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Article contents

Work, stress, coping, and stress management.

• Sharon Glazer Sharon Glazer University of Baltimore
•  and  Cong Liu Cong Liu Hofstra University
• https://doi.org/10.1093/acrefore/9780190236557.013.30
• Published online: 26 April 2017

Work stress refers to the process of job stressors, or stimuli in the workplace, leading to strains, or negative responses or reactions. Organizational development refers to a process in which problems or opportunities in the work environment are identified, plans are made to remediate or capitalize on the stimuli, action is taken, and subsequently the results of the plans and actions are evaluated. When organizational development strategies are used to assess work stress in the workplace, the actions employed are various stress management interventions. Two key factors tying work stress and organizational development are the role of the person and the role of the environment. In order to cope with work-related stressors and manage strains, organizations must be able to identify and differentiate between factors in the environment that are potential sources of stressors and how individuals perceive those factors. Primary stress management interventions focus on preventing stressors from even presenting, such as by clearly articulating workers’ roles and providing necessary resources for employees to perform their job. Secondary stress management interventions focus on a person’s appraisal of job stressors as a threat or challenge, and the person’s ability to cope with the stressors (presuming sufficient internal resources, such as a sense of meaningfulness in life, or external resources, such as social support from a supervisor). When coping is not successful, strains may develop. Tertiary stress management interventions attempt to remediate strains, by addressing the consequence itself (e.g., diabetes management) and/or the source of the strain (e.g., reducing workload). The person and/or the organization may be the targets of the intervention. The ultimate goal of stress management interventions is to minimize problems in the work environment, intensify aspects of the work environment that create a sense of a quality work context, enable people to cope with stressors that might arise, and provide tools for employees and organizations to manage strains that might develop despite all best efforts to create a healthy workplace.

• stress management
• organization development
• organizational interventions
• stress theories and frameworks

Introduction

Work stress is a generic term that refers to work-related stimuli (aka job stressors) that may lead to physical, behavioral, or psychological consequences (i.e., strains) that affect both the health and well-being of the employee and the organization. Not all stressors lead to strains, but all strains are a result of stressors, actual or perceived. Common terms often used interchangeably with work stress are occupational stress, job stress, and work-related stress. Terms used interchangeably with job stressors include work stressors, and as the specificity of the type of stressor might include psychosocial stressor (referring to the psychological experience of work demands that have a social component, e.g., conflict between two people; Hauke, Flintrop, Brun, & Rugulies, 2011 ), hindrance stressor (i.e., a stressor that prevents goal attainment; Cavanaugh, Boswell, Roehling, & Boudreau, 2000 ), and challenge stressor (i.e., a stressor that is difficult, but attainable and possibly rewarding to attain; Cavanaugh et al., 2000 ).

Stress in the workplace continues to be a highly pervasive problem, having both direct negative effects on individuals experiencing it and companies paying for it, and indirect costs vis à vis lost productivity (Dopkeen & DuBois, 2014 ). For example, U.K. public civil servants’ work-related stress rose from 10.8% in 2006 to 22.4% in 2013 and about one-third of the workforce has taken more than 20 days of leave due to stress-related ill-health, while well over 50% are present at work when ill (French, 2015 ). These findings are consistent with a report by the International Labor Organization (ILO, 2012 ), whereby 50% to 60% of all workdays are lost due to absence attributed to factors associated with work stress.

The prevalence of work-related stress is not diminishing despite improvements in technology and employment rates. The sources of stress, such as workload, seem to exacerbate with improvements in technology (Coovert & Thompson, 2003 ). Moreover, accessibility through mobile technology and virtual computer terminals is linking people to their work more than ever before (ILO, 2012 ; Tarafdar, Tu, Ragu-Nathan, & Ragu-Nathan, 2007 ). Evidence of this kind of mobility and flexibility is further reinforced in a June 2007 survey of 4,025 email users (over 13 years of age); AOL reported that four in ten survey respondents reported planning their vacations around email accessibility and 83% checked their emails at least once a day while away (McMahon, 2007 ). Ironically, despite these mounting work-related stressors and clear financial and performance outcomes, some individuals are reporting they are less “stressed,” but only because “stress has become the new normal” (Jayson, 2012 , para. 4).

This new normal is likely the source of psychological and physiological illness. Siegrist ( 2010 ) contends that conditions in the workplace, particularly psychosocial stressors that are perceived as unfavorable relationships with others and self, and an increasingly sedentary lifestyle (reinforced with desk jobs) are increasingly contributing to cardiovascular disease. These factors together justify a need to continue on the path of helping individuals recognize and cope with deleterious stressors in the work environment and, equally important, to find ways to help organizations prevent harmful stressors over which they have control, as well as implement policies or mechanisms to help employees deal with these stressors and subsequent strains. Along with a greater focus on mitigating environmental constraints are interventions that can be used to prevent anxiety, poor attitudes toward the workplace conditions and arrangements, and subsequent cardiovascular illness, absenteeism, and poor job performance (Siegrist, 2010 ).

Even the ILO has presented guidance on how the workplace can help prevent harmful job stressors (aka hindrance stressors) or at least help workers cope with them. Consistent with the view that well-being is not the absence of stressors or strains and with the view that positive psychology offers a lens for proactively preventing stressors, the ILO promotes increasing preventative risk assessments, interventions to prevent and control stressors, transparent organizational communication, worker involvement in decision-making, networks and mechanisms for workplace social support, awareness of how working and living conditions interact, safety, health, and well-being in the organization (ILO, n.d. ). The field of industrial and organizational (IO) psychology supports the ILO’s recommendations.

IO psychology views work stress as the process of a person’s interaction with multiple aspects of the work environment, job design, and work conditions in the organization. Interventions to manage work stress, therefore, focus on the psychosocial factors of the person and his or her relationships with others and the socio-technical factors related to the work environment and work processes. Viewing work stress from the lens of the person and the environment stems from Kurt Lewin’s ( 1936 ) work that stipulates a person’s state of mental health and behaviors are a function of the person within a specific environment or situation. Aspects of the work environment that affect individuals’ mental states and behaviors include organizational hierarchy, organizational climate (including processes, policies, practices, and reward structures), resources to support a person’s ability to fulfill job duties, and management structure (including leadership). Job design refers to each contributor’s tasks and responsibilities for fulfilling goals associated with the work role. Finally, working conditions refers not only to the physical environment, but also the interpersonal relationships with other contributors.

Each of the conditions that are identified in the work environment may be perceived as potentially harmful or a threat to the person or as an opportunity. When a stressor is perceived as a threat to attaining desired goals or outcomes, the stressor may be labeled as a hindrance stressor (e.g., LePine, Podsakoff, & Lepine, 2005 ). When the stressor is perceived as an opportunity to attain a desired goal or end state, it may be labeled as a challenge stressor. According to LePine and colleagues’ ( 2005 ), both challenge (e.g., time urgency, workload) and hindrance (e.g., hassles, role ambiguity, role conflict) stressors could lead to strains (as measured by “anxiety, depersonalization, depression, emotional exhaustion, frustration, health complaints, hostility, illness, physical symptoms, and tension” [p. 767]). However, challenge stressors positively relate with motivation and performance, whereas hindrance stressors negatively relate with motivation and performance. Moreover, motivation and strains partially mediate the relationship between hindrance and challenge stressors with performance.

Figure 1. Organizational development frameworks to guide identification of work stress and interventions.

In order to (1) minimize any potential negative effects from stressors, (2) increase coping skills to deal with stressors, or (3) manage strains, organizational practitioners or consultants will devise organizational interventions geared toward prevention, coping, and/or stress management. Ultimately, toxic factors in the work environment can have deleterious effects on a person’s physical and psychological well-being, as well as on an organization’s total health. It behooves management to take stock of the organization’s health, which includes the health and well-being of its employees, if the organization wishes to thrive and be profitable. According to Page and Vella-Brodrick’s ( 2009 ) model of employee well-being, employee well-being results from subjective well-being (i.e., life satisfaction and general positive or negative affect), workplace well-being (composed of job satisfaction and work-specific positive or negative affect), and psychological well-being (e.g., self-acceptance, positive social relations, mastery, purpose in life). Job stressors that become unbearable are likely to negatively affect workplace well-being and thus overall employee well-being. Because work stress is a major organizational pain point and organizations often employ organizational consultants to help identify and remediate pain points, the focus here is on organizational development (OD) frameworks; several work stress frameworks are presented that together signal areas where organizations might focus efforts for change in employee behaviors, attitudes, and performance, as well as the organization’s performance and climate. Work stress, interventions, and several OD and stress frameworks are depicted in Figure 1 .

The goals are: (1) to conceptually define and clarify terms associated with stress and stress management, particularly focusing on organizational factors that contribute to stress and stress management, and (2) to present research that informs current knowledge and practices on workplace stress management strategies. Stressors and strains will be defined, leading OD and work stress frameworks that are used to organize and help organizations make sense of the work environment and the organization’s responsibility in stress management will be explored, and stress management will be explained as an overarching thematic label; an area of study and practice that focuses on prevention (primary) interventions, coping (secondary) interventions, and managing strains (tertiary) interventions; as well as the label typically used to denote tertiary interventions. Suggestions for future research and implications toward becoming a healthy organization are presented.

Defining Stressors and Strains

Work-related stressors or job stressors can lead to different kinds of strains individuals and organizations might experience. Various types of stress management interventions, guided by OD and work stress frameworks, may be employed to prevent or cope with job stressors and manage strains that develop(ed).

A job stressor is a stimulus external to an employee and a result of an employee’s work conditions. Example job stressors include organizational constraints, workplace mistreatments (such as abusive supervision, workplace ostracism, incivility, bullying), role stressors, workload, work-family conflicts, errors or mistakes, examinations and evaluations, and lack of structure (Jex & Beehr, 1991 ; Liu, Spector, & Shi, 2007 ; Narayanan, Menon, & Spector, 1999 ). Although stressors may be categorized as hindrances and challenges, there is not yet sufficient information to be able to propose which stress management interventions would better serve to reduce those hindrance stressors or to reduce strain-producing challenge stressors while reinforcing engagement-producing challenge stressors.

Organizational Constraints

Organizational constraints may be hindrance stressors as they prevent employees from translating their motivation and ability into high-level job performance (Peters & O’Connor, 1980 ). Peters and O’Connor ( 1988 ) defined 11 categories of organizational constraints: (1) job-related information, (2) budgetary support, (3) required support, (4) materials and supplies, (5) required services and help from others, (6) task preparation, (7) time availability, (8) the work environment, (9) scheduling of activities, (10) transportation, and (11) job-relevant authority. The inhibiting effect of organizational constraints may be due to the lack of, inadequacy of, or poor quality of these categories.

Workplace Mistreatment

Workplace mistreatment presents a cluster of interpersonal variables, such as interpersonal conflict, bullying, incivility, and workplace ostracism (Hershcovis, 2011 ; Tepper & Henle, 2011 ). Typical workplace mistreatment behaviors include gossiping, rude comments, showing favoritism, yelling, lying, and ignoring other people at work (Tepper & Henle, 2011 ). These variables relate to employees’ psychological well-being, physical well-being, work attitudes (e.g., job satisfaction and organizational commitment), and turnover intention (e.g., Hershcovis, 2011 ; Spector & Jex, 1998 ). Some researchers differentiated the source of mistreatment, such as mistreatment from one’s supervisor versus mistreatment from one’s coworker (e.g., Bruk-Lee & Spector, 2006 ; Frone, 2000 ; Liu, Liu, Spector, & Shi, 2011 ).

Role Stressors

Role stressors are demands, constraints, or opportunities a person perceives to be associated, and thus expected, with his or her work role(s) across various situations. Three commonly studied role stressors are role ambiguity, role conflict, and role overload (Glazer & Beehr, 2005 ; Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964 ). Role ambiguity in the workplace occurs when an employee lacks clarity regarding what performance-related behaviors are expected of him or her. Role conflict refers to situations wherein an employee receives incompatible role requests from the same or different supervisors or the employee is asked to engage in work that impedes his or her performance in other work or nonwork roles or clashes with his or her values. Role overload refers to excessive demands and insufficient time (quantitative) or knowledge (qualitative) to complete the work. The construct is often used interchangeably with workload, though role overload focuses more on perceived expectations from others about one’s workload. These role stressors significantly relate to low job satisfaction, low organizational commitment, low job performance, high tension or anxiety, and high turnover intention (Abramis, 1994 ; Glazer & Beehr, 2005 ; Jackson & Schuler, 1985 ).

Excessive workload is one of the most salient stressors at work (e.g., Liu et al., 2007 ). There are two types of workload: quantitative and qualitative workload (LaRocco, Tetrick, & Meder, 1989 ; Parasuraman & Purohit, 2000 ). Quantitative workload refers to the excessive amount of work one has. In a summary of a Chartered Institute of Personnel & Development Report from 2006 , Dewe and Kompier ( 2008 ) noted that quantitative workload was one of the top three stressors workers experienced at work. Qualitative workload refers to the difficulty of work. Workload also differs by the type of the load. There are mental workload and physical workload (Dwyer & Ganster, 1991 ). Excessive physical workload may result in physical discomfort or illness. Excessive mental workload will cause psychological distress such as anxiety or frustration (Bowling & Kirkendall, 2012 ). Another factor affecting quantitative workload is interruptions (during the workday). Lin, Kain, and Fritz ( 2013 ) found that interruptions delay completion of job tasks, thus adding to the perception of workload.

Work-Family Conflict

Work-family conflict is a form of inter-role conflict in which demands from one’s work domain and one’s family domain are incompatible to some extent (Greenhaus & Beutell, 1985 ). Work can interfere with family (WIF) and/or family can interfere with work (FIW) due to time-related commitments to participating in one domain or another, incompatible behavioral expectations, or when strains in one domain carry over to the other (Greenhaus & Beutell, 1985 ). Work-family conflict significantly relates to work-related outcomes (e.g., job satisfaction, organizational commitment, turnover intention, burnout, absenteeism, job performance, job strains, career satisfaction, and organizational citizenship behaviors), family-related outcomes (e.g., marital satisfaction, family satisfaction, family-related performance, family-related strains), and domain-unspecific outcomes (e.g., life satisfaction, psychological strain, somatic or physical symptoms, depression, substance use or abuse, and anxiety; Amstad, Meier, Fasel, Elfering, & Semmer, 2011 ).

Individuals and organizations can experience work-related strains. Sometimes organizations will experience strains through the employee’s negative attitudes or strains, such as that a worker’s absence might yield lower production rates, which would roll up into an organizational metric of organizational performance. In the industrial and organizational (IO) psychology literature, organizational strains are mostly observed as macro-level indicators, such as health insurance costs, accident-free days, and pervasive problems with company morale. In contrast, individual strains, usually referred to as job strains, are internal to an employee. They are responses to work conditions and relate to health and well-being of employees. In other words, “job strains are adverse reactions employees have to job stressors” (Spector, Chen, & O’Connell, 2000 , p. 211). Job strains tend to fall into three categories: behavioral, physical, and psychological (Jex & Beehr, 1991 ).

Behavioral strains consist of actions that employees take in response to job stressors. Examples of behavioral strains include employees drinking alcohol in the workplace or intentionally calling in sick when they are not ill (Spector et al., 2000 ). Physical strains consist of health symptoms that are physiological in nature that employees contract in response to job stressors. Headaches and ulcers are examples of physical strains. Lastly, psychological strains are emotional reactions and attitudes that employees have in response to job stressors. Examples of psychological strains are job dissatisfaction, anxiety, and frustration (Spector et al., 2000 ). Interestingly, research studies that utilize self-report measures find that most job strains experienced by employees tend to be psychological strains (Spector et al., 2000 ).

Leading Frameworks

Organizations that are keen on identifying organizational pain points and remedying them through organizational campaigns or initiatives often discover the pain points are rooted in work-related stressors and strains and the initiatives have to focus on reducing workers’ stress and increasing a company’s profitability. Through organizational climate surveys, for example, companies discover that aspects of the organization’s environment, including its policies, practices, reward structures, procedures, and processes, as well as employees at all levels of the company, are contributing to the individual and organizational stress. Recent studies have even begun to examine team climates for eustress and distress assessed in terms of team members’ homogenous psychological experience of vigor, efficacy, dedication, and cynicism (e.g., Kożusznik, Rodriguez, & Peiro, 2015 ).

Each of the frameworks presented advances different aspects that need to be identified in order to understand the source and potential remedy for stressors and strains. In some models, the focus is on resources, in others on the interaction of the person and environment, and in still others on the role of the person in the workplace. Few frameworks directly examine the role of the organization, but the organization could use these frameworks to plan interventions that would minimize stressors, cope with existing stressors, and prevent and/or manage strains. One of the leading frameworks in work stress research that is used to guide organizational interventions is the person and environment (P-E) fit (French & Caplan, 1972 ). Its precursor is the University of Michigan Institute for Social Research’s (ISR) role stress model (Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964 ) and Lewin’s Field Theory. Several other theories have since evolved from the P-E fit framework, including Karasek and Theorell’s ( 1990 ), Karasek ( 1979 ) Job Demands-Control Model (JD-C), the transactional framework (Lazarus & Folkman, 1984 ), Conservation of Resources (COR) theory (Hobfoll, 1989 ), and Siegrist’s ( 1996 ) Effort-Reward Imbalance (ERI) Model.

Field Theory

The premise of Kahn et al.’s ( 1964 ) role stress theory is Lewin’s ( 1997 ) Field Theory. Lewin purported that behavior and mental events are a dynamic function of the whole person, including a person’s beliefs, values, abilities, needs, thoughts, and feelings, within a given situation (field or environment), as well as the way a person represents his or her understanding of the field and behaves in that space. Lewin explains that work-related strains are a result of individuals’ subjective perceptions of objective factors, such as work roles, relationships with others in the workplace, as well as personality indicators, and can be used to predict people’s reactions, including illness. Thus, to make changes to an organizational system, it is necessary to understand a field and try to move that field from the current state to the desired state. Making this move necessitates identifying mechanisms influencing individuals.

Role Stress Theory

Role stress theory mostly isolates the perspective a person has about his or her work-related responsibilities and expectations to determine how those perceptions relate with a person’s work-related strains. However, those relationships have been met with somewhat varied results, which Glazer and Beehr ( 2005 ) concluded might be a function of differences in culture, an environmental factor often neglected in research. Kahn et al.’s ( 1964 ) role stress theory, coupled with Lewin’s ( 1936 ) Field Theory, serves as the foundation for the P-E fit theory. Lewin ( 1936 ) wrote, “Every psychological event depends upon the state of the person and at the same time on the environment” (p. 12). Researchers of IO psychology have narrowed the environment to the organization or work team. This narrowed view of the organizational environment is evident in French and Caplan’s ( 1972 ) P-E fit framework.

Person-Environment Fit Theory

The P-E fit framework focuses on the extent to which there is congruence between the person and a given environment, such as the organization (Caplan, 1987 ; Edwards, 2008 ). For example, does the person have the necessary skills and abilities to fulfill an organization’s demands, or does the environment support a person’s desire for autonomy (i.e., do the values align?) or fulfill a person’s needs (i.e., a person’s needs are rewarded). Theoretically and empirically, the greater the person-organization fit, the greater a person’s job satisfaction and organizational commitment, the less a person’s turnover intention and work-related stress (see meta-analyses by Assouline & Meir, 1987 ; Kristof-Brown, Zimmerman, & Johnson, 2005 ; Verquer, Beehr, & Wagner, 2003 ).

Job Demands-Control/Support (JD-C/S) and Job Demands-Resources (JD-R) Model

Focusing more closely on concrete aspects of work demands and the extent to which a person perceives he or she has control or decision latitude over those demands, Karasek ( 1979 ) developed the JD-C model. Karasek and Theorell ( 1990 ) posited that high job demands under conditions of little decision latitude or control yield high strains, which have varied implications on the health of an organization (e.g., in terms of high turnover, employee ill-health, poor organizational performance). This theory was modified slightly to address not only control, but also other resources that could protect a person from unruly job demands, including support (aka JD-C/S, Johnson & Hall, 1988 ; and JD-R, Bakker, van Veldhoven, & Xanthopoulou, 2010 ). Whether focusing on control or resources, both they and job demands are said to reflect workplace characteristics, while control and resources also represent coping strategies or tools (Siegrist, 2010 ).

Despite the glut of research testing the JD-C and JD-R, results are somewhat mixed. Testing the interaction between job demands and control, Beehr, Glaser, Canali, and Wallwey ( 2001 ) did not find empirical support for the JD-C theory. However, Dawson, O’Brien, and Beehr ( 2016 ) found that high control and high support buffered against the independent deleterious effects of interpersonal conflict, role conflict, and organizational politics (demands that were categorized as hindrance stressors) on anxiety, as well as the effects of interpersonal conflict and organizational politics on physiological symptoms, but control and support did not moderate the effects between challenge stressors and strains. Coupled with Bakker, Demerouti, and Sanz-Vergel’s ( 2014 ) note that excessive job demands are a source of strain, but increased job resources are a source of engagement, Dawson et al.’s results suggest that when an organization identifies that demands are hindrances, it can create strategies for primary (preventative) stress management interventions and attempt to remove or reduce such work demands. If the demands are challenging, though manageable, but latitude to control the challenging stressors and support are insufficient, the organization could modify practices and train employees on adopting better strategies for meeting or coping (secondary stress management intervention) with the demands. Finally, if the organization can neither afford to modify the demands or the level of control and support, it will be necessary for the organization to develop stress management (tertiary) interventions to deal with the inevitable strains.

Conservation of Resources Theory

The idea that job resources reinforce engagement in work has been propagated in Hobfoll’s ( 1989 ) Conservation of Resources (COR) theory. COR theory also draws on the foundational premise that people’s mental health is a function of the person and the environment, forwarding that how people interpret their environment (including the societal context) affects their stress levels. Hobfoll focuses on resources such as objects, personal characteristics, conditions, or energies as particularly instrumental to minimizing strains. He asserts that people do whatever they can to protect their valued resources. Thus, strains develop when resources are threatened to be taken away, actually taken away, or when additional resources are not attainable after investing in the possibility of gaining more resources (Hobfoll, 2001 ). By extension, organizations can invest in activities that would minimize resource loss and create opportunities for resource gains and thus have direct implications for devising primary and secondary stress management interventions.

Transactional Framework

Lazarus and Folkman ( 1984 ) developed the widely studied transactional framework of stress. This framework holds as a key component the cognitive appraisal process. When individuals perceive factors in the work environment as a threat (i.e., primary appraisal), they will scan the available resources (external or internal to himself or herself) to cope with the stressors (i.e., secondary appraisal). If the coping resources provide minimal relief, strains develop. Until recently, little attention has been given to the cognitive appraisal associated with different work stressors (Dewe & Kompier, 2008 ; Liu & Li, 2017 ). In a study of Polish and Spanish social care service providers, stressors appraised as a threat related positively to burnout and less engagement, but stressors perceived as challenges yielded greater engagement and less burnout (Kożusznik, Rodriguez, & Peiro, 2012 ). Similarly, Dawson et al. ( 2016 ) found that even with support and control resources, hindrance demands were more strain-producing than challenge demands, suggesting that appraisal of the stressor is important. In fact, “many people respond well to challenging work” (Beehr et al., 2001 , p. 126). Kożusznik et al. ( 2012 ) recommend training employees to change the way they view work demands in order to increase engagement, considering that part of the problem may be about how the person appraises his or her environment and, thus, copes with the stressors.

Effort-Reward Imbalance

Siegrist’s ( 1996 ) Model of Effort-Reward Imbalance (ERI) focuses on the notion of social reciprocity, such that a person fulfills required work tasks in exchange for desired rewards (Siegrist, 2010 ). ERI sheds light on how an imbalance in a person’s expectations of an organization’s rewards (e.g., pay, bonus, sense of advancement and development, job security) in exchange for a person’s efforts, that is a break in one’s work contract, leads to negative responses, including long-term ill-health (Siegrist, 2010 ; Siegrist et al., 2014 ). In fact, prolonged perception of a work contract imbalance leads to adverse health, including immunological problems and inflammation, which contribute to cardiovascular disease (Siegrist, 2010 ). The model resembles the relational and interactional psychological contract theory in that it describes an employee’s perception of the terms of the relationship between the person and the workplace, including expectations of performance, job security, training and development opportunities, career progression, salary, and bonuses (Thomas, Au, & Ravlin, 2003 ). The psychological contract, like the ERI model, focuses on social exchange. Furthermore, the psychological contract, like stress theories, are influenced by cultural factors that shape how people interpret their environments (Glazer, 2008 ; Thomas et al., 2003 ). Violations of the psychological contract will negatively affect a person’s attitudes toward the workplace and subsequent health and well-being (Siegrist, 2010 ). To remediate strain, Siegrist ( 2010 ) focuses on both the person and the environment, recognizing that the organization is particularly responsible for changing unfavorable work conditions and the person is responsible for modifying his or her reactions to such conditions.

Stress Management Interventions: Primary, Secondary, and Tertiary

Remediation of work stress and organizational development interventions are about realigning the employee’s experiences in the workplace with factors in the environment, as well as closing the gap between the current environment and the desired environment. Work stress develops when an employee perceives the work demands to exceed the person’s resources to cope and thus threatens employee well-being (Dewe & Kompier, 2008 ). Likewise, an organization’s need to change arises when forces in the environment are creating a need to change in order to survive (see Figure 1 ). Lewin’s ( 1951 ) Force Field Analysis, the foundations of which are in Field Theory, is one of the first organizational development intervention tools presented in the social science literature. The concept behind Force Field Analysis is that in order to survive, organizations must adapt to environmental forces driving a need for organizational change and remove restraining forces that create obstacles to organizational change. In order to do this, management needs to delineate the current field in which the organization is functioning, understand the driving forces for change, identify and dampen or eliminate the restraining forces against change. Several models for analyses may be applied, but most approaches are variations of organizational climate surveys.

Through organizational surveys, workers provide management with a snapshot view of how they perceive aspects of their work environment. Thus, the view of the health of an organization is a function of several factors, chief among them employees’ views (i.e., the climate) about the workplace (Lewin, 1951 ). Indeed, French and Kahn ( 1962 ) posited that well-being depends on the extent to which properties of the person and properties of the environment align in terms of what a person requires and the resources available in a given environment. Therefore, only when properties of the person and properties of the environment are sufficiently understood can plans for change be developed and implemented targeting the environment (e.g., change reporting structures to relieve, and thus prevent future, communication stressors) and/or the person (e.g., providing more autonomy, vacation days, training on new technology). In short, climate survey findings can guide consultants about the emphasis for organizational interventions: before a problem arises aka stress prevention, e.g., carefully crafting job roles), when a problem is present, but steps are taken to mitigate their consequences (aka coping, e.g., providing social support groups), and/or once strains develop (aka. stress management, e.g., healthcare management policies).

For each of the primary (prevention), secondary (coping), and tertiary (stress management) techniques the target for intervention can be the entire workforce, a subset of the workforce, or a specific person. Interventions that target the entire workforce may be considered organizational interventions, as they have direct implications on the health of all individuals and consequently the health of the organization. Several interventions categorized as primary and secondary interventions may also be implemented after strains have developed and after it has been discerned that a person or the organization did not do enough to mitigate stressors or strains (see Figure 1 ). The designation of many of the interventions as belonging to one category or another may be viewed as merely a suggestion.

Primary Interventions (Preventative Stress Management)

Before individuals begin to perceive work-related stressors, organizations engage in stress prevention strategies, such as providing people with resources (e.g., computers, printers, desk space, information about the job role, organizational reporting structures) to do their jobs. However, sometimes the institutional structures and resources are insufficient or ambiguous. Scholars and practitioners have identified several preventative stress management strategies that may be implemented.

Planning and Time Management

When employees feel quantitatively overloaded, sometimes the remedy is improving the employees’ abilities to plan and manage their time (Quick, Quick, Nelson, & Hurrell, 2003 ). Planning is a future-oriented activity that focuses on conceptual and comprehensive work goals. Time management is a behavior that focuses on organizing, prioritizing, and scheduling work activities to achieve short-term goals. Given the purpose of time management, it is considered a primary intervention, as engaging in time management helps to prevent work tasks from mounting and becoming unmanageable, which would subsequently lead to adverse outcomes. Time management comprises three fundamental components: (1) establishing goals, (2) identifying and prioritizing tasks to fulfill the goals, and (3) scheduling and monitoring progress toward goal achievement (Peeters & Rutte, 2005 ). Workers who employ time management have less role ambiguity (Macan, Shahani, Dipboye, & Philips, 1990 ), psychological stress or strain (Adams & Jex, 1999 ; Jex & Elaqua, 1999 ; Macan et al., 1990 ), and greater job satisfaction (Macan, 1994 ). However, Macan ( 1994 ) did not find a relationship between time management and performance. Still, Claessens, van Eerde, Rutte, and Roe ( 2004 ) found that perceived control of time partially mediated the relationships between planning behavior (an indicator of time management), job autonomy, and workload on one hand, and job strains, job satisfaction, and job performance on the other hand. Moreover, Peeters and Rutte ( 2005 ) observed that teachers with high work demands and low autonomy experienced more burnout when they had poor time management skills.

Person-Organization Fit

Just as it is important for organizations to find the right person for the job and organization, so is it the responsibility of a person to choose to work at the right organization—an organization that fulfills the person’s needs and upholds the values important to the individual, as much as the person fulfills the organization’s needs and adapts to its values. When people fit their employing organizations they are setting themselves up for experiencing less strain-producing stressors (Kristof-Brown et al., 2005 ). In a meta-analysis of 62 person-job fit studies and 110 person-organization fit studies, Kristof-Brown et al. ( 2005 ) found that person-job fit had a negative correlation with indicators of job strain. In fact, a primary intervention of career counseling can help to reduce stress levels (Firth-Cozens, 2003 ).

Job Redesign

The Job Demands-Control/Support (JD-C/S), Job Demands-Resources (JD-R), and transactional models all suggest that factors in the work context require modifications in order to reduce potential ill-health and poor organizational performance. Drawing on Hackman and Oldham’s ( 1980 ) Job Characteristics Model, it is possible to assess with the Job Diagnostics Survey (JDS) the current state of work characteristics related to skill variety, task identity, task significance, autonomy, and feedback. Modifying those aspects would help create a sense of meaningfulness, sense of responsibility, and feeling of knowing how one is performing, which subsequently affects a person’s well-being as identified in assessments of motivation, satisfaction, improved performance, and reduced withdrawal intentions and behaviors. Extending this argument to the stress models, it can be deduced that reducing uncertainty or perceived unfairness that may be associated with a person’s perception of these work characteristics, as well as making changes to physical characteristics of the environment (e.g., lighting, seating, desk, air quality), nature of work (e.g., job responsibilities, roles, decision-making latitude), and organizational arrangements (e.g., reporting structure and feedback mechanisms), can help mitigate against numerous ill-health consequences and reduced organizational performance. In fact, Fried et al. ( 2013 ) showed that healthy patients of a medical clinic whose jobs were excessively low (i.e., monotonous) or excessively high (i.e., overstimulating) on job enrichment (as measured by the JDS) had greater abdominal obesity than those whose jobs were optimally enriched. By taking stock of employees’ perceptions of the current work situation, managers might think about ways to enhance employees’ coping toolkit, such as training on how to deal with difficult clients or creating stimulating opportunities when jobs have low levels of enrichment.

Participatory Action Research Interventions

Participatory action research (PAR) is an intervention wherein, through group discussions, employees help to identify and define problems in organizational structure, processes, policies, practices, and reward structures, as well as help to design, implement, and evaluate success of solutions. PAR is in itself an intervention, but its goal is to design interventions to eliminate or reduce work-related factors that are impeding performance and causing people to be unwell. An example of a successful primary intervention, utilizing principles of PAR and driven by the JD-C and JD-C/S stress frameworks is Health Circles (HCs; Aust & Ducki, 2004 ).

HCs, developed in Germany in the 1980s, were popular practices in industries, such as metal, steel, and chemical, and service. Similar to other problem-solving practices, such as quality circles, HCs were based on the assumptions that employees are the experts of their jobs. For this reason, to promote employee well-being, management and administrators solicited suggestions and ideas from the employees to improve occupational health, thereby increasing employees’ job control. HCs also promoted communication between managers and employees, which had a potential to increase social support. With more control and support, employees would experience less strains and better occupational well-being.

Employing the three-steps of (1) problem analysis (i.e., diagnosis or discovery through data generated from organizational records of absenteeism length, frequency, rate, and reason and employee survey), (2) HC meetings (6 to 10 meetings held over several months to brainstorm ideas to improve occupational safety and health concerns identified in the discovery phase), and (3) HC evaluation (to determine if desired changes were accomplished and if employees’ reports of stressors and strains changed after the course of 15 months), improvements were to be expected (Aust & Ducki, 2004 ). Aust and Ducki ( 2004 ) reviewed 11 studies presenting 81 health circles in 30 different organizations. Overall study participants had high satisfaction with the HCs practices. Most companies acted upon employees’ suggestions (e.g., improving driver’s seat and cab, reducing ticket sale during drive, team restructuring and job rotation to facilitate communication, hiring more employees during summer time, and supervisor training program to improve leadership and communication skills) to improve work conditions. Thus, HCs represent a successful theory-grounded intervention to routinely improve employees’ occupational health.

Physical Setting

The physical environment or physical workspace has an enormous impact on individuals’ well-being, attitudes, and interactions with others, as well as on the implications on innovation and well-being (Oksanen & Ståhle, 2013 ; Vischer, 2007 ). In a study of 74 new product development teams (total of 437 study respondents) in Western Europe, Chong, van Eerde, Rutte, and Chai ( 2012 ) found that when teams were faced with challenge time pressures, meaning the teams had a strong interest and desire in tackling complex, but engaging tasks, when they were working proximally close with one another, team communication improved. Chong et al. assert that their finding aligns with prior studies that have shown that physical proximity promotes increased awareness of other team members, greater tendency to initiate conversations, and greater team identification. However, they also found that when faced with hindrance time pressures, physical proximity related to low levels of team communication, but when hindrance time pressure was low, team proximity had an increasingly greater positive relationship with team communication.

In addition to considering the type of work demand teams must address, other physical workspace considerations include whether people need to work collaboratively and synchronously or independently and remotely (or a combination thereof). Consideration needs to be given to how company contributors would satisfy client needs through various modes of communication, such as email vs. telephone, and whether individuals who work by a window might need shading to block bright sunlight from glaring on their computer screens. Finally, people who have to use the telephone for extensive periods of time would benefit from earphones to prevent neck strains. Most physical stressors are rather simple to rectify. However, companies are often not aware of a problem until after a problem arises, such as when a person’s back is strained from trying to move heavy equipment. Companies then implement strategies to remediate the environmental stressor. With the help of human factors, and organizational and office design consultants, many of the physical barriers to optimal performance can be prevented (Rousseau & Aubé, 2010 ). In a study of 215 French-speaking Canadian healthcare employees, Rousseau and Aubé ( 2010 ) found that although supervisor instrumental support positively related with affective commitment to the organization, the relationship was even stronger for those who reported satisfaction with the ambient environment (i.e., temperature, lighting, sound, ventilation, and cleanliness).

Secondary Interventions (Coping)

Secondary interventions, also referred to as coping, focus on resources people can use to mitigate the risk of work-related illness or workplace injury. Resources may include properties related to social resources, behaviors, and cognitive structures. Each of these resource domains may be employed to cope with stressors. Monat and Lazarus ( 1991 ) summarize the definition of coping as “an individual’s efforts to master demands (or conditions of harm, threat, or challenge) that are appraised (or perceived) as exceeding or taxing his or her resources” (p. 5). To master demands requires use of the aforementioned resources. Secondary interventions help employees become aware of the psychological, physical, and behavioral responses that may occur from the stressors presented in their working environment. Secondary interventions help a person detect and attend to stressors and identify resources for and ways of mitigating job strains. Often, coping strategies are learned skills that have a cognitive foundation and serve important functions in improving people’s management of stressors (Lazarus & Folkman, 1991 ). Coping is effortful, but with practice it becomes easier to employ. This idea is the foundation for understanding the role of resilience in coping with stressors. However, “not all adaptive processes are coping. Coping is a subset of adaptational activities that involves effort and does not include everything that we do in relating to the environment” (Lazarus & Folkman, 1991 , p. 198). Furthermore, sometimes to cope with a stressor, a person may call upon social support sources to help with tangible materials or emotional comfort. People call upon support resources because they help to restructure how a person approaches or thinks about the stressor.

Most secondary interventions are aimed at helping the individual, though companies, as a policy, might require all employees to partake in training aimed at increasing employees’ awareness of and skills aimed at handling difficult situations vis à vis company channels (e.g., reporting on sexual harassment or discrimination). Furthermore, organizations might institute mentoring programs or work groups to address various work-related matters. These programs employ awareness-raising activities, stress-education, or skills training (cf., Bhagat, Segovis, & Nelson, 2012 ), which include development of skills in problem-solving, understanding emotion-focused coping, identifying and using social support, and enhancing capacity for resilience. The aim of these programs, therefore, is to help employees proactively review their perceptions of psychological, physical, and behavioral job-related strains, thereby extending their resilience, enabling them to form a personal plan to control stressors and practice coping skills (Cooper, Dewe, & O’Driscoll, 2011 ).

Often these stress management programs are instituted after an organization has observed excessive absenteeism and work-related performance problems and, therefore, are sometimes categorized as a tertiary stress management intervention or even a primary (prevention) intervention. However, the skills developed for coping with stressors also place the programs in secondary stress management interventions. Example programs that are categorized as tertiary or primary stress management interventions may also be secondary stress management interventions (see Figure 1 ), and these include lifestyle advice and planning, stress inoculation training, simple relaxation techniques, meditation, basic trainings in time management, anger management, problem-solving skills, and cognitive-behavioral therapy. Corporate wellness programs also fall under this category. In other words, some programs could be categorized as primary, secondary, or tertiary interventions depending upon when the employee (or organization) identifies the need to implement the program. For example, time management practices could be implemented as a means of preventing some stressors, as a way to cope with mounting stressors, or as a strategy to mitigate symptoms of excessive of stressors. Furthermore, these programs can be administered at the individual level or group level. As related to secondary interventions, these programs provide participants with opportunities to develop and practice skills to cognitively reappraise the stressor(s); to modify their perspectives about stressors; to take time out to breathe, stretch, meditate, relax, and/or exercise in an attempt to support better decision-making; to articulate concerns and call upon support resources; and to know how to say “no” to onslaughts of requests to complete tasks. Participants also learn how to proactively identify coping resources and solve problems.

According to Cooper, Dewe, and O’Driscoll ( 2001 ), secondary interventions are successful in helping employees modify or strengthen their ability to cope with the experience of stressors with the goal of mitigating the potential harm the job stressors may create. Secondary interventions focus on individuals’ transactions with the work environment and emphasize the fit between a person and his or her environment. However, researchers have pointed out that the underlying assumption of secondary interventions is that the responsibility for coping with the stressors of the environment lies within individuals (Quillian-Wolever & Wolever, 2003 ). If companies cannot prevent the stressors in the first place, then they are, in part, responsible for helping individuals develop coping strategies and informing employees about programs that would help them better cope with job stressors so that they are able to fulfill work assignments.

Stress management interventions that help people learn to cope with stressors focus mainly on the goals of enabling problem-resolution or expressing one’s emotions in a healthy manner. These goals are referred to as problem-focused coping and emotion-focused coping (Folkman & Lazarus, 1980 ; Pearlin & Schooler, 1978 ), and the person experiencing the stressors as potential threat is the agent for change and the recipient of the benefits of successful coping (Hobfoll, 1998 ). In addition to problem-focused and emotion-focused coping approaches, social support and resilience may be coping resources. There are many other sources for coping than there is room to present here (see e.g., Cartwright & Cooper, 2005 ); however, the current literature has primarily focused on these resources.

Problem-Focused Coping

Problem-focused or direct coping helps employees remove or reduce stressors in order to reduce their strain experiences (Bhagat et al., 2012 ). In problem-focused coping employees are responsible for working out a strategic plan in order to remove job stressors, such as setting up a set of goals and engaging in behaviors to meet these goals. Problem-focused coping is viewed as an adaptive response, though it can also be maladaptive if it creates more problems down the road, such as procrastinating getting work done or feigning illness to take time off from work. Adaptive problem-focused coping negatively relates to long-term job strains (Higgins & Endler, 1995 ). Discussion on problem-solving coping is framed from an adaptive perspective.

Problem-focused coping is featured as an extension of control, because engaging in problem-focused coping strategies requires a series of acts to keep job stressors under control (Bhagat et al., 2012 ). In the stress literature, there are generally two ways to categorize control: internal versus external locus of control, and primary versus secondary control. Locus of control refers to the extent to which people believe they have control over their own life (Rotter, 1966 ). People high in internal locus of control believe that they can control their own fate whereas people high in external locus of control believe that outside factors determine their life experience (Rotter, 1966 ). Generally, those with an external locus of control are less inclined to engage in problem-focused coping (Strentz & Auerbach, 1988 ). Primary control is the belief that people can directly influence their environment (Alloy & Abramson, 1979 ), and thus they are more likely to engage in problem-focused coping. However, when it is not feasible to exercise primary control, people search for secondary control, with which people try to adapt themselves into the objective environment (Rothbaum, Weisz, & Snyder, 1982 ).

Emotion-Focused Coping

Emotion-focused coping, sometimes referred to as palliative coping, helps employees reduce strains without the removal of job stressors. It involves cognitive or emotional efforts, such as talking about the stressor or distracting oneself from the stressor, in order to lessen emotional distress resulting from job stressors (Bhagat et al., 2012 ). Emotion-focused coping aims to reappraise and modify the perceptions of a situation or seek emotional support from friends or family. These methods do not include efforts to change the work situation or to remove the job stressors (Lazarus & Folkman, 1991 ). People tend to adopt emotion-focused coping strategies when they believe that little or nothing can be done to remove the threatening, harmful, and challenging stressors (Bhagat et al., 2012 ), such as when they are the only individuals to have the skills to get a project done or they are given increased responsibilities because of the unexpected departure of a colleague. Emotion-focused coping strategies include (1) reappraisal of the stressful situation, (2) talking to friends and receiving reassurance from them, (3) focusing on one’s strength rather than weakness, (4) optimistic comparison—comparing one’s situation to others’ or one’s past situation, (5) selective ignoring—paying less attention to the unpleasant aspects of one’s job and being more focused on the positive aspects of the job, (6) restrictive expectations—restricting one’s expectations on job satisfaction but paying more attention to monetary rewards, (7) avoidance coping—not thinking about the problem, leaving the situation, distracting oneself, or using alcohol or drugs (e.g., Billings & Moos, 1981 ).

Some emotion-focused coping strategies are maladaptive. For example, avoidance coping may lead to increased level of job strains in the long run (e.g., Parasuraman & Cleek, 1984 ). Furthermore, a person’s ability to cope with the imbalance of performing work to meet organizational expectations can take a toll on the person’s health, leading to physiological consequences such as cardiovascular disease, sleep disorders, gastrointestinal disorders, and diabetes (Fried et al., 2013 ; Siegrist, 2010 ; Toker, Shirom, Melamed, & Armon, 2012 ; Willert, Thulstrup, Hertz, & Bonde, 2010 ).

Comparing Coping Strategies across Cultures

Most coping research is conducted in individualistic, Western cultures wherein emotional control is emphasized and both problem-solving focused coping and primary control are preferred (Bhagat et al., 2010 ). However, in collectivistic cultures, emotion-focused coping and use of secondary control may be preferred and may not necessarily carry a negative evaluation (Bhagat et al., 2010 ). For example, African Americans are more likely to use emotion-focused coping than non–African Americans (Knight, Silverstein, McCallum, & Fox, 2000 ), and among women who experienced sexual harassment, Anglo American women were less likely to employ emotion focused coping (i.e., avoidance coping) than Turkish women and Hispanic American women, while Hispanic women used more denial than the other two groups (Wasti & Cortina, 2002 ).

Thus, whereas problem-focused coping is venerated in Western societies, emotion-focused coping may be more effective in reducing strains in collectivistic cultures, such as China, Japan, and India (Bhagat et al., 2010 ; Narayanan, Menon, & Spector, 1999 ; Selmer, 2002 ). Indeed, Swedish participants reported more problem-focused coping than did Chinese participants (Xiao, Ottosson, & Carlsson, 2013 ), American college students engaged in more problem-focused coping behaviors than did their Japanese counterparts (Ogawa, 2009 ), and Indian (vs. Canadian) students reported more emotion-focused coping, such as seeking social support and positive reappraisal (Sinha, Willson, & Watson, 2000 ). Moreover, Glazer, Stetz, and Izso ( 2004 ) found that internal locus of control was more predominant in individualistic cultures (United Kingdom and United States), whereas external locus of control was more predominant in communal cultures (Italy and Hungary). Also, internal locus of control was associated with less job stress, but more so for nurses in the United Kingdom and United States than Italy and Hungary. Taken together, adoption of coping strategies and their effectiveness differ significantly across cultures. The extent to which a coping strategy is perceived favorably and thus selected or not selected is not only a function of culture, but also a person’s sociocultural beliefs toward the coping strategy (Morimoto, Shimada, & Ozaki, 2013 ).

Social Support

Social support refers to the aid an entity gives to a person. The source of the support can be a single person, such as a supervisor, coworker, subordinate, family member, friend, or stranger, or an organization as represented by upper-level management representing organizational practices. The type of support can be instrumental or emotional. Instrumental support, including informational support, refers to that which is tangible, such as data to help someone make a decision or colleagues’ sick days so one does not lose vital pay while recovering from illness. Emotional support, including esteem support, refers to the psychological boost given to a person who needs to express emotions and feel empathy from others or to have his or her perspective validated. Beehr and Glazer ( 2001 ) present an overview of the role of social support on the stressor-strain relationship and arguments regarding the role of culture in shaping the utility of different sources and types of support.

Meaningfulness and Resilience

Meaningfulness reflects the extent to which people believe their lives are significant, purposeful, goal-directed, and fulfilling (Glazer, Kożusznik, Meyers, & Ganai, 2014 ). When faced with stressors, people who have a strong sense of meaning in life will also try to make sense of the stressors. Maintaining a positive outlook on life stressors helps to manage emotions, which is helpful in reducing strains, particularly when some stressors cannot be problem-solved (Lazarus & Folkman, 1991 ). Lazarus and Folkman ( 1991 ) emphasize that being able to reframe threatening situations can be just as important in an adaptation as efforts to control the stressors. Having a sense of meaningfulness motivates people to behave in ways that help them overcome stressors. Thus, meaningfulness is often used in the same breath as resilience, because people who are resilient are often protecting that which is meaningful.

Resilience is a personality state that can be fortified and enhanced through varied experiences. People who perceive their lives are meaningful are more likely to find ways to face adversity and are therefore more prone to intensifying their resiliency. When people demonstrate resilience to cope with noxious stressors, their ability to be resilient against other stressors strengthens because through the experience, they develop more competencies (Glazer et al., 2014 ). Thus, fitting with Hobfoll’s ( 1989 , 2001 ) COR theory, meaningfulness and resilience are psychological resources people attempt to conserve and protect, and employ when necessary for making sense of or coping with stressors.

Tertiary Interventions (Stress Management)

Stress management refers to interventions employed to treat and repair harmful repercussions of stressors that were not coped with sufficiently. As Lazarus and Folkman ( 1991 ) noted, not all stressors “are amenable to mastery” (p. 205). Stressors that are unmanageable and lead to strains require interventions to reverse or slow down those effects. Workplace interventions might focus on the person, the organization, or both. Unfortunately, instead of looking at the whole system to include the person and the workplace, most companies focus on the person. Such a focus should not be a surprise given the results of van der Klink, Blonk, Schene, and van Dijk’s ( 2001 ) meta-analysis of 48 experimental studies conducted between 1977 and 1996 . They found that of four types of tertiary interventions, the effect size for cognitive-behavioral interventions and multimodal programs (e.g., the combination of assertive training and time management) was moderate and the effect size for relaxation techniques was small in reducing psychological complaints, but not turnover intention related to work stress. However, the effects of (the five studies that used) organization-focused interventions were not significant. Similarly, Richardson and Rothstein’s ( 2008 ) meta-analytic study, including 36 experimental studies with 55 interventions, showed a larger effect size for cognitive-behavioral interventions than relaxation, organizational, multimodal, or alternative. However, like with van der Klink et al. ( 2001 ), Richardson and Rothstein ( 2008 ) cautioned that there were few organizational intervention studies included and the impact of interventions were determined on the basis of psychological outcomes and not physiological or organizational outcomes. Van der Klink et al. ( 2001 ) further expressed concern that organizational interventions target the workplace and that changes in the individual may take longer to observe than individual interventions aimed directly at the individual.

The long-term benefits of individual focused interventions are not yet clear either. Per Giga, Cooper, and Faragher ( 2003 ), the benefits of person-directed stress management programs will be short-lived if organizational factors to reduce stressors are not addressed too. Indeed, LaMontagne, Keegel, Louie, Ostry, and Landsbergis ( 2007 ), in their meta-analysis of 90 studies on stress management interventions published between 1990 and 2005 , revealed that in relation to interventions targeting organizations only, and interventions targeting individuals only, interventions targeting both organizations and individuals (i.e. the systems approach) had the most favorable positive effects on both the organizations and the individuals. Furthermore, the organization-level interventions were effective at both the individual and organization levels, but the individual-level interventions were effective only at the individual level.

Individual-Focused Stress Management

Individual-focused interventions concentrate on improving conditions for the individual, though counseling programs emphasize that the worker is in charge of reducing “stress,” whereas role-focused interventions emphasize activities that organizations can guide to actually reduce unnecessary noxious environmental factors.

Individual-Focused Stress Management: Employee Assistance Programs

When stress become sufficiently problematic (which is individually gauged or attended to by supportive others) in a worker’s life, employees may utilize the short-term counseling services or referral services Employee Assistance Programs (EAPs) provide. People who utilize the counseling services may engage in cognitive behavioral therapy aimed at changing the way people think about the stressors (e.g., as challenge opportunity over threat) and manage strains. Example topics that may be covered in these therapy sessions include time management and goal setting (prioritization), career planning and development, cognitive restructuring and mindfulness, relaxation, and anger management. In a study of healthcare workers and teachers who participated in a 2-day to 2.5-day comprehensive stress management training program (including 26 topics on identifying, coping with, and managing stressors and strains), Siu, Cooper, and Phillips ( 2013 ) found psychological and physical improvements were self-reported among the healthcare workers (for which there was no control group). However, comparing an intervention group of teachers to a control group of teachers, the extent of change was not as visible, though teachers in the intervention group engaged in more mastery recovery experiences (i.e., they purposefully chose to engage in challenging activities after work).

Individual-Focused Stress Management: Mindfulness

A popular therapy today is to train people to be more mindful, which involves helping people live in the present, reduce negative judgement of current and past experiences, and practicing patience (Birnie, Speca, & Carlson, 2010 ). Mindfulness programs usually include training on relaxation exercises, gentle yoga, and awareness of the body’s senses. In one study offered through the continuing education program at a Canadian university, 104 study participants took part in an 8-week, 90 minute per group (15–20 participants per) session mindfulness program (Birnie et al., 2010 ). In addition to body scanning, they also listened to lectures on incorporating mindfulness into one’s daily life and received a take-home booklet and compact discs that guided participants through the exercises studied in person. Two weeks after completing the program, participants’ mindfulness attendance and general positive moods increased, while physical, psychological, and behavioral strains decreased. In another study on a sample of U.K. government employees, study participants receiving three sessions of 2.5 to 3 hours each training on mindfulness, with the first two sessions occurring in consecutive weeks and the third occurring about three months later, Flaxman and Bond ( 2010 ) found that compared to the control group, the intervention group showed a decrease in distress levels from Time 1 (baseline) to Time 2 (three months after first two training sessions) and Time 1 to Time 3 (after final training session). Moreover, of the mindfulness intervention study participants who were clinically distressed, 69% experienced clinical improvement in their psychological health.

Individual-Focused Stress Management: Biofeedback/Imagery/Meditation/Deep Breathing

Biofeedback uses electronic equipment to inform users about how their body is responding to tension. With guidance from a therapist, individuals then learn to change their physiological responses so that their pulse normalizes and muscles relax (Norris, Fahrion, & Oikawa, 2007 ). The therapist’s guidance might include reminders for imagery, meditation, body scan relaxation, and deep breathing. Saunders, Driskell, Johnston, and Salas’s ( 1996 ) meta-analysis of 37 studies found that imagery helped reduce state and performance anxiety. Once people have been trained to relax, reminder triggers may be sent through smartphone push notifications (Villani et al., 2013 ).

Smartphone technology can also be used to support weight loss programs, smoking cessation programs, and medication or disease (e.g., diabetes) management compliance (Heron & Smyth, 2010 ; Kannampallil, Waicekauskas, Morrow, Kopren, & Fu, 2013 ). For example, smartphones could remind a person to take medications or test blood sugar levels or send messages about healthy behaviors and positive affirmations.

Individual-Focused Stress Management: Sleep/Rest/Respite

Workers today sleep less per night than adults did nearly 30 years ago (Luckhaupt, Tak, & Calvert, 2010 ; National Sleep Foundation, 2005 , 2013 ). In order to combat problems, such as increased anxiety and cardiovascular artery disease, associated with sleep deprivation and insufficient rest, it is imperative that people disconnect from their work at least one day per week or preferably for several weeks so that they are able to restore psychological health (Etzion, Eden, & Lapidot, 1998 ; Ragsdale, Beehr, Grebner, & Han, 2011 ). When college students engaged in relaxation-type activities, such as reading or watching television, over the weekend, they experienced less emotional exhaustion and greater general well-being than students who engaged in resources-consuming activities, such as house cleaning (Ragsdale et al., 2011 ). Additional research and future directions for research are reviewed and identified in the work of Sonnentag ( 2012 ). For example, she asks whether lack of ability to detach from work is problematic for people who find their work meaningful. In other words, are negative health consequences only among those who do not take pleasure in their work? Sonnetag also asks how teleworkers detach from their work when engaging in work from the home. Ironically, one of the ways that companies are trying to help with the challenges of high workload or increased need to be available to colleagues, clients, or vendors around the globe is by offering flexible work arrangements, whereby employees who can work from home are given the opportunity to do so. Companies that require global interactions 24-hours per day often employ this strategy, but is the solution also a source of strain (Glazer, Kożusznik, & Shargo, 2012 )?

Individual-Focused Stress Management: Role Analysis

Role analysis or role clarification aims to redefine, expressly identify, and align employees’ roles and responsibilities with their work goals. Through role negotiation, involved parties begin to develop a new formal or informal contract about expectations and define resources needed to fulfill those expectations. Glazer has used this approach in organizational consulting and, with one memorable client engagement, found that not only were the individuals whose roles required deeper re-evaluation happier at work (six months later), but so were their subordinates. Subordinates who once characterized the two partners as hostile and akin to a couple going through a bad divorce, later referred to them as a blissful pair. Schaubroeck, Ganster, Sime, and Ditman ( 1993 ) also found in a three-wave study over a two-year period that university employees’ reports of role clarity and greater satisfaction with their supervisor increased after a role clarification exercise of top managers’ roles and subordinates’ roles. However, the intervention did not have any impact on reported physical symptoms, absenteeism, or psychological well-being. Role analysis is categorized under individual-focused stress management intervention because it is usually implemented after individuals or teams begin to demonstrate poor performance and because the intervention typically focuses on a few individuals rather than an entire organization or group. In other words, the intervention treats the person’s symptoms by redefining the role so as to eliminate the stimulant causing the problem.

Organization-Focused Stress Management

At the organizational level, companies that face major declines in productivity and profitability or increased costs related to healthcare and disability might be motivated to reassess organizational factors that might be impinging on employees’ health and well-being. After all, without healthy workers, it is not possible to have a healthy organization. Companies may choose to implement practices and policies that are expected to help not only the employees, but also the organization with reduced costs associated with employee ill-health, such as medical insurance, disability payments, and unused office space. Example practices and policies that may be implemented include flexible work arrangements to ensure that employees are not on the streets in the middle of the night for work that can be done from anywhere (such as the home), diversity programs to reduce stress-induced animosity and prejudice toward others, providing only healthy food choices in cafeterias, mandating that all employees have physicals in order to receive reduced prices for insurance, company-wide closures or mandatory paid time off, and changes in organizational visioning.

Organization-Focused Stress Management: Organizational-Level Occupational Health Interventions

As with job design interventions that are implemented to remediate work characteristics that were a source of unnecessary or excessive stressors, so are organizational-level occupational health (OLOH) interventions. As with many of the interventions, its placement as a primary or tertiary stress management intervention may seem arbitrary, but when considering the goal and target of change, it is clear that the intervention is implemented in response to some ailing organizational issues that need to be reversed or stopped, and because it brings in the entire organization’s workforce to address the problems, it has been placed in this category. There are several more case studies than empirical studies on the topic of whole system organizational change efforts (see example case studies presented by the United Kingdom’s Health and Safety Executive). It is possible that lack of published empirical work is not so much due to lack of attempting to gather and evaluate the data for publication, but rather because the OLOH interventions themselves never made it to the intervention stage, the interventions failed (Biron, Gatrell, & Cooper, 2010 ), or the level of evaluation was not rigorous enough to get into empirical peer-review journals. Fortunately, case studies provide some indication of the opportunities and problems associated with OLOH interventions.

One case study regarding Cardiff and Value University Health Board revealed that through focus group meetings with members of a steering group (including high-level managers and supported by top management) and facilitated by a neutral, non-judgemental organizational health consultant, ideas for change were posted on newsprint, discussed, and areas in the organization needing change were identified. The intervention for giving voice to people who initially had little already had a positive effect on the organization, as absence decreased by 2.09% and 6.9% merely 12 and 18 months, respectively, after the intervention. Translated in financial terms, the 6.9% change was equivalent to a quarterly savings of £80,000 (Health & Safety Executive, n.d. ). Thus, focusing on the context of change and how people will be involved in the change process probably helped the organization realize improvements (Biron et al., 2010 ). In a recent and rare empirical study, employing both qualitative and quantitative data collection methods, Sørensen and Holman ( 2014 ) utilized PAR in order to plan and implement an OLOH intervention over the course of 14 months. Their study aimed to examine the effectiveness of the PAR process in reducing workers’ work-related and social or interpersonal-related stressors that derive from the workplace and improving psychological, behavioral, and physiological well-being across six Danish organizations. Based on group dialogue, 30 proposals for change were proposed, all of which could be categorized as either interventions to focus on relational factors (e.g., management feedback improvement, engagement) or work processes (e.g., reduced interruptions, workload, reinforcing creativity). Of the interventions that were implemented, results showed improvements on manager relationship quality and reduced burnout, but no changes with respect to work processes (i.e., workload and work pace) perhaps because the employees already had sufficient task control and variety. These findings support Dewe and Kompier’s ( 2008 ) position that occupational health can be reinforced through organizational policies that reinforce quality jobs and work experiences.

Organization-Focused Stress Management: Flexible Work Arrangements

Dewe and Kompier ( 2008 ), citing the work of Isles ( 2005 ), noted that concern over losing one’s job is a reason for why 40% of survey respondents indicated they work more hours than formally required. In an attempt to create balance and perceived fairness in one’s compensation for putting in extra work hours, employees will sometimes be legitimately or illegitimately absent. As companies become increasingly global, many people with desk jobs are finding themselves communicating with colleagues who are halfway around the globe and at all hours of the day or night (Glazer et al., 2012 ). To help minimize the strains associated with these stressors, companies might devise flexible work arrangements (FWA), though the type of FWA needs to be tailored to the cultural environment (Masuda et al., 2012 ). FWAs give employees some leverage to decide what would be the optimal work arrangement for them (e.g., part-time, flexible work hours, compressed work week, telecommuting). In other words, FWA provides employees with the choice of when to work, where to work (on-site or off-site), and how many hours to work in a day, week, or pay period (Kossek, Thompson, & Lautsch, 2015 ). However, not all employees of an organization have equal access to or equitable use of FWAs; workers in low-wage, hourly jobs are often beholden to being physically present during specific hours (Swanberg McKechnie, Ojha, & James, 2011 ). In a study of over 1,300 full-time hourly retail employees in the United States, Swanberg et al. ( 2011 ) showed that employees who have control over their work schedules and over their work hours were satisfied with their work schedules, perceived support from the supervisor, and work engagement.

Unfortunately, not all FWAs yield successful results for the individual or the organization. Being able to work from home or part-time can have problems too, as a person finds himself or herself working more hours from home than required. Sometimes telecommuting creates work-family conflict too as a person struggles to balance work and family obligations while working from home. Other drawbacks include reduced face-to-face contact between work colleagues and stakeholders, challenges shaping one’s career growth due to limited contact, perceived inequity if some have more flexibility than others, and ambiguity about work role processes for interacting with employees utilizing the FWA (Kossek et al., 2015 ). Organizations that institute FWAs must carefully weigh the benefits and drawbacks the flexibility may have on the employees using it or the employees affected by others using it, as well as the implications on the organization, including the vendors who are serving and clients served by the organization.

Organization-Focused Stress Management: Diversity Programs

Employees in the workplace might experience strain due to feelings of discrimination or prejudice. Organizational climates that do not promote diversity (in terms of age, religion, physical abilities, ethnicity, nationality, sex, and other characteristics) are breeding grounds for undesirable attitudes toward the workplace, lower performance, and greater turnover intention (Bergman, Palmieri, Drasgow, & Ormerod, 2012 ; Velez, Moradi, & Brewster, 2013 ). Management is thus advised to implement programs that reinforce the value and importance of diversity, as well as manage diversity to reduce conflict and feelings of prejudice. In fact, managers who attended a leadership training program reported higher multicultural competence in dealing with stressful situations (Chrobot-Mason & Leslie, 2012 ), and managers who persevered through challenges were more dedicated to coping with difficult diversity issues (Cilliers, 2011 ). Thus, diversity programs can help to reduce strains by directly reducing stressors associated with conflict linked to diversity in the workplace and by building managers’ resilience.

Organization-Focused Stress Management: Healthcare Management Policies

Over the past few years, organizations have adopted insurance plans that implement wellness programs for the sake of managing the increasing cost of healthcare that is believed to be a result of individuals’ not managing their own health, with regular check-ups and treatment. The wellness programs require all insured employees to visit a primary care provider, complete a health risk assessment, and engage in disease management activities as specified by a physician (e.g., see frequently asked questions regarding the State of Maryland’s Wellness Program). Companies believe that requiring compliance will reduce health problems, although there is no proof that such programs save money or that people would comply. One study that does, however, boast success, was a 12-week workplace health promotion program aimed at reducing Houston airport workers’ weight (Ebunlomo, Hare-Everline, Weber, & Rich, 2015 ). The program, which included 235 volunteer participants, was deemed a success, as there was a total weight loss of 345 pounds (or 1.5 lbs per person). Given such results in Houston, it is clear why some people are also skeptical over the likely success of wellness programs, particularly as there is no clear method for evaluating their efficacy (Sinnott & Vatz, 2015 ).

Moreover, for some, such a program is too paternalistic and intrusive, as well as punishes anyone who chooses not to actively participate in disease management programs (Sinnott & Vatz, 2015 ). The programs put the onus of change on the person, though it is a response to the high costs of ill-health. The programs neglect to consider the role of the organization in reducing the barriers to healthy lifestyle, such as cloaking exempt employment as simply needing to get the work done, when it usually means working significantly more hours than a standard workweek. In fact, workplace health promotion programs did not reduce presenteeism (i.e., people going to work while unwell thereby reducing their job performance) among those who suffered from physical pain (Cancelliere, Cassidy, Ammendolia, & Côte, 2011 ). However, supervisor education, worksite exercise, lifestyle intervention through email, midday respite from repetitive work, a global stress management program, changes in lighting, and telephone interventions helped to reduce presenteeism. Thus, emphasis needs to be placed on psychosocial aspects of the organization’s structure, including managers and overall organizational climate for on-site presence, that reinforces such behavior (Cancelliere et al., 2011 ). Moreover, wellness programs are only as good as the interventions to reduce work-related stressors and improve organizational resources to enable workers to improve their overall psychological and physical health.

Concluding Remarks

Future research.

One of the areas requiring more theoretical and practical attention is that of the utility of stress frameworks to guide organizational development change interventions. Although it has been proposed that the foundation for work stress management interventions is in organizational development, and even though scholars and practitioners of organization development were also founders of research programs that focused on employee health and well-being or work stress, there are few studies or other theoretical works that link the two bodies of literature.

A second area that requires additional attention is the efficacy of stress management interventions across cultures. In examining secondary stress management interventions (i.e., coping), some cross-cultural differences in findings were described; however, there is still a dearth of literature from different countries on the utility of different prevention, coping, and stress management strategies.

A third area that has been blossoming since the start of the 21st century is the topic of hindrance and challenge stressors and the implications of both on workers’ well-being and performance. More research is needed on this topic in several areas. First, there is little consistency by which researchers label a stressor as a hindrance or a challenge. Researchers sometimes take liberties with labels, but it is not the researchers who should label a stressor but the study participants themselves who should indicate if a stressor is a source of strain. Rodríguez, Kozusznik, and Peiró ( 2013 ) developed a measure in which respondents indicate whether a stressor is a challenge or a hindrance. Just as some people may perceive demands to be challenges that they savor and that result in a psychological state of eustress (Nelson & Simmons, 2003 ), others find them to be constraints that impede goal fulfillment and thus might experience distress. Likewise, some people might perceive ambiguity as a challenge that can be overcome and others as a constraint over which he or she has little control and few or no resources with which to cope. More research on validating the measurement of challenge vs. hindrance stressors, as well as eustress vs. distress, and savoring vs. coping, is warranted. Second, at what point are challenge stressors harmful? Just because people experiencing challenge stressors continue to perform well, it does not necessarily mean that they are healthy people. A great deal of stressors are intellectually stimulating, but excessive stimulation can also take a toll on one’s physiological well-being, as evident by the droves of professionals experiencing different kinds of diseases not experienced as much a few decades ago, such as obesity (Fried et al., 2013 ). Third, which stress management interventions would better serve to reduce hindrance stressors or to reduce strain that may result from challenge stressors while reinforcing engagement-producing challenge stressors?

A fourth area that requires additional attention is that of the flexible work arrangements (FWAs). One of the reasons companies have been willing to permit employees to work from home is not so much out of concern for the employee, but out of the company’s need for the focal person to be able to communicate with a colleague working from a geographic region when it is night or early morning for the focal person. Glazer, Kożusznik, and Shargo ( 2012 ) presented several areas for future research on this topic, noting that by participating on global virtual teams, workers face additional stressors, even while given flexibility of workplace and work time. As noted earlier, more research needs to be done on the extent to which people who take advantage of FWAs are advantaged in terms of detachment from work. Can people working from home detach? Are those who find their work invigorating also likely to experience ill-health by not detaching from work?

A fifth area worthy of further research attention is workplace wellness programing. According to Page and Vella-Brodrick ( 2009 ), “subjective and psychological well-being [are] key criteria for employee mental health” (p. 442), whereby mental health focuses on wellness, rather than the absence of illness. They assert that by fostering employee mental health, organizations are supporting performance and retention. Employee well-being can be supported by ensuring that jobs are interesting and meaningful, goals are achievable, employees have control over their work, and skills are used to support organizational and individual goals (Dewe & Kompier, 2008 ). However, just as mental health is not the absence of illness, work stress is not indicative of an absence of psychological well-being. Given the perspective that employee well-being is a state of mind (Page & Vella-Brodrick, 2009 ), we suggest that employee well-being can be negatively affected by noxious job stressors that cannot be remediated, but when job stressors are preventable, employee well-being can serve to protect an employee who faces job stressors. Thus, wellness programs ought to focus on providing positive experiences by enhancing and promoting health, as well as building individual resources. These programs are termed “green cape” interventions (Pawelski, 2016 ). For example, with the growing interests in positive psychology, researchers and practitioners have suggested employing several positive psychology interventions, such as expressing gratitude, savoring experiences, and identifying one’s strengths (Tetrick & Winslow, 2015 ). Another stream of positive psychology is psychological capital, which includes four malleable functions of self-efficacy, optimism, hope, and resilience (Luthans, Youssef, & Avolio, 2007 ). Workplace interventions should include both “red cape” interventions (i.e., interventions to reduce negative experiences) and “green cape” interventions (i.e., workplace wellness programs; Polly, 2014 ).

A Healthy Organization’s Pledge

A healthy workplace requires healthy workers. Period. Among all organizations’ missions should be the focus on a healthy workforce. To maintain a healthy workforce, the company must routinely examine its own contributions in terms of how it structures itself; reinforces communications among employees, vendors, and clients; how it rewards and cares for its people (e.g., ensuring they get sufficient rest and can detach from work); and the extent to which people at the upper levels are truly connected with the people at the lower levels. As a matter of practice, management must recognize when employees are overworked, unwell, and poorly engaged. Management must also take stock of when it is doing well and right by its contributors’ and maintain and reinforce the good practices, norms, and procedures. People in the workplace make the rules; people in the workplace can change the rules. How management sees its employees and values their contribution will have a huge role in how a company takes stock of its own pain points. Providing employees with tools to manage their own reactions to work-related stressors and consequent strains is fine, but wouldn’t it be grand if organizations took better notice about what they could do to mitigate the strain-producing stressors in the first place and take ownership over how employees are treated?

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Understanding the Role of Oxidative Stress, Neuroinflammation and Abnormal Myelination in Excessive Aggression Associated with Depression: Recent Input from Mechanistic Studies

Affiliations.

• 1 Laboratory of Psychiatric Neurobiology, Institute of Molecular Medicine and Department of Normal Physiology, Sechenov First Moscow State Medical University, 119991 Moscow, Russia.
• 2 Laboratory of Cognitive Dysfunctions, Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, 125315 Moscow, Russia.
• 3 Neuroplast BV, 6222 NK Maastricht, The Netherlands.
• 4 Hotchkiss Brain Institute, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB T2N 4N1, Canada.
• 5 Centre de Recherche en Neurosciences de Lyon (CRNL), 69500 Bron, France.
• 6 P.K. Anokhin Research Institute of Normal Physiology, 125315 Moscow, Russia.
• 7 Preventive and Environmental Medicine, Kastanienhof Clinic, 50858 Köln-Junkersdorf, Germany.
• 8 Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Maastricht University, 6229 ER Maastricht, The Netherlands.
• 9 Division of Molecular Psychiatry, Center of Mental Health, University Hospital Würzburg, 97080 Würzburg, Germany.
• PMID: 36674429
• PMCID: PMC9861430
• DOI: 10.3390/ijms24020915

Aggression and deficient cognitive control problems are widespread in psychiatric disorders, including major depressive disorder (MDD). These abnormalities are known to contribute significantly to the accompanying functional impairment and the global burden of disease. Progress in the development of targeted treatments of excessive aggression and accompanying symptoms has been limited, and there exists a major unmet need to develop more efficacious treatments for depressed patients. Due to the complex nature and the clinical heterogeneity of MDD and the lack of precise knowledge regarding its pathophysiology, effective management is challenging. Nonetheless, the aetiology and pathophysiology of MDD has been the subject of extensive research and there is a vast body of the latest literature that points to new mechanisms for this disorder. Here, we overview the key mechanisms, which include neuroinflammation, oxidative stress, insulin receptor signalling and abnormal myelination. We discuss the hypotheses that have been proposed to unify these processes, as many of these pathways are integrated for the neurobiology of MDD. We also describe the current translational approaches in modelling depression, including the recent advances in stress models of MDD, and emerging novel therapies, including novel approaches to management of excessive aggression, such as anti-diabetic drugs, antioxidant treatment and herbal compositions.

Keywords: aggression; insulin receptor; major depressive disorder (MDD); myelination; neuroinflammation; oxidative stress.

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Conflict of interest statement

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the outcome.

Pathological molecular pathways of neuroinflammation,…

Pathological molecular pathways of neuroinflammation, myelination and insulin receptor signalling resulting in impaired…

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Managing Ideas, People, and Projects: Organizational Tools and Strategies for Researchers

Samuel pascal levin.

1 Beverly, MA 01915, USA

Michael Levin

2 Allen Discovery Center at Tufts University, Suite 4600, 200 Boston Avenue, Medford, MA 02155-4243, USA

Primary Investigators at all levels of their career face a range of challenges related to optimizing their activity within the constraints of deadlines and productive research. These range from enhancing creative thought and keeping track of ideas to organizing and prioritizing the activity of the members of the group. Numerous tools now exist that facilitate the storage and retrieval of information necessary for running a laboratory to advance specific project goals within associated timelines. Here we discuss strategies and tools/software that, together or individually, can be used as is or adapted to any size scientific laboratory. Specific software products, suggested use cases, and examples are shown across the life cycle from idea to publication. Strategies for managing the organization of, and access to, digital information and planning structures can greatly facilitate the efficiency and impact of an active scientific enterprise. The principles and workflow described here are applicable to many different fields.

Graphical Abstract

Information Systems; Knowledge Management

Introduction

Researchers, at all stages of their careers, are facing an ever-increasing deluge of information and deadlines. Additional difficulties arise when one is the Principal Investigator (PI) of those researchers: as group size and scope of inquiry increases, the challenges of managing people and projects and the interlocking timelines, finances, and information pertaining to those projects present a continuous challenge. In the immediate term, there are experiments to do, papers and grants to write, and presentations to construct, in addition to teaching and departmental duties. At the same time, however, the PI must make strategic decisions that will impact the future direction(s) of the laboratory and its personnel. The integration of deep creative thought together with the practical steps of implementing a research plan and running a laboratory on a day-to-day basis is one of the great challenges of the modern scientific enterprise. Especially difficult is the fact that attention needs to span many orders of scale, from decisions about which problems should be pursued by the group in the coming years and how to tackle those problems to putting out regular “fires” associated with the minutiae of managing people and limited resources toward the committed goals.

The planning of changes in research emphasis, hiring, grant-writing, etc. likewise occur over several different timescales. The optimization of resources and talent toward impactful goals requires the ability to organize, store, and rapidly access information that is integrated with project planning structures. Interestingly, unlike other fields such as business, there are few well-known, generally accepted guidelines for best practices available to researchers. Here we lay out a conceptual taxonomy of the life cycle of a project, from brainstorming ideas through to a final deliverable product. We recommend methods and software/tools to facilitate management of concurrent research activities across the timeline. The goal is to optimize the organization, storage, and access to the necessary information in each phase, and, crucially, to facilitate the interconnections between static information, action plans, and work product across all phases. We believe that the earlier in the career of a researcher such tools are implemented and customized, the more positive impact they will exert on the productivity of their enterprise.

This overview is intended for anyone who is conducting research or academic scholarship. It consists of a number of strategies and software recommendations that can be used together or independently (adapted to suit a given individual's or group's needs). Some of the specific software packages mentioned are only usable on Apple devices, but similar counterparts exist in the Windows and Linux ecosystems; these are indicated in Table 1 (definitions of special terms are given in Table 2 ). These strategies were developed (and have been continuously updated) over the last 20 years based on the experiences of the Levin group and those of various collaborators and other productive researchers. Although very specific software and platforms are indicated, to facilitate the immediate and practical adoption by researchers at all levels, the important thing is the strategies illustrated by the examples. As software and hardware inevitably change over the next few years, the fundamental principles can be readily adapted to newer products.

Software Packages and Alternatives

A Glossary of Special Terms

Basic Principles

Although there is a huge variety of different types of scientific enterprises, most of them contain one or more activities that can be roughly subsumed by the conceptual progression shown in Figure 1 . This life cycle progresses from brainstorming and ideation through planning, execution of research, and then creation of work products. Each stage requires unique activities and tools, and it is crucial to establish a pipeline and best practices that enable the results of each phase to effectively facilitate the next phase. All of the recommendations given below are designed to support the following basic principles:

• • Information should be easy to find and access, so as to enable the user to have to remember as little as possible—this keeps the mind free to generate new, creative ideas. We believe that when people get comfortable with not having to remember any details and are completely secure in the knowledge that the information has been offloaded to a dependable system and will be there when they need it, a deeper, improved level of thinking can be achieved.
• • Information should be both organized hierarchically (accessible by drill-down search through a rational structure) and searchable by keywords.
• • Information should be reachable from anywhere in the world (but secure and access restricted). Choose software that includes a cell phone/tablet platform client.
• • No information should ever be lost—the systems are such that additional information does not clog up or reduce efficiency of use and backup strategies ensure disaster robustness; therefore, it is possible to save everything.
• • Software tools optimized for specific management tasks should be used; select those tools based on interoperability, features, and the ability to export into common formats (such as XML) in case it becomes expedient someday to switch to a newer product.
• • One's digital world should be organized into several interlocking categories, which utilize different tools: activity (to-dos, projects, research goals) and knowledge (static information).
• • One's activity should be hierarchically organized according to a temporal scale, ranging from immediate goals all the way to career achievement objectives and core mission.
• • Storage of planning data should allow integration of plans with the information needed to implement them (using links to files and data in the various tools).
• • There should be no stored paper—everything should be obtained and stored in a digital form (or immediately digitized, using one of the tools described later in this document).
• • The information management tasks described herein should not occupy so much time as to take away from actual research. When implemented correctly, they result in a net increase in productivity.

The Life Cycle of Research Activity

Various projects occupy different places along a typical timeline. The life cycle extends from creative ideation to gathering information, to formulating a plan, to the execution for the plan, and then to producing a work product such as a grant or paper based on the results. Many of these phases necessitate feedback to a prior phase, shown in thinner arrows (for example, information discovered during a literature search or attempts to formalize the work plan may require novel brainstorming). This diagram shows the product (end result) of each phase and typical tools used to accomplish them.

These basic principles can be used as the skeleton around which specific strategies and new software products can be deployed. Whenever possible, these can be implemented via external administration services (i.e., by a dedicated project manager or administrator inside the group), but this is not always compatible with budgetary constraints, in which case they can readily be deployed by each principal investigator. The PIs also have to decide whether they plan to suggest (or insist) that other people in the group also use these strategies, and perhaps monitor their execution. In our experience, it is most essential for anyone leading a complex project or several to adopt these methods (typically, a faculty member or senior staff scientist), whereas people tightly focused on one project and with limited concurrent tasks involving others (e.g., Ph.D. students) are not essential to move toward the entire system (although, for example, the backup systems should absolutely be ensured to be implemented among all knowledge workers in the group). The following are some of the methods that have proven most effective in our own experience.

Information Technology Infrastructure

Several key elements should be pillars of your Information Technology (IT) infrastructure ( Figure 2 ). You should be familiar enough with computer technology that you can implement these yourself, as it is rare for an institutional IT department to be able to offer this level of assistance. Your primary disk should be a large (currently, ∼2TB) SSD drive or, better, a disk card (such as the 2TB SSD NVMe PCIe) for fast access and minimal waiting time. Your computer should be so fast that you spend no time (except in the case of calculations or data processing) waiting for anything—your typing and mouse movement should be the rate-limiting step. If you find yourself waiting for windows or files to open, obtain a better machine.

Schematic of Data Flow and Storage

Three types of information: data (facts and datasets), action plans (schedules and to-do lists), and work product (documents) all interact with each other in defining a region of work space for a given research project. All of this should be hosted on a single PC (personal computer). It is accessed by a set of regular backups of several types, as well as by the user who can interact with raw files through the file system or with organized data through a variety of client applications that organize information, schedules, and email. See Table 2 for definitions of special terms.

One key element is backups—redundant copies of your data. Disks fail—it is not a question of whether your laptop or hard drive will die, but when. Storage space is inexpensive and researchers' time is precious: team members should not tolerate time lost due to computer snafus. The backup and accessibility system should be such that data are immediately recoverable following any sort of disaster; it only has to be set up once, and it only takes one disaster to realize the value of paranoia about data. This extends also to laboratory inventory systems—it is useful to keep (and back up) lists of significant equipment and reagents in the laboratory, in case they are needed for the insurance process in case of loss or damage.

The main drive should be big enough to keep all key information (not primary laboratory data, such as images or video) in one volume—this is to facilitate cloning. You should have an extra internal drive (which can be a regular disk) of the same size or bigger. Use something like Carbon Copy Cloner or SuperDuper to set up a nightly clone operation. When the main disk fails (e.g., the night before a big grant is due), boot from the clone and your exact, functioning system is ready to go. For Macs, another internal drive set up as a Time Machine enables keeping versions of files as they change. You should also have an external drive, which is likewise a Time Machine or a clone: you can quickly unplug it and take it with you, if the laboratory has to be evacuated (fire alarm or chemical emergency) or if something happens to your computer and you need to use one elsewhere. Set a calendar reminder once a month to check that the Time Machine is accessible and can be searched and that your clone is actually updated and bootable. A Passport-type portable drive is ideal when traveling to conferences: if something happens to the laptop, you can boot a fresh (or borrowed) machine from the portable drive and continue working. For people who routinely install software or operating system updates, I also recommend getting one disk that is a clone of the entire system and applications and then set it to nightly clone the data only , leaving the operating system files unchanged. This guarantees that you have a usable system with the latest data files (useful in case an update or a new piece of software renders the system unstable or unbootable and it overwrites the regular clone before you notice the problem). Consider off-site storage. CrashPlan Pro is a reasonable choice for backing up laboratory data to the cloud. One solution for a single person's digital content is to have two extra external hard drives. One gets a clone of your office computer, and one is a clone of your home computer, and then you swap—bring the office one home and the home one to your office. Update them regularly, and keep them swapped, so that should a disaster strike one location, all of the data are available. Finally, pay careful attention (via timed reminders) to how your laboratory machines and your people's machines are being backed up; a lot of young researchers, especially those who have not been through a disaster yet, do not make backups. One solution is to have a system like CrashPlan Pro installed on everyone's machines to do automatic backup.

Another key element is accessibility of information. Everyone should be working on files (i.e., Microsoft Word documents) that are inside a Dropbox or Box folder; whatever you are working on this month, the files should be inside a folder synchronized by one of these services. That way, if anything happens to your machine, you can access your files from anywhere in the world. It is critical that whatever service is chosen, it is one that s ynchronizes a local copy of the data that live on your local machine (not simply keeps files in the cloud) —that way, you have what you need even if the internet is down or connectivity is poor. Tools that help connect to your resources while on the road include a VPN (especially useful for secure connections while traveling), SFTP (to transfer files; turn on the SFTP, not FTP, service on your office machine), and Remote Desktop (or VNC). All of these exist for cell phone or tablet devices, as well as for laptops, enabling access to anything from anywhere. All files (including scans of paper documents) should be processed by OCR (optical character recognition) software to render their contents searchable. This can be done in batch (on a schedule), by Adobe Acrobat's OCR function, which can be pointed to an entire folder of PDFs, for example, and left to run overnight. The result, especially with Apple's Spotlight feature, is that one can easily retrieve information that might be written inside a scanned document.

Here, we focus on work product and the thought process, not management of the raw data as it emerges from equipment and experimental apparatus. However, mention should be made of electronic laboratory notebooks (ELNs), which are becoming an important aspect of research. ELNs are a rapidly developing field, because they face a number of challenges. A laboratory that abandons paper notebooks entirely has to provide computer interfaces anywhere in the facility where data might be generated; having screens, keyboards, and mice at every microscope or other apparatus station, for example, can be expensive, and it is not trivial to find an ergonomically equivalent digital substitute for writing things down in a notebook as ideas or data appear. On the other hand, keeping both paper notebooks for immediate recording, and ELNs for organized official storage, raises problems of wasted effort during the (perhaps incomplete) transfer of information from paper to the digital version. ELNs are also an essential tool to prevent loss of institutional knowledge as team members move up to independent positions. ELN usage will evolve over time as input devices improve and best practices are developed to minimize the overhead of entering meta-data. However, regardless of how primary data are acquired, the researcher will need specific strategies for transitioning experimental findings into research product in the context of a complex set of personal, institutional, and scientific goals and constraints.

Facilitating Creativity

The pipeline begins with ideas, which must be cultivated and then harnessed for subsequent implementation ( Altshuller, 1984 ). This step consists of two components: identifying salient new information and arranging it in a way that facilitates novel ideas, associations, hypotheses, and strategic plans for making impact.

For the first step, we suggest an automated weekly PubCrawler search, which allows Boolean searches of the literature. Good searches to save include ones focusing on specific keywords of interest, as well as names of specific people whose work one wants to follow. The resulting weekly email of new papers matching specific criteria complements manual searches done via ISI's Web of Science, Google Scholar, and PubMed. The papers of interest should be immediately imported into a reference manager, such as Endnote, along with useful Keywords and text in the Notes field of each one that will facilitate locating them later. Additional tools include DevonAgent and DevonSphere, which enable smart searches of web and local resources, respectively.

Brainstorming can take place on paper or digitally (see later discussion). We have noticed that the rate of influx of new ideas is increased by habituating to never losing a new idea. This can be accomplished by establishing a voicemail contact in your cell phone leading to your own office voicemail (which allows voice recordings of idea fragments while driving or on the road, hands-free) and/or setting up Endnote or a similar server-synchronized application to record (and ideally transcribe) notes. It has been our experience that the more one records ideas arising in a non-work setting, the more often they will pop up automatically. For notes or schematics written on paper during dedicated brainstorming, one tool that ensures that nothing is lost is an electronic pen. For example, the Livescribe products are well integrated with Evernote and ensure that no matter where you are, anything you write down becomes captured in a form accessible from anywhere and are safe no matter what happens to the original notebook in which they were written.

Enhancing scientific thought, creative brainstorming, and strategic planning is facilitated by the creation of mind maps: visual representations of spatial structure of links between concepts, or the mapping of planned activity onto goals of different timescales. There are many available mind map software packages, including MindNode; their goal is to enable one to quickly set down relationships between concepts with a minimum of time spent on formatting. Examples are shown in Figures 3 A and 3B. The process of creating these mind maps (which can then be put on one's website or discussed with the laboratory members) helps refine fuzzy thinking and clarifies the relationships between concepts or activities. Mind mappers are an excellent tool because their light, freeform nature allows unimpeded brainstorming and fluid changes of idea structure but at the same time forces one to explicitly test out specific arrangements of plans or ideas.

Mind Mapping

(A and B) The task of schematizing concepts and ideas spatially based on their hierarchical relationships with each other is a powerful technique for organizing the creative thought process. Examples include (A), which shows how the different projects in our laboratory relate to each other. Importantly, it can also reveal disbalances or gaps in coverage of specific topics, as well as help identify novel relationships between sub-projects by placing them on axes (B) or even identify novel hypotheses suggested by symmetry.

(C) Relationships between the central nervous system (CNS) and regeneration, cancer, and embryogenesis. The connecting lines in black show typical projects (relationships) already being pursued by our laboratory, and the lack of a project in the space between CNS and embryogenesis suggests a straightforward hypothesis and project to examine the role of the brain in embryonic patterning.

It is important to note that mind maps can serve a function beyond explicit organization. In a good mapped structure, one can look for symmetries (revealing relationships that are otherwise not obvious) between the concepts involved. An obvious geometric pattern with a missing link or node can help one think about what could possibly go there, and often identifies new relationships or items that had not been considered ( Figure 3 C), in much the same way that gaps in the periodic table of the elements helped identify novel elements.

Organizing Information and Knowledge

The input and output of the feedback process between brainstorming and literature mining is information. Static information not only consists of the facts, images, documents, and other material needed to support a train of thought but also includes anything needed to support the various projects and activities. It should be accessible in three ways, as it will be active during all phases of the work cycle. Files should be arranged on your disk in a logical hierarchical structure appropriate to the work. Everything should also be searchable and indexed by Spotlight. Finally, some information should be stored as entries in a data management system, like Evernote or DevonThink, which have convenient client applications that make the data accessible from any device.

Notes in these systems should include useful lists and how-to's, including, for example:

• • Names and addresses of experts for specific topics
• • Emergency protocols for laboratory or animal habitats
• • Common recipes/methods
• • Lists and outlines of papers/grants on the docket
• • Information on students, computers, courses, etc.
• • Laboratory policies
• • Materials and advice for students, new group members, etc.
• • Lists of editors, and preferred media contacts
• • Lists of Materials Transfer Agreements (MTAs), contract texts, info on IP
• • Favorite questions for prospective laboratory members

Each note can have attachments, which include manuals, materials safety sheets, etc. DevonThink needs a little more setup but is more robust and also allows keeping the server on one's own machine (nothing gets uploaded to company servers, unlike with Evernote, which might be a factor for sensitive data). Scientific papers should be kept in a reference manager, whereas books (such as epub files and PDFs of books and manuscripts) can be stored in a Calibre library.

Email: A Distinct Kind of Information

A special case of static information is email, including especially informative and/or actionable emails from team members, external collaborators, reviewers, and funders. Because the influx of email is ever-increasing, it is important to (1) establish a good infrastructure for its management and (2) establish policies for responding to emails and using them to facilitate research. The first step is to ensure that one only sees useful emails, by training a good Bayesian spam filter such as SpamSieve. We suggest a triage system in which, at specific times of day (so that it does not interfere with other work), the Inbox is checked and each email is (1) forwarded to someone better suited to handling it, (2) responded quickly for urgent things that need a simple answer, or (3) started as a Draft email for those that require a thoughtful reply. Once a day or a couple of times per week, when circumstances permit focused thought, the Draft folder should be revisited and those emails answered. We suggest a “0 Inbox” policy whereby at the end of a day, the Inbox is basically empty, with everything either delegated, answered, or set to answer later.

We also suggest creating subfolders in the main account (keeping them on the mail server, not local to a computer, so that they can be searched and accessed from anywhere) as follows:

• • Collaborators (emails stating what they are going to do or updating on recent status)
• • Grants in play (emails from funding agencies confirming receipt)
• • Papers in play (emails from journals confirming receipt)
• • Waiting for information (emails from people for whom you are waiting for information)
• • Waiting for miscellaneous (emails from people who you expect to do something)
• • Waiting for reagents (emails from people confirming that they will be sending you a physical object)

Incoming emails belonging to those categories (for example, an email from an NIH program officer acknowledging a grant submission, a collaborator who emailed a plan of what they will do next, or someone who promised to answer a specific question) should be sorted from the Inbox to the relevant folder. Every couple of weeks (according to a calendar reminder), those folders should be checked, and those items that have since been dealt with can be saved to a Saved Messages folder archive, whereas those that remain can be Replied to as a reminder to prod the relevant person.

In addition, as most researchers now exchange a lot of information via email, the email trail preserves a record of relationships among colleagues and collaborators. It can be extremely useful, even years later, to be able to go back and see who said what to whom, what was the last conversation in a collaboration that stalled, who sent that special protocol or reagent and needs to be acknowledged, etc. It is imperative that you know where your email is being stored, by whom, and their policy on retention, storage space limits, search, backup, etc. Most university IT departments keep a mail server with limited storage space and will delete your old emails (even more so if you move institutions). One way to keep a permanent record with complete control is with an application called MailSteward Pro. This is a front-end client for a freely available MySQL server, which can run on any machine in your laboratory. It will import your mail and store unlimited quantities indefinitely. Unlike a mail server, this is a real database system and is not as susceptible to data corruption or loss as many other methods.

A suggested strategy is as follows. Keep every single email, sent and received. Every month (set a timed reminder), have MailSteward Pro import them into the MySQL database. Once a year, prune them from the mail server (or let IT do it on their own schedule). This allows rapid search (and then reply) from inside a mail client for anything that is less than one year old (most searches), but anything older can be found in the very versatile MailStewardPro Boolean search function. Over time, in addition to finding specific emails, this allows some informative data mining. Results of searches via MailStewardPro can be imported into Excel to, for example, identify the people with whom you most frequently communicate or make histograms of the frequency of specific keywords as a function of time throughout your career.

With ideas, mind maps, and the necessary information in hand, one can consider what aspects of the current operations plan can be changed to incorporate plans for new, impactful activity.

Organizing Tasks and Planning

A very useful strategy involves breaking down everything according to the timescales of decision-making, such as in the Getting Things Done (GTD) philosophy ( Figure 4 ) ( Allen, 2015 ). Activities range from immediate (daily) tasks to intermediate goals all the way to career-scale (or life-long) mission statements. As with mind maps, being explicit about these categories not only force one to think hard about important aspects of their work, but also facilitate the transmission of this information to others on the team. The different categories are to be revisited and revised at different rates, according to their position on the hierarchy. This enables you to make sure that effort and resources are being spent according to priorities.

Scales of Activity Planning

Activities should be assigned to a level of planning with a temporal scale, based on how often the goals of that level get re-evaluated. This ranges from core values, which can span an entire career or lifetime, all the way to tactics that guide day-to-day activities. Each level should be re-evaluated at a reasonable time frame to ensure that its goals are still consistent with the bigger picture of the level(s) above it and to help re-define the plans for the levels below it.

We also strongly recommend a yearly personal scientific retreat. This is not meant to be a vacation to “forget about work” but rather an opportunity for freedom from everyday minutiae to revisit, evaluate, and potentially revise future activity (priorities, action items) for the next few years. Every few years, take more time to re-map even higher levels on the pyramid hierarchy; consider what the group has been doing—do you like the intellectual space your group now occupies? Are your efforts having the kind of impact you realistically want to make? A formal diagram helps clarify the conceptual vision and identify gaps and opportunities. Once a correct level of activity has been identified, it is time to plan specific activities.

A very good tool for this purpose, which enables hierarchical storage of tasks and subtasks and their scheduling, is OmniFocus ( Figure 5 ). OmniFocus also enables inclusion of files (or links to files or links to Evernote notes of information) together with each Action. It additionally allows each action to be marked as “Done” once it is complete, providing not only a current action plan but a history of every past activity. Another interesting aspect is the fact that one can link individual actions with specific contexts: visualizing the database from the perspective of contexts enables efficient focus of attention on those tasks that are relevant in a specific scenario. OmniFocus allows setting reminders for specific actions and can be used for adding a time component to the activity.

Project Planning

This figure shows a screenshot of the OmniFocus application, illustrating the nested hierarchy of projects and sub-projects, arranged into larger groups.

The best way to manage time relative to activity (and to manage the people responsible for each activity) is to construct Gantt charts ( Figure 6 ), which can be used to plan out project timelines and help keep grant and contract deliverables on time. A critical feature is that it makes dependencies explicit, so that it is clear which items have to be solved/done before something else can be accomplished. Gantt charts are essential for complex, multi-person, and/or multi-step projects with strict deadlines (such as grant deliverables and progress reports). Software such as OmniPlanner can also be used to link resources (equipment, consumables, living material, etc.) with specific actions and timelines. Updating and evaluation of a Gantt chart for a specific project should take place on a time frame appropriate to the length of the next immediate phase; weekly or biweekly is typical.

Timeline Planning

This figure shows a screenshot of a typical Gantt chart, in OmniPlan software, illustrating the timelines of different project steps, their dependencies, and specific milestones (such as a due date for a site visit or grant submission). Note that Gantt software automatically moves the end date for each item if its subtasks' timing changes, enabling one to see a dynamically correct up-to-date temporal map of the project that adjusts for the real-world contingencies of research.

In addition to the comprehensive work plan in OmniFocus or similar, it is helpful to use a Calendar (which synchronizes to a server, such as Microsoft Office calendar with Exchange server). For yourself, make a task every day called “Monday tasks,” etc., which contains all the individual things to be accomplished (which do not warrant their own calendar reminder). First thing in the morning, one can take a look at the day's tasks to see what needs to be done. Whatever does not get done that day is to be copied onto another day's tasks. For each of the people on your team, make a timed reminder (weekly, for example, for those with whom you meet once a week) containing the immediate next steps for them to do and the next thing they are supposed to produce for your meeting. Have it with you when you meet, and give them a copy, updating the next occurrence as needed based on what was decided at the meeting to do next. This scheme makes it easy for you to remember precisely what needs to be covered in the discussion, serves as a record of the project and what you walked about with whom at any given day (which can be consulted years later, to reconstruct events if needed), and is useful to synchronize everyone on the same page (if the team member gets a copy of it after the meeting).

Writing: The Work Products

Writing, to disseminate results and analysis, is a central activity for scientists. One of the OmniFocus library's sections should contain lists of upcoming grants to write, primary papers that are being worked on, and reviews/hypothesis papers planned. Microsoft Word is the most popular tool for writing papers—its major advantage is compatibility with others, for collaborative manuscripts (its Track Changes feature is also very well implemented, enabling collaboration as a master document is passed from one co-author to another). But Scrivener should be seriously considered—it is an excellent tool that facilitates complex projects and documents because it enables WYSIWYG text editing in the context of a hierarchical structure, which allows you to simultaneously work on a detailed piece of text while seeing the whole outline of the project ( Figure 7 ).

Writing Complex Materials

This figure shows a screenshot from the Scrivener software. The panel on the left facilitates logical and hierarchical organization of a complex writing project (by showing where in the overall structure any given text would fit), while the editing pane on the right allows the user to focus on writing a specific subsection without having to scroll through (but still being able to see) the major categories within which it must fit.

It is critical to learn to use a reference manager—there are numerous ones, including, for example, Endnote, which will make it much easier to collaborate with others on papers with many citations. One specific tip to make collaboration easier is to ask all of the co-authors to set the reference manager to use PMID Accession Number in the temporary citations in the text instead of the arbitrary record number it uses by default. That way, a document can have its bibliography formatted by any of the co-authors even if they have completely different libraries. Although some prefer collaborative editing of a Google Doc file, we have found a “master document” system useful, in which a file is passed around among collaborators by email but only one can make (Tracked) edits at a time (i.e., one person has the master doc and everyone makes edits on top of that).

One task most scientists regularly undertake is writing reviews of a specific subfield (or Whitepapers). It is often difficult, when one has an assignment to write, to remember all of the important papers that were seen in the last few years that bear on the topic. One method to remedy this is to keep standing document files, one for each topic that one might plausibly want to cover and update them regularly. Whenever a good paper is found, immediately enter it into the reference manager (with good keywords) and put a sentence or two about its main point (with the citation) into the relevant document. Whenever you decide to write the review, you will already have a file with the necessary material that only remains to be organized, allowing you to focus on conceptual integration and not combing through literature.

The life cycle of research can be viewed through the lens of the tools used at different stages. First there are the conceptual ideas; many are interconnected, and a mind mapper is used to flesh out the structure of ideas, topics, and concepts; make it explicit; and share it within the team and with external collaborators. Then there is the knowledge—facts, data, documents, protocols, pieces of information that relate to the various concepts. Kept in a combination of Endnote (for papers), Evernote (for information fragments and lists), and file system files (for documents), everything is linked and cross-referenced to facilitate the projects. Activities are action items, based on the mind map, of what to do, who is doing what, and for which purpose/grant. OmniFocus stores the subtasks within tasks within goals for the PI and everyone in the laboratory. During meetings with team members, these lists and calendar entries are used to synchronize objectives with everyone and keep the activity optimized toward the next step goals. The product—discovery and synthesis—is embodied in publications via a word processor and reference manager. A calendar structure is used to manage the trajectory from idea to publication or grant.

The tools are currently good enough to enable individual components in this pipeline. Because new tools are continuously developed and improved, we recommend a yearly overview and analysis of how well the tools are working (e.g., which component of the management plan takes the most time or is the most difficult to make invisible relative to the actual thinking and writing), coupled to a web search for new software and updated versions of existing programs within each of the categories discussed earlier.

A major opportunity exists for software companies in the creation of integrated new tools that provide all the tools in a single integrated system. In future years, a single platform will surely appear that will enable the user to visualize the same research structure from the perspective of an idea mind map, a schedule, a list of action items, or a knowledge system to be queried. Subsequent development may even include Artificial Intelligence tools for knowledge mining, to help the researcher extract novel relationships among the content. These will also need to dovetail with ELN platforms, to enable a more seamless integration of project management with primary data. These may eventually become part of the suite of tools being developed for improving larger group dynamics (e.g., Microsoft Teams). One challenge in such endeavors is ensuring the compatibility of formats and management procedures across groups and collaborators, which can be mitigated by explicitly discussing choice of software and process, at the beginning of any serious collaboration.

Regardless of the specific software products used, a researcher needs to put systems in place for managing information, plans, schedules, and work products. These digital objects need to be maximally accessible and backed up, to optimize productivity. A core principle is to have these systems be so robust and lightweight as to serve as an “external brain” ( Menary, 2010 )—to maximize creativity and deep thought by making sure all the details are recorded and available when needed. Although the above discussion focused on the needs of a single researcher (perhaps running a team), future work will address the unique needs of collaborative projects with more lateral interactions by significant numbers of participants.

Acknowledgments

We thank Joshua Finkelstein for helpful comments on a draft of the manuscript. M.L. gratefully acknowledges support by an Allen Discovery Center award from the Paul G. Allen Frontiers Group (12171) and the Barton Family Foundation.

• Allen D. Revised edition. Penguin Books; 2015. Getting Things Done: The Art of Stress-free Productivity. [ Google Scholar ]
• Altshuller G.S. Gordon and Breach Science Publishers; 1984. Creativity as an Exact Science: The Theory of the Solution of Inventive Problems. [ Google Scholar ]
• Menary R. MIT Press; 2010. The Extended Mind. [ Google Scholar ]

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Back to Journals » Psychology Research and Behavior Management » Volume 17

Efficacy of Progressive Muscle Relaxation in Adults for Stress, Anxiety, and Depression: A Systematic Review

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Authors Muhammad Khir S   , Wan Mohd Yunus WMA   , Mahmud N , Wang R   , Panatik SA   , Mohd Sukor MS , Nordin NA

Received 22 September 2023

Accepted for publication 15 January 2024

Published 1 February 2024 Volume 2024:17 Pages 345—365

DOI https://doi.org/10.2147/PRBM.S437277

Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 3

Editor who approved publication: Dr Gabriela Topa

Syazwina Muhammad Khir, 1 Wan Mohd Azam Wan Mohd Yunus, 1– 3 Norashikin Mahmud, 1 Rui Wang, 1 Siti Aisyah Panatik, 1 Mohammad Saipol Mohd Sukor, 1 Nor Akmar Nordin 1 1 Department of Psychology, School of Human Resource Development and Psychology, Faculty of Social Sciences and Humanities, Universiti Teknologi Malaysia, Johor, Malaysia; 2 INVEST Research Flagship, University of Turku, Turku, Finland; 3 Research Centre for Child Psychiatry, University of Turku, Turku, Finland Correspondence: Syazwina Muhammad Khir, Email [email protected] Background: The rise in the prevalence of mental health problems among adults worldwide has raised concerns, highlighting the critical need for evidence-based mental health interventions that are accessible, comprehensive, and effective. Previous research suggests that Progressive Muscle Relaxation (PMR) is a promising intervention widely used to reduce mental health problems. Nevertheless, the current literature on the efficacy of PMR among adults globally is fragmented, indicating a potential gap in this research area. Hence, this paper aims to systematically compile the research evidence on the efficacy of PMR in adults for stress, anxiety, and depression. Methods: The Scopus, Web of Sciences, PubMed, PsycINFO, and Cochrane Central Register of Controlled Trials were searched from the earliest available evidence to 28th March 2023. The PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-analyses) guidelines were followed, and the protocol was registered on the Open Science Framework. Joanna Briggs Institute (JBI) Critical Appraisal Tools were used to assess the quality of the included studies. Results: A total of forty-six (46) publications from sixteen (16) countries covering more than 3402 adults were included in the review. The results show that PMR are effective in reducing stress, anxiety, and depression in adults. When PMR is combined with other interventions, the combined techniques have also consistently exhibited enhanced efficacy. Moreover, findings also indicate that the efficacy of PMR is heightened when implemented in conjunction with other interventions, surpassing its standalone efficacy. Funding and Registration: This research was supported/funded by the Ministry of Higher Education (MoHE) under the Fundamental Research Grant Scheme (FRGS) (FRGS/1/2020/SS0/UTM/02/23). The review was registered on Open Science Framework (OSF) on the 7th of March 2023; DOI: https://doi.org/10.17605/OSF.IO/U2HZP . Keywords: progressive muscle relaxation, stress, anxiety, depression

Introduction

There is more to mental health than the absence of mental disorders. According to the World Health Organization (WHO), 1 the term “mental health” refers to a state of psychological well-being that allows individuals to successfully manage the challenges of life, recognize their strengths, participate in study and work, and make significant contributions to the communities. There is a broad continuum of mental health that is experienced differently by each individual. It carries diverse levels of challenges and distress as well as possibly highly distinct social and psychological impacts. Being typically capable of thinking, feeling, and acting in a way that satisfies one’s desires in life is a sign of good mental health. However, if one has experienced a phase of poor mental health such as stress, anxiety, and depression, they will likely find everyday life as challenging or even impossible to deal with the frequent thoughts, feelings, or responses. These poor conditions could lead to more serious psychiatric disorders or conditions such as clinical anxiety, depression, bipolar disorders, schizophrenia, or even suicide. 2–4 The aforementioned statement emphasizes the critical need to swiftly address stress, anxiety, and depression as these are major contributors to the wider range of mental health issues that people may encounter.

Stress may not be typical of the person or the environment; rather, it is a complex system formed by the interplay of specific psychological and physiological elements with the surroundings, 5 while anxiety is a mental condition characterized by unpleasant emotions, unease, anxiety about the future, or dread of reacting to the present without a clear trigger. 6 According to World Health Organization, 7 depression is a widespread mental health condition that impacts over 300 million individuals globally. Depression is commonly characterized by symptoms like poor mood, interest loss, changes in weight or appetite, sleep difficulties, psychomotor changes, guilt feelings, lack of focus, and suicidal thoughts or attempts in the past. 8 An earlier research conducted among adult population in 2020 revealed that nearly half of the study sample (48.1%) were affected with mild to extremely severe stress, anxiety, and depression. 9 These figures are very alarming since they could trigger negative affect, which includes erratic feelings and apathy 10 among the adults.

To address those mental health issues, experts have suggested several recommendations like maintaining physical well-being, partaking in recreational activities, staying positive, socializing, and learning relaxation exercises 11 Relaxation exercises have been found to be effective for a person’s physical and mental well-being by enabling one’s breathing to calm down, decreasing blood pressure, easing stress, and minimizing muscle spasm. 12 , 13 Moreover, there are emerging studies on the use of relaxation exercises as part of an interdisciplinary prevention or intervention approach for stress, anxiety, and depression, 14–17 and relaxation techniques like progressive muscle relaxation (PMR) are capable of successfully tensing and relaxing different muscle groups. 18

Of all the relaxation techniques, the PMR technique is the most straightforward to understand and to be used as it is accessible, affordable, self-induced, and offers no adverse impacts. 19 Utilizing PMR is particularly effective in reducing stress, anxiety, and depression. By differentiating between sensations of tension (a purposeful tensing of the muscles) and relaxation (a conscious, deliberate release of the muscles’ tension), PMR makes it easier to identify muscles or muscle groups that are persistently tense. 18 , 20

Systematic reviews on PMR by previous scholars have focused on the impact of the exercises on patients with serious illnesses such as cancer patients, schizophrenic patients, and those who are undergoing surgery 14 , 21 , 22 in reducing their mental health problems. However, to our knowledge, there are no systematic reviews that assess the efficacy of PMR interventions on stress, anxiety, and depression of the general adult population, thus contributing to the current body of knowledge.

Methodology

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided the present study. PRISMA was developed to assist reviewers in clearly describing their studies’ purpose, methods, and findings. 23 Using this guideline, the reviewers developed pertinent research questions based on the PICO framework. This framework aids reviewers in structuring research questions by dividing them into four main parts: Population, Intervention, Comparison, and Outcome. 24 Based on the framework, one research question is formulated: Does Progressive Muscle Relaxation (PMR) effectively reduce stress, anxiety, and depression among adults? In this review, adults are defined as those who are 18 years of age or older. 25 The review’s objectives, inclusion criteria, and methods of analysis were pre-specified and documented in a protocol filed on Open Science Framework (OSF) on the 7th March 2023; DOI: https://doi.org/10.17605/OSF.IO/U2HZP .

Search Strategy

Selection Criteria

This review includes publications that fit two distinct criteria: (1) Those that explore the effects of PMR on stress, anxiety, and depression in adults, either as a standalone intervention or in combination with additional intervention approaches; and (2) Studies that implement rigorous methodologies, utilizing either a Randomized Controlled Trial (RCT) or a Quasi-Experimental Design (QED). For this review, the inclusion criteria necessitate studies to includes all studies that investigate the efficacy of PMR on stress, anxiety, and/or depression symptoms, focus on experimental research, look at non-clinical cases among adults, and have been published in English language from earliest time until 28th March 2023. Conversely, the review excludes all meta-analysis papers, systematic review papers, students’ thesis, or unauthorized or unrecognized dissertations, any non-experimental research, all clinical cases, and non-English articles or studies.

Study Search, Selection, and Retrieval Processes

The research procedure includes a methodical flow that starts with a thorough database search, followed by exporting the identified articles into the reference management software EndNote X7. After that, duplicates were removed and both the titles and abstracts were screened for relevancy. The process continued by retrieving the full texts of the publications that had been shortlisted. Some articles were unable to be retrieved due to access restrictions on databases, full-text not available, limited database archive, and is a conference abstracts. Finally, a thorough evaluation of these full texts was done to determine which articles are most significant based on the aforementioned criteria. The process was carried out independently by two different reviewers, who then met to compare their findings and reach a consensus. In cases where a consensus was elusive, the reviewers engaged a senior researcher for guidance and resolution.

Quality Assessment of the Included Study

Following the screening procedure, two (2) reviewers used revised Joanna Briggs Institute (JBI) Critical Appraisal Tools 26 , 27 to complete the quality assessment on all the selected papers. The reviewers used two (2) different checklists from the revised JBI critical appraisal tools.

The first tool was a checklist called the “Revised Randomized Controlled Trial Checklist”. This checklist was used to review papers that used the Randomized Controlled Trial (RCT) design. The checklist provided a thorough, standardized methodology for evaluating many components of RCTs, including internal validity, all types of bias checklists, statistical conclusion validity, randomization protocols, blinding methods, and attrition rates, among other crucial variables. 26 This tool examines thirteen (13) significant components for the systematic review. The checklists consist of four distinct responses: Yes, No, Unclear, and Not Applicable. 28 For this checklist, each of the items received a score for adherence. Items marked with a “Yes” earn a score of one (1), signifying adherence to the checklist criterion, whilst any other replies - “No”, “Unclear”, or “Not Applicable”, receive a score of zero (0), suggesting a lack of assurance or non-relevance to the specific criterion. Previous research on the JBI critical appraisal tool confirms that the attribution of cut-off values or scores that identify a study as being of low, moderate, or high quality is best selected by the systematic reviewers themselves. 29 The aforementioned approach enables reviewers to determine these thresholds based on the specific requirements and circumstances of their assessment, resulting in a more personalized and precise evaluation process. For the current review, the reviewers opted to implement the scoring system from earlier studies. 30 , 31 Under the assessment criteria, studies obtaining 70% or more of the maximum attainable score were classified as “high quality”, those scoring between 50% and 70% were classified as “moderate quality”, while studies with scores falling below the 50% threshold were classified as “poor quality”. Moreover, for this checklist, those earning ten (10) points or more were classified as “high quality”, those that scored between seven (7) and ten (10) points were deemed “moderate quality”, and articles that accrued six (6) points or less were categorized as “poor quality”.

The second tool was the “Revised Checklist for Quasi-Experimental Studies”. This checklist functioned as an evaluative measure for all studies that used a quasi-experimental design (QED), offering a formal framework for examining the robustness and dependability of the procedures used, how they were carried out, and the subsequent validity of the results. 26 This tool examines nine (9) significant components for the systematic review. Similar to RCT tool, this checklist consists of four distinct responses: Yes, No, Unclear, and Not Applicable. Each of the items received a score for adherence. Items marked with a “Yes” earn a score of one (1), signifying adherence to the checklist criterion, whilst any other replies - “No”, “Unclear”, or “Not Applicable”, receive a score of zero (0), suggesting a lack of assurance or non-relevance to the specific criterion. Moreover, studies obtaining 70% or more of the maximum attainable score were classified as “high quality”, those scoring between 50% and 70% were classified as “moderate quality”, while studies with scores falling below the 50% threshold were classified as “poor quality”. 30 , 31 Those earning seven (7) points or more were classified as “high quality”, those that scored between five (5) and seven (7) points were deemed “moderate quality”, and articles that received four (4) points or less were categorized as “poor quality”.

The quality assessment instructs reviewers to include articles with high and moderate qualities only. Two reviewers made decisions on the study’s eligibility and quality. All possible disagreements were settled through discussion. If no conclusion was achieved, a third reviewer who is a senior researcher is brought in to assist in reaching a final decision. The careful assessments ensured that the research included in the review met a high standard of methodological quality. Next, two independent reviewers extracted the data, and the findings are provided in the next section.

Data Extraction

Results of the Search

Quality of the Included Studies

Two independent reviewers conducted a quality assessment of each included study. As a results, twenty-four (24) studies were rated as high quality, whereas twenty-two (22) studies were rated as moderate quality. The quality of the studies is presented in the extraction tables from high to moderate quality ( Table 2 and Table 3 ).

Standalone Progressive Muscle Relaxation (PMR) Studies Vs PMR Combined with Other Interventions Studies

Progressive muscle relaxation (pmr) studies.

Randomized Controlled Trial (RCT)

Using the “Revised Randomized Controlled Trial Checklist”, 28 the reviewers found three (3) studies of high quality, 43 , 54 , 57 and seven (7) studies of moderate quality. 59–62 , 64 , 66 , 68

Following an exhaustive review, major findings demonstrated a significant trend in three (3) studies 43 , 59 , 64 that reported a substantial decrease in stress outcomes among adult volunteers, nurses and university students at posttest compared to pretest within the PMR group. Moreover, one (1) study 64 among university students discovered the potential efficacy of PMR, finding a substantial decrease in stress outcomes in the PMR group compared to the control group at the posttest evaluations. Nonetheless, one (1) study 59 found no significant reduction in stress levels among adult volunteers in the PMR group when compared to the control group at the post-test intervention stage.

For the anxiety outcomes, the systematic review’s key findings revealed that six (6) studies 43 , 57 , 59 , 62 , 66 , 68 showed a significant reduction in anxiety levels on adult volunteers, nurses, and university students at posttest compared to pretest within the PMR group. Additionally, two (2) studies 59 , 62 further underscored the potential efficacy of PMR on anxiety among adult volunteers, and nursing students, respectively, finding a significant outcome in the PMR group in comparison to the control group at the posttest assessments.

In terms of depression, the key outcomes revealed that in four (4) studies 54 , 59–61 among adult volunteers, caregivers of elders, and elderly women, there was a significant decrease in depression post-test compared to pretest within the PMR group. Two (2) studies, 60 , 61 which further support the evidence for PMR, found a significant decrease in depressive outcomes in the PMR group compared to the control group among the caregivers of elders, and elderly women at the post-test measurement. However, a notable exception was observed in one (1) study 59 where there is no significant reduction in depression levels among adult volunteers in the PMR group compared to the control group at the post-test stage, adding a layer of complexity to the overall findings. The researcher points out, emphasizing the implications of the study’s findings, that the PMR intervention may lack the requisite potency to effectively improve depression outcomes, underscoring the need for more comprehensive or integrated procedures. These results emphasize the potential of PMR as an effective relaxation training in the therapy for stress, anxiety, and depression. In numerous studies, the consistent reduction in stress, anxiety, and depression produces in the PMR group indicates its efficacy as a relaxing technique on adults’ population.

Quasi-Experimental Design (QED)

Using the “Revised Checklist for Quasi-Experimental Studies”, 28 the reviewers identified fifteen (15) studies of high quality, 34 , 36 , 38 , 40–42 , 45–47 , 49–53 , 56 and six (6) studies of medium quality. 44 , 58 , 67 , 69 , 71 , 72

Following a thorough assessment, nine (9) studies 38 , 40 , 41 , 45 , 46 , 51 , 52 , 58 , 67 revealed noteworthy insights, indicating a discernable pattern of considerable drop in stress outcomes posttest in contrast to pretest within the PMR group among the female health care workers, nurses, university students and employees. Moreover, two (2) more studies 36 , 72 reported a significant reduction in stress outcomes in the PMR group compared to the control group among the athletes and female clerical workers, adding weight to the information at hand.

Next, when anxiety outcomes were analyzed, seven (7) studies 42 , 44 , 50 , 52 , 56 , 69 , 71 reported a significant decrease in levels of anxiety among university students, and nurses at posttest compared to pretest in the PMR group, highlighting the effective role of PMR in anxiety reduction. Besides, two (2) further studies 36 , 56 supported the discussion for PMR by demonstrating a substantial reduction in anxiety outcomes among athletes, and nursing students in the PMR group compared to the control group in the posttest phase. Interestingly, two (2) studies 42 , 50 conducted among university students and nurses, respectively, found a significant reduction in anxiety in the control group, a finding that calls for more research to uncover the underlying causes. However, in contrast to the great majority of the findings, three (3) studies 34 , 49 , 51 found no significant reduction in anxiety levels among university students, beginner athletes, and female nurses, respectively, at posttest compared to pretest in the PMR group.

Lastly, in analyzing depression outcomes, three (3) studies 47 , 51 , 53 found a notable decrease in depression levels among the elders, and female nurses’ posttest compared to pretest in the PMR group, showing PMR’s potential efficacy in battling depression. In addition, one (1) study among elders 47 reported a significant reduction in depression outcomes in the PMR group compared to the control group at the posttest stage. PMR has significant potential for cultivating mental well-being as a non-drug-based intervention, particularly or adults dealing with stress, anxiety, and depression.

Overall, the comprehensive analysis of the PMR studies in this review reveals a spectrum of Cohen’s d effect sizes, spanning from d=0.29 to d=4.57 for stress, suggesting a range from small to large impact. Similarly, the effect sizes for anxiety fall between d=0.25 and d=2.54, indicative of a spectrum from small to large, while for depression, the range of d=0.58 to d=1.95 suggests a medium-to-large effect size. The effect sizes for each PMR studies are displayed in Table 2 .

PMR Combined with Other Interventions Studies

Using the “Revised Randomized Controlled Trial Checklist”, 28 the reviewers found eight (8) studies of moderate quality. 66 , 68 , 80 , 81 , 83 , 85 , 86 , 89

Upon the completion of an in-depth review, three (3) different research 80 , 81 , 85 evaluating stress outcomes found a significant decrease in stress levels among nursing students, general adults, and caregivers’ posttest compared to pretest in the group receiving PMR paired with music therapy (MT), mindfulness meditation (MM), and deep breathing (DB), respectively. Furthermore, two (2) additional studies 80 , 83 found a significant reduction in stress outcomes in the PMR group, where PMR was combined with MT, when compared to the control group among nursing students, and nurses, respectively, at the posttest stage, adding to the evidence for the integrative approach.

When it comes to anxiety outcomes, three (3) studies 66 , 68 , 86 clearly demonstrate a significant decrease in levels of anxiety among university students, and caregivers following posttest compared to pretest within the group receiving PMR when coupled with nature sound (NS), MT, and guided imagery (GI), respectively, reinforcing the efficacy of this combined therapeutic approach in managing anxiety. In addition, a study among caregivers of patients 89 found a substantial reduction in anxiety outcomes in the group receiving PMR paired with health education (HE), when compared to the control group at posttest, lending credence to these findings. Nonetheless, one (1) study 81 found no statistically significant decrease in levels of anxiety among general adults at posttest compared to pretest in the group that received PMR alongside MM, highlighting the complexity and variability of coping with anxiety.

In terms of depressive outcomes, only one (1) study 89 demonstrating a significant reduction in depressive outcomes among caregivers of patients at the posttest stage in the group receiving PMR in combination with HE, when compared to the control group.

Using the “Revised Checklist for Quasi-Experimental Studies”, 28 the reviewers identified six (6) studies of high quality, 73 , 74 , 76–79 and one (1) study of moderate quality. 88

Following an extensive assessment, five (5) studies 73 , 74 , 76 , 79 , 88 found a substantial decline in levels of stress among elderlies, general adults, unemployed individuals, male automotive workers, and caregivers, respectively, at the posttest stage compared to pretest in groups receiving PMR alongside relaxation therapy (RT): music, physical exercise and laughter therapy, stress control (SC), counseling services (CS), and DB, respectively, highlighting the significant efficacy of this integrated approach in alleviating stress. Furthermore, three (3) other studies 76 , 77 , 79 strengthen these findings, indicating a significant reduction in stress outcomes among nursing students, unemployed individuals, and male automotive workers at the posttest phase in groups where PMR was administered in conjunction with cognitive behavioral therapy (CBT), CS, and DB, respectively, when compared to the control group.

In terms of anxiety outcomes, four (4) studies 73 , 74 , 76 , 78 reported a substantial reduction in levels of anxiety among elderlies, general adults, unemployed individuals, and caregivers, respectively, in the posttest as compared to the pretest in groups receiving a combination of PMR with RT: music, physical exercise and laughter therapy, SC, CS, and stress management skills (SMS), respectively. Besides, three (3) further papers 76–78 found a substantial reduction in depressive outcomes among unemployed individuals, nursing students, and caregivers at posttest in the group receiving PMR paired with CS, CBT, and SMS, respectively, when compared to the control group. However, one (1) study 79 contradicted the dominant discoveries, presenting a lack of significant decrease in levels of anxiety among male automotive workers at posttest compared to pretest, and also when compared with the control group, in the group that received PMR combined with DB, indicating the need for a more comprehensive investigation of this therapeutic approach.

When analyzing depression outcomes, reports from three (3) studies 73 , 76 , 78 revealed a significant reduction in levels of depression among elderlies, unemployed individuals, and caregivers, respectively, at the posttest compared to the pretest within the group that received PMR in combination with RT: music, physical exercise and laughter therapy, CS, and SMS, respectively. Along with the previous findings, another two (2) studies 76 , 78 have reported a substantial reduction in depressive outcomes among unemployed individuals, and caregivers, respectively, at the posttest stage in the group that got PMR integrated with CS, and SMS, respectively, when compared to the control group. Two (2) studies, 74 , 79 however, deviated from the majority of outcomes, presenting no significant decrease in symptoms of depression among general adults and male automotive workers, respectively, at posttest compared to pretest in the group receiving PMR alongside SC, and DB, respectively, and also when compared with the control group. Unexpectedly, one (1) study 78 found a significant increase in levels of depression among adults in the wait-list control group at posttest, where no interventions were provided. It is a finding that warrants additional investigation to determine the underlying causes, and therefore highlighting the need for further studies.

Overall, for the PMR combined with other intervention studies, the Cohen’s d effect sizes are ranging from d=0.40 to d=2.24 for stress, signifying an impact spectrum spanning from small to large. Similarly, the effect sizes for anxiety, falling between d=0.15 and d=2.10, indicate a spectrum from small to large impact. In the case of depression, the range of d=0.27 to d=0.74 suggests a small-to-medium effect size. The effect sizes for each study are displayed in Table 3 .

This paper presents a systematic literature review on the efficacy of Progressive Muscle Relaxation (PMR) in adults for stress, anxiety, and depression. Our review identified 46 studies, from sixteen (16) countries, covering 3402 total sample. This review is a pioneering endeavor in that it is the first to systematically assembled and report findings relating to the efficacy of PMR and PMR combined with other interventions among general adult, thus contributing to the current body of knowledge. Furthermore, this review is notable for its comprehensive approach, providing studies employing Randomized Controlled Trial (RCT) and Quasi-Experimental Design (QED) research designs. As a result, it provides a thorough view of the many approaches used to examine the efficacy of PMR. This comprehensive approach not only broadens the spectrum of evidence reviewed but also allows for the analysis of a diverse variety of study designs, resulting in a deeper comprehension of PMR’s conceivable effect. Besides, this review attempted to look at the impact of PMR as a stand-alone intervention as well as those that explore PMR in combination with other interventions. By presenting in this way, this review promotes a broad knowledge of PMR’s efficacy in various therapeutic conditions by offering evidence from both methods. The comparison of PMR itself versus PMR paired with various interventions may aid in identifying potential synergistic benefits, directing future study and potential therapeutic application.

Based on the outcome measures, overall, PMR has been demonstrated to be beneficial in reducing stress, anxiety, and depression in adults. When PMR is combined with other interventions, the combined techniques have also consistently exhibited enhanced efficacy, particularly for stress (n=10) and anxiety (n=9). There are a total of 24 studies that support PMR’s efficacy in reducing stress, 21 studies in reducing anxiety, and 11 studies in reducing depression, either on its own or in combination with other interventions.

There is a consistent trend in this review that emerges where the majority of studies using Jacobson’s Progressive Muscle Relaxation (PMR) exercise show that it is beneficial in reducing stress, anxiety, and depression in adults, whether used in its original form 18 or as adapted by later research. 35 , 37 , 55 , 63 , 70 , 90 In our review, we discovered that when people engaged in PMR exercises on their own in private spaces, the lengths of the sessions varied, with the lowest session lasting 5 minutes 45 and the longest lasting 28 minutes. 54 , 61 When combining with other interventions or variables, the shortest duration becomes 15 minutes, 74 while the longest is 37 minutes. 85 In our analysis, we observed that the duration of the PMR exercises, whether shorter or longer, did not significantly influence the outcome measures. Our study shows that there was a pervasive pattern of decreasing mental health outcomes across time. Moreover, our findings show that the regularity, whether daily or only a few days a week, does not significantly change the outcomes when analyzing the frequency of PMR implementation. Regardless of the exact frequency of PMR sessions, the overall trend in the majority of studies consistently demonstrates a reduction in outcome measures.

When delving deeper into individual outcome measures, for stress, one (1) study 59 found no significant reduction in stress level when compared to the control group at posttest. For anxiety, there are five (5) studies 34 , 49 , 51 , 79 , 81 reported no reduction in anxiety at the posttest. Interestingly, there are two (2) studies 42 , 50 that show a significant reduction of anxiety in the control group which calls for more research to uncover the underlying causes. Lastly, the majority of the studies on depression involved elderly people and those who looked after patients and senior citizens. There are three studies 59 , 74 , 79 revealed no significant reduction compared to control groups. Alarmingly, one study 78 even indicated an increase in depression levels post-intervention of a wait-list control group.

For the record, we found an interesting pattern in our thorough review. It seems that statistically insignificant results tend to occur when PMR is explored in the context of a general adult population, without defining or focusing on specific subgroups. 59 , 74 , 81 This recurring trend of non-significant results in wider adult populations raises the possibility that the efficacy of PMR may depend on particular demographic, psychographic, or clinical traits that are unusually absent from a generalized group. However, it does not reduce PMR’s potential benefit in specific therapeutic applications, where its efficacy can be clearly seen. Future studies should investigate the efficacy of PMR in specific demographics or under predetermined circumstances to identify where its advantages are most noticeable.

When measuring the efficacy of PMR combined with other interventions versus PMR as a standalone relaxation technique, there are two (2) studies in this review 66 , 68 that found combining PMR with other variables to be more effective compared to the PMR training alone in their respective study. Korkut, Ülker, Çidem, Şahin 66 found combining PMR with nature sound to be more effective in reducing anxiety among the nursing students, while Robb 68 highlighted that combination of PMR with music to be more effective in reducing anxiety among the university students compared to PMR alone.

Because of its diverse approach, PMR and its combination with other therapies appear to be viable interventions for stress, anxiety, and depression in adults. Combining PMR with different interventions may simultaneously access several relaxing mechanisms. Moreover, additional interventions might concentrate on other psychological or physiological aspects in addition to PMR, which can only alleviate muscular tension and relaxation. Compared to employing PMR alone, this holistic approach may provide a more comprehensive course of relaxation that potentially results in increased efficacy. With the assistance of an increasing amount of evidence and research, 66 , 74 , 76 , 79 these interventions provide an approachable and well-researched way to manage stress, anxiety, and depression.

There is certain limitation to the current review that could be addressed in future research. First, while this research provides invaluable findings, it is crucial to highlight that due to limited resource, it only included studies in English from English-language databases. This linguistic and database limitation may unintentionally exclude important studies published in different languages or databases. Future reviews may thereby strengthen the extent of coverage and generalizability of data by including papers in other languages and expanding the search to non-English databases. This will ensure a more thorough understanding of the efficacy of PMR among adults for stress, anxiety, and depression in varied cultural and language areas.

In conclusion, there has been large amount of evidence that supports the efficacy of PMR in reducing stress, anxiety, and depression among adults. Studies also shows that PMR combined with other interventions are more effective compared when applied by itself. Given these findings, researchers could find it beneficial to consider combining or integrating PMR with other interventions to enhance its potential in reducing stress, anxiety, and depression. Future research could also expand on the current review’s findings by incorporating a more targeted goal such as focusing PMR interventions among the wider working population, rather than to mostly health care workers, which may further refine our knowledge of PMR’s potential advantages and appropriate implementation in diverse circumstances.

Acknowledgment

Authors acknowledge the Ministry of Higher Education (MoHE) for funding under the Fundamental Research Grant Scheme (FRGS) (FRGS/1/2020/SS0/UTM/02/23).

The authors report no conflicts of interest in this work.

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Dr. Hasan Al Nashash

Assessment of mental stress in isolation and confined environment.

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Dr. Hasan Al-Nashash, Dr. Fares Al-Shargie and Dr. Usman Tariq

Department of Electrical Engineering

Email: [email protected] , [email protected] , [email protected]

• Engineers and scientists around the world are researching into technologies that astronauts will need during their long-duration space journeys. We are interested in understanding the physiological and mental challenges astronauts may face during their long journeys.
• The Analog Mission program aims at testing any proposed technology to be used during the complex journey. Another objective is to study the effects of isolation and confinement on human psychology, physiology and team dynamics.
• The Scientific International Research in Unique Terrestrial Station (SIRIUS) is currently conducting an 8-month Analog Mission in Moscow, Russia. The Crewmembers are isolated in a confined environment. In addition to learning how to cope with restricted resources and equipment, Crewmembers will conduct many experiments to help us study the effects of isolation and confinement on human psychology and physiology.
• The objective of this experiment is to assess mental stress during long-term confinement using multiple neuroimaging modalities with simultaneous subjective and behavioral data.
• Brain neural activity reflect cognitive functions. It can be measured directly from the changes in the electrical field or indirectly from blood oxygenation. The Electroencephography (EEG) measures the electrical potentials from the scalp resulting from the brain. The functional near-infrared spectroscopy (fNIRS) reflects the blood oxygenation changes in the brain. In this project, we use the Alpha amylase Meter, Functional Near Infrared Spectroscopy (fNIRS) and Electroencephalography (EEG). We also collect reaction time to stimuli data.
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