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.