achievable, employees have control over their work, and skills are used to support organizational and individual goals (Dewe & Kompier, 2008 ). However, just as mental health is not the absence of illness, work stress is not indicative of an absence of psychological well-being. Given the perspective that employee well-being is a state of mind (Page & Vella-Brodrick, 2009 ), we suggest that employee well-being can be negatively affected by noxious job stressors that cannot be remediated, but when job stressors are preventable, employee well-being can serve to protect an employee who faces job stressors. Thus, wellness programs ought to focus on providing positive experiences by enhancing and promoting health, as well as building individual resources. These programs are termed “green cape” interventions (Pawelski, 2016 ). For example, with the growing interests in positive psychology, researchers and practitioners have suggested employing several positive psychology interventions, such as expressing gratitude, savoring experiences, and identifying one’s strengths (Tetrick & Winslow, 2015 ). Another stream of positive psychology is psychological capital, which includes four malleable functions of self-efficacy, optimism, hope, and resilience (Luthans, Youssef, & Avolio, 2007 ). Workplace interventions should include both “red cape” interventions (i.e., interventions to reduce negative experiences) and “green cape” interventions (i.e., workplace wellness programs; Polly, 2014 ).

A Healthy Organization’s Pledge

A healthy workplace requires healthy workers. Period. Among all organizations’ missions should be the focus on a healthy workforce. To maintain a healthy workforce, the company must routinely examine its own contributions in terms of how it structures itself; reinforces communications among employees, vendors, and clients; how it rewards and cares for its people (e.g., ensuring they get sufficient rest and can detach from work); and the extent to which people at the upper levels are truly connected with the people at the lower levels. As a matter of practice, management must recognize when employees are overworked, unwell, and poorly engaged. Management must also take stock of when it is doing well and right by its contributors’ and maintain and reinforce the good practices, norms, and procedures. People in the workplace make the rules; people in the workplace can change the rules. How management sees its employees and values their contribution will have a huge role in how a company takes stock of its own pain points. Providing employees with tools to manage their own reactions to work-related stressors and consequent strains is fine, but wouldn’t it be grand if organizations took better notice about what they could do to mitigate the strain-producing stressors in the first place and take ownership over how employees are treated?

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Workplace stress: an occupational health case study

This case study on workplace stress shows how the evidence base for occupational health underpinned a successful intervention. Anne Donaldson and Anne Harriss explain.

Stress, anxiety or depression underpin much work-related ill health, accounting for 9.9 million days of sickness absence in 2014-15, with, on average, 23 days lost per person. It resulted in 35% of all days missed from work due to ill health. Industries reporting the highest prevalence of ill health from work-related stress included health and social care, teaching, public administration and defence (HSE, 2015).

The Mental Health Foundation claims 12 million adults consult their GP each year due to mental illness, much of it stress related; one in six of the population experiences anxiety (MHF, 2014).

The main causes of work-related stress reported to GPs (THOR – GP) were workload pressures, interpersonal relationships, including bullying, harassment and difficulty with superiors, and work changes, including responsibilities and reduction of resources (HSE, 2014). A YouGov survey (2012) found 48% of the British workforce said they were stressed most of the time and 47% cited performance issues as key reasons.

Impact of workplace stress on individuals and work colleagues

Stress wanes when stressors are reduced. Conversely, anxiety can persist without a clear cause to the individual.

Anxiety and stress are closely linked with similar signs and symptoms; anxiety may be associated with depression as the most common mood disorder seen in primary care (Kumar and Clark, 2012). People with low psychosocial resources are more likely to succumb to mood disturbance when stress levels increase despite experiencing few stressors (DeLongis et al, 1988).

Colleagues often undertake the work responsibilities of absent staff. This may lead to spiralling absences among co-workers, who are stressed because of the additional responsibility (HSE, 2014). This case study presents the assessment of an employee, Norman, in order to ensure his fitness to return to his role without impacting on his health (Palmer et al, 2013).

The objectives of the consultation were two-fold:

• evaluating whether work had adversely affected Norman’s health and whether it may continue to do so; and
• providing impartial advice to management regarding his sickness absence, suggesting modifications for their consideration in order to support a successful return to work.

Norman’s referral by management was precipitated by a four-week absence related to stress and anxiety. There had been four further single-day absences in the preceding six months attributed to gastrointestinal upsets.

The consultation

Norman, a 22-year-old part-time receptionist and administrative assistant, had been employed in this role for 10 months working 30 hours per week. He had been absent from work for a month on the day of the consultation and was preparing to return to work. On entering the department, his mobility difficulties and an obviously awkward gait and altered balance were noted. He disclosed treatment by his GP for stress, anxiety and depression.

He described previous short-term absences resulting from nausea and vomiting, relating these to his anxiety at attending work. In the previous five to six weeks, in addition to nausea he also referred to difficulty sleeping, restlessness, loss of appetite, palpitations and rumination on his low self-esteem. Rumination can be a negative effect of stress. Genet and Siemer (2012) claim that rumination moderates the relation between unpleasant daily effects and negative mood.

Although excessive rumination is maladaptive, McFarland et al (2007) agree that some limited self-focus can be beneficial. Norman felt anxious about returning to the same situation and was accessing counselling support to help anxiety management. Hunsley et al (2014) suggest that psychological treatments are of at least equal benefit to medication for common mental disorders.

He had been prescribed 75mg of Venlafaxine a day with good effect. Venlafaxine is a serotonin and noradrenaline re-uptake inhibitor used to treat depression or generalised anxiety disorder. His GP also prescribed 5mg of diazepam – a long-acting benzodiazepine anxiolytic – to be taken as required. Recently he had not taken this as he felt better.

Past health and social history

Norman had cerebral palsy and experienced difficulty walking during his early years. Achilles tendon surgery in childhood improved this, although surgery left him with residual lower leg discomfort if he walked too far or stood for sustained periods without resting. The orthopaedic team monitored him every 18 months.

Norman described excellent family support. A non-smoker and non-drinker of alcohol, he took no formal exercise but walked as much as he felt able. Increasing physical activity within his ability was advised as it is found to improve mental health (Crone & Guy, 2008; McArdle et al, 2012).

Work issues

Norman generally enjoyed his role, shared with an able-bodied colleague with whom he alternated his reception duties. He indicated the interface with the public could be challenging and stressful. His workload had increased in the previous four months following the resignation of a colleague who indicated that he too found this role stressful. Financial constraints resulted in this position remaining unfilled, increasing Norman’s responsibilities. Stress is recognised as contributing to high staff turnover and low morale (Wolever et al, 2012).

Although working primarily at the reception desk, Norman frequently got up from his chair to deal with customers and to undertake photocopying duties. On one occasion he spent an afternoon mostly standing, which resulted in leg discomfort. No workplace adjustments had been effected to support his disability.

On recruitment, his manager had enquired whether he required any adjustments. Norman declined this offer, not wanting to “make a fuss”. He had not disclosed his disability at pre-employment screening (PES) as he did not consider himself disabled.

Many of Norman’s perceived stressors are normal daily occurrences of reception duties, but his physical disability exacerbated this. As he had not requested adjustments, there was nothing in place to support him in relation to his mobility difficulties.

Although his disability had not been disclosed at PES, under s.2 of the Health and Safety at Work etc Act 1974, Norman’s employer has a duty of care to him. Withholding information at PES that later comes to light could lead to disciplinary action but Norman considered that declaring his disability may have precluded his employment.

Cerebral palsy describes a group of childhood syndromes, apparent from birth or early childhood, characterised by abnormalities in motor function and muscle tone caused by genetic, intrauterine or neonatal insults to brain development. Resulting disabilities, of varying degrees, may be physical and mental.

A full functional capability assessment should have been performed at the start of his employment, facilitating adjustments enabling him to function effectively (Palmer et al, 2013). This had not been undertaken.

Norman usually managed his leg discomforts but occasionally had been unable to rest them at work. A study of workers with rheumatoid arthritis suggested that the workers reported greater discomfort on the days when they experienced more undesirable work events or job “strain” (Fifield et al, 2004).

Although this study looked at rheumatoid arthritis, issues concerning chronic pain and discomfort are relevant in this case. Although ultimately a legal decision, Norman was likely to be covered under the Equality Act 2010 as he had a long-term disability.

Withholding information at PES was fundamental to the case of  Cheltenham Borough Council v Laird (2009) . The council accused Laird of lying on her PES questionnaire by not disclosing her mental health history. She had been taking long-term antidepressants that kept her depression under control, but after some work problems her health deteriorated and she retired on health grounds. The judge confirmed there was no general duty of disclosure of information that was not specifically requested.

Thus, if a PES form does not directly ask about cerebral palsy, disclosure was not required. Kloss (2010) mentions these types of dilemmas are often only answered through the courts, but unless the employer is given information regarding disability, he cannot reasonably put adjustments in place. In the case of  Hanlon v Kirklees Metropolitan Council and others , the employee declined to consent to the disclosure of medical records, arguing this would contravene his right to privacy, and subsequently lost his case of disability discrimination.

The Health and Safety Executive (HSE 2007) defines stress as: “The adverse reaction people have to excessive pressures or other types of demand placed on them at work.”

The stress response

Stressors initiate physiological responses, evolved to protect and preserve the individual in times of threat by ensuring a reaction (Alexander et al, 2006).

This response is triggered by the limbic system within the brain. This is a series of centres controlling emotions, reproductive and survival behaviours (Blows, 2011). When survival is threatened, the system is instantly triggered into action to protect the individual, regardless of the threat magnitude.

A chain reaction occurs: the hypothalamus mediates the autonomic nervous system (Alexander et al, 2006), resulting in a sequence of physiological changes. The initial reaction is very fast, and only when the information reaches the cerebrum can the urgency of the situation be determined and responses modified (Blows, 2011).

The initial flight-or-fight response acts on the sympathetic division of the autonomic nervous system. Noradrenaline from the adrenal medulla immediately prepares the body for physical activity, mobilising glucose and oxygen to the heart, brain and skeletal muscles, preparing for flight or fight.

Non-essential functions, including digestion, are inhibited. Reduced bloodflow to the skin and kidneys promote the release of rennin, triggering the angiotensin – aldosterone pathway leading to fluid retention and hypertension. The resistance reaction results from corticotropin-releasing factor from the hypothalamus, stimulating the release of adrenocorticotropic hormone from the pituitary. This effects a release of cortisol from the adrenal cortex.

Cortisol effects are far-reaching, including lipolysis, gluconeogenesis and reducing inflammation. (Tortora and Grabowski, 2003). The body compensates for the effects of stress as long as possible. Three phases of stress are described as the general adaptation syndrome: alarm phase, resistance and exhaustion (Blows, 2011). The resistance and exhaustion phases may lead to immunosuppression and consequent disease (Tortora and Grabowski, 2003).

There is a reciprocal feedback link between the thalamus and amygdala. When the amygdala becomes overactive, fear and anxiety result. While adrenaline keeps the stress response active, endorphins protect the brain from the effects of fear (Blows, 2011). With so many physiological responses, there are numerous symptoms of stress that vary with each individual.

Significantly, stress causes muscle tension (HSE, 2007), exacerbating Norman’s discomfort, influencing his quality of life. As Kumar and Clark (2012) note, this is associated with depression.

The HSE (2007) management standards for work stress cover six main areas of primary work design that can contribute to stress if not properly managed. These include:

• Demands – including work patterns, workloads and work environment.
• Control – the extent of the worker’s job control.
• Support – provided by the organisation, management and colleagues.
• Role – understanding of their role and avoiding role-conflict.
• Change – management and communication of organisational change.
• Conflict – avoiding conflict, unacceptable behaviour and promoting positive working.

Fitness to work

The fitness-for-work assessment was based on a phenomenological appraisal as the effects of stress vary with each individual and their resilience (Alexander et al, 2006). A bio-psychosocial model informed the assessment. Norman stated that his condition was improving and he was ready to return to work. He no longer experienced symptoms that had taken him to the GP, but he was concerned at ending up in the same situation as before.

A patient health questionnaire (PHQ-9), providing an indication of depression, could have been used to assess Norman. Arroll et al (2010) found that the PHQ-9 is unreliable for diagnosing depression, whereas Manea et al (2012) refutes this assertion. At the time it seemed to be of limited value as he was making good progress.

Norman was advised to discuss his work concerns with his manager. With Norman’s consent, his manager was contacted and advised to carry out a comprehensive stress risk assessment as per the HSE management standards. It was suggested to Norman that he contact the organisation’s employee assistance programme and Access to Work, which offers grants for practical support for individuals with disabilities/health conditions to assist them with starting and staying at work. A phased return to work was formulated assisting Norman back into work and supporting him to stay at work. The following work regime was recommended:

• Week 1: Four hours on two days.
• Week 2: Four hours on four days.
• Week 3: Six hours on four days.
• Week 4: Full working week with the option of a review should Norman struggle.

Norman was to meet with his manager at the end of each week to review his progress, with the option to delay the next stage if this programme proved ineffective. In general, Norman had indicated that he had let his concerns take over without making any attempt to talk with his managers. He realised he should have discussed his work issues with his managers at an earlier stage. As Waddell and Burton (2006) note, early interventions are more effective at reducing long-term sickness absence and keeping workers at work.

Norman’s case illustrates how lack of control and apparent excessive demands and change can influence stress at work to negatively affect health. It reached a successful conclusion, but Norman’s case may have been prevented from requiring OH intervention had he been able to discuss his concerns and feelings with his manager in the first instance and a proactive approach, including the use of HSE stress management standards, been used at an earlier stage.

Anne Donaldson is an occupational health adviser. Anne Harriss is associate professor and course director, London South Bank University.

Alexander MF, Fawcett JN, and Runciman PJ (2006). Nursing Practice: Hospital and Home. 3rd edition. Edinburgh, Elsevier.

Arroll B, Goodyear-Smith F, Crengle S, Gunn J, Kerse N, Fishman T, Falloon K, and Hatcher S (2010). Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. vol.8(4), pp.348-353. doi: 10.1370/afm.1139.

Blows W (2011). The biological basis of mental health nursing. 2nd edition. Abingdon, Oxon. Routledge.

Crone D, and Guy H (2008). “I know it is only exercise, but to me it is something that keeps me going: a qualitative approach to understanding mental health service users’ experiences of sports therapy”. International Journal of Mental Health Nursing, vol.17(3), pp.197-207.

DeLongis A, Folkman S, and Lazarus Richard S (1988). “The impact of daily stress on health and mood: psychological and social resources as mediators”. Journal of Personality and Social Psychology, vol.54(3), pp.486-495. Available online. Accessed 19 April 2014.

Fifield J, McQuillan J, Armeli S, Tennen H, Reisne S, and Affleck G (2004). “Chronic strain, daily work stress and pain among workers with rheumatoid arthritis: does job stress make a bad day worse?” Work & Stress, vol.18(4), pp.275-291. Accessed 12 April 2014.

Genet JJ and Siemer M (2012). “Rumination moderates the effects of daily events on negative mood: results from a diary study”. Emotion, vol.12(6), pp.1,329-1,339.

Health and Safety Executive (2007). Managing the causes of work-related stress. A step-by-step approach using the management standards. 2nd edition HSE books. Available online. Accessed 12 April 2016.

Health and Safety Executive (2015). Stress-related and psychological disorders in Great Britain (2014). Available online. Accessed 22 April 2016.

Hunsley J, Elliott K, and Therrien Z (2014). “The efficacy and effectiveness of psychological treatments for mood, anxiety and related disorders”. Canadian Psychology/Psychologie Canadienne, vol.55(3), pp.161-176.

Kloss D (2010). Occupational Health Law, 5th edition, Oxford Wiley Blackwell.

Kumar P and Clark M (2012). Clinical Medicine, 8th edition, Edinburgh, Saunders Elsevier.

Manea L, Gilbody S, and McMillan D (2012). “Optimal cut-off score diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis”. CMAJ, vol.184(3). doi: 10.1503/cmaj.110829.

McArdle S, McGale N, and Gaffney P (2012). “A qualitative exploration of men’s experiences of an integrated exercise/CBT mental health promotion programme”. International Journal Of Men’s Health, vol.11(3), pp.240-257. doi:10.3149/jmh.1103.240.

McFarland C, Buehler R, von Rüti R, Nguyen L, and Alvaro C (2007). “The impact of negative moods on self-enhancing cognitions: the role of reflective versus ruminative mood orientations”. Journal of Personality And Social Psychology, vol.93(5), pp.728-750.

Mental Health Foundation (2014). Mental Health Statistics Available online. Accessed 17 April 2016.

Palmer K, Brown I, and Hobson J (2013). Fitness for Work, 5th edition, Oxford University Press.

Tortora G and Grabowski S (2003). Principles of anatomy and physiology, 10th edition, Hoboken NJ, John Wiley & Sons.

Waddell G, Burton K, and Kendall N (2008). Vocational Rehabilitation, what works, for whom and when? London: TSO pdf. Available online. Accessed 19 April 2016.

Wolever RQ, Bobinet KJ, McCabe K, Mackenzie ER, Fekete E, Kusnick CA, and Baime M (2012). “Effective and viable mind-body stress reduction in the workplace: a randomized controlled trial”. Journal of Occupational Health Psychology, vol.17(2), pp.246-258.

YouGov (2012). Stress Survey. Available online. Accessed 19 April 2016.

Cheltenham Borough Council v Laird [2009] IRLR 621.

Hanlon v Kirklees Metropolitan Council and others [2004] EAT 0119/04 (IDS Brief 767).

• 1 No poverty
• 2 Zero hunger
• 3 Good health and well-being
• 4 Quality education
• 5 Gender equality
• 6 Clean water and sanitation
• 7 Affordable and clean energy
• 8 Decent work and economic growth
• 9 Industry, innovation and infrastructure
• 10 Reduced inequalities
• 11 Sustainable cities and communities
• 12 Responsible consumption and production
• 13 Climate action
• 14 Life below water
• 15 Life on land
• 16 Peace, justice and strong institutions
• 17 Partnership for the goals

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How to Relax in Stressful Situations: A Smart Stress Reduction System

Yekta said can.

1 Computer Engineering Department, Bogazici University, 34342 Istanbul, Turkey; [email protected] (N.C.); [email protected] (D.E.); rt.ude.nuob@yosre (C.E.)

Heather Iles-Smith

2 Leeds Teaching Hospitals NHS Trust/University of Leeds, Leeds LS1 3EX, UK; [email protected]

Niaz Chalabianloo

Javier fernández-Álvarez.

3 General Psychology and Communication Psychology, Catholic University of Milan, 20123 Milan, Italy; [email protected] (J.F.-Á.); [email protected] (C.R.); [email protected] (G.R.)

Claudia Repetto

Giuseppe riva.

Stress is an inescapable element of the modern age. Instances of untreated stress may lead to a reduction in the individual’s health, well-being and socio-economic situation. Stress management application development for wearable smart devices is a growing market. The use of wearable smart devices and biofeedback for individualized real-life stress reduction interventions has received less attention. By using our unobtrusive automatic stress detection system for use with consumer-grade smart bands, we first detected stress levels. When a high stress level is detected, our system suggests the most appropriate relaxation method by analyzing the physical activity-based contextual information. In more restricted contexts, physical activity is lower and mobile relaxation methods might be more appropriate, whereas in free contexts traditional methods might be useful. We further compared traditional and mobile relaxation methods by using our stress level detection system during an eight day EU project training event involving 15 early stage researchers (mean age 28; gender 9 Male, 6 Female). Participants’ daily stress levels were monitored and a range of traditional and mobile stress management techniques was applied. On day eight, participants were exposed to a ‘stressful’ event by being required to give an oral presentation. Insights about the success of both traditional and mobile relaxation methods by using the physiological signals and collected self-reports were provided.

1. Introduction

Stress constitutes a complex process that is activated by a physical or mental threat to the individuals’ homeostasis, comprising a set of diverse psychological, physiological and behavioral responses [ 1 ]. Although it is usually considered a negative response, stress actually constitutes a key process for ensuring our survival. However, when a stress response is repeatedly triggered in the absence of a challenging stimulus, or if there is constant exposure to challenging situations, stress can become harmful. Evidence suggests that, in either of these two contexts, stress is a persistent factor for the development of psycho-pathological conditions [ 2 , 3 ].

When faced with stressful events, people make autonomic and controlled efforts to reduce the negative impact and maximize the positive impact that every specific situation may provoke. Generally, this process is denominated as emotion regulation, formally defined as the process by which individuals can influence what emotions they have, when they have them and how they experience and express those emotions [ 4 ]. It has been suggested that the term emotion regulation can be understood as a broad tag that comprises the regulation of all responses that are emotionally charged, from basic emotions to complex mood states as well as regulation of everyday life [ 5 ].

Failure to address triggers of stress has been shown to lead to chronic stress, anxiety and depression, and attributed to serious physical health conditions such as cardiovascular disease [ 6 ]. The World Health Organization concluded that psychological stress is one of the most significant health problems in the 21st-century and is a growing problem [ 7 ]. There are various interventions to minimize stress based on individual preferences and requirements. Stress management techniques including ancient practices such as Tai Chi [ 8 ] and yoga [ 9 ] as well as other physical activities [ 10 ] are often cited as being helpful in combating stress. Likewise traditional meditation, mindfulness [ 11 ] and cognitive behavioural therapy (CBT) [ 12 ] all have established benefits. These techniques are not applicable in office or social environments, or during most daily routines. Therefore, a smart device based stress management application may be of benefit. Recently, smartphone applications such as Calm, Pause, Heartmath and Sway have been developed for indoor environments. However, these applications are not individualized nor do they include biofeedback and studies that validate their effects are limited [ 13 ].

In this study, we used the stress level detection scheme using physiological signals and added a physical activity based context analyzer. When the user experiences a high stress level, the system suggests appropriate stress reduction methods (traditional or mobile). We further compare the effects of traditional and mobile stress alleviation methods on physiological data of 15 international Ph.D. students (participants) during eight days of training. In addition, 1440 h of physiological signals from Empatica E4 smart bands were collected in this training event. Stress management techniques based on the emotion regulation model of James Gross [ 4 ] were applied to reduce participant stress levels. To the best of our knowledge, this work is the first one suggesting appropriate stress reduction methods based on contextual information and comparing both traditional and mobile stress management interventions in the real-life environment using a commercial smart-band based automatic stress level detection system that eliminates motion artifacts. Using such a system is essential because these offline stress level detection algorithms could be used in real-time biofeedback apps.

Application of our stress level detection algorithm, in a real world context, could allow individuals to receive feedback regarding high stress levels along with recommendations for relaxation methods. Additional continued monitoring may also enable the individual to better understand the effectiveness of any stress reduction methods. However, for our stress detection algorithm to be applied in daily life, the smart device should be unobtrusive (i.e., should not be comprised of cables, electrodes, boards). Our system works on smart-bands which are perfect examples of this type of unobtrusive wearable device.

This paper describes emotion regulation in the context of stress management and how yoga and mindfulness can be used for regulating emotions ( Section 2 ). Methods of detecting stress and analyzing context based on physical activity are described ( Section 3 ) and data are presented related to our method for stress level detection with the use of smart-bands ( Section 4 ). Experimental results and discussion are also presented ( Section 5 ) and we present the conclusions and future works of the study ( Section 6 ).

The major research contributions of this study are the following:

• Developing a physical activity based context analyzer and relaxation method suggestion system
• Comparison of stress reduction methods (mobile mindfulness, traditional mindfulness and yoga) and their effectiveness in the context of stress management with the use of an unobtrusive smartwatch based stress level detection system
• Application of James Gross’s prominent emotion regulation model in the context of stress management and measuring the physiological component with smart bands.

2. Background

2.1. emotion regulation in the context of stress management.

Stress is a normal part of daily life. However, its effects often vary across individuals and despite similar circumstances, some people do not feel under strain while others may be severely affected. Multiple reasons exist for these differences between individuals, including how people perceive reality and how they respond to the numerous stimuli to which they are exposed. When a person believes that a certain situation surpasses their available coping mechanisms, it is referred to as perceived stress. Thus, perceived stress varies from person to person depending on the value that an individual gives to a situation and their self-recognition of the resources to deal with it.

Numerous psychological scientists have investigated perceived stress. Individuals who display a mismatch between contextual demands and perceived resources constantly (rather than during a specific moment in time) are referred to as experiencing chronic stress. Chronic stress has not only been shown to be very relevant in people’s well-being and quality of life, but also important in the appearance and maintenance of several physical and mental diseases [ 14 ].

As a consequence, mounting research has focused on the mechanisms that people implement in order to alleviate the physical and cognitive burden associated with that perceived stress. Coping styles, stress management techniques, self-regulation, or emotion regulation techniques are different labels that define the way people implement certain behavioral, cognitive, or emotional strategies to maintain allosteric load [ 15 ]. In other words, every living organism needs to vary among plasticity and stability in order to survive. Human beings are not the exception to the rule and the complex system that applies to every single person and the necessity of reaching a constant level of regulation permits the individuals to pursue their goals.

Specifically, emotion regulation has been defined as the study of “the processes by which we influence which emotions we have when we have them, and how we experience and express them” [ 4 ]. A large body of evidence has shown that there are very different consequences depending on the effectiveness people achieve to regulate their emotions. Naturally, both at an implicit or explicit level, people regulate emotions in order to maintain those allosteric levels previously mentioned. Therefore, when there are specific stressors that demand a particular cognitive or physical response, the emotional reactivity may be stronger and the need for a proper regulation more relevant. Indeed, emotion regulation has shown to be a transdiagnostic factor that is present at a wide range of mental disorders. In other words, the way people initiate, implement and monitor their emotional processes, in order to reach more desirable states, has a significant impact on the stress levels. Some emotion regulation (ER) strategies have shown to be correlated with mental health issues. Among these strategies, cognitive reappraisal, problem-solving, or acceptance shall be mentioned as strategies that are negatively correlated with psychopathology, while rumination, experiential avoidance, or suppression are positively correlated with psychopathology [ 16 ]. In this regard, hinging on the different ER strategies deployed, ER can constitute a protective factor to face stress responses that all individuals experience after minor or major stressors [ 17 ]. Additionally, an adaptive regulation of emotions, by managing stress, may also be beneficial for clinical populations, such as people suffering from affective disorders [ 18 , 19 ].

Therefore, from whole psychotherapeutic treatments to single self-applied applications, studies in the literature have focused on how people can better regulate their emotions and manage their stress levels. Among many other techniques, cognitive behavioral therapy, autogenic training, biofeedback, breathing exercises, relaxation techniques, guided imagery, mindfulness, yoga, or Tai-Chi, are some of the stress management interventions that have received attention from researchers [ 20 , 21 ].

2.2. Yoga and Mindfulness: As Tools for Emotion Regulation

2.2.1. yoga.

Yoga is an ancient Eastern practice that developed more than 2000 years ago. Although its original creator and source are uncertain, the earliest written word ‘Yoga Sutra’ describes the philosophy of yoga focussing on growing spirituality, regulating emotions and thoughts. Initially, the focus was on awareness of breathing and breathing exercises ‘pranayama’ to calm the mind and body, ultimately reaching a higher state of consciousness.

As yoga evolved, physical movement in the form of postures was included and integrated with yogic breathing ‘prana’ and elements of relaxation. The underlying purpose is to create physical flexibility, reduce pain and unpleasant stimuli and reduce negative thoughts and emotions to calm the mind and body, thereby improving well-being. In the healthcare literature, the benefits are reported to be far-reaching both for mental and physical health conditions such as anxiety, depression, cardiovascular disease, cancer and respiratory symptoms. It is also reported to reduce muscular-skeletal problems and physical symptoms through increasing the awareness of the physical body.

Yoga has become a global phenomenon and is widely practiced in many different forms. Generally, all types of yoga include some elements of relaxation. Additionally, some forms include mainly pranayama and others are more physical in nature. One such practice is vinyasa flow which involves using the inhale and exhale of the breathing pattern to move through a variety of yoga postures; this leads to the movement becoming meditative. The practice often includes pranayama followed by standing postures linked together with a movement called vinyasa, (similar to a sun salutation) which helps to keep the body moving and increases fitness, flexibility and helps maintain linkage with the breath. The practice also often includes a range of seated postures, an inversion (such as headstand or shoulder stand) and final relaxation ‘savasana’.

2.2.2. Mindfulness

Mindfulness involves being more present at the moment by acknowledging the here and now, often referred to as ‘being present’ rather than focussing on the past or future [ 8 ]. Being present may include being aware of our surroundings and the environment, or of what we are eating and drinking and physical sensations such as the sun or wind on our skin.

Acknowledging the thoughts and body are also aspects of mindfulness. Each day humans experience thousands of thoughts, the majority being of no consequence. In some instances, these thoughts are repetitive and negative in nature which can lead to increased stress and the related unpleasant physical symptoms such as feeling anxious, nausea and tension headaches. Being mindful includes an awareness of our thinking and whether we are caught up with our thoughts rather than being aware of the moment. Additionally, on a daily basis, awareness of the physical body may be minimal; being mindful includes increasing this awareness through becoming more connected with the sensations in the body. This might include experiencing the legs moving when walking, or feeling the ground under the feet or the natural way of the body whilst standing.

Mindfulness has been shown to be of benefit to physical and mental health. It is currently recommended by the National Institute for Clinical Excellence [ 22 ] as adjunctive therapy to Cognitive Behavioural Therapy (CBT) for the prevention of relapse depression.

However, it may be challenging for some individuals to do this with a multitude of distractions around them and, therefore, they may choose to identify a particular time and place when and where they can sit in a comfortable position to start to become aware of their breathing and bodily sensations.

2.2.3. Mobile Mindfulness Inspired By Tai-Chi—Pause

Tai-Chi is an internal Chinese martial art practiced for both its defense training, its health benefits and meditation. There is good evidence of benefits for depression, cardiac and stroke rehabilitation and dementia [ 23 ]. The term Tai-Chi refers to a philosophy of the forces of yin and yang, related to the moves. An iPhone application Pause inspired by Tai-Chi is used for guided mindfulness which draws upon the principles of mindfulness meditation to trigger the body’s rest and digest response, quickly restoring attention [ 24 ].

3. Related Work

Researchers have created the ability to detect stress in laboratory environments with medical-grade devices [ 25 , 26 , 27 , 28 ]; smartwatches and smart bands started to be used for stress level detection studies [ 29 , 30 , 31 ]. These devices provide high comfort and rich functionality for the users, but their stress detection accuracies are lower than medical-grade devices due to low signal quality and difficulty obtaining data in intense physical activity. If data are collected for long periods, researchers have shown that their detection performance improves [ 32 ]. During movement periods, the signal can be lost (gap in the data) or artifacts might be generated. Stress level detection accuracies for 2-classes by using these devices are around 70% [ 29 , 30 , 33 , 34 ].

After detecting the stress level of individuals, researchers should recover from the stressed state to the baseline state. To the best of our knowledge, there are very few studies that combine automatic stress detection (using physiological data) with recommended appropriate stress management techniques. Ahani et al. [ 35 ] examined the physiological effect of mindfulness. They used the Biosemi device which acquires electroencephalogram (EEG) and respiration signals. They successfully distinguished control (non-meditative state) and meditation states with machine learning algorithms. Karydis et al. [ 36 ] identified the post-meditation perceptual states by using a wearable EEG measurement device (Muse headband). Mason et al. [ 37 ] examined the effect of yoga on physiological signals. They used PortaPres Digital Plethtsmograph for measuring blood pressure and respiration signals. They also showed the positive effect of yoga by using these signals. A further study validated the positive effect of yoga with physiological signals; researchers monitored breathing and heart rate pulse with a piezoelectric belt and a pulse sensor [ 21 ]. They demonstrated the effectiveness of different yogic breathing patterns to help participants relax. There are also several studies showing the effectiveness of mobile mindfulness apps by using physiological signals [ 20 , 38 , 39 ]. Svetlov et al. [ 20 ] monitored the heart rate variability (HRV), electrodermal activity (EDA), Salivary alpha-amylase (sAA) and EEG values. In other studies, EEG and respiration signals were also used for validating the effect of mobile mindfulness apps [ 38 , 39 ]. When the literature is examined, it could be observed that the effect of ancient relaxation methods and mobile mindfulness methods are examined separately in different studies. Ancient methods generally require out of office environments that are not suitable for most of the population, since, in the modern age, people started to spend more time in office-like environments. On the other hand, some smartphone applications such as Pause, HeartMath and Calm do not require extra hardware or equipment and be applicable in office environments. Hence, an ideal solution depends on the context of individuals. A system that monitors stress levels, analyzes the context of individuals and suggests an appropriate relaxation method in the case of high stress will benefit society. Furthermore, mobile methods along with the ancient techniques should be applied in stressful real-life events and their effectiveness should be compared by investigating physiological signals. When the literature is examined, there is not any study comparing the performance of these methods in real-life events (see Table 1 ). Another important finding is that these methods should be compared with unobtrusive wearable devices so that they could be used for a biofeedback system in daily lives. Individuals may be reluctant to use a system with cables, electrodes and boards in their daily life. Therefore, a comparison of different states with such systems could not be used in daily life. There is clearly a need for a suggestion and comparison of ancient and mobile meditation methods by using algorithms that could run on unobtrusive devices. An ideal system should detect high stress levels, suggest relaxation methods and control whether users are doing these exercises right or not with unobtrusive devices. Our algorithm is suitable to be embedded in such daily life applicable systems that use physiological signals such as skin temperature (ST), HRV, EDA and accelerometer (ACC). In this paper, we present the findings of our pilot study that tested the use of our algorithm during general daily activities, stress reduction activities and a stressful event.

Comparison of our work with the studies applying different types of meditation techniques for stress management in the literature.

4. Methodology

4.1. unobtrusive stress detection system with smart bands.

Our stress detection system developed in [ 32 ] allows users to be aware of their stress levels during their daily activities without creating any interruption or restriction. The only requirement to use this system is the need to wear a smart band. Participants in this study wore the Empatica E4 smart band on their non-dominant hand. The smart band provides Blood Volume Pressure, ST, EDA, IBI (Interbeat Interval) and 3D Acceleration. The data are stored in the memory of the device. Then, the artifacts of physiological signals were detected and handled. The features were extracted from the sensory signals and fed to the machine learning algorithm for prediction. In order to use this system, pre-trained machine learning models are required. For training the models, feature vectors and collected class labels were used.

4.1.1. EDA Preprocessing Artifact Detection and Removal Methods

The body sweats when emotional arousal and stress are experienced and, therefore, skin conductance increases [ 40 ]. This makes EDA a promising candidate for stress level detection. Intense physical activity and temperature changes contaminate the SC (Skin Conductance) signal. Therefore, affected segments (artifacts) should be filtered out from the original signal. In order to detect the artifacts in the SC signal, we used an EDA toolkit [ 41 ] which is 95% accurate on the detection of the artifacts. While developing this tool, technicians labeled the artifacts manually. They trained a machine learning model by using the labels. In addition to the SC signal, 3D acceleration and ST signals were also used for artifact detection. We removed the parts that this tool detected as artifacts from our signals. We further added batch processing and segmentation to this tool by using custom software built-in Python 2.7.

4.1.2. EDA Feature Extraction Methods

After the artifact removal phase, features were extracted from the EDA signal. This signal has two components phasic and tonic; features from both components were extracted (see Table 2 ). The cvxEDA tool [ 42 ] was used for the decomposition of the signal into these components. This tool uses convex optimization to estimate the Autonomic Nervous System (ANS) activity that is based on Bayesian statistics.

EDA features and their definitions.

Tonic Component Features

The tonic component in the EDA signal represents the long-term slow changes. This component is also known as the skin conductance level. It could be regarded as the indicator of general psychophysiological activation [ 43 ].

Phasic Component Features

The phasic component represents faster (event-related ) differences in the SC signal. The Peaks of phasic SC component as a reaction to a stimulus is also called Skin Conductance Response [ 43 ]. After we decompose the phasic component from the EDA signal, peak related features were extracted.

4.1.3. Heart Activity Preprocessing (Artifact Detection and Removal) and Feature Extraction Methods

Heart activity (or, more specifically, HRV) reacts to changes in the autonomic nervous system (ANS) caused by stress [ 44 ] and it is, therefore, one of the most commonly used physiological signal for stress detection [ 40 ]. However, vigorous movement of subjects and improperly worn devices may contaminate the HRV signal collected from smartwatches and smart bands. In order to address this issue, we developed an artifact handling tool in MATLAB programming language [ 45 ] that has batch processing capability. First, the data were divided into 2 min long segments with 50% overlapping. Two-minute segments were selected because it is reported that the time interval for stress stimulation and recovery processes is around a few minutes [ 46 ]. The artifact detection percentage rule (also employed in Kubios [ 47 ]) was applied after the segmentation phase. In this rule, each data point was compared with the local average around it. When the difference was more than a predetermined threshold percentage, (20% is commonly selected in the literature [ 48 ]), the data point was labeled as an artifact. In our system, we deleted the inter-beat intervals detected as the artifacts and interpolated these points with the cubic spline interpolation technique which was used in the Kubios software [ 47 ]. The time-domain features of HRV are calculated. In order to calculate the frequency domain features, we interpolated the RR intervals to 4 Hz. Then, we applied the Fast Fourier Transform (FFT). These time and frequency domain features (see Table 3 ) were selected because these are the most discriminative ones in the literature [ 30 , 49 , 50 ].

HRV features and their definitions [ 32 ].

4.1.4. Accelerometer Feature Extraction Methods

Research has shown that movements of the human body and postures can indeed be employed as a means to detect signs of different emotional states. The dynamics of body movement were investigated by Castellano et al. who used multimodal data to identify human affective behaviors. Specific movement metrics, such as the amount of movement, intensity and fluidity, were used to help deduct emotions, and it was found that the amount of movement was a major factor in distinguishing different types of emotions [ 51 ]. Melzer et al. investigated whether movements comprised of collections of Laban movement components could be recognized as expressing basic emotions [ 52 ]. The results of their study confirm that, even when the subject has no intention of expressing emotions, particular movements can assist in the perception of bodily expressions of emotions. Accelerometer sensors may be used to detect these movements and different types of affect. The accelerometer sensor data are used for two different purposes in our system. Firstly, we extracted features from the accelerometer sensor, for detecting stress levels. We also selected the features to be used as described in Table 4 [ 53 ] and, as mentioned above, this sensor was also employed to clean the EDA signal in the EDAExplorer Tool [ 41 ].

ACC features and their definitions.

4.1.5. Skin Temperature

A skin temperature signal is used for the artifact detection phase of the EDA signal in the EDAExplorer Tool [ 41 ]. After we divide our data into segments, different modalities were merged into one feature vector. The heart activity signal started with a delay (to calculate heartbeats per minute at the start) and all signals were then synchronized. We included start and end timestamps for each segment, and each modality was merged with a custom Python script.

4.1.6. Machine Learning Classifier Algorithms

The Weka machine learning toolkit [ 54 ] is used for identifying stress levels. The Weka toolkit has several preprocessing features before classification. Our data set was not balanced when the number of instances belonging to each class was considered. We solved this issue by removing samples from the majority class. We selected random undersampling because it is the most commonly applied method [ 55 ]. In this way, we prevented classifiers from biasing towards the class with more instances. In this study, we employed five different machine learning classification algorithms to recognize different stress levels: MultiLayer Perceptron (MLP), Random Forest (RF) (with 100 trees), K-nearest neighbors (kNN) ( n = 1–4), Linear discriminant analysis (LDA), Principal component analysis (PCA) and support vector machine (SVM) with a radial basis function. These algorithms were selected because they were the most commonly applied and successful classifiers for detecting stress levels [ 30 , 48 ]. In addition, 10-fold stratified cross-validation was then applied and hyperparameters of the machine learning algorithms were fine-tuned with grid search. The best performing models have been reported.

4.1.7. Dimensionality Reduction

We applied correlation-based feature selection (CBFS) technique which is available in the Weka machine learning package for combined signal [ 56 ]. The CBFS method removes the features that are less correlated with the output class. For every model, we selected the ten most important features. This method is applied for MLP, RF, kNN and LDA. In order to create an SVM based model, we applied PCA based dimensionality reduction where the covered variance is selected as 0.95 (the default setting).

4.1.8. Insights from the Feature Selection Process

The CBFS method computes the correlation of features with the ground truth label of the stress level. Insights about the contribution of the features to the stress detection performance can be obtained from Figure 1 and Figure 2 . Three of the best features (over 0.15 correlation) are frequency domain features. These features are high, low and very-low frequency components of the HRV signal (see Figure 1 ). When we examine the EDA features, peaks per 100 s feature are the most important and distinctive feature by far. Since the EDA signal is distorted under the influence of the stimuli, the number of peaks and valleys increases. Lastly, when the acceleration signal is investigated, the most discriminative feature is mean acceleration in the z -axis (see Figure 2 b). This could be due to the nature of hand and body gestures which are caused by stressed situations.

Top-ranking features selected for the HRV signal.

Top-ranking features selected for the EDA and ACC signals.

4.2. Relaxation Method Suggestion by Analyzing the Physical Activity-Based Context

Context is a broad term that could contain different types of information such as calendars, activity type, location and activity intensity. Physical activity intensity could be used to infer contextual information. In more restricted environments such as office, classrooms, public transportation and physical activity intensity could be low, whereas, in outdoor environments, physical activity intensity could increase. Therefore, an appropriate relaxation method will change according to the context of individuals.

For calculating physical activity intensity, we used the EDAExplorer tool [ 41 ]. The stillness metric is used for this purpose. It is the percentage of periods in which the person is still or motionless. Total acceleration must be less than a threshold (default is 0.1 [ 41 ]) for 95 percent of a minute in order for this minute to count as still [ 41 ]. Then, the ratio of still minutes in a session can be calculated. For the ratio of still minutes in a session, we labeled sessions below 20% as still, above 20% as active and suggested relaxation method accordingly (see Figure 3 ).

The whole system diagram is depicted. When a high stress level is experienced, by analyzing the physical activity based context, the system suggests the most appropriate reduction method.

4.3. Description of the Data Collection Procedure

The proposed stress level monitoring mechanism, for real-life settings, was evaluated during an eight day Marie Skłodowska-Curie Innovative Training Network (ITN) training event in Istanbul, Turkey, for the AffecTech project. AffecTech is a program funded by Horizon 2020 (H2020) framework established by the European Commission. The AffecTech project is an international collaborative research network involving 15 PhD students (early stage researchers (ESR)) with the aim of developing low-cost effective wearable technologies for individuals who experience affective disorders (for example, depression, anxiety and bipolar disorder).

The eight-day training event included workshops, lectures and training with clearly defined tasks and activities to ensure that the ESR had developed the required skills, knowledge and values outline prior to the training event. At the end of the eight-day training, ESRs were required to deliver a presentation about their PhD work to two evaluators from the European Union where they received feedback about their progress (see Figure 4 for raw physiological signals at the start of the presentation). For studying the effects of emotion regulation on stress, yoga, guided mindfulness and mobile-based mindfulness, sessions were held by a certified instructor.

Sample data belong to a presentation session. The increase in EDA, ST and IBI could be observed when the subject started the presentation.

During the training, physiological and questionnaire data were collected from the 16 ESR participants (9 men, mean age 28); 15 ESRs and one of the AffecTech project academics, all of whom gave informed consent to participate in the study. Participants were from different countries with diverse nationalities (two from Iran, two from Spain, two from Italy, one from Argentina, one from Pakistan, one from China, one from Switzerland, one from Belarus, one from France, one from England, one from Barbados, one from Turkey and one from Bulgaria). Due to the fault of one of the Empatica E4 devices, it was not possible to include data from one participant. The remaining 15 participants completed all stages of the study successfully.

During the eight days of training and presentations, psychophysiological data were collected from 16 participants during the training event from Empatica E4 smart band while they are awake. For studying the effects of emotion regulation on stress, yoga, guided mindfulness and mobile-based mindfulness sessions were held by a certified instructor. The timeline of the event is shown in Figure 5 .

Time-line depicting eight days of the training event. Presentations, relaxations and lectures are highlighted.

4.3.1. Physiological Stress Data

The psychophysiological signal data were collected using the Empatica E4 smart band whilst participants were awake throughout the eight days of the AffecTech training. Physiological data included IBI, EDA, ACC (Accelerometer) and ST and stored in different csv files. In addition, 27.39% of the data are obtained from free times (free day and after training until subjects slept 5:00 p.m.–10:00 p.m.), 43.83% of the data comes from lectures in the training, 11.41% is the presentation session and relax sessions consist of 17.35% of the data. As mentioned previously, we randomly undersampled (most commonly applied method [ 55 ] ) the data to overcome the class imbalance problem. The participants’ blood pressure (BP) was also recorded using CE(0123) Harvard Medical Devices Ltd. automated sphygmomanometer prior to and after each stress reduction event (yoga and mindfulness), in order to demonstrate whether the participants stress levels were modified. On each occasion that the participants’ BP was recorded, the mean of three recordings was used as the final BP. A reduction in the participants’ blood pressure and/or pulse rate may be seen, which demonstrates a reduction in stress level.

4.3.2. Ethics

The procedure used in this study was approved by the Institutional Review Board for Research with Human Subjects of Boğaziçi University with the approval number 2018/16. Prior to data acquisition, each participant received a consent form describing the experimental procedure and its benefits and implications to both the society and the subject. The procedure was also explained verbally to the subject. All of the data are stored anonymously.

4.3.3. Questionnaire Self-Report Stress Data

A session-based self-report questionnaire comprised of six questions based on the Nasa Task Load Index (NASA-TLX) [ 57 ]. The frustration scale was specifically used to measure perceived stress levels [ 32 ]. We asked the following question to the participants for each session:

How irritated, stressed and annoyed versus content, relaxed and complacent did you feel during the task?

Questionnaires were completed daily (at the end of the day) and, after each presentation, lecture and stress reduction event (such as yoga and mindfulness).

4.3.4. Stress Management Scheme Using Yoga and Mindfulness

During the eight day training, it is assumed that the participants’ stress levels are likely to have increased day by day because they were required to give a presentation (perceived as a stressful event) reporting their PhD progress to the EU project evaluators at the end of the training.

Underpinned by James Gross’s Emotion Regulation model (see Figure 6 ) [ 4 ], we modified the situation to help the participants to reduce their thoughts of the end of the training presentation. To help participants manage their stress levels, we applied Yoga and mindfulness sessions on two separate days (day three and day four, respectively). These sessions lasted approximately 1 h and, throughout the sessions, participants wore an Empatica E4 smartband. In addition to the physiological signals coming from the Smartbands, participants’ blood pressure values were also recorded before and after the yoga and mindfulness sessions.

Application of James Gross’s Emotion Regulation model [ 4 ] in the context of stress management.

5. Experimental Results and Discussion

5.1. statistical data analysis, 5.1.1. validation of different perceived stress levels by using the self-reports.

In order to validate that the participants experienced different perceived stress levels in different contexts (lecture, relaxation, presentation), we used the Frustration item (see Section 4.5) from the NASA-TLX [ 57 ]. The distribution of answers is demonstrated in Figure 7 . Our aim is to show that the perceived stress levels (obtained from self-report answers) differ in relaxation sessions considerably when compared to the presentation session (high stress). To this end, we applied the t -test (in R programming language) to the perceived stress self-report answers of yoga versus presentation, mindfulness versus presentation and pause (mobile mindfulness) versus presentation session pairs. The paired t -test is used to evaluate the separability of each session. The degree of freedom is 15. We applied the variance test to each session tuple; we could not identify equal variance in any of the session tuples. Thus, we selected the variance as unequal. We used 99.5% confidence intervals. The t -test results’ ( p -values and test statistics) are provided in Table 5 . For all tuples, the null hypothesis stating that the perceived stress of the relaxation method is not less than the presentation session is rejected. The perceived stress levels of participants for all meditation sessions are observed to be significantly lower than the presentation session (high stress).

Visual representation of the frustration scores collected in different types of sessions.

T -test results for session tuple comparison of perceived stress levels using self-reports.

5.1.2. Before and After Physiological Measurements for Evaluating Performance of Yoga and Mindfulness with Blood Pressure

In this section, we compared the effect of stress management tools such as yoga and mindfulness on blood pressure. It is expected that blood pressure sensors will be part of unobtrusive wrist-worn wearable sensors soon. We plan to integrate a blood pressure (BP) module to our system when they are available. Therefore, by using the measurements of a medical-grade blood pressure monitor, we provided insights about how stress reaction affects BP. We further applied and tested the prominent emotion regulation model of James Gross by analyzing these measurements in the context of stress management. We measured the diastolic and systolic BP and pulse using a medical-grade blood pressure monitor before and after the yoga and mindfulness sessions. In order to ensure that the participants were relaxed and that an accurate BP was recorded, BP was measured three times with the mean as the recorded result. A one-sample t -test was applied to the difference between mean values. The results are shown in Table 6 .

The difference between the mean diastolic blood pressure, the mean systolic blood pressure and the mean pulse, before and after sessions of guided mindfulness and guided yoga. (* p < 0.05).

Mindfulness decreased the systolic BP, –1.13% (ns), increased diastolic BP, +1.75% ( p < 0.05) and decreased the pulse –5.75% ( p < 0.05). Medicine knows that systolic blood pressure (the top number or highest blood pressure when the heart is squeezing and pushing the blood around the body) is more important than diastolic blood pressure (the bottom number or lowest blood pressure between heartbeats) because it gives the best idea of the risk of having a stroke or heart attack. In this view, the significant reduction of systolic BP after mindfulness is an important result.

Moreover, the difference between systolic and diastolic BP is called pulse pressure. For example, 120 systolic minus 60 diastolic equals a pulse pressure of 60. It is also known that a pulse pressure greater than 60 can be a predictor of heart attacks or other cardiovascular diseases, while a low pulse pressure (less than 40) may indicate poor heart function. In our study, pulse pressure was lower after mindfulness (we had both a significant reduction in systolic BP and an increase in diastolic BP), but its value was higher than 40 (42.69 mean difference before the mindfulness and 40.48 mean difference after the mindfulness), suggesting that this result can also be considered clinically positive.

During yoga, there was a decrease in systolic BP by −5.81% ( p < 0.05), diastolic BP by −1.93% (ns) and increase in pulse +8.06% ( p < 0.05). Yoga appears to be more effective than mindfulness at decreasing systolic and diastolic blood pressure, although mindfulness seems to be more effective than yoga for decreasing the pulse due to the activity involved in yoga.

5.2. Physiological Stress Level Detection with Wearables by Using Context Labels as the Class Label

We tested our system by using the known context labels of sessions as the class label. We used Lecture (mild stress), Yoga and Mindfulness (relax) and Presentation in front of the board of juries (high stress) as class labels by examining perceived stress self-report answers in Figure 6 . We investigated the success of relaxation methods, different modalities and finding the presenter.

5.2.1. Effect of Different Physiological Signals on Stress Detection

We evaluated the effect of using the interbeat-interval, the skin conductance and the accelerometer signals separately and in a combined manner on two and three class classification performance. These classes are mild stress, high stress and relax states from mindfulness and yoga sessions. The results are shown in Table 7 , Table 8 and Table 9 . For the three-class classification problem, we achieved a maximum accuracy of 72% by using MLP on only HRV features and 86.61% with only accelerometer features using the Random Forest classifier and 85.36% accuracy combination of all features with LDA classifier (see Table 7 ). The difficulty in this classification task is a similar physiological reaction to relax and mild stress situations. However, since the main focus of our study is to discriminate high stress from other classes to offer relaxation techniques in this state, it did not affect our system performance. We also investigated high-mild stress and high stress-relax 2-class classification performance. For the discrimination of high and mild stress, HRV outperformed other signals with 98% accuracy using MLP (see Table 8 ). In the high stress-relax 2-class problem, only HRV features with RF achieved a maximum accuracy of 86%, whereas ACC features with MLP achieved a maximum of 94% accuracy. In this problem, the combination of all signals with RF achieved 92% accuracy which is the best among all classifiers (see Table 9 ). For all models, EDA did not perform well. This might be caused by the loose contact with EDA electrodes in the strap due to loosely worn smartbands.

Effect of different modalities and their combination on the system performance. Note that the number of classes is fixed at 3 (high stress, mild stress and relax).

Effect of different modalities and their combination on the system performance. Note that the number of classes is fixed at 2 (high stress and mild stress).

Effect of different modalities and their combination on the system performance. Note that the number of classes is fixed at 2 (high stress and relax).

5.2.2. Effectiveness of Yoga, Mindfulness and Mobile Mindfulness (Pause)

We applied three different relaxation methods to manage stress levels of individuals. In order to measure the effectiveness of each method, we examined how easily these physiological signals in the relaxation sessions can be separated from high stress presentations. If it can be separated from high stress levels with higher classification performance, it could be inferred that they are more successful at reducing stress. As seen in Table 10 and Table 11 , mobile mindfulness has lower success in reducing stress levels. Yoga has the highest classification performance with both HR and EDA signals.

The classification accuracy of the relaxation sessions using stress management methods and stressful sessions using EDA.

The classification accuracy of the relaxation sessions using stress management methods and stressful sessions using HRV.

6. Conclusions

In this study, by using our automatic stress detection system with the use of Empatica-E4 smart-bands, we detected stress levels and suggested appropriate relaxation methods (i.e., traditional or mobile) when high stress levels are experienced. Our stress detection framework is unobtrusive, comfortable and suitable for use in daily life and our relaxation method suggestion system makes its decisions based on the physical activity-related context of a user. To test our system, we collected eight days of data from 16 individuals participating in an EU research project training event. Individuals were exposed to varied stressful and relaxation events (1) training and lectures (mild stress), (2) yoga, mindfulness and mobile mindfulness (PAUSE) (relax) and (3) were required to give a moderated presentation (high stress). The participants were from different countries with diverse cultures.

In addition, 1440 h of mobile data (12 h in a day) were collected during this eight-day event from each participant measuring their stress levels. Data were collected during the training sessions, relaxation events and the moderated presentation and during their free time for 12 h in a day, demonstrating that our study monitored daily life stress. EDA and HR signals were collected to detect physiological stress and a combination of different modalities increased stress detection, performance and provided the most discriminative features. We first applied James Gross ER model in the context of stress management and measured the blood pressure during the ER cycle. When the known context was used as the label for stress level detection system, we achieved 98% accuracy for 2-class and 85% accuracy for 3-class. Most of the studies in the literature only detect stress levels of individuals. The participants’ stress levels were managed with yoga, mindfulness and a mobile mindfulness application while monitoring their stress levels. We investigated the success of each stress management technique by the separability of physiological signals from high-stress sessions. We demonstrated that yoga and traditional mindfulness performed slightly better than the mobile mindfulness application. Furthermore, this study is not without limitations. In order to generalize the conclusions, more experiments based on larger sample groups should be conducted. As future work, we plan to develop personalized perceived stress models by using self-reports and test our system in the wild. Furthermore, attitudes in the psychological field constitute a topic of utmost relevance, which always play an instrumental role in the determination of human behavior [ 58 ]. We plan to design a new experiment which accounts for the attitudes of participants towards relaxation methods and their effects on the performance of stress recognition systems.

Acknowledgments

We would like to show our gratitude to the Affectech Project for providing us the opportunity for the data collection in the training event and funding the research.

Author Contributions

Y.S.C. is the main editor of this work and made major contributions in data collection, analysis and manuscript writing. H.I.-S. made valuable contributions in both data collection and manuscript writing. She was the yoga and mindfulness instructor in the event and contributed the related sections regarding traditional and mobile methods. She also led the blood pressure measurement efforts before and after relaxation methods. D.E. and N.C. contributed equally to this work in design, implementation, data analysis and writing the manuscript. J.F.-Á., C.R. and G.R. contributed the experiment design and provided valuable insights into both emotion regulation theory. They also contributed to the related sections in the manuscript. C.E. provided invaluable feedback and technical guidance to interpret the design and the detail of the field study. He also performed comprehensive critical editing to increase the overall quality of the manuscript. All authors have read and agreed to the published version of the manuscript.

This work has been supported by AffecTech: Personal Technologies for Affective Health, Innovative Training Network funded by the H2020 People Programme under Marie Skłodowska-Curie Grant Agreement No. 722022. This work is supported by the Turkish Directorate of Strategy and Budget under the TAM Project number DPT2007K120610.

Conflicts of Interest

The authors declare no conflict of interest.

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A CASE STUDY ON STRESS MANAGEMENT WITH REFERENCE TO LAKSHMI NISSAN AUTOMOTIVES PVT.LTD, HYDERABAD

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• Published: 16 September 2024

Hybrid emergency care at the home for patients – A multiple case study

• Åsa Falchenberg   ORCID: orcid.org/0000-0001-8956-8011 1 , 2 ,
• Ulf Andersson   ORCID: orcid.org/0000-0002-1789-8158 1 , 3 ,
• Gabriella Norberg Boysen   ORCID: orcid.org/0000-0003-3203-3838 1 ,
• Henrik Andersson   ORCID: orcid.org/0000-0002-3308-7304 1 , 2 , 4 &
• Anders Sterner   ORCID: orcid.org/0000-0002-2430-5285 1 , 2  

BMC Emergency Medicine volume  24 , Article number:  169 ( 2024 ) Cite this article

Metrics details

Introduction

Healthcare systems worldwide are facing numerous challenges, such as an aging population, reduced availability of hospital beds, staff reductions and closure of emergency departments (ED). These issues can exacerbate crowding and boarding problems in the ED, negatively impacting patient safety and the work environment. In Sweden a hybrid of prehospital and intrahospital emergency care has been established, referred to in this article as Medical Emergency Team (MET), to meet the increasing demand for emergency care. MET, consisting of physicians and nurses, moving emergency care from EDs to patients’ home. Physicians and nurses may encounter challenges in their healthcare work, such as limited resources for example medical equipment, sampling and examination, in unfamiliar varying home environments. There is a lack of knowledge about how these challenges can influence patient care. Therefore, the aim of this study was to explore the healthcare work of the METs when addressing patients’ emergency care needs in their homes, with a focus on the METs reasoning and actions.

Using a qualitative multiple case study design, two METs in southwestern Sweden were explored. Data were collected from September 2023 – January 2024 and consist of field notes from participant observations, short interviews and written reflections. A qualitative manifest content analysis with an inductive approach was used as the analysis method.

The result of this study indicates that physicians and nurses face several challenges in their daily work, such as recurring interruptions, miscommunication and faltering teamwork. Some of these problems may arise because physicians and nurses are not accustomed to working together as a team in a different care context. These challenges can lead to stress, which ultimately can expose patients to unnecessary risks.

When launching a new service like METs, which is a hybrid of prehospital and intrahospital emergency care, it is essential to plan and prepare thoroughly to effectively address the challenges and obstacles that may arise. One way to prepare is through team training. Team training can help reduce hierarchical structures by enabling physicians and nurses to feel that they can contribute, collaborate, and take responsibility, leading to a more dynamic and efficient work environment.

Peer Review reports

According to the World Health Organization (WHO), healthcare is facing several challenges, including an aging population [ 1 ] rising rates of chronic diseases, often characterized by exacerbation [ 2 ], which place greater demands on healthcare services. Simultaneously, the number of available hospital beds is decreasing, and due to staff cuts, there will be fewer ambulances and emergency departments (EDs) are closing [ 3 ]. In EDs, this leads to issues such as crowding and boarding, and which have a negative impact on the work environment such as workload that is too high, which may cause stress and risk of burnout [ 4 ]. Furthermore, crowding and boarding and have negative impacts on patient safety since of delays in medical treatment and inadequate monitoring, which can lead to increased mortality [ 5 ].

One way to meet patients’ needs for emergency care is to shift the care provided from the hospital to patients’ homes [ 6 , 7 ]. Offering home-based care (HBC) has been shown to be cost-effective [ 8 ] and safe for patients [ 9 ]. However, it may entail longer treatment times than hospital care, especially for certain chronic conditions [ 10 ]. Studies indicate that exacerbations of chronic conditions such as heart failure and chronic obstructive pulmonary disease, as well as pneumonias [ 11 ], symptoms such as fever, dyspnea [ 12 ], nonspecific symptoms in frail elderly patients, patients with cognitive impairment [ 13 ], and pain or injury to the skeletal or muscular system [ 14 ] can be effectively managed at patients homes. Currently, there is no consensus on what HBC entails or how it can be termed [ 15 ]. Terms such as “Hospital At Home” [ 9 , 16 ], “Same Day Emergency" [ 17 ], “Hospital In The Home” [ 18 ] or “Residential In Reach” [ 19 ] are used internationally, while in Sweden, general terms such as “Mobile teams”, “Mobile emergency teams”, or “Mobile home care teams” are used [ 20 ].

The Swedish healthcare system is divided into three levels of governance: state, region, and municipality. These levels are responsible for different parts of healthcare, specialized hospital care, primary care, and municipal care [ 21 ]. Currently, all levels are undergoing a transformation process called “good and integrative care” [ 22 ]. This initiative resembles the Integrated Care System in England [ 23 ] and aims to make healthcare more accessible and closer to the patient, focusing on their unique care needs [ 24 , 25 ]. As part of the Swedish transformation process to meet the increased need for emergency care, a hybrid of pre- and intrahospital emergency care has been established [ 25 ]. This hybrid version of emergency care will, in this article be referred to as the Medical Emergency Team (MET). The MET, consisting of two organizations, ambulance services (AS), and EDs, has merged and operates outside the hospital setting. MET is not the same as care provided by ambulance, primary or municipal care, MET is rather a combination of these services. The MET is staffed with ED physicians and nurses from the ED or AS and provide emergency care to patients who have suffered from sudden illness or injury [ 26 ] and operates wholly or partially from hospital-affiliated EDs.

When emergency care is provided in patients’ homes, a holistic approach is required to ensure that all aspects of patients’ care needs, including medical, caring, physical, psychological, social, and existential needs, are addressed [ 27 ]. This means that METs must be prepared to handle a wide range of care-related issues with limited resources, in an unfamiliar environment to ensure that the care provided in patients’ homes meets their needs [ 28 ]. This requires the MET to collaborate across boundaries both within the MET, and outside the team with other care providers such as AS, primary care or municipal care [ 25 , 29 ]. If the expectations of the MET’s care work, i.e., what they can do, are unclear, difficulties may arise [ 28 ]. In this study, healthcare work refers to performing various tasks which not only including technical skills such as collecting blood samples and managing medical equipment but also through understanding and responding to patients’ needs, both expressed and unexpressed. Furthermore, healthcare work includes communication within the MET, with patients and their relatives, as well as other healthcare actors. By examining how physicians and nurses reason and act when encountering patients’ care needs at home through the MET, obstacles and opportunities can be identified when hybrid emergency care is shifted to patients’ homes. The aim of this study was to explore the healthcare work of the METs when addressing patients’ emergency care needs in their homes, with a focus on the METs reasoning and actions.

Employing a qualitative multiple case study design [ 30 ], this study explored the MET as a contextually and socially bounded system [ 31 ]. The data were collected through participant observations, which enabled participation in daily activities, interactions, and events [ 32 ].

The research settings were two METs in the southwestern part of Sweden: MET A, which operated from a hospital-affiliated ED, and MET B, which operated from the AS. The possible assignments providers for MET A and MET Bs were similar. However, MET B could have paced assignments identified by the ED and AS when the MET was not operational. MET B could also be assigned to time-critical medical conditions to make initial assessments/treatments while waiting for AS. Primarily, the nurses were responsible for checking the equipment and restocking supplies in the vehicle. When the MET had no assignments, the physicians in the MET A supported their colleagues in the ED, carried out administrative tasks, and answered incoming calls to the MET. The physicians in MET B had administrative tasks and handled incoming calls to the MET when the team had no assignments. The two METs had varying conditions and staffing, and the equipment was slightly different between MET A and MET B, consisting of up to 13 different units. For more information see Table  1 .

Study participants and recruitment

The study received ethical approval from the Swedish Ethical Review Authority in Stockholm (NO: 2023-02186-01) and access to the research field was granted and formally approved by the managers of the participating facilities. All physicians and nurses who staffed the MET were invited to participate in the study. MET A was informed by the first author through a staff meeting and email, while MET B received the information verbally from the medical chief of the department. Each participant received both oral and written information about the study from the first author and signed a consent form. Other ethical considerations regarding data protection and data security were followed in accordance with the Swedish Data Protection Act [ 33 ]. All data are presented at the group level for the purpose of ensuring and maintaining the participants’ integrity and confidentiality, and the study aligns with accepted ethical principles for research [ 34 ]. The studies included five physicians and five nurses from MET A and five physicians and five nurses from MET B, see Table  2 for further information.

Data collection

The data were collected during the period from September 2023 to January 2024 and consisted of participant observations with field notes [ 32 ], interview notes [ 35 ] and written reflections [ 32 ].

Observations

The first author conducted all observations by following both METs for full work-shifts, and each patient visit was defined as one observation. The duration of the observations varied between the METs, se Table  3 . Physicians and nurses were encouraged to work as usual and to ignore the researcher, who aimed to maintain a low profile throughout. When arriving at the patient, the researcher was briefly introduced as a person who was there to observe how they worked.

All observations began when the MET received the assignment and ended when the door to the patients’ home closed. During the observation field notes were written containing what physicians and nurses said and how they reasoned when the assignment was received, during the assignment, and when it was completed. In total, 25 observation days were completed, comprising 73 observation instances. The observations lasted an average of 41 to 44 min and generated two to three pages of transcribed text, see Table  3 for further details.

To obtain a deeper understanding of METs reasoning about their actions when patients’ care needs were met, the following questions were asked; What are your thoughts about the assignment and what are your thoughts on the teamwork? Follow-up questions were posed in response to the answers given. To gain a deeper understanding, questions such as “Can you tell me more?” were used frequently. The interviews took place after the observations were completed, conducted in the car while leaving the patient.

After the completion of the observation and interviews, the first author wrote down reflections in a reflective text. The purpose of the reflection was to gain additional understanding of the research questions. These reflections were utilized in the discussion of the results.

Data Analysis

The collected data consisted of field notes, interview texts, and reflection texts were transcribed by the first author. During transcription, the text became more descriptive than the original because several fieldnotes were written with incomplete sentences when trying to write down as much as possible. The data were sorted into three phases of the MET assignment- preparatory, during the patient visit, and the reflection phase - which is a way to structure the data chronologically and provide organization [ 30 ]. To ensure that the analysis was as free as possible from interpretations, the author group discussed och reflected during the process. The qualitative manifest content analysis was conducted using an inductive apporach [ 36 ] and began with the first author reading the fieldnotes and interview texts multiple times to understand the content and obtain an overall sense of the data. In the second step, units from the text were extracted that addressed the aim of the study, to capture and describe METs healthcare work such as communication, physical actions, understanding and responding to patients’ care needs. These units were condensed without losing the content and coded based on their content. The codes were then sorted into categories and subcategories describing different aspects, similarities, or differences, ultimately forming four categories: Assignment reception and preparation phase, patient interaction and examination phase, decision-making and treatment phase and reflection and evaluation phase.

The results will be presented in chronological order, from when the METs receive the assignment until the assignment is completed, concluding with reflections from the METs. The results will include situational descriptions and quotes to present general patterns for MET A and MET B; unless otherwise specified, the aspects were the same. Each phase begins with a generic vignette that encompasses of several observation sessions. Individual observations are presented with the unique observations number.

Assignment reception and preparation phase

The METs are on their way to a patient , the physician reads loud from the patient’s medical record , the phone rings repeatedly , regarding new assignments and questions from AS , municipality care, etc. After each call , the physician gives a summary to the nurse. The nurse asks “inquisitively”… which patient are you referring to? The one we’re heading to , or is it another? Transportation time is then spent with the physician dictating notes in the patient’s medical records where recommendations to seek other levels of care or stay at home are given. When the nurse parks the vehicle outside the patient’s address , the METs discuss which equipment to bring.

Patient assignments could be provided at any time during the shift via phone or radio, and the information was sometimes vague or incomplete. The time for preparation varied depending on when the assignment was received, where the METs were geographically located in relation to the patient’s address, whether in an apartment in the same building or several kilometers away. Physicians received the most calls; occasionally, the speakerphone function was used so that the nurse could take part in the conversation and ask questions. On occasions when nurses answered the phone, a brief report was taken, and the nurse was asked to call back after consulting with the physician, or the phone was handed directly to the physician. Unlike MET A, MET B could receive assignments from the ED and AS when the MET was not operational. Messages were then written on notes handed over in person during shift changes at the ambulance station or at the ED. MET B could also be assigned to a critically ill patient, resulting in all delays for all other accepted assignments. On some days, assignments could pile up, causing patients to wait for several hours or for the METs to decline assignments. When assignments were received, the METs discussed the pros and cons to determine if it was a suitable patient; the physician had the authority to accept the assignment.

Nurses drove the vehicle, and transportation time could occur in silence, with the phone ringing incessantly, or with the METs discussing private matters. Physicians read and documented in the patient’s journal for upcoming and completed patient assignments. The METs could have difficulties finding the correct address; the functionality of the navigation system varied, and on several occasions, it did not work at all or provide incorrect directions. Upon arrival at the correct address, the need for additional information, such as a gate code or miscommunication regarding contagious patients, was discovered. When the vehicle was parked outside the patient’s residence, the decision on which equipment to use was made. Physicians were responsible for bringing the laptop bag and ultrasound equipment, while nurses were responsible for carrying other equipment. In instances where physicians were in an ongoing call, the nurse entered the patient’s home alone, but usually, the METs entered together.

Patient interaction and examination phase

When the METs entered the patient’s home , the physician approached first , either standing or squatting in front of the patient and said: Hello , my name is xxx and I am a physician , how are you? The nurse stands quietly behind , not wanting to interrupt the patient’s conversation with the physician and beginning to retrieve and set up the lab equipment. The physician examines the patient , is interrupted several times by phone calls , and then prescribes which tests to take. The nurse , who has been in another room , is not prepared for which tests to take and does not understand why.

When the METs arrived at the patient, they introduced themselves by name and title, and that they were from the MET. The physician was often the first to reach the patient. In instances where the MET had been assigned a critically ill patient, which was a part of MET B’s mission, there were usually already one or two ambulances on site. The physician then first contacted the ambulance nurse. When MET B was the first unit on site, the physician took the medication unit and went in alone to see the patient while the nurse parked the vehicle and brought in the rest of the equipment.

After the introduction, physicians usually immediately began gathering information about what had happened and how the patient was feeling. This meant that the nurse did not have a natural opportunity to greet, which could result in the nurse’s introduction occurring later during the visit or being completely omitted. Physicians often choose to sit down beside the patient or squat down. Before the examination, lights were sometimes turned on, blinds were pulled up, and the bed was raised. This was sometimes initiated by the patient, other individuals present, or the METs themselves. Examinations could also be conducted by leaning over the patient, in dim light where mobile flashlights were used to read vital signs. Depending on how many other people were in the room, information about the sequence of events could come from multiple sources. Nurses sometimes chose to listen as physicians gathered information, sometimes asked questions, or assisted when communication between the patient and physician did not work. When several people were present, it could sometimes become noisy in the room, resulting in the patient not hearing or understanding what the physician was asking, and the patient’s voice not being heard. The METs could be interrupted several times by phone calls with requests for new assignments, pending assignments, and advisory calls from AS.

The examinations were conducted based on the ABCDE principle (airway, breathing, circulation, disability, and exposure) and were carried out by a physician, while the nurse performed the examination, when agreed upon during the preparation phase. Physicians always listen to patients’ lungs. The nurse sometimes participated in the initial examination by handing equipment such as a stethoscope to the physician or standing quietly by the side and listening. Unlike in the MET A group physicians in the MET B group were interested in improving nurses’ examination techniques, such as listening to the lungs and interpreting electrocardiograms (ECG). Physicians encouraged the nurses to listen and report what they heard or allowed the nurses to make the initial assessment of the ECG. Different examination findings were discussed openly, which could lead to various expressions of curiosity and questions among those present. Most often, the nurse chose to begin measuring vital parameters (respiratory rate, saturation, blood pressure, pulse, and temperature) or to prepare the laboratory equipment during the ongoing examination. The cold blood pressure cuff was warmed on rare occasions. The clothing of patients could be partially or fully removed during the examination and was not routinely returned after the examination. Once vital parameters had already been taken, the nurse waited to take new until the physician indicated a desire for them. Nurses could express concerns about patients’ well-being, such as affected vital parameters during the ongoing examination, which the physician did not confirm or did not consider noteworthy.

The nurse measures the patient’s saturation… looks at the meter… furrows brow in concern , asks the patient to take a few deep breaths. Says to the physician: …are you noting the value? Yes , says the physician , who continues to sanitize the equipment [Observation 45].

Problems that could arise when vital parameters were taken included that they were often said out loudly in the room, which colleagues did not always hear. The values could be noted on journal sheets, pieces of paper, on gloves, or not at all. This resulted in uncertainties about which parameters had been taken and what they showed. The mission of MET B, unlike that of MET As, was to care for elderly patients. They could be interrupted during ongoing examinations to care for another patient, residing in the same assisted living facility, who had suddenly deteriorated. In those instances, the nurse stayed with the patient and continued the examination.

Sampling, which occurred after a physician’s order, was performed by nurses. Sometimes, the nurse could interrupt the ongoing examination to obtain blood samples without a physician’s order; other times, the nurse stood by and waited, ready with the sampling materials. When the nurse took the samples, the physician usually chose to sit down in another room to read the patient’s journal and plan for potential treatment. Nurses were responsible for retrieving the laboratory equipment and placing it where there was sufficient space, usually in an adjacent room; patients were then left alone while blood samples were analyzed. The results from sampling were crucial in some cases, such as when patients could not participate in the visit due to a disability. Blood samples could be taken via arterial, venous, or capillary methods, with the choice of method varying. In MET A, it was the patient’s symptoms and signs determine the choice of sampling method, while in MET B, arterial or capillary blood samples are usually taken. The reason for choosing the sampling technique was unfamiliarity with the venous sampling technique and the nurses’ interest in learning to collect arterial samples. This resulted in patients being punctured multiple times, and the decision regarding sampling could suddenly be re-evaluated when the sampling failed when there was a lack of available analysis material.

The issues that could arise with laboratory equipment included its sensitivity to cold temperatures and the shortage of the special cards. Attempts to warm the laboratory equipment were made by placing it near warm sources in the patient’s home, warming it against the body, and re-evaluating the need for sampling. MET A chose to place the sensitive equipment in another location in the vehicle, which MET B did not have the opportunity to do. The lab equipment was space-consuming, which challenged the METs in homes with many personal belongings and dirty surfaces. MET A, which had more lab equipment than MET B, forgot part of the equipment at the patients’ homes. METs can carry up to seven units into the patient, depending on the patient’s condition. Space constraints combined with large jackets during cold weather caused patients personal belongings to fall to the floor and break.

Decision-making and treatment phase

Physicians made decisions regarding treatment , which could involve medication , palliative care orders , expanded sampling , and continued hospital care. Physicians discussed treatment options with patients , when possible , as well as other healthcare personnel present. The nurse , who often remained in another room to manage patient sampling and pack equipment , did not hear the discussions and thus was unprepared for potential treatment and lacked knowledge of prescribed medications. When the decision for hospital transport was made , the nurse arranged it while the physician documented.

Decisions about treatment were typically made by physicians during the examination or sampling phase and could involve medication, expanded sampling, continued hospital care, palliative care orders, or observation. During this phase, METs could be interrupted repeatedly, resulting in incomplete perceptions of orders and important decisions made. Nurses repeated the current medication orders and awaited confirmation from the physician before administering the medication. Nurses could ask patients and relatives several questions but did not wait for or expect a response. Physicians usually provide medical self-care advice, while nurses ask if they have sufficient support from other healthcare providers. Nurses could also take initiative and suggest treatments to patients who had not communicated with the physician, which could sometimes lead to misunderstandings regarding patients’ degree of illness.

Patient with diarrhea , vomiting , high fever , and dizziness for five days. The patient said , “I find it hard to drink”. Nurses responded “ … it is a shame to go to the hospital , better to stay at home. You should take paracetamol and ibuprofen regularly throughout the day for the fever , and then you must drink properly , preferably soup or oral rehydration solution”. Meanwhile , the physician stands a short distance away , looks worried , makes a few attempts to intervene in the conversation but fails and eventually gives up [Observation 45].

Physicians typically proposed treatment options to patients, and in cases where patients had conditions such as impaired cognitive abilities or were in the end-of-life stage, they were not involved in decision-making. Decisions were discussed with other healthcare personnel if they were present. Relatives were involved when possible, and some decisions required physicians to try to help the patient understand, such as patients with mental health issues. The mission of MET B included, for example patients who experienced cardiac arrest and patients who died. During these missions, the MET took the time to talk about and support the relatives present and reassured them that the patient had not suffered.

The familiarity with handling the medications that METs carry varies. Nurses in the MET A were accustomed to administering the medications typically used in the ED, such as antibiotics, unlike those in the MET B. When questions and uncertainties arose regarding medications, which could concern how antibiotics should be diluted and administered, nurses consulted physicians, but they lacked practical knowledge. They then searched for information together on the internet or called the hospital’s ED for advice. On occasion, prescribed medication was not given because both the physician and the nurse lacked knowledge of how the medication should be administered.

Patient with suspected sepsis… the MET has called an ambulance… Physicians have ordered intravenous antibiotics. The nurse asks;… should we skip giving the antibiotics… the ambulance will be here soon? [Observation 42].

When multiple tasks needed to be performed, physicians could offer to administer medications. Since physicians were not familiar with the units containing medications and equipment, nurses had to interrupt their ongoing tasks to show the physician which unit the equipment was in and how it worked.

Patients who expressed insecurity about staying at home or being too ill were offered hospital care. The nurse arranged transportation to the hospital, assisted in moving the patient from, for example, the bed to the ambulance stretcher, and was responsible for filling out the journal sheet accompanying the patient to the hospital. The physician was responsible for documentation and contact with the receiving unit. When the physician had a probable working diagnosis and when there were available beds in the hospital wards, patients could be admitted directly. However, when there was a shortage of beds, which was common in MET A, or when the diagnosis was unclear, patients were transported to the hospital’s emergency department for further evaluation, treatment, and waiting for an available bed. The physicians were always documented in patients’ journals, while the extent of nurses’ routine documentation varied. The differences included nurses in the MET A documenting the reason for the visit, nursing status, entering test results, updating interventions from community care, and phone numbers for the patient and relatives in the patient’s hospital journal. MET B’s nurses documented by creating a case log in an ambulance journal, with reference to the physician’s notes in patients’ hospital journal.

The other healthcare providers with whom the METs collaborated with varied depending on the differences in the mission descriptions. Cooperation with municipal care was common, and physicians were responsible for handovers. MET visits often include takeovers, which could consist of newly prescribed medications, administration of antibiotics and intravenous fluids, as well as vital sign monitoring. There were regulations at certain special accommodations in MET B’s catchment area that governed, for example, the use of IV stands inside patients’ rooms. This resulted in the application rule being broken at the MET initiative when a patient needed intravenous fluids. The extent to which the prescribed medications were left varied. MET A left newly prescribed medications, either for the entire treatment period, which last up to 10 days, or for the first two to three days. Intravenous antibiotics were always left for the first day, then a follow-up visit was usually scheduled for the next day, or the patient could transition to oral treatment. In MET B, the first dose of antibiotics was given intravenously, and possibly the first tablet dose, with the remaining doses prescribed by the physician.

When the mission was considered completed, it was usually the nurse who sanitized the equipment and packed it. The MET usually said goodbye together and tried to restore the patient’s home to how it was when they arrived. Nevertheless, on occasion bright lights were forgotten to be turned off, the patient’s bed was not turned down, and that the patient would not become cold was not ensured. Usually, the nurses carried the equipment to the car, while the physician was responsible for the computer and printer and possibly the ultrasound on occasion.

Reflection and evaluation phase

The METs reflected on whether the mission had involved an ‘appropriate patient’ and considered whether additional examinations that the METs did not perform, such as X-rays, could have affected or improved the quality of care. Patient benefit was viewed as crucial, where the METs considered patients’ preferences alongside potential risks of staying at home, such as an increased risk of falling. The assigned missions often concerned patients who could be effectively treated at home, where a visit to the ED would not have added value.

The assignment involved a patient with addiction problems. The apartment was filled with cigarette smoke , with stacks of newspapers along the walls and personal belongings scattered everywhere. The MET had been contacted by home healthcare. The patient was not very responsive during the examination [Observation 9]. The doctor said; “The patient would have been sent to the ED if the MET had not assessed and treated the patient at home. However , an ED visit would not have made any difference to the patient’s outcome”. The nurse added: “I noticed he was so tired and lethargic… he seemed affected.” The physician responded , “…I had no thoughts of that at all” [Interview 9].

However, the METs also acknowledged that some missions required skills they did not possess, particularly in psychiatry. They expressed uncertainty about their role in certain missions and believed some were better suited for ambulance care, such as patients needing oxygen therapy. For patients requiring oxygen, the METs felt hospital care was necessary and that their involvement could delay treatment. Missions solely based on telephone assessments of patients’ needs were often considered less reliable compared to those assessed by licensed personnel on site. Patients’ emergency care needs varied, from requiring rapid hospital transport to care within primary care settings. The METs noted that some missions were not about providing home care but rather about optimizing ambulance resources, using methods like stretcher transport or a single-nurse ambulance. The METs agreed that in some cases, patients had waited too long for an ambulance and needed quicker intervention.

The METs expressed that within the team, there was an enabling and safe climate where they complemented each other and worked beyond professional boundaries, which they considered a strength. However, nurses sometimes felt that their skills were underutilized in missions that solely involved transporting physicians to patients. Nurses in the MET B group perceived ambiguity in their professional roles, while those in the MET A group experienced inequalities in task distribution. They expressed feeling responsible for multiple tasks, which could be time-consuming and challenging, such as checking vital signs, conducting tests, and addressing patients’ care needs, where they believed physicians could offer more support. The METs highlighted several strengths in teamwork, such as having one team member communicate with the patient to establish a strong connection and contribute different perspectives, with doctors focusing on the medical aspect and nurses on the care perspective. While the METs felt confident in the medical aspect, physicians found nursing tasks challenging, including assessing patients’ nutrition, elimination, personal hygiene, and fall risk assessment.

The mission involves an elderly patient in a nursing home with deteriorated general condition , diagnosed with dehydration by the time the MET leaves the patient [Observation 14]. On the way back , the nurse says; ”The patient resides in a facility , and it is not our responsibility to take over the facility’s duties. Since the patient did not express a desire for anything to drink , nursing interventions can be deprioritized in favor of other patients who are waiting [Interview 14].

The METs reflected on whether the decisions made were right or if they could have done things differently. Physicians in MET B viewed receiving many questions as positive because it prompted deeper thought. There was a clear need for confirmation among physicians during missions involving difficult-to-assess patients or making challenging decisions, such as end-of-life discussions and initiating palliative care orders. However, this need for confirmation was not always recognized by colleagues. Instead, nurses expressed concern about the lack of written information detailing the actions taken and the treatment plan implemented.

The results of the multiple case study indicate that physicians and nurses face several challenges in their daily work such as recurring interruptions, miscommunication and faltering teamwork. This can lead to stress, which not only exposes patients to unnecessary risks but also negatively affects physicians and nurses [ 37 ]. One way to attempt to understand and interpret the work systems within which physicians and nurses operate within is to investigate what happens within and outside the MET and how it can affect caregiving [ 29 ].

The results indicate that the MET could be interrupted multiple times during a patient visit by incoming calls regarding potential new patient assignments, ongoing consultations, or advisory calls from, for example, the AS. Additionally, as described in the assignment reception and preparation phase , MET B could be assigned to a critically ill patient. These interruptions could cause ongoing examinations to be disrupted and force physicians to start over, resulting in inefficient work. Constant interruptions can create feelings of losing control, leading to dissatisfaction and stress, which can result in burnout over time [ 38 ]. Emergency physicians and nurses are more frequently affected by burnout and emotional exhaustion [ 39 ]. Interruptions can negatively impact their ability to concentrate, potentially leading to inadequate or incorrect decisions regarding the care and treatment required for the patient’s condition [ 40 ]. In addition, the MET did not have necessary information such as access codes, and lacked knowledge about whether patients were carrying infectious diseases such as COVID-19 or gastroenteritis. Sometimes, the physician had received this information but had not shared it with the team. The failure to have such information exposed the MET to unnecessary risks of either contracting infections themselves or spreading them further. Previous research indicates, for example, that staff in AS are at greater risk of acquiring infections due to the uncontrolled environment in which they work [ 41 ].

Physicians were often the first to acknowledge the patient and would begin taking the medical history when MET arrived unless it involved a critically ill patient, which could be the case in MET B. On those occasions, as described in the patient interaction and examination phase , the physician took on a more withdrawn role. It was evident during the observations that the AS were accustomed to handling these situations and that the METs medical contribution was limited. Many patients who received care and treatment from the MET, especially MET B were elderly residents living in nursing homes. On several occasions, the MET expressed that these elderly patients were ideal candidates for emergency care at home, but also perceived that many of the visits would have been more appropriately managed by primary care. This is supported by previous research, which shows that emergency physicians and nurses perceived a lack of competence and insufficient involvement in patient care as contributing factors to AS being called out and the patient being transported to the ED [ 42 ].

During the examination, physicians might ask the nurse to measure vital signs, hand over a stethoscope, or remove the patient’s clothing to facilitate a more thorough examination This approach could be due by the fact that physicians working in EDs are accustomed to having limited time for gathering necessary information for making treatment and diagnosis decisions [ 43 ]. Medical history and examination results sometimes occurred simultaneously but could also occur separately. The questions asked were often open-ended, such as ”How are you feeling?” and ”Can you tell me why we are here today?”. Nurses often choose not to participate during the physician’s examination, as described in the patient interaction and examination phase . Instead, they prepared the lab equipment and carried out the physicians’ orders, acting as assistants. MET A, had more lab equipment to prepare than MET B, which could be time-consuming to unpack and set up. This withdrawn role that nurses sometimes adopted could lead to care becoming primarily medically focused, potentially overlooking patients’ comprehensive care needs. It is not surprising and not a new phenomenon that emergency care primarily has a medical focus [ 44 ]. Previous research shows that in EDs, there are deficiencies in both identifying and responding to patients’ fundamental care needs, such as nutrition, elimination, and fall prevention, which can lead to adverse events [ 45 ]. MET A was more likely to follow the ED’s routines and guidelines, such as documenting provided care and collecting blood cultures before administering intravenous antibiotics—a practice that was not followed at all in MET B. By adhering to these guidelines, MET A not only ensured compliance with established protocols but also enhanced patient safety. Guidelines are an essential tool for providing updated information and increasing the standard of [ 46 ]. In conclusion, while the medical focus in emergency care is undeniably important, integrating a comprehensive approach that includes adherence to guidelines is crucial, especially since this type of mobile care is primarily provided for frail elderly patients [ 25 ].

One way to increase patient safety and quality of care could be to work in teams [ 47 ] where collaboration is highly emphasized [ 25 ]. Collaborating is important in all care context, but is especially crucial in emergency care, where decision need to be made rapidly with limited information [ 48 ]. When emergency care is delivered in patients’ homes, MET face several challenges, including weighing the benefits and risks of providing care at home while also considering the patient’s wishes and autonomy [ 49 ]. The results of this multiple case study indicate that teamwork in the MET could be insufficient. Physicians and nurses had differing perceptions of the goal of the patient visit. A possible explanation for this could be a lack of sufficient communication between physicians and nurses. Nurses were not always involved when assignments were accepted, resulting in them having little or inadequate information when they arrived at the patients’ homes. During patient visits, physicians and nurses often worked separately, indicating a sequential working method, as described in the patient interaction and examination phase . A work system consists of several interdependent parts with various characteristics that rely on each other, making caregiving complex [ 29 ]. A sequential working method can thus contribute to unsynchronized, inefficient care, with risks for patient harm, such as missed nursing interventions or the failure to treat time-critical conditions according to standard protocols, such as early administration of antibiotics in suspected sepsis patients [ 50 ]. Another possible explanation for physicians and nurses working separately could be hierarchical structures within the MET. These hierarchical structures might have included ambiguities regarding professional roles and who was expected to be responsible for and carry out different parts of the healthcare work when identifying and meeting patients’ care needs [ 50 ]. In addition, previous research has highlighted the necessity of shared responsibility for patient care, which develops over time [ 51 ]. Another explanation could be that both METs were relatively new, involving a completely new way of working for which physicians’ and nurses were not trained for.

However, this study reveals that the phases described in the results can happen at any time and affect each other, underscoring the complexity the MET encounters when managing patients’ care at home. These factors, when combined, can negatively impact both care and patient safety [ 50 ] especially if the skills within the MET are not fully utilized. To address this, it is suggested that interprofessional simulation be implemented. This approach brings together different disciplines, allowing them to practice collaborative care in a controlled setting, which could enhance patient safety [ 52 ].

Strengths and limitations

A strength of this study is that it was conducted as a multiple case study, which is more compelling and robust than single case study [ 30 ]. Data also describe current phenomena in their real-world context, which is advantageous when the boundaries between the phenomenon and the context are unclear [ 30 , 32 ]. Another strength is that several approaches were used to gather data such as participant observations, short interviews and reflections. This enabled triangulation, which is a method used to explore complex phenomena that cannot be fully understood, with a single method or data source [ 53 ], can provide a broader and deeper understanding of physicians’ and nurses’ healthcare work in this hybrid form.

However, there are also some limitations to acknowledge. When the study was conducted, the METs were relatively new, which may have led to certain issues related to their ongoing development. To gain access to the research environments, gatekeepers were used. This can be seen as a weakness since gatekeepers are often key individuals within the organization with certain power, which may have influenced the participants to take part in the study to appease the chief. There were also differences in the number of observations between the METs. A reason for this was METs differed in missions and geographic catchment areas. The size of the area they served may have affected the number of completed observations due to the time they spent traveling between patients’ homes. Technical differences regarding the vehicles between the METs, as well as the inability to control incoming phone calls, may have resulted in important information being overlooked.

Finally, a limitation may be the professional role of the observer as a licensed nurse, which complicated maintaining the researcher role. On a few occasions, the first author had to abandon the observer role to assist with equipment and medication, which may have led to some data not being recorded. However, patient safety was a priority.

Conclusion & implications

This study highlighted the challenges physicians and nurses meet when a new service is launched in emergency care. The challenges include the expectation for physicians and nurses to collaborate in teams, ambiguity in job descriptions leads to inefficiencies and uncertainty. Moreover, physicians and nurses are not accustomed to working together, and team compositions change almost every shift. As a result, established work routines are difficult to maintain, requiring team members to constantly adapt to new colleagues and workflows.

It is also important to note that these challenges can contribute to increased stress levels among staff, which can negatively impact patient care. When there are deficiencies in communication and collaboration within the team, this can lead to mistakes or delays in care, exposing patients to unnecessary risks. To counteract these problems, it is crucial to invest in team training and to develop clear job descriptions and routines that support effective and coordinated teamwork. Team training can help reduce hierarchical structures by enabling physicians and nurses to feel that they can contribute, collaborate, and take responsibility, leading to a more dynamic and efficient work environment. By practicing reflection and feedback after completing assignments, a more inclusive and development-oriented environment can be fostered, which in turn can positively impact the care provided by METs.

In summary, the study shows that it is essential to place great emphasis on planning and preparation when introducing new forms of care such as MET. By ensuring that all team members are well-prepared and that there are clear structures and support in place, a more dynamic and efficient work environment that benefits both staff and patients can be created. This hybrid version of prehospital and intrahospital emergency care is a complement to traditional hospital care, ED, AS, primary and municipal care. This requires collaboration between different organizations and staff categories, where patients’ current needs and situations are the focus, without boundaries. Further research is needed to define or explain what MET entails or how it can be termed. Likewise, can physicians and nurses experience to meet patients emergency care needs at their homes provide valuable insights.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

Acknowledgements The authors would like to express their deepest gratitude to the physicians and nurses who participated in this study. It was a privilege to take part in your daily work as well to listening to your thoughts on the research topic.

No funding was received for conducting this study. Open access funding was provided by the University of Borås.

Open access funding provided by University of Boras.

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Åsa Falchenberg, Ulf Andersson, Gabriella Norberg Boysen, Henrik Andersson & Anders Sterner

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Contributions

Authors’ contributions The study design was proposed by ÅF, GNB, HA and AS. The observation and interview guide were designed by ÅF, GNB, HA and AS and the observations and interviews were performed by ÅF. The data analysis and interpretation of data was performed by ÅF and further was discussed with UA and AS. ÅF drafted the manuscript, and AS and UA substantively revised it. All authors read and approved the submitted version of the manuscript.

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Correspondence to Åsa Falchenberg .

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The study was approved by Swedish Ethical Review Authority in Stockholm (Approval Number: 2023-02186-01), and access to the research field was granted and formally approved by the managers of the participating facilities. All methods were carried out in accordance with regulations (e.g. Declaration of Helsinki). Other ethical considerations regarding data protection and data security were followed in accordance with the Swedish Data Protection Act.

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Falchenberg, Å., Andersson, U., Boysen, G.N. et al. Hybrid emergency care at the home for patients – A multiple case study. BMC Emerg Med 24 , 169 (2024). https://doi.org/10.1186/s12873-024-01087-7

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Received : 20 June 2024

Accepted : 09 September 2024

Published : 16 September 2024

DOI : https://doi.org/10.1186/s12873-024-01087-7

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