Essay: Stress, its causes in a medical/dental facility and methods and techniques for its management

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How to manage stress
in medical facilities-with special emphasis on dental-
using ergonomic design, relaxation techniques and patient education

# Chapter page
1 What is Stress
2 Consequences of Stress
3 Stress Management Interventions
4 Primary Stress Management Interventions
5 Secondary Stress Management Interventions

Chapter One:
What is stress?
The non-specific response of the human body to any demand made on it.
A person under stress chooses to either fight or attempt to escape which is termed fight-or-flight reaction.
There is a two types of stress:
1. Good stress (Eustress) which provides challenges to motivate individuals to work hard and meet their goals.
2. Bad stress (Distress) which results from stressful situations that persists over time and produces negative health outcomes.
Stress mechanism of action or progression: ( General Adaptation Syndrome or GAS)
It is divided into three stages:
1. Alarm reaction: the bod mobilizes resources to cope with the added stress by increasing stress hormones such as adrenalin, noradrenalin, epinephrine and cortisol.
2. Resistance stage: the body copes with the original source of stress but resistance to other sources is lowered.
3. Exhaustion stage: overall resistance drops and adverse consequences, including burnout,severe illness, and even death can result unless stress is reduced.
Fight-or-flight reaction comes in response to type of stress that comes suddenly and is likely to last only a short time -episodic, acute stress- whereas GAS tracks the bod response to stress over a longer period of time.
Coping with stress:
Individuals cope with stress in different ways but they are typically divided into:
1. Problem-focused coping: which is directed at managing and altering the problem that is causing the stress. Such type of coping may include defining the problem , generating different solutions and weighing their costs and benefits and acting to solve the problem.
2. Emotion-focused coping: which is directed at reducing the emotional response to the problem , which can mean avoiding, minimizing, and distancing oneself from the problem.
What is a Stressor:
Physical or psychological demand to which an individual responds whereas reactions and responses to these stressors are called strains.
Types of Stressors:
Work stressors fall into two major categories
1. Physical/Task Stressors: Physical such as noise, light, heat and cold. Cohen, Evans, Stokols & Krantz,1986; have showed that uncontrollable noise is particularly stressful and leads to lower task performance and diminished motivation. Evans & Johnson(2000) have shown that low-level noise is associated with elevated levels of stress hormones and lower task performance. The importance of the increased hormone levels is that stressors may exist even when the worker is not aware of the stressor.
Task stressors such as demands of a given job ( e.g., pace of work, workload, the number of hours worked) can also contribute to the experience of stress and to subsequent strains. For example, Hurrel (1985) studied several thousand postal workers and found that those working in machine-paced jobs experiences greater stress, anxiety, fatigue and tension than those working in jobs where the pace is set by employees(e.g., hand sorting, helping customers, delivering mail).
2. Psychological Stressors: Lack of control/predictability Control is a major theme in the literature on stress(Ganster & Murphy, 2000;Landy, Quick, & Kasl, 1994). Varying levels of personal control and predictability have clear effects on job performance and work stress (Rastegary & Landy, 1993; Spector, 1986). As with any stressor, the individual’s perception of control or predictability determines his or her response to the situation, and such perceptions are affected by characteristics of the job and work environment. The scheduling and pace of work can influence feelings of control. For example, flexible time schedules enhance feelings of control over one’s schedule, even though the average arrival and departure times may differ only by minutes after a flexible time schedule has been introduced (Baltes, Briggs, Huff, Wright, & Newman,1999). Flextime also increases perceptions of control by helping employees to balance work and family commitments (Ralston, 1989). Perceptions of control in the workplace are also related to autonomy, the extent which employees can control how and when they perform the tasks of their job (Hackman & Oldham,1980). Overall, interventions that enhance perceptions of control on the job ,such as participative decision making or flexible time schedules, are likely to reduce stress and subsequent strains.
Interpersonal conflict is the negative interactions with co-workers, supervisors, or clients. It can range from heated arguments to subtle incidents of unfriendly behavior (Jex,1998). It can occur when resources at wok are scarce, when employees have incompatible interests, or when employees feel they are not being treated fairly. It can distract workers from important job tasks, and it can have physical health consequences.
Role Stressors they are role ambiguity, role conflict, and role overload. Most jobs have multiple task requirements and responsibilities or roles (Rizzo, House, & Lirtzman, 1970), and that a job is likely to be particularly stressful if these roles conflict with one another or unclear. Role ambiguity occurs when employees lack clear knowledge of what behavior is expected in their job. In such cases, individuals experience uncertainty about which actions they should take in performing their job most effectively. Role conflict occurs when demands from different sources are incompatible.
A more specific form of conflict is role overload, a stressor that occurs when an individual is expected to fulfill too many roles at the same time. It can cause people to work very long hours, increasing stress and subsequent strains.
Work-Family conflict A different type of role stressor which occurs when workers experience conflict between the roles they fulfill at work and their roles in their personal lives. Because working women and dual-career families have become the norm rather than the exception , work-family conflict has become a common source of stress . In a study of men and women n high ranking positions, women were more stressed by their greater responsibility for household and family duties. In addition, women with children at home or any of the men in the study (Lundenberg & Frankenhaeuser, 1999). One study concluded that, compared to men , women appear to have better coping strategies to handle stress (Korbaik & McDonald, 1991). In particular, women are more likely than men to have access to social support which is a critical factor in reducing stress and it’s harmful effects.
Emotional Labor Interest in role of emotions in the workplace has increased rapidly over the past decade ( Fisher & Ashkanasy, 2000). Emotions are important to consider because stress is, first and foremost , an emotional reaction. Emotional labor is the regulation of one’s emotions to meet the job or organizational demands. The study of emotional labor addresses the stress of managing emotions when jobs require that workers display only certain expressions to clients or customers ( Adelmann, 1995). Workers can regulate their actions through surface acting and deep acting ( Morris & Feldman, 1996). Surface acting consists of managing or ‘faking’ one’s expressions or emotions. Deep acting consists of managing one’s feelings including trying to feel the emotions required by the job. Imagine a telemarketer who learns during lunch break a parent has been diagnosed with a life threatening disease. The struggle to maintain a cheery demeanor with customers would require considerable acting.
Consequences of Stress
The link between occupational stress and adverse health outcomes among employees is clear ( Cooper et al., 2001). The negative consequences of chronic stress can be divided into three categories: behavioral, psychological, and physiological.
1) Behavioral consequences of Stress
Among the behavioral consequences of stress are absenteeism, accidents, alcohol and drug abuse, poor job performance, and counterproductive behaviors including workplace violence (Kahn & Boysiere, 1992). We will focus on the effects of stressors on two particularly important behavioral outcomes:
1. Information processing, which affects a variety of other critical work outcomes.
2. Job performance, which can include information processing, but often involves global measures of effectiveness.
1. Information processing The influence of stress has been widely investigated . Chronic stress has detrimental effects on memory, reaction times, accuracy, and performance of variety of tasks (Smith, 1990). In addition, individuals under stress often have difficulty focusing their attention. Stress leads to premature reactions to stimuli, restricted use of relevant cues, and increased errors on cognitive tasks (Svenson & Maule, 1993).
Because each of us has limited cognitive resources, stressful situations that restrict such resources will impair our ability to cope with the task at hand . Stress also correlates with lower creativity and poorer decision making , particularly under time pressure (Rastegary & Landy, 1993; Shanteau & Dino, 1993). For example, fast-food delivery drivers commonly have accidents during the rush period of deliveries (usually Thursday & Friday nights between 5:00 P.M. And 11:00 P.M.). They often report never seeing the object( e.g., car, truck, jogger, motorcycle) whose path they turned across. They simply did not ‘process’ that information when they turned left because they were looking for a street sign or a street number during the hectic evening hours
2. Job Performance For a century it has been investigated that arousal and performance have an inverted ‘U’ relationship. (Yerkes & Dodson, 1908). The hyposthesis is that as arousal increases, performance increases, but only up to a certain point, and then performance begins to decline. Thus, compared to situations with moderate arousal, both low levels of arousal (boredom) and high levels of arousal (extreme danger) result in lower performance. Alternatively, moderate arousal can lead to high motivation, energy, and attentiveness; this outcome is consistent with Selye’s concept of eustress. It is important to acknowledge that stress represents only one of many factors that may impact job performance (Jex, 1998).
2) Psychological Consequences of Stress
They include anxiety,depression, burnout, fatigue, job tension, and dissatisfaction with one’s job and life (Kahn & Byosiere, 1992). Burnout is a particularly important consequence of stress. It is an extreme state of psychological strain that results from a prolonged response to chronic job stressors that exceed an individual’s resources to cope with them ( Maslach, Schaufeli, & Leiter, 2001). Burnout was first observed in ‘caring professions’: dentists, doctors, nursing, social work, and teaching.
3) Physical Consequences of Stress:

Theories of Stress
Several theories have been developed to organize the relationships among stressors, strains and potential moderators of those relationships. Two theories that have received a great deal of attention are Karasek’s Demand-Control Model and French’s Person-Environment Fit Model. In addition, stress models have considered individual difference variables that influence the relationship between stressors and strain.
1. Karasek’s (1979) Demand-Control Model suggests that the two factors are prominent in producing job stress: job demands and control (also known as decision latitude). In this model, job demands are defined as the workload and intellectual requirements of the job. Job control is defined as a combination of autonomy in the job and discretion for using different skills. Karasek proposed that the combination of high work demands with low control results in ‘high strain’ jobs that result in a variety of health problems. Food services worker, waitperson , nurse’s aide, and assembly-line worker are considered high strain jobs. Machine-paced jobs, in particular, were highlighted as having high demands and low control. In contrast , jobs characterized by high demands also provide sufficient control create an ‘active’ job situation that is stimulating and health promoting. Active jobs include lawyer, engineer, manager, and physician. Jobs with low control and low demands (e.g., janitor, night watchmen) were labeled as ‘passive’ jobs. Finally, jobs with high control and low demands (e.g, architect, dentist) were considered as particularly low strain jobs.
Tests of the Demand-Control model are often conducted is using the Job Content Questionnaire (JCQ), designed to measure the ‘content’ of a respondent’s work (Karasek, 1985). The JCQ includes the following subscales:
‘ Role overload and role conflict (demands).
‘ Skill utilization and job decision latitude (control).
‘ Depression, job dissatisfaction, and sleep problems (health consequences).
The scales have been used extensively to investigate job-related stress and coronary heart disease in the United States and Sweden. For example, in a series of surveys involving U.S. and Swedish male workers, Karasek (1979) found that the combination of low control heavy job demands correlated positively with mental strain (i.e., depression and exhaustion) and job dissatisfaction.
Karasek and Theorell (1990) found an increased risk of illness(two to four more times more likely) for individuals whose lives or jobs make high demands on them but allow little control. Thus, an individual who has a demanding work schedule or environment and does not have have much decision latitude or control will have an increased risk of stress-related illnesses, both physiological and psychological. In contrast, individuals in active jobs that have high demands but high maintained good health and high job satisfaction. Karasek and Theorell (1990) noted that individuals in active jobs appear to participate actively in a variety of leisure activities as well, despite their high work demands. This finding is another example of the benefits of developing or designing jobs that allow workers to have control over decisions, resources, or skills that they can use.
Ganster, Fox, and Dwyer (2001) tested the Demand-Control model in a sample of 105 full-time nurses . They found that nurses with the lowest perceptions of personal control and highest workload demand were ill more often and incurred the highest cumulative healthcare costs over the ensuing five-year period. Thus, jobs that have high demands and low control are costly to both individuals and the organizations for which they work.
Person-Environment Fit Model
The Person-Environment (P-E) Fit Model (French, Caplan, Harrison, 1982) hypothesizes that the fit between a person and the environment determines the amount of stress that person perceives. A good person-environment fit occurs when a person’s skills and abilities match the requirements of the job and work environment. For example, an introvert with PhD in literature would be likely to have a good P-E fit with the job of university librarian, while an extraverted MBA have a good P-E fit with the job of sales manager. The amount of stress a worker feels is influenced by perceptions of the demands made by the environment, and by perceptions of his or her capability to deal with those demands. Using this model, French et al. found that a poor fit between a person and the environment was frequently associated with increased strains. Alternatively, employees whose skills and abilities fit well with the work environment reported less stress and fewer strains (Edwards, 1996; French et al., 1982).
Karasek (1979) did not formally emphasize perception in the Demand-Control model. In contrast, the P-E fit approach focuses explicitly on the perception of individuals concerning their skills and abilities relative to the demands of the work environment. In addition, unlike the Demand-Control model, the P-E fit approach considers external influences such as social support from family and work sources. For example, Edwards and Rothbard (1999) found that the well-being of the employees varied according to their perceptions of work and family experiences. The results of this study indicate that interventions to manage stress should consider the fit between employees and both their work and family environments, which is consistent with the research we discussed above on work-family conflict. In particular, if it is bad in both the family and the work environment, the cumulative stress is likely to lead to low job performance and high health problems.
Early work did not always specify what ‘environment’ was referred to in the P-E fit model. Recent work has more clearly differentiated between person-job fit and person-organization fit (Lauver & Kristof-Brown, 2001). Person-job fit refers to the extent to which the skills abilities and interests of an individual are compatible with the demands of the particular job. Alternatively, person-organization fit refers to whether the values of an employees are consistent with the values of held by most others in the organization. In a diverse sample of managers, Lovelace and Rosen (1996) found that perceptions of poor person-organization fit were associated with greater levels of stress, job dissatisfaction, and intentions to quit one’s job. Similarly, Saks and Ashforth (1997) found that favorable employee perception of person-job fit correlated positively with job satisfaction and organizational commitment, and negatively with stress.
It is clear that different types of fit have influence on a variety of problems, including stress, job dissatisfaction, and intentions to leave the organization. Organizations should strive to ensure that employees fit well in their jobs and have the skills necessary to complete their job tasks. In fact, fit is often increased through recruitment and selection processes that help applicants and those doing the hiring assess the likelihood that candidates will fit well in the job and in the organization (Schneider. 1987).
The P-E fit model suggests mechanisms by which individuals can protect themselves from the stress that accompanies the mismatch between the person and the environment. One of these protective mechanisms is social support. For example, employees who have seemingly impossible deadlines might seek informational and emotional support from co-workers. By reducing their experience of stress in this way, employees might be able to focus better and come closer to meeting their deadlines than if they were overwhelmed and suffering from strains. Overall, the P-E fit model allows us to examine work stress by looking at the interaction between the person and stressors in the work environment. This approach specifically acknowledges that stress can influence individuals differently depending on their preferences, values, and abilities (Edwards, 1996).

Individual Differences in resistance to stress
When you have been part of a group in a stressful situation, not everyone responds to stress in the same way. Several individual characteristics has been studied as the potential moderators of stressor-strain relationship. A moderator is a variable that affects the direction or strength of the association between two other variables. For example, if stressors led to strains for individuals with low self-esteem but not for those with high self-esteem, then self-esteem would be a moderator of the stress-strain relationship. If moderators reduce strains for only certain types of individuals, they are said to have an indirect effect on the reduction of strains. Individual difference characteristics that have received the most attention as moderators of the stressor-strain are locus of control, hardiness, self-esteem, and the Type A behavior pattern.
Locus of control (LOC) is a construct that refers to whether individuals believe that happens to them is under their control or beyond it (Rotter,1996). Individuals characterized as internals believe that outcomes are result of their own personal effort and ability, whereas persons classified as externals believes that outcomes are determined laregely by other people, luck, or fate. Many elite professional atheletes are confident-sometimes overconfident- that success lies completely in their hands (i.e., they have an internal LOC). In team sports, they like to be thought of as the ‘go to’ person. Several studies have indicated that internal experience lower strains than do externals. Researchers have proposed that because internals believe they can control a stressful situation to achieve their goals, they experience fewer strains than externals exposed to the same stressors. Overall, evidence indicates that having an internal locus of control moderates the relationship between stressors and strains (Horner,1996; Kahn & Byosiere,1992).
Hardiness is a set of personality characteristics that provide resistance to stress(Kobasa,1979). Specifically, individuals described as having a ‘hardy personality’ possess three characteristics:
1. They feel they are in control of their lives.
2. They feel a sense of commitment to their family and their work goals and values.
3. They see unexpected change as a challenge rather than an obstacle.
Cohen and Edwards (1989) observed that hardy individuals actively adopt problem-focused and support-seeking strategies. Kobasa, Maddi, and Kahn (1982) found that hardy individuals had fewer physiological reactions to stressors, reported fewer illnesses, and had higher levels of general well-being than those who were not hardy personalities were found to have significantly fewer strains than those who were not hardy. Among executives and lawyers who were under a great deal of stress, those who were hardy personalities were found to have significantly fewer strains than those who were not characterized as hardy (Maddi & Kobasa, 1984). Overall, evidence indicates that hardiness moderates the relationship between stressors and strains ( Cohen & Edwards, 1989). A key component of hardiness is transformational coping, which involves actively changing perceptions of a stressful event by viewing it as a challenge that can be overcome. For example, hardy students facing an important and stressful exam might cope by interpreting their exam as an opportunity to show their knowledge, thereby exerting control through preparation and good study habits (Quick et al.,1997).
Self-esteem, or positive self-worth or self-concept, is considered an important resource for coping. Individuals with high self-esteem are more likely to adopt more effective coping strategies in the face of stress than individuals with low self-esteem (Ganster & Schaubroeck,1995). Thus when faced with the same environmental stressors, individuals with low self-esteem will experience more strains compared to those with high self-esteem. Overall, research generally indicates that self-esteem is a moderator of the stress-strain relationship (Cooper et al., 2001). Although high self-esteem is clearly important in reducing the effects of stress at work, there is some evidence that the effects of high self-esteem are not always positive. Although many people assume that low self-esteem is related to work-place violence, Baumeister, Smart, and Boden (1996) conducted an extensive literature review that indicated that aggression and workplace violence were most characteristic of individuals with high self-esteem.
Type A Behavior Pattern
The potential moderator of stress-strain relationship that has been most intensively studied is the Type A behavior pattern (TABP), which was first identified in the late 1950s by two cardiologists, Meyer Friedman and Ray Rosenman (1959). Fifteen years later, Friedman and Roseman wrote Type A Behavior and Your Heart (1974), in which they described the Type A behavior pattern as a set of characteristics exhibited by ‘individuals who are engaged in a relatively chronic struggle to obtain an unlimited number of poorly defined things from their environment in the shortest period of time and, if necessary , against the opposing of other things or persons in the same environment’ (p.67).
The Type A behavior pattern is also known as the coronary-prone personality because of its proposed links to coronary heart disease and heart attacks. Individuals who exhibit this behavior pattern ( known as Type As) are characterized by ambitiousness, impatience, easily aroused hostility, and time urgency. Friedman & Roseman (1974) suggested that the core characteristic of TABO is an incessant struggle to achieve more and in less and less time. In fact, descriptions of Type As who are overly obsessed with saving time are common. For example, Typpe A men have been known to use two electric razors (one for each side of the face ) at the same time to shave more quickly as possible (Bluedorn,2002; Gilberth & Carey, 1948). Generally Type As seem to thrive on ‘life in the fast lane’ as they focus on quickly doing things that result in occupational and material success. In contrast, Type Bs are often described as relaxed patient, and easygoing.
Sapolsky (1998) described the history of how Friedman and Roseman missed an opportunity to identify some of the typical characteristics of Type As in the early 1950s. In the waiting room outside Friedman and Roseman’s Cardiology office, the lining of the chairs was worn down so much that the upholstery needed to be replaced frequently. Only years later that they began their formal work on Type A behavior pattern and thus realize that their heart patients had a consistent pattern of behavior , including nervous energy and fidgeting, that was related to heart disease. Research has indicated that Type As do tend to desire control and responsibility, and they prefer to work alone (Clark & Miller, 1990; Strube, Lott, Heilizer, & Gregg,1986). As for the outcomes compared to Type Bs, Type As are more punctual , work at faster rates, and are high achievers in college and in their professional careers (Gastorf, 1980; Taylor, Locke, Lee & gist,1984; Yarnold & Grimm,1982). So, although the Type A behavior pattern was initially because of its association with health problems, it also appears to be associated with positive outcome such as high work performance and career success.
It was important to have a clear evidence that these positive outcomes came at the cost of high stains and sucdequent health problems. Specifically, researchers were interested in whether Type As respond to stressful situations with greater physiological arousal and thus suffer greater strains than Type Bs. Accordingly, many studies have attempted to link TABP to increased physiological arousal and to the development of coronary heart disease. However these efforts were slowed by the use of imprecise, global TABP measures that attempted to assess several TABP subcomponents (Booth-Kewley & Friedman,1987). This led researchers to focus on identifying specific subcomponents of the TABP that were most predictive of coronary heart disease. Subsequent studies indicated that hostility is the primary TABP subcomponent associated with increased secretion of stress hormones as well as increased risk of coronary heart disease and other long-term, harmful health outcomes ( Krantz & McCeney, 2002; Miller,Smith, Turner, Guijarro, & Hallet, 1996). Thus, Type As who exhibit hostility pay a price for their accomplishments in terms of increasing their likelihood of suffering from a variety of long-term health problems.
They continued on examine other TABP subcomponents in their attempts to predict work and short-term health outcomes in Type As. Two TABP subcomponents that have received attention are achievement striving and impatience/irritability (Spence, Helmreich, & Pred, 1987). Achievement striving is the tendency to be active and to work hard in achieving one’s goals, whereas impatience/irritability reflects the intolerance and frustration that results from being slowed down.
The Achievement striving dimension is positively corelated with academic performance, sales performance, and job satisfaction (Bluen, Barling, & Burns, 1990; Spence et al., 1987). The impatience/irritability dimension is associated with health problems such as insomnia, headaches, poor digestion, and respiratory difficulties (Barling & Boswell,1995; Bluen et al.,1990). These studies indicate that achievement striving and impatience/irritability are independent from each other and that these TABP subcomponents can be used to differentially predict performance and health outcomes.
An additional TABP subcomponent that appears to be related to important work and health problems is time urgency, which refers to the feeling of being pressured by inadequate time. Time-urgent individuals check their watches repeatedly, even when they are not under the pressure of deadlines, and they are concerned with saving relatively small amounts of time (often measured in minutes or seconds). Time-urgent individuals seem to always know what time it is even when they are not wearing a watch. Increasing evidence indicates that individuals differ widely from one another in the degree to which they concern themselves with the passage of time and how to cope with it in accomplishing work-related and personal goals (Conte, Mathieu, & Landy, 1998). For example, some individuals are constantly making schedules, lists, and deadlines for themselves, whereas others do not pay attention to such temporal concerns.
Recent evidence suggests that time urgency has multiple dimensions including time awareness, eating behavior, nervous energy, list making, scheduling, speech patterns, and deadline control. Landy, Rastegary, Thayer, and Colcvin (1991) developed Behaviorally Anchored Rating Scales (BARS) for these dimensions of time urgency. Research indicates that these time urgency dimensions are relatively independent, which means that individuals can be high on some dimensions are relatively lower on others (Conte, Landy, & Mathieu, 1995; Landy et al.,1991). For exampple, workers may eat very quickly during a brief lunch break, but they may not focus much on making lists or following schedules very closely. Alternatively, some task-oriented individuals may work quickly and focus closely on schedules and deadlines, but they may not speak quickly or exhibit nervous energy.
Research also indicates that certain time urgency dimensions (e.g., list making, scheduling) are related to work outcomes, whereas other time urgency dimensions (e.g., eating behavior, nervous energy, speech patterns) are related to health outcomes. Menon, Narayanan, Spector (1996) related time urgency to occupational stress and health outcomes in a sample of nurses and physicians. They found that rapid talking and eating behaviors were positively correlated with arguments on the job and with lowered resistance to physical illness. In contrast, scheduling, list-making, and time-awareness behaviors were positively related to job satisfaction indicating that some time urgency dimensions can result in positive work outcomes.
Conte, Schenneker, Dew, and Romano (2001) found that the deadline control time urgency dimension was significantly related to work pace, that is, individuals who were focused on deadlines worked faster than those who were not controlled by them. This finding is likely to be usedful in organizations and industries in which a fast work pace is crucial. For example, there are immense pressures for efficient and timely development of new products in computer industry. Time-urgent individuals who have experience working under time constraints may be able to withstand a higher level of time pressure when the work situation requires it (Freedman & Edwards, 1998). However, difference in the way team members approach and utilize time may be a source of tension and may make it difficult for teams to function well under deadline pressures (Waller, Conte, Gibson, & Carpenter, 2001).
Overall, specific TABP subcomponents do a better job of predicting particular criteria than a global Type A measure that combines a variety of different subcomponents. Thus researchers and practitioners concerned about health and performance outcomes will have more success using TABP subcomponents to predict health and performance outcomes.
In summary, research on TABP subcomponents indicates that :
‘ Achievement striving is positively related to desirable work outcomes.
‘ Impatience/irritability is related to short-term health problems.
‘ Hostility is most predictive of long-term health outcomes ( e.g., coronary heart disease).
‘ The multiple dimensions of time urgency are related to a variety of work and health outcomes.
Reducing and managing stress
In 1990 stress was listed for the first time as one of the top 10 occupational health risks in the United States. As a result, concerns about stress at work became much more prominent in public and government discussions of health(Sauter, Murphy, & Hurrell, 1990). These concerns led to the development of the field of Occupational Health Psychology, which involves the application of psychology to improving the quality of work life, and to protecting and promoting the safety, health, and well-being of workers.
Occupational health psychologists often divide their approaches to stress reduction and management into three major categories: primary, secondary, and tertiary interventions (Cooper et al., 2001; Quick et al., 1997)
Primary Prevention Strategies
They are concerned with modifying or eliminating stressors in the work environment and therefore said to be ‘stressor-directed’ (Cooper & Cartwright, 2001). Primary interventions are the most proactive and preventative approaches to stress management (Cooper et al., 2001). Many primary intervention strategies give workers increased control over the job and work environment, which directly lowers stressors and increases employees satisfaction and well-being.
Primary prevention approaches include redesigning the task or work environment, encouraging participative management, developing clearer role descriptions, and modifying or changing Type A thought patterns. Another primary prevention strategy involves providing flexible work schedules which can be seen in recent trends toward flextime, shorter work weeks, and job sharing. Primary prevention approaches are aligned with problem-focused coping strategies, which are directed at managing or altering the source of stress (Lazarus, 2000).
Work and Job Design
Work and jobs can be designed or redesigned to reduce such stressors as noise, interruptions, time pressure, role ambiguity, and the number of hours worked (Sparks, Cooper, Fried, & Shirom, 1997). In addition, jobs can be redesigned to increase worker participation in decision making and to increase autonomy on the job. Decades ago, restaurant owners decided to reduce the stress on stress on short-order cooks by requiring waitpersons to clip their orders to a small, circular, revolving order stand. The cooks could then spin the stand around, see what orders were pending, and decided to pull off first. This principle was extended to auto manufacturing by Saab and Volvo. Automobile bodies circled work teams on oval track, and the teams decide which ones to pull off first for assembly and paint operations. Another example of redesigning of is the common ‘queuing’ process that is found at many service centers. Customers stand in one line and are not permitted to approach a service desk until their number is flashed or an available agent is identified by electronic screen. This process increases the customer service agent’s control over how quickly customers are served and thereby reduces the agent’s stress. Such changes can help workers feel that their work is more meaningful and that they have control over work outcomes. This in turn leads to a higher motivation and satisfaction as well as lower stress at work (Hackman & Oldham, 1980).
A study by Jackson (1983) provides a good example of the benefit of participative decision making. Jackson found out that nursing and clerical employees who participated in decision making at staff meetings had increased perceptions of control and reduced role ambiguity and role conflict. With stressors reduced by this relatively simple change in the way meeting were conducted, employees had higher job satisfaction and lower emotional strain at work, which over time led to fewer absences and lower intentions to leave the job.
Cognitive Re-structuring
Several of the approaches that we have discussed, including the Person-Environment Fit model and Type A behavioral pattern, highlight the role of perceptions in the stress process. Cognitive restructuring interventions focus on changing perceptions and thought process that lead to stress. These approaches reduce stress by changing an individual’s perception of the work environment or one’s capacities to meet the demands of the environment. Cognitive restructuring approaches encourage individuals to change negative thoughts to more positive ones (Quick et al., 1997). for example, a worker who thinks, ‘ I can’t handle this heavy workload’, might be encouraged to think instead: ‘This workload is a challenge that I can handle if I break it down into manageable parts’, or ‘ I won’t be considered a complete failure if I don’t push very hard to finish this task today’.
Secondary Prevention Strategies
It involves modifying responses to inevitable demands or stressors; thus, they are said to be ‘response-directed’. Because it addresses the experience of stress rather than the stress or stressors, it’s role is often one of damage control. Thus, this type of intervention is often described as the ‘Band-Aid’ approach (Cooper & Cartwright, 2001). They are aligned with emotion-focused coping strategies, which seek to reduce the emotional response to the stressor and can involve avoiding, minimizing, and distancing oneself from the stressor (Lazarus, 2000). For example, emotion-focused coping might be used to reduce the stress experienced in a job that requires emotional labor.
Secondary prevention strategies that require no special training (but might be formally encouraged through an employer-sponsored program) include lifestyle choices such as phyiscal fitness, healthy eating, and weight control, as well as a reduction in smoking and caffiene. Skills-training programs such as negotiation and conflict resolution are another form of secondary intervention. In addition, secondary stress management methods include relaxation techniques, biofeedback, and providing or encouraging social support at work. Many approaches use a combination of the above methods.
It is important to note that secondary prevention can be proactive or reactive. For example, Cooper et el. (2001) noted that training in conflict resolution skills can be used to reduce interpersonal conflict and its effects after it has occurred. Alternatively, such training can be used proactively to prevent interpersonal conflict from developing. Similarly, individuals can be proactive in exercising and maintaining a healthy diet, which can reduce or moderate future stress.
Stress Management Training
Programs involving stress management training are very popular with employers and employees. Cooper and Cartwright (2001) noted that the continued demand for stress management programs and the increasing stress levels reported in the literature are indicative of the acceptance by organizations that stress is an inherent and enduring feature of the work environment. Stress management training programs are useful for helping employees deal with those stressors that are difficult to remove or change. They often include a variety of secondary prevention techniques and may even include some primary techniques. For example , many stress management programs are described as cognitive behavioral skills training programs.
Cognitive-Behavioral Skills Training
It’s a variety of techniques designed to help workers modify the appraisal processes that determine how stressful they perceive a situation to be, and to develop behavioral skills for managing stressors (Murphy, 1996). The most common type of cognitive-behavioral skills-training is stress inoculation, which usually consists of an educational component ‘ learning about how a person has responded to past stressful experiences; rehearsal ‘ learning various coping skills such as problem solving, time management, relaxation, and cognitive coping; and application ‘ practicing those skills under simulated conditions (Murphhy, 1996). Thus, in many cases these approaches are a combination of primary (i.e., to reduce stressors by means of cognitive restructuring) and secondary (i.e., to manage or cope with symptoms of stress through behavioral skills training) prevention strategies.
Jones et al. (1998) developed an organization-wide stress management program that was used with employees of several hospitals. The program included video modules that enhanced understand of stress and provided information regarding how to develop and improve coping skills, health behaviors, and relaxation routines. In a longitudinal investigation that evaluated the impact of this stress management program, Jones et al., found that one result was a significant drop in the average number of monthly medication errors by doctors and nurses. In an additional two-year longitudinal investigation, they found that 22 hospitals that implemented the same organization-wide stress management program had significantly fewer medical malpractice claims compared with a similar, matched sample of 22 hospital that did not participate. This study showed that well-conducted , psychological research efforts can decrease malpractice claims through stress management interventions.
Relaxation and Biofeedback Techniques
Relaxation techniques include progressive muscle relaxation and deep breathing exercises. Progressive muscle relaxation involves starting at the top or bottom on one’s body, tightening one set of muscles at a time for five to seven seconds, and then letting those muscles relax. Individuals can work through each major muscle group and thus help to progressively relax the entire body. These relaxation techniques are effective in reducing arousal and anxiety (Murphy, 1996).
Biofeedback is a stress management technique that involves teaching individuals to control certain body functions such as heart rate, blood pressure, even skin temperature by responding to feedback about their body from an electronic instrument (Quick et al., 1997). One simple and inexpensive biofeedback device is a skin-sensitive ‘biodot’ that monitors stress levels and physiological changes according to color changes. The dot darkens after individuals discuss a stressful event and lightens when they feel more relaxed (Ulmer & Schwartzburd, 1996). Thus, this device shows individuals that stress ‘ and relaxation for that matter ‘ leads to measurable changes in the body and that careful monitoring of the body can reduce anxiety and arousal.
Social Support
Is the comfort , assistance, or information an individual receives through formal or informal contacts with individuals or groups. Social support has been widely investigated as a way to reduce stress and strain at work. House (1981) identified four different kinds of social support.
1. Instrumental support ‘ direct help, often of a practical nature; for example, a friend encourages a co-worker to slow down by suggesting joint walks during the lunch hour.
2. Emotional support ‘ interest in, understanding of, caring for, and sympathy with a person’s difficulties ; this type of support is often provided by a therapist or a family member.
3. Informational support ‘ information to help a person solve a problem; this type of support is often supplied by a health care professional. In addition, an increasing number of websites are popping up with useful information.
4. Appraisal support ‘ feedback about a person’s functioning that his or her self-esteem; this often comes from a close friend, a therapist, family members, or other members of a support group.
Researchers have given considerable attention to the possibility that social support moderates or reduces health problems by protecting individuals from the negative effects of work stressors. Studying such effects is called the buffer or moderator hypothesis because it seeks to determine whether the negative effects of work can be buffered or moderated by social support (Cohen & Wills, 1985). Evidence is mixed on the buffering hypothesis, which could be due to the failure of researchers to emphasize the match between stressors and support. That is , buffering should work when there is a reasonable match between the stressors and the available social support. A longitudinal study of 90 blue-collar metalworkers found evidence for the buffering hypothesis in reducing anxiety and other strains when social support was matched directly to a social stressor such as conflict with one’s supervisors (Frese, 1999). Social support at work may be particularly important as a moderator of stress-strain relationship in the present day when traditional societal structures such as the extended family are smaller than they once were (Quick et al., 1997). For example, in the 21st century American society, many adult children no longer live close to their parents or siblings. They may see family members infrequently, usually over holiday periods that carry their own stress and strain.
Employers can help build their own social support systems at work. For example, formal mentoring programs, reward and recognition system, and newcomer socialization programs can make work environments more supportive. Allen, McManus, and Russell (1999) found evidence for the important role that more experienced peers can serve in mentoring newcomers and in enhancing socialization. In turn they found a negative relationship between socialization and work stress, indicating that formal peer relationships can be critical in reducing stress and subsequent strains. Finally, the supportive relationships formed in team building have been shown to improve performance and reduce stress (Svyantek, Goodman, Benz, & Gard, 1999).
Tertiary Prevention Strategies
They are ‘symptom-directed’ and thus they are focused on healing the negative effects of stressors. Tertiary interventions include employee assistance programs and the use of medical care, individual psychotherapy, and career counseling (Quick et al., 1997).
Employee assistance program (EAPs) were originally developed by organizations to address alcohol and drug problems, and they were subsequently broadened to include stress management interventions. In most organizations, EAPs involve some form of counseling to deal with work stress, alcohol or drug difficulties, and problems outside the job (e.g., family problems, behavioral and emotional difficulties). Employee assistance programs can be provided by the human resources department within an organization, or they may be provided by an external consultants or vendors. If an organization is to have successful EAPs, its management must express support for th program, educate employees about it, provide the necessary training on its use, and make the program accessible to employees (Milne, Blum, & Roman, 1994). Organizations must ensure that confidentiality is maintained and that the use of an EAPs programs does not harm job security or advancement. These suggestions are particularly important because unhealthy work climates and distrust in EAPs often prevent employees from seeking help for alcohol or drug abuse problems. For example, police officers often avoid in-house EAPs because they are uncertain of confidentiality assurances and fear that will be stigmatized by commanding officers and colleagues. Even to be seen talking with an EAP coordinator is ‘dangerous’. Integrating positive messages about EAP into different types of training programs may be effective in improving the use of EAPs by skeptical employees (Bennet & Lehmann, 2001).
Although EAPs are not often systematically evaluated by the organizations using them, the few evaluations that have been done indicate that EAPs are successful. Cooper and Saderi (1991) found improvements in the mental health and self-esteem of employees participating in EAPs . In addition, Cooper and Cartwright (1994) found that EAP programs can be very cost effective for organizations in terms of reducing absences, accidents, and health care costs. Nevertheless, even though focusing on the treatment of strains may be an effective short-term strategy, the approach is essential reactive and reciprocative rather than proactive and preventative (Cooper et al., 2001). Because EAPs focus on dealing with the long-term outcomes of stress, they should certainly not be the only approach that organizations utilize in the stress prevention and management process.
Summary of Stress intervention strategies
Several recent studies have evaluated a variety of stress management interventions. In a study by Bellarosa and Chen (1997), 96 stress management experts evaluated occupational stress management interventions (e.g., relaxation, physical fitness, cognitive restructuring, stress inoculation, meditation, and assertiveness training) on the basis of practicality and effectiveness. Evaluations by stress management experts are useful, but psychologists are also interested in more quantitative assesments of stress management interventions (Murphy, 1996; van der Klink, Blonk, Schene, & van Dijk, 2001).
Murphy (1996) conducted a comprehensive review of effects of worksite stress management interventions on a variety of health work outcomes (e.g., blood pressure, anxiety, headaches, and job satisfaction). The stress management programs included in this review were progressive muscle relaxation, meditation, biofeedback, cognitive-behavioral skills, and combinations of these techniques. Meditation produced the most consistent results across outcome measures, but it was infrequently used in organizations. Relaxation and cognitive-behavioral techniques were found to be quite successful. Overall, the study indicated that using a combination of techniques (e.g., muscle relaxation and cognitive-behavioral skills) was more effective across outcome measures than using any single technique. In another review of stress management interventions, Bunce (1997) also concluded that combining various stress management interventions is more effective than using any single approach. A recent meta-analysis found general support for the benefits of interventions for work-related stress (van der Klink et al., 2001). This study found that cognitive-behavioral approaches worked best in reducing stress, but relaxation techniques were also successful. Overall, these studies show reason for optimism about stress management interventions, particularly when a combination of techniques is used. In addition, successful stress management interventions must accurately identify the stressors causing strains, and then actively determine ways to reduce those stressors (Briner & Reynolds, 1999). Employees should also participate in the process of identifying stressors and implementing the various interventions deigned to reduce stress ans strains.
Primary stress prevention strategies are generally preferred over the other interventions because they take an active approach to removing and reducing stressors (Quick et al., 1997). Secondary and tertiary interventions can play a useful role in stress management, but their effectiveness is limited because they fail to address the source of stress itself. Thus, identifying and recognizing the stressors and taking steps to remove or reduce them through job redesign, flexible work schedules, or other primary prevention strategies should receive the highest attention in organizations. Indeed, the limited research that has examined primary-level interventions has shown that they yield consistently positive and beneficial long-term effects (Cooper & Cartwright, 2001). Similarly, the National Institute for Occupational Safety and Health (NIOSH) urges occupational health psychology professionals to give special attention to the primary prevention of organizational risk factors for stress, illness, and injury at work.
Human Factors Engineering
The importance and meaning of human factors
Workers are exposed to a wide variety of work ‘conditions’. They included physical conditions such as heat, light, and noise. The individual worker was expected to either adapt, or at least put up with, these conditions.
The humman factors approach uses the ‘knowledge of human (Capabilities) to design systems, organizations, jobs, machines, tools, and consumer products for safe, efficient and comfortable human use’ (Helander,1997, p.4). The term ‘ human factors’ is synonymous to human factors engieering or human factors psychology. Human factors overlaps with related discilpines such as ergonomics, the study of the physical demands of work, such as reaching, streching, lifting, and carrying; applied experimental psychology; occupational medicine; and exercise physiology.
The human factors assumes that workers are constant , and that the work needs to adapt to the worker. Human capacities and limitations include physical and cognitive abilities, knowledge, presonality, and even physiology. The goal of the human factors is to develop a physical and psychological environment that is optimaly compatible with the capacities and limitations of humans. Rather than accepting the environment as a constant, and selecting those few individuals who may be most compatible with it, the human factors catalogs the human capacities and limitations and develops an environment that is ideally suited as possible to them.
This was not the case. In the early days of the factory system, machines were designed by mechanical engineers who had little concern for the capacities and limitations of humans. An exampke of that cab be seen in the design of a popular machine for working on metal parts called lathe. The purpose of a lathe is to create a shape in a piece of steel or aluminum by spining that piece at a high speed and applying a sharp bit to its surface while it is spinning. Before computers were introduced to the factory floor, lathes were operated by hand with lots of manual controls, usually in the form of wheels, levers, and buttons which were used to bring the bit into contact with the piece to be shaped.
Consider the two individuals depiceted in figure 16.1 The person in the top portion of the figure (A) represents a typical lathe designed by mechanical engineers in 1920s, as sketched in the lower portion (B), would look much different. The ideal operator would be slightly over 4.5 feet tall and 12 feet across the shoulder, and would have an 8-foot arm span. This ideal operator was determined by the way the mechanical engineers designed the lathe, and we can be fairly certain that few real-life lathe operaotrs resembeled the ideal. The engineers most likely began their design with standard measurements of the components from which the machine would be built. From the human perspective, this was foolish. The mechanical engineers should have begun their design with an appreciation of the range of likely characteristics, capacities, and the limitations of the operators of the lathe. The implications are clear. If the equipment and environment are not compatible with the human who will use that equipment and populate that enviroment, we also can expect problems in the form of lowered production, injuries, and accidents. We also expect to see unhappy workers who are continuallu ‘taxed’ by their work.
Figure 16.2 is a reminder of the fact that we often take human factors for granted. Imagine an elevator with such a control panel. Think of the extra time you might need to locate the button corresponding to the floor you wanted to visit. Worse than that, imagine the chaos of a telephone keypad with a rendomly arranged numbers. There are literally hundreds of devices you use every day that have been designed or modified by human factors specialits; the configuration of an automobile dashboard, the height and tilt of a chair; the keyboard and screen at a computer workstation, the arrangement of knobs and burners on the stove top, the positioning of the brakes on a mountain bike, even the way a radio dial or a TV remote control works. All of these are examples of products or objects desgined to acheive user friendliness – that is, to be comfortable, easy to use, and compatible with human capacities and limitations. In this chapter, we will consider the concept and discipline of human factors engineering as it applies to work.
Human Factors Models
Howel (1993) identified human factors as the dynamic force in both technology design ans society. We have adapted his view in Table 16.1. In the left-hand column is the ‘need’ or driving force. In the right-hand column is the himan factor, or applied, issue or area of concentration. this table provides a good overview of the substance of human factors. Two very simple models can be used to poosition human factors in the broader perspective of the study of work behavior. Consider figure 16.3. In a series of concentric circles, we see that the worker is embedded in a series of increasingly larger environments which include, respectively, equipment(e.g., computers), physical workplace (e.g., work cubicle or office), social work space(e.g., teams), and organizational work space (e.g., climate or culture). Each of these environmentshas an influence on the performance of of the individual. Traditionally, the human factors appoach has concentrated on the interface between the worker and the equipment – and in the very last several decades, the ‘equipment of choice’ has been the computer. Figure 16.4 illustrates a very basic model of the interactionof the worker and equipment.
There are several components of the model. There is a worker. the equipment, the way the worker receives information from the equipment, and the way the worker controls the equpment, the way that the worker receives information from the equipment, and the way the worker controls the equipment. Both the equipment and the worker have an input component and an output component. An everyday example of the this model is that you’re supposed to prepare a paper for one of your classes and you were preparing it on the computer. As you sit infront of the computer you see a screen and a keyboard. What appears on the screen is the output from computer ans input to you. what you type on the keyboard represents output from you, but input to the computer. You and the computer are connected through this information flow loop. You ask the computer to access information in a literature base related to industrial safety by first activating a search engine, then typing in a website, and finally inputting some key words for the search. With that instruction, the computer accompishes the search and provides you with the relevant journal articles. There have been a string of interactions between you and the computer. You truned it on, you activated its operating system, you started the search engine, you identified the website, and you listed the key words. At each point in this process, the computer asked you to make choices. You made these choices with the mouse or the keyboard, and when you made each choice, the computer ‘did its thing’. These was considerable input and output in both sides of the keyboard.
This simple example introduces two additional technical terms that are important in human factors; displays and controls. Displays (e.g., computer screen)provide an individual with information, while controls (e.g., keyboard or mouse) permit an individual to take actions. there is a rich history as well as an active current research interest in the design of the most effective methods of display and control (Salvendy,1997; Wickens, Gordon, & Liu, 1998). But displays and controls are only two components of a more elaborate model of work from the human factors approach perspective. Figure 16.5 presents a more complete systems view of the human factors approach to work.
Human factors is a global discipline. The same human factors issues affect virtually any industrialized country. Helander (1997) identified a number of human factors challenges characterise work in 25 different countries. These include the change of work organization and design, work-related musculoskeletal disorders, and human-computer interface. Muskuloskeletal disorders of the lower back and upper extremities are the most commonly studied injuries related to workspace safety. Human-computer interface (HCI) is the interaction between a human and a computer. Other factors that Helander identified are the change in social systems of work environments, high technology system design (particularly nuclear power plant control rooms), mental workload, and human reliability.
Work Schedules
The scheduling of work is under the control of the organization, and thus can be considered an issue of work design. Work schedules are playing an increasingly important role in managing work-life balance in two ways: Individuals desire the freedom to pursue leisure activities outside of work, and they often have obligations to fulfill multiple roles as spouse, caregiver, and the parent. This suggests that the scheduling of work can have substantial effects on worker well-being. There are three different scheduling formats that bear discussion: Shift work, flextime, and compressed workweeks.
Shift work
The scheduling of work according to a prticular time period is called shift work. The study of shift work and its effects on workeres has a long and rich research history. This history is well presented in a number of sources (e.g, Johnson, Tepas, Colquhoun, & Colligan, 1981; Landy, 1989; Tepas, Paley, & Popkin, 1997; Wedderburn, 1981). Much of this work has centered on the 24-hour a circadian cycle of humans, whose physiology tends to make them active during hours of light and inactive(e.g., sleeping or resting) during hours of darkness. Thus, workers assigned to shifts during daylight hours are following the circadian cycle, while those whose shift includes hours of darkness are working against the cycle. Psychologists found that, in general, the disturbance of thee circadian cycle has adverse effects on the health, performance, and general satisfaction. Shift work is categroized in to two different types: fixed shifts and rotating shifts. If workers are permenantly assigned to a particular shift, the shift is called fixed shift. Typical shifts inlude the day shift (e.g., 7:00 A.M. to 3:30 P.M.), the afternoon or evening shift – often called the ‘swing’ shift (e.g., 3:00 P.M. to 11:30 P.M.), and the night shift – often called the ‘ midnight’ or ‘graveyard’ shift (e.g., 11:00 P.M. to 7:00 A.M.). Workers who move from shift to shift are said to be working a rotating shift schedule. Shiftscan rotate rapidly (e.g., move to a different shift every week) or slowly (e.g., a worker may change shifts every three months). In union environments, worker can often bid on shifts based on seniority, resulting in more frequent shift changes for workers less seniority.
Generally speaking, rotating shifts are more likely to be associated with problems that fixed shifts (Parkes,1999). This is particularly true if the direction of the rotation is from day to night to evening (as opposed to day to evening to night). Rotating shifts and particularly rapidly rotating shifts, lead to sleep disturbances , which in turn are associated with medical (e.g., gastrointestinal) and psychological (e.g., anxiety and depression) difficulties. Rotating shifts also seem to be hard on older workers (Landy, 1989).
Shift work is more common in some occupational groups than others. Nurses, blue collar workers, and public safety personnel have higher concentrations of shift workers than professional, managerial, or white-collar groups ( Smith et al.,1999). The most frequently studied of those occupations is the nursing profession. Barton (1994) examined the nurses who take night shifts on permanent basis and nurses who where assigned to rotating night shifts. Permanent night shift nurses reported significantly fewer problems with health, sleep, and social or domestic activities. This was particularly true for individual nurse who chose to work on the permanent night shift compared with nurses who chose to work on permanent night shift compared with nurses who chose rotating shift schedule. The most important reasons the nurses in this study gave for choosing the permanent night shift were the night shift work permitted them to more easily fulfill domestic responsibilities, and it paid better. Thus, for those who chose permanent night work, it actually improved control and scheduling of work-nonwork roles. But the nurses on a rotating shift schedule felt that their lives were disrupted every time they had to work afternoon or night shifts (Barton, 1994). It appears that night shift work provides a significant opportunity for establishing a work-life balance that is not possible for rotating shifts or, in some circumstances, day or afternoon shifts. This seems to be a particularly true of dual wage earning families with young children. In another study of nurses, Bohle and Tilley (1998) found that work-nonwork conflict was one of the strongest predictors of satisfaction with shift work.
These balancing advantages notwithstanding, some research has shown that permanent day shift tends to be more intrinsically satisfying that afternoon, night, or rotating shift work. Blau and Lunz (1999) analyzed the effect of various shift schedules on 705 medical technicians (MTs) and found that MTs who worked a permanent day shift reported that their jobs were less routine than the jobs of MTs on any other shift. To some extent, this perception conforms with the reality of this job across shifts. Night shift MTs tend to perform standardized tests on samples gathered during the day. In addition, since many medical procedures are performed during the day. Since many medical procedures are performed during the day and vary substantially from patient to patient, it makes sense that the work of the day shift MT would be less routine. The day shift MTs were also more satisfied with supervision, mainly because supervisors were available on the day shift, as opposed to the night shift, which often functioned without any direct supervision.
Flexible and compressed workweek schedules
Shift work regardless of whether it is fixed or rotating, defines the work schedule rigidly. In general, shift workers are expected to work eight hours per day, five days per week. But there are other scheduling variations that are not so rigid.
Flextime Individual workers who are given discretion over the time they report to work and the time they leave work on a given day are working a flextime schedule. Such schedules are uncommon in manufacturing organizations, since the interdependence among workers in assembly-line and continuous process operations makes the absence of a particular worker particularly problematic (Baltes, Briggs, Huff, Wright, & Newuman, 1999). A survey of a diverse sample of more than 1000 organizations in 1995 revealed that 66% of them permitted some form of flexible workday (Hewitt Associates, 1995). That percentage has probably increased since 1995. In a typically flexible work schedule, every worker is expected to be at work during a ‘core’ period (e.g., 10:00 A.M. – 3:00 P.M.) but is permitted to arrive as early as 7:00 A.M. and leave as late as 9:00 P.M. (Baltes et al., 1999). Regardless of when they arrive and leave, they are expected to be at workplace for 40 hours a week. Ronen (1984) after the introduction of flextime the average arrival time of workers was 8 minutes later than it had been before, and that the average departure time was 22 minutes later after the introduction of flextime. The benefits of flextime to the individual worker are obvious. In addition to the psychological advantages of perceiving some control over the work schedule, there is the practical advantage of achieving a better balance between work and nonwork. Most workers express satisfaction with flexible schedules.
Compressed workweek Another nontraditional work schedule is the compressed workweek, which permits an employee to work for longer than eight hours a day and fewer than five days a week. A common plan is 4/10 plan, which permits a worker to accumulate the 40 hours of the workweek in four days. For some workers, this affords the opportunity to enjoy an ongoing series three-day weekends. For others it permits them to take another jobs or pursue further education on a more regular basis while still working. A 1995 survey of 1000 companies found that 21% offered workers the possibility of a compressed workweek. This type of schedule is found most commonly in the manufacturing organizations (Baltes et al., 1999). As with flextime, workers tend to express satisfaction with the compressed workweek (Landy,1989).
Consecuqeunces of Flextime and Compressed workweek Schedules Worker satisfaction with flextime and compressed workweek schedules is well documented (Baltes et al., 1999; Landy, 1989). But are these work schedules associated with organizational outcomes such as productivity, performance, and absenteeism? The activity of creating and maintaining nontraditional work schedules inevitably incurs some administrative costs, so organizations may well ask, What’s in it for us? Baltes et al., (1999) conducted a meta-analysis of 39 studies on the effects of flextime (27 studied) and compressed workweeks (12 studies). The results of analysis are useful and encouraging for both of these scheduling variations. They found that flextime was associated with higher productivity and lower absenteeism, although the impact on absenteeism was considerably greater than the effect on productivity. For the compressed workweek, they found that while absenteeism was unaffected, supervisors’ ratings of performance were higher (though productivity was not).
Baltes et al, (1999) did some further analyses of their data and found that flextime had little effect on productivity, performance ratings, or absenteeism for professionals and managers such as accountants or sales managers. In addition, they found that for non-professional, non-sales managerial workers =, programs with extremely flexible hours were less effective than more conservative programs. They concluded that this was probably the result of the inability of employees in the workplace to communicate with absent employees. This would be problematic in organizations that depend heavily on teams and groups as opposed to single contributors. They also found that the effects of flextime tended to diminish after the initial period of adjustment (typically a few months); as workers became accustomed to the new scheduling, it became the norm. Remember also that one study demonstrated that actual arrival and departure schedules remained very much the same (Ronen,1981).
Approaches to work design and redesign
With the study of different work design issues; which included technological variables (computers and automation) and social variables ( work scheduling). Campion and Thayer (1985, 1987; Campion, 1988, 1989) have proposed that one might take many different approaches to designing and redesigning work, and since each approach has different goals, we might expect different outcomes, Campion and Thayer (1985) examined 700 different ‘rules’ that have been suggested for designing work and reduced them to four different outcome. In table 16.3, you will see the specific questions that might be asked in designing or redesigning a job. Any given design change includes several different approaches, not just one, which includes elements of motivational, mechanistic, and perceptual-motor approaches. The motivational approach to work design and redesign is used to increase worker satisfaction and reduce turnover through modification of motivational levels. The mechanistic approach to work design and re-dseign is used to increase productive efficiency through the modification of tasks or equipment. The perceptual-motor approach is used to reduce errors or accidents through knowledge of perceptual-motor skills and abilities. Finally, the biological approach is used to reduce injuries and increase the physical comfort of workers thought the reduction of fatigue and discomfort. Automation included elements of the mechanistic, biological, and perceptual-motor approaches. Work scheduling is related to the motivational and biological approaches.
Campion’s (1988,1989) models have several implications. First, we need to be clear about what outcomes we expect or desire in the design or re-design of work. If we are designing work to increase worker satisfaction and reduce turnover, we may want to choose the motivational appoach. If , instead, we are trying to reduce injuries and increase the physical comfort of workers, we would rely on the biological model. A second implication is that conflict may occur between the approaches, resulting in both anticipated and unanticipated outcomes. If you were to use the mechanistic approach to increase productivity efficiency, you would simplify work. But by doing that, you would also make the work less interesting and motivating for the worker.

Safety in the workplace
Workplace injuries costs millions of losses annually in wages as well as medical, administrative and other costs.
Safety Regulation
In 1970 – in USA – Congress passed the Occupational Safety and Health Act. The purpose was to ensure safe and healthful working conditions for every working man and woman in the United States. Two federal agencies were established to maintain and enforce this act. The first was the Occupational Safety and Health Administration (OSHA). OSHA’s role is regulatory. It establishes standards and enforses them. The second agency was the National Institute of Occupational Safety and Health (NIOSH). Its responsibility is to conduct safety-related research; a great deal of the recent research in the area of work-related stress has been funded by NIOSH.
Traditional approaches to workplace safety
A model of unsafe behavior

Treatment room design
Basic considerations for safe practice
Basic factors involved in the conduct of safe practice include the following:
1. Treatment room features
2. Instrument management
3. Preparation for appointment
4. Unit water lines
5. Environmental surfaces
6. Care of sterile instruments
1. Treatment room features
The design of many treatment room may not be conductive to ideal planning for infection control &/or ergonomic design. Changes can be made in routines so that updated , preferred systems can be adapted.
When renovations or a new dental office or clinic are anticipated, plans can reflect the most advanced knowledge available relative to safety, disease control and stress. A partial list of notable features is included here and illustrated in figure . The objective is to have materials, shapes, and surface textures that facilitate the effective use of infection control measures.
‘ Designed for easy cleaning and disinfection, with smooth, uncluttered surfaces.
‘ Removable hoses that can be cleaned and disinfected.
‘ Syringes with autoclavable tips or fitted with disposable tips.
‘ Handpieces with anti-retraction valves.
‘ Handpieces that can be autoclaved.
Dental Chair:
‘ All foot-operated controls. If manually operated need disposable barrier cover for switches.
‘ Surfaces and seamless finish of easily cleaned plastic material that withstand chemical disinfection without damage or discoloring, cloth upholstery to be avoided.
‘ Foot-activated switches.
‘ Removable handle for sterilization or disposable barrier cover.
Clinician’s stool:
‘ Smooth, plastic seat cover that is easily disinfected and has a minimum of seams and creases.
‘ Foot-operated controls. If manually operated, needs a barrier cover for the control.
‘ No cloth carpeting.
‘ Smooth floor covering, easily cleaned, nonabsorbent.
‘ Smooth material ( stainless steel).
‘ Wide and deep enough for effective handwashing without splashing.
‘ Water faucets ad soap dispensers with electronic , ‘knee’ or foot-operated controls.
‘ Separate room or area for contaminated instrument care.
Supplies: All sterilizable and disposable.
‘ Receptacle with opening large enough to prevent contact with sides when material is dropped in: heavy-duty plastic bag liner to be sealed lightly for disposal.
‘ Sharps disposal.
‘ Small bio-hazard receptacle near treatment area to receive contaminated sponges and other waste for disposal in large waste container clearly marked for contaminated waste.
Instrument processing center
The successful practice of standard precaution to prevent cross-contamination depends on the development of, and strict adherence to, a planned program for instrument management.
A good rule is to learn the most effective, safe system and them to follow that method without exception.
A specific routine is easier for the entire dental team to follow, and peer review is built-in.
The basic steps in the recirculation of instruments from the time an appointment procedure is completed until the instruments are sterilized and ready for use in the next clinical appointments are sterilized and ready for use in the next clinical appointment are shown in the flow chart in figure. Each of the steps is described in the following sections.
Cleaning procedures
The three methods for cleaning instruments prior to sterilizatation are instrument washers/thermal disinfectors, ultrasonic processing , and manual scrubbing. Benefits from the use of washers/thermal disinfectors over manual scrubbing include the following:
1. Increased efficiency in obtaining a high degree of cleanliness.
2. Reduced danger to clinician from direct contact with potentially pathogenic microorganisms.
3. Improved effectiveness for disinfection.
4. Elimination of possible dissemination of microorganisms
5. through release of aerosols and droplets, which
6. can occur during the scrubbing process.
7. Penetration into areas of the instruments where the bristles of a brush may be unable to contact.
8. Ideally the instruments are contained within a cassette so that little or no handling is required.
A. Procedure for Manual Scrubbing
1. Wear heavy-duty gloves, protective eyewear, and mask.
2. Dismantle instruments with detachable parts. Open jointed instruments.
3. Use detergent and scrub with a long-handled brush under running water; hold the instruments low in the sink. Scrubbing one instrument at a time minimizes risk of puncture injury.
4. Brush with strokes away from the body; use care not to splash and contaminate the surrounding area.
5. Rinse thoroughly.
6. Dry on paper towels (same reasons as those listed for ultrasonic processing).
B. Care of Brushes
1. Color code brushes to distinguish from handwash brushes.
2. Soak and wash contaminated brushes in detergent; rinse thoroughly and sterilize
A. To prevent contamination of newly sterilized instruments as soon as they are removed from the sterilizer.
B. To provide a means of storing instruments to keep them in sets for individual appointment use and sterilized and ready for immediate use on opening.
A. Preset cassettes or packages can be preplanned to contain all the items usually needed for a particular appointment.
B. Each package is dated and marked for identification of contents: for examples, Adult Scaling and Root Planing; Examination.
C. Clear packages with self-seal permit instrument identification without special labeling. Figure 6-3 shows clear, ‘see-through’ packages for easy identification of package contents.
A. Materials
‘ Each method of sterilization has specific requirements, and the manufacturers’ recommendations are
‘ Sturdy wrapping is necessary to prevent punctures or tears that break the chain of asepsis and require a repeat of the process.
‘ The wrap permits the steam or chemical vapor to pass through the contents.
B. Seal
‘ Indicator tape is used. Pins, paper clips, or other types of metal fasteners are not used because they provide holes for the entry of microorganisms.
‘ Chemical indicator tape is used to seal all packages, except when the wrap has built-in indicators. The chemical, usually in the form of a series of stripes, changes color during the sterilization process ( Figure 6-3).
‘ The change of color means that the autoclave reached a designated temperature required for penetration but does not designate sterilization.
‘ Distinct black stripes will appear. A lighter color change may be a warning signal that the autoclave function needs to be checked.
‘ The striped indicator tape is left on the sealed package and thereby serves to identify those packages ready for use. Packages are kept completely sealed until unwrapped in front of the patient.
Each of the methods listed here is described in the sections following. Table 6-1 summarizes the operating requirements of each.
A. Steam under pressure (autoclave)
B. Dry heat
C. Chemical vapor
‘ All materials and items cannot be treated by the same system of sterilization.
Supplement with disposable single-use products when
sterilization is not possible.
‘ The method for sterilization selected provides complete destruction of all microorganisms, viruses, and spores and yet must not damage the instruments and other materials.
‘ Procedures cannot be overly complex, or many errors in processing may occur.
‘ Careful, specific use of sterilizing equipment in accord with the manufacturer’s specifications is necessary.
‘ Incomplete sterilization frequently results from inadequate preparation of the materials to be sterilized (cleaning, packaging), misuse of the equipment (overloading, timing, temperature selection), or inadequate maintenance.
Sterilization is the process by which all forms of life are destroyed. That definition provides the rationale for testing whether a sterilizer is working properly. Three tests are used: an external and an internal chemical indicator and a biologic monitor.
‘ External Chemical Indicator: to seal the package and change color to show the autoclave temperature
has been reached ( Figure 6-3 ).
‘ Internal Chemical Indicator: color change assesses instrument exposure to temperature and steam for the required time.
‘ Biologic Monitor: tests that the autoclave is functioning properly.
A. The testing system requires the use of selected test microorganisms that are put through a regular
cycle of sterilization and then are cultured. When no growth occurs, the sterilizer has performed with
maximum efficiency.
B. Microorganisms Used
1. Steam Autoclave: Geobacillus stearothermophilus (formerly Bacillus stearothermophilus ) vials, ampules, or strips.
2. Dry Heat Oven: Bacillus atrophaeus (formerly Bacillus subtilis ) strips.
3. Chemical Vapor: Geobacillus / stearothermophilus (formerly Bacillus stearothermophilus ) strips.
C. Procedures
1. The ampule, vial, or strip is placed in the center of a package, which in turn is placed in the middle of the load of packages to be sterilized.
2. After the cycle has been completed at the customary time and temperature, the ampule or strip is incubated. Ampules and vials show the color change associated with no living microorganisms, whereas the strip organisms are cultured and show no growth if the sterilizer has performed properly.
3. Table 6-2 shows indications for performing spore tests in dental settings. Records that are kept show dates and outcomes.
D. Frequency
1. At least weekly testing is recommended; more often when heavy autoclave use.
2. Equipment can be obtained for performing the testing, or commercial mail-in services are available.
Destruction of microorganisms by heat takes place because of inactivation of essential cellular proteins or enzymes. Moist heat causes coagulation of protein.
‘ Gravity Displacement : Self-generation of steam forces out the air; steam enters to penetrate through the cassettes or packages
‘ High-Speed Prevacuum : pump removes the air from the chamber and allows faster penetration of the steam for sterilizing.
‘ A time/temperature comparison of the two autoclave systems is provided in Table 6-1 .
‘ Moist heat may be used for all materials except oils, waxes, and powders that are impervious to steam or for materials that cannot be subjected to high temperatures.
A. Advantages
‘ All microorganisms, spores, and viruses are destroyed quickly and efficiently.
‘ Wide variety of materials may be treated; most economical method of sterilization.
B. Disadvantages
‘ May corrode carbon steel instruments if precautions are not taken.
‘ Unsuitable for oils or powders that are impervious to heat.
The action of dry heat is oxidation.
‘ Primarily for materials that cannot safely be sterilized with steam under pressure.
‘ For oils and powders when they are thermo-stable at the required temperatures.
‘ For small metal instruments enclosed in special containers or that might be corroded or rusted by moisture.
A. Advantages
‘ Useful for materials that cannot be subjected to steam under pressure.
‘ When maintained at correct temperature, this method is well suited for sharp instruments.
‘ No corrosion compared with steam under pressure.
B. Disadvantages
‘ Long exposure time required; penetration slow and uneven.
‘ High temperature critical to certain materials.
The unsaturated chemical vapor sterilizer is also called the Chemiclave or Harvey sterilizer.
A combination of alcohols, formaldehyde, ketone, water, and acetone heated under pressure produces a gas that is effective as a sterilizing agent.
Chemical vapor sterilization cannot be used for materials or objects that can be altered by the chemicals that make the vapor or that cannot withstand the high temperature.
Examples are low-melting plastics, liquids, or heat-sensitive handpieces.
A. Advantages
‘ Corrosion- and rust-free operation for carbon steel instruments.
‘ Ability to sterilize in a relatively short total cycle.
‘ Ease of operation and care of the equipment.
B. Disadvantages
‘ Adequate ventilation is needed; cannot use in a small
‘ Slight odor, which is rarely objectionable.
‘ Instruments stored without sealed wrappers are only
momentarily sterile because of airborne contamination.
‘ Labeled, sterilized, and sealed packages are stored
unopened in clean, dry cabinets or drawers. Paperwrapped
packages are handled carefully to prevent
tearing. All stored packages are dated and used in rotation.
‘ Packages wrapped and sealed in paper may not need
resterilizing for several months to 1 year.
‘ Plastic or nylon wrap with a tape or heat seal may be
expected to remain sterile longer.
‘ The expected shelf life before resterilizing depends on
the area surrounding the stored packages. A closed,
protected area without exposure, such as a cabinet or
drawer that can be disinfected routinely, is preferred.
Chemical disinfectants are used in several forms, including
as surface disinfectants, immersion disinfectants,
immersion sterilants, and hand antimicrobials. Each variety
has specifi c chemicals, dilutions, and directions for
Disinfectants are categorized by their biocidal activity as
high level, intermediate level, or low level. Biocidal activity
refers to the ability of the chemical disinfectant to
destroy or inactivate living organisms.
A. High Level
High-level disinfectants inactivate spores and all forms
of bacteria, fungi, and viruses. Applied at different time
schedules, the high-level chemical is either a disinfectant
or a sterilant.
B. Intermediate Level
Intermediate-level disinfectants inactivate all forms of
microorganisms but do not destroy spores.
C. Low Level
Low-level disinfectants inactivate vegetative bacteria and
certain lipid-type viruses but do not destroy spores, tubercle
bacilli, or nonlipid viruses.
A. Environmental Surfaces Disinfection
Following each appointment, the treatment area is cleaned
and disinfected.
B. Dental Laboratory Impressions and Prostheses
Impressions can be carriers of infectious material to a
dental laboratory. Completed prostheses must be disinfected
before delivery to a patient.
The objective is to select a product that is effective in the control of microorganisms and practical to use. Properties of an ideal disinfectant are shown in Box 6-2 .
‘ EPA approval.
‘ Use EPA-registered hospital disinfectant for lowlevel requirements.
‘ Use EPA-registered hospital disinfectant with a tuberculocidal claim for intermediate and high especially when there is visible blood or other potentially infectious material.
‘ Manufacturer’s informational literature and container labels
‘ Provide facts about the product that ensure its effectiveness.
‘ When the label has insufficient information, the manufacturer is contacted and instructions are obtained.
‘ The criteria include at least the following: must be tuberculocidal, bacteriocidal, virucidal, and fungicidal.
‘ Label must state:
1. Effectiveness and stability expressed by
a. Shelf life : the expiration date indicating the termination of effectiveness of the unopened container.
b. Use life : the life expectancy for the solution once it has been activated but not actually put to use with contaminated items.
c. Reuse life : the amount of time a solution can be used and reused while being challenged with instruments that are wet or coated with bioburden.
2. Directions for activation (mixing proportions).
3. Type of container for storage and place (conditions such as heat and light).
4. Directions for use
a. Precleaning and drying of items to be submerged.
b. Time/temperature ratio.
5. Instructions for disposal of used solution.
6. Warnings
a. Toxic effects (on eyes, skin).
b. Specific directions for emergency care in the event of an accident (e.g., splash in eye).
c. Keep manufacturer’s Materials Safety Data Sheets for reference.
‘ After the product has been selected, it is the responsibility of the dental personnel to use it as directed to obtain the best possible infection control.
‘ The cleanliness and neatness of the treatment room reflect the character and conscientiousness of the dental personnel.
‘ The patient, with limited knowledge of dental science, may judge the ability of the dental personnel by the appearance of the office or clinic.
‘ Other patients may inquire about sterilization and infection control.
‘ The patient’s attitude is important, but more important is the relationship of cleanliness to the presence of microorganisms. The need is to provide clinical services in an environment that minimizes cross-contamination.
‘ The orderliness and immaculate cleanliness of the treatment rooms result from continuing care. An excellent test for the effects of care and any minor oversights is for each dental team member to sit in the dental chair occasionally and look around at what the patient sees from that vantage point.
Ergonomic Practice
The patient’s presence in the offi ce or clinic is an expression of confidence in the dentist and the dental hygienist.
Confidence is inspired by the reputation for professional knowledge and skill, the appearance of the office, and the actions of the workers in it.
‘ The physical arrangement and interpersonal relationships provide the setting for specific services to be performed.
‘ The patient’s well-being is the all-important consideration throughout the appointment.
‘ At the same time, the clinician must function effectively and efficiently in a manner that minimizes stress and fatigue to ensure personal health.
‘ Muscular skeletal disorders, repetitive stress injuries, and cumulative trauma disorders are common workrelated conditions for dental hygienists that require continuing preventive physical and mental energy on the part of each clinical dental hygienist.
‘ The science of ergonomics has provided information for the development of standards for human performance and workplace design that can maximize health, comfort, and efficiency for dental hygienists in clinical practice.
The requirements for preparation of the treatment area are standard precautions for all patients whether or not the presence of a communicable disease is known.
‘ Environmental surfaces . All contact areas are thoroughly disinfected or covered to control cross-contamination
‘ Instruments . Sterile packaged instruments remain sealed until the start of the appointment.
‘ Equipment . Prepare and make ready other materials that will be used, such as for the determination of blood pressure and patient instruction. Anticipate specific needs for procedures being delivered.
‘ Patient’s dental chair . Upright for current patient reception; chair arm up for access.
‘ Clinician’s chair . Set at proper height for the entire day when same clinician will be there.
‘ For the patient of record, the patient’s medical and dental history for pertinent appointment information, updating, and assessment are reviewed.
‘ Read previous appointment progress notes to focus the current treatment plan.
‘ Anticipate examination procedures and new record making for a new patient.
Four body positions for delivery of care are shown in Figure 7-1 .
A. Upright
This is the initial position for patient reception from which chair adjustments are made.
B. Semi-Upright
Patients with certain types of cardiovascular, respiratory, or vertigo problems may need this position.
C. Supine
‘ In a supine or fl at position the brain is on the same level as the heart.
‘ A patient is ideally situated for support of the circulation; rarely could a patient faint while lying in a supine position.
‘ Position used most for treatment procedures.
D. Trendelenburg
‘ The patient is in the supine position and tipped back and down 35 �� to 45 �� so that the heart is higher than the head.
‘ A dental chair provides complete body support for the patient, which increases patient relaxation.
‘ A comfortable patient is more compliant and allows the procedure to be completed more efficiently.
‘ Seat and leg support moves as a unit; back and headrest move as a unit; both are power controlled.
‘ Has a thin back so that the chair may be lowered close to the clinician’s elbow height.
‘ Chair base permits the chair to be lowered as needed for appropriate treatment position.
‘ Chair controls need to be available to both the assistant and clinician.
A. Prepositioning for Patient Reception
‘ Chair at low level; back upright.
‘ Chair arm raised on side of approach.
B. Adjustment Steps
‘ Patient is seated with back upright.
‘ Chair seat and foot portion are raised first to help the patient settle back.
‘ Lower back to the supine position for maxillary instrumentation and to a 20 �� angle with the floor for mandibular treatment.
‘ Request patient to slide up to rest the head at upper edge of the headrest or backrest and turn head to left or right as needed for visibility and access.
‘ Adjust chair until patient’s mouth is at the clinician’s elbow height with shoulder relaxed ( Figure 7-2 ) .
C. Conclusion of Appointment
‘ Move instrument tray away and turn off light.
‘ Slowly raise back of chair and tilt chair forward.
‘ Request patient to remain seated in upright position briefly to avoid postural hypotension.
D. Contraindications for Supine Position
‘ Review patient history for indications of need for adaptation.
‘ Patient may request a position variation.
‘ Conditions that may contraindicate the supine position include congestive heart disease, vertigo, and a breathing difficulty such as emphysema, severe asthma, or sinusitis.
‘ During the third trimester of pregnancy, some women may be uncomfortable. Chair positioning for the pregnant patient is described on page 748 and illustrated in Figure 48-2, page 749.
‘ The clinician is in neutral working position, with good access, light, and visibility, which in turn contribute to an efficient procedure.
‘ The patient is positioned so that a thorough, biologically oriented service may be performed conveniently and effi ciently within a reasonable length of time.
‘ The positions of the patient and the clinician are interdependent.
‘ When clinician and patient positioning is considered, it is realistic to remember that the patient’s position will be assumed for a relatively short time compared with that of the clinician.
Objectives concern the health of the clinician, the service to be performed, and the effect on the patient.
FIGURE 7-2 Clinician’s Working Distance. Acceptable positioning shows the patient at the clinician’s elbow level and the oral cavity of the patient between 15 and 22 inches from the clinician’s eyes.
The preferred neutral position attempts to accomplish the following:
‘ Contribute to and preserve rather than detract from clinician’s health and wellness.
‘ Contribute to ease and effi cacy of performance thatencourages patient cooperation.
‘ Allow endurance for prolonged periods of peak effi -ciency.
‘ Reduce potential for overexertion and injury from mental and physical stress and fatigue.
‘ Give the patient a sense of well-being, security, and confidence.
‘ Accommodate a patient with special needs.
‘ Neutral working position (NWP) needs to be developed, practiced daily, and made habitual.
‘ Habitual neutral position will translate to all activities, outside of work as well. An internal environment can be created for on-going physical ease, comfort, safety, and activity.
‘ Without practicing the principles of neutral position on a regular daily basis, a clinician can experience discomfort, pain, and work-related stress disorders. The longterm result can be shortened or compromised career longevity with changes in daily life activities.
Analysis and assessment of posture can give direction to corrections for treatment. A posture assessment instrument is available. 1
‘ Back: in neutral alignment with natural spinal curves, including cervical lordosis, thoracic kyphosis, and lumbar lordosis
‘ Head: on top of neutral spine with forward neck flexion between 15 and 20 degrees or less.
‘ Eyes: directed downward to prevent neck and eye strain.
‘ Shoulders: relaxed and parallel with the hips and floor.
‘ Elbows: close to the body.
‘ Forearms: parallel with the floor.
‘ Wrist: forearm and wrist are in a straight line.
‘ Thighs: full body weight distributed evenly on seat; comfortable space (about 3 inches) between edge of seat and back of knee.
‘ Knees: slightly apart.
‘ Feet: flat on the floor.
A. Distance
‘ Patient’s oral cavity is adjusted to clinician’s elbow
‘ Distance from clinician’s eyes to the patient’s oral cavity when the clinician is seated in neutral position will be within the range of 15 to 22 inches ( Figure 7-2 ).
‘ The distance is defined as the ‘working distance,’ which is a significant measurement when fitting loupes for an individual clinician.
B. Selection
‘ Neutral working position is combined with effective access to the patient for treatment procedures.
‘ Orientation of position of the clinician to patient can be compared to the hours of a clock around the patient’s head with 12:00 noon at the top of the patient’s head as shown in Figure 7-3 .
‘ Clock hours correspond with clinician/patient relation associated with instrumentation in different areas of the patient’s oral cavity.
C. Flexibility
Orientation for the right-handed clinician is associated with 8:00 AM to 2:00 to 3:00 PM; and for the left-handed clinician orientation is associated with 10:00 to 11:00 AM to 4:00 PM.
‘ Access and visual adjustment determines which side the clinician will select for a given procedure.
‘ Movement of the clinician’s chair freely on wheels and turning of the patient’s head facilitate positioning and patient treatment from either side.
‘ Crossing over the midline improves access and visibility in certain areas.
‘ In treatment rooms with limited space, the dental chair may be swiveled to change the angle of the chair to allow the clinician space to move across the midline.
‘ The treatment area centers around the patient’s oral cavity.
‘ The entire ‘work area’ refers to the dental chair with patient, the unit, and the instrument tray as they are positioned for the convenience and accessibility of the clinician and assistant for 4-handed dental hygiene.
‘ For the clinician, the essentials for access and visibility for patient care are provided by the flexibility of movement of the clinician’s chair and appropriate lighting, supplemented by the clinician’s own visibility enhanced by wearing magnification loupes with head light.
‘ The chair is a signifi cant adjunct to implement ergonomic practice.
‘ Optimal design provides adequate support and the opportunity and means to change body posture frequently during the workday as clinicians, patients, and procedures change.
‘ The clinician adjusts the chair to personal specifications.
‘ Many clinicians own their own chair to accommodate or prevent a personal health problem.
A. Characteristics of an Acceptable Chair
‘ Base: broad and heavy with no fewer than four casters; a chair with five casters provides greater stability.
‘ Seat: seamless upholstery, padded firmly; accommodates requirements for neutral seated position.
‘ Height: adjustable for wide personal variability.
‘ Back: adjustable lumbar support to accommodate different positions, procedures, and clinicians.
‘ Mobility: completely mobile; built with free-rolling casters; not connected to other dental equipment; free movement around the patient’s head for instrumentation from either side.
‘ Adjustment: multiple adjustments for different positions, procedures, and clinicians; mechanisms easy to learn and use.
‘ Infection control friendly: all surfaces able to withstand standard precautions regimen.
‘ During treatment, visibility in the oral cavity is prerequisite to thoroughness without undue trauma to the tissues.
‘ With adequate light, effi ciency increases, treatment time is decreased, and patient cooperation increases.
‘ Many lighting options are available. All need to be directed properly to the oral cavity for adequate visualization, optimal patient care, and clinician comfort and safety.
A. Dental Light: Suggested Features
‘ Is readily adjustable both vertically and horizontally.
‘ Beam of light is capable of being focused.
‘ Set within a comfortable arm’s reach.
‘ Does not require awkward or forceful movement to position it for visualization.
B. Dental Light: Location Attachment
‘ Unit attachment.
‘ Ceiling-mounted light on a track is most versatile.
Dual Lighting
‘ Advantages of the use of two clinic lights have been demonstrated with a supine patient position in a contoured chair.
‘ One light directed from the front of the patient may be attached to the dental unit; the other light is mounted on a ceiling track.
C. Dental Light: Adjustment Principles
‘ Light allows clear illumination of entire treatment area.
‘ Figure 7-4 shows position of light for maxillary and mandibular treatment.
FIGURE 7-4 Lighting. Light does not obstruct clinician, allows clear illumination of the treatment area. (A) Maxillary arch; chin up position; beam of light often between 60 �� ‘ 45 �� angle to fl oor. (B) Mandibular arch; chin down position; beam of light nearly perpendicular to floor.
Magnification is needed to improve visualization, support neutral working position, and enhance treatment procedures.
A. Choice of Loupe Systems
‘ Through-the-lens: adjusted with the clinician’s prescription as needed.
‘ Flip-up for magnification only.
‘ Loupes with head light: for added improvement in visualization.
B. Features
‘ Proper fit is essential to successful incorporation of magnifi cation into the clinician’s treatment environment.
‘ Proper fit is dependent on the clinician’s working distance and neutral position.
‘ Clinicians need to research the differences to select best option.
‘ Technology has provided handpieces that are ergonomically compatible with procedures clinicians provide.
‘ Designs are smaller, lighter, and better fitted to dental hygienists’ hands.
A. Ergonomically Designed Handpieces
‘ Are lightweight, decreasing stress on hand and wrist.
‘ Fit in the contours of the clinician’s hand and allow functional light grasp.
‘ Reduce fatigue and strain.
‘ Allow maneuverability.
‘ Provide power assist without strain.
‘ Produce less heat buildup.
‘ Are available in a cordless option.
A. Management
‘ Managing cords is a significant aspect of ergonomic practice.
‘ Cords are part of dental units and are an integral part of delivery of care for every patient.
‘ Ultrasonics, air/water syringes, slow-speed handpieces and all power-driven equipment requires cords connected to a power source.
‘ Improper management and inefficient design of the cords can increase drag on hand, wrist, and arm increasing risk of repetitive injury.
‘ Care is needed that cords can be sanitized, and are not dragging on the floor of the clinic.
B. Curly Cords
‘ Can cause excessive stretching and pulling by clinician.
‘ Associated with bending, reaching, and awkward postures to position for treatment.
‘ Increase the strain on hand, wrist, arm, and shoulder of clinician.
‘ Provide an ergonomic risk by increasing fatigue level and creating muscle imbalances.
‘ Straight cords may be generally easier to manage.
‘ Includes all practices that make work safe, decrease strain and fatigue, eliminate hazards, and improve work process affecting health and well-being of clinician and patient.
‘ Terminology related to ergonomics is included in Box 7-1 .
‘ Box 7-2 lists items of the equipment, work layout, and work process organization that need attention during practice if physical occupational disorders are to be prevented.
‘ The physical challenges inherent in dental hygiene practice place the clinicians at risk for developing work-related musculoskeletal disorders.
‘ Table 7-1 describes a variety of disorders that can occur among clinicians.
‘ Prevention of the slow developing conditions is a daily responsibility.
‘ Prevention begins with the recognition of the risk factors that can point to potential body injury and more serious permanent musculoskeletal disorders. 3,4
‘ Table 7-2 lists and defines significant risk factors and provides examples of various practices that can lead to musculoskeletal disorders.
‘ Responsible self-care and attention to the risk factors of musculoskeletal disorders are central to ergonomic practice.
‘ Self-care is built on but not limited to all safe work practices that incorporate ergonomic principles for health and well-being. Self-care includes but is not limited to:
‘ Physical fitness: Immunizations, healthy diet, adequate sleep, exercise.
‘ Standard precautions: Personal protective equipment (PPE).
‘ Clinical practice: Clinician/patient positioning (CPP), instrument selection and use, prevention of sharps injuries.
‘ Neutral working position: In all activities, not only clinical practice.
‘ Stress management: Reasonable patient scheduling, adequate breaks.
‘ In dental hygiene practice, it is necessary to give constant attention to maintaining a healthy spine.
A. Achieving neutral work posture throughout the work day.
B. Performing effective clinician/patient positioning, and practicing daily functional movement exercises will protect and encourage a healthy spine. 5
‘ A healthy spine requires that it be flexible. To accomplish a flexible spine, encourage movement in all directions so that no one area of the spine becomes overused, limiting its movement potential and affecting other areas of the spine.
‘ With impingement of an area of the spine for any length of time, blood fl ow and oxygenation to the area is affected.
‘ Chronic poor postural habits can lead to nerve impingement resulting in chronic pain and possible injury.
‘ Practicing daily functional movement exercises for the spine and other joints in the practice setting and at home is a preventive strategy for all dental personnel.
A. Objectives of Exercises
With consistent practice, the following can be accomplished:
‘ Stretch, lengthen, and maintain the health of muscles.
‘ Support the structure of the natural curves of the spine.
‘ Stabilize range of motion of the joints.
‘ Maintain balance of musculoskeletal system.
‘ Maintain flexibility and comfort.
‘ Decrease stress of physical challenges on internal systems.
‘ Aid in development and maintenance of good postural work habits.
‘ Improve awareness to develop skill in creating necessary adjustments to maintain dynamic postural integrity.
‘ Foster ideal upright posture that translates to all functional movement.
‘ Retrain muscles and develop neuromuscular patterns for good postural habits that will transfer to all life activities.
‘ Develop a safe internal environment for injury prevention.
‘ Provide a structurally organized base upon which to build strength and conditioning.
B. Functional Movement Exercises
‘ Sequence designed specifically for dental personnel
‘ Create functional movement patterns.
‘ Gently stretch and lengthen muscles that have occupational demands.
‘ Encourage full range of motion for healthy joints.
‘ Support the natural curves of the spine.
‘ Exercises can be performed during clinical practice hours, at chair-side between patients, in non-patient areas of the office, and/or at home.
‘ Do movement exercises slowly and with awareness.
Figure 7-6 describes and illustrates a series of functional movement exercises.
‘ Other exercises for use during dental hygiene practice are shown in Figure 38-20, page 597.
Documentation for a patient with requirements for a personalized dental chair positioning during instrumentation would include:
‘ Medical history notations indicating health history and current problem causing breathing difficulties.
‘ Potential emergency that could occur if patient is over-stressed; need for preparation at future appointments.
‘ Notation for reference to length of appointment and time of day if needed.
‘ A sample progress note can be reviewed in Box 7-3 .

Relaxation techniques
What are relaxation techniques?
Our fast-paced society can cause people to push their minds and bodies to the limit, often at the expense of physical and mental wellbeing. According to the Mind/Body Medical Institute at Harvard University, 60 to 90% of all medical office visits in the United States are for stress related disorders. Such stress has damaging effects on health and the immune system. Relaxation techniques are helpful tools for coping with stress and promoting long-term health by slowing down the body and quieting the mind. Such techniques generally entail: refocusing attention (for example, noticing areas of tension), increasing body awareness, and exercises (such as meditation) to connect the body and mind together. Used daily, these practices can lead to a healthier perspective on stressful circumstances. In fact, more than 3,000 studies show the beneficial effects of relaxation on health and wellbeing.
What are the types of relaxation techniques?
There are 3 major types of relaxation techniques:
‘ Autogenic training: This technique uses both visual imagery and body awareness to move a person into a deep state of relaxation. The person imagines a peaceful place and then focuses on different physical sensations, moving from the feet to the head. For example, one might focus on warmth and heaviness in the limbs, easy, natural breathing, or a calm heartbeat.
‘ Breathing: In breathing techniques, you place one hand on your chest and the other on your belly. Take a slow, deep breath, sucking in as much air as you can. As you’re doing this, your belly should push against your hand. Hold your breath and then slowly exhale.
‘ Progressive muscle relaxation: This technique involves slowly tensing and then releasing each muscle group individually, starting with the muscles in the toes and finishing with those in the head.
‘ Meditation: The two most popular forms of meditation in the U.S. include Transcendental Meditation (students repeat a mantra — a single word or phrase) and mindfulness meditation (students focus their attention on their thoughts and sensations).
‘ Guided imagery: Similar to autogenic training, guided imagery involves listening to a trained therapist or a guided imagery CD to move into a state of deep relaxation. Once in a relaxed state, the images that come up in your mind can help you uncover important realizations about your emotional, spiritual, and physical health.
How do relaxation techniques work?
When we become stressed, our bodies engage in something called the “fight-or-flight response.” The fight-or-flight response refers to changes that occur in the body when it prepares to either fight or run. These changes include increased heart rate, blood pressure, and rate of breathing, and a 300 to 400% increase in the amount of blood being pumped to the muscles. Over time, these reactions raise cholesterol levels, disturb intestinal activities, and depress the immune system. In general, they leave us feeling “stressed out.”
However, we also possess the opposite of the fight-or-flight response — the “relaxation response.” This term, first coined in the mid 1970s by a Harvard cardiologist named Herbert Benson, refers to changes that occur in the body when it is in a deep state of relaxation. These changes include decreased blood pressure, heart rate, muscle tension, and rate of breathing, as well as feelings of being calm and in control. Learning the relaxation response helps to counter ill effects of the fight-or-flight response and, over time, allows the development of a greater state of alertness. The relaxation response can be developed through a number of techniques, including meditation and progressive muscle relaxation. It is now a recommended treatment for many stress-related disorders.
What are relaxation techniques good for?
Research suggests that meditation can help improve a person’s quality of life and reduce stress hormone levels.
Clinical studies also show that relaxation techniques reduce the perception of pain. One clinical study found that among patients undergoing colorectal surgery, those who listened to guided imagery tapes before, during, and after the operation had less pain and needed fewer pain medications than those who did not. Another found that relaxation practices, such as deep breathing, progressive relations, and visualization enhanced the immune response among breast cancer patients.
Meditation has also been used as part of the treatment for post traumatic stress disorder in Vietnam veterans, and to break substance abuse patterns in drug and alcohol abusers. Relaxation techniques can also enhance coping skills in migraine sufferers and reduce stress, as well as improve mood in those with cancer.
In general, studies show that with consistent practice, relaxation techniques can potentially reduce symptoms or improve outcomes in the following conditions:
‘ Stress
‘ Premenstrual syndrome
‘ Pain
‘ Irritable bowel syndrome
‘ Anxiety
‘ Infertility
‘ High blood pressure
‘ High cholesterol
‘ Diabetes
‘ Panic disorders
‘ Chronic tension headaches
‘ Fibromyalgia
‘ Insomnia
‘ Psoriasis
‘ Arthritis
‘ Hyperactivity in children, as in attention deficit hyperactivity disorder (ADHD)
‘ Labor and child birth
It is extremely important that usual medical care and advice be followed for these conditions as well. Relaxation techniques are meant to complement usual medical care.
Is there anything I should watch out for?
Relaxation techniques are considered very safe. There have been unusual cases where people become more, rather than less, anxious when using the techniques because of a heightened awareness of body sensations. Even more rare are reports of pain, heart palpitations, muscle twitching, and crying spells associated with the use of relaxation techniques. When this happens, it is often related to the process of relaxing and reflecting inward such that emotions become very poignant.
Experts advise people with schizophrenia and other forms of psychosis (thought disorders that distort reality) to avoid relaxation techniques.
Can I learn relaxation techniques by myself?
If you want to generally reduce stress and enhance wellbeing, you can teach yourself some relaxation techniques. Look for videotapes and audiobooks on popular techniques, such as guided imagery and meditation, and check for community classes in your area. However, if you have a specific medical or psychological disorder or concern, it is best to see a health care professional, such as a clinical psychologist, social worker, or guided imagery therapist who teaches relaxation techniques as part of their therapeutic practice. Your health care professional will help you decide what relaxation method is best for you.
Relaxation Techniques for Stress Relief
Finding the Relaxation Exercises That Work for You

For many of us, relaxation means zoning out in front of the TV at the end of a stressful day. But this does little to reduce the damaging effects of stress. To effectively combat stress, we need to activate the body’s natural relaxation response.
You can do this by practicing relaxation techniques such as deep breathing, meditation, rhythmic exercise, and yoga. Fitting these activities into your life can help reduce everyday stress and boost your energy and mood.
The relaxation response: Bringing your nervous system back into balance
Stress is necessary for life. You need stress for creativity, learning, and your very survival. Stress is only harmful when it becomes overwhelming and interrupts the healthy state of equilibrium that your nervous system needs to remain in balance. Unfortunately, overwhelming stress has become an increasingly common characteristic of contemporary life. When stressors throw your nervous system out of balance, relaxation techniques can bring it back into a balanced state by producing the relaxation response, a state of deep calmness that is the polar opposite of the stress response.
When stress overwhelms your nervous system your body is flooded with chemicals that prepare you for “fight or flight.” While the stress response can be lifesaving in emergency situations where you need to act quickly, it wears your body down when constantly activated by the stresses of everyday life. The relaxation response puts the brakes on this heightened state of readiness and brings your body and mind back into a state of equilibrium.
Producing the relaxation response
A variety of different relaxation techniques can help you bring your nervous system back into balance by producing the relaxation response. The relaxation response is not lying on the couch or sleeping but a mentally active process that leaves the body relaxed, calm, and focused.
Learning the basics of relaxation techniques isn’t difficult, but it does take practice. Most stress experts recommend setting aside at least 10 to 20 minutes a day for your relaxation practice. If you’d like to get even more stress relief, aim for 30 minutes to an hour. If that sounds like a daunting commitment, remember that many of these techniques can be incorporated into your existing daily schedule’practiced at your desk over lunch or on the bus during your morning commute.
Finding the relaxation technique that’s best for you
There is no single relaxation technique that is best for everyone. When choosing a relaxation technique, consider your specific needs, preferences, fitness, and the way you tend to react to stress. The right relaxation technique is the one that resonates with you, fits your lifestyle, and is able to focus your mind and interrupt your everyday thoughts in order to elicit the relaxation response. In many cases, you may find that alternating or combining different techniques will keep you motivated and provide you with the best results.
How you react to stress may influence the relaxation technique that works best for you:
‘ The ‘fight’ response. If you tend to become angry, agitated, or keyed up under stress, you will respond best to stress relief activities that quiet you down, such as meditation, progressive muscle relaxation, deep breathing, or guided imagery.
‘ The ‘flight’ response. If you tend to become depressed, withdrawn, or spaced out under stress, you will respond best to stress relief activities that are stimulating and energize your nervous system, such as rhythmic exercise, massage, mindfulness, or power yoga.
‘ The immobilization response. If you’ve experienced some type of trauma and tend to ‘freeze’ or become ‘stuck’ under stress, your challenge is to first rouse your nervous system to a fight or flight response (above) so you can employ the applicable stress relief techniques. To do this, choose physical activity that engages both your arms and legs, such as running, dancing, or tai chi, and perform it mindfully, focusing on the sensations in your limbs as you move.
Using exercise and movement as a relaxation technique
Rhythmic exercise or physical activity that engages both your arms and legs’such as running, walking, swimming, dancing, rowing, or climbing’is most effective at relieving stress when performed mindfully. As with meditation, mindfulness requires being fully engaged in the present moment, focusing your mind on how your body feels right now. As you move, instead of continuing to focus on your thoughts, focus on the sensations in your limbs and how your breathing complements your movement. If your mind wanders to other thoughts, gently return to focusing on your breathing and movement.
If walking or running, for example, focus on each step’the sensation of your feet touching the ground, the rhythm of your breath while moving, and the feeling of the wind against your face. If you’ve experienced trauma, adding this mindfulness element can help your nervous system become ‘unstuck’ and move on.
Relaxation technique 1: Breathing meditation for stress relief
With its focus on full, cleansing breaths, deep breathing is a simple yet powerful relaxation technique. It’s easy to learn, can be practiced almost anywhere, and provides a quick way to get your stress levels in check. Deep breathing is the cornerstone of many other relaxation practices, too, and can be combined with other relaxing elements such as aromatherapy and music. All you really need is a few minutes and a place to stretch out.
Practicing deep breathing meditation
The key to deep breathing is to breathe deeply from the abdomen, getting as much fresh air as possible in your lungs. When you take deep breaths from the abdomen, rather than shallow breaths from your upper chest, you inhale more oxygen. The more oxygen you get, the less tense, short of breath, and anxious you feel.
‘ Sit comfortably with your back straight. Put one hand on your chest and the other on your stomach.
‘ Breathe in through your nose. The hand on your stomach should rise. The hand on your chest should move very little.
‘ Exhale through your mouth, pushing out as much air as you can while contracting your abdominal muscles. The hand on your stomach should move in as you exhale, but your other hand should move very little.
‘ Continue to breathe in through your nose and out through your mouth. Try to inhale enough so that your lower abdomen rises and falls. Count slowly as you exhale.
If you find it difficult breathing from your abdomen while sitting up, try lying on the floor. Put a small book on your stomach, and try to breathe so that the book rises as you inhale and falls as you exhale.
Relaxation technique 2: Progressive muscle relaxation for stress relief
Progressive muscle relaxation involves a two-step process in which you systematically tense and relax different muscle groups in the body.
With regular practice, progressive muscle relaxation gives you an intimate familiarity with what tension’as well as complete relaxation’feels like in different parts of the body. This awareness helps you spot and counteract the first signs of the muscular tension that accompanies stress. And as your body relaxes, so will your mind. You can combine deep breathing with progressive muscle relaxation for an additional level of stress relief.
Practicing progressive muscle relaxation
Before practicing progressive muscle relaxation, consult with your doctor if you have a history of muscle spasms, back problems, or other serious injuries that may be aggravated by tensing muscles.
Most progressive muscle relaxation practitioners start at the feet and work their way up to the face.
‘ Loosen your clothing, take off your shoes, and get comfortable.
‘ Take a few minutes to relax, breathing in and out in slow, deep breaths.
‘ When you’re relaxed and ready to start, shift your attention to your right foot. Take a moment to focus on the way it feels.
‘ Slowly tense the muscles in your right foot, squeezing as tightly as you can. Hold for a count of 10.
‘ Relax your right foot. Focus on the tension flowing away and the way your foot feels as it becomes limp and loose.
‘ Stay in this relaxed state for a moment, breathing deeply and slowly.
‘ When you’re ready, shift your attention to your left foot. Follow the same sequence of muscle tension and release.
‘ Move slowly up through your body, contracting and relaxing the muscle groups as you go.
‘ It may take some practice at first, but try not to tense muscles other than those intended.
Relaxation technique 3: Body scan meditation for stress relief
A body scan is similar to progressive muscle relaxation except instead of tensing and relaxing muscles you simply focus on the sensations in each part of your body.
Practicing body scan meditation
‘ Lie on your back, legs uncrossed, arms relaxed at your sides, eyes open or closed. Focus on your breathing, allowing your stomach to rise as you inhale and fall as you exhale. Breathe deeply for about two minutes, until you start to feel comfortable and relaxed.
‘ Turn your focus to the toes of your right foot. Notice any sensations you feel while continuing to also focus on your breathing. Imagine each deep breath flowing to your toes. Remain focused on this area for one to two minutes.
‘ Move your focus to the sole of your right foot. Tune in to any sensations you feel in that part of your body and imagine each breath flowing from the sole of your foot. After one or two minutes, move your focus to your right ankle and repeat. Move to your calf, knee, thigh, hip, and then repeat the sequence for your left leg. From there, move up the torso, through the lower back and abdomen, the upper back and chest, and the shoulders. Pay close attention to any area of the body that causes you pain or discomfort.
‘ Move your focus to the fingers on your right hand and then move up to the wrist, forearm, elbow, upper arm, and shoulder. Repeat for your left arm. Then move through the neck and throat, and finally all the regions of your face, the back of the head, and the top of the head. Pay close attention to your jaw, chin, lips, tongue, nose, cheeks, eyes, forehead, temples and scalp. When you reach the very top of your head, let your breath reach out beyond your body and imagine hovering above yourself.
‘ After completing the body scan, relax for a while in silence and stillness, noting how your body feels. Then open your eyes slowly. Take a moment to stretch, if necessary.
For a guided body scan meditation, see the Resources section below.
Relaxation technique 4: Mindfulness for stress relief
Mindfulness is the ability to remain aware of how you’re feeling right now, your ‘moment-to-moment’ experience’both internal and external. Thinking about the past’blaming and judging yourself’or worrying about the future can generate stress. But by staying calm and focused in the present moment, you can bring your nervous system back into balance. Mindfulness can be applied to activities such as walking, exercising, eating, or meditation.
Meditations that cultivate mindfulness have long been used to reduce stress. Some of these meditations bring you into the present by focusing your attention on a single repetitive action, such as your breathing, a few repeated words, or the flickering light of a candle. Other forms of mindfulness meditation encourage you to follow and then release internal thoughts or sensations.
Practicing mindfulness meditation
To practice mindfulness meditation, you’ll need:
‘ A quiet environment. Choose a secluded place in your home, office, or outdoors where you can relax without distractions or interruptions.
‘ A comfortable position. Get comfortable, but avoid lying down as this may lead to you falling asleep. Sit up with your spine straight, either in a chair or on the floor. You can also try a cross-legged or lotus position.
‘ A point of focus. You can meditate with your eyes closed or open so this point can be internal’a feeling or imaginary scene’or external’a flame, an object in your surroundings, or a meaningful word or phrase that you repeat throughout the meditation.
‘ An observant, noncritical attitude. Don’t worry about distracting thoughts that go through your mind or about how well you’re doing. If thoughts intrude during your relaxation session, don’t fight them, just gently turn your attention back to your point of focus. If emotions surface during the meditation that you are uncomfortable experiencing, you can learn to tolerate these emotions by exploring HelpGuide’s emotional intelligence toolkit.
Relaxation technique 5: Visualization meditation for stress relief
Visualization, or guided imagery, is a variation on traditional meditation that requires you to employ not only your visual sense, but also your sense of taste, touch, smell, and hearing. When used as a relaxation technique, visualization involves imagining a scene in which you feel at peace, free to let go of all tension and anxiety.
Choose whatever setting is most calming to you, whether it’s a tropical beach, a favorite childhood spot, or a quiet wooded glen. You can do this visualization exercise on your own in silence, while listening to soothing music, or with a therapist (or an audio recording of a therapist) guiding you through the imagery. To help you employ your hearing you can use a sound machine or download sounds that match your chosen setting’the sound of ocean waves if you’ve chosen a beach, for example.
Practicing visualization
Find a quiet, relaxed place. Beginners sometimes fall asleep during a visualization meditation, so you might try sitting up.
Close your eyes and let your worries drift away. Imagine your restful place. Picture it as vividly as you can’everything you can see, hear, smell, taste, and feel. Visualization works best if you incorporate as many sensory details as possible, using at least three of your senses. When visualizing, choose imagery that appeals to you; don’t select images because you think they should be appealing. Let your own images come up and work for you.
If you are thinking about a dock on a quiet lake, for example:
‘ Walk slowly around the dock and notice the colors and textures around you.
‘ Spend some time exploring each of your senses.
‘ See the sun setting over the water.
‘ Hear the birds singing.
‘ Smell the pine trees.
‘ Feel the cool water on your bare feet.
‘ Taste the fresh, clean air.
Enjoy the feeling of deep relaxation that envelopes you as you slowly explore your restful place. When you are ready, gently open your eyes and come back to the present.
Don’t worry if you sometimes zone out or lose track of where you are during a guided imagery session. This is normal. You may also experience feelings of stiffness or heaviness in your limbs, minor, involuntary muscle-movements, or even cough or yawn. Again, these are normal responses.
Relaxation technique 6: Yoga and tai chi for stress relief
Yoga involves a series of both moving and stationary poses, combined with deep breathing. As well as reducing anxiety and stress, yoga can also improve flexibility, strength, balance, and stamina. Practiced regularly, it can also strengthen the relaxation response in your daily life. Since injuries can happen when yoga is practiced incorrectly, it’s best to learn by attending group classes, hiring a private teacher, or at least following video instructions.
What type of yoga is best for stress?
Although almost all yoga classes end in a relaxation pose, classes that emphasize slow, steady movement, deep breathing, and gentle stretching are best for stress relief.
‘ Satyananda is a traditional form of yoga. It features gentle poses, deep relaxation, and meditation, making it suitable for beginners as well as anyone primarily looking for stress reduction.
‘ Hatha yoga is also reasonably gentle way to relieve stress and is suitable for beginners. Alternately, look for labels like gentle, for stress relief, or for beginners when selecting a yoga class.
‘ Power yoga, with its intense poses and focus on fitness, is better suited to those looking for stimulation as well as relaxation.
If you’re unsure whether a specific yoga class is appropriate for stress relief, call the studio or ask the teacher.
Tai chi
If you’ve ever seen a group of people in the park slowly moving in synch, you’ve probably witnessed tai chi. Tai chi is a self-paced, non-competitive series of slow, flowing body movements. These movements emphasize concentration, relaxation, and the conscious circulation of vital energy throughout the body. Though tai chi has its roots in martial arts, today it is primarily practiced as a way of calming the mind, conditioning the body, and reducing stress. As in meditation, tai chi practitioners focus on their breathing and keeping their attention in the present moment.
Tai chi is a safe, low-impact option for people of all ages and fitness levels, including older adults and those recovering from injuries. Like yoga, once you’ve learned the basics of tai chi or qi gong, you can practice alone or with others, tailoring your sessions as you see fit.
Relaxation technique 7: Massage therapy for stress relief
You’re probably already aware how much a professional massage at a spa or health club can help reduce stress, relieve pain, and ease muscle tension. What you may not be aware of is that you can experience many of the same benefits at home or work by practicing self-massage’or trading massages with a loved one.
Try taking a few minutes to massage yourself at your desk between tasks, on the couch at the end of a hectic day, or in bed to help you unwind before sleep. To enhance relaxation, you can use aromatic oil, scented lotion, or combine self-message with mindfulness or deep breathing techniques.
A five-minute self-massage to relieve stress
A combination of strokes works well to relieve muscle tension. Try gentle chops with the edge of your hands or tapping with fingers or cupped palms. Put fingertip pressure on muscle knots. Knead across muscles, and try long, light, gliding strokes. You can apply these strokes to any part of the body that falls easily within your reach. For a short session like this, try focusing on your neck and head:
‘ Start by kneading the muscles at the back of your neck and shoulders. Make a loose fist and drum swiftly up and down the sides and back of your neck. Next, use your thumbs to work tiny circles around the base of your skull. Slowly massage the rest of your scalp with your fingertips. Then tap your fingers against your scalp, moving from the front to the back and then over the sides.
‘ Now massage your face. Make a series of tiny circles with your thumbs or fingertips. Pay particular attention to your temples, forehead, and jaw muscles. Use your middle fingers to massage the bridge of your nose and work outward over your eyebrows to your temples.
‘ Finally, close your eyes. Cup your hands loosely over your face and inhale and exhale easily for a short while.
Adapted with permission from Stress Management: Approaches for Preventing and Reducing Stress, a special health report published by Harvard Health Publications.
Making relaxation techniques a part of your life
The best way to start and maintain a relaxation practice is to incorporate it into your daily routine. While it can be tough to find the time in a busy schedule, many of the techniques can be practiced while you’re doing other things. You can meditate while commuting to work on a bus or train, for example, or waiting for an appointment. Try deep breathing while you’re doing housework or mowing the lawn. Mindfulness walking can be done while exercising your dog, walking to your car, or climbing the stairs at work. Once you’ve learned techniques such as tai chi, you can practice them in your office or in the park at lunchtime.
Other tips for making relaxation techniques part of your life
‘ If possible, schedule a set time to practice each day. Set aside one or two periods each day. You may find that it’s easier to stick with your practice if you do it first thing in the morning, before other tasks and responsibilities get in the way.
‘ If you exercise, improve the relaxation benefits by adopting mindfulness. Instead of zoning out or staring at a TV as you exercise, try focusing your attention on your body. If you’re resistance training, for example, focus on coordinating your breathing with your movements and pay attention to how your body feels as you raise and lower the weights.
‘ Avoid practicing when you’re sleepy. These techniques can relax you so much that they can make you very sleepy, especially if it’s close to bedtime. You will get the most benefit if you practice when you’re fully awake and alert. Do not practice after eating a heavy meal or while using drugs, tobacco, or alcohol.
‘ Expect ups and downs. Don’t be discouraged if you skip a few days or even a few weeks. It happens. Just get started again and slowly build up to your old momentum.
‘ ‘

Relaxation techniques: Try these steps to reduce
Relaxation techniques can reduce stress symptoms and help you enjoy a better quality
of life, especially if you have an illness. Explore relaxation techniques you can do by
By Mayo Clinic Staff
Relaxation techniques are a great way to help with stress management. Relaxation isn’t
just about peace of mind or enjoying a hobby. Relaxation is a process that decreases
the effects of stress on your mind and body. Relaxation techniques can help you cope
with everyday stress and with stress related to various health problems, such as
cancer and pain.
Whether your stress is spiraling out of control or you’ve already got it tamed, you can
benefit from learning relaxation techniques. Learning basic relaxation techniques is
easy. Relaxation techniques also are often free or low cost, pose little risk, and can be
done just about anywhere.
Explore these simple relaxation techniques and get started on de-stressing your life
and improving your health.
The benefits of relaxation techniques
When faced with numerous responsibilities and tasks or the demands of an illness,
relaxation techniques may take a back seat in your life. But that means you might miss
out on the health benefits of relaxation.
Practicing relaxation techniques can reduce stress symptoms by:
‘Slowing your heart rate
‘Lowering blood pressure
‘Slowing your breathing rate
‘Reducing activity of stress hormones
‘Increasing blood flow to major muscles
‘Reducing muscle tension and chronic pain
‘Improving concentration and mood
‘Lowering fatigue
‘Reducing anger and frustration
‘Boosting confidence to handle problems
To get the most benefit, use relaxation techniques along with other positive coping
methods, such as thinking positively, finding humor, problem-solving, managing time,
exercising, getting enough sleep, and reaching out to supportive family and friends.

Physical Activity Reduces Stress
Stress is an inevitable part of life. Seven out of ten adults in the United States say they experience stress or anxiety daily,
and most say it interferes at least moderately with their lives, according to the most recent ADAA survey on stress and
anxiety disorders. When theAmerican Psychological Association surveyed people in 2008, more people reported physical
and emotional symptoms due to stress than they did in 2007, and nearly half reported that their stress has increased in the
past year.
It’s impossible to eliminate, but you can learn to manage stress, and most people usually do. According to a recent ADAA
online poll, some 14 percent of people make use of regular exercise to cope with stress. Others reported talking to friends
or family (18 percent); sleeping (17 percent); watching movies or TV (14 percent), as well as eating (14 percent) and
listening to music (13 percent).
While all of these are well-known coping techniques, exercise may be the one most recommended by health care
professionals. And among ADAA poll takers who exercise, a healthy percentage is already on the right track: Walking (29
percent), running (20 percent), and yoga (11 percent) are their preferred strategies.
Exercising Body and Mind
The physical benefits of exercise’improving physical condition and fighting disease’have long been established, and
physicians always encourage staying physically active. Exercise is also considered vital for maintaining mental fitness, and
it can reduce stress. Studies show that it is very effective at reducing fatigue, improving alertness and concentration, and at
enhancing overall cognitive function. This can be especially helpful when stress has depleted your energy or ability to
When stress affects the brain, with its many nerve connections, the rest of the body feels the impact as well. So it stands to
reason that if your body feels better, so does your mind. Exercise and other physical activity produce
endorphins’chemicals in the brain that act as natural painkillers’and also improve the ability to sleep, which in turn
reduces stress. Meditation, acupuncture, massage therapy, even breathing deeply can cause your body to produce
endorphins. And conventional wisdom holds that a workout of low to moderate intensity makes you feel energized and
Scientists have found that regular participation in aerobic exercise has been shown to decrease overall levels of tension,
elevate and stabilize mood, improve sleep, and improve self-esteem. Even five minutes of aerobic exercise can stimulate
anti-anxiety effects.

Exercise and stress: Get moving to manage stress
Exercise in almost any form can act as a stress reliever. Being active can boost your
feel-good endorphins and distract you from daily worries.
By Mayo Clinic Staff
You know that exercise does your body good, but you’re too busy and stressed to fit it into
your routine. Hold on a second ‘ there’s good news when it comes to exercise and stress.
Virtually any form of exercise, from aerobics to yoga, can act as a stress reliever. If you’re not
an athlete or even if you’re out of shape, you can still make a little exercise go a long way
toward stress management. Discover the connection between exercise and stress relief ‘
and why exercise should be part of your stress management plan.
Exercise and stress relief
Exercise increases your overall health and your sense of well-being, which puts more pep in
your step every day. But exercise also has some direct stress-busting benefits.
‘It pumps up your endorphins. Physical activity helps bump up the production of
your brain’s feel-good neurotransmitters, called endorphins. Although this function
is often referred to as a runner’s high, a rousing game of tennis or a nature hike
also can contribute to this same feeling.
‘It’s meditation in motion. After a fast-paced game of racquetball or several laps in
the pool, you’ll often find that you’ve forgotten the day’s irritations and concentrated
only on your body’s movements.
‘As you begin to regularly shed your daily tensions through movement and physical
activity, you may find that this focus on a single task, and the resulting energy and
optimism, can help you remain calm and clear in everything you do.
‘It improves your mood. Regular exercise can increase self-confidence, it can
relax you, and it can lower the symptoms associated with mild depression and
anxiety. Exercise can also improve your sleep, which is often disrupted by stress,
depression and anxiety. All of these exercise benefits can ease your stress levels
and give you a sense of command over your body and your life.
Put exercise and stress relief to work for you
A successful exercise program begins with a few simple steps.
‘Consult with your doctor. If you haven’t exercised for some time and you have
health concerns, you may want to talk to your doctor before starting a new exercise
‘Walk before you run. Build up your fitness level gradually. Excitement about a
new program can lead to overdoing it and possibly even injury.
‘For most healthy adults, the Department of Health and Human Services
recommends getting at least 150 minutes a week of moderate aerobic activity (such
as brisk walking or swimming) or 75 minutes a week of vigorous aerobic activity
(such as running). You also can do a combination of moderate and vigorous
‘Also, incorporate strength training exercises at least twice a week.
‘Do what you love. Virtually any form of exercise or movement can increase your
fitness level while decreasing your stress. The most important thing is to pick an
activity that you enjoy. Examples include walking, stair climbing, jogging, bicycling,
yoga, tai chi, gardening, weightlifting and swimming.
‘Pencil it in. Although your schedule may necessitate a morning workout one day
and an evening activity the next, carving out some time to move every day helps
you make your exercise program an ongoing priority.
Stick with it
Starting an exercise program is just the first step. Here are some tips for sticking with a new
routine or reinvigorating a tired workout:
‘Set SMART goals. Write down SMART goals ‘ specific, measurable, attainable,
relevant and time-limited goals.
‘If your primary goal is to reduce stress in your life and recharge your batteries, your
specific goals might include committing to walking during your lunch hour three
times a week or, if needed, finding a baby sitter to watch your children so that you
can slip away to attend a cycling class.
‘Find a friend. Knowing that someone is waiting for you to show up at the gym or
the park can be a powerful incentive. Working out with a friend, co-worker or family
member often brings a new level of motivation and commitment to your workouts.
‘Change up your routine. If you’ve always been a competitive runner, take a look
at other less competitive options that may help with stress reduction, such as
Pilates or yoga classes. As an added bonus, these kinder, gentler workouts may
enhance your running while also decreasing your stress.
‘Exercise in increments. Even brief bouts of activity offer benefits. For instance, if
you can’t fit in one 30-minute walk, try three 10-minute walks instead. Interval
training, which entails brief (60 to 90 seconds) bursts of intense activity at almost
full effort, is being shown to be a safe, effective and efficient way of gaining many of
the benefits of longer duration exercise. What’s most important is making regular
physical activity part of your lifestyle.
Whatever you do, don’t think of exercise as just one more thing on your to-do list. Find an
activity you enjoy ‘ whether it’s an active tennis match or a meditative meander down to a
local park and back ‘ and make it part of your regular routine. Any form of physical activity
can help you unwind and become an important part of your approach to easing stress.

Human beings were designed to move, not sit on chairs. So exercise is an essential part of good body function. But the good
news is that exercise is your shortest route to a feeling of well-being and a physical glow. Everyone knows that exercise is
good for you and that it is one of the best stress combatants available; however the majority of peoples’ excuse is that they
are too busy and stress to fit it into their routines.
Not only does it keep the heart healthy and get oxygen into the system, but it helps deplete stress hormones and releases
mood-enhancing chemicals which help us cope with stress better.
Endorphins: These are often classified to be the happy hormones. Any form of physical activity leads to the release of these feel
good neurotransmitters. The increase in endorphins in your body leads to a feeling of euphoria, modulation of appetite, the release of
different sex hormones and an enhancement of immune response. This helps combat the negative effects of stress.
Whether you are building muscle or stamina, all types of exercise relaxes tense muscles and tissue. These can strongly contribute to
stress-related aches and pains such as neck or back pains and headaches.
Exercise is also particularly good when it’s competitive. This will enable you to raise your game to a higher performance level that you
would otherwise achieve. Try a sport with an opponent such as tennis or badminton, or a situation where you can set up a race against
someone else, such as cycling, swimming or even power walking with a friend.

But whatever exercise you try, you will soon discover its major benefit is that it allows you to forget your problems. Exercise helps you
to shed the day’s irritations and the focus you place on your feel good exercise results in higher energy levels and optimism can help
you feel clearer and calmer. Not only do you become completely absorbed in what you are doing at the time. But the positive
endorphins that exercise releases will also help you maintain a more positive outlook afterwards.

Exercise tips:
We know it can be hard to get into a good exercise routine so here are a few tips to get you well on your way to a healthier and stress
free life:
Do something you love:
Select sports or other physical activities that you enjoy. If you enjoy lifting weights then don’t begin training for a marathon or try a
triathlon. Any form of exercise or physical activity will increase your fitness and combat stress so stick with what you like doing to
keep motivation levels high.
Don’t run before you can walk:
Start off slow! Don’t go throwing yourself into the deep end as this will result in a higher risk of injury and you will feel less motivated
as you won’t be enjoying the exercising that you are partaking in. So instead, build up your fitness levels slowly, perhaps start with
20-30 minutes initially and work your way up to an hour over three months.
Is There a Stress Management Diet?
Stress: We all have it, and how we handle it can make all the difference. Stress management
can be a powerful tool for wellness, since too much stress is bad for you. There are many
strategies, and one of them includes what you eat. Read on to learn how a stress
management diet can help.
Stress-Busting Foods: How They Work
Foods can help tame stress in several ways. Comfort foods, like a bowl of warm oatmeal,
boost levels of serotonin, a calming brain chemical. Other foods can cut levels of cortisol and
adrenaline, stress hormones that take a toll on the body over time. A healthy diet can help
counter the impact of stress by shoring up the immune system and lowering blood pressure.
Do you know which foods are stress busters?
Complex Carbs
All carbs prompt the brain to make more serotonin. For a steady supply of this feel-good
chemical, it’s best to eat complex carbs, which take longer to digest. Good choices include
whole-grain breads, pastas, and breakfast cereals, including old-fashioned oatmeal. Complex
carbs can also help you feel balanced by stabilizing blood sugar levels.
Simple Carbs
Dietitians usually recommend steering clear of simple carbs, which include sweets and soda.
But in a pinch, these foods can hit the spot. They’re digested quickly, leading to a spike in
serotonin. Still, it doesn’t last long, and there are better options. So don’t make these a
stress-relieving habit; you should limit them.
Oranges make the list for their wealth of vitamin C. Studies suggest this vitamin can curb
levels of stress hormones while strengthening the immune system. In one study of people
with high blood pressure, blood pressure and levels of cortisol (a stress hormone) returned to
normal more quickly when people took vitamin C before a stressful task.
Too little magnesium may trigger headaches and fatigue, compounding the effects of stress.
One cup of spinach helps you stock back up on magnesium. Don’t like spinach? Other green,
leafy vegetables are good magnesium sources. Or try some cooked soybeans or a fillet of
salmon, also high in magnesium.
Fatty Fish
To keep stress in check, make friends with naturally fatty fish. Omega-3 fatty acids, found in
fish such as salmon and tuna, can prevent surges in stress hormones and may help protect
against heart disease, depression, and premenstrual syndrome (PMS). For a steady supply of
feel-good omega-3s, aim to eat 3 ounces of fatty fish at least twice a week.
Black Tea
Drinking black tea may help you recover from stressful events more quickly. One study
compared people who drank 4 cups of tea daily for 6 weeks with people who drank another
beverage. The tea drinkers reported feeling calmer and had lower levels of the stress
hormone cortisol after stressful situations.
Pistachios, as well as other nuts and seeds, are good sources of healthy fats. Eating a
handful of pistachios, walnuts, or almonds every day may help lower your cholesterol, ease
inflammation in your heart’s arteries, make diabetes less likely, and protect you against the
effects of stress. Don’t overdo it, though: Nuts are rich in calories.
One of the best ways to reduce high blood pressure is to get enough potassium, and half an
avocado has more potassium than a medium-sized banana. A little bit of guacamole, made
from avocado, might be a good choice when stress has you craving a high-fat treat. Avocados
are high in fat and calories, though, so watch your portion size.
Almonds are chock-full of helpful vitamins: vitamin E to bolster the immune system, plus B
vitamins, which may make you more resilient during bouts of stress or depression. To get the
benefits, snack on a quarter of a cup every day.
Raw Veggies
Crunchy raw vegetables can help ease stress in a purely mechanical way. Munching celery or
carrot sticks helps release a clenched jaw, and that can ward off tension.
Bedtime Snack
Carbs at bedtime can speed the release of the brain chemical serotonin and help you sleep
better. Since heavy meals before bed can trigger heartburn, stick to something light.
Another bedtime stress buster is the time-honored glass of warm milk. Research shows that
calcium eases anxiety and mood swings linked to PMS. Dietitians typically recommend skim
or low-fat milk.
Herbal Supplements
There are many herbal supplements that claim to fight stress. One of the best studied is St.
John’s wort, which has shown benefits for people with mild to moderate depression. Although
more research is needed, the herb also appears to reduce symptoms of anxiety and PMS.
There is less data on valerian root, another herb said to have a calming effect. Tell your
doctor about any supplements you take, so they can check on any possible interactions.
De-Stress With Exercise
Besides changing your diet, one of the best stress-busting strategies is to start exercising.
Aerobic exercise boosts oxygen circulation and spurs your body to make feel-good chemicals
called endorphins. Aim for 30 minutes of aerobic exercise three to four times a week. If you’re
not active now, tell your health care provider you’re going to start exercising — they’ll root for
you and make sure you’re ready to get moving.
Turkey breast
You’ve probably heard that the tryptophan in turkey is to blame for that food
coma on Thanksgiving. The amino acid, found in protein-containing foods, helps
produce serotonin, “the chemical thatregulates hunger and feelings of
happiness and well-being,” Mangieri says. On its own, tryptophan may have a
calming effect. In a 2006 study published in the Journal of Psychiatry
Neuroscience, men and women who were argumentative (based on personality
tests) took either tryptophan supplements or a placebo for 15 days. Those who
took tryptophan were perceived as more agreeable by their study partners at
the end of the two weeks compared with when they didn’t take it. (The study
was funded by the Canadian Institutes of Health Research.) Other foods high in
tryptophan include nuts, seeds, tofu, fish, lentils, oats, beans, and eggs.,,20909426_3,00.html

As bizarre as it may sound, the bacteria in your gut might be contributing to
stress. Research has shown that the brain signals to the gut, which is why
stress can inflame gastrointestinal symptoms; communication may flow the
other way too, from gut to brain. A 2013 UCLA study among 36 healthy women
revealed that consuming probiotics in yogurt reduced brain activity in areas that
handle emotion, including stress compared to people who consumed yogurt
without probiotics or no yogurt at all. This study was small so more research is
needed to confirm the results’but considering yogurt is full of calcium and
protein in addition to probiotics, you really can’t go wrong by adding more of it
to your diet.
“When you’re stressed, there’s a battle being fought inside you,” Mangieri says.
“The antioxidants and phytonutrients found in berries fight in your defense,
helping improve your body’s response to stress and fight stress-related free
radicals.” Research has also shown that blueberry eaters experience a boost in
natural killer cells, “a type of white blood cell that plays a vital role in immunity,
critical for countering stress,” says Cynthia Sass, MPH, RD, Health’s contributing
nutrition editor.
Dark chocolate
Calling all chocoholics: a regular healthy indulgence (just a bite, not a whole
bar!) of dark chocolate might have the power to regulate your stress levels.
“Research has shown that it can reduce your stress hormones, including
cortisol,” Sass says. “Also, the antioxidants in cocoa trigger the walls of your
blood vessels to relax, lowering blood pressure and improving circulation. And
finally, dark chocolate contains unique natural substances that create a sense of
euphoria similar to the feeling of being in love!” Go for varieties that contain at
least 70% cocoa.
Fortified milk is an excellent source of vitamin D, a nutrient that might boost
happiness. A 50-year-long study by London’s UCL Institute of Child Health
found an association between reduced levels of vitamin D and an increased risk
of panic and depression among 5,966 men and women. People who had
sufficient vitamin D levels had a reduced risk of panic disorders compared to
subjects with the lowest levels of vitamin D. Other foods high in vitamin D
include salmon, egg yolks, and fortified cereal.
Flaxseed, pumpkin seeds, and sunflower seeds are all great sources of
magnesium (as are leafy greens, yogurt, nuts, and fish). Loading up on the
mineral may help regulate emotions. “Magnesium has been shown to help
alleviate depression, fatigue, and irritability,” Sass says. “Bonus: When you’re
feeling especially irritable during that time of the month, the mineral also helps
to fight PMS symptoms, including cramps and water retention.”

One ounce of the buttery nut packs 11% of the daily recommended value of
zinc, an essential mineral that may help reduce anxiety. When researchers gave
zinc supplements to people who were diagnosed with both anxiety symptoms
(irritability, lack of ability to concentrate) and deficient zinc levels over a course
of eight weeks, the patients saw a 31% decrease in anxiety, according to
Nutrition and Metabolic Insights. This is likely because zinc affects the levels of
a nerve chemical that influences mood. If you’re already getting enough zinc,
then it may not help your mood to chow down on cashews (or other zinc-rich
foods like oysters, beef, chicken, and yogurt). But, cashews are also rich in
omega-3s and protein, so they’re a smart snack no matter what.


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