Occupational stress, anxiety and coping strategies in police officers

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1 Occupational Medicine 2015;65: Advance Access publication 4 June 2015 doi: /occmed/kqv060 Occupational stress, anxiety and coping strategies in police officers D. Acquadro Maran 1, A. Varetto 2, M. Zedda 1 and V. Ieraci 2 1 Department of Psychology, Università di Torino, Via Verdi 10, Torino, Italy, 2 Città della Salute e della Scienza, Torino, Torino, Italy. Correspondence to: D. Acquadro Maran, Department of Psychology, Università di Torino, Via Verdi 10, Torino, Italy. Tel: ; daniela.acquadro@unito.it Background Studies on occupational stress have shown that police officers are exposed to stressful events more often than other workers and this can result in impaired psychosocial well-being and physical health. Aims Methods To measure the level of stress experienced, the consequences in terms of anxiety and the coping strategies adopted in a sample of police officers working in a large city in northern Italy. We used the Police Stress Questionnaire and the Distress Thermometer to measure occupational stress, the State-Trait Anxiety Inventory to measure anxiety and the Brief COPE questionnaire to measure coping strategies. Results Six hundred seventeen police officers completed the questionnaire, a response rate of 34%. Differences between genders, sectors and roles emerged, but overall the study population generally demonstrated good use of positive coping strategies. Women in all operational service roles were more vulnerable to both organizational and operational stressors than men (P < 0.001), while in the interior department, men were more vulnerable to organizational stressors (P < 0.05). Conclusions Our results suggest that for Italian police officers, training courses and support in dealing with occupational stress should take into account gender, role and type of work. Tailored training courses and support programmes could be useful and effective tools for preventing stress before it becomes chronic. Key words Introduction Occupational stress; police; stressors. Studies on occupational stress have shown that police officers are exposed to acute and chronic stressful events at work, which can result in impaired psychosocial wellbeing and physical health [1,2]. Perceptions of stress have been investigated in relation to gender, role and sector of intervention. Researchers have found female police officers to be exposed to more stressors, which may in part be explained by their attempts to gain acceptance and win the esteem of colleagues and superiors within what has historically been a male-dominated profession. Berg et al. [3] found that policewomen reported higher stress levels than their male colleagues, although the latter reported greater exposure to serious incidents. Previous studies investigating the relationship between stress and role have often produced discordant findings. Workers with more years of service reported lower stress levels than colleagues with less experience [4], apparently due to their having acquired more efficient coping strategies and greater ability to cope with traumatic events (resilience) over time. Some authors have suggested that the experience of emotional trauma is reduced by the possibility of achieving a better position within the organization. Other research has shown that belonging to a particular occupational sector can affect perceptions of distress [5,6]. Abdollahi [7] reported that police officers required to deal with cases of violence and those patrolling the streets were more vulnerable to stress than officers in other sectors, such as those involved in training new recruits. Identifying mechanisms that make individuals less vulnerable to stressors is obviously important. Active and instrumental coping strategies (e.g. gaining social support) have been associated with good adaptation to traumatic stress, while more passive or avoidant strategies The Author Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please journals.permissions@oup.com

2 D. Acquadro Maran ET AL.: STRESS, ANXIETY AND COPING STRATEGIES IN POLICE OFFICERS 467 (e.g. excessive alcohol intake) are often considered as maladaptive, negative coping strategies. In general, strategies involving disengagement increase the likelihood of experiencing ongoing distress and of developing posttraumatic stress disorder [8]. The aim of this research was to investigate the stressors perceived by a sample of police officers working in a large city in northern Italy and to consider the effects of gender, organizational role and sector of operation on the perception of stress. Methods The police force studied operates 7 days a week, 24 h a day and the number of workers varies according to requirements (e.g. increased numbers during rush hour). Their goals are timely intervention in emergencies and specialist interventions such as traffic patrols. We measured the level of stress experienced by the target population, the consequences in terms of anxiety and the coping strategies adopted, using a questionnaire. The first page of the questionnaire included the presentation of the study and the privacy statement. We used the Police Stress Questionnaire and the Distress Thermometer to measure occupational stress, the State-Trait Anxiety Inventory (STAI Y-1 and STAI Y-2) to measure anxiety and the Brief COPE questionnaire to measure coping strategies. The last page asked for socio-demographic data. The Police Stress Questionnaire consists of two scales (each of 20 items) designed to assess operational (PSQ-Op) and organizational (PSQ-Org) stress [9]. The PSQ-Op measures stressors concerning, for instance, fatigue and health problems as a consequence of the job. The PSQ-Org measures stressors such as difficulties associated with red tape, lack of resources and staff shortages. The Distress Thermometer is a single-item measure that assesses subjective stress on a visual analogue scale [10]. The scale ranges from 0 (not distressed) to 10 (extremely distressed) and asks people to rate their level of distress during the previous week. As reported by Mitchell [11], most studies use a cut-off score of 4 5 to indicate distress. The STAI Y-1 and Y-2 scales rate state anxiety (a temporary interruption in the emotional continuum, characterized by a subjective feeling of tension and associated with the arousal of the autonomic nervous system) and trait anxiety (which denotes relatively stable individual differences in anxiety proneness) [12]. Each of the two scales comprises 20 items. Total scores can range from 20 to 80, with 40 being the threshold value predictive of anxiety symptoms. A rating scale defines the level of severity: from 40 to 50 mild, 51 to 60 moderate and over 60 severe. The Brief COPE questionnaire is a 28-item measure of coping responses under stressful conditions [13,14]. It evaluates the subtlest differences in coping and the person s ability to balance general coping strategies (How would you react if?) with those used in response to the current stressful situation (How did you react to specific stress situations?). Scores range from 1 (I would not normally do this) to 4 (I would usually do this). The 28 items measure 14 coping strategies (Table 1) [15]. After completing the questionnaire, the participants were asked to provide some personal information (gender and age) and job details (role and sector of employment). The questionnaires were self-administered. After obtaining the permission of the chief of police, an internal memo was sent to all executives informing them of the study. On the dates agreed with the officers-in-charge and heads of department, all police officers were informed of the aims of the study and received their copies of the questionnaires. Additional copies were left for officers who were absent or not on duty that day. Participants were asked to complete the questionnaires and then place them in boxes that had been left at the various places of work, specially designed to guarantee privacy and anonymity. The questionnaires were collected eight working days later. To increase the number of participants, on the deadline date, a new box was left with a new deadline after a further seven working days. Statistical analyses were performed using the statistical software SPSS, version 18. Descriptive measures (means ± SD) were calculated for all test variables for all groups of participants. For each sector of employment, we identified subgroups in order to compare role and gender. Chi-square tests were used to measure the differences between groups. Differences were considered statistically significant if P < Correlations were calculated to examine the relationship between organizational and operational stressors, perceived stress, anxiety scores and coping strategies for each group of participants. Multiple linear regression analysis was performed with the subject s perception of distress as the dependent variable with gender, role, sector and coping strategies as explanatory variables. Ethical clearance for the study was obtained from the ethics committee of this police force before the study began. The committee was composed of two unit managers (one with a degree in law and the other a clinical psychologist) and one supervisor (head of general affairs). Results Six hundred seventeen out of 1840 police officers completed the questionnaire, a response rate of 34%. The sample consisted of patrol police officers directly responsible for their actions who undertake a range of tasks depending on the needs of the community (61%), non-commissioned officers supporting the work of officers (26%), officers

3 468 OCCUPATIONAL MEDICINE Table 1. Psychometric properties of the study scales Measure M SD SE 95% CI P α LL UL PSQ-Op NS 0.92 PSQ-Org NS 0.94 Distress Thermometer < STAI Y < STAI Y < Brief COPE 0.78 Self-distraction <0.001 Active coping <0.01 Denial NS Substance use <0.001 Emotional support NS Instrumental support NS Behavioural disengagement NS Venting NS Positive reframing NS Planning <0.05 Humour <0.05 Acceptance NS Religion NS Self-blame NS M = mean; SD = standard deviation; SE = standard error; CI = confidence interval; LL = lower limit; UL = upper limit; NS = not statistically significant; α = Cronbach s alpha. responsible for a service (9%), unit managers responsible for implementing and monitoring outcomes within a unit (2%) and executives or heads of department (n = 4; <1%) [16]. The sectors were classified according to the type of work. The operational service (OS) comprises front line police officers, responsible for enforcing the law, who intervene directly in cases of assault, investigate crimes and ensure public safety. The interior department (ID) contains those with organizational roles or responsible for personnel management. The internal consistency and psychometric characteristics of each scale used in the study are presented in Table 1. Our sample s overall PSQ-Op scores corresponded to a non-excessive range of stress, while the PSQ-Org revealed higher scores for stress levels (Table 1; χ 2 = 46.4, P < 0.001). Participants answers ranged from 1 to 5 on both scales. The comparison of subgroups (grouped by gender and role in each sector) enabled us to observe any differences in levels and type of stress. Generally, mean scores for organizational stressors were higher than those for operational stressors. The PSQ-Op and PSQ- Org findings revealed that women in all OS roles were more vulnerable to both organizational and operational stressors (χ 2 = 33.3, P < 0.001). In terms of role, male and female patrol officers were found to be most exposed to operational stressors (χ 2 = 31.2, P < 0.05). officers in general and male patrol police officers were most susceptible to organizational stressors (respectively χ 2 = 29.5, P < 0.05 and χ 2 = 23.2, P < 0.05). Within the ID sector, mean scores revealed that the highest levels of operational stressors were reported by male and female executives. s were more vulnerable to this type of stressor, with the exception of unit managers. In this sector, males were more vulnerable to organizational stressors (χ 2 = 22.4, P < 0.05). Distress Thermometer results (Supplementary Tables 1 and 2, available as Supplementary data at Occupational Medicine Online) indicated that in the OS sector, female unit managers, non-commissioned officers and patrol police officers exceeded the cut-off score. In the ID sector, male non-commissioned officers and female patrol police officers also exceeded the cut-off level. The overall mean state and trait anxiety reached the cut-off level for moderate anxiety (Supplementary Table 1, available as Supplementary data at Occupational Medicine Online). Patrol police officers reported higher levels of trait anxiety (χ 2 = 39.1, P < 0.05). police patrol officers in the OS sector had the highest scores of all groups for trait anxiety (χ 2 = 26.3, P < 0.05). In the ID sector (Supplementary Table 2, available as Supplementary data at Occupational Medicine Online), female officers achieved the highest scores on STAI-Y1 (χ 2 = 28.2, P < 0.05), while female non-commissioned officers achieved the highest scores on STAI-Y2 (χ 2 = 27.6, P < 0.05).

4 D. Acquadro Maran ET AL.: STRESS, ANXIETY AND COPING STRATEGIES IN POLICE OFFICERS 469 Analysis of mean scores showed that active coping, planning and acceptance strategies were those used the most across genders, roles and sectors (Tables 2 and 3). In the OS sector, patrol police officers and unit managers used more venting (respectively χ 2 = 20.9, P < 0.05 and χ 2 = 19.6, P < 0.05) and emotional support (respectively χ 2 = 14.1, P < 0.05 and χ 2 = 22.1, P < 0.001) as coping strategies than their colleagues in the same sector. Maladaptive strategies, such as self-blame, were used in the OS sector by unit managers (χ 2 = 4.1, P < 0.05), whilst patrol police officers in the ID used self-distraction (χ 2 = 15.9, P < 0.05). Correlations for each group of participants were calculated to examine the relationship between PSQ-Op, PSQ-Org, the Distress Thermometer, STAI Y-1 and Y-2 scores (Tables 4 and 5) and coping strategies. In the OS sector, male officers Distress Thermometer scores were significantly related to self-blame, r = 0.72, P < 0.001, and negation coping strategies, r = 0.78, Table 2. Coping strategies adopted operational service Unit managers Officers Non-commissioned officers (n = 6), (n = 3), (n = 25), (n = 6), (n = 63), (n = 39), Patrol police officers (n = 143), (n = 123), Self-distraction 1.9 (0.8) 2.3 (1.0) 1.6 (0.7) 1.9 (1.1) 1.9 (0.85) 2.2 (0.9) 1.9 (0.9) 2.0 (0.7) Active coping 3.9 (0.2) 3.7 (0.3) 2.9 (1.0) 3.6 (0.5) 3.2 (0.89) 3.3 (0.8) 3.2 (0.7) 3.4 (0.7) Denial 1.2 (0.4) 1.5 (0.5) 1.3 (0.6) 1.1 (0.2) 1.6 (0.65) 1.3 (0.5) 1.3 (0.5) 1.4 (0.6) Substance use 1.0 (0.0) 1.0 (0.0) 1.0 (0.0) 1.0 (0.0) 1.0 (0.19) 1.0 (0.0) 1.1 (0.3) 1.0 (0.1) Emotional support 2.0 (0.9) 2.0 (0.5) 1.7 (0.7) 2.0 (0.6) 1.7 (0.71) 2.1 (0.7) 1.9 (0.7) 2.2 (0.8) Instrumental support 2.3 (0.6) 2.0 (0.9) 2.2 (0.7) 2.0 (1.0) 2.3 (0.91) 2.4 (0.8) 2.4 (0.8) 2.5 (0.8) Behavioural disengagement 1.3 (0.6) 1.2 (0.3) 1.3 (0.5) 1.4 (0.6) 1.4 (0.57) 1.4 (0.6) 1.3 (0.5) 1.5 (0.7) Venting 2.7 (0.8) 2.8 (0.6) 2.3 (0.8) 2.6 (0.5) 2.4 (0.7) 2.6 (0.7) 2.2 (0.7) 2.6 (0.7) Positive reframing 2.8 (0.4) 3.0 (1.3) 2.7 (0.8) 3.2 (0.9) 2.8 (0.9) 2.9 (0.8) 2.7 (0.8) 2.8 (0.8) Planning 3.9 (0.7) 4.0 (0.0) 3.5 (0.8) 3.9 (0.2) 3.3 (0.8) 3.4 (0.7) 3.3 (0.7) 3.4 (0.7) Humour 2.6 (0.9) 2.3 (0.8) 2.2 (1.0) 2.3 (1.3) 2.2 (0.9) 2.1 (0.9) 2.2 (0.8) 2.2 (0.8) Acceptance 3.5 (0.5) 3.7 (0.3) 3.0 (0.8) 3.7 (0.4) 3.0 (0.8) 3.7 (0.6) 3.0 (0.8) 3.0 (0.7) Religion 1.9 (1.2) 1.7 (1.1) 1.7 (1.0) 1.5 (1.2) 1.2 (1.0) 2.4 (1.0) 1.7 (0.9) 1.9 (1.0) Self-blame 3.1 (0.5) 3.5 (0.5) 2.7 (0.7) 2.7 (0.7) 2.8 (0.7) 2.7 (0.7) 2.7 (0.7) 2.9 (0.7) M = mean; SD = standard deviation. Table 3. Coping strategies adopted interior division Executives Unit managers Officers Non-commissioned officers (n = 3), (n = 1), (n = 5), (n = 1), (n = 21), (n = 6), (n = 45), (n = 19), Patrol police officers (n = 48), (n = 64), Self-distraction 1.9 (0.6) 1.0 ( ) 2.7 (0.9) 1.0 ( ) 1.3 (0.5) 1.8 (0.9) 2.0 (0.7) 2.7 (0.9) 1.9 (0.9) 2.1 (0.9) Active coping 2.9 (1.3) 4.0 ( ) 3.7 (0.3) 4.0 ( ) 3.0 (0.9) 3.1 (0.9) 3.1 (0.9) 3.3 (0.9) 3.3 (0.7) 3.2 (0.7) Denial 1.4 (0.7) 1.0 ( ) 1.4 (0.2) 1.0 ( ) 1.3 (0.6) 1.2 (0.3) 1.5 (0.7) 1.2 (0.5) 1.4 (0.6) 1.4 (0.6) Substance use 1.3 (0.6) 1.0 ( ) 1.0 (0.0) 1.0 ( ) 1.0 (0.1) 1.0 (0.0) 1.1 (0.4) 1.0 (0.0) 1.0 (0.1) 1.0 (0.2) Emotional support 1.4 (0.5) 2.0 ( ) 2.0 (0.6) 2.5 ( ) 1.7 (0.8) 1.7 (0.9) 1.8 (0.7) 2.2 (0.8) 2.1 (0.9) 2.1 (0.7) Instrumental support 2.2 (0.3) 2.0 ( ) 2.2 (0.9) 1.6 ( ) 2.0 (0.9) 1.8 (0.7) 2.4 (0.7) 2.6 (0.7) 2.4 (0.8) 2.3 (0.8) Behavioural disengagement 1.4 (0.7) 1.0 ( ) 1.0 (0.0) 1.0 ( ) 1.7 (0.9) 1.3 (0.4) 1.5 (0.7) 1.3 (0.4) 1.3 (0.6) 1.5 (0.6) Venting 1.8 (0.3) 2.5 ( ) 1.9 (0.5) 2.5 ( ) 2.0 (0.6) 2.2 (0.7) 2.2 (0.7) 2.4 (0.7) 2.2 (0.7) 2.3 (0.8) Positive reframing 3.5 (0.6) 3.1 ( ) 2.7 (0.3) 2.5 ( ) 2.4 (0.7) 2.7 (1.1) 2.8 (1.0) 2.9 (0.9) 2.6 (0.8) 2.7 (0.8) Planning 3.1 (1.1) 4.0 ( ) 3.2 (0.6) 4.0 ( ) 2.9 (0.8) 3.6 (0.7) 3.4 (0.7) 3.4 (0.9) 3.3 (0.7) 3.1 (0.7) Humour 1.9 (0.2) 2.0 ( ) 2.1 (1.3) 2.0 ( ) 2.2 (0.8) 2.7 (0.5) 2.2 (0.8) 1.9 (0.6) 2.3 (0.7) 2.2 (0.8) Acceptance 3.0 (0.7) 3.0 ( ) 2.7 (0.5) 4.0 ( ) 2.8 (0.7) 3.8 (0.3) 3.2 (0.7) 3.2 (0.8) 3.1 (0.8) 3.1 (0.7) Religion 2.0 (1.4) 1.5 ( ) 1.7 (1.0) 3.0 ( ) 1.7 (0.9) 1.5 (0.8) 2.2 (1.0) 2.0 (0.9) 1.8 (1.0) 1.9 (0.9) Self-blame 2.1 (0.7) 3.0 ( ) 2.6 (0.5) 4.0 ( ) 2.6 (0.7) 2.6 (0.9) 2.8 (0.6) 2.3 (0.8) 2.9 (0.8) 2.8 (0.7) M = mean; SD = standard deviation.

5 470 OCCUPATIONAL MEDICINE Table 4. Summary of correlations for scores in PSQ-Op, PSQ-Org, distress thermometer, STAI Y-1, and Y-2 operational service Measure Unit managers male 2. PSQ-Org 0.95* 3. Thermometer STAI Y STAI Y * Unit managers female 2. PSQ-Org Thermometer STAI Y STAI Y Officers male 2. PSQ-Org Thermometer STAI Y STAI Y * Officers female 2. PSQ-Org Thermometer STAI Y STAI Y Non-commissioned officers male 2. PSQ-Org Thermometer STAI Y STAI Y Non-commissioned officers female 2. PSQ-Org 0.71* 3. Thermometer STAI Y STAI Y * 0.76* Patrol police officers male 2. PSQ-Org 0.73* 3. Thermometer STAI Y STAI Y Patrol police officers female 2. PSQ-Org 0.78* 3. Thermometer STAIY STAIY * P < P < In the ID sector, male executives PSQ- Org scores were significantly correlated with religion coping strategy, r = 0.99, P < For male officers in the ID sector, their planning coping was correlated with active coping, r = 0.74, P < In addition, for female non-commissioned officers in the ID sector, a significant correlation was found between active coping and venting (r = 0.80, P < 0.001) and between active coping and planning (r = 0.76, P < 0.001) coping strategies. Multiple linear regression analysis showed that perceived distress was correlated with self-distraction

6 D. Acquadro Maran ET AL.: STRESS, ANXIETY AND COPING STRATEGIES IN POLICE OFFICERS 471 Table 5. Summary of correlations for scores in PSQ-Op, PSQ-Org, distress thermometer, STAI Y-1 and Y-2 interior department Measure Executives male 2. PSQ-Org 0.99* 3. Thermometer STAI Y STAI Y Unit managers male 2. PSQ-Org Thermometer STAI Y STAI Y Officers male 2. PSQ-Org 0.86* 3. Thermometer STAI Y STAI Y Officers female 2. PSQ-Org Thermometer STAI Y STAI Y Non-commissioned officers male 2. PSQ-Org 0.79* 3. Thermometer STAI Y STAI Y Non-commissioned officers female 2. PSQ-Org 0.78* 3. Thermometer STAI Y STAI Y Patrol police officers male 2. PSQ-Org 0.77* 3. Thermometer STAI Y STAI Y Patrol police officers female 2. PSQ-Org 0.71* 3. Thermometer STAI Y STAI Y *P < (P < 0.01), negation (P < 0.05) and self-blame (P < 0.05) and negatively associated with humour (P < 0.01) and planning (P < 0.05) coping strategies (R 2 = 0.14, F = 4.84, P < 0.001). The analysis found no correlations with the independent variables gender, role and sector. Discussion In the OS, our findings showed that general levels of distress were higher among female officers, non-commissioned officers and patrol police officers than among their male colleagues in the same roles. s in all roles

7 472 OCCUPATIONAL MEDICINE exhibited higher levels of organizational stress and distress than males. These results are particularly interesting because they differ from those reported in previous studies involving policewomen. Bowler et al. [17] found that female police officers in low-ranking roles who are faced with violent situations and exposed to human suffering were the most vulnerable category and at the highest risk of distress, whereas in this investigation, the stressors were of a more organizational than operational nature and distress was linked to the actual job performed within the organization. A difference between genders emerged with respect to the strategies used. As shown by data resulting from correlations, male officers showed traits of anxiety that influenced the way they perceived the difficulties associated with their role and their professional context. They reacted to an increase in stressors by adopting coping strategies such as self-blame and negation: on the one hand, they blamed themselves for their unease (for instance, attributing this to their inability to deal efficiently with the situation) and on the other, they tried to diminish the sense of responsibility by denying that the problem existed. This may be due to the fact that male officers with more years of service become disillusioned and are thus at greater risk of suffering from chronic distress [18]. operational unit managers exhibited operational stress when faced with situations characterized by high levels of organizational stress, and problems associated with organizational aspects led to high levels of unease in performing their functions. This was particularly evident in individuals prone to trait anxiety. More in-depth research is needed to investigate the use of maladaptive strategies among this population: for instance alcohol may be consumed to reduce anxiety without associating its misuse with negative consequences [19]. In the ID, male executives exhibited operational and organizational distress, using religion as a coping strategy. officers exhibited organizational and operational distress and implemented adaptive planning strategies. non-commissioned officers exhibited the same operational and organizational distress but used an active venting coping strategy; they also used the self-distraction strategy more than male officers in the same sector. non-commissioned officers and male and female patrol police officers exhibited both organizational and operational distress. We consider these findings interesting in that they differ from those of previous research in which organizational stress emerged as the principal reason for distress [20]. The investigation of variables such as gender, role and sector of work enabled us to better understand the sources of distress in this population. In multiple regression analysis, a negative association with coping strategies humour and planning was noted for the variable distress level: the use of good strategies is traditionally associated with a reduced risk of general psychological distress [21], which can therefore be regarded as a protective factor against anxiety and organizational distress. This study has some limitations to be considered. First, the low response rate and lack of information about non-respondents will inevitably limit our conclusions by preventing any further analysis of responder bias. Non-response may possibly have been associated with increased negativity about distress issues [22] or with denial of the problem. Moreover, the overall statetrait anxiety levels that emerged in this study are indicative of unease and can potentially give rise to a variety of psychological problems and hinder the adoption of useful coping strategies. However, depressive symptoms and post-traumatic stress disorder (PTSD), which according to the literature are associated with this population, were not investigated in depth in this study. A second limit is the absence of any comparison with another population engaged in the same type of work, but operating in another context. This research may provide the means to help police organizations find ways to limit stressors and their consequences. In particular, a greater understanding of police stress may provide opportunities to develop better training courses to improve stress management skills. These courses may increase officers abilities to cope with psychologically arduous situations (e.g. self-efficacy enhancement programmes) and the severe psychological distress that can often undermine social functioning (e.g. trauma-focused cognitive behavioural therapy). The results from this study suggest that training courses and support for Italian police officers must necessarily take into account not only the stressors that characterize police work but also the gender, role and type of work in which the officer is involved. Tailored training courses and support programmes could be useful and effective tools for preventing stress before it becomes chronic. Key points In this study, female and male police officers suffered from distress caused by different stressors. The consequences and coping strategies adopted differed according to gender, role and sector of operation. police officers in all roles exhibited higher levels of organizational stress and distress than their male counterparts. Tailored training courses and support programmes could be useful and effective tools for preventing stress before it becomes chronic. Conflicts of interest None declared.

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