Child Care in PracticeVol. 10, No. 3, July 2004, pp. 213–224
Causes and Alleviation ofOccupational Stress in Child CareWorkKarola Dillenburger
Occupational stress in not a new phenomenon in the working population. However, inthe helping professions it has only recently attracted attention. The survey reported herewas carried out in order to assess the extent of occupational stress, identify its causes, andsuggest ways in which occupational stress can be alleviated. Field social workers workingin family and child care services took part in this study. The questionnaire devised forthis survey included the General Health questionnaire. The findings showed that socialworkers experience more stress than would be expected in the general population.Consistent with a Demand–Control–Support model, this was mainly caused by highworkloads, high staff turnover, and insufficient leadership and support.
Introduction
The debate as to whether stress enhances performance or infringes upon it has a longhistory (Jamal & Baba, 2001). Some have thought that in general “… there is nothingwrong with stress” (Blundell, 1990, p. 16), that the body is able to respond totemporarily stressful situations quickly—for example, to avoid threat or danger—and that these situations actually ensure that people give their best. However, therecent upsurge in attention given to occupational stress in child care work indicatesthat things are not just as straightforward as that.
A number of questions have been raised. For example, one may ask whystress-related issues have received so much attention recently. Was it simply thatpeople in the past were oblivious to stress or was the shift in perspective due to the“sources” of occupational stress; in other words, has the working environment inwhich child care workers find themselves changed in a way that makes child carework more stressful today than it has been in the past? Is increased attention due to
Karola Dillenburger Senior Lecturer, is from the School of Social Work, Queen’s University of Belfast.Correspondence to: K. Dillenburger, School of Social Work, Queen’s University of Belfast, 7 Lennoxvale,Belfast BT9 5BY, UK. Email: [email protected].
the focus on the “effects” of stress; that is, do the effects of stress cause moreproblems today (Lu, Kao, Cooper, & Spector, 2000)? Is it that stress has become tooexpensive? For example, in the USA the cost of stress was estimated in the region of3.5% of the gross national product (Gibson, McGrath, & Reid, 1989).
Furthermore, we have to see how the service delivery; in other words, therelationship between clients and workers is affected by the increasing levels of stress.How does coping with stress affect the worker? Do the coping and adjustmentprocesses themselves pose inherent demands and cause additional stress (Mudrack &Naughton, 2001)? Finally we have to ask what we can do in order to reduce stresslevels in child care work so that people who are dedicated to human service work canmaintain satisfactory levels of professionalism and gain increasing levels of jobsatisfaction.
The Effects of Stress
The main reasons why occupational stress has been identified as a disruptivephenomenon can be found in its various manifestations. As the central measure inthe assessment of stress has to be the behaviour of the worker in the context ofhis/her agency, distressed behavioural patterns have to be viewed as the key measuresof stress (Kaplan, 1990).
Behavioural patterns such as low work morale, high number of bed-disability daysand institutional confinement, high staff turnover, high absenteeism, and ineffectiveservice delivery can easily be identified and assessed. When these patterns are givenmore detailed attention one may find that the individual worker experiences deficitson three levels: motor behaviour, emotional behaviour, and physical health (Table1).
An accumulation of these symptoms can lead to social isolation, marital/personalbreakdown, insomnia, neuroses, and even heart disease. Kaplan (1990) and others(cf. Hobson & Delunas, 2001) argued that attention has to be given to these typesof behavioural patterns of ill-health because the life expectancy of individualsexposed to stressful contingencies may be shortened, the quality of their life may becompromised, either now or at some time prior to death, or a combination of thetwo may be experienced. This has been recognised in Japan where relieving stress has
become big business. The Japanese even have a word for death from overwork:“karoshi” (McGill, 1991). However, the Labour Ministry in Japan accepted only 29out of 676 cases of death from overwork as eligible for compensation in one year.
These types of behaviour patterns have been labelled “burnout”. “Burnout isgenerally defined as a stress syndrome characterised by emotional exhaustion, cynicalor depersonalised attitudes to clients, and low self evaluation in terms of workaccomplishment” (Reid, 1990, p. 31). Professionals in helping professions are pri-marily affected by burnout because they tend to experience themselves as contribut-ing much more than they get back from their clients, supervisors, and colleagues(Gibson et al., 1989; Rafferty, Friend, & Landsbergis, 2001).
Although a label usually simplifies matters, the term burnout is problematic. Notonly does it have connotations of finality, there are also problems in definition of theterm. In the present context the term “stress” is preferred. The behaviour that canbe observed when a person is said to experience stress is viewed as a process, whichmay, however, progress in time to cause chronic health outcomes.
The Causes of Stress
While it is important to recognise the effects of occupational stress, it is even morecrucial to identify its causes in order to seek alleviation from stress. An obviousstarting point is the development of a clear concept and definition of occupationalstress. What do we actually mean when we use the term “occupational stress”?Lazarus (1966) identifies stress in situations when the demands on the person eithertax or exceed his/her personal resources. He emphasises two important concepts: (1)individuals strive to maintain a state of emotional equilibrium, and (2) individualssubjectively appraise each event in relation to its potential stressor.
In this sense, occupational stress may be regarded as the outcome of a mismatch(or imbalance) between a person’s skill and abilities and the demands encounteredby the job. In keeping with the Demand–Control–Supply model, work that presentshigh demands, little decision autonomy, and low support reduces health andwell-being (Van der Doef & Maes, 1999). As a person appraises a situation asharmless, challenging, or threatening, he/she also appraises his/her ability to copewith any situation adequately. If he/she concludes that he/she is not able to cope,he/she experiences stress (Houkes, Peter, Janssen, de Jonge, & Nijhuis, 2001).
The notion of “appraisal” was more recently replaced with the concept of“perception” (Reid, 1990). It was proposed that occupational stress occurs if animbalance is experienced between “perceived” demand and “perceived” capability. Inboth cases the personal assessment of the situation by the worker was viewed as thestarting point for gauging the level of stress experienced. In summary, it can be saidthat the notion of stress as being caused by the perception of imbalance promotesthe following definition of occupational stress: “Stress arises as a consequence ofdiscrepancy between individual worker expectations and the experienced reality ofthe work situation” (Reid, 1990, p. 39).
Although this concept incorporates an appreciation of the person’s interaction
with the environment to some degree, it places the origin of stress inside theindividual (Eriksen & Ursin, 1999; Jimmieson, 2000). This view poses seriouslimitations for the identification of those factors that are responsible of the stress inthe first place (Dillenburger, 2000). That is, labelling a group of symptoms asindicators of stress is to be viewed as only the starting point for the identification ofthose factors that are responsible for this bodily condition. It also follows from thisperspective that it is mistaken to view a person’s perception of a situation as a directcause of stress when in fact their perception and the experience of stress are the endproducts of a series of interactions with their environment (Burke, 2001).
If the emphasis is put on delineating those behaviours (including feelings andthoughts) that are shaped by individuals’ exposure to certain environmental condi-tions, an explanation is to be found outside of individuals in terms of the systemiccontingencies that collectively define their historical and current context. Historicalcontext refers to what is usually called the individuals’ “learning history” (i.e. all pastexperiences that arise from interactions between the individual and his/her environ-ment), while current context refers to the contingencies presently operating. Bysuggesting that stress is an entity that is inside a person (as opposed to a process),the term “stress” is not properly conceived as a label for a pattern of behaviours.Given that stress behaviours are a function of the environmental context, the mainfocus of concern should be in finding out what actually goes on in the workenvironment.
From this analysis it is clear why some people perceive a situation as stressful thatothers do not. People’s learning histories and their current context determine theirperceptions of the situation. The young inexperienced child care worker, forexample, may feel stressed at the time of her first house call, while the experiencedchild care worker may even look forward to the challenge of a difficult case; thefemale child care worker may feel sexually harassed by a certain member of staff,while her male colleagues may enjoy his company. It also becomes clear why somecontexts are responsible for stress-related behaviour outcomes in almost all people,especially if they are exposed to them for an extended time period. Many of thecontingencies operating in child care, particularly in child protection work, havesuch effects.
If we are to alleviate the detrimental effects of occupational stress on child careworkers, their clients, and agencies, we have to identify those contexts responsible fortheir emergence. In the main attention has to be focused on three areas (adaptedfrom Handy, 1985).
1. Nature of work and social context:Clients and their problems.Community/public/social attitudes.Conflict and ambiguity.Reorganisation.Economic factors.Legislative factors.
2. Occupational and management issues:Leadership and management styles.Interpersonal relationships.Training issues.Organisational factors.
3. Individual factors:Personal standard.Worker’s commitment.Individual involvement.Availability of positive feedback.Fear or reality of attack.
Depending on the interaction between these factors, individuals exposed to themexperiences different levels of stress. It therefore is important to identify thosecomponents that are part of the experience of occupational stress. The studyreported here addresses this issue under three main headings: (1) the actual levels ofstress as experienced by child care workers, (2) the contexts responsible for the stressexperience (work related and personal), and (3) changes necessary in these contextsin order to alleviate stress.
Methodology
Participants and Setting
Sixteen social workers took part in this study. They were employed in three statutorychild care teams, all with a similar small town and rural client group. The work focusvaried slightly: one team concentrated mainly on short-term work, the other onlong-term work, and the third team worked with both long-term and short-termcases. One-quarter of the participants had been qualified for less than one year; theremainder for longer, with nearly one-half of the workers qualified for over fiveyears. One-quarter of the sample was male and three-quarters female. Nearlyone-half of the sample was younger than 35 years old; the remainder were older,with two workers aged over 50 years of age. In terms of marital status, participantswere equally divided between single and married people.
Instrument
The study was based on a questionnaire that included three sections. Section 1,following a short introduction to the questionnaire, posed some demographicquestions and questions regarding the workers’ attitudes towards their job and childcare work in general. Some open questions were included in order to establish thepersonal opinion of the respondents regarding the circumstances that caused stressin their work situation and ideas about what may alleviate stress for them.
Section 2 was presented in the form of rating scales. In the first part of this sectionrespondents were asked to rate causes of stress on a three-point scale, concentrating
218 K. Dillenburger
on stress levels experienced in connection with a number of job-related as well asprivate issues. In the second part, respondents were asked to indicate how, in theiropinion, stress can be alleviated by ticking the appropriate answers from a list ofpreviously established factors (adapted from Gibson et al., 1989).
In order to establish more objective and comparable data, Section 3 comprisedGoldberg’s (1978) General Health Questionnaire (GHQ). The GHQ has been vali-dated against a standardised psychiatric interview in community settings and iswidely used (Cairns & Wilson, 1984; Dillenburger, 1992). In the analysis, thefour-way responses were coded in a bi-modal scale and Goldberg’s (1978) thresholdof 4/5 was used to identify workers that experience “just significant clinical disturb-ance” (p. 26).
Procedure
The questionnaire was applied separately in each of the participating teams. Afterweekly team meetings participants remained seated in the room where the teammeeting had taken place. The researcher briefly introduced the questionnaire,confirming that the line managers of the participants had consented to the researchbeing carried out, that participation was voluntary, and that replies wereconfidential. She asked participants to complete questionnaires without consultingwith each other and leave the completed questionnaires on the table in the room.She then distributed the questionnaires and left the room. After completion,participants left the room and the researcher collected the questionnaires. Teamleaders completed the questionnaires separately.
Results
The return rate of the questionnaires was 100%. In the analysis, Pearson correlationwas calculated for all variables; however, only statistically significant results arereported. Age and marital status were significantly correlated (r � 0.50, p � 0.05).This means that fewer of the young child care workers were married when comparedwith their somewhat older colleagues. Gender and length of qualification weresignificantly correlated (r � 0.58, p � 0.05). While this means that in general maleswere qualified longer than females, this result obviously has to be viewed inconnection with the gender–age distribution of the sample mentioned earlier. Agewas also significantly related to team membership (r � 0.57, p � 0.05), with more ofthe younger child care workers in the intake team and more of the older workers inthe generic team. The age in the long-term team lay between that of the two otherteams. It is therefore not surprising that the length of qualification was alsosignificantly correlated with team membership (r � 0.67, p � 0.05). Workers in theintake team were qualified for shorter periods than workers in the generic team.
Twenty-five per cent of the respondents considered their job to be “very stressful”,and 75% considered it to be “stressful”. None of the respondent rated their job as“not stressful”. Fifty-six per cent of the respondents stated that they were “verysatisfied” or “satisfied” with their job, 25% stated that they were neither satisfied nordissatisfied, and 19% of the workers stated that they were “dissatisfied” or “verydissatisfied” with their job. Job satisfaction and levels of stress experienced weresignificantly correlated (r � 4.6, p � 0.05). Child care workers who found their jobsatisfying experienced lower stress levels than child care workers who were notsatisfied with their job. However, 56% of the workers had considered leaving theirjob, while 44% had not considered this. Forty-four per cent of the workers hadconsidered leaving the profession of social work, while 56% had not considered suchan action.
The results from the GHQ show that, overall, 37.5% of child care workers in thissample scored five or more points in the GHQ and therefore could be consideredprobable “cases” in need of further psychological assessment according to Goldberg’s(1978) definition. This percentage far exceeds percentages found in the generalpopulation, which established a level of 23% “cases” (Barker et al., 1988) or 26%“cases” (Cairns & Wilson, 1984).
The overall GHQ mean score in this sample was 5.8. At closer examination it wasfound that there was an interesting difference in the GHQ mean score for child careworkers when the mean was calculated separately for different child care teams. Theintake team had a GHQ mean score of 5.0 (4.0 when the senior social worker [SSW]was excluded). The long-term team had a GHQ mean score of 4.9 (1.2 when theSSW was excluded) and the generic team had a mean score of 7.6 (9.1 when SSWwas excluded).
The GHQ mean scores found in this survey were significantly correlated withself-assessed stress levels (r � 0.55, p � 0.01). Respondents who experienced highlevels of stress scored highly on the GHQ; in other words, they displayed a relativelyhigh level of psychological distress. The level of job satisfaction was also significantlycorrelated to GHQ mean scores (r � 0.86, p � 0.001). Child care workers whoexperienced low levels of job satisfaction experienced high levels of psychiatricdistress. The correlation between the intention to leave the profession and GHQmean scores was also significant (r � 0.44, p � 0.05). Child care workers who hadconsidered leaving the profession scored higher in the GHQ, thus experiencingpoorer psychological health, than child care workers that had not considered this asan option.
Causes of Stress
The factors that caused stress are summarised in Table 2.It was apparent that pressures due to heavy workloads (i.e. too little time, meeting
deadlines) were experienced as stressful more often than client-related issues (i.e.
100Experiencing too little time to perform duties to your satisfaction94Meeting deadlines imposed by others
Imposing controls that curtail or restrict the personal autonomy of the clients 88Emotional demands of clients 88
88Administrative responsibilitiesRationing or scarce services or resources 81Counteracting unhelpful views others hold of your job 44
44Direct contact with clientsContact with other professionals 44Contact with significant others such as relatives 38
38Physically uncongenial or uncomfortable work environmentsSupervision of subordinate’s work 25
13Working with support/ancillary staff
contact with clients). This was also reflected in the replies to the open question inregard to causes of stress (not in order of preference): workload, continually workingin crisis situation, removing children into care, record keeping, lack of acknowledge-ment of stress, negative managerial response to staff displaying symptoms of stress,aggression and potential violence of clients, feeling constrain by organisation,management changes, temporary workers, poor line-management, conflict withline-management and lack of support, isolation in the situation and impropersupervision and management.
In terms of the kind of stresses that were experienced for the team, the followingissues were identified: pressures of crisis work, individual work rather than teamwork, unclear management lack of resources, instability of team membership, poorline management, sense of being more subject to stress than most other teams, andorganised confusion.
Table 3 presents results in relation to stress caused by factors in the workers’private lives.
Overall, fewer workers stated that factors in their private lives were the maincauses of stress when compared with work-related issues (see Table 2). Only one
Table 3. Causes of Stress in Private Lives.
Causes of stress Response rate (%)
Adult relatives in immediate family 44Other personal adult relationships 38
38Violence in the communityFear of redundancy 25Your own children 25
19Financial difficultiesOther relatives 13Unemployed close relatives 13Housing difficulties 6
Child Care in Practice 221
Table 4. Alleviation of Stress.
Response rate (%)Alleviation of stress
94More support/appreciation from seniors75A reduced work load
More financial resources 69More resources (other than financial) 69
38A change in senior personnelA course of further training 38
31More payA change of location (same work) 19
13More social contact with colleaguesA change of profession 0Promotion 0
0A change in peer group colleagues
worker stated that trying to do a good job while attending to family commitmentswas causing stress.
Alleviation of Stress
Table 4 summarises how stress could be alleviated.In the main, participants felt that more support and appreciation from senior
workers, together with reduced workload and more financial resources, wouldreduce stress. The issue of the effect of the quality of line management was recurring.The replies to the open question confirm this finding: more time, knowledge andsupport, room to develop areas that are of particular interest, more flexibility ofworking time, parental involvement, more stable management, responsible leader-ship, lower workload, more resources, moves to other fields of work, improvedsupervision, change of line manager. In terms of alleviating stress for the team thefollowing initiatives were suggested: back-up call with other teams, clearer decisionsabout what constitutes a crisis, increased staffing numbers, opportunity for personalwork objectives to be accommodated, to be really heard, clearer communication andclearer policies, fewer changes in management and thus a more stable management,suitable accommodation for meeting children and other clients, permanent teamleaders, more resources and training, better line management, less time on form-filling and recording, recognition of difficulties in the team via support, moreopenness in team, more sharing of cases and better supervision.
Discussion
In the past the most stressful combination of contingencies for child care workerswas described in the experience of “high demands and low control” (Gibson et al.,1989, p. 3). This was an experience well known to basic grade child care workers andit had been recognised that it was most damaging “… if maintained for a long period
222 K. Dillenburger
of time” (Blundell, 1990, p. 16). The study reported here confirms this statement. Agenerally youthful and well-qualified workforce in family and child care workexperienced stress levels that were considerably higher than those expected in theoverall population. The question as to whether this is due to the fact that personswith a particularly stressful learning history choose to become child care workers orwhether it is due to the contingencies that operate in child care work as a professioncan be addressed when one looks at the results in more detail. A distinct differencebetween the different teams emerged.
In the short-term team the average intake child care worker was young, unmar-ried, and qualified for a relatively short period of time. High workload and crisisintervention caused stress for these workers. Their average general psychologicalhealth was just above the threshold and would cause some concern to a somewhatconservative researcher (Goldberg, 1978). Stress for these workers could be alleviatedthrough a reduction in workload (more staff) and more flexibility in time manage-ment as well as the opportunity to develop personal working objectives.
The average long-term worker was somewhat older, longer qualified, and foundthings like record-keeping and taking children into care as being stressful. Theaverage general psychological health of long-term workers did not reach a level thatwould cause major concern. Stress could be alleviated if more stability was experi-enced in the team and in the leadership of this team (the team had experiencednumerous changes of SSW prior to the study) and if suitable accommodation wasoffered for individual work with clients.
The average worker in the generic team was somewhat older and longer qualifiedthan workers in the other teams. This team had a relatively high percentage of maleworkers (n � 3) when compared with the other teams. The general psychologicalhealth in this team lay well above the threshold and therefore causes concern. Stresscould be alleviated by improved supervision, better line management, reducedworkload, and more recognition of difficulties within the team.
The study described here clearly shows the important role of line managers notonly in the allocation of cases and thus workload, setting of priorities, andclarification of policy, but also in the alleviation of stress. Senior personnel have akey role to play as a source of support for staff (Bliese & Castro, 2000). Theacknowledgement that the worker is involved in a particularly stressful case or thatstaff shortage causes high levels of stress during a certain time may help to alleviatestress. However, this is often not enough. Successful alleviation of occupational stressrequires that line management is fully aware of and well trained in stress manage-ment. The question as to who cares for the carers arises here. If line managers carryout these tasks conscientiously, who cares for them? Who supports them?
The important role of stability not only in terms of staff membership in the team,but also in team leadership has to be acknowledged in this context. In situationswhere temporary work contracts are widely used, issues such as team cohesion andreliability have to be addressed (Albertsen, Nielsen, & Borg, 2001). There is a needto ensure that temporary work contracts as well as “acting up” is kept at an absoluteminimum and that roles are clearly defined and carried out.
Child Care in Practice 223
The study also confirmed the need for a reduction in workload (Bussing & Glaser,2000). More staff is needed. The more satisfying aspect of child care work, such asdirect contact with clients and communicating with children, often has to take abackseat when workers are overloaded by the sheer number of cases. Yet this typeof work should be fostered and suitable accommodation to carry out such workmade available.
While generally there is a good level of qualification and expertise within the staffteams studied here, this is often not adequately tapped into. Workers do not feel thattheir ability to develop skills and share these with others is fully utilised. Workerswho are encouraged to develop advanced personal working and learning objectivesand are in more control of their work environment feel more fully appreciated asskilful professionals, less isolated, and consequently less stressed (cf. Beehr, Glaser,Canali, & Wallwey, 2001).
Conclusion
One of the most stressful areas of work for social workers, health visitors and alliedprofessionals is child care work. Workers in this field often experience occupationalstress. In the past the cause of stress was placed inside the person (e.g. his/herperception) and the individual was expected to find some kind of coping mechanismto adjust to stress. This can lead to feelings of guilt and inadequacy in child careworkers. It is obvious that a worker who feels this way, in turn, will not be able toachieve high-quality service delivery. This can lead to frustration and the viciouscircle closes when high absenteeism and staff turnover is the consequence; othercolleagues experience increased stress levels. The difference of stress levels betweenthe teams reported here shows that it is not the case that individuals with a stressfulexperimental history choose to become child care workers, but that the contingen-cies in the working environment are the main factors in the cause of stress. If thecontingencies that caused the stress in the first place are properly identified (placingthe problem outside of the individual), skilfully introduced contingency manage-ment can alleviate occupational stress and make counterproductive coping mecha-nisms unnecessary.
References
Albertsen, K., Nielsen, M. L., & Borg, V. (2001). The Danish psychosocial work environment andsymptoms of stress: The main, mediating and moderating role of sense of coherence. Work& Stress, 15, 241–253.
Barker, M. E., McClean, S. I., McKenna, P. S., Reid, N.,G., Strain, J. J., Thompson, K. A.,Williamson, A. P., & Wright, M. E. (1988). Diet, lifesyle and health in Northern Ireland.Unpublished report, University of Ulster, Coleraine.
Beehr, T. A., Glaser, K. M., Canali, K. G., & Wallwey, D. A. (2001). Back to basics: Re-examinationof Demand–Control Theory of occupational stress. Work & Stress, 15, 115–130.
Bliese, P. D. & Castro, C. A. (2000). Role clarity, work overload and organizational support:multilevel evidence of the importance of support. Work & Stress, 14, 65–73.
224 K. Dillenburger
Blundell, G. (1990). The art and science of biofeedback. Caduceus, 10, 35–40.Burke, R. J. (2001). Predictors of workaholism components and behaviors. International Journal
of Stress Management, 8(2), 113–127.Bussing, A. & Glaser, J. (2000). Four-stage process model of the core factors of burnout: The role
of work stressors and work-related resources. Work & Stress, 14, 329–346.Cairns, E. & Wilson, R. (1984). The impact of political violence on mild psychiatric morbidity in
Northern Ireland. British Journal of Psychiatry, 145, 631–635.Dillenburger, K. (1992). Violent bereavement. Widows in Northern Ireland. Avebury: Ashgate
Publishing Company.Dillenburger, K. (2000). Functional assessment and functional analysis. In M. Davies (Ed.),
Encyclopaedia of social work. Oxford: Blackwell Publishers.Eriksen, H. R. & Ursin, H. (1999). Subjective health complaints: Is coping more important than
control? Work & Stress, 13, 238–252.Gibson, F., McGrath, A., & Reid, N. (1989). Occupational stress in social work. British Journal of
Social Work, 19, 1–16.Goldberg, D. P. (1978). Manual of the General Health Questionnaire. Slough, UK. NFER Publishing
Company.Handy, C. (1985). Understanding organisations. London, UK. Penguin.Hobson, C. J. & Delunas, L. (2001). National norms and life-event frequencies for the Revised
Social Readjustment Rating Scale. International Journal of Stress Management, 8(4), 299–314.Houkes, I., Peter, P. M. Janssen, P. P. M., de Jonge, J., & Nijhuis, F. J. N. (2001). Work and
individual determinants of intrinsic work motivation, emotional exhaustion, and turnoverintention: A multi-sample analysis. International Journal of Stress Management, 8(4),257–283.
Jamal, M. & Baba, V. V. (2001). Type-A behavior, job performance, and well-being in collegeteachers. International Journal of Stress Management, 8(3), 231–240.
Jimmieson, N. L. (2000). Employee reactions to behavioural control under conditions of stress:The moderating role of self-efficacy. Work & Stress, 14, 262–280.
Kaplan, R. M. (1990). Behavior as the central outcome in health care. American Psychologist,45(11), 1211–1220.
Mudrack, P. E. & Naughton, T. J. (2001). The Assessment of workaholism as behavioraltendencies: Scale development and preliminary empirical testing. International Journal ofStress Management, 8(2), 93–111.
Lazarus, R. S. (1966). Psychological stress and the coping process. New York: McGraw Hill.Lu, L., Kao, S. F., Cooper, C. L., & Spector, P. E. (2000). Managerial stress, locus of control, and
job strain in Taiwan and UK: A comparative study. International Journal of Stress Manage-ment, 7(3), 209–226,
McGill, P. (1991, January 4). Working for the Japanese can kill you. The Irish Times, p. 3.Rafferty, Y., Friend, R., & Landsbergis, P. A. (2001). The association between job skill discretion,
decision authority and burnout. Work & Stress, 15, 73–85.Reid H. (1990). Theoretical and emperical analysis of occupational stress: A study of residential social
workers in child care. Unpublished Ph.D. thesis, University of Ulster, Coleraine.Van der Doef, M. & Maes, S. (1999). The job Demand–Control (–Support) model and
psychological well-being: A review of 20 years of empirical research. Work & Stress, 13,87–114.
