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FOREIGN STUDIES AND FOREIGN LITERATURE ABOUT STRESS AND SOURCES OF STRESS Stress in the Workplace: A Costly Epidemic

by Rebecca Maxon Three out of every four American workers describe their work as stressful. And the problem is not limited to these shores. In fact, occupational stress has been defined as a "global epidemic" by the United Nations' International Labor Organization. While the physical effects of this epidemic are often emphasized, the economic consequences also are alarming. Workplace stress costs U.S. employers an estimated $200 billion per year in absen teeism, lower productivity, staff turnover, workers' compensation, medical insur ance and other stress-related expenses. Considering this, stress management may be business's most important challenge of the 21st century. Of course, stress is a factor in every one's life, particularly during major events such as marriage, divorce or buying a home. But according to the Holmes-Rahe Life Events Scale, which rates the levels of stress caused by such events, many of the most stressful events are related to the workplace: firings, business readjustments, changes in financial status, altered responsibilities, a switch to a different line of work, trouble with the boss, variations in work hours or conditions, retirement and vacations. Surprisingly, stress is not always a bad thing. It can stimulate creativity and productivity. According to Robert Ostermann, professor of psychology at FDU's Teaneck-Hackensack Campus, "No one reaches peak performance without being stressed, whether an athlete, an office worker or a manager." The natural pattern of human behavior is to experience a stress-causing event or situation, react to it with increased tension and then return to a normal, relaxed state. The problem occurs when stress is so overwhelming or constant that this pattern is broken. TRACING THE ROOTS OF STRESS Ostermann has found that the level of occupational stress is determined by three dimensions -life situations, work and self -- and that the balance between the causes of stress and available systems of support must be considered. An inter nationally applicable measure of occupa tional stress developed by Ostermann, named SWS for situations, work and self, encompasses all three dimensions because, Ostermann says, "surveys that only look at work factors are not giving the full picture." Sources of stress vary tremendously. For factory workers, stress often is related directly to the work situation, such as dealing with dangerous heavy equipment or working in an uncomfortable environment. In contrast, office workers are more likely to experience stress related to interpersonal relationships on the job. "People pressures" such as unclear supervision, tension among team members and fear or aversion of conflict can cause stress.

"For many people the core of their social life is the people with whom they work," explains Ostermann. "But work is not a social situation, so you begin to get some things that are antagonistic to good relationships, such as rumors and power plays among executives who are competing for the next promotion." Occupational stress is not related only to what goes on at work. Conflicts between the demands of the workplace and of home life are increasingly common. According to a survey completed for the U.S. Department of Labor, 10 percent of people who are married or living with children under 18 experience severe work-family conflict, and an additional 25 percent report moderate levels of conflict. Internationally, Ostermann has observed, "There is less stress in developing countries than in developed countries." This may be due in part to increased consumerism and the growing influence of advertisers who "try to convince the consuming public that a want is a need." The sense of values also is different in many of the developing countries. In developed nations, there often is an emphasis on what is possessed or how much money is earned. "In many developing countries," Ostermann states, "the value of family and nation is much stronger than it is here in the U.S." This strong value system provides support for people in these cultures and may enable them to deal with greater amounts of stress. Some cultures -- like those in Taiwan, Hong Kong and Singapore -- are emulating the American model and, therefore, Ostermann has found, are growing more stressed. Joel Harmon, associate professor of management and chair of the management, marketing, information systems and sciences department on the Florham-Madison Campus, says, "The greatest reported cause of stress is workload. Employees work more today than they did 25 years ago -- the equivalent of a 13th month every year. Staff are getting downsized but the work remains, so workloads are getting upsized." Changes in office procedures are happening more rapidly than at any other time in history. "Fifty years ago, the nature of someone's job did not change during their entire tenure at that job," Ostermann says. "Now, everything is different." And, in the current "information age" things move at a faster pace than ever before with faxes and instant e-mail messages. Some professions are especially prone to stress resulting from changing technology. Take airline pilots, for example: "They are flying more complicated planes, carrying more people under morepressing time demands and with much more airport traffic than ever before," Ostermann observes. Technology in automation has en abled employers to eliminate many jobs. Not only does this result in a fear of being replaced by a machine, but those who keep their jobs must undergo retraining and tend to have a higher level of respon sibility, and thus greater stress, thrust up on them. "Other organizational changes," Harmon adds, "especially increased use of part-timers, management changes, increased diversity and pay cuts or freezes," lead to increased levels of job insecurity. "Now only about half of managers and employees rate security as good or very good, down from 75 to 80 percent in the 1980s."

A particularly alarming cause of stress, and part of a vicious circle as it also is a symptom of stress, is aggression or violence in the workplace. It is estimated by the U.S. Justice Department that each year more than a million people are the victims of violence at work, accounting for about 15 percent of all violent crime in the country. This causes a half million workers to miss time on the job at the rate of 1,751,000 work days per year, costing $55 million in lost wages. Everyone has heard cases of disgruntled employees "going postal," an expression derived from a 1986 incident at an Edmond, Okla., post office in which 14 postal workers were shot to death by a co-worker before he turned a gun on himself. And, people worldwide witnessed the stress that teachers and students at Columbine High School in Littleton, Colo., and their families endured when two gun-toting students massacred 12 of their peers and a faculty member and laced the school property with explosives. (For more on violence in schools, see "Those Who Can, Teach," 1998 spring/summer.) More common than such extreme cases is violence that occurs in retail or service industries: attacks on taxicab drivers, health care employees, convenience store clerks, workers in government offices and police officers, among others. According to Harmon, aggressive behavior in the workplace ranges from the rare "serious instances of physical assault" to the more widespread "'passive' forms of aggression, such as withholding resources, not responding to phone calls and memos and being late to meetings." Though these passive-aggressive behaviors seem benign, Harmon notes that "when constantly repeated, they can result in great psychological harm and loss of personal and organizational productivity." A HEAVY PRICE The physical effects of excessive stress have long been recognized -- from heart attacks and strokes to ulcers and other gastrointestinal disorders. Continual stress also takes a toll on the body's immune system, causing frequent colds and other illnesses. Psychologically, stress can lead to depression, anxiety and even panic attacks. Specifically, the stress produced by aggression in the workplace has "been associated with physical and psychological distress, resulting in decreased productivity, commitment and loyalty," says Harmon. Also, victims of or witnesses to violence in the workplace may suffer from a range of trauma-related illness including post-traumatic stress disorder. Sixty percent of lost workdays each year can be attributed to stress. In addition, an estimated 75 to 90 percent of visits to health care providers are due to stress-related conditions, costing employers in increased health care costs. A list of physical and psychological warning signs of stress exhaustion appears on this page. Stress also can have a direct effect on the way people handle their jobs. Employees under stress may make more mistakes, have trouble concentrating, become disorganized, become angry or just stop caring about their work. The Wall Street Journal reported that one third of people surveyed considered quitting their jobs because of stress and 14 percent actually did. COPING WITH STRESS

Many people look for help to resolve their problems with stress, and employers are responding. "We look for support systems, things that will offset the stress," comments Ostermann. Options include flexible work weeks, telecommuting opportunities and encouraging personnel to live balanced lives. Harmon cites the Business Work-Life Study conducted by the Families and Work Institute, which "suggests that organizations adopt work-family programs, inform employees that help is available and hold managers accountable for sensitivity to their employees' work-family needs." On the physical side, some organizations provide health clubs where employees can work out and keep fit and cafeterias where workers can choose from a healthy range of meals. Most corporations make counseling readily available, if not on site then through the health care benefits they provide their employees. Handling stress, however, is a very individual matter. Alice Mills, co-director of counseling services in the Teaneck-Hackensack Campus Wellness Center, suggests several ways individuals can deal with stress. "The first step is to analyze the situation to determine what is causing the stress and what techniques might best suit the individual," she says. Mills notes that there are many relaxation skills including the use of music, meditation, diaphragmatic breathing exercises, aerobic exercise, muscle relaxation and imagery. Many of these techniques can be learned through books and video- and audiotapes such as those that the Wellness Center makes available to students, faculty and staff through its stress lab. Some people bring stress with them to the workplace through their disposition. "By telling yourself you're going to fail or by expecting negative reactions from other people, you may create your own stress," Mills says. Cognitive techniques help people monitor their thinking, identify "unrealistic" negative thoughts and replace those thoughts with more positive coping statements. These techniques, used by psychiatrists and other professional counselors, help reduce negative moods such as anxiety and depression. They also are helpful when teaching individuals to manage their own angry reactions to people and situations. Another important way to combat stress is to sharpen one's communication skills. "You need to learn how to speak about your own needs and wants and how to give positive and negative feedback to others," Mills explains. This is what many know as assertiveness. "Some techniques can be implemented on the spot to try to restore the natural rhythm of stress and relaxation," Mills says. Take a break, talk with colleagues, go to the bathroom or water cooler or do breathing exercises to restore balance. "Take stock of your stress-creating habits and take action to change them," she says. And, perhaps most importantly, "Take care of yourself." (http://www.fdu.edu/newspubs/magazine/99su/stress.html)

Occupational Stress and Adaptation Experiences of Foreign Educated Nurses from the Philippines ProQuest Dissertations and Theses, 2011 Dissertation Author: Jorgia Briones Connor Abstract: Immigrant nurses face multiple challenges that create vulnerability to occupational stress which may affect quality of care. The purpose of this study was to explore occupational stress and coping among Filipina nurses within the context of immigration and adaptation. A crosssectional qualitative research design was used to gain a holistic understanding of the participants' experiences. Data collection included in-depth interviews and self-administered questionnaires. Twenty women, 28-48 years old, working as registered nurses in the Chicago metropolitan area were interviewed. All received their Bachelor's degree in Nursing in the Philippines and lived in the U.S. 2 - 17 years. The findings revealed that FENS faced resettlement demands because of unexpected social and environmental challenges. Experiences with communication problems, discrimination and alienation interact with and intensify work- related stressors. The data also revealed three phases within which occupational and adaptation process occurs: 1) surviving 2) achieving, and 3) self-determining and that certain stressors predominate during each phase. Culture undergirds their stressors and preferred coping strategies. This study illustrates that stress and coping are dynamic, multidimensional and highly influenced by culture. This study provides initial groundwork for a program of research to create culturally relevant interventions to improve understanding and working conditions within a diverse workforce, and assist immigrants adapt and cope with stress. Table of Contents CHAPTER I. INTRODUCTION 1 A. Significance and Purpose 1 B. Background 3 CHAPTER II. REVIEW OF THE LITERATURE 9 A. Research on Foreign Educated Nurses (FENs) 9 1. Sources of occupational stress of FENs from the Philippines 10 2. Immigration experiences of FENs 10 B. Occupational Stress in Nursing 13 1. Physical work environment 13 2. Psychological work environment 15 3. Social work environment 15 C. Occupational Stress Concepts and Models 16 CHAPTER III. METHODS 18 A. Design and Rationale 18 B. Conceptual framework 19 C. Sampling and Recruitment 20 1. Sample design, selection criteria and rationale 20 2. Sample demographics and characteristics 21 D. Instrument

22 E. Protection of human subjects 22 F. Procedure 23 G. Data analysis 27 H. Coding procedure 28 1. Thematic analysis 28 2. Content analysis 28 I. Maintenance of rigor 29 1. Credibility 29 2. Transferability 30 3. Dependability 30 4. Confirmability 30 CHAPTER IV. RESULTS 31 A. Pre-migration Background and Initial U.S. Work Setting 31 1. Pre-migration work history 31 2. Coming to the U.S 32 3. Work settings in the U.S 33 IV B. Stress and Coping Findings 34 1. Immigration and resettlement challenges related to the unexpected social and living environments 34 2. Immigration stressors interact with and intensify work-related stressors 41 3. Challenges arise from encountering cultural contradictions 46 4. Cultural characteristics and values influence preferred coping strategies and behaviors. 56 C. Occupational and Adaptation Phases 72 1. Surviving 73 2. Achieving 77 3. Self-determining 81 D. Summary 84 CHAPTER V. DISCUSSION 92 A. Sources of non-work related and work related stress 92 B. Factors that influence occupational stress among FENs 93 C. How FENs cope with work-related and non-work related stress 98 D. The occupational and adaptation process for FENs 100 E. Limitations 104 F. Conclusion and Implications 106 REFERENCES 110 APPENDICES 122 CURRICULUM VITAE 139 v LIST OF TABLES Table Page I. Pseudonym assignment 27 II. Immigration and resettlement challenges 35 III. Immigration stressors that interact with and intensify work related stressors 41 IV. Challenges arising from cultural contradictions 47 V. Familial coping strategies 57 VI. Intracultural coping strategies 61 VII. Fate and faith-based coping strategies 64 VIII. Forbearance/patience and self-control strategies 68 IX. Avoidance and escape coping strategies 71 X. Milestones during the "surviving phase" 73 XI. Milestones during the "achieving phase" 77 XII. Milestones during the "self-determining phase" 81 XIII. Predominant stressors along with the adaptation phase and occupational milestones 85 XIV. Coping typology and strategies 88 VI Figure LIST OF FIGURES Page 1 Preliminary framework: Model of Model of Occupational Stress for FENs 123 2 Recruitment of participants 124 3 Adaptation phase and occupational milestones 125 vii 1 Chapter I. Introduction A. Significance and Purpose Occupational stress has long been recognized as a hazard of the workplace (Sauter et al., 2002; Sauter, Murphy, & Hurrell Jr, 1990). The National Institute of Occupational Safety and Health (NIOSH) defines occupational stress or job stress as the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker (Sauter,

Murphy, Colligan, Swanson, Hurrell, Scharf, et al. 1999). The economic, personal and societal cost of the inability to cope with job-related stress is very high. Reports have estimated that stress costs U.S. industry about $300 billion dollars a year as a result of accidents, absenteeism, employee turnover, diminished productivity, direct medical, legal, and insurance costs, workers' compensation awards and tort judgments (American Institute of Stress (AIS), 2007; Tangri). This is exemplified in the nursing profession by the National Sample Survey of Registered Nurses findings that 46% of registered nurses (RNs) cited burnout or stressful environment as their reason for leaving their current nursing position (U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, 2004). Many other studies have implicated occupational stress as a significant factor in causing burnout, turnover, absenteeism and departure of staff nurses from healthcare settings (McGrath, Reid, & Boore, 2003; McVicar, 2003; Payne, 2001). The work of health care workers is indisputably stressful because on a daily basis they are challenged with multiple sources of stress such as dealing with severely ill patients, being confronted with death and dying, facing time pressure and work overload, and dealing with potentially challenging interpersonal relationships with patients, their families, and a host of other healthcare colleagues. Despite the growing 2 interest in occupational stress of nurses there is a dearth of research on this topic on foreignborn nurses whose work-related stress may be complicated by the fact that they are immigrants who were educated in another country. Understanding the occupational stress of foreign educated nurses (FENs) is important because they are now a substantial part of the U.S. RN workforce. The proportion of FENs in the U.S. increased from approximately 5% in 1998 to 14% in 2003 (Brash, Sochalski, & Berger, 2004; Polsky, Ross, Brush, & Sochalski, 2007). The steady rise of the FEN population in the U.S. can be attributed to the practice of importing registered nurses (RNs) in order to fulfill the gap left by the U.S. nursing shortage (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004; Buchan, 2001; Buchan & Sochalski, 2004; Davis & Nichols, 2002; Kingma, 2006). The proposed study will focus on FENs who come from the Philippines because over half (50,052) of the total FEN population in the U.S. come from the Philippines (USDHHS, 2004). The Philippines has been the preferred source for importing nurses because their nursing education mirrors that of the U.S. and they are able to speak English (Aiken et al., 2004; Buchan & Sochalski, 2004; Kingma, 2006). Aggressive recruiting of experienced FENs by U.S. health care facilities coupled with the Philippine government's support of labor exportation as a way to stabilize the economy through remittances, fueled the diaspora of qualified RNs to the U.S. and other Western countries (Auerbach, Buerhaus, &

Staiger, 2007; Lorenzo, 2002; Lorenzo et al., 2005; Ronquillo, Elegado-Lorenzo, & Nodora, 2005). Nursing is viewed as an opportunity for working abroad in order to earn high salaries (Estella, 2005; Lorenzo, Galvez-Tan, Icamina, & Javier, 2007). Health care facilities invest considerable time and money recruiting and training FENs yet very little attention has been paid to what happens to them once they are working in this 3 country. From a cost-benefit standpoint, it is critical to understand the occupational health issues that FENs face in order to prevent costly negative health outcomes and staff turnover. More importantly, all workers deserve to be valued and their health and well-being should be safeguarded from potential occupational hazards. After all, providing quality health care to the society at large is affected not only by the availability of nursing staff but also the nurses' ability to provide care that is not encumbered by their own stress and poor health. Occupational stress is a complex phenomenon because it has multiple causes and varied outcomes. Yet occupational stress can be prevented and managed if the factors affecting the stress and coping process and the relationship among these factors are appropriately identified. Despite the fact that registered nurses have been subjects of a growing body of research on occupational stress (e.g. Abu AlRub, 2004; Bakker, Killmer, Siegrist, & Schaufeli, 2000; Jenkins & Elliott, 2004; McVicar, 2003; Muncer, 2001), these studies have not parsed the issues pertaining specifically to FENs from the Philippines who simultaneously face demands as nurses and immigrants. Furthermore, the conceptual frameworks and the measurement tools used in these studies may not be relevant for studies of FENs as they were developed and validated for populations in Western cultures. It is vitally important that researchers gather knowledge about this issue through culturally appropriate research. Therefore, the purpose of this study is to explore occupational stress among Filipina FENs within the context of immigration and adaptation. B. Background 1. Impact of stress on health There has been significant research attempting to clarify the links between stress and disease (e.g. Levenstein, Prantera, Varvo, Scribano, Berto, Andreoli et al., 1994; McCarty & 4 Gold, 1996; Sephton & Spiegel, 2003; Thomason, Brantley, Jones, Dyer, & Morris, 1992). Although the pathophysiologic mechanisms often remain unclear and the true causal relationship has not been confirmed, there is significant evidence associating occupational stress with several diseases and health conditions (Seward, 2004). Stress-related disorders include a wide-range of conditions, including psychological/mental disorders and biological outcomes - e.g. cardiovascular disease, gastrointestinal disorders, musculoskeletal disorders, and altered immune system (Baker & Karasek, 2000; Crandall, 1995; Dewe, Cooper, & O'Driscoll, 2001; Sauter, Brightwell, Colligan, Hurrell, Katz, LeGrande, et al., 2002). These circumstances could lead to

sick-leaves, poor work performance or even injury. 2. Immigrants and health FENs not only have to face stress at work, but also have to deal with the demands of immigration. Researchers have identified migrants and immigrants as a vulnerable population, exposed to many stressors related to their migration experiences (Kandula, Kersey, & Lurie, 2004; Lipson & Meleis, 1999; Messias & Rubio, 2004). Even when the reason for migration is to improve their lives, moving to a foreign community implies changes of identity and values, loss of support and disempowerment of the migrant. In coping with multiple challenges, immigrants experience high levels of psychological distress that can manifest as depression, anxiety disorders, somatic complaints, and sense of helplessness (Aroian, 2001; Aroian & Norris, 2000; Aroian & Norris, 2003; Mak & Zane, 2004; Miller & Chandler, 2002; Pang, 2000; Ritsner, Ponizovsky, Kurs, Lib, & Modai, 2000). There is also evidence that the level of psychological distress among immigrant women is higher than among immigrant men (Aroian, 2001; Aroian, Norris, & Chiang, 2003; Ritsner, Ponizovsky, Nechamkin, & Modai, 2001; Wiking, Johansson, & Sundquist, 2004). 5 Aroian and Norris (2002) conducted a longitudinal study to determine what variables predict depression among recent immigrants. At the 2 year follow up, they found that baseline depression, unemployment, novelty, and not having relatives in the local area were significant predictors of depression at the 2 year follow-up. In their follow-up analysis of this data, Aroian and Norris (2003) found that the groups whose depression worsened or remained the same had relatively little change from baseline in their immigration demands, whereas the group whose depression lifted had lower immigration demand scores at the 2-year follow-up than they had at baseline. In addition, poor acculturation, economic difficulties, low sense of coherence, and poor sense of control were strong predictors of psychological and psychosomatic symptoms (Sundquist, Bayard-Burfield, Johansson, & Johansson, 2000). Hovey and Magana (2002) hypothesized that education was a resource to help individuals cope; however, their findings indicated that higher education was related to anxiety and depression possibly because of the sense of failure that they feel about not being able to find jobs commensurate to their ability. On the other hand, Christopher and Kulig (2000) found that education was not a factor that is predictive of psychological mental health amongst Irish immigrants. Her explanation is that perhaps these immigrants feel that the jobs that they occupy initially are just "stepping- stones" to future positions that are more fitting with their education and ability. Hovey and Magana (2002) also looked at individual's control and choice to immigrate as a determinant of psychological distress; as expected, immigrants who were willing to migrate were at less risk for depression than those who were not willing. Control and choice are important variables that

empower individuals; indicating that when they have the ability to choose or control their destiny, they are able to better cope with whatever adversities may come their way. 6 Resilience is a predictive variable that has also been studied in relation to immigrants and psychological distress (Aroian & Norris, 2000; Christopher & Kulig, 2000; Miller & Chandler, 2002). Christopher & Kulig (2000) found that a resilient personality, along with satisfaction with one's life is associated with higher psychological well-being. Miller & Chandler (2002) chose a negative outcome variable and found that women (from the former Soviet Union) who scored high on the Resiliency Scale had lower scores for depressive symptoms. In contrast, Aroian & Norris (2000) found that resilience did not modify or mediate relationship between demands of immigration and depression. This finding is contrary to theories that resilience is related to psychological outcome. However, the authors' explanation for this discrepancy is that the effects of resiliency may be more distal than what was captured in their study. Studies have looked at interactions between the immigrants and the host and co-national population (Ward & RanaDeuba, 2000; Zheng, Sang, & Wang, 2004). Strong association with the culture of origin was associated with greater psychological distress in a sample of predominantly Western subjects living in Nepal (Ward & Rana-Deuba, 2000). They also found that identification with the host culture was unrelated to adjustment outcome. This is in contrast with Zheng et al.'s (2004) findings regarding contact with host and culture of origin. In his study of Chinese students, he found that identification with both culture of origin and host culture is correlated with subjective well-being; for integrated individuals who have attained a balanced identification, subjective well-being is increased. This discrepancy indicates that there may be differences in the psychological adjustment mechanisms of Eastern and Western cultures. Ward & Rana-Deuba (2000) also found that it is the quality of interpersonal relationship, rather than the quantity, that impacts adjustment. Individuals who are satisfied with the quality of relationship with their social support network are less lonely. (http://udini.proquest.com/view/occupational-stress-and-adaptation-pqid:2447113191/) Foreign Literature About Stress The incidence of study-related stress in international students in the initial stage of the international sojourn 1Abstract This paper explores the incidence of stress in international students in relation to the requirements of an international Masters Programme. The data presented here were taken from a doctoral ethnographic study of the adaptation of international postgraduate students to life in the UK, involving

individual interviews with thirteen students over the academic year 2003/4 as well as participant observation of the entire cohort of 150 Masters students. It is suggested that article stress related to the academic task 2is caused by academic cultural differences particularly in regard to critical evaluation and participation in discussion in class, and by language ability. This study shows that stress is intense at the beginning of the academic programme and declines gradually as a function of a reduction in the academic workload, rather than as a function of time. (http://www.studymode.com/essays/Foreign-Literature-About-Stress-1056860.html)