Researchers may disagree on the meaning of the term stress. However, there is a basic agreement that perceived work-related stress may be implicated in behavioural outcomes such as absenteeism, substance abuse, sleep disturbances, smoking and caffeine use (Kahn and Byosiere 1992). Recent evidence supporting these relationships is reviewed in this chapter. Emphasis is placed upon the aetiological role of work-related stress in each of these outcomes. There are qualitative differences, along several dimensions, among these outcomes. To illustrate, in contrast to the other behavioural outcomes, which are all considered problematic to the health of those engaging in them excessively, absenteeism, while detrimental to the organization, is not necessarily harmful to those employees who are absent from work. There are, however, common problems in the research on these outcomes, as discussed in this section.
The varying definitions of work-related stress have already been mentioned above. By way of illustration, consider the different conceptualizations of stress on the one hand as events and on the other as chronic demands at the workplace. These two approaches to stress measurement have seldom been combined in a single study designed to predict the sorts of behavioural outcome considered here. The same generalization is relevant to the combined use, in the same study, of family-related and work-related stress to predict any of these outcomes. Most of the studies referred to in this chapter were based on a cross-sectional design and employees’ self-reports on the behavioural outcome in question. In most of the research that concerned behavioural outcomes of work-related stress, the joint moderating or mediating roles of predisposing personality variables, like the Type A behaviour pattern or hardiness, and situational variables like social support and control, have hardly been investigated. Seldom have antecedent variables, like objectively measured job stress, been included in the research designs of the studies reviewed here. Finally, the research covered in this article employed divergent methodologies. Because of these limitations, a frequently encountered conclusion is that the evidence for work-related stress as a precursor of a behavioural outcome is inconclusive.
Beehr (1995) considered the question of why so few studies have systematically examined the associations between work- related stress and substance abuse. He argued that such neglect may be due in part to the failure of researchers to find these associations. To this failure, one should add the well-known bias of periodicals against publishing research that reports null results. To illustrate the inconclusiveness of the evidence linking stress and substance abuse, consider two large-scale national samples of employees in the United States. The first, by French, Caplan and Van Harrison (1982), failed to find significant correlations between types of work-related stress and either smoking, drug use or on-the-job caffeine ingestion. The second, an earlier research study by Mangione and Quinn (1975), did report such associations.
The study of the behavioural outcomes of stress is further complicated because they frequently appear in pairs or triads. Different combinations of outcomes are the rule rather than the exception. The very close association of stress, smoking and caffeine is alluded to below. Yet another example concerns the comorbidity of post-traumatic stress disorder (PTSD), alcoholism and drug abuse (Kofoed, Friedman and Peck 1993). This is a basic characteristic of several behavioural outcomes considered in this article. It has led to the construction of “dual diagnosis” and “triple diagnosis” schemes and to the development of comprehensive, multifaceted treatment approaches. An example of such an approach is that in which PTSD and substance abuse are treated simultaneously (Kofoed, Friedman and Peck 1993).
The pattern represented by the appearance of several outcomes in a single individual may vary, depending on background characteristics and genetic and environmental factors. The literature on stress outcomes is only beginning to address the complex questions involved in identifying the specific pathophysiological and neurobiological disease models leading to different combinations of outcome entities.
Smoking Behaviour
A large body of epidemiological, clinical and pathological studies relates cigarette smoking to the development of cardiovascular heart disease and other chronic diseases. Consequently, there is a growing interest in the pathway leading from stress, including stress at work, to smoking behaviour. Stress, and the emotional responses associated with it, anxiety and irritability, are known to be attenuated by smoking. However, these effects have been shown to be short-lived (Parrott 1995). Impairments of mood and affective states tend to occur in a repetitive cycle between each cigarette smoked. This cycle provides a clear pathway leading to the addictive use of cigarettes (Parrott 1995). Smokers, therefore, obtain only a short-lived relief from adverse states of anxiety and irritability that follow the experience of stress.
The aetiology of smoking is multifactorial (like most other behavioural outcomes considered here). To illustrate, consider a recent review of smoking among nurses. Nurses, the largest professional group in health care, smoke excessively compared with the adult population (Adriaanse et al. 1991). According to their study, this is true for both male and female nurses, and is explained by work stress, lack of social support and unmet expectations that characterize nurses’ professional socialization. Nurses’ smoking is considered a special public health problem since nurses often act as role models to patients and their families.
Smokers who express high motivation to smoke have reported, in several studies, above-average stress that they had experienced before smoking, rather than below-average stress after smoking (Parrott 1995). Consequently, stress management and anxiety reduction programmes in the workplace do have the potential of influencing motivation for smoking. However, workplace-based smoking-cessation programmes do bring to the fore the conflict between health and performance. Among aviators, as an example, smoking is a health hazard in the cockpit. However, pilots who are required to abstain from smoking during and before flights may suffer cockpit performance decrements (Sommese and Patterson 1995).
Drug and Alcohol Abuse
A recurrent problem is that often researchers do not distinguish between drinking and problem-drinking behaviour (Sadava 1987). Problem-drinking is associated with adverse health or performance consequences. Its aetiology has been shown to be associated with several factors. Among them, the literature refers to prior incidents of depression, lack of supportive family environment, impulsiveness, being female, other concurrent substance abuse and stress (Sadava 1987). The distinction between the simple act of drinking alcohol and problem drinking is important because of the current controversy on the reported beneficial effects of alcohol on low density lipoprotein (LDL) cholesterol and on the incidence of heart disease. Several studies have shown a J-shaped or U-shaped relationship between alcohol ingestion and the incidence of cardiovascular heart disease (Pohorecky 1991).
The hypothesis that people ingest alcohol even in an incipiently abusive pattern to reduce stress and anxiety is no longer accepted as adequate. Contemporary approaches to alcohol abuse view it as determined by processes set forth in a multifactorial model or models (Gorman 1994). Among risk factors for alcohol abuse, recent reviews refer to the following factors: sociocultural (i.e., whether alcohol is readily available and its use tolerated, condoned or even promoted), socio-economic (i.e., the price of alcohol), environmental (alcohol advertising and licensing laws affect the consumers’ motivation to drink), interpersonal influences (such as family drinking habits), and employment-related factors, including stress at work (Gorman 1994). It follows that stress is but one of several factors in a multidimensional model that explains alcohol abuse.
The practical consequence of the multifactorial model view of alcoholism is the decrease in the emphasis on the role of stress in the diagnosis, prevention and treatment of substance abuse in the workplace. As noted by a recent review of this literature (Peyser 1992), in specific job situations, such as those illustrated below, attention to work-related stress is important in formulating preventive policies directed at substance abuse.
Despite considerable research on stress and alcohol, the mechanisms that link them are not entirely understood. The most widely accepted hypothesis is that alcohol disrupts the subject’s initial appraisal of stressful information by constraining the spread of activation of associated information previously stored in long-term memory (Petraitis, Flay and Miller 1995).
Work organizations contribute to and may induce drinking behaviour, including problem drinking, by three basic processes documented in the research literature. First, drinking, abusive or not, may be affected by the development of organizational norms with respect to drinking on the job, including the local “official” definition of problem drinking and the mechanisms for its control established by management. Secondly, some stressful working conditions, like sustained overload or machine-paced jobs or the lack of control may produce alcohol abuse as a coping strategy alleviating the stress. Thirdly, work organizations may explicitly or implicitly encourage the development of occupationally based drinking subcultures, such as those that often emerge among professional drivers of heavy vehicles (James and Ames 1993).
In general, stress plays a different role in provoking drinking behaviour in different occupations, age groups, ethnic categories and other social groupings. Thus stress probably plays a predisposing role with respect to alcohol consumption among adolescents, but much less so among women, the elderly and college-age social drinkers (Pohorecky 1991).
The social stress model of substance abuse (Lindenberg, Reiskin and Gendrop 1994) suggests that the likelihood of employees’ drug abuse is influenced by the level of environmental stress, social support relevant to the experienced stress, and individual resources, particularly social competence. There are indications that drug abuse among certain minority groups (like Native American youth living on reservations: see Oetting, Edwards and Beauvais 1988) is influenced by the prevalence of acculturation stress among them. However, the same social groups are also exposed to adverse social conditions like poverty, prejudices and impoverished opportunities for economic, social and educational opportunities.
Caffeine Ingestion
Caffeine is the most widely consumed pharmacologically active substance in the world. The evidence bearing upon its possible implications for human health, that is whether it has chronic physiological effects on habitual consumers, is as yet inconclusive (Benowitz 1990). It has long been suspected that repeated exposure to caffeine may produce tolerance to its physiological effects (James 1994). The consumption of caffeine is known to improve physical performance and endurance during prolonged activity at submaximal intensity (Nehlig and Debry 1994). Caffeine’s physiological effects are linked to the antagonism of adenosine receptors and to the increased production of plasma catecholamines (Nehlig and Debry 1994).
The study of the relationship of work-related stress on caffeine ingestion is complicated because of the significant inter-dependance of coffee consumption and smoking (Conway et al. 1981). A meta-analysis of six epidemiological studies (Swanson, Lee and Hopp 1994) has shown that about 86% of smokers consumed coffee while only 77% of the non-smokers did so. Three major mechanisms have been suggested to account for this close association: (1) a conditioning effect; (2) reciprocal interaction, that is, caffeine intake increases arousal while nicotine intake decreases it and (3) the joint effect of a third variable on both. Stress, and particularly work-related stress, is a possible third variable influencing both caffeine and nicotine intake (Swanson, Lee and Hopp 1994).
Sleep Disturbances
The modern era of sleep research began in the 1950s, with the discovery that sleep is a highly active state rather than a passive condition of nonresponsiveness. The most prevalent type of sleep disturbance, insomnia, may occur in a transient short-term form or in a chronic form. Stress is probably the most frequent cause of transient insomnia (Gillin and Byerley 1990). Chronic insomnia usually results from an underlying medical or psychiatric disorder. Between one-third and two-thirds of patients with chronic insomnia have a recognizable psychiatric illness (Gillin and Byerley 1990).
One of the mechanisms suggested is that the effect of stress on sleep disturbances is mediated via certain changes in the cerebral system at different levels, and changes in the biochemical body functions that disturb the 24-hour rhythms (Gillin and Byerley 1990). There is some evidence that the above linkages are moderated by personality characteristics, such as the Type A behaviour pattern (Koulack and Nesca 1992). Stress and sleep disturbances may reciprocally influence each other: stress may promote transient insomnia, which in turn causes stress and increases the risk of episodes of depression and anxiety (Partinen 1994).
Chronic stress associated with monotonous, machine-paced jobs coupled with the need for vigilance—jobs frequently found in continuous-processing manufacturing industries—may lead to sleep disturbances, subsequently causing decrements in performance (Krueger 1989). There is some evidence that there are synergetic effects among work-related stress, circadian rhythms and reduced performance (Krueger 1989). The adverse effects of sleep loss, interacting with overload and a high level of arousal, on certain important aspects of job performance have been documented in several studies of sleep deprivation among hospital doctors at the junior level (Spurgeon and Harrington 1989).
The study by Mattiason et al. (1990) provides intriguing evidence linking chronic job stress, sleep disturbances and increases in plasma cholesterol. In this study, 715 male shipyard employees exposed to the stress of unemployment were systematically compared with 261 controls before and after the economic instability stress was made apparent. It was found that among the shipyard employees exposed to job insecurity, but not among the controls, sleep disturbances were positively correlated with increases in total cholesterol. This is a naturalistic field study in which the period of uncertainty preceding actual layoffs was allowed to elapse for about a year after some employees received notices concerning the impending layoffs. Thus the stress studied was real, severe, and could be considered chronic.
Absenteeism
Absence behaviour may be viewed as an employee coping behaviour that reflects the interaction of perceived job demands and control, on the one hand, and self-assessed health and family conditions on the other. Absenteeism has several major dimensions, including duration, spells and reasons for being absent. It was shown in a European sample that about 60% of the hours lost to absenteeism were due to illness (Ilgen 1990). To the extent that work-related stress was implicated in these illnesses, then there should be some relationship between stress on the job and that part of absenteeism classified as sick days. The literature on absenteeism covers primarily blue-collar employees, and few studies have included stress in a systematic way. (McKee, Markham and Scott 1992). Jackson and Schuler’s meta-analysis (1985) of the consequences of role stress reported an average correlation of 0.09 between role ambiguity and absence and -0.01 between role conflict and absence. As several meta-analytic studies of the literature on absenteeism show, stress is but one of many variables accounting for these phenomena, so we should not expect work-related stress and absenteeism to be strongly correlated (Beehr 1995).
The literature on absenteeism suggests that the relationship between work-related stress and absenteeism may be mediated by employee-specific characteristics. For example, the literature refers to the propensity to use avoidance coping in response to stress at work, and to being emotionally exhausted or physically fatigued (Saxton, Phillips and Blakeney 1991). To illustrate, Kristensen’s (1991) study of several thousand Danish slaughterhouse employees over a one-year period has shown that those who reported high job stress had significantly higher absence rates and that perceived health was closely associated with absenteeism due to illness.
Several studies of the relationships between stress and absenteeism provide evidence that supports the conclusion that they may be occupationally determined (Baba and Harris 1989). To illustrate, work-related stress among managers tends to be associated with the incidence of absenteeism but not with days lost attributed to illness, while this is not so with shop-floor employees (Cooper and Bramwell 1992). Occupational specificity of the stresses predisposing employees to be absent has been regarded as a major explanation of the meagre amount of absence variance explained by work-related stress across many studies (Baba and Harris 1989). Several studies have found that among blue-collar employees who work on jobs considered stressful—that is those that possess a combination of the characteristics of assembly-line type of jobs (namely, a very short cycle of operations and a piece-rate wage system)—job stress is a strong predictor of unexcused absence. (For a recent review of these studies, see McKee, Markham and Scott 1992; note that Baba and Harris 1989 do not support their conclusion that job stress is a strong predictor of unexcused absence).
The literature on stress and absenteeism provides a convincing example of a limitation noted in the introduction. The reference is to the failure of most research on stress-behavioural outcome relations to cover systematically, in the design of this research, both work and non-work stresses. It was noted that in research on absenteeism non-work stress contributed more than work-related stress to the prediction of absence, lending support to the view that absence may be non-work behaviour more than work-related behaviour (Baba and Harris 1989).