Work-related stress and occupational therapy

Occupational Therapy International, 8(4), 227–243, 2001 © Whurr Publishers Ltd 227

Work-related stress andoccupational therapy

CHRIS LLOYD Integrated Mental Health Service, Gold Coast Hospital andDepartment of Occupational Therapy, University of Queensland, Australia

ROBERT KING Department of Psychiatry, University of Queensland, Australia

ABSTRACT: Occupational stress and burnout have been studied extensively inthe human services. It has been suggested that healthcare professionals in particularare at risk of stress owing to the caring nature of their work. Articles related to occu-pational therapy and work-related stress were reviewed in regard to practice inAustralia, Canada, the United Kingdom, the United States and Sweden. Althoughthe empirical literature is relatively weak for occupational therapy, it has been arguedthat occupational therapists in health care share risk factors with other healthcareprofessionals. These risk factors include repeated exposure to distress and difficultbehaviour, prolonged interventions and uncertain outcome. Issues such as profes-sional status, staffing issues and the nature of the profession have been identified asadditional risk factors for occupational therapists. However, empirical studies thatenable burnout rates of occupational therapists to be compared with those of relatedoccupational groups suggest that this may not be the case. Occupational therapistsmay in fact be protected from some stress and burnout factors. Further research isrecommended to clarify the nature of stress experienced by occupational therapistsand to identify both risk and protective factors characteristic of the profession.

Key words: burnout, professional identity, stress

Introduction

The past two decades have seen an increasing interest in the issues of occupa-tional stress in human service professionals. Research has looked at socialworkers (Collings and Murray, 1996), nurses (McLeod, 1997), teachers (Jack-son et al., 1986), psychologists (Cushway and Tyler, 1994), physicians(Scheiber, 1987), police officers (Jackson and Maslach, 1982) and employeesin other occupations that require substantial contact with people in need of

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aid. According to Payne and Firth-Cozens (1987), healthcare professionalsface an occupational stressor that is not part of most other occupations. Theysuggest that healthcare professionals deal with people in situations, for exam-ple those involving death and suffering, that have a profound effect on them.In addition, they may carry out procedures that are invasive and they areinvolved in making decisions, which, if wrong, may lead to the exacerbationof the disease or even the patient’s death. Other stressors may include the pos-sibility of infection, physical injury or litigation because of negligence (Payneand Firth-Cozens, 1987).

In addition to stress, the phenomenon of job burnout has been investigatedin a variety of service occupations and settings. Burnout has been linked tojob stress and is thought to be a unique response to frequent and intense clientinteractions (Tee and Ashforth, 1996). People in the healthcare professionsregularly experience stress that is to some extent attributable to the job. Stresslevels vary across the different health professionals, and research has focusedon the symptoms experienced, the stress levels experienced, the level within aprofession and the location of work.

This article examines studies of occupational therapy on stress and burnoutfrom Australia, Canada, the United Kingdom, the United States and Sweden.The types of research represented include surveys and semi-structured inter-views. Comparisons have been made with professions allied to medicine andthe norms for the Maslach Burnout Inventory, which represent data from adiverse selection of helping professions.

Definition of stress and burnout

Every job has potential stress but each will vary in terms of the degree of stressexperienced from factors such as the task requirements of the job, expecta-tions and demands, relationships with others, career development andorganizational structure. The sources of potential stress that might exist in theenvironment together with the individual’s personal characteristics can resultin symptoms of physical and psychological stress (Sutherland and Cooper,1990). Job stress can have a detrimental effect on the individual, work pro-ductivity and society. Chronic stress can be emotionally draining and can leadto burnout. The person who burns out is unable to deal successfully with thechronic emotional stress of the job, and this failure to cope can be manifestedin a number of ways, including low morale, impaired performance, absen-teeism and high turnover. Common responses to burnout are to change jobs,to move into administrative work or even to leave the profession entirely.Additionally, burnout is correlated with various indices of personal dysfunc-tion. Emotional exhaustion is often accompanied by physical exhaustion,illness, psychosomatic symptoms, increased use of alcohol and drugs andincreased marital and family conflict. As a result of these factors, the qualityof care or service given may deteriorate (Maslach, 1978a).

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Following the consistent findings their research yielded, Maslach et al.(1996) developed a specific syndrome of burnout and devised an instrumentto measure it. The Maslach Burnout Inventory (MBI) was designed to assessthe three aspects of the burnout syndrome. Key aspects of burnout areincreased feelings of emotional exhaustion and a depletion of the psychologi-cal energy required to do the job. The person withdraws emotionally from thework they previously enjoyed and develops a negative, cynical attitudetowards their clients. These changes may also lead to a questioning of theirwork, a sense of dissatisfaction with their work performance and a belief thattheir work lacks purpose and meaning. Although the three aspects of burnoutare distinct, their effects are cumulative and contribute to the degree ofburnout experienced (Maslach et al., 1996).

Professional concerns and issues

An overview of risk factors

As members of a caring profession, occupational therapists are subject to stressas part of their work. Craik (1988) highlighted a number of characteristicsthat she believed might increase occupational therapists’ risk of experiencingstress and burnout. The areas that she identified included (1) role blurring inthe multidisciplinary team, with inexperienced practitioners being unsure oftheir unique contributions to client care; (2) lack of a balanced caseload asclients referred to occupational therapy tend to have high levels of disability;(3) chronic staff shortages in the profession which serve to increase the pres-sure on staff; and (4) the ongoing debate concerning the role and function ofthe profession. She considered that these characteristics might exacerbate lev-els of stress. A number of writers have echoed these sentiments (for example,Jenkins, 1991; Price, 1993; Sweeney, Nichols and Kline, 1993; Lloyd-Smith,1994; and Craik et al., 1998). The concerns that have been raised includestaffing issues, pressure of demands, unrewarding patient contact, and profes-sional issues, including professional status and lack of recognition,professional role and supervision. These issues may render occupational thera-pists more vulnerable to stress than other healthcare professionals.

Staff recruitment and retention

It has been well reported that the supply of trained therapists in Australia,Canada and the United States is lagging behind the present and anticipatedfuture demand and that this has led to critical manpower shortages in occupa-tional therapy (Graham and Allen, 1990; Salvatori et al., 1992; Trickey andKennedy, 1995). Price (1993) suggested that occupational therapists andoccupational therapy students hold a negative image of the psychiatricfield. In the Australian study conducted by Cusick et al. (1993) a negative

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perception of the mental health work setting and role was found to be influ-enced by social stigma, disillusionment with the role of occupational therapy,inadequate course preparation and difficulty dealing with chronicity. InOntario, Canada, continually escalating client care requirements within anenvironment of limited numbers of occupational therapy graduates and lack ofseniority or upward mobility were some of the main reasons for manpowershortages in occupational therapy (Salvatori et al., 1992). Staff shortages are aconcern because they put pressure on staff to fulfil the demands of the job.This has been identified as a stressor in a number of studies (Jenkins, 1991;Brown and Pranger, 1992; Pranger and Brown, 1992; Sweeney, Nichols andCormack, 1993). Craik (1988) postulated that the pressure placed on thera-pists by staffing shortages may be exacerbated by the trend to justify the roleand functions of the profession.

Maslach et al. (1996) reported that high burnout scores on the MBI sub-scales were correlated with the expressed intention to leave one’s job withinthe year. Greensmith and Blumfield (1989) conducted a study to examinewhy occupational therapists may be thinking of leaving or do actually leavethe profession in the National Health Service (NHS) in the United Kingdom.They surveyed 106 practising occupational therapists in Leicestershire, Eng-land (response rate 68%), and 19 non-practising occupational therapists inthe United Kingdom (response rate 79%). The main reasons given for wishingto leave the profession included unrealistic workload, lack of resources, lack ofprofessional status and disillusionment. Forty-two per cent of practising thera-pists felt that their career expectations were not fully met and this reason wasgiven by an even higher proportion of those who may be permanently leavingthe profession (58%). More than half of those at senior level (54%) and morethan one-third of those at basic grade level (40%) were thinking of leavingthe profession.

A later study conducted by Jenkins (1991) in Northern Ireland found thatreasons occupational therapists gave for leaving a position included lack ofresources (72%), unrealistic workload (64%), lack of promotional prospects(60%) and lack of professional status with regard to other disciplines (60%).Thirty-two per cent of the respondents indicated leaving the profession alto-gether, with poor staffing (40%) given as the major reason for occupationaltherapists leaving their current job. Graham and Allen (1990) conducted astudy examining the working conditions for the profession in the various typesof employing institution in Australia. Three hundred and twenty-one practis-ing therapists and 114 non-practising therapists were surveyed. Therespondents who were occupational therapists in charge reported that lack offunds (54%) and recruitment problems (42.5%) were the two main reasonswhy facilities did not recruit adequate numbers of occupational therapists. Inrural areas, 26% of respondents reported difficulty in retaining occupationaltherapy staff. The two most common reasons advanced by this group wereburnout (31%) and professional isolation (24%).

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A study of occupational therapists in the United States looked at whatoccupational therapists liked least about their jobs which contributed to theirleaving the field (Bailey, 1990). Reasons given for leaving the field were otherprofessionals’ lack of respect for occupational therapy, other professionals’ lackof understanding of occupational therapy, stress and overload, chronicity ofclients, continually having to justify the occupational therapy role, role con-flict, professional isolation and lack of a career ladder. A Canadian study of165 male occupational therapists showed that they were dissatisfied with cer-tain aspects of their job, including the work, pay, promotional opportunities,supervision and co-workers, and were planning to leave the profession at somepoint (Brown, 1995).

Professional status

It seems that professional status, or rather lack of it, is a common concernamong occupational therapists. Fleming and Piedmont (1989) found that occu-pational therapists feel that they are not recognized. Their respondents believedthat the profession has low visibility, recognition and status and that those out-side the profession are not fully aware of the effects of the occupational therapyservice. Falk-Kessler and Ruopp (1993) surveyed 150 mental health profession-als in New York, United States, where participants were asked to rate theirperception of each profession’s prestige. In this study occupational therapistsascribed less prestige to themselves than they ascribed to social workers, psy-chologists and psychiatrists. Occupational therapists were ranked as the secondleast prestigious team member by all other disciplines, with recreational therapybeing the least prestigious and psychiatrists the most prestigious.

Professional role

More recently there has been much debate concerning the profession’s coreskills, especially in the mental health setting (Craik, Chacksfield andRichards, 1998). Duncan (1999) commented that much of the debate seemsto have developed from a self-imposed negative professional image in whichoccupational therapists have struggled to identify their own role. It might besaid that the difficulty in defining occupational therapy contributes to thelack of professional identity that many occupational therapists experience.Feaver and Creek (1993) suggested that occupational therapists are noted fortheir lack of certainty and self-doubt. Creek and Feaver (1993) furtherclaimed that the profession of occupational therapy suffers from role confu-sion and a weak sense of identity. According to Price (1993), the absence of aunified well-defined basis in occupational therapy and the lack of research inmental health contribute to role confusion.

With the shift to community-based care, there is an emphasis on team-work and an interdisciplinary perspective. Concerns have been raised in the


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occupational therapy literature about the blurring of roles and lack of under-standing about the functions of occupational therapy in community mentalhealth (Kaur et al., 1996; Taylor and Rubin, 1999). Leonard and Corr (1998)found that lack of professional identity and low status of the profession werestressors for newly qualified occupational therapists. This lack of professionalidentity and low status of the profession have been mentioned in a number ofstudies (Greensmith and Blumfield, 1989; Bailey, 1990; Jenkins, 1991;Sweeney et al., 1991).

Supervision

The occupational therapy literature is relatively silent on the subject of super-vision and few studies have been carried out examining supervision andoccupational therapy. One such study was carried out by Allan and Ledwith(1998) who surveyed 211 occupational therapists (response rate of 70%) toexamine the links between self-reported levels of stress in senior occupationaltherapists, the perceived need for professional supervision and future jobintentions. One-third of the staff reported high or very high levels of stressand 19% of respondents said that they intended to have a job outside occupa-tional therapy within five years. About 40% wished for more of each aspect ofsupervision – namely, opportunities to reflect on practice, offload feelings andgain professional support, as well as to learn and experience encouragement ofprofessional development. Only 25% were satisfied with all of these aspects ofsupervision. There was evidence that those who felt most stressed were likelyto want more supervision and that those intending to leave the profession par-ticularly missed opportunities to offload feelings. Mental health staff weremore likely to want more supervision, with 38% of respondents reporting highor very high levels of stress.

Yuen (1990) raised the issue of burned-out student supervisors. He consid-ered that supervisors in the clinical setting should help students reduce thestress generated by interpersonal conflict. However, the senior staff usuallyreceived little formal training in supervision, which may in itself be an addi-tional stressor. Some previous research has shown that supervisory cliniciansgenerally experience higher levels of burnout than staff clinicians (Brollier etal., 1986, 1987).

Work-related stress

The evaluation of stressful situations is based on each individual’s personalcharacteristics, experiences and use of coping strategies. In Britain, Sweeneyet al. (1991) conducted a pilot study that set out to design and validate aninstrument to measure the factors that contribute to work-related stress inoccupational therapists. One hundred and fifty-six occupational therapists outof a population of 222 participated in this study, yielding a 60% response rate.

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The factors they identified as stressors were mostly management issues andrelated to staffing levels, time management, caseload management, availabili-ty of resources, supervision levels, rewards and recognition.

In a further study of 310 occupational therapists (response rate of 87%)four dimensions of job stress were identified – namely, professional value,resources and demands, rewards and recognition, and patient contact(Sweeney, Nichols and Kline, 1993). Analysis indicated that occupationaltherapists who worked longer hours, who had been in the job for a longerperiod of time and who were employed in the social services tended to scorehigher on the dimensions of rewards and recognition. Employment at basicgrade and senior I and II levels tended to be predictive of a high score on thedimension of stress related to patient contact. Occupational therapists whohad been qualified for longer periods of time tended to score lower on boththese dimensions of job stress.

Pressure of demands

The emotional demands of human services work have been identified asmajor contributors to burnout (Maslach, 1978b; Jackson et al., 1986). Thesedemands may be generated from service recipients, perceptions of work over-load and interpersonal conflict with colleagues and supervisors (Maslach etal., 1996). Rees and Smith (1991) conducted a study in Britain to examinestress in all occupational groups of health service employees. They reportedon a stratified sample of 60 clinicians from two district occupational therapydepartments using the Occupational Stress Indicator (OSI) to identify sourcesof pressure. Their results showed that occupational therapy staff perceivedhigher levels of pressure from their relationships with other people in theworkplace than did other professions. In comparison with nurses, they felt lessstress from their career achievements and progress and had fewer problemswith the organizational design structure and climate. The professional groupswith the highest levels of perceived sources of pressure were community psy-chiatric nurses and speech therapists. These groups experienced higher stressratings from both career and achievement issues and problems arising fromthe organizational structure and climate.

Occupational therapy staff ranked seventh out of the 17 occupationalgroups examined in terms of the stress experienced. The investigators went onto comment that the scores on job satisfaction suggest that the profession isintrinsically attractive to its members in terms of its philosophy and valuesbut that its problems of retention may relate to stress at work, particularly thatderived from relationships with others in the workplace. Limitations of thisstudy include the small sample size of 60, the mixture of clinical and mana-gerial grades that were represented, and the mixture of qualified andunqualified staff in the sample. No details were given of the speciality areas inthe sample. Adamson et al. (1998) used a purposive sampling procedure to


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survey 144 Australian occupational therapy graduates (response rate 28.7%)to investigate the adequacy of their undergraduate education in equippingthem for the workplace. The results revealed that the graduates perceivedthemselves to be insufficiently prepared for practice, particularly in the area ofcommunication with other health professionals. Further work is needed toinvestigate the possibility that the reported perceived low status of the profes-sion and the difficulties in communicating about the profession and withother professionals underlies much workplace stress.

Wressle and Oberg (1998) conducted a study to examine work-relatedstress among occupational therapists in Sweden using the instrument intro-duced by Sweeney et al. (1991). The purpose of the study was to identifyspecific stress factors among occupational therapists that contribute to work-related stress and the influence of these factors on the individual. Onehundred and sixty-two participant responses were included in the study out of200 surveyed. The lack of resources and lack of time were graded high as stressfactors. It was concluded that Swedish occupational therapists have a lowlevel of stress compared with British occupational therapists. The researchersconsidered that occupational therapists had an important job with a strongprofessional role and identity but that financial conditions had not kept pacewith the status of the profession.

Sweeney, Nichols and Cormack (1993) reported the results of semi-struc-tured interviews with 30 participants (occupational therapists) related tofactors contributing to job stress and coping strategies. Occupational therapists’impressions of their professional worth seemed to be related to their role and tothe amount of communication and consultation in the organization. The sec-ond dimension of job stress in occupational therapy resulted from the demandsthat were made on the clinician and that were perceived by the occupationaltherapist to be in excess of his or her resources. This was seen as being a resultof the shortfall of occupational therapists to vacancies and from the high rateof turnover in the profession. The lack of rewards and recognition – in particu-lar, working with the chronically disabled – is the third dimension of job stressthat is relevant to occupational therapists. Stressors arising from contact withpatients seemed to be the most pertinent to occupational therapists at the clin-ical grades. These individuals traditionally carry the biggest patient caseload,have fewer opportunities for non-patient-related activities and tend to haveless control over allocating and balancing their caseload.

Occupational therapy and burnout

Patient contact

A relationship has been found between job characteristics and experiencedburnout – for example, the greater the number of clients one must deal with,the higher the burnout scores. People who spend all or most of their working

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time in direct contact with patients score high on emotional exhaustion(Maslach et al., 1996). Burnett-Beaulieu (1982) suggested that the emotionalprocess of clinical practice and the lack of expected rewards may offer anexplanation for the short clinical careers of occupational therapists. Shehypothesized that as occupational therapists develop in their careers they mayexperience unconscious, aversive affective responses to the difficultiesencountered with those who have severe, chronic disabilities. She suggestedthat this may correspond to burnout. This leads to problems for the professionbecause new therapists remain in clinical practice for only a short period oftime, and then switch to alternative areas of practice or move to administra-tive positions to gain upward mobility.

One of the earliest studies examining burnout in occupational therapistswas an Australian study conducted by Sturgess and Poulsen (1983). The MBIwas administered to 126 occupational therapists working in the Brisbane met-ropolitan area. The participants were assigned according to the reported areaof speciality into which most of their work fell. Their findings revealed thatpsychosocial occupational therapists seemed to have lower frequency scoreson the items measuring job satisfaction and sense of personal accomplishmentthan did paediatric or physical rehabilitation occupational therapists. Thissuggested that psychosocial occupational therapists experienced more burnoutthan other occupational therapists.

The psychosocial occupational therapists saw the most clients overall, themost clients in a group setting and had the least number of rest hours. On fiveof the six burnout subscales, the mean scores of the occupational therapy sur-vey data were at lower levels than the mean scores for the test norms. Thelower frequency scores on sense of personal accomplishment may possibly beexplained by the types of clients seen, the high patient:therapist ratio and thechronicity of patients – factors that correlate significantly with burnout. Butthe Sturgess and Poulsen (1983) study has a number of limitations. The sam-pling method was not stated and 21% of the sample had worked for less thanone year, with 14% of this group having worked less than three months. Itwould be unlikely for therapists to have experienced burnout in such a shorttime. In addition, the participants who were included in the psychosocialgroup not only worked in mental health but also with clients with intellectualand geriatric disabilities. To date this remains the only study on stress andburnout of Australian occupational therapists.

A study in the United States examining burnout in occupational thera-pists was conducted by Rogers and Dodson (1988). The 99 participants weresurveyed using the MBI. The findings from this study suggested that, on aver-age, occupational therapists experience less burnout than other human serviceprofessionals, which concurs with the findings by Sturgess and Poulsen(1983). Both these findings and the Australian data indicate that occupation-al therapists generally score lower than the MBI normative sample on theemotional exhaustion and depersonalization subscale, with the scores on the


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personal accomplishment subscale remaining comparable to those of the nor-mative sample. Rogers and Dodson (1988) postulated that the component ofburnout to which occupational therapists are most susceptible is a decreasedfeeling of personal accomplishment. They proposed that tolerance to burnoutmay be higher than average as long as a sense of personal accomplishment issustained.

Using the MBI, Schlenz et al. (1995) examined the prevalence of burnoutamong occupational and physical therapists working in head injury rehabilita-tion in metropolitan areas of the Pacific Northwest of the United States. Theresults from this study showed that, on average, the participants displayedhigh feelings of personal accomplishment, average levels of emotional exhaus-tion and low levels of depersonalization. As a group, occupational therapistsand physical therapists tended to experience higher emotional exhaustion,lower depersonalization, and notably higher personal accomplishment thanthe total MBI norm reference group of human service professionals and thenorm group of medical professionals. The researchers suggested that the par-ticipants in this study might be at risk of burnout. They found that a notablerelationship existed between feelings of personal accomplishment and profes-sional development activities. The results of this study suggested thatparticular professional development activities such as continuing educationand reading journal articles might be instrumental in the reduction of a highdegree of burnout.

Managerial role

Brollier et al. (1986) surveyed 129 female registered occupational therapists(OTRs) in Virginia, United States, using the MBI. A convenience sample wasused for this study. Their findings suggested that the OTR respondents experi-enced moderate levels of burnout. Managers/supervisors scored higher thanstaff members on the depersonalization subscale. Managers/supervisors seemedto have developed a more intensive negative attitude towards the recipients oftheir services than staff occupational therapists. The authors queried whetherthis might be related to inadequate managerial training, with lack of prepara-tion increasing the potential for stress in the managerial role. Alternatively,they queried whether these people had moved into administration fromburnout and found other duties to be an escape from clients. This group alsoscored higher on the emotional exhaustion subscale.

The findings from this study also revealed that OTRs employed by the gov-ernment experienced lower levels of personal accomplishment. This could bea result of increased bureaucracy, with policy and decision-making beyond theemployees’ authority, thereby contributing to lack of control and decreasedopportunities for personal accomplishment. Marital status, primary clinicalexpertise, percentage of time spent in direct clinical contact, and lengthof client stay were not found to be statistically significant between the

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subgroups. In other studies client-related aspects have been found to be riskfactors (Savicki and Cooley, 1987; Maslach and Florian, 1988). The only sta-tistically significant finding was that the OTRs who spent the least time withpatients reported more depersonalization than their peers (Brollier et al.,1987). There were no significant differences between three clinical practicespecialities (physical disabilities, mental health and developmental disability)in the extent and type of burnout experienced. The results of this study didnot replicate those from a previous report (Sturgess and Poulsen, 1983) whichsuggested that psychiatric occupational therapists experienced more burnoutthan other occupational therapists.

One hundred and thirty-two occupational therapy personnel employed innine of the 10 psychiatric hospitals in Ontario, Canada, were surveyed using asample of convenience (Brown and Pranger, 1992; Pranger and Brown, 1992).The researchers sought to determine whether burnout occurred at significantlevels and whether there was a relationship between burnout, work environ-ment factors and demographic characteristics in a group of psychiatricoccupational therapy personnel. The findings from this study indicated thatwork involvement, a large number of clients in one’s caseload diagnosed withschizophrenia, work pressure, age, income level, the length of time working inpsychiatric occupational therapy, size of caseload and the amount of overtimeperformed on a weekly basis were significant predictors of burnout. Unlikesome of the earlier studies (Sturgess and Poulsen, 1983; Brollier et al., 1986;Rogers and Dodson, 1988), the mean score for emotional exhaustion for allrespondents was significantly higher than that of the normative group of theMBI. This was found to be influenced by the particularly high scores of thesenior therapists. The managers and other staff had significantly lower fre-quency of feelings of personal accomplishment.

Results from this study regarding burnout on the job revealed that 43% ofrespondents were concerned with departmental supervision; 40% were con-cerned with hospital administration, including the use of an excessive numberof rules and regulations, multiple levels of authority, little opportunity for inputinto decision-making, and reorganization of the hospital; and 30% expressedconcerns over staffing such as inadequate numbers and a high turnover rate(Brown and Pranger, 1992; Pranger and Brown, 1992). The finding that occu-pational therapists experienced lower feelings of personal accomplishmentwhen compared with the established norms for mental health workers is con-sistent with the findings of Sturgess and Poulsen (1983) and Rogers andDodson (1988). Further research on burnout is needed to compare occupation-al therapists with other professional groups who work in mental health.

Coping strategies and protective factors

Response to stress is the product of the situation and the individual’s personalresources and takes into account all the factors that influence resistance and


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vulnerability to stress. People have different ways of coping with stressors(Sutherland and Cooper, 1990). Ways of coping are varied and may includesuch strategies as seeking social support, training, escape-avoidance and exer-cise. Craik (1988) considered that remedies that enhance an individual’sability to cope with a demanding situation will also improve his or her controlover events, thereby lessening the effect of organizational stress. Cox (1988)suggested that occupational therapists are well versed in the application ofstress management techniques with their patients, which should give themsome advantage in coping with their own stress. She advocated that occupa-tional therapists needed to build up their personal and professional copingstrategies in order to reduce levels of negative stress. Adamson et al. (1998)found that new graduates felt that they were poorly equipped to cope in theworkplace and recommended that topics related to stress and burnout beincluded in undergraduate programmes.

It has been suggested that healthcare providers who specialize in AIDScare are particularly susceptible to work-related stress and resulting burnout.Hooley (1997) conducted a qualitative study of three occupational therapiststo test this assumption. The results showed that stress and burnout were notdominant themes in these interviews. Instead the themes centred around loss,death and dying, boundaries and coping strategies. Coping strategies most fre-quently mentioned included talking to others, exercise and having a lifeoutside work. Similarly, Sweeney et al. (1993) found that coping strategiesused by occupational therapists included balancing the workload, using socialsupport and participating in energy-using and diversionary activities.

Brollier (1970) and Craik, Chacksfield and Richards (1998) have suggest-ed that occupational therapists who engage exclusively in mental healthwork are concerned with the concept and practice of the therapeutic use ofself and have strong affective orientations in their work. The occupationaltherapy process in mental health settings requires a substantial degree ofautonomy and creativity, two qualities which, if they are absent, have beenlinked to feelings of emotional exhaustion. Rogers and Dodson (1988) sug-gested that the occupational therapy process allows for inherent opportunitiesfor control and creativity which may revitalize emotional reserves and shieldagainst emotional depletion. Therefore, it may be that the creative nature ofthe job in part protects occupational therapists from the damaging effects ofstress.

Using the OSI, Rees and Smith (1991) found that the total score on cop-ing strategies for occupational therapists was significantly higher than that forthe other professions allied to medicine. They were ranked second out of the17 occupational groups studied in the use of coping strategies. Overall, incomparison with other professions, the occupational therapy staff made signif-icantly more frequent use of social support and were more likely to breakdown their work into tasks as a means of overcoming pressure. This is aninteresting finding that warrants further investigation.

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Implications and future research

A major finding of this review article is an apparent discrepancy between highlevels of concern in the profession about professional identity, staff retention,occupational status and relations with other professions and relatively lowlevels of burnout. There are several possible explanations for this. First, it ispossible that the Maslach Burnout Inventory, which is by far the most widelyused instrument for the measurement of stress and burnout, is not sensitive tosome important dimensions of occupational stress. In particular it may be aninadequate measure of anxieties associated with role, status and professionalidentity. Occupational therapists may judge their work to be valuable andeffective and may enjoy positive relationships with clients while at the sametime experiencing anxieties about how they are valued by the organizationand/or their colleagues. Second, it is possible that satisfactions associated withthe practice of occupational therapy outweigh anxieties associated with role,status and identity. Although recognized in the profession as issues and mat-ters for professional attention, they are not of sufficient magnitude to createhigh levels of stress and burnout because the overwhelming experience of thework is positive. Third, it is possible that occupational therapists have highlevels of resilience and capacity to manage uncertainty. If this is the case,issues of role, status and professional identity may not be experienced asthreatening because the individual is confident that these challenges can beovercome.

Given the diversity and size of the profession, there are not enough pub-lished reports to be confident that results can be generalized across worksettings and times. We live in a period of rapid organizational and occupation-al change. A work environment characterized by low stress and burnout inone decade may become a high-stress environment in the next decade. Notonly do we need to look at developing more sensitive measures; we also needto ensure that we can monitor stress and burnout in changing environments.In the absence of adequate empirical data, the response of the profession toissues of stress and burnout will rely on anecdotal reports which, even whenwell informed, are limited in their generalizability.

A number of implications for the profession have become evident sincereviewing the literature. Stress and burnout have been identified as issues foroccupational therapists, although this may be less than for comparable occu-pational professions. There is a discrepancy between the anecdotal literature,which suggests all sorts of stressors, and the empirical literature, which sug-gests low levels of burnout. Although burnout levels seem to be low, it wouldbe a mistake to assume that stress and burnout are the same phenomenon.Burnout is one of several possible indicators of occupational stress. It ispossible that high job satisfaction means that occupational therapists absorbstress without experiencing burnout. This may well be because the professionis intrinsically attractive. In addition, it seems that occupational therapists


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make good use of active coping strategies in their work, which may act as aprotective factor.

It is a matter of concern that the reasons put forward as stressors relatemainly to the nature of the profession itself. This may be interpreted in termsof professional value. Occupational therapists seem to be concerned with theirlack of professional identity, the low status of the profession and feelings ofbeing undervalued by their peers. In particular it is evident that much of thestress experienced by occupational therapists involves their relationships withother members of the healthcare team. Unmet job expectations in generaland specific aspects of employees’ job experiences are associated with burnout.It may well be that there is a prevalence of unrealistic job expectations amongoccupational therapists and that this mismatch between expectations andreality is a major contributor to the stress that they experience.

The somewhat ad hoc nature of occupational therapy research is illustratedby examining this topic. It is hard to find studies that are predicated on previ-ous work, thereby building a body of knowledge related to the topic area.Comparative studies with other healthcare professionals (for example, socialworkers) are needed, to determine whether levels of stress and burnout differbetween the groups. Additional research questions could include, Whatexpectations do occupational therapists hold about their role in the work-place? What is the discrepancy between how occupational therapists perceivetheir role and others’ expectations? Do these factors contribute to occupation-al therapists’ experience of stress and burnout?

Conclusion

Occupational stress is a matter of concern for employers, healthcare profes-sionals and the clients with whom they interact. The earlier anecdotaloccupational therapy literature suggested that there were a range of stressorsthat may place occupational therapists at risk of experiencing occupationalstress. These have been identified as role blurring, patient contact, staff short-ages and the role and function of the profession. The later empirical literatureindicates that stress is an issue for occupational therapists. Dominant themesthat emerged are those concerning the identity of the profession, its status andthe relationship between occupational therapists and other healthcare profes-sionals. One possible outcome of chronic stress is burnout, which has alsobeen identified as an issue for occupational therapists. Interestingly, theresearch has indicated that overall it seems that the levels of burnout experi-enced by occupational therapists are lower than those for comparableoccupational groups. It has been postulated that tolerance to burnout may behigher than average as long as a sense of personal accomplishment issustained. The active use of coping strategies by occupational therapists mayalso be instrumental in reducing the level of burnout they experience. Furtherresearch is warranted to examine the relationship between professional

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identity, work practices and feelings of personal accomplishment among occu-pational therapists.

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Address correspondence to Chris Lloyd, Senior Occupational Therapist, Psychiatric Unit, GoldCoast Hospital, 108 Nerang Street, Southport Q 4215, Australia. Email: [email protected]


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