This article was downloaded by: [New York University] On: 16 February 2015, At: 23:35 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Behavioral Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vbmd20

Reliability and Validity of the Work-Related Strain Inventory among Health Professionals a

b

Dr Dennis A. Revicki PhD , Dr Harold J. May PhD & Dr Theodore W. Whitley PhD a

c

Battelle Medical Technology Assessment and Policy Research Center , Washington, DC, USA

b

Department of Family Medicine , East Carolina University School of Medicine , Greenville, NC, USA c

Department of Emergency Medicine Published online: 09 Jul 2010.

To cite this article: Dr Dennis A. Revicki PhD , Dr Harold J. May PhD & Dr Theodore W. Whitley PhD (1991) Reliability and Validity of the Work-Related Strain Inventory among Health Professionals, Behavioral Medicine, 17:3, 111-120 To link to this article: http://dx.doi.org/10.1080/08964289.1991.9937554

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions

Reliability and Validity of the Work-Related Strain Inventory Among Health Professionals

Downloaded by [New York University] at 23:35 16 February 2015

Dennis A. Revicki, PhD; Harold J. May, PhD; and Theodore W. Whitley, PhD

Thk article provides evidence from jive samples of different health professionals (family physicians, emergency medical technicians, hospital nurses, flight nurses, and emergency medicine residents)for the reliability and validity of the Work-Related Strain Inventory (WRSI). The inventory conskts of 18 items and was designed to measure perceptions of strain in occupational settings. Internal consktency reliability ranged from .85 to .90 and, as predicted, was correlated with the Maslach Burnout Inventory and m e m r e s of depression, role ambiguity, j o b satkfaction, and work-group functioning. When compared with different measures of depression symptoms (eg, Zung Self-Rating of Depression Scale, Center for Epidemiologic Studies Depression Scale), the Work-Related Strain Inventory was found to measure a different and independent construct. Thk inventory, a short, easily administered measure with good reliability, may be useful for appraking levels of work-related strain in behavioral and organizational models of the consequences of stress in different work environments. INDEX TERMS: health professions, occupational stress, psychometric characterktics, Work-Related Strain In ventoty

headaches, muscle tension, insomnia-and psychological complaints-depression, anxiety, helplessness. Consequences of work-related stress in the health professions include reduced job satisfaction, poor delivery of healthcare, reduced quality of care, absenteeism, somatic complaints, and mental health Organizational consequences include lower job satisfaction, deterioration in the quality and delivery of services, and inability to retain experienced personnel.. Recent research suggests that protracted job stress among healthcare workers may be a major factor in the poor delivery of health servand is also related to the development of negative, cynical attitudes toward patients."*" A number of scales have been used in studying occupational stress in healthcare work environments. Some of these scales are specific to a particular professi~n,'~-'~ others are more general. 1*4*15-17 Several questionnaires are designed primarily for use with hospital nurse^'^''^ and,

Reliable, valid measures of occupational stress and strain in the healthcare environment are needed to evaluate the possible negative effects of advances in medical technology, new configurations of health services delivery, inadequate staffing, and patient contact (eg, longterm care, hospice care). Stress resulting from workrelated frustrations may decrease morale, lower productivity, and lead to emotional withdrawal. Work-related frustrations and stress are exacerbated in professions that require constant and intense involvement with people. Individuals who experience chronic stressful circumstances have reported increases in physiological symptomsDr Revicki is with the Battelle Medical Technology Assessment and Policy Research Center, Washington. DC; Dr May is with the Department of Family Medicine, East Carolina University School of Medicine, Greenville, NC, where Dr Whitley is with the Department of Emergency Medicine.

111

Downloaded by [New York University] at 23:35 16 February 2015

WORK-RELATED STRAIN INVENTORY

although they are helpful in identifying relationships between stress and other variables, their usefulness is restricted to nurse populations. Maslach developed what is probably the most widely used human service stress inventory, the Maslach Burnout Inventory (MBI).I5 The instrument consists of 22 items, each of which requires two different kinds of responses. .The MBI measures perceptions of professionalclient or professional-patient interaction along three dimensions: emotional exhaustion, depersonalization, and personal accomplishment. A recent investigation of occupational stress in emergency medical technicians (EMTs), however, found that 28 of 269 (10.4%) respondents did not complete the MBI or made responses of questionable validity such as marking identical responses for all question^.'^.'^ One to 4% of respondents failed to complete the other scales in the study. Respondent questions and comments during the administration of the survey indicated that other EMTs may have experienced difficulty completing the MBI and probably provided invalid responses. The time required to complete the MBI also resulted in a number of complaints to one investigator (TWW). This article reports on the development, reliability, and validity of a new instrument designed to measure perceived strain associated with work in a variety of directservice health professionals. Work-related stress symptoms were evaluated for samples of family medicine residents and practicing physicians, hospital-based nurses, EMTs, flight nurses, and emergency medicine residents. The development of a reliable and valid occupational strain scale will make it possible to compare across different health professions, at different levels of training, experience, and practice location within these professions, and to explore causal models of work strain, mental health. and other work-related outcomes. METHOD

Work-Related Strain Inventory (WRSI)

The content of the WRSI was based on a review of the occupational stress and strain literature, interviews with physicians and nurses, and clinical observation. Initially, we constructed 45 statements to represent symptoms indicative of or associated with occupational strain in health and other professionals. We attempted to include items that represented individuals’ behavior or personal responses to stressors experienced in their work environment. To ensure generalizability across different health professions, we made items nonspecific to any particular occupational group.

112

The quality of construction of the WRSI was examined, using criteria developed by Edwards.% The initial scale was pilot tested using a sample of 82 physicians, nurses, and other health-related staff working in an ambulatory care center, and we then eliminated questions if there was apparent confusion or ambiguity, lack of response variability, or expressed qualification of an item. For initial studies of family physicians,” we used a 26item version of the scale called the Physician Stress Inventory (PSI). Further analysis of data from physicians=-” and hospital nursesz resulted in the 18-item WRSI (see Appendix). It uses a Cpoint response scale, ranging from Does not apply to me (1) to Does apply to me (4). WRSI scores are obtained by reversing the scores on the six positive items (2,4,8,9,11, and 15) and then summing all 18 items. Total scale scores for the WRSI may range from 18 to 72. The WRSI can be completed in 5 minutes. We completed five independent validation studies, using groups of family physicians, hospital nurses, and EMTs in North Carolina and national samples of flight nurses and emergency medicine residents. The sample, measures, and data-collection procedures will be discussed separately for each study. Table 1 summarizes the demographic characteristics of the five groups of health professionals. Family Physician Sample We sampled 460 residents, faculty, and community family physicians practicing in North The survey instrument we developed included the PSI, the Self-Rating Depression Scale (SRDS),% social support measures, and a social desirability scale. As noted above, the WRSI was derived from the items contained in the PSI. The SRDS is a diagnostic questionnaire designed to assess 20 common symptoms of depression. It has been used extensively in studies of depression in general community populations. The internal consistency reliability (coefficient alpha) was .84 for the physician sample. Social desirability was measured by an abbreviated version of the Marlow-Crowne Social Desirability Scale.27 The internal consistency reliability coefficient for this measure was .76. Social support w& measured using items derived from the Family Inventory of Resources for Management.28The social support scale was designed to assess family esteem and communication and family mastery and health. Internal consistency reliability coefficients for the family esteem and communication scale was .77, for the family mastery and health scale, .87; and for peer support, .73. In spring 1982, we mailed the survey instrument to the

Behavioral Medicine

REVICKI ET AL

physician sample; 65% of the sampled family physicians completed and returned the questionnaire. Respondents’ ages ranged from 26 to 73 years, with an average age of 44 years. Most were male, white, married, and had had residency training (68@/’0)(Table 1). Comparisons between the sample physician demographic characteristics and data available on the population of North Carolina family physicians indicated that the study sample was representative of family physicians practicing in the state .= Hospital Nume Sample

Downloaded by [New York University] at 23:35 16 February 2015

We sampled 400 hospital nurses during spring 1983.2J All the nurses were employed full time. Of those sampled, 278 completed a survey instrument containing the WRSI; the MBI, and measures of job satisfaction, workgroup function, role ambiguity, and mental health. Internal consistency reliability coefficients for the intensity scales of the MBI are .80 for personal accomplishment, .88 for emotional exhaustion, and .77 for depersonalization. Reliability coefficients for the frequency scales are .77 for depersonalization, .74 for personal accomplishment, and .% for emotional exhaustion. We adopted measures of job satisfaction, work group function, and role ambiguity from an organizational questionnaire used by Gray-Toft and A n d e r ~ o n .The ~ content of the instrument was based on interviews with hospital staff and on the Michigan Organizational Assessment Questionnaire.B The job satisfaction scale measures intrinsic and extrinsic satisfaction with work, and its internal consistency reliability was .88. The work-

group function scale measures perception of the cohesiveness and support in the work group (internal consistency reliability = .86). Role ambiguity was assessed by a 13-item scale with internal consistency reliability of .74. To measure life satisfaction, depression, and emotion$ insecurity, we included mental health scales from Williams, Ware, and Donald.m Internal consistency reliability coefficients were .88 for the depression scale and .88 for the emotional insecurity scale. Life satisfaction was assessed using one question requiring the nurse to report her or his general satisfaction with life. Ages of the nurses ranged from 20 to 62 years, with an average of 33 years. Most of the nurses were female, white, and married (Table 1); 70% had registered nurse degrees. The study group members were representative of nurses employed in the community hospital.

Emergency Medical Technician Sample We sampled rescue squads and emergency medical services representative of a 29-county health planning region’”’’ and developed a survey questionnaire that included the WRSI, Center for Epidemiologic Studies Depression Scales (CESD),32MBI, and measures of life satisfaction, job satisfaction, work-group function, and role ambiguity. The CESD is a self-report scale designed to assess depressive symptomatology in the general population.” Internal consistency reliability for the CESD was .87. A single-item life satisfaction scale was included. To assess EMT perceptions of job satisfaction, role ambiguity, and work-group function, we used the same organizational questionnaire used in the nurse study. Internal con-

Table I Demographic Characteristics of Health Professional Samples

N Age (years) M

SD Range Male (To) White (Vo) Married (Vo)

Family physicians

Hospital nurses

EMTs

EM residents

Flight nurses

2%

27 8

269

637

380

43.7 14.0 26-73 88

33.4 8.7 20-62 5 94 61

33.2 9.8 19-69 75 93 68

30.1 3.5 23-57 74

33.4 5.6 24-62 23

58

49

94 84

t

99

?Variable not included in study.

Fall 1991

113

Downloaded by [New York University] at 23:35 16 February 2015

WORK-RELATED STRAIN INVENTORY

sistency reliability for the job satisfaction scale was .88; for role ambiguity it was .67; and for work-group function, .88. During 1984, the questionnaire was administered to EMTs in 27 rescue units; and 50% of the EMTs working in the units” completed the forms. The average age of the EMTs was 33 years (Table 1); 75% were male; and the majority were married (68%), white (93Olo), and high school graduates (68%). Sixty percent possessed EMT Basic certification, and 37% had EMT Intermediate certification. Only 43% were paid members of emergency medical services. Comparisons between the sample demographic characteristics and available information on EMTs in eastern North Carolina suggested that the study sample was representative of EMTs working in this region. ”.” Flight Nurse Sample

In fall 1987, we mailed a questionnaire to 749 members of the National Flight Nurse Association.M Completed questionnaires were returned by 380 flight nurses, a response rate of 50.7%. The survey included the WRSI, the CESD, and a job satisfaction scale. The job satisfaction scale consisted of 25 items covering various aspects of the occupation of flight nurse, including adequacy of training, continuing educational opportunities, and participation in decision making. The internal consistency reliability coefficients for the CESD was .89, and for the job satisfaction scale it was .93. The majority of the flight nurses were white women (Table 1); their average age was 33 years (more than half were under 32); only 49% were married. Comparisons with available data on flight nurses’’ suggested that the sample was similar in education, experience, and demographic characteristics.

in their third year of residency. First-year residents made up only 13% of the sample, and were underrepresented. The small number of first-year residents was not unexpected because the survey was conducted soon after the standard July initiation of training. RESULTS Descriptive Statistics

Mean WRSI scores and standard deviations for the family physician, hospital nurse, EMT, flight nurse, and emergency medicine resident samples are shown in Table 2. Although the nurse scores were somewhat higher, mean WRSI scores were quite similar across the five groups. Except for the residents, average WRSI scores for men and women within the samples were not significantly different. The significant difference between the mean WRSI scores for the men and women emergency medicine residents was not large enough to be practically significant and was probably attributable to the large sample size. The sample ranges were 18 to 58 for hospital nurses, 18 to 62 for EMTs, 18 to 62 for emergency medicine residents, 18 to 69 for family physicians, and 18 to 72 for flight nurses. Age was significantly correlated with WRSI scores in three groups. There was a small negative correlation between age and WRSI scores. The correlation between age and WRSI scores was - .15 for hospital nurses, - .16 for EMTs, and - . 1 1 for family physicians. This suggested that older individuals were slightly more likely to report lower levels of work-related strain than were their younger peers. In the emergency medicine resident and flight nurse groups, age and WRSI scores showed correlations of - .04 and - .02, respectively.

Emergency Medicine Resident Sample

We surveyed members of the Emergency Medicine Residents Association by mail during fall 1987.%Six hundred thirty-seven residents returned the questionnaire. Some emergency physicians who were no longer residents were inadvertently included in the survey. The response rate for those surveyed was 60%. The questionnaire developed for the survey included the WRSI, the CESD, and previously described scales designed to assess role ambiguity, work-group function, and job satisfaction. The internal consistency reliability coefficient for the CESD was .91; for the role ambiguity scale, .58; for the work-group function scale, .83; and for the job satisfaction scale, .84. The majority of respondents were men and were married (Table 1). The average age was 30 years, with a range from 23 to 57 years; most (39%) were

114

Table 2 WRSI Means, Standard Deviations, and Reliability Group Family physicians Hospital nurses

EMTs EM residents Flight nurses

N

M

SD

rt

2% 278 269 637 380

34.19 36.25 33.69 30.33 30.95

10.03 8.70 9.09 8.72 9.32

.87 .90 .85 .86 .88

tlnternal consistency reliability.

Behavioral Medicine

REVICKI ET AL

Downloaded by [New York University] at 23:35 16 February 2015

Exploration of WRSI Factor Structure We performed factor analysis, with squared multiple correlations used as estimates of communalities, to examine the factor structure of the WRSI, using data from the family physician and hospital nurse samples. Although there was some evidence for three factors, they correlated from .44to .61, and similar correlations were found between the factor scores and MBI subscales and the measures of depression. Subsequent factor analyses of the EMT, flight nurse, and emergency medicine resident data failed to support any consistent factor structure after orthogonal or oblique rotation of two to five factor solutions. We concluded, therefore, that there was no fm evidence that meaningful subscales could be generated from the original WRSI items. Using data from the combined EMT, emergency medicine resident, and flight nurse samples, we performed a one-factor principal components analysis. Factor loadings ranged from .37 to .66,with a mean value of .55 and median of .58 (Appendix). Two thirds of the factor loadings were greater than .50. Although shorter versions of the WRSI could be constructed, they would not adequately cover the full range of symptoms of work-related strain included in the complete scale. Factor loadings are reported for each WRSI item to allow other investigators to explore shorter versions of the measure. Reliability The internal consistency reliability for the WRSI was greater than .85 in all five study groups, with a range from .85 to .90(Table 2). The magnitude of the alpha coefficients indicate that the WRSI is relatively homogeneous in content. Test-retest reliability was assessed over a 2-month interval, using a sample of 82 nurses, physicians, and other allied health professionals working in an ambulatory care clinic (ie, the pilot test group). The test-retest correlation equaled .63 (p < .01) for the entire group. The correlations by health profession were .69 for physicians, .62 for nurses, and .57 for other groups. The moderate retest correlation was expected because of the time interval between questionnaire administrations and fluctuations in individuals’ perceptions of occupational strain. Concurrent Validity The WRSI was correlated with other variables thought to be theoretically related to a measure of occupational strain. A number of different measures of the same constructs (eg, depression) were used in the validation studies. The hospital nurse and EMT samples were ad-

Fall 1991

ministered identical batteries of questionnaires to obtain some degree of cross validation across different groups of health professionals. It could be argued that WRSI scores were distorted because of a socially desirable response set, especially among groups of physicians.” To evaluate this possibility, we correlated WRSI scores with scores on an abbreviated version of the Marlow-Crowne Social Desirability Scale. The WRSI was not significantly correlated with the social desirability measure (r = - .09, p > .05). Correlations Between WRSI and Maslach Burnout Inventory Different instruments purporting to measure characteristics of perceived work-related stress or strain are expected to be strongly correlated. WRSI scores were therefore correlated with the subscale scores of the MBI. We found small-to-moderate correlations between the MBI scales and the WRSI (Table 3). A similar pattern of correlations was found for both the hospital nurse and EMT groups. Occupational strain, as measured by the WRSI, shared from 8% to 41% of the variance with the MBI subscales. The largest part of the variance in WRSI scores was not shared with the MBI, suggesting that the two instruments measured different attributes of the same related construct. Correlations Between WRSI and Organizational Variables A measure of work-related strain, to be useful, should be related to important individual-level variables in the work environment. Previous studies of the relationships between organizational characteristics, individual perceptions, and occupational stress in hospital nurses,’*25 E M T S , ~ * ~and ~ ~ other * ” ~ c c u p a t i o n swere ’ ~ ~ used to iden-

Table 3 Correlations Between WRSl and MBI Scores

Hospital nurses

EMTs

Emotional exhaustion

.64

Depersonalization Personal accomplishment

.45

.63 .52

- .28

-

.m

All correlations are at the level of p < .05.

115

WORK-RELATED STRAIN INVENTORY

Downloaded by [New York University] at 23:35 16 February 2015

tify critical variables. The data in Table 4 summarize the correlations between the WRSI and measures of role ambiguity, work-group function, and job satisfaction. We found moderate negative correlations between the WRSl and work-group function and job satisfaction. As expected, there were moderate correlations between the occupational strain scale and role ambiguity for emergency medicine residents, EMTs, and hospital nurses. All correlations were in the expected direction, according to previous research by investigators such as Gray-Toft and Anderson3 and Kahn and colleague^.^

medicine residents, and flight nurses, and a brief depression scale in hospital nurses. Only 20% to 45% of the variance in WRSI scores was shared with the depression measures. This finding suggested that the WRSI may be tapping a construct that is related but not equivalent to depressive symptomatology. Individuals reporting a greater number of indicators of occupational strain also tend to report a greater amount of depressive symptoms. No causal inferences are implied in these correlations. Increased depression may cause increased perceptions of strain, or occupational strain may induce depression. To establish the validity of the WRSI, we had to examine further the correlation between the WRSl and the depression measures. It is likely that there was a substantial overlap between what was assessed by the WRSI and what was measured by the depression scales. This overlap was mainly due to the consideration of perceptions of strain as possible symptoms of Because of the magnitude of this correlation, it was necessary to demonstrate that the two scales were not measuring the same construct. To accomplish this, we computed partial correlations, using data from each validation study. In the family physician study, depression was partialled out of the correlation between WRSI and family social support. Conversely, WRSI was partialled out of the correlation between depression and family social support. For WRSI and family social support, the correlation was - .18 (p < .05); for depression symptomatology and family social support, the correlation was - .38 (p < .05).

Correlations Between WRSI and Psychological Symptomatology Additional validation of the WRSI is provided by distinguishing it from measures of psychological constructs that may be confounded with occupational strain such as depression. The correlation between WRSl scores and life satisfaction was negative (hospital nurses, r = - .46, p < .001; EMTs, r = - 30,p < .001). Emotional insecurity, as measured in the hospital nurse validation study, was moderately correlated with the WRSI (Table 5). We expected that the WRSI would be correlated with measures of depression, but that these correlations would not be so large as to question its independence. The data in Table 5 confirm this prediction for depressive symptomatology. Significant, moderate correlations were found between the WRSI scores and the SRDS in family physicians, the CESD in emergency technicians, emergency

Table 4 Correlations Between WRSI and Work-Related Variables

Work group function

Group

Work-related variable Job satisfaction

Role ambiguity

~

Hospital nurses

rt

EMTs

‘PS 1

Flight nurses

EM residents

‘P 1 P ‘ 1 P ‘

-

.32

- .22 -

.34 .23

- .48 - .35

.45

.44

- .35

.25 .49 .23

-

.31 .26 - .55 - .40

-

-

.55 - .41 -

-

.56 .37

tPearson product-moment correlation coefficient. $Partial correlation coefficient adjusting for depression VP). All correlations are at the level of p < .05. I

116

Behavioral Medicine

REVlCKl ET AL

was 27%. The percentage of flight nurses reporting mild-

Table 5 Correlations Between WRSI and Psychological Symptomatology

Depression

Downloaded by [New York University] at 23:35 16 February 2015

Family physicians Hospital nurses EMTs EM residents Flight nurses

Emotional security

.45 .51 .58 .56

.58 -

.67

-

-

All correlationsare at the level of p < .05.

Therefore, despite the moderate correlation between depression and the WRSI, both scales remained significant, independent predictors of family social support. Identical subsets of variables were used for the partial correlation analysis, using the hospital nurse and EMT samples. Depression was partialled out of the correlation between the WRSI and role ambiguity, and the WRSI was partialled out of the correlation between depression and role ambiguity. The WRSI remained strongly correlated with role ambiguity, even after controlling for the depression measure (Table 4). The correlation between depression and role ambiguity was reduced from .30 to .07 for hospital nurses and from .36 to . I 1 for EMTs after the WRSl was partialled out. Depression was partialled out of all of the correlations between the WRSI and job satisfaction and work-group function in the hospital nurse, EMT, emergency medicine resident, and flight nurse samples (Table 4). In each case, the partial correlation was slightly attenuated but still remained significant. For example, in EMTs, the correlation between WRSl scores and job satisfaction was reduced from -.31 to -2. The measures used in all five studies were obtained by self-report and may, therefore, reflect bias in reporting and contamination of the different variables. It is likely that physicians and other health professionals knowledgeable about depressive symptomatology may underestimate or fail to report depressive symptoms. We believe that this is not the case because 5% of the physicians reported symptoms in the clinically depressed range, based on the Zung SRDS, and 30% reported symptoms consistent with mild-to-moderate depression. The proportion of EMTs endorsing depressive symptoms

Fall 1991

to-moderate depression was 21070, and of emergency medicine residents was 31%. These percentages were comparable to those found in studies of depression in the general community-dwelling pop~lation.~'

DISCUSSION The WRSI has acceptable internal and test-retest reliability. It is correlated in the expected direction and magnitude with a variety of self-report measures. The WRSI is related to another occupational stress questionnaire, the Maslach Burnout Inventory. The WRSI is easier to complete than the MBI, equally reliable and valid, and correlated as strongly with measures of mental and physical health. Although the WRSI is moderately correlated with different measures of depressive symptomatology, it was demonstrated to measure a different and independent construct. The WRSI was correlated .45 to .67 with measures of depressive symptomatology, providing a somewhat stronger relationship than that reported for life event scores.4*~43 The correlations were of similar magnitude to those found by Cohen, Kamarck, and MermelsteinNbetween the Perceived Stress Scale and the CESD (r = .65-.76). As previously noted, these correlations may be inflated because of some similarity in the operational def. ~ ~ WRSI has been inition of stress and d e p r e s s i ~ n The used successfully in three studies that tested two different theoretical models of the structural relationships between occupational strain and mental Revicki and M a p used the WRSI in a sample of family physicians to operationalize work-related strain. The relationships among strain, social support, and depression were explored. The findings indicated that occupational strain exerted a direct effect on depression. This relationship was moderated by family social and emotional support and, indirectly, by the influence of locus of control on family social s u ~ p o r t . ~ Using samples of hospital nurses and EMTs, Revicki and his c o U e a g ~ e s studied ~ ~ ~ ' the relationships between organizational characteristics, occupational strain, and mental health. In both organizational settings, role ambiguity is a critical intervening variable between supervisory practices, work-group support, and work-related strain. The findings suggest that both EMTs and hospital nurses are more satisfied with their jobs, and subsequently less depressed, in a work environment that encourages open expression and group problem solving. This kind of environment results in increased co-worker support in the unit (eg, hospital work, rescue squad), reduction in role conflict and ambiguity, and decreased

117

WORK-RELATED STRAIN INVENTORY

The perception of occupational strain and depres~ion.~*” results of the hospital nurse and EMT investigations provide additional confirmation of previous studies of organizational stress. Work-related strain among healthcare professionals is influenced by several factors. Physicians and nurses often function in an atmosphere of acute as well as chronic stressors. Most individuals entering healthcare fields have high expectations of their ability to work with and to help others. The job stress inherent in many healthcare disciplines, plus the expectations of achievement and motivation exhibited by many professionals, may contribute to occupational dysfunction or impairment. In developing the Work-Related Strain Inventory, we attempted to add conceptual clarity to the measurement of occupational strain among healthcare providers. Results of this investigation suggest that strain experienced by healt hcare providers involves a multidimensional cluster of factors that includes both internal dissatisfaction (eg, irritability, frustration, disengagement) and external devaluation (eg, lack of support, recognition). In addition, the perception of declining productivity and decreased contribution is clearly associated with heightened perceptions of stress or strain. It appears that the health professional experiencing job-related pressures may feel emotionally drained and less productive, while perceiving increased distance or isolation from co-workers. Both the WRSI and the MBI identify a fundamental theme of emotional distance or exhaustion. The affective impact of occupational strain probably constitutes the central mechanism of this constellation of symptoms. It is not surprising that depression scores correlated positively with scores on both instruments and accounted for roughly 20% to 45% of the variance in WRSI scores. Martin4 has recently questioned whether job stress is simply a disguised form of clinical depression. Although the findings of this study suggest a higher probability of depression among individuals with higher scores on the WRSI, work-related strain appears to be an affective phenomenon with a composition different from that of clinical depression. The WRSI and the MBI both appear to indicate that individuals who report increased occupational stress tend to devalue their personal accomplishment and professional productivity. This devaluation of one’s productivity seems to imply a cognitive element, work-related strain. L a z a r ~ s discussed ~ ~ * ~ the role of perception and individual appraisal in stressful situations; results of this study support this cognitive model and suggest the presence of negative self-appraisal as a central element in occupational strain. Certainly, job stress among health professionals does

Downloaded by [New York University] at 23:35 16 February 2015

’*‘

118

not occur in isolation from peers or colleagues. In fact, this analysis indicates that with increased levels of work strain, co-worker relations may also become strained or viewed as not supportive. Recognition by peers is clearly a significant factor in occupational strain; as strain increases, health professionals may sense a decline in support from others or perceive the work contribution of colleagues as not matching their own. This interpersonal aspect of occupational strain underscores the importance of peer relationships as a significant index in monitoring job performance and the self-assessment of levels of work-related stress. Further investigations using the WRSI should attempt to broaden the population base of the instrument by including such other allied health professionals as emergency room physicians, physical and occupational therapists, respiratory therapists, medical social workers, and laboratory technicians. It may be useful to determine whether the intensity or frequency of patient care and patient contact in different occupations or healthcare settings is related to perceptions of occupational strain. By determining differential patterns of work-related strain among a broad range of health occupations, more tailored intervention strategies aimed at prevention or remediation may be designed. In conclusion, the WRSI is a short, easily administered measure of perceived occupational strain in health professionals and other groups. It has been demonstrated to have good reliability and adequate validity across five different groups of health services personnel. The WRSI may therefore prove to be a useful instrument for appraising levels of perceived occupational strain and examining work-related strain in behavioral and organizational models of the consequences of stress in healthcare environments. APPENDIX The Work-Related Strain Inventory (WRSI) Factor loading

Individual I . Work interferes with family life ( - ) 2. My initial job expectationsare being realized ( + ) 3. I am more than I used to be ( - ) 4. I am still the contributor I used to be ( + ) 5 . I occasionally hide in my office in order shut out others ( - ) 6. It seems like I cannot get the recognition that I deserve ( - ) 7. I feel guilty when I cannot completely understand my patients or clients ( - )

.55 .62 .62 .45

.44 .60 .48

Behavioral Medicine

REVICKI ET AL

Downloaded by [New York University] at 23:35 16 February 2015

8. Colleagues at work d o contribute their fair share(+) 9. My productivity has increased ( + ) 10. My responsibilities are much different than 1 had anticipated ( - ) 11. My professional growth and skills are continuing ( + ) 12. My preoccupation with work makes it hard t o disengage from the job at home ( - ) 13. I often feel that others are out to take advantage of me ( - ) 14. Arguments at home with those close to me have increased recently ( - ) IS. I rarely daydream at work ( + ) 16. I am working harder but getting less done ( - ) 17. Support for my contribution at work has been consistently lacking ( - ) 18. I often arrive late for work ( - )

.62

fessions. In: Sanders G, Suls J, eds. Social Psychology of Health and Illness. Hillsdale, NJ: Lawrence Erlbaum; 1982.

.63 .42

I I. Wills TA. Perceptions of clients by professional helpers. Psychol Bull. I975 ;85~9681OOO. 12. Gray-Toft P, Anderson JG. Stress among hospital nursing staff: Its causes and effects. Soc Sci Med. 1981;15:639-647.

.64 .58

.37 .45 .52 .61 .58

.66

Nores: The items with a positive sign ( + ) need 10 be reverse scored. Factor loadings are from a I-factor principal components analysis; n = 1,345.

ACKNOWLEDCMENT The survey of family physicians was supported by the Family Health Foundation, the survey of flight nurses was supported in part by the National Flight Nurses Association, and the survey of emergency medicine residents was supported in part by the American College of Emergency Physicians. The authors thank the three organizations for their assistance.

NOTE For further information or reprints, get in touch with Dennis A. Revicki, PhD, Battelle Medical Technology Assessment and Policy Research Center, 370 L'Enfant Promenade, SW, Suite 900, Washington, DC 20024-21 IS.

REFERENCES 1. Caplan RD. Cobb S, French JRP, et al. Job Demands and Worker Health. Washington, DC: US Department of Health, Educa-

tion and Welfare, HEW Publication No. (NIOSH); 1975. 2. Cartwright LK. Sources and effects of stress in health careers. In: Stone GC. Cohen F, Adler NE, eds. Health Psychology. San Francisco: Jossey-Bass; 1979. 3. Gray-Toft P , Anderson JG. Organizational stress in the hospital: Development of a model for diagnosis and prediction. Health Serv Res. 1985;19:753-774. 4. Kahn R. Wolfe D, Quinn R. et al. Occupational Stress. New York: John Wiley; 1984. 5. LaRocco JM, House JS, French JRP. Social support, occupational stress and health. J Health Soc Eehav. 1980;21:202-218. 6. Locke EA. The nature and causes of j o b satisfaction. In: Dunnette MD, ed. Handbook of Industrial and Organuational Psychology. Chicago: Rand McNally; 1976. 7. Price JL. Mueller CW. Professional Turnover: The Case of Nurses. New York: Spectrum; 1981. 8. Freudenberger H. Staff burnout. J Social Issues. 1974;30:159165. 9. Maslach C. Burned-out. Human Behavior. 19776;s: 16-22. 10. Maslach C, Jackson SE. The burnout syndrome in the health pro-

Fall 1991

13. Gray-Toft P , Anderson JG. The Nursing Stress W e : Development of an instrument. J Eehav ASWSS.1981;3:11-23. 14. Numerof RE, Abrams MN. Sources of stress among nurses: An empirical investigation. J Human S t m . 1984;10:88-100. IS. Maslach C. Jackson SE. The measurement of experienced burnout. J Occup Eehav. 1981;2:9-113. 16. House JS, McMichael AJ. Wells JA, et al. Occupational stress and health among factory workers. J Health Soc Eehav. 1979;u): 139- 160. 17. Quinn RP. Staines GL. The 1977 Quality of Employment Survey. Ann Arbor, Michigan: University of Michigan; 1979. 18. Allison EJ Jr, Whitley TW, Revicki DA, et al. Specific occupational satisfaction and stresses that differentiate paid and volunteer EMTs. Ann Emerg Med. 1987;16:676-679. 19. Whitley TW. Revicki DA. Allison EJ Jr, et al. The rural EMT and work-related stress. Emergency Medical Services. 1988;17: 61-64. 20. Edwards A. Techniques of Attitude Scale Construction. Englewood Cliffs. NJ: Prentice Hall; 1957. 21. Revicki DA, May HJ. Development and validation of the Physician Stress Inventory. Family Practice Research J. 1983;2:21 I 218. 22. May HJ, Revicki JA, Jones JG. Professional stress and the practicing family physician. South Med J. 1983;76: 1273-1276. 23. May HJ, Revicki DA. Professional stress among family physicians. J Fam Pract. 1985;20:165-171. 24. Revicki DA. May HJ. Occupational stress, social support, and depression. Health Psychol. 1985;4:61-77. 25. Revicki DA, May HJ. Organizational characteristics, occupational stress, and mental health in nurses. Eehav Med. 1989;15: 30-36. 26. Zung W. A self-rating depression scale. Arch Gen Psychiatry. 1%5;12:63-70. 27. Strahan R, Gerbase K. Short homogeneous versions of the Marlow-Crowne social desirability scale. J CIin Psychol. 1972;28: 191- 193. 28. McCubbin H, Patterson J. Systematic Assessment of Family Stress, Resources, and Coping: Tools for Research, Education and Clinical Intervention. St. Paul, Minnesota: Department of Family Social Science, University of Minnesota; 1981. 29. Camman C. Fichman M, Jenkins GD, et al. Assessing the attitudes and perceptions of organizational members. In: Seashore SE, Lawler EE. Mirvis PH, et al, eds. A m s i n g Occupational Change: A Guide to Methods. Mecrrures, and Practices. New York: John Wiley; 1983. 30. William AW, Ware JE. Donald CA. A model of mental health, life events, and social supports applicable to general populations. J Health Soc Eehav. 1981;22:324-336.

31. Revicki DA. Whitley TW, Landis SS, et al. Organizational characteristics, occupational stress and depression in rural emergency medical technicians. J RUM/Health. 1988;4:73-83. 32. Radloff LS. The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement. 1977; 1 :385-401.

119

WORK-RELATED STRAIN INVENTORY

33. Williamson JE, Landis SS, Allison EJ Jr. The evolution of a rural EMT-Intermediate training program. NC Med J. 1983;44:737742. 34. Whitley TW. Benson NH, Allison EJ Jr. et al. Occupational stress and job satisfaction among flight nurses: A survey of National Right Nurses Association members. Hospiral Aviarion. 1989;8:6-8. 10-11. 35. Batterman K, Markel N. Profile of a flight nurse. Aeromedical Journal. 1986; 1:26-28.

Downloaded by [New York University] at 23:35 16 February 2015

36. Whitley TW, Gallery ME, Allison EJ Jr. et al. Factors associated with stress among emergency medicine residents. Ann Emerg Med. 1989; 18: 1157-1 161. 37. McCue JD. The effects of stress on physicians and their medical practice. N Engl Med J. 1982;306:458-463. 38. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Healrh Soc Behav. 1983;24:385-3%. 39. Dohrenwend BS. Krasboff L, Askenasy AR, et al. Exemplification of a method for scaling life events: The PER1 Life Events

STRESS IN CONTEMPORARY LIVING FOURTH INTERNATIONAL CONFERENCE ON

TWELFTH INTERNATIONAL CONFERENCE ON THE SOCIAL SCIENCES AND MEDICINE

STRESS

PEEBLES HOTEL HYDRO PEEBLES, SCOTLAND SEPTEMBER 14-18, 1992

MANAGEMENT /ash ISMA

Kw PIERRE E T MARIE CURIE UNIVERSITY PARIS, FRANCE SEPTEMBER 1-5 1992 Sponsored by

INTERNATIONAL STRESS MANAGEMENT ASSOCIATION Head Office & UK Branch: The Priory Hospital, Priory Lane, London SW15

Information and registration forms are available in the United States from F. J. McGuigan, Institute of Stress Management, USIU, 10455 Pomerado Road, San Diego, CA 92131.

120

Scale. J Health Soc Behav. 1978; 19:205-229. 40. Gore S. Stress-buffering functions of social supports: An appraisal and clarification of research models. In: Dohrenwend BS, Dohrenwend BP. eds. Stressful Lge Events and Their Contexrs. New York: Prodist; 1981. 41. Boyd J H , Weissman MM. The epidemiology of affective disorders: A reexamination and future direction. Arch Gen Psychiatry. 1981;38:1039-1046. 42. Rabkin JG, Stuening EL. Life events, stress, and illness. Science. 1976; 194: 1013-1020. 43. Tausig M. Measuring life events. J Healrh Soc Behav. 1982;23: 52-64. 44. Martin MJ. Burnout: Fact or fad? Psychosomatics. 1982;23:461. 45. Lazarus RS. Psychological Stress and the Coping Process. New York: McGraw-Hill; 1966. 46. Lazarus RS, Launier R. Stress-related transactions between person and environment. In: Pervin LA, Lewis M, eds. Perspectives in Interactional Psychology. New York: Plenum; 1978.

Themes to be discussed include Assessment of outcomes of health interventions Changes in disease patterns Concept of risk and risk-taking in healthcare and health behavior Dying with dignity Effects of family position and status on health Ethical and legal issues in substance abuse and control Health and social problems of refugee? For further details and application forms, write to Dr P. J. M. McEwan, Glengarden, Ballater, Aberdeenshire AB 35 5 UB Scotland.

Behavioral Medicine