Workplace stress: A neglected aspect of mental health wellbeing

Workplace stress is defined by the World Health Organization as ‘the response people may have when presented with work demands and pressures that are not matched to their knowledge and abilities and which challenge their ability to cope’, and elaborated that it can be caused ‘by poor work organization (the way we design jobs and work systems, and the way we manage them), by poor work design (e.g., lack of control over work processes), poor management, unsatisfactory working conditions and lack of support from colleagues and supervisors’1. While workplace stress, stigma and attitudes towards employees suffering from stress or mental illness have been researched and interventions developed to address them better, globally2,3, it still remains an oft-neglected aspect across different industries and countries, including India, and only a few of the learnings are actually implemented.

International laws have been in force for many decades to protect human rights of employees at workplace, and the key ones being Article 23 of the Universal Declaration of Human Rights4, Articles 6 and 7 of the International Covenant on Economic, Social and Cultural Rights5 and Article 27 of United Nations Convention on the Rights of Persons with Disabilities6. However, the execution of policies is variable and often suboptimal. Moreover, low- and middle-income countries where one has the largest population in working age groups, continue to lag behind in conducting or identifying suitable interventions, and often do not have adequate policies in place to prevent discrimination against employees with mental disorders7.

Workplace-related stress – a reality that needs to be addressed through evidence-based interventions

Brouwers et al8 conducted a cross-sectional study across 35 countries including India and reported that about two-third of employees who had suffered from depression either faced discrimination at work or faced discrimination while applying for new jobs. This study also found that both anticipated and perceived discrimination was more in high-income countries compared to lower-income countries. Both perceived and anticipated discrimination are major causes for people suffering silently at the workplace and not seeking proper care. This by itself can be a major issue when seeking care for mental disorders as it adds to stigma related to help-seeking and increases treatment gap - the gap in the proportion of people who suffer from mental disorders and the proportion of them who actually receive adequate mental health care. If organizations are made aware of this, and they encourage staff to seek appropriate mental health care as per need, then it will not only lead to improved care for persons with mental disorders, but also to a situation where employees are comfortable discussing their mental health issues with appropriate staff and take actions early on, so that more severe mental disorders do not manifest.

Another risk factor is that besides depression or anxiety being an outcome of stress, physical disorders such as hypertension and diabetes can also be caused due to stress. While research has established the two-way link between stress and these physical disorders9,10, organizations need to realize this and encourage staff to maintain a good work-life balance. This by itself can be a difficult task to implement given deadlines, having a competitive edge, sustaining growth and one's personal need to earn more by doing overtime. Thus, organizations need to have guidelines about working hours based on good industrial practices and take measures to enforce these routinely.

Sexual harassment and bullying at workplace is another workplace-related stress that can happen at any organization. Both genders could be affected by these, but often women and those lower in the hierarchy are at increased risk. Organizations should be cognizant of this and take active measures to ensure that workplace is a safe and secure place for every worker. In India, there are specific legal provisions to ensure safety at workplace (http://labour.gov.in/policies/safety-health-and-environment-work-place), and there are specific laws to prevent sexual harassment of women (http://indiacode.nic.in/acts-in-pdf/142013.pdf). Strict guidelines and processes are advocated, and every organization should have identified committees to handle any such issue.

While extant research has tended to focus on alleviation of symptoms and risk factors associated with workplace-related mental disorders, less emphasis has been placed on gathering evidence on how mental disorders affect performance and absenteeism and how interventions have resulted in improvement of work performance and absenteeism3. Thus, more research is needed to gather evidence on the cost-effectiveness of interventions and the cost of mental disorder-related loss of productivity on the larger community. This is relevant to all countries and becomes specifically significant when each employment sector tries to become more competitive and wants to increase productivity while at the same time tries to keep their cost to a minimum. In low- and middle-income countries, there are additional needs to (i) conduct basic epidemiological studies to understand the prevalence of workplace-related mental disorders and specific risk factors associated with different employment sectors, (ii) understand what kind of systems are being put in place by different sectors to manage them, and (iii) to what degree are existing laws being followed and implemented, and what organizational restructuring is needed to improve the situation. Current evidence suggests that no single intervention can work in isolation and it is recommended to have a package of interventions at organization level which could be accessed by those in need3. Some interventions that were specifically found to be useful were enhancing employee control, promoting physical activity, cognitive behaviour therapy for stress management and problem-focused return to work programmes. On the contrary, counselling and debriefing following trauma were not effective3 and any exposure to trauma should be followed by provision of psychological first aid and formal psychological support by trained professionals. Workplace screening for mental disorders followed by access to basic mental health services has been found to be effective, but could lead to a potential increase in anxiety levels in those who are screened as false positives, so routine screening at workplace is not recommended3.

Guidelines to improve workplace culture and reduce stress

The World Health Organization has outlined key factors related to stress at workplace and advocated guidelines to redeem them11. Some factors that cause increased stress at workplace include ‘workload (both excessive and insufficient work), lack of participation and control in the workplace, monotonous or unpleasant tasks, role ambiguity or conflict, lack of recognition at work, inequity, poor interpersonal relationships, poor working conditions, poor leadership and communication and conflicting home and work demands’11. This document also outlined guidelines to improve the situation and enumerated four key steps which are not only relevant to individual organizations, but to other stakeholders also, such as trade unions, employees, government and employees11.

Step 1: Analyzing the mental health issues - As a first step, it is essential to have a clear understanding of not only the prevalence/incidence and risk factors associated with workplace stress, but also a better knowledge about the cost implications to an organization in terms of lost productivity. This is an exercise that can be done at individual organizations, at specific employment sector level in specific regions or across regions. This may need gathering new data through surveys or collating data available with the human resources or anonymized health records.

Step 2: Developing the policy - A policy can be developed once the initial knowledge gained through the first step is available. The primary objective of such a policy should be to address concerns of all stakeholders and adhere to the organizations vision and mission. This should involve multiple meetings with different stakeholders to identify key components that need to be addressed. This engagement should be a continuous process throughout the development and execution of the policy.

Step 3: Developing strategies to implement the policy - While implementing the policies, care should be taken to identify the key strategies that need to be implemented, the processes that need to be in place to implement such strategies, targets to be achieved and timelines that need to be adhered to while implementing the strategies. Finally, any additional budgetary allocations or training required to implement the policies, need to be made available.

Step 4: Implementing and evaluating the policy - The implementation of any strategy will need collaboration and clear buy-in from all stakeholders. For some strategies, one might need to have a small demonstration project to start off, and based on the results tweak the strategies and then scale it up to a larger forum. Before implementing a policy, information should be disseminated widely either through a formal launch meeting or individual organizations’ dissemination network. For example, major government level policies that impact large number of employees or employers could have a launch meeting, whereas policies affecting only one organization with limited staff could be disseminated through office emails. This would enable everyone to be aware of the policies. One major drawback of many policies is that they lack a formal evaluation. This should be built into the system and appropriately funded from the outset. Specific guidelines about how to monitor and evaluate the policies should be in place at the time of the launch of the policies and conducted as per agreed timelines.

Role of government

The government should play a key role in ensuring that policies are in place that address workplace stress. Not only should the government identify vulnerable populations such as women, children, persons with disability at different workplaces, but also ensure that every sector has appropriate safeguards to protect the rights of all employees including vulnerable populations. The government should also monitor how different sectors are performing with respect to workplace stress and have additional strategies in place to address issues related to sectors which have specifically higher level of physical or psychological stress such as mines, factories, health sector, among others. Legal mechanisms should be in place to enforce laws and regulate them and penalize organizations which flout existing laws. The legal system should provide avenues that can be accessed both by employers and employees alike. The aim should be that workplace is seen as a fair and non-discriminatory zone as far as stress, and mental ill-health are concerned.

Conclusion

Workplace stress and associated mental ill-health is a fact that every employer and employee lives with on a daily basis. However, it often is the case that neither are aware of the issues fully and nor are well informed about its ramifications. Although laws are present in most countries to ensure that the rights of persons suffering from mental disorders related to workplace stress are safeguarded, often such are not executed or regulated effectively, leading to a situation where persons with mental disorders are not able to verbalize their problems and suffer silently - a situation that ultimately leads to increasing mental health-related disability that affects productivity. In this year, when workplace stress is being identified globally as a cause for concern, all stakeholders should take additional notice of its importance and see what needs to be done to improve the situation on the ground and make workplace a safer and healthier place for all.