Published for the British Institute of Learning Disabilities

Journal of Applied Research in Intellectual Disabilities 2009, 22, 561–573

Staff Stress and Burnout in Intellectual

Disability Services: Work Stress Theory and its
Application
Jason Devereux*, , Richard Hastingsà and Steve Noone§
*School of Psychology, Bangor University, Bangor, Gwynedd, Wales, UK; Trust Headquarters, Wrexham, Wales, UK;
à
Department of Psychology, School of Psychology, Bangor University, Bangor, Gwynedd, Wales, UK; §Department of Clinical
Psychology, School of Psychology, Bangor University, Bangor, Gwynedd, Wales, UK

Accepted for publication 17 February 2009

Background Staff in intellectual disability services can be ity research relates to these theories is explored. Some of
at risk of stress and burnout at work. Given that staff the key theoretical constructs within these work stress
well-being has implications for the quality of life of the models have been explored in intellectual disability
staff themselves and people with intellectual disabilities research but frequently the underlying processes within
themselves, this is an important research and practical work stress models have not been fully tested.
topic. In this paper, we review work stress theories that Conclusion Partial exploration of work stress theories
have been applied within intellectual disability research. means that theoretical understanding of how best to
Method A search of the literature identified five stress explain work stress in intellectual disability staff is lim-
theories that have been applied in intellectual disability ited. Suggestions for future research are discussed, par-
research: person–environment, demand–support–control, ticularly concerning the relationship between empirical
cognitive-behavioural, emotional overload, and equity research and work stress theory.
theory.
Results Each of the five work stress theories is described Keywords: intellectual disability, staff, work stress theory
and the extent to which data within intellectual disabil-

disability services have found between 32.5% (Hatton

Introduction
et al. 1999a,b) and 25% (Robertson et al. 2005) of staff
Work can provide a sense of meaning and structure in experienced significant levels of stress. Understanding
modern life (Tetrick & Quick 2001) but by its nature work stress in intellectual disability staff is important
work may be stressful (Kenny & Cooper 2003). Success- for a number of reasons. First, the health of the
ful management of stress can lead to growth and devel- employee is to some extent the responsibility of the
opment (eustress). Where stress cannot be managed, employer. Second, it is in the employer’s direct interest
there may be the experience of distress (negative stress). to reduce staff stress, as there is an association between
Further, long-term exposure to stress may result in staff stress, sickness, absenteeism, and turnover (Razza
burnout at work. Stress and burnout can impact on the 1993; Rose 1995). Third, research suggests that staff–
well being of the worker and the quality of the service client interactions may be negatively affected if they are
or production within organizations (Seaward 2004). under stress or experiencing burnout (Lawson &
The focus of this paper is on paid support staff work- O’Brien 1994; Rose et al. 1998a), staff stress responses
ing in intellectual disability services. This is because may impede their ability to deal effectively with chal-
they are services’ most costly and valuable resource and lenging behaviours (Hastings 2002; Rose et al. 2004), and
the quality of their work reflects the quality of the ser- the organizational culture where staff are stressed and
vice. However, research suggests that staff report high burnt out may be associated with increased risk of abu-
levels of stress and burnout. Surveys of intellectual sive practices (White et al. 2003). Finally, it is important

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562 Journal of Applied Research in Intellectual Disabilities

to note that there is no comprehensive theoretical frame- models have been applied to varying extents in
work to explain staff stress in intellectual disability. intellectual disability research: person–environment,
In this paper, we review work-stress theories that demand–support–control, cognitive–behavioural, emo-
have been explored or referenced within intellectual dis- tional overload, and equity theory. For each model, we
ability research. The theories chosen are those to which provide a brief overview of the core concepts (see
researchers have referred in presenting work stress and Table 1), and evaluate research in the intellectual disabil-
burnout data in the intellectual disability field. Thus, the ity field that has a bearing on the model, including draw-
theories reviewed do not represent the full range of per- ing on research where an explicit link with the theory
spectives that may be applicable, but those to which has not yet been made but where these data may relate
researchers have turned in explaining their data. Papers to concepts derived from theory. Therefore, evidence is
were identified for the review from a search of Psychi- included from the published literature if studies contain
nfo using the following terms in a Boolean string: (burn- data relevant to any of these theoretical models.
out or stress) and (staff or nurse* or carer* or support
worker*) and (learning disabilit* or intellectual disabilit*
Person–Environment Fit
or mental retardation). This was supplemented by fol-
lowing up references cited in the papers. Examination of In person–environment theory, stress results neither
this literature identified five major theoretical explana- from the person or the environment but from the degree
tions that had been explored in intellectual disability of fit between them (French & Kahn 1962; Edwards et al.
research. The aim of the present paper is not to review 1999; Spielberger et al. 2001). Three distinctions are
the general support for each theoretical perspective but made regarding fit. The first and most basic distinction
to consider how some of the models, or the concepts is between the person and the environment, which is a
within them, have been applied specifically to staff prerequisite for the conceptualization of person–environ-
working in intellectual disability services. We will also ment fit. The second distinction is between the objective
consider some conceptual frameworks developed from and subjective representations of the person and the
within intellectual disability research. Finally, we con- environment. It is the notion of subjective fit, where
sider the implications of our analysis for the direction of there is a mismatch between workers’ perception of the
future research. environment and perception of themselves that is seen
as the major cause of work stress (Matteson 1987;
Edwards et al. 1999). The third distinction in the per-
Work Stress Theories
son–environment model focuses on two further dimen-
Reflecting the complexity of work stress, there are a sions of fit. First, there is the needs-supplies dimension,
number of work stress models derived from differing where needs are described as the innate biological and
perspectives (Spielberger et al. 2001; Arthur 2004). Five psychological needs of the person, and supplies are

Table 1 Key features of five work stress theories

Theory Key variables Key processes leading to stress

Person–environment Work characteristics worker An interaction between the person and the work environment.
characteristics A mismatch between the person and the environment can
lead to strain experienced through role overload, role ambigu-
ity and role conflict
Demand–support–control Job demands decision latitude An interaction between demand, supports and control at work.
support Where demand is high and control low and support low then
greater risk of stress
Cognitive-behavioural Job demands appraisal coping Primary appraisal of job demands and secondary appraisal of
resources coping resources
Emotional overload Interpersonal demands Interpersonal demands in human services deplete emotional
resources leading to stress ⁄ burnout
Equity theory Outcomes and inputs in The perception on inequity in a relationship leads to distress
relationships

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Journal of Applied Research in Intellectual Disabilities 563

described as the rewards of the job that meet the per- port staff, although they were not clear, in theoretical
son’s needs. Supplies can be financial, social, and related terms, if they were exploring needs-supplies or
to the opportunity to achieve. Second, there is the demands-abilities fit.
demands-abilities dimension. This dimension describes In intellectual disability research there has also been
the fit between the demands of the job and the abilities limited exploration of some of the predicted relation-
of the person to meet those demands (Edwards et al. ships within the person–environment fit model. There
1999). Demands include quantitative and qualitative has been a tendency, as in the general work stress litera-
aspects of the work and abilities refer to the skills, time, ture, to investigate the putative outcomes of role con-
and energy required to meet the demands. Stress is flict, role ambiguity, and stress rather than subjective fit.
most clearly predicted to emerge on the needs-supplies Empirical evidence confirming that workers experience
dimension where the supplies do not match the person’s role conflict and role ambiguity, and that this is associ-
needs but also may occur in some situations where sup- ated with the experience of stress and burnout, has been
plies exceed the person’s need if, for instance, they inhi- found in several studies of staff in intellectual disability
bit the fulfilment of other needs. Similarly, stress is services (Aitken & Schloss 1994; Blumenthal et al. 1998;
predicted to emerge on the demands-abilities dimension Dyer & Quine 1998; Hatton et al. 1999b). For example,
when the demands of the job exceed the person’s abili- Hatton et al. (1999a,b) measured general distress and
ties but it also may occur in some situations where abili- work stress. Role ambiguity was found to be directly
ties exceed demands such as when underused skills associated with general distress and role conflict
may result in boredom and reduced self-esteem was associated with work-home conflict, which was in
(Matteson 1987; Edwards et al. 1999). turn associated with general distress. Role ambiguity
In person–environment theory, where poor fit occurs, was also directly associated with work stress, and role
individuals may experience work overload, role ambigu- conflict was indirectly associated through lack of staff
ity, and role conflict (Spielberger et al. 2001). Role over- support and having a low status job, which were in turn
load can be quantitative in terms of physical demands were associated with work stress. Dyer & Quine (1998)
and number of tasks and qualitative, where the worker found an association between burnout and role conflict
perceives that they do not have the skills or ability to and role ambiguity. Aitken & Schloss (1994) identified a
satisfactorily complete work tasks (Cooper et al. 2001). similar association, and found that role conflict was a
Role ambiguity refers to a state of confusion about what stronger predictor of burnout than role clarity.
is expected within the role. Role conflict refers to the In summary, the person–environment model has been
conflict between what workers are asked to do and their a significant development in work stress theory. The
norms and values (Winnubst et al. 1996). The lack of fit model would predict a relationship between the concept
experienced through overload, role ambiguity, and role of fit, the experience of role ambiguity and role conflict,
conflict is seen as producing strain in the individual. and the experience of work stress. Within intellectual
This strain may result in the stress response whereby disability research, there is evidence of association
workers experience physical and psychological symp- between the concepts of role conflict and stress, and role
toms (Spielberger et al. 2001). ambiguity and burnout. Hatton, Rivers, et al. have also
We only found one study in which the concept of per- identified that poor person-organization fit may be asso-
son–environment fit has been explored within intellec- ciated with negative outcomes for staff. However, the
tual disability services. Hatton et al. (1999b) in a survey Person-Environment model has not been fully explored
of staff stress and satisfaction used a measure of per- in intellectual disability research. We found no study
ceived real and ideal organizational characteristics, testing the hypothesized pathway from Person-Environ-
factored into nine subscales of organizational charac- ment fit, through role ambiguity ⁄ conflict to staff work
teristics. Mismatch on the ‘tolerant ⁄ staff-orientated’ stress.
characteristic was associated with general stress and job
stress. Further associated with job stress were the
Demand–Control–Support
organizational characteristics ‘achievement-orientated’,
‘rewarding staff’, and ‘conflict management’. Better The demand–control–support model (Karasek &
person-organization fit was found to be associated with Theorell 1990) proposes that the development of stress
work satisfaction. Hatton, Rivers, et al. claim that their at work is influenced by an interaction between the
findings lend some support to person-organization fit perception of work demands, perception of control, and
theory and its applicability to intellectual disability sup- the degree of support workers perceive. Control is

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564 Journal of Applied Research in Intellectual Disabilities

conceptualized specifically as workers’ degree of control the interpretation of their data because staff reporting
over their work activities. Support is classified as socio- high levels of stress may perceive the same demands to
emotional or instrumental. Socioemotional support is be more difficult to cope with than staff reporting lower
described as the degree of social and emotional integra- levels of stress.
tion and trust between workers, supervisors, and others. The concept of control in Karasek and Theorell’s
Instrumental support is the extra resources or assistance model has also been explored to a limited extent in the
given in work by co-workers and supervisors. Karasek intellectual disability literature. Corrigan (1993) in a sur-
and Theorell suggest that support at work can act as a vey of 322 staff in a hospital setting found that staff
buffer, promote health, facilitate active coping, and help identified lack of control over administrative decisions
foster a sense of identity. The demand–control–support as highly stressful. In terms of relationships with staff
model proposes that jobs that are high in demands, low outcomes, Hatton et al. (1999a,b) found a low indirect
in control, and low in social support are those that carry association between job control and job strain. Innstrand
the highest risk of stress for workers. The model has et al. (2004), after an intervention designed to increase
implications for job design in developing support and worker control, found a reduction in burnout on the
control with a view to increasing worker engagement emotional exhaustion component. Dyer & Quine (1998),
and productivity (Karasek & Theorell 1990; Theorell in the only study in intellectual disability to at least par-
2001). tially consider some of the interaction effects proposed
Karasek and Theorell’s model has not yet been tested by Payne, found no significant relationship between
within intellectual disability research. However, some of non-participation in decision-making and burnout and
the concepts including demands, support, and control no interaction effect between non-participation in deci-
have been investigated within Payne’s (1979) slightly sion making and support on burnout.
more expansive model of demands–supports–constraints In the Karasek and Theorell model, support is seen as
(Rose 1993; Dyer & Quine 1998; Rose et al. 1998b). Payne having a moderating effect: interacting with demand
suggests that occupational stress results from the inter- and control to determine stress. Beehr et al. (2003), when
action between job demands, supports, and constraints reviewing the literature outside of the intellectual dis-
and it is proposed that as demands and constraints ability field, highlighted that support has been proposed
increase stress is likely to increase but this can be to have both a main effect and in some studies a moder-
reduced by an increase in support. The Payne model ating effect, but the results for either effect have been
proposes that different combinations of demand, sup- weak and inconclusive. Within intellectual disability
port, and constraint produce different psychological out- research, there has been some attention given to the
comes, more than one of which lead to the experience of types of support that may be associated with staff out-
stress. Jobs that are high in demands, low in support comes. Hatton et al. (1999a,b) collectively measured sup-
and high in constraints are those that are predicted to port from colleagues and immediate supervisors finding
be associated with the most stress. However, jobs low in that there was a small but direct relationship with work
demands, low in support, and high in constraint can stress and that there was also an indirect relationship
also lead to psychological stress. via wishful thinking coping with general distress. Con-
Rose (1993), Elliot & Rose (1997), and Rose et al. cerning supervisor support, Ito et al. (1999) found that
(1998b) have found some support for Payne’s demands– staff members who felt they could consult with supervi-
supports–constraints model. Rose (1993), from a series sors about personal or work problems, reported lower
of staff interviews, developed a measure of demands, levels of burnout than those who thought that they
supports, and constraints. When related to staff well- could not. In relation to colleague support, Ford & Hon-
being, it was found that a number of demands were nor (2000) found that immediate colleagues were the
found to be positively associated with staff stress and most significant source of support in the work place;
that where staff perceived lower constraints and higher providing an opportunity to talk about the frustrations
support, they reported less stress. Extending this work, of the job and share the workload in a social way. Dyer
Rose et al. (1998b) compared staff in low stress and high & Quine (1998) also identified that staff found other
stress community houses. Findings suggest that staff staff to be an important source of support. In their anal-
reporting higher levels of stress also experienced higher ysis, support was positively correlated with job satisfac-
levels of demand and constraint at work and lower lev- tion and negatively correlated with burnout. Consistent
els of support. Although the results do suggest support with theory, Dyer and Quine explored interaction effects
for aspects of Payne’s model, Rose et al. urge caution in of demand and support. They found evidence for a

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Journal of Applied Research in Intellectual Disabilities 565

main effect of support on burnout, but no interaction would seem to be warranted given that they also have
between demands and support. This suggested that the direct implications for job design.
effect of support was consistent in situations of high
and low demand. With a greater emphasis on the staff
Cognitive Behavioural Approach
team, Rose & Schewela-Davies (1997) and Rose et al.
(2006) have also found that the nature of the support Lazarus & Folkman’s (1984) contribution to understand-
that the team provides, particularly around participative ing stress is that the experience of stress is a cognitive
safety and the support it gives for new ideas is associ- process and an individual phenomenon. Within this
ated with reduced staff stress. cognitive-behavioural model, it is proposed that stress is
Rose (1995, 1999) has proposed a model that may neither inherent in the environment nor the person but
explain some aspects of staff stress specific to intellec- results from the relationship between them which is
tual disability contexts. Rose’s work draws heavily on called transaction. Therefore, nothing by itself is consid-
the demands-supports-constraints model (Payne 1979); ered a stressor. A stimulus, no matter what it is, only
particularly on the concept of support with the sugges- becomes a stressor if it is perceived as such (Lazarus
tion that support can act either as a buffer against stress 1995). This idea helps to explain how people can vary in
or a mediator of work stress. In Rose’s model, sources their stress response when exposed to similar situations
of support, demand, and constraint in intellectual dis- and even to similar situations but at different times.
ability services are clients, colleagues, immediate man- Influencing the development of stress are processes of
agers, the organization, external professionals, and the appraisal and coping. Lazarus (1995) described two
community. Rose proposes that the effect of demand kinds of appraisal. Primary appraisal is concerned with
and support factors is influenced by one’s relative posi- an initial evaluation of a situation, with the consider-
tion in the organization. For example, direct care staff ation of whether there is a threat. Secondary appraisal is
would be more affected by direct management within a concerned with making a judgement about whether the
community home rather than the external higher levels person can cope with the situation and what they can
of management within an organization (Rose 1999). Fol- do about it. Coping is defined as the ‘cognitive and
lowing Payne’s model, the constructs of demand, sup- behavioural efforts a person makes to manage demands
port and constraint are seen as operating in the same that tax or exceed his or her personal resources’
interactive manner. However, despite the potential face (Lazarus 1995; p. 6). Lazarus describes two main types
validity of the model, it has not been subject to rigorous of coping. Problem-focused coping is where information
empirical examination. is sought and used to change either the person’s behav-
In summary, results of empirical studies in intellectual iour or the environment to eliminate or reduce the psy-
disabilities suggest a relationship between support and chological threat. Emotion-focused coping involves
stress in staff, and most studies report main effects for seeking to manage the emotional distress. The latter can
support. Apart from Dyer & Quine (1998), little atten- involve avoidance, denial, or positive thinking. In this
tion has been given to the potential moderator effects of case, it is the interpretation of the situation rather than
support. Hence, there has been limited exploration of the situation itself that is changed. Lazarus (1995) pro-
models such as Karasek and Theorell’s and Payne’s. poses that stress occurs when the person’s appraisal is
That demands, support, and control are important vari- that the external or internal demands placed upon them
ables that does seem evident from the available exceed their resources to cope with these demands.
research. However, the critical issue is that researchers Folkman & Lazarus (1991) propose key roles for
have almost exclusively ignored an exploration of the appraisal and coping in the development of stress in
interaction between these variables. This is unfortunate, that they mediate the emotional response. Lazarus
as support work in intellectual disability services seems (1999) suggests that coping is not a moderator as it is
to lend itself to examination via these constructs. For not present as a personality variable before the stressful
example, work in intellectual disability services can be encounter. On the other hand, Harris (1995) has ques-
demanding and it can also, in some cases, be a role tioned whether coping is acting as a mediator, suggest-
where there are low demands. Staff also frequently ing that it may be a trait variable. If the latter is the
work in small teams and organizations that may deliver case, then coping may well have a moderating effect, as
various types of support, and the role of support worker coping becomes an antecedent condition that changes
is one where there is a mixture of control and lack of the causal relationship in the transaction process: coping
control. Further examination of these key constructs as a moderator affects the perception of the situation

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 14683148, 2009, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1468-3148.2009.00509.x by Cochrane Thailand, Wiley Online Library on [16/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
566 Journal of Applied Research in Intellectual Disabilities

rather than being a strategy that is selected based on coping strategies, and who were also exposed to low
appraisal. The question of whether coping acts as a levels of challenging behaviour, did not experience
mediator or moderator has implications for the concep- increased emotional exhaustion.
tualization of variables within the model and the analyt- In summary, the empirical literature in intellectual
ical strategies used for testing the cognitive-behavioural disability to date is supportive of an association
model. However, the important implication at this point between staff coping strategies and psychological out-
is that researchers should clearly explain the nature of comes, and there is some evidence of a moderating
the mechanisms they are proposing to test. effect of coping. This latter result is at odds with the
Several studies have explored the cognitive-behavio- Lazarus (1999) model and further research exploring
ural model in intellectual disability research. Gardner the moderating or mediating role of coping strategies
et al. (2005) compared a group of staff who received is required. However, the potential mediation role of
stress management focussed on changing appraisal, coping has not been formally tested in intellectual dis-
using techniques from cognitive-behavioural therapy, ability studies. In relation to the type of coping strat-
with a second group who received stress management egy adopted by staff, associations between coping and
focused on teaching behavioural coping techniques. work stress have been clearest for emotion-focused
Findings showed that both groups reported reduced coping such as wishful thinking or disengagement cop-
stress but those in the cognitive intervention group ing. There has been little systematic research exploring
showed stronger improvement. Using an intervention the role of primary appraisal, particularly how staff
design, this study suggests that primary appraisal may appraise situations and the relationship this appraisal
be subject to influence and that this may influence sub- process has with coping.
sequent staff well-being. However, no measure of pri-
mary appraisal was included in the research to
Emotional Overload
demonstrate that change in this variable was the mecha-
nism by which positive outcomes were achieved. Maslach (1982) described burnout as having three
As with the wider work stress literature (Cooper et al. dimensions: emotional exhaustion, depersonalization,
2001), within the intellectual disability field, the general and reduced personal accomplishment. Within Mas-
emphasis has been on secondary appraisal ⁄ coping lach’s conception of burnout, emotional exhaustion is
(Cottle et al. 1995; Hatton et al. 1995; Hatton et al. the stress component and it refers to being drained of
1999a,b; Mitchell & Hastings 2001; Hastings & Brown one’s emotional resources. Depersonalization is related
2002). Hatton et al. (1995, 1999a,b) found a positive rela- to interpersonal relations, and personal accomplishment
tionship between the use of wishful thinking coping and with self-evaluation (Maslach 1993; Schaufeli & Enzman
staff general stress and work stress but no association 1998). Burnout was originally thought to occur in
with problem focused coping. Mitchell & Hastings people-orientated professions such as the human ser-
(2001), in a study of staff working with people with vices, education, and health care. Subsequent extension
challenging behaviour, found that most staff reported of burnout research has identified that burnout can
using adaptive problem-focused coping strategies that occur across a range of work situations (Maslach 1999).
predicted feelings of personal accomplishment at work. Within human services, the interpersonal demands of
In the same study, disengagement coping, an emotion the helping relationship are seen as the source of stress
focused strategy, was a positive predictor of emotional and subsequent emotional exhaustion (Maslach 1999).
exhaustion burnout, and a negative predictor of per- Whilst these relationships can be rewarding (Hastings &
sonal accomplishment. Hastings & Brown (2002) in a Horne 2004), they can also be emotionally charged and
study of special education staff working with children psychologically demanding (Schaufeli & Enzman 1998).
with challenging behaviour, found that exposure to These interpersonal demands can be quantitative and
challenging behaviour was associated with emotional qualitative in nature. The former include heavy case-
exhaustion. However, the use of emotion-focused coping loads and long and continuous contact with demanding
strategies was found to moderate the impact of exposure clients. The latter include a lack of support and poor
to challenging behaviour on staff burnout. Those staff skills to handle these difficult relationships (Schaufeli &
exposed to high levels of challenging behaviour who Enzman 1998). In burnout research, job demands such
more frequently used emotion-focused coping strategies as workload and personal conflict and a lack of key
were more likely to experience higher levels of resources such as control, coping, social support, skill
emotional exhaustion. Staff who used emotion-focused use, autonomy, and involvement in decision-making

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 14683148, 2009, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1468-3148.2009.00509.x by Cochrane Thailand, Wiley Online Library on [16/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Journal of Applied Research in Intellectual Disabilities 567

have been implicated as antecedents of burnout tion that is most frequently reported as stressful has been
(Maslach 1999). challenging behaviour (Hastings 2002; Jenkins et al. 1997).
Maslach (1999) describes the process through which Research exploring the interactions between workers and
burnout may develop. Within human services, the inter- clients who present challenging behaviour has suggested
personal nature of the work is a major demand factor. that in these situations workers may experience negative
Where resources are not available to meet these emotional reactions (Bromley & Emerson 1995; Cottle
demands, workers may come to experience exhaustion et al. 1995; Jones & Hastings 2003; Hastings 2002; Mitchell
over time. Characteristic of burnout, leading from emo- & Hastings 2001; Mossman, Hastings & Brown 2002; Rose
tional exhaustion, is a change in the relationship of et al. 2004).
workers with their work. This change involves workers Within the intellectual disability field we know that
distancing themselves, both cognitively and emotionally, staff may experience stress, and we also know that there
from their work. In human services, this may manifest is empirical evidence of a link between working with
itself in the depersonalization of clients and the percep- people with challenging behaviour and staff negative
tion of them in negative and dehumanizing ways. A emotions. As challenging behaviour may be a key
temporal relationship from emotional exhaustion to demand characteristic, measuring staff negative emo-
depersonalization has been empirically supported in tional experiences may give an indication of the extent
burnout research (Maslach 1999). The relationship with of worker perceived interpersonal demands. Despite
personal accomplishment is not so clear. Maslach (1999) this, only a few studies have examined the link between
suggests that the dysfunctional coping strategy of deper- the interpersonal demands of the worker-client relation-
sonalization may further damage the relationship with ship and stress or burnout in a way that might be con-
clients, with the consequence that less successful interac- sidered consistent with Maslach’s conceptual
tions are experienced and personal accomplishment is framework. In one of the few studies to consider worker
reduced. Leiter (1993) has suggested that lack of per- emotional reactions, Mitchell & Hastings (2001) mea-
sonal accomplishment may develop in parallel with sured staff emotional reactions to challenging behaviour,
emotional exhaustion and depersonalization, rather than finding that staff experienced a range of negative emo-
sequentially. Emotional exhaustion and depersonaliza- tional reactions and that these were predictive of emo-
tion may be linked with interpersonal demands and tional exhaustion and depersonalization burnout.
workload, whilst lack of personal accomplishment may Similar results were found by Rose et al. (2004). How-
be associated with lack of resources (Leiter 1993). ever, these studies have not controlled for demands
Central to Maslach’s theory is the focus on the rela- relating to other dimensions of work, including organi-
tionship between the human service worker and the cli- zational characteristics, and so the unique interpersonal
ent as a source of stress. However, this is seen as more effects of challenging behaviour are not known (Skirrow
problematic where the demands of this work exceed & Hatton 2007).
resources. Maslach’s theory is also yet to be subjected to From a theoretical perspective, Hastings (2002) has
a rigorous examination within intellectual disability ser- proposed that staff negative emotional reactions from
vices, but some of the theoretical ideas have been inves- being exposed to challenging behaviour mediate the
tigated and the Maslach Burnout Inventory has been experience of staff stress ⁄ burnout. There has been lim-
used several times. That it has not been more of a focus ited research examining the relationship between these
for researchers is surprising given the emphasis on emotional reactions and stress ⁄ burnout but this is the
interpersonal relationships with clients within the the- closest reference to some of the original the ideas of
ory, and that in intellectual disability services the qual- Maslach. Various dimensions of Maslach’s concept of
ity of the service depends on that relationship. burnout in human services find resonance within
Some of the research that has taken place in the intellec- intellectual disability research. Whether Masalch’s
tual disability field has identified, as might be predicted, theory accounts for the development of burnout is not
that the worker-client relationship can be a source of known, as the full model has not been explicitly tested
stress. Dyer & Quine (1998) found that the client demand (Schaufeli & Enzman 1998). In intellectual disability, to
characteristics of client habits, difficulties in communicat- fully test Maslach’s model, clarity on the interpersonal
ing, the level of disability, working with people who self- demands in the worker-client relationship is necessary.
injure, and working with other challenging behaviour Whilst challenging behaviour is clearly an important
were positively correlated with burnout. The demand demand factor, and a useful way to explore the model,
characteristic associated with the client-worker interac- not all clients display challenging behaviour. Workers

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568 Journal of Applied Research in Intellectual Disabilities

will support clients without challenging behaviour and Further, in cases of extreme inequity, there is the strat-
may still experience emotional demands. Research to egy of actually leaving the relationship.
examine the nature of these other demands would be Buunk & Schaufeli (1993) have incorporated the con-
useful. Exploration of those resources that most signifi- cept of equity into understanding the development of
cantly impact on burnout would also be an important burnout in caregivers. They draw on two types of rela-
area for future research. Only then can understanding of tionship that can be seen as being vulnerable to inequity
the core conditions under which burnout develops be and the subsequent development of burnout: the rela-
extended. Also needed is research to test the causal tionship with clients and the relationship with the orga-
pathway from emotional exhaustion to depersonaliza- nization. Bunk and Schaufeli, influenced by the work of
tion as well as research on the role of personal accom- Maslach (1982), consider that one root cause of burnout
plishment. may be in the relationship between the caregiver and
the recipient. At its outset, the relationship may be
unbalanced because one party, the carer, is expected to
Equity Theory
deliver care and the other, the recipient, is expected to
Equity theory (Adams 1965), one of the most influential receive. Carers may, although the relationship may seem
social exchange theories, suggests that people evaluate imbalanced, expect some sort of reward for their efforts
their relationships and that there is a tendency when in such as gratitude or improvement in the recipient’s con-
a relationship with another to seek equity. According to dition. However, according to Buunk and Schaufeli this
equity theory, individuals will feel that a relationship is may not always happen and caregivers may perceive
equitable if they perceive that the ratio between their inequity and experience distress. When this occurs,
outcomes and inputs is similar to the ratio of outcomes there is a desire to restore equity to the relationship and
and inputs from the other party in the relationship. typically this may involve investing more in the rela-
Adams suggests that the concept of equity is applicable tionship with the recipient. This situation can be emo-
both to interpersonal relationships and to those between tionally exhausting and when the expected rewards are
the worker and the organization. Equity theory predicts not forthcoming then there may be a tendency to reduce
distress where there is an inequitable relationship and the input into the relationship and withdraw emotion-
suggests that this distress will be proportional to the ally. Bunk and Schaufeli consider this to be a way of
degree of perceived inequity. Feelings of inequity may restoring equity in the relationship. However, this may
emerge from the perception of benefitting too little from also be a dysfunctional strategy as there is a negative
a relationship where the ratio of one’s outcomes com- effect on the quality of the caring relationship and this
pared with one’s inputs is less than the ratio of out- may result in a diminished sense of personal accom-
comes and inputs for the other in the relationship. plishment (Schaufeli & Enzman 1998). Equity theory
Alternatively, an individual might perceive that they might also predict burnout in situations where carers
benefit too much from a relationship where the ratio of overbenefit from a relationship. This may be stressful in
their outcomes and inputs is greater than for the other caring relationships where the person engaging in the
in the relationship (Meill & Croghan 1996; Van Diere- caring sees it as a vocation, where they feel some
ndonck et al. 2001). responsibility for the recipient’s well-being and thus
An assumption within equity theory is that where might expect to have an equitable situation where they
there is the perception of inequity in the relationship give as much as they receive.
there is an attempt to resolve this and to reach a situa- Similar processes of equity have been used to explain
tion where there is the perception of equity (Adams the relationship that the person might have with the
1965). This can be done in a number of ways. For exam- organization. Schaufeli et al. (1996b) have suggested that
ple, there may be a case for altering one’s own contribu- where workers perceive a lack of equity in their rela-
tion to the relationship, or altering one’s outcomes from tionship with the organization they may experience dis-
the relationship. Alternatively, there may be the expecta- tress and that in these situations they may withdraw
tion of a change in the inputs and outcomes related to both cognitively and behaviourally from their work and
the other party in the relationship (Adams 1965; Meill & that this situation may contribute to the development of
Croghan 1996). Adams also proposes that individuals burnout. This situation also has the additional effect of
may cognitively distort their inputs and outputs to reducing the organization’s outputs as workers put less
restore equity although it is suggested that doing this is into their work and it will also impact in caring situa-
difficult when inequity is perceived as substantial. tions on those in receipt of the workers’ efforts.

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Journal of Applied Research in Intellectual Disabilities 569

In intellectual disability services, workers may be they also make different predictions about how stress
engaged in interpersonal relationships with clients, col- occurs in the workplace. From an analysis of the intel-
leagues, and other professionals; as well as relationships lectual disability research, there are also common
with the organization and the wider community. When themes emerging, and from this areas for development
equity theory has been applied to intellectual disability are apparent.
services there is evidence that where staff feel inequity, One of the common themes to emerge from stress the-
in either direction, in their relationships with clients ory, and the most obvious, is that jobs will exert some
there is an association with burnout (Van Yperen 1995; demands on the individual worker. Positive outcomes
Van Dierendonck et al. 1996). Van Dierendonck, Buunk, and negative outcomes such as stress and burnout seem
and Schaufeli found that staff were more likely to feel related to whether demands can be met or not. A sec-
that they benefit too little from their relationships with ond common theme is that resources are drawn upon or
clients in intellectual disability services. However, levels used to meet these demands. Further to this, all the
of burnout were also found to be higher where staff felt models, to varying degrees, propose some sort of inter-
that they benefitted too much from the relationship. A action and cognitive process. Although there are com-
longitudinal study of inequity confirmed a curvilinear monalities, the theories reviewed here describe different
relationship between the perception of inequity and processes through which stress develops. The person–
aspects of burnout (Van Dierendonck et al. 2001). In environment model sees stress as a result of the person
terms of the relationship between the staff and the orga- environment mismatch; the demand–control–support
nization, Van Yperen (1995) found that where staff per- model posits a major role for the concepts of control
ceived inequity with the staff ⁄ organization relationship and support at work in moderating the demands of the
there was an association with emotional exhaustion and job; the cognitive-behavioural model places emphasis on
reduced personal accomplishment. Van Dierendonck appraisal and coping skills; the emotional overload
et al. (1998) in an intervention study found that they model puts the focus on the client-worker relationship;
could influence staff perception of equity and that there and equity theory also focuses on the perception of the
was an associated reduction in staff burnout. However, relationships that the staff have with clients but also
this effect was limited to influencing the perception of with the organization.
the relationship with the organization and not the client The contribution of the current body of research has
which in this intervention seemed less amenable to been to raise awareness of staff stress and burnout
change. and its relevance for the quality of the services deliv-
In summary, although there is only a small amount of ered to support individuals with intellectual disabili-
research, there seems to be a fairly robust exploration of ties. Many of the key concepts from the five work
equity theory within intellectual disability research with stress theories discussed here have been applied to
attention paid to key relationships as proposed by the some degree in intellectual disability research. How-
model and both cross-sectional, longitudinal, and inter- ever, research findings offer limited support for predic-
vention data. The interesting aspect of equity theory, tions derived from each theory. Contributing to this
when applied to intellectual disability services, is that it state, the theoretical basis of research questions has
can be seen as helping to explain the individual’s rela- not always been made explicit and little attention has
tionship with clients, with colleagues, and the wider been given to the processes hypothesized within each
organization. In this sense, as a model, it can draw theoretical framework. The consequence of using theo-
aspects of intellectual disability research together whilst retical models as a heuristic for exploring staff stress
presenting a common process to explain burnout. Fur- rather than testing the underlying processes inherent
ther investigations using this model would seem to be in the models is that it is not clear whether models
warranted. give an adequate explanation of worker stress in intel-
lectual disability services. Because models have not
been fully applied and tested, intellectual disability
Conclusions
research also currently makes little contribution to the
The five theoretical approaches described in this paper wider literature on work stress.
represent those models most frequently applied in intel- A further point is that work stress theory is evolving,
lectual disability research and are also some of the major and intellectual disability research has generally failed
theoretical developments in work stress theory over the to keep abreast of these developments. Indeed, some of
past 50 years. The models have common themes, but the more recent theoretical developments in work stress

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 14683148, 2009, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1468-3148.2009.00509.x by Cochrane Thailand, Wiley Online Library on [16/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
570 Journal of Applied Research in Intellectual Disabilities

seem to have considerable face validity in intellectual From the macro perspective, one might focus on job
disability. One example is the Job demands–resources design, supervision and support from managers or col-
model of burnout (Dermouti et al. 2001). In this model, leagues, and other organizational features. We found
job demands are those aspects of the job (physical, only two staff stress intervention studies that have
social, or organizational) that require physical or mental reported data working from this perspective. Rose et al.
effort and are associated with psychological costs such (1998b) using Payne’s stress model attempted to help
as exhaustion. Resources are those physical, psychologi- workers reduce demands ⁄ constraints and improve sup-
cal, social, or organizational aspects that help do the job, ports. Innstrand et al. (2004), based on the work of
reduce demands, or stimulate personal growth and Chernis (1980), asked workers to identify sources of
development (Dermouti et al. 2001; Halbesleben & stress and then find possible solutions for reducing the
Buckley 2004). This model has been found to provide a stressor. Common to both studies is a problem-solving
fairly good explanation of burnout, with demands seen approach, the involvement of workers, and particularly
as predicting exhaustion and lack of resources as pre- in the Innstrand et al. study some increases in support
dicting depersonalization (Dermouti et al. 2001). Work coupled with organizational change.
in intellectual disability services is demanding and Following the more micro perspective, one might
resources are clearly needed to meet those demands. instead focus intervention on helping staff to develop
Research that explored these issues and applied this behavioural or cognitive coping strategies to deal with
model to understanding stress would be useful in help- the emotional demands of their work. Two studies were
ing understand staff stress and developing the resources found that operate at this level. Van Dierendonck et al.
that might help meet demands and reduce staff stress. (1998) (see earlier) were able to influence staff percep-
There has also been a tendency to explore stress in tions of the organization, and Gardner et al. (2005)
intellectual disability research with reference to negative focused on staff coping strategies. Data from interven-
events. However, Folkman & Moskowitz (2000) point tion studies are encouraging in that they attempt to
out that in caring situations, negative and positive emo- reduce staff stress in a practical way whilst adopting a
tions often co-exist and they advocate the broadening of theoretical orientation. However, published intervention
stress models to include positive affect. In intellectual studies are limited in number and the range of theoreti-
disability research there is evidence of staff positive per- cal perspectives explored and questions asked of theory
ceptions of people with intellectual disability (Hastings have been limited.
& Horne 2004), but there has yet to be an exploration of Also largely missing to date is an explicit attempt to
any function these perceptions might serve in relation to find the common ground between macro and micro
staff stress. A direction for future research in intellectual perspectives in intellectual disability research on staff
disability is to therefore consider the emerging trends in work stress. The exploration of equity theory is per-
work stress theory, possibly drawing on these more haps an exception in that it can integrate both perspec-
holistic models of stress. tives. However, despite some promising findings with
Developments within intellectual disability research to reference to equity it remains to be seen whether this
date might largely be characterized as approaching theory can account for the complexity of staff–client
stress in intellectual disability staff from one of two dif- and staff-organization relationships. A pragmatic solu-
ferent perspectives. First, some researchers have focused tion to guide research and especially practice at this
at a macro-level on the organizational aspects of job stage is perhaps a common perspective centered on
design: the demands staff face, the support they receive, the relationships between support staff and people
and the constraints they experience (e.g., Rose 1995, with intellectual disabilities. From a more macro per-
1999). Second, other researchers have focused at a more spective and concern with the quality of services, it is
micro-level where clients are viewed as the primary important that staff–client interactions are positive and
stressor and the emotional reactions staff experience are promote social inclusion, independence, and other
perceived as a key factor in the development of work dimensions of client quality of life. From a more micro
stress and burnout (e.g., Hastings 2002; Mossman et al. perspective, staff–client interactions and relationships
2002). Although in practice the macro-micro distinction are also crucial – being seen as a potential source of
is not clear-cut in research, the main reason for making work stress. Intervention approaches that seek to maxi-
this distinction is that each would lead logically to quite mize positive or high quality dimensions of staff–client
different foci for support interventions designed to relationships would be worth exploring in future
reduce work stress. research. Such interventions might include organiza-

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Journal of Applied Research in Intellectual Disabilities 571

tional aspects, support for staff, but also techniques to Cottle M., Kuipers L., Murphy G. & Oakes P. (1995) Expressed
equip staff with psychological resilience that enables emotion, attributions and coping in staff who have been vic-
them to maintain positive relationships in the face of tims of violent incidents. Mental Handicap Research 8, 168–183.
challenging circumstances. More basic research is also Dermouti E., Bakker A. B., Nachreiner F. & Schaufeli W. B.
(2001) The job demands resources model of burnout. Journal
needed to understand the nature of and determining
of Applied Psychology 86, 499–512.
factors for staff–client relationships. Within this interac-
Dyer S. & Quine L. (1998) Predictors of job satisfaction and
tion, work stress theories suggest, we may more fully burnout among the direct-care staff of a community learning
understand work stress in intellectual disability ser- disability service. Journal of Applied Research in Intellectual Dis-
vices and also how to ameliorate some of the negative abilities 11, 320–332.
effects that can result. Edwards J. R., Caplan R. D. & Van Harrison R. (1999) Person–
environment theory. In: Theories of Organisational Stress
(ed C. L. Cooper), pp. 28–67. Oxford University Press, Oxford.
Correspondence Elliot J. L. & Rose J. (1997) An investigation of stress experi-
Any correspondence should be directed to Jason enced by managers of community homes for people with
Devereux, School of Psychology, Bangor University, intellectual disabilities. Journal of Applied Research in Intellec-
tual Disabilities 10, 48–53.
Bangor, Gwynedd, Wales, LL57 2DG, UK (e-mail:
Folkman S. & Lazarus R. S. (1991) Coping and emotion. In:
j.m.devereux@btinternet.com).
Stress and Coping, 3rd edn. (eds A. Monat & R. S. Lazarus),
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