Stress Management

Human Relations
http://hum.sagepub.com Participants' accounts of a stress management intervention

Raymond Randall, Tom Cox and Amanda Griffiths Human Relations 2007; 60; 1181 DOI: 10.1177/0018726707081660 The online version of this article can be found at: http://hum.sagepub.com/cgi/content/abstract/60/8/1181
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Human Relations DOI: 10.1177/0018726707081660 Volume 60(8): 11811209 Copyright 2007 The Tavistock Institute SAGE Publications Los Angeles, London, New Delhi, Singapore http://hum.sagepub.com
Participants accounts of a stress management intervention

Raymond Randall, Tom Cox and Amanda Grifths
A B S T R AC T
Organizational-level stress management interventions are usually evaluated using quasi-experimental methods. In order to test intervention effectiveness, such methods examine the outcomes of between-group differences in intervention exposure: participants are rarely asked about their experiences of the intervention. However, this approach has been criticized because it provides little or no information about why interventions succeed or fail. The aim of this study was to examine whether an analysis of participants narratives of what had happened during an organizational-level intervention might prove useful during evaluation. Nurses working in a UK hospital (n = 26) who had received an intervention to help them balance their administrative and clinical workloads, provided information about their experiences of it, and how these experiences were related to the effectiveness of the intervention. Template analysis of the data in their narratives identied codes relating to: i) intervention contexts (both pre-intervention and during the intervention); ii) implementation processes (including how participants made use of the intervention); and iii) participants perceptions of the interventions impact. The results indicated that participants accounts provided information that is not captured by the dominant evaluation paradigm. Specically, these data can i) help organizations to make better use of interventions, and ii) enhance research into the links between intervention processes, contexts and outcomes.
K E Y WO R D S
change healthcare organizations participation and workplace democracy stress the work environment
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Organizational-level stress management interventions are designed to deal with the sources of stress by changing the design, management and organization of work (Cox et al., 2000; Semmer, 2003). Contemporary stress theory suggests that these interventions (such as increasing job control and social support, and reducing job demands) have a positive impact on a key determinant of well-being, that is, the balance between the demands placed on the individual and the resources they have to deal with those demands (Cox, 1993). Therefore, they can be an effective means of protecting and enhancing employee well-being in the medium to long term (Ivancevich et al., 1990; Murphy, 1996; Semmer, 2003, 2006; Van der Hek & Plomp, 1997). These interventions are usually evaluated by dichotomizing participants experience of the intervention (i.e. by establishing intervention and control groups) in quasi-experiments that focus entirely on the evaluation of outcomes without examining intervention processes (Beehr & OHara, 1987; Cook & Campbell, 1979; Jackson, 1983). This reductionist approach dominates the research, but has produced equivocal evidence about the effectiveness of these interventions: similar interventions work well in some studies, but fail in others (Kompier & Kristensen, 2000; Semmer, 2006). This article examines whether a post-intervention analysis of qualitative participants accounts of their experiences can help us to understand why these interventions produce inconsistent outcomes. In job stress intervention research it is not uncommon for change in dependent variables to be in the opposite direction to that hypothesized, or for an intervention to produce both positive and negative, or unexplained changes within a group of outcome variables, or for effect sizes to be small or short-lived (e.g. Dunham et al., 1987; Heaney et al., 1993; Jackson, 1983; Michie et al., 2004; Nielsen et al., 2006; Petterson et al., 2006; Pierce & Newstrom, 1983). It has been argued that the lack of consistent evidence for the efcacy of organizational-level interventions already indicates that such interventions are not effective (Briner & Reynolds, 1999; Reynolds, 1997). However, ways of enhancing the evaluation of these interventions are needed because outcome evaluations that depend on strong positivist research design are often beset by methodological problems (Parkes & Sparkes, 1998). Without an accompanying analysis of the processes and context of change, alternative explanations for disappointing outcomes cannot be discounted (Dobson & Cook, 1980; Grifths, 1999; Nielsen et al., 2006; Randall et al., 2005; Semmer, 2006; Taris et al., 2003). It may be, for example, that the inconsistency in ndings across outcome-focused evaluation studies occurs because the implementation of these interventions involves changing complex social systems that are difcult to control (Saksvik et al., 2002; Semmer, 2006). The processes involved
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Participants accounts of interventions
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in implementing interventions, and the intervention context, have the potential to modify both the interventions themselves and their outcomes (Cook & Shadish, 1994; Grifths, 1999; Kompier & Kristensen, 2000; Semmer, 2003). These modications can result in: i) the intervention not reaching its intended targets (or reaching unintended targets) because the implementation processes are faulty or disrupted, or ii) the intervention as experienced (or perceived) by participants being different from the intended intervention, or iii) heterogeneity in participants experiences or perceptions of the intervention that may be moderated by differences in individual circumstances (Grifths, 1999; Semmer, 2006). It has been suggested that when the applied research setting is complex and changeable, more should be done to capture information about these processes in order to explain the effects obtained for job stress interventions (Semmer, 2006). Unfortunately, evaluations of such interventions have rarely gathered data about these processes from the participant perspective. Such an omission is surprising given the importance of: i) individual perception in theories of work stress (Lazarus & Folkman, 1984), ii) sense-making in determining behaviour in organizations (Weick et al., 2005) and iii) individual differences in the interpretation of organizational context (Alvesson & Deetz, 2000). However, participants accounts of the change process have been collected during the evaluation of organizational development/change and job re-design interventions. In this literature the use of qualitative methods in non-positivist research has allowed rich (and relatively unconstrained) participant accounts of change processes to be collected, and negrained and exible analysis of them to be carried out. This has identied important issues rarely examined during quasi-experiments. For example, the analysis of interview data has shown that different individuals appear to have different views about the types of activities that are deemed as amounting to adequate participation in a change process (Symon & Clegg, 2005). These methods have also added to our understanding of individual and temporal differences in emotional responses to major changes such as outsourcing (Morgan & Symon, 2006). Qualitative analysis of discussions with key personnel and the inspection of organizational records have been used to show that several different change mechanisms may operate for a single intervention (Wall et al., 1986). Therefore, a qualitative analysis of participants experiences of organizational-level stress management interventions may also provide valuable data about the constituent parts of intervention processes, subjective evaluations of the intervention itself, important contextual factors, and the possible impact of all three on intervention outcomes (Briner, 1999; Harachi et al., 1999; Lipsey, 1996). If feasible, this analysis could be used to
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address the signicant gaps in the research produced by the dominant quasiexperimental paradigm by helping to identify: i) why interventions can have unpredictable and inconsistent outcomes in terms of employee well-being and satisfaction and organizational outcomes, and ii) what could be done to make interventions more effective (Grifths, 1999; Randall et al., 2005). This article examines the feasibility of one possible approach to analysing such participant accounts, and discusses the utility of its results.
The nature of intervention processes and context

From a relatively small amount of research it is possible to identify a preliminary model of the intervention processes and context factors that can be important when evaluating organizational-level stress management intervention outcomes. This model contains three clusters of factors: macroprocesses (intervention implementation and maintenance processes); microprocesses (the cognitive appraisal processes that occur when participants appraise an intervention and its impact); and the contextual factors present in the environment in which the intervention is implemented (Grifths, 1999; Kompier & Kristensen, 2000; Kompier et al., 2000a; Mikkelsen et al., 2000; Nielsen et al., 2006; Nytro et al., 2000). These three clusters are likely to have many constituent parts that have not yet been formally identied, and may inuence each other. Intervention macroprocesses include: the processes by which the intervention is delivered to participants (Randall et al., 2005; Semmer, 2003); the mechanisms in place to ensure participants actively engage in intervention activities (Heaney et al., 1995; Symon & Clegg, 2005); the mechanisms used to ensure the delity of the implementation of intervention plans (Schaubroeck et al., 1993); and the involvement of various stakeholders in intervention design and delivery (Grifths, 1999). A number of stimulating factors that may also facilitate implementation include: the quality of intervention organization; the team, managerial and organizational commitment given to the intervention; and the adequacy of communication, and ow of information, about the intervention (Axtell et al., 2006; Kompier et al., 1998, 2000a; Taris et al., 2003). Intervention processes may also set in motion events that have an impact on outcome variables: Wall et al. (1986) found that the introduction of autonomous work groups had a positive impact on job design, but led to increased difculties in dealing with problematic employees. Established theories of stress suggest that cognitive processes play an important role in determining intervention outcomes (Cox & Mackay, 1981; French et al., 1982; Karasek & Theorell, 1990; Lazarus, 1966; Lazarus & Folkman, 1984). It has been argued that cognitive appraisals (microprocesses)
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underpin participants active perception of i) the intervention itself, and ii) any changes in working conditions resulting from the intervention (Cox et al., 2000; Grifths, 1999; Meijmen et al., 1992; Tetrick, 1999). Within participant groups exposed to the same intervention some individuals (Bond & Bunce, 2001, 2003) and well-dened sub-groups (Smith & Zehel, 1991) report more positive change (in terms of well-being and working conditions) than others, perhaps because of their particular circumstances (Semmer, 2006). However, stress management intervention research rarely asks individuals to directly appraise the intervention itself and how it relates to their own work situation (e.g. how they appraise an interventions relevance given their own unique circumstances). This appraisal might moderate or mediate intervention effects and may help explain why group-level analysis of intervention outcome data produces inconsistent or weak results (Kompier & Kristensen, 2000; Lipsey, 1996; Nielsen et al., 2006; Semmer, 2006). Most published intervention studies have taken place in a uctuating and unpredictable organizational context (Parkes & Sparkes, 1998; Semmer, 2006). Contextual factors range from minor changes such as changes in management personnel, to major re-organizations or re-structuring of the organization (e.g. Landsbergis & Vivona-Vaughan, 1995; Schweiger & Denisi, 1991). The national and global context (e.g. changes in employment and health and safety legislation, uctuations in the labour market or the structure of organizations) have a signicant impact on many aspects of management interventions (Cascio, 1995; CIPD, 2007; Wall et al., 1986). Anecdotal evidence suggests that these events may dilute or enhance intervention outcomes by: i) affecting the delivery of the intervention itself, and ii) by having a direct impact upon the working conditions targeted by the intervention (Cox et al., 2000; Grifths, 1999; Kompier & Kristensen, 2000; Landsbergis & Vivona-Vaughan, 1995; Mikkelsen et al., 2000; Parkes & Sparkes, 1998; Swanson & Power, 2001). However, without rigorous process evaluation, it is difcult to evaluate the impact of context on the ndings of intervention studies (Cook & Shadish, 1994; Randall et al., 2005). It is feasible, for example, that the intended design of the evaluation can be fundamentally altered by a context which modies participants exposure to the intervention itself, or that introduces new variables into the study (Kompier et al., 2000a; Randall et al., 2005; Yin, 1994; Yin & Kaftarian, 1997).
The present study

The study had two specic aims. The rst aim was to use a qualitative method to determine whether the content of participants narrative accounts of their experience of an intervention can be mapped onto at least three codes
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(microprocesses, macroprocesses and intervention context). The second aim was to examine the inter-participant variability in the accounts. To achieve these aims, participants from a hospital setting were asked a series of questions about an organizational intervention they had recently experienced. The information in their narratives of their experiences was analysed and interpreted using template analysis (see Method). The study was designed to explore the feasibility of this method of evaluation and attempted to identify what, if anything, it could contribute to evaluation that conventional methods do not.
Method Participants
Data were gathered from interview participants (n = 26) who were all female senior nursing staff. In addition to their clinical workload, all of them had signicant administrative and managerial responsibilities. They were all employed in the childrens nursing directorate of a large hospital in the Midlands of the UK which employed approximately 100 senior nursing staff. Participants were drawn from 15 different wards (each ward had its own specialty, e.g. intensive care, oncology, orthopaedics, etc.). One or two senior nursing staff were selected at random from each ward (all of which were targeted by the intervention) and asked if they would volunteer to take part in the research. In order to provide staff with additional re-assurances about condentiality, the only information about the participants that was recorded was their gender, the ward they were based in, and their grade. During the interview all participants conrmed they had worked in the directorate for at least one year. Senior managers within the directorate conrmed that the sample was representative of the available study population in terms of gender, the distribution of senior staff across different wards and the distribution of staff at different grades within the directorate.
The intervention
Over the four months preceding the interviews, an intervention was implemented that was intended to increase the amount of dedicated and uninterrupted time that participants had available to them to complete their administrative and managerial tasks. The intervention was designed to tackle a number of problems that had been identied via a questionnaire survey. These included: problems with balancing the administrative or managerial
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demands of the job with the clinical caseload; taking administrative work home to complete outside of work hours; the lack of time set aside to complete administrative and clinical workload; and a lack of time to complete complex administrative tasks (especially those requiring uninterrupted concentrated thought). Before the intervention, time to complete administrative and managerial workload was only available if there was spare time after the completion of clinical work, and there was no formal guidance on how that time should be protected. All the directorates staff were invited to participate in consultations about how the situation could be improved: there were a series of away days in which groups of nurses worked in groups to identify possible solutions to the problems they were facing. Senior management took the results of these discussions and worked with a small representative group of senior nurses to devise the intervention described in this study. The intervention was communicated through a revised set of guidelines about how ofce hours should be scheduled to staff (via staff meetings and written memorandums). The guidelines were intended to change ofce hours in two ways. First, senior nursing staff were informed that they should be taking a minimum number of ofce hours (equivalent of approximately one whole day every two weeks for full-time employees) regardless of clinical workload, and that management would support staff taking more time if necessary. Senior management informed senior nursing staff that their ofce hours should be formally scheduled in work rotas. Second, it was made clear to all staff that if ofce time was scheduled, senior nurses should not be required to relinquish it in order to cover others clinical work (e.g. if staff were absent, when workload was especially high, or if there were unlled vacancies on the ward). It was made clear to senior nurses (through both staff meetings and written communications) that they should use additional staff (e.g. temporary cover staff, agency staff or staff overtime) to carry out clinical work if there was a signicant risk that a senior nurses scheduled ofce hours might be at risk of being cancelled, curtailed or subject to frequent interruptions.
Epistemology and choice of methodology

Participants narratives can be used to answer Grifthss (1999) and Semmers (2006) call for the complexity of the particular organizational setting for, and processes of, an intervention to be better understood (Drummond, 1998). In the present study narratives were examined using a phenomenological epistemology for two reasons. First, the analysis of participant narratives post-intervention is a new way of examining intervention processes and context. Although there is some evidence from
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previous research that has highlighted issues (see Initial template) for investigation, these processes and context are not yet well understood. Taking a phenomenological approach allows the narratives about intervention processes and context to be collected and analysed without the tight constraints of incrementalism (such as the replication of previous results) imposed by a positivist research process (Alvesson & Deetz, 2000; Elliot et al., 1999). Second, individual perceptions, appraisal and sense-making are: i) central to contemporary theories of work stress (Lazarus & Folkman, 1984) and ii) important in determining how people respond to organizational interventions (Weick et al., 2005) and interpret organizational context (Alvesson & Deetz, 2000). Therefore, it appears important to collect and analyse this type of information, without seeking to establish its objectivity, in order to understand the effectiveness of stress management interventions (Drummond, 1998; Madill et al., 2000). A qualitative research method (template analysis) was used in this study. Such methods have been under-utilized in the evaluation of organizational-level stress management interventions (Grifths, 1999; Semmer, 2006). Qualitative methods can be rigorously applied in the unpredictable, complex and difcult to control research settings providing small participant populations that are often the backdrop for organizational interventions (Grifths, 1999; Miles & Huberman, 1994; Yin, 1994). These settings rarely allow strong quantitative research designs to be implemented and maintained, but are suitable for qualitative methods (Colarelli, 1998; Cook & Shadish, 1994; Elliot et al., 1999; Kompier & Kristensen, 2000; Randall et al., 2005; Semmer, 2003; Yin & Kaftarian, 1997). Thematic analysis is well suited to the research question: within the boundaries of the investigation it facilitates understanding of the intervention from the participants view (Boyatzis, 1998). Template analysis can be seen as occupying a position between content analysis where codes are all predetermined . . . and grounded theory where there is no a priori denition of codes (King, 1998: 118). Data are analysed by beginning with a set of a priori codes, which are then expanded upon as additional themes emerge from the data (Crabtree & Miller, 1992). The technique was suitable for the present study for two reasons. First, the purpose of the study was to adopt an exploratory phenomenological epistemology that allowed an understanding of the content of intervention processes and intervention context to develop from participants accounts of an organizationallevel intervention. Second, template analysis does not constrain data collection and analysis within the established constructs (Crabtree & Miller, 1992). This approach allowed us to use previous research as a starting point, but not a constraint, for data collection and analysis: research into intervention
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processes and context in job stress interventions is not developed enough to abandon an exploratory stance to the investigation of preliminary models (Semmer, 2006). Data were gathered post-intervention to allow participants to comment as fully as possible on their experiences of the intervention and because sense-making is conceptualized as a retrospective activity (Weick et al., 2005).
Initial template
A review of the literature relating to intervention processes was used to design an initial coding template (Figure 1). Three level-one codes were included in the initial template: microprocesses, macroprocesses and intervention context. The intervention microprocess portion of the template contained three level-two codes: magnitude of impact, valence of impact and the working
1. Intervention microprocesses 1. Magnitude of impact 2. Valence of impact 3. Working conditions affected 1. Homework interface 2. Workload and workpace 3. Job content 4. Control 2. Intervention macroprocesses 1. Design of the intervention 1. Involvement in design 2. Fit to the presenting problem 2. Initial delivery of the intervention 1. Exposure to the intervention 2. Frequency of dedicated ofce time 3. Maintenance of intervention 1. Management support and commitment 2. Staff support and commitment 3. Communication and ow of information 3. Intervention context 1. Ward context 1. Stafng levels 2. Changes implemented at the ward level 1. Ward context affecting the intervention 2. Ward context affecting the working conditions targeted by the intervention 2. Hospital context 1. Changes implemented hospital-wide affecting nursing staff 1. Hospital context affecting the intervention 2. Hospital context affecting the working conditions targeted by the intervention 3. National context 1. Changes implemented nationally affecting nursing staff 1. National context affecting the intervention 2. National context affecting the working conditions targeted by the intervention
Figure 1
Initial coding template
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conditions affected. As a way of establishing a credible initial template, the four categories of working conditions within the microprocesses portion (level-three codes) potentially affected by the intervention (the homework interface, workload and workpace, job content and control) were identied through informal discussions with the senior managers who had facilitated the design and implementation of the intervention (n = 4). These stressors are all problems frequently targeted by stress management interventions (Ivancevich et al., 1990; Murphy, 1996; Parkes & Sparkes, 1998; Semmer, 2003). The initial coding template contained three level-two codes relating to intervention macroprocesses: the design, delivery and maintenance of the intervention. The information used to design the intervention context section of the initial template was taken from two sources. The rst source was the numerous extant quasi-experimental intervention studies, which have mentioned context (such as organizational change and re-structuring) as a possible source of threats to validity (such as the modication of intervention exposure patterns, and the introduction of confounding variables: see Parkes & Sparkes, 1998). The second source was information gathered from senior managers (n = 4) within the participating organization: this indicated that one aspect of the intervention context could be particularly important in the present study. Stafng levels were low in some wards and there was anecdotal evidence that participants were lling these gaps by abandoning ofce time to deal with the residual clinical workload. Three level-two codes were used in this part of the template: ward context, organizational context and national context.
Data collection
Two researchers carried out one-to-one semi-structured interviews. After introductions and explanation of the research and interview process, each interview lasted, on average, around 20 minutes (minimum = 10 minutes, maximum = 50 minutes). The purpose of the study was explained to participants and their informed consent obtained. The interview protocol was designed to allow participants the opportunity to describe their own experiences of the intervention processes and context from a research-based starting point (the Initial template), but without pre-imposing a rigid structure on their accounts. Only the level-one and level-two codes in the initial template were used to stimulate the discussion, beyond which the open questions were used to allow exible exploration of participant accounts.
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The rst question was primarily designed to explore microprocesses. It was: What impact has this intervention had on working conditions?. Questions two and three were designed to explore macroprocesses. They were: How did the intervention come about how was it designed, why did it happen?, and, Has it been implemented as effectively as it could have been?. Finally, intervention context was explored using the fourth and fth questions: Did anything stop the intervention being as effective as it could have been?, and Did anything make the intervention even more effective?. Each of these two questions was followed up by the sixth (open) question: What happened?. Using open questions (e.g. what do you mean by that?; can you tell me a bit more about that please?, etc.) interviewees were encouraged to give more detail around each of their answers to these six questions. Care was taken to keep these questions exploratory and non-directive so as not to steer the results of the study towards the perspective of the researchers (King, 1994; Kvale, 1996). Hence, the interviews were not standardized and, inevitably, the interviewer played some role in determining the amount and quality of data collected. Given the epistemology adopted, this was not thought to signicantly harm the utility of the data obtained. Audio recordings of interviews were not made: several members of the participant group indicated that there were likely to be elements of their accounts that they would be reluctant to have audio-taped, despite re-assurances about the condentiality of data. Therefore, interviewers typed participants responses directly into a word processor program on a portable computer. An atmosphere of collaboration was established to allow the credibility of the data to be checked: participants were asked to review the accuracy of the data many times during the interview (Elliot et al., 1999). Before the interview began, this data collection process was explained to participants. They were informed it may be a little stilted. However, in practice, setting this expectation allowed most interviews to ow quite freely.
Data analysis
Each interview transcript was deconstructed into meaningful segments of text (dened as a piece of text that conveyed clear meaning about some aspect of the intervention process or context [or both]). Two researchers (one of whom had conducted some of the interviews) worked together on this process. Using coloured highlighter pens, segments of text were identied in transcripts of interviews. A total of 486 segments of text were isolated. Each segment of text was then transferred onto cards and the two researchers coded each segment by comparing it to the template, with parallel coding
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being used when necessary (King, 1998). The data were prepared and analysed in this way in order to allow the coders to develop a deep understanding of the content of the interviews. The coding of text segments was carried out over two passes of the data (Miles & Huberman, 1994; Yin, 1994). In the rst pass there were two possibilities when coding each segment of text. The rst possibility was that it could be adequately coded according to the existing template. The second possibility was that some modication of the template was required before it could be accommodated. The second pass was then used to re-examine the coding and position of each segment of text in relation to the nal template. To examine the reliability of the coding, two other subject matter experts (who had no involvement in the interview phase of the study) each repeated the template construction process (Boyatzis, 1998). The names they gave to codes showed some inter-rater differences. These were discussed by the four raters. For all disagreements the underlying meanings of the codes, and the segments of text used that generated them, were highly similar: differences were resident in preferences about the names given to codes. An agreed set of names for the codes was arrived at through discussion. The agreed template was then used to calculate the reliability of the coding of text segments in the second pass coding. Reliability between the two researchers initial categorization of data and each of the independent raters was calculated at 94 and 92 per cent using the formula recommended by Miles and Huberman (1994). The removal of the text segments that adversely affected reliability did not result in the deletion of codes. Only three new codes emerged from the last ve interviews that were coded, suggesting that additional interviews were unlikely to add much to the template. The naming of categories was then tested using a modied version of recaptured item technique (Ferguson & Cox, 1993). Two additional subject matter experts (raters) were each presented with half the segments of texts arranged in the categories in which they appeared in the nal template. The names of the categories were then supplied to the raters who were tasked with matching the category names to the clusters of segments. Each rater then repeated the process for the other half of the text segments. Each rater matched 100 per cent of the category names to the clusters of text segments.
Results
The nal template presented in Figures 2 to 5 presents the agreed coding structure. Data analysis resulted in substantial modications to the initial template. A large and diverse template was generated to accommodate the
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data drawn from participants accounts. This is indicative of a degree of richness and diversity in participants intervention experiences that may not be captured through the simple manipulation checks employed in quasiexperimental studies. The codes developed within each of the level-one codes are described below.
Microprocesses (Figure 2)
Within this portion of the template, the most signicant alteration came through the insertion of new level-three codes: the direct and indirect impact of the intervention on the working conditions of participants. Twelve participants mentioned that the intervention had an indirect effect on their own work situation, because the intervention had improved things for their colleagues (My own manager now has more time to deal with performance appraisals and health and safety problems. That, in itself, has made a noticeable difference to me [participant 12]). Some participants said that their fellow managers were completing paperwork more quickly, which was helping those dependent on the completion of that paperwork to work more efciently (job content). The direct impact of the intervention on managers was also said to have resulted in them being able to have improved contact with, and give more support to, other senior staff (interpersonal relations at work). The improved delivery of ward meetings and cascading of information (the development of organizational culture through the development of shared understanding and goals), and the improved delivery of career development mechanisms (specically by improving the delivery of performance appraisals and mentoring) were also identied. These inter-participant change mechanisms have not generally been considered in previous intervention research. The direct impact on participants working conditions contained only one code not in the initial template: interpersonal relations at work. Several participants indicated that the intervention had enhanced their managerial performance (On an ofce day, I get a chance to talk more with staff. This isnt just about identifying their concerns, it means we can just chat and that helps everyone to get on better [participant 8]). Several mentioned a reduction in the amount of late working and in the amount of work completed at home. Four positive changes in workload and workpace were mentioned by participants. These related to the additional protection (participant 2) that the intervention had given to the time in which ofce work was carried out (When we get this protection, work takes less time, I am more efcient. It frees up time for other things [participant 2]). Two codes were required to capture information about the impact of the intervention on job content:
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1. Microprocesses 1. Magnitude of impact 2. Valence of impact 1. Neutral Positive 3. Working conditions affected 1. Direct impact on own working conditions 1. Homework interface 1. Amount of time working late 2. Amount of work taken home 2. Workload & workpace 1. Opportunities to complete tasks 2. Availability of additional time at work 3. Amount of workload congestion 4. Time needed to complete admin tasks 3. Job content 1. Number of errors 2. Degree of job enrichment 1. Time for planning improvements to the ward 2. Time to carry out managerial tasks 4. Control 1. Availability of quiet time 5. Interpersonal relations at work 1. Management competence 2. Indirect: impact on others working conditions 1. Job content 1. Completion of ward paperwork 2. Interpersonal relations at work 1. Availability of manager 2. Amount of support for staff from management 3. Availability of quiet time with others in management positions 3. (Development of) organizational culture and function 1. Delivery of ward meetings 2. Cascading of information 4. Career development 1. Delivery of appraisals by other managers 2. Awareness of study days and personal development opportunities
Figure 2
Final template: Microprocesses portion of template
the reduction in errors (brought about by having more quality time [participant 7] to complete tasks) and job enrichment (from segments of text in which participants described, for example, how much more interesting the job has become since weve got signicant time to plan improvements and to deliver better quality management [participant 20]). A wide variety of different tasks were cited by participants as being affected by the intervention. The nine mentioned during the interviews were: staff appraisals, analysis of health and safety data, organization of ward staff working hours (the off-duty rota), collaborative work with other wards, auditing of clinical work, dealing with problems reported by ward staff, ward development and improvement projects, ward meetings, and the planning of staff training and development). Different participants reported different tasks being affected by the intervention (no one participants account
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required more than three of these codes). Quasi-experimental research into intervention effects has largely ignored the possibility that such interindividual differences in change mechanisms and outcomes exist within a group exposed to an intervention.
Macroprocesses (Figure 3)
The level-two codes of this portion of the template did not require any modication. The level-three codes within the intervention design portion of the template were modied to include: staff participation in intervention design (and its relationship with their subsequent decision-making), the amount of discussion of participants needs in relation to the intervention, and the visibility of senior managements involvement in intervention design. These codes are similar to the facilitating factors found in previous research (Kompier et al., 2000b). Two codes were required to encompass participants accounts of the impact of these design processes. These related to the amount of condence
2. Macroprocesses 1. Design of intervention 1. Amount of involvement in the review of ofce hours 2. Amount of discussion of needs 3. Visibility of management backing for the intervention during the design phase 4. Staff participation in making decisions about the intervention 1. Impact of design factors on self-management of intervention 1. Condence when managing own ofce hours 2. Assertiveness of ofce day management 2. Delivery of interventions 1. Exposure to the intervention: additional ofce hours 2. Regularity of delivery of extra ofce hours 3. Raw frequency of ofce days 4. Length of time intervention in place at time of evaluation 5. Sufciency of ofce time 6. Change of ofce hours from baseline situation (increase, decrease, same) 3. Maintenance of intervention 1. Support and commitment by management 1. Existence and strength of the unspoken contract legitimizing of ofce days 2. Maintenance of a regular supply of ofce days 3. Support for use of agency staff to cover staff shortages 4. Sufciency of ofce time 5. Scheduling of ofce days on the work rota 6. Active recognition/legitimizing of the necessity of ofce time 2. Self-management of the intervention 1. Control over scheduling of own ofce hours 2. Use of initiative to schedule ofce hours 3. Communication and ow of information 1. Active recognition/legitimizing of the necessity of ofce time 2. Existence and strength of the unspoken contract legitimizing of ofce days
Figure 3
Final template: Macroprocesses portion of template
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participants had when scheduling or planning ofce hours (Because I helped design the change, I just go ahead and take ofce days now, regardless of whats happening, I dont consider not doing it [participant 19]) and the assertiveness they felt they were able to convey when challenged about ofce hours, or when facing problems when implementing them (I am certain I will not get into trouble for taking it [participant 24]). These results highlight how intervention design processes may inuence the way staff manage their own exposure to, and involvement in, an intervention. The level-three codes relating to the initial delivery of intervention were as expected. However, there was a new code that related to the amount of time that the intervention had been in place at the time of the evaluation: participants reported that the intervention took longer to appear in some wards than in others, meaning that some participants had only just begun to experience the intervention. For others, protected and extended ofce hours had become the norm (participant 1). For some the intervention had meant a major change in the amount of ofce time. Other participants had managed to organize their own ofce hours prior to the intervention. These ndings suggest that the length of exposure to the active ingredients of an intervention cannot be assumed to be uniform across participants (even if it was implemented at the same time for all). The maintenance of the intervention portion of this part of the template required only minor modications to one of the level-three codes. Staff support and commitment was re-named as self-management of the intervention. Support and commitment by management contained codes reecting constructs not previously considered. Some accounts mentioned the importance of the unspoken contract that allows me to use ofce hours when I need to. This really stems from my close working relationship with [my manager]. Not all of my colleagues have that (participant 16). The other level-four codes in this section of the template related to management actively embracing and supporting the intervention (participant 10) through concrete and visible actions. These ndings suggest that any formal evaluation needs to examine the behaviours and actions of those managing the intervention after its initial implementation. Several accounts discussed the inuence of working conditions on the amount of control participants had over the scheduling of their ofce hours (this ward is so busy I cant even sit down to plan ofce time [participant 26]). One of the few codes relating to participants skills or abilities appeared in this part of the template (the use of initiative to schedule ofce hours). There is very little research that explores how an individuals skills or competence impacts on the implementation of the intervention. Communication and ow of information contained codes which captured the movement of information about the legitimacy of the changes to ofce hours.
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Intervention context (Figures 4 and 5)

Separate level-one codes were inserted for the baseline intervention context (i.e. the context when the intervention was being planned and initiated) and the context of the activated intervention. Level-two codes in the baseline preintervention portion of the template covered a wide range of factors referring to individuals particular circumstances. For example, some staff reported having satisfactory ofce hours before the intervention, and there were several references to the distribution of ofce work before the intervention (I can imagine this is really helping others, but not me, we made changes a while ago that mean I have enough admin[istration] time already [participant 11]). A number of level-three codes were required to encompass segments of text that referred to the size and nature of the managerial workload before the intervention. Some participants reported that the intervention would vary in its impact because of factors such as the uniqueness of the ofce work carried out (participant 4), the complexity of the tasks carried out during ofce hours, their variety and difculty and importance, and the overall size of an individuals administrative workload. This extensive set of codes identies the potential for variability in an individuals own situation at the beginning of an intervention. Many participants mentioned the individual coping strategies they used before the intervention. These included a refusal to take work home, completing ofce work in quiet shifts and an aggressive scheduling of [my own] ofce time, regardless of whether management like it or
3. Baseline pre-intervention context 1. Pre-existing intervention components (existing ofce hours arrangements) 1. Provision of ofce time before intervention 2. Potential for improvement to existing arrangements 3. Distribution (spread or concentration) of ofce work within the ward 2. Pre-existing administrative and managerial workload 1. Extent of need for dedicated time to manage staff 2. Uniqueness of administrative tasks undertaken (e.g. doing tasks no-one else does) 3. Complexity and difculty of administrative tasks 4. Variety of administrative tasks 5. Size of administrative workload/number of administrative tasks undertaken 6. Importance of administrative tasks 3. Personal creative coping strategies in place 1. Amount of ofce work completed during night shifts 2. Fitting ofce work around other tasks 3. Refusal/acceptance of taking work home 4. Amount of ofce work completed during quiet weekend shifts 5. Scheduling of own ofce time 4. Work context and role 1. Amount of ward-based and community-based workload 2. Importance of clinical tasks in core job 3. Specialized clinical skill and knowledge possessed
Figure 4
Final template: Baseline pre-existing context portion of template
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4. Context of activated intervention 1. Personal work context/role 1. Personal work context factors 1. Consequences of continuing with ofce work during heavy clinical demands 2. Predictability of clinical demands 3. Demands to cover the work of more senior staff 2. Impact of personal work context on intervention 1. Impact of personal work context on intervention delivery and management 1. Degree of difculty in planning ofce time 2. Ease of legitimizing of ofce days/time 3. Frequency of cancellation of ofce days/time 2. Impact of personal work context on microlevel change 2. Ward context 1. Ward context factors 1. Size of clinical caseload allocated on ofce days 2. Feasibility of using bank staff to cover for staff absence 3. Visibility of colleagues problems in coping with clinical workload 4. Size of ward workforce 5. Availability of computer facilities 6. Acute ward stafng uctuations (sickness and leave) 7. Demands to cover colleagues work over the length of a shift 8. Demands to cover colleagues work for short periods 9. Extent of chronic ward stafng problems (unlled vacancies) 10. Skill mix on the ward 2. Impact of ward context on intervention 1. Impact of local context on intervention delivery and management 1. Amount of ofce work 2. Scheduling and use of ofce time 3. Number of changes to/re-scheduling of ofce hours 4. Importance of clinical work in relation to administrative work 5. Ceiling on ofce hours that can be organized 2. Impact of local context on microlevel change 1. Dilution of the impact of change 3. Hospital context 1. Hospital context factors 1. Devolving of more responsibility to wards 2. Impact of hospital context on intervention 1. Impact of hospital context on intervention management 1. Extent to which work demands can be inuenced to accommodate ofce hours 4. Context of demands placed on the service 1. Demands placed on the service 1. Seasonal uctuations in patient numbers and dependency 2. Unpredictable uctuations in patient numbers and dependency 2. Impact of demands placed on the service on the intervention 1. Impact of demands placed on the service on intervention macroprocesses 1. Exposure to the intervention 2. Self-management of exposure to the intervention 5. National context 1. National context factors 1. Availability of appropriately trained nursing staff to ll vacancies 2. Availability of agency nurse cover 2. Impact of national context on the intervention 2. Impact of national context on intervention macroprocesses 1. Initial exposure to the intervention 2. Sustainability of the intervention
Figure 5
Final template: Context of activated intervention portion of template
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not (participant 19). Another level-two code was needed to capture the individuals role in the service. For example, those who spent time working in the community indicated that this allowed them more time for ofce work even before the intervention. Others worked in wards where clinical tasks were of critical importance . . . there is no way I can wait for cover staff to arrive if there is work to do its just not safe or fair (participant 20). This set of codes indicates that even in an apparently homogenous work group, subtle difference in individual circumstances may generate the potential for variability in the impact of the intervention. The context of the activated intervention contained an extensive set of new codes. There were ve level-two codes that related to the different contexts that were mentioned in relation to the intervention. These were: ones own personal work role, the ward context, the wider hospital context, the context of the demands placed on the service and the national context. Levelthree codes within the personal work context related to how the clinical workload impacted on the delivery and maintenance of the intervention. The degree of difculty involved in planning ofce time, how easily it could be justied and frequency with which ofce hours were needed were all codes that emerged from participants accounts. The ward context was a source of a large number of level-four codes (see Figure 5). These included the ease with which cover could be arranged, how obvious it was that junior colleagues were struggling to deal with high workload, and the prevailing levels of staff with an appropriate range of skills to deal with workload on the ward. Several segments of text were coded as referring to the impact of the ward context on intervention macroprocesses such as the scheduling and rescheduling of ofce time, and the ceiling on ofce hours that could be organized (. . . for me to have ofce time to do all my admin in this ward would mean I never did any clinical work [participant 7]). Only one levelfour code was needed for hospital context factors (the devolving of more managerial responsibility to ward staff); only two for the context of demands placed on the service (seasonal and non-seasonal uctuations in workload, i.e. demand increasing in the winter months) and two for national context factors (the availability of qualied staff to ll vacancies or to provide temporary cover). These results suggest that evaluation methods should assess the impact of context on the implementation of the intervention.
Discussion and conclusions

This study demonstrated that it is important and useful to gather data about intervention experiences from participants. The qualitative method used in
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this study revealed complex and multifaceted accounts of the intervention process and context which are in sharp contrast to the simple manipulation checks used (and exposure-based mechanisms tested) by quasi-experimental evaluation research. A diverse and rich template was needed to adequately code participants data: this provides preliminary evidence of the potential for heterogeneity in participants experiences of a relatively simple intervention. Since intervention effect sizes are likely to be modest at best (Zapf et al., 1996), it is crucial that data on intervention processes and context are gathered and used to inform outcome evaluation (Lipsey, 1996). In the present study, the use of an outcome-only evaluation strategy may have led to disappointing results, and the possibly erroneous conclusion that the intervention was ineffective. However, our data suggest alternative interpretations: it may have been that problems with implementation, differences in the individual context among the target population, and differences in perceptions of the intervention, were related to its impact. Narrative accounts focus on examining the complexity of a particular situation, rather than identifying generalizable ndings, but they may resonate with other organizations and researchers (Drummond, 1998). The template illustrates that the evaluation of stress management interventions needs to consider the relevance of intervention processes, and the utility of process measurement methods, found in the wider research into organizational change (e.g. in evaluating the impact of outsourcing, or the implementation of new ways of working). In the present study, analysis of participant accounts identied six ways in which intervention processes and context may inuence the relationship between intervention exposure and intervention outcomes. First, individual differences in work circumstances among a group of staff (all in the same role in the same organization) prior to, during, and after the intervention may magnify, dilute or even nullify the impact of an intervention. Several different change mechanisms may operate for a single intervention. There may also be inter-individual differences in the nature of the work tasks affected by a particular intervention. Participant accounts can be used to identify the different change processes that might be operating for different individuals, or in different circumstances (i.e. provide explanations that could be examined through various research methods and epistemologies). Second, there could, in some circumstances, be secondary (or indirect) inter-participant effects of an intervention (i.e. the effect of an intervention on one employee becomes an intervention that affects others). For example, the result an intervention that ring-fences time to do solitary job tasks can result in participants having more uninterrupted time to interact with each
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other. These secondary effects need to be considered when evaluating intervention outcomes. Third, organizational and personal historical factors (such as previous attempts at interventions) and inconsistent implementation processes may lead to inter-individual differences in the length of exposure to an intervention that is designed to be delivered to all participants at the same time. This needs to be taken into account in the evaluation of intervention outcomes. Fourth, participants exert some control and choice over how they experience the intervention. They may integrate their own coping strategies (i.e. individual modications to work design) with the intervention (i.e. organizational modications to work design). Moreover, employees knowledge, skills and attitudes may inuence their perception of, and exposure to an intervention and the benet they get from it. In addition, the involvement of participants in the design of an intervention may be linked to their subsequent experience of the intervention (through their perception of, and condence in, the intervention). Fifth, the perceived actions and attitudes of line managers and senior managers may introduce substantial between-participant differences in intervention implementation and context (e.g. by blocking implementation or by establishing a favourable context). Sixth, and nally, intervention context may not only impact directly on intervention outcomes, but also modify the intervention itself. The ndings indicate that viewing participant groups as homogenous and interventions as simple manipulations may be an inappropriate basis for evaluation. It could be argued that randomized control trials minimize the impact of heterogeneity in the participant group, rendering redundant such detailed process evaluation. However, such studies are rarely practicable in complex applied research environments, and will not help to identify the process and contextual factors that organizations need to inuence in order to successfully implement interventions. Meta-analysis of intervention studies could also be used to identify common process-outcome relationships (Wagner, 1994). The methods used in our study may help to provide more research that gathers detailed information about intervention processes and contextual factors (not that gathered in a more or less anecdotal way (Semmer, 2006: 523)) so that such analyses can be attempted. The nal template from the present study could also be used as an analytical framework for further investigations regardless of the intervention evaluated, epistemology adopted or the methodology employed. For example, it may be useful to examine how participant narratives are related to veriable events by examining documentary evidence (such as stafng records, patient workload statistics, etc.).
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Qualitative methods may be particularly suitable for examining how an intervention can be linked to intervention outcomes in a specic research setting (Fitzgerald & Rasheed, 1998; Green & Caracelli, 1997; Johnson & Cassell, 2001). These methods can provide detailed data more quickly and with smaller samples than can quasi-experiments (Smith et al., 1999). Given that research into the processes of stress management interventions is in its infancy, qualitative methods allow for the collection of data with few researcher-specied restrictions on the breadth of the investigation. However, quantitative process evaluation (using questionnaire measures of process and context) has also been successfully used to identify process-outcome relationships (Randall et al., 2005; Semmer, 2006). Axtell et al. (2006) used questionnaire data to test relatively complex change processes (i.e. that as interventions to improve innovation reach maturity, team support grows in importance, and managerial support decreases in importance). Therefore, it would not be appropriate to use our results to argue that qualitative methods are the only way of gathering and analysing data about the processes and contextual factors examined in this study (Grifths, 1999; Kompier et al., 2000b). Our study focused on gathering and analysing descriptive data about the nature of intervention processes and contexts that have been the subject of speculative discussion in the existing research. However, research into work stress suggests that qualitative studies of participants accounts of interventions could be used to understand a broader set of issues. It may be that these accounts serve a purpose, perhaps by legitimizing (Harkness et al., 2005), or providing a vehicle for, the discussion of on-going un-solved problems that are of particular importance to participants. They may also provide valuable information about cultural norms (Dick, 2000) and how they impact on the way the purpose or goal of an intervention is perceived. Qualitative accounts of intervention experiences may also provide data about participants perceptions of their own and others accountability (Hepburn & Brown, 2001) for the success or failure of an intervention. For example, it was noteworthy that participants rarely mentioned their own knowledge, skills, abilities, motivation or personality in relation to the success or failure of the intervention. Instead many of the problems they identied with the intervention were attributed to external sources. However, there is good evidence that individual resources (e.g. self-efcacy) play a role in determining the effectiveness of an intervention (Schaubroeck & Merritt, 1997). Furthermore, not all of those exposed to the intervention took the opportunity to make full use of it: in this study participants accounts focused on external forces resident in the intervention context (e.g. stafng levels) as the reasons for their non-participation. However, it
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may be that individual differences such as perceived inuence over the intervention, expectations of success, and perceived organizational motivation for change may also play a role in decisions to participate and moderate the relationship between intervention exposure and outcomes (Nielsen et al., 2006). The absence of individual resources, and perceptions of power and motives from the template may have been a result of the interview questions employed. Many participants were under pressure to return to their ward and may have led to them focusing on the stimulus questions in the interview, rather than taking the opportunity to think about a broader set of issues. Alternatively, these ndings may be a result of an external attribution bias on the part of the participant (Weiner, 1986). These possibilities could be examined by gathering broader qualitative data about the intervention experience. It is possible that memory effects such as primacy and recency inuenced the data presented. Therefore, future research should examine how participant narratives develop over the course of an intervention, and possibly integrate such data with quantitative data on intervention outcomes. However, the way people make sense of their experiences retrospectively can also be an important determinant of future behaviour, rendering individual accounts (even if they deviate from those of other participants) important in the understanding of intervention outcomes (Weick et al., 2005). Moreover, a narrative that considers all aspects of the experience of an intervention can only be obtained after the full range of intervention activities has been implemented and the intervention had been given time have an effect. In this study, the epistemology adopted and methods of data collection and analysis used may have led to context-specic data and results (Symon & Cassell, 1998). It is not possible to use the results of this study to evaluate what the effectiveness of the intervention described might be outside of this research setting. However, it has identied a variety of themes that can be useful when assessing the efcacy of this, and other, interventions in other settings. It is important to note that although the participants were deemed to be representative of the population from which they were drawn, the sample size was relatively small. Therefore, it is important to view our ndings as preliminary ones that may help to guide future research: our nal template is in no way intended to be a denitive map of the constructs of intervention processes and contexts. Analysis of the impact of demographic factors on participants accounts of the intervention was not attempted. Factors such as length of service, age and grade may inuence participants appraisals of an intervention and should be examined in future research. The method of evaluation used in this study did identify a number of specic, evidence-based descriptions of inter-participant differences in
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narratives. These could be useful in two ways: i) to inform adjustments to implementation, or to help tailor interventions to individual or organizational circumstances to give the intervention a better chance of being effective (Semmer, 2006), and ii) to focus further data collection and analyses that allows for the examination of specic process-outcome relationships (Randall et al., 2005). It is important to note that the data gathered in this study were of great interest to the participating organization, and were put to use to improve the intervention. For example, regular meetings were instigated to discuss the progress of the intervention in order to deal with individuals difculties in managing their ofce time, and to underline management support for it. Budgets were also re-assessed to ensure that sufcient funds were made available for cover staff particularly during times of the year when there was high demand on the service. The methods described in this study could be used by organizations to examine the experiences of participants in a pilot study group, so that the full-scale implementation of an intervention could be better managed, with organizational-level interventions better aligned with individual needs and circumstances (Semmer, 2006).
Conclusions
Participants accounts of their experiences of an intervention are a rich source of data that should be incorporated into future research into the effectiveness of organization-level stress management interventions. Such accounts may be particularly useful when the organizational environment does not allow for the use of controlled quasi-experiments. Organizations should use these accounts to critically appraise and modify the intervention itself, or the way it is implemented or the context within which it operates. The results of the present study indicate that there is a need for evaluation research to better integrate process and outcome evaluation in order to better assess the efcacy of organizational-level interventions.
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Raymond Randall is a Lecturer in Occupational Psychology in the Department of Psychology at the University of Leicester. His research interests are: the assessment and management of work-related stress (including the design and implementation of risk management methods to help organizations tackle the problem); the evaluation of organizational change; and selection and assessment (where his work has included the development and implementation of selection processes in the medical profession). He has worked on two large research grants for the UK Health and Safety Executive which have examined the impact of organizational-level stress management (interventions in both private sector organizations and the UK National Health Service). It was during this work that he began developing alternative methods of evaluating the impact of interventions. [E-mail: rjr15@le.ac.uk]
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Tom Cox is Professor of Organizational Psychology at the University of Nottingham where he is Director of the Institute of Work, Health & Organizations, a postgraduate research school in the Faculty of Law, Social Science & Education. His research interests include: risk management for work stress, the evaluation of organizational interventions for improving organizational and employee health, work-related reproductive health and transport health and safety. He has published over 150 scientic articles in books and journals, contributed to both national and international Guidance Notes on issues related to work stress and workplace violence; and been sometime adviser to government departments and agencies in the European Union, and in the UK, Eire, the USA, Chile and Australia. He has also advised the World Health Organization (Occupational Health). He was awarded a CBE for his services to occupational health in 2000. [E-mail: tom.cox@nottingham.ac.uk] Amanda Grifths is Professor of Occupational Health Psychology at the University of Nottingham where she is Director of Research in the Institute of Work, Health & Organisations, a postgraduate research school in the Faculty of Law, Social Science & Education. Her current research interests include: the ageing workforce; the evaluation of organizational interventions for improving employee health and performance; occupational health and safety law, policy and practice; and the management of long-term health conditions at work. She has published over 90 chapters and articles. She has provided policy and related advice to international agencies, government departments, the legal profession, and public and private sector organizations. [E-mail: amanda.grifths@nottingham.ac.uk]

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Human Relations

http://hum.sagepub.com Participants' accounts of a stress management intervention

The Tavistock Institute

Participants accounts of a stress management intervention

Human Relations 60(8)

Participants accounts of interventions

Human Relations 60(8)

The nature of intervention processes and context

Participants accounts of interventions

The present study

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Participants accounts of interventions

Epistemology and choice of methodology

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Participants accounts of interventions

Initial coding template

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Participants accounts of interventions

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Participants accounts of interventions

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Final template: Microprocesses portion of template

Participants accounts of interventions

Final template: Macroprocesses portion of template

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Participants accounts of interventions

Intervention context (Figures 4 and 5)

Final template: Baseline pre-existing context portion of template

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Final template: Context of activated intervention portion of template

Participants accounts of interventions

Discussion and conclusions

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Participants accounts of interventions

Human Relations 60(8)

Participants accounts of interventions

Human Relations 60(8)

Participants accounts of interventions

Human Relations 60(8)

Participants accounts of interventions

Human Relations 60(8)

Participants accounts of interventions

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