5 DISCUSSION
A qualitative study was conducted with the aim of developing a mental
health promotion model in the workplace for the design and
implementation of interventions. The findings are based on the
perception of employees, supervisors, and managers of occupational
stress in HCW working in primary health centers. A qualitative study was
conducted with the aim of developing a conceptual model for promoting
mental health in the workplace for the design and implementation of
interventions. The findings are based on the perception of employees,
supervisors, and managers of occupational stress in HCW working in
primary health centers. To achieve the goal of the research, the
PRECEDE-PROCEED planning model was used as the basic model and the
concepts of the JD-R model. Based on the PRECEDE-PROCEED model, it was
discovered that first the stressful factors of the workplace were
identified, then the effective factors to control workplace stress.
Finally, the necessary factors for the implementation of workplace
stress interventions at the levels of organizational management policies
and the development of stress control training were identified.
Based on the results of this research, workplace stress has
environmental and individual origins. Job demand is an important
environmental factor. In previous studies, the effect of high job demand
on increasing mental pressure, stress and poor job performance was
observed (Broetje et al., 2020; Deng, Guo, Ma, Yang, & Tian, 2019).
According to what was determined in this study, HCWs have a high
workload due to their extensive duties. Furthermore, they have to answer
to multiple high-level organizational units. As a result of this volume
of demands, it significantly causes confusion and anxiety for HCWs. In
this study, the pressures were exacerbated by the outbreak of
coronavirus disease. Moreover, HCWs deal with a diverse range of clients
(culturally, socially, economically, and educationally). This issue
confronts the HCWs with many challenges. Similar to this finding, Kool
et al ( 2019) found working in diverse populations a job demand. These
pressures were more in HCWs with fixed-term contracts. In addition to
the mentioned factors, they were afraid of contract termination and
unemployment after the end of the contract, and they endured a lot of
pressure to satisfy their superiors or clients.
The importance of characteristics of in workplace stress has been
noticed and confirmed by many studies (Riley et al., 2018). Role load is
one of the characteristics of the role. We found that there is a
significant role burden in foremen because they have to perform
administrative and organizational tasks in addition to the multiple
tasks of a HCW, and therefore experience multitasking and role pressure.
This can be a special job condition for foreman HCWs in Iran. Similar to
previous studies (Sonnentag, 2018), we found that role conflict is a
stressor. Role conflict is a situation in which a HCW is required to
follow a set of conflicting job demands and values. In this study,
foremen provide care alongside their colleagues and also have the role
of employer for them. Therefore, sometimes foremen get confused on the
border between supervision and colleague. In other words, they get
involved in psychological pressure in the gap between responsibility and
friendly/social relationships.
Moreover, the findings of this study indicated that poor payment
policies lead to the perception of injustice among HCWs. In this regard,
a study of (Olafsen, Halvari, Forest, & Deci, 2015) introduces
distributive justice as an internal motivation against the amount of
payment. A review study also found that pay is not a motivator, but the
unfairness of payment is annoying (Broetje et al., 2020).
It was found that in addition to the factors related to the work
environment, sometimes the aspects related to the social role (wife,
parent, and child) can also put pressure on the HCW at the workplace. In
this regard, scientific evidence shows that sometimes people are
psychologically victims of managing the relationship between work and
home (Houlfort, Cécire, Koestner, & Verner-Filion, 2022).
In previous studies, the need to pay attention to multi-layered
investigations of workplace stress has been emphasized (Havermans et
al., 2017; Moll, 2014). One of the prominent findings of this study was
the identification of individual factors along with environmental
factors. It was found that the personal characteristics of HCWs can be
effective in the occurrence of occupational stress. Other evidence also
argued that personality influences stress assessment and coping
(Bosmans, Setti, Sommovigo, & van der Velden, 2019; van der Wal,
Wallage, & Bucx, 2018). One of the most important individual
differences is people’s different interpretations of different
situations and conditions (Karasek, 1998). In this regard, a significant
result of this study is the identification of the cognitive performance
of HCWs in the event of stress. Employees experience severe mental
pressure when they perceive what is happening in the organization as
cruelty and injustice, have negative beliefs about the organization,
superiors and colleagues, and also when they cannot accept the
organizational position of the role. In addition to the mentioned
factors, researchers stated that the quality of relationships between
employees at different levels of the organization and relationships with
clients is related to occupational stress (Akbar, Elahi, Mohammadi, &
Khoshknab, 2016; Tran, Nguyen, Dang, & Ton, 2018). The results of our
study similarly show the pressure caused by undesirable behaviors such
as harassment, verbal abuse, and humiliating behavior, especially among
clients and supervisors.
Another prominent result in this study was the identification of
supervisors’ performance as an important and stimulating individual
factor in the emergence of stress. The weak performance and skills of
the supervisors in the field of monitoring and supervision, for the
HCWs, results in unfair judgment, pressure, and threats. To our
knowledge, very limited studies have investigated the role of supervisor
performance in health care workers’ workplace stress. This may be due to
different regulatory structures among organizations.
Based on the PRECEDE-PROCEED planning model, in addition to discovering
the causes of stress in HCWs, the effective factors in modulating
stressful factors and creating healthy behavior are determined. One of
the special results of this study is the identification of the
employee’s personal context as the underlying factor in controlling the
mental pressure caused by the workplace. Previous studies have pointed
out the importance of the role of self-efficacy, self-esteem, and
optimism in work-related well-being (Xanthopoulou, Bakker, Demerouti, &
Schaufeli, 2009). Bandura (1997) defined self-efficacy as a person’s
confidence in his or her ability to organize and implement a certain
action to solve a problem or perform a task. Other evidence reported a
negative correlation between self-efficacy and stress control (Jurado,
Pérez-Fuentes, Ruiz, Márquez, & Linares, 2019). Moreover, it has been
found that HCWs with low self-esteem are more exposed to high stress (A.
R. Johnson et al., 2020). In this study, it was also found that HCWs who
understand the value of themselves and their work and have confidence in
their abilities to manage work, have high job satisfaction and
motivation. On the other hand, the employee’s belief in the impact of
his or her job performance in the emergence of stress and the desire to
self-monitor, can lead to the discovery and elimination of job
performance weaknesses and ultimately reduce stress in some situations.
Employees’ knowledge and attitude to stress at work is another important
aspect for implementing a targeted stress control intervention at the
individual level, especially for training related to stress management.
Several theories focus on how beliefs relate to successful behaviors
(Eccles & Wigfield, 2002). This issue is especially important from the
aspect of the source of control as a predictor of job-related attitudes
and behaviors (Galvin, Randel, Collins, & Johnson, 2018; Nykänen,
Salmela-Aro, Tolvanen, & Vuori, 2019). According to locus of control
theory (Rotter, 1966), believing that others are responsible for
creating an outcome, as a source of external control, predicts avoidance
behavior in the face of stress. On the other hand, the internal locus of
control is related to help-seeking and positive thinking (Gianakos,
2002). Similarly, we found that caregivers who perceive the source of
stress as internal factors have different attitudes, such as the
importance of their role and the ability to control stress.
Similar to other qualitative studies (Akbar et al., 2016; Gilstrap &
Bernier, 2017), the participants of this study tended to use
problem-focused, emotional self-control, and maladaptive strategies to
cope with stress. The results show that using problem-focused strategies
is more useful in controlling stress. A study conducted by Rolin et al
(2022) shows that HCWs who used a problem-focused coping style had low
perceived threat and high perceived control. Meanwhile, similar to our
findings, the study by Bakker & de Vries ( 2021) reports that employees
turn to maladaptive self-regulation strategies when faced with increased
job pressure. Furthermore, what we have found out is that some HCWs turn
to one of these two modes when faced with job pressures out of necessity
and compulsion or voluntarily; first, they manage to provide themselves
with false safe conditions by pretending to be committed to work, do
less work, and receive their salary. If they do not achieve this goal,
they will experience disappointment and even depression.
Enabling factors are needed to achieve stress control in the workplace.
Neglecting the enabling factors can act as a barrier to achieving the
goal of the intervention. Most studies have identified job autonomy as a
moderating factor of stress in the workplace (Broetje et al., 2020;
Ibrahim et al., 2021). In this study, it was observed that the existence
of high levels of organizational control causes a decrease in the levels
of personal control and an increase in psychological pressure.
While occupational and organizational changes are a natural feature of
work, if the management of changes is weak, such as forced transfers, it
causes resistance to change, feelings of job insecurity, and anxiety
(Bagheri Hosseinabadi et al., 2018). Similarly, our findings confirm
this issue.
To create and sustain the motivation and workplace stress controlling
behaviors, reinforcing factors are needed. The reinforcing factors in
this present study have individual, social and organizational aspects.
We found that when HCWs feel that they are supported by managers and
supervisors, there is a sense of commitment, peace of mind, and reduced
anxiety. Receiving feedback from the manager can strengthen performance
and motivation, and the lack of it may be the cause of workplace stress
(Randall R. Ross, 2000). We found that if performance feedback is
accompanied by guidance and encouragement, it can motivate and improve
performance; otherwise it can be a key stressor. Also, praise and
recognition from the supervisor and clients is effective support. In
addition, according to the findings of Kokoroko and Sanda ( 2019) and
our study, the support of colleagues in the form of work partnerships
and emotional support is also important in reducing stress. Although the
HCWs participating in our study had the same duties, the foremen, who
had another different and administrative role, reported poor co-workers’
support in increasing work and psychological stress. It seems that the
difference in tasks can affect the importance of co-worker support.
Similarly, the findings of several studies emphasize the importance and
positive impact of organizational and social support on improving
workplace mental health and job motivation (Hayward, McVilly, & Stokes,
2020; Kisely et al., 2020; Moll, 2014).
Moreover, the participants of this study repeatedly mentioned the
understanding, importance and impact of internal rewards, such as
personal satisfaction from completing an activity and gaining a sense of
competence. Other studies have acknowledged the importance of intrinsic
rewards in increasing motivation and improving job performance (Anjum,
Islam, Choudhury, & Saha, 2021; Manzoor, Wei, & Asif, 2021;
Senanayake, 2021).
Finally, the results of this research show that it is important to
develop, change and revise organizational policies, managerial and
supervisory approaches to make changes and implement interventions in
the workplace. It seems necessary to pay attention to increasing job
authority and participation for changes among HCWs and especially
foremen. In this regard, Kool et al (2019) reported that a high level of
independence is required both for service delivery and
organizational/administrative aspects of the job. Organizations can
minimize organizational control by redesigning jobs, developing new
skills, and empowering employees for autonomy (Fagerlind Ståhl, Ståhl,
& Smith, 2018; Weinberg, Sutherland, & Cooper, 2010). Furthermore, job
changes can be done with the participation of employees and provide them
with the opportunity to influence the changes.
Similar to a review study, we found that constructive supervision not
only protects the individual from the negative effects of stress
(Mcvicar, 2016), but also increases the productivity and motivation of
employees. Therefore, it seems important to empower managers and
supervisors by focusing on improving supervisory techniques and skills,
positive support and guidance in monitoring, and adopting appropriate
policies to deal with poor performance.
On the other hand, the findings of this study show that, for the
implementation of interventions at the individual level, the development
of effective behaviors for stress control, including the improvement of
interpersonal relationships and stress management strategies training,
is needed. In addition, the results of our study indicate that the
participants have a desire to increase knowledge and skills related to
stress management. Considering the inevitability of some stressors in
health-related professions and the impact of individual stressors, this
argument seems reasonable.