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Administration in Social Work
ISSN: 0364-3107 (Print) 1544-4376 (Online) Journal homepage: http://www.tandfonline.com/loi/wasw20
How Social Workers Cope with Managed Care
Gila M. Acker
To cite this article: Gila M. Acker (2010) How Social Workers Cope with Managed Care,
Administration in Social Work, 34:5, 405-422
To link to this article: http://dx.doi.org/10.1080/03643107.2010.518125
Published online: 09 Nov 2010.
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Date: 20 October 2017, At: 19:42
Administration in Social Work, 34:405–422, 2010
Copyright © Taylor & Francis Group, LLC
ISSN: 0364-3107 print/1544-4376 online
DOI: 10.1080/03643107.2010.518125
How Social Workers Cope
with Managed Care
GILA M. ACKER
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Department of Social Sciences, York College of The City University of New York,
Jamaica, New York, USA
The study reported in this paper examined the relationships
between social workers’ experiences when interfacing with managed care organizations, coping strategies, burnout, and somatic
symptoms associated with stress. A sample of 591 social workers completed questionnaires that included demographic questions
and measures of perceived competence in the context of managed care, coping strategies, burnout, and somatic symptoms.
Multiple regression analyses revealed that coping had statistically
significant correlations with several burnout dimensions and with
workers’ perceived competence in the context of managed care.
As coping provided the most comprehensive influence on workers’
psychological and somatic reactions associated with burnout, the
author suggests that agencies provide social workers with adequate
training to promote workers’ use of effective coping styles that are
appropriate when interfacing with managed care organizations.
KEYWORDS managed care, emotional exhaustion, depersonalization, personal accomplishment, somatic symptoms, perceived
competence in the context of managed care, coping strategies
INTRODUCTION
Social workers, along with other human service workers, have shown to be
vulnerable to work stresses characteristic of those occupations that involve
ongoing contacts with people. External and internal pressures including role conflict, overload, economic problems of the health and mental
health systems, and increased accountability to managed care organizations,
Address correspondence to Gila M. Acker, Department of Social Sciences, York College
of The City University of New York, Jamaica, NY 11451, USA. E-mail: acker@york.cuny.edu
405
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406
G. M. Acker
have created new pressures for service providers, including social workers (Cohen, 2003; Daniels, 2001; Hall & Keefe, 2000; Keefe & Hall, 1998).
Job stress is thought to be largely a function of conflicts within the work environment, such as when workers feel that they cannot master organizational
and work demands, and that their job activities are inappropriate and incongruent with their training and expertise (Acker, 2004; Al-Garni, 2003; Arches,
1997; Cohen, 2003; Hall & Keefe, 2000; Lambert, Pasupuleti, Cluse-Tolar,
Jennings & Baker, 2006; Lloyd, King & Chenoweth, 2002). Prolonged stress
is associated with chronic anxiety, psychosomatic illness, emotional fatigue,
frustration, irritability, and a variety of other emotional problems (Lloyd, King
& Chenoweth, 2002). Burnout is a syndrome composed of three dimensions
including emotional exhaustion, depersonalization, and reduced personal
accomplishment (Maslach, Jackson & Leiter, 1996). Burnout has serious
implications for both the worker and the organization including poor job
performance, absenteeism, psychosomatic illnesses, and turnover (MontesBerges & Augusto, 2007; Thoresen, Kaplan, Barsky, Warren & Chermont,
2003).
Addressing burnout can increase employees’ efficiency and effectiveness in today’s increasingly cost-prohibitive world of care. Although the
empirical literature has emphasized that the ways that workers cope with
job stressors may be more important than the amount of stress itself (Gellis,
2002; Latack, 1992), insufficient attention has been paid to how social workers cope with the new culture of mental health care (Cohen, 2003; Feldman,
2001; Gellis, 2002; Hall & Keefe, 2000). In this study, the negative outcomes of job stress, including the psychological and the psychosomatic
disturbances of social workers, were explored in relation to workers’ coping
strategies.
BURNOUT
Burnout is defined as a negative psychological experience that is a reaction of workers to job-related stress such as challenging organizational
demands, lack of autonomy, unsupportive work environment, and large
caseload size (Acker, 2003, 2004; Arches, 1997; Gellis, 2002; Maslach,
Jackson & Leiter, 1996; Pines, 1983; Rosenbaum, 1992). Burnout refers
to a cluster of physical and emotional symptoms, including emotional
exhaustion, a lacking sense of personal accomplishment, and depersonalization of clients. Burnout symptoms can also include common colds,
flu-like symptoms, gastroenteritis, headaches, fatigue, poor self-esteem, difficulty in interpersonal relationships, and substance abuse (Maslach, 1982;
Maslach, Jackson & Leiter, 1996; Mohren, Swaen, Kant, Van Schayck &
Galama, 2005). It is critical to recognize that social workers confronted
by the complex needs of clients and the organizational demands of cost
How Social Workers Cope with Managed Care
407
containment are at risk to experience the negative symptoms associated
with burnout.
Job resources like supervision and other supportive mechanisms
directed toward workers have been diminishing with the lack of funding
associated with social services (Acker, 2003, 2004; Adams, 2001; Pumariega,
Winters, & Huffine, 2003). Lack of social support is known to be another
stressor associated with burnout, as workers who feel professionally unsupported are more likely to develop negative attitudes toward their job (Acker,
2003; Pines, 1983; Um & Harrison, 1998; Winnbust, 1993).
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MANAGED CARE
During the past two decades, managed care has become the new approach
and organizing theme for the delivery of mental health care services in
the United States. It strives to provide efficient quality care at a lower cost
than that offered in the fee-for-service professional community. The emergence of managed care has created a new source of stress for social
workers and other helping professionals. Managed care’s cost containment
approach, which includes limited access to necessary services, strict practice
guidelines, reduced autonomy, and increased accountability, has created
new challenges for social workers, who used to enjoy much more professional freedom and opportunities for decision making (Cohen, 2003; Egan
& Kadushin, 2007; Feldman, 2001; Keefe & Hall, 1998; Lu, Miller & Chen,
2002; Mechanic, 2007).
The increased involvement of managed care has had vast implications
for the role of social workers in the mental health care field. Social workers who perform the largest portion of mental health work in the United
States have been required to alter their role from serving as clients’ advocates to balancing clients’ needs against the need for cost control. In their
new roles as gatekeepers and treatment providers, social workers must learn
new strategies and skills to reduce considerable cost-savings expenditures
when providing services to clients (Cohen, 2003). Skills that social workers
need in the managed care environment involve computers and technology,
documentation and paperwork, empirical validation of treatment methods,
knowledge of brief treatment methods, and a business orientation in managing services in a profitable way (Bolen & Hall, 2007; Feldman, 2001;
Lu, Miller & Chen, 2002). Building on the concept of competence, which
describes feelings of confidence about one’s abilities to master organizational and work demands (Hall & Keefe, 2000; Wagner & Morse, 1975;
White, 1967), several theorists argue that a person’s belief that he or she cannot perform well professionally increases their risk of becoming burned out
(Bandura, 1989; Cherniss, 1993; Harrison, 1980). Participating in managed
care is complicated, and those who are not apprised about the managed
408
G. M. Acker
care world are likely to suffer stress and anxiety concerning their ability to
provide effective services in the context of managed care (Hall and Keefe,
2000; Spevack, 2009).
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COPING STRATEGIES
Coping strategies are defined as the cognitive and behavioral efforts that
people use to manage external and/or internal demands appraised as taxing or exceeding the person’s resources (Lazarus, 1993; Lazarus & Folkman,
1984; Sears, Urizar & Evans, 2000; Shikai, et al., 2007). Lazarus and Folkman
(1984) describe two major strategies for coping with stress: problem-focused
coping and emotion-focused coping. Problem-focused coping consists of
active behaviors and deliberate efforts to solve the situation, and the use
of social support, including collaborative efforts to educate and support
each other at the workplace (Brooks & Riley, 1996; Jenaro, Flores & Arias,
2007). Emotion-focused coping, on the other hand, is directed at regulating
emotional responses to a problem, such as using alcohol, drugs, excessive sleep, and denial and disengagement behaviors (Lazarus & Folkman,
1984; Jenaro, Flores & Arias, 2007; Shikai, et al., 2007). Previous studies
have found problem-focused coping to be effective for reducing stress in
the workplace (Gellis, 2002; Jenaro, Flores & Arias, 2007; Koeske, Kirk &
Koeske, 1993; Riolli, 2003). On the other hand, previous studies have found
emotion-focused coping to be related to negative psychological outcomes
such as higher levels of occupational stress (Gellis, 2002; Jenaro, Flores &
Arias, 2007; Thornton, 1992; Koeske, Kirk & Koeske, 1993).
A growing body of literature is stressing that personal resources (coping strategies) may help workers adjust to job demands, and diminish the
stress associated with a difficult and demanding job environment (Gellis,
2002; Jenaro, Flores & Arias, 2007; Latack, 1992). With the impact of managed care on the professional lives of social workers, such as increased
demands for new management activities and paperwork, cost containment,
and ongoing demonstration that continued treatment is needed (Rupert &
Baird, 2004), it is important to understand how workers cope with these
job situations. Types of coping strategies that workers use when interfacing with managed care are important to explore as they are likely to affect
work outcomes of social workers (i.e., burnout). Although managed care
has not suffered from any lack of attention from both the public and the
professional media, there is limited data to support the notion that social
workers feel that they are not competent and/or able to master the organizational demands associated with managed care (Feldman, 2001; Cohen,
2003; Hall & Keefe, 2000; Keefe & Hall, 1998; Shera, 1996; Stone, 1995).
There is also scarce data about how social workers cope when interfacing with managed care, and the impact of managed care on negative job
How Social Workers Cope with Managed Care
409
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outcomes such as burnout (Feldman, 2001; Cohen, 2003; Rupert & Baird,
2004).
The aim of the present study was to explore in more depth the professional lives of social workers heavily involved in managed care, and to
identify the coping strategies they find most useful in helping them to deal
more effectively with the job demands associated with managed care and
in reducing negative work outcomes. This study will add to the knowledge of how managed care impacts social workers, and how social workers
respond to the new demands and challenges associated with managed care.
The hypotheses of the study include:
1. Social workers who use problem-focused coping are more likely to feel
more competent in the context of managed care.
2. Social workers who use emotion-focused coping strategies are less likely
to feel competent in the context of managed care.
3. Social workers who use problem-focused coping strategies are less likely
to suffer from burnout, including emotional exhaustion, depersonalization, reduced personal accomplishment, and somatic symptoms.
4. Social workers who use emotion-focused coping strategies are more likely
to suffer from burnout, including emotional exhaustion, depersonalization, reduced personal accomplishment, and somatic symptoms.
MATERIALS AND METHODS
Procedure
The sample of this study, which was obtained from a professional list of
social workers practicing in New York State, consisted of 591 social workers. Self-administered and anonymous questionnaire packets were mailed to
1,000 randomly selected individuals from this list. The overall response rate
was 58%. The institutional review board of the university where the author
is employed approved the study.
Sample
Educational levels of respondents included 89% with master degrees in
social work, and 5% with doctoral degrees. The respondents were primarily
females (80%). The mean age was 51, ranging from 21 to 80. Seventy-one
percent were married or involved in long-term relationship with a partner;
28% were not married. The respondents were predominantly White (86%);
5% were African American or Black, 7% were Latino, and 1% were Asian.
The mean for years of experience in social work was 22 years, ranging
from 2 to 50 years of employment. The median for client contact hour per
week was 25. Forty-three percent were employed in outpatient mental health
410
G. M. Acker
settings, 13% in community support systems, 23 % in private practice, 7% in
substance abuse rehabilitation settings, 8% in inpatient psychiatric settings,
and 6% in schools.
Measures
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PERCEIVED
COMPETENCE IN THE CONTEXT OF MANAGED CARE
(CMC)
In this study, perceived competence in the context of managed care was
defined as workers’ feelings of confidence about their abilities in mastering organizational and work demands associated with managed care.
The CMC developed by Hall and Keefe (2000) included 16 items ranging
from “1 = strongly disagree” to “4 = strongly agree.” Higher scores indicated a perception of greater competence in the context of managed care.
Example of items included: “Managed care allows me enough direction to
be effective in treating clients”; “Coordinating care under managed care conditions is easy once you understand the various managed care company
requirements”; and, “Managed care allows me enough freedom to be effective in treating clients.” Hall and Keefe (2000) demonstrated that the CMC
had adequate validity and reliability. In this study, the Cronbach’s alpha for
the CMC was .86.
PROBLEM-FOCUSED
COPING STRATEGIES
(PFCS)
Problem-focused coping strategies described assertive efforts of the individual to alter stressful situations. PFCS were measured by a 10-item scale
developed by Folkman and Lazarus (1988). Examples of items are: “Stood
my ground and fought for what I wanted”; “I expressed anger to the person(s) who caused the problem”; and, “Talked to someone who could do
something concrete about the problem.” Respondents were asked to rate
each item on a 4-point Likert-type scale for the extent to which they used
each strategy during stressful job encounters in the past (0 = did not use;
1 = used somewhat; 2 = used quite a bit; 3 = used a great deal). PFCS
are known to have both good reliability and validity (Carver, Scheier &
Weintraub, 1989; Folkman, Lazarus, Dunkel-Schetter, DeLongis & Gruen,
1986). Cronbach’s alpha for this study sample was .84.
EMOTION-FOCUSED
COPING STRATEGIES
(EFCS)
This 9-item scale (Folkman & Lazarus, 1988) described wishful thinking
and efforts to escape or avoid stressful job related situations. Examples of
items were: “wished that the situation would go away or somehow be over
with,” “didn’t let it get to me; refused to think about it too much,” and
“tried to make myself feel better by eating, drinking, smoking, using drugs,
How Social Workers Cope with Managed Care
411
or medications.” Respondents were asked to rate each item on a 4-point
Likert-type scale as described before. EFCS are known to have both good
reliability and validity (Carver, Scheier & Weintraub, 1989; Folkman et al.,
1986). Cronbach’s alpha for this study sample was .76.
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SOCIAL
SUPPORT AT THE WORKPLACE
This scale was adapted from the social support from supervisor and social
support from co-workers scales (Caplan, Cobb, French, van Harrison, &
Pinneau, 1980). The new scale comprised eight questions about the extent to
which people around the worker (the worker’s supervisor and co-workers)
provided support by listening and by being persons that the worker can
rely on for help. Examples of questions are: “How much does your supervisor go out of the way to do things to make your life easier?” and “How
much are other people at work willing to listen to your personal problems?”
Cronbach’s alpha for this study sample was .88.
BURNOUT
Emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) were measured by a slightly modified version of the Maslach
Burnout Inventory (Maslach, Jackson, & Leiter, 1996). The EE subscale comprised nine items reflecting feelings of being emotionally overextended,
exhausted, physical exhaustion, and emptiness. Examples of items included:
“Working with people all day is really a strain for me” and “I feel frustrated by my job.” The four items of the DP subscale described an unfeeling
and impersonal response toward clients of one’s service. It included such
items as “I feel I treat some as if they were impersonal objects” and “I
don’t really care what happens to some clients.” The PA subscale consisted
of six items that describe feelings of competence and successful achievement in one’s work. Examples of items included: “accomplishing worthwhile
things at work” and “positively influencing my clients’ lives through work.”
Respondents were asked to rate each statement on a 7-point Likert-type
scale for frequency of agreement (0 = never, 1 = a few times a year or
less; 2 = once a month or less; 3 = a few times a month; 4 = once a
week; 5 = a few times a week; 6 = every day). Cronbach’s alpha coefficient for this study’s sample included .92 for EE, .78 for DP, and .77
for PA.
SOMATIC
SYMPTOMS
This measure included two scales based on previous research done by
Mohren and colleagues (2005) and Nakao, Tamiya and Yano (2005). The first
scale (12 items) measured flu-like symptoms (e.g., colds, sore throat, cough,
412
G. M. Acker
and fever). The second scale (3 items) measured symptoms of gastroenteritis
(GA). Respondents were asked to rate each item on a 7-point Likert-type
scale in terms of how often they have been experiencing each of those
symptoms for the past six months (0 = never, 1 = rarely; 2 = sometimes;
3 = fairly often; 4 = often; 5 = very often; and, 6 = all or most of the time).
Cronbach’s alpha coefficient for this study’s sample included .85 for common
colds and flu-like symptoms, and .75 for symptoms of gastroenteritis.
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DATA ANALYSIS
Pearson product-moment correlation coefficient was used to investigate the
research hypotheses and other relationships among the study’s variables.
A correlation matrix was computed for all the study’s variables. To further explore how coping strategies contributed to the burnout measures
above and beyond work-related variables (i.e., competence in the context
of managed care, social support, caseload size, satisfaction with the salary,
and years of experience practicing social work), as well as workers’ sociodemographic variables (i.e., age, race, and gender), hierarchical regression
analyses were used. Data analyses utilized SPSS computer software.
Nominal variables such as gender and race (people of color or Whites)
were included in the regression analysis by coding them as dummy variables.
RESULTS
The analysis began with the investigation of the relationships among the
variables included in the study’s hypotheses and the other variables of the
study. As shown in Table 1, problem-focused coping was found to have
statistically significant low positive correlations with emotional exhaustion
(EE), depersonalization (DP), flu-like symptoms, and symptoms of gastroenteritis (GA); and low negative correlations with perceived competence in
the context of managed care (CMC) and age. Emotion-focused coping was
found to have statistically significant low to medium positive correlations
with CMC, EE, DP, reduced personal accomplishment (PA), flu-like symptoms and GA; and low negative correlations with age and work experience.
EE had low negative correlations with CMC, satisfaction with the salary,
and social support, and positive low correlation with size of caseload. DP
was found to have statistically significant medium positive correlation with
emotion-focused coping, and statistically significant low negative correlations with age and work experience. PA had statistically significant low
negative correlation with emotion-focused coping and low positive correlations with age and work experience. CMC had statistically significant
413
EE
2
DP
3
PA
4
FLS
5
GA
6
PFCS
7
EFCS
8
∗
p < .05,
1.
2.
3.
4.
5.
∗∗
p < .01.
CMC
−.17∗∗ −.07
.02
−.14∗∗ −.05
−19∗∗
.14∗∗
.32∗∗
.29∗∗
.26∗∗
.41∗∗
EE
.50∗∗ −.29∗∗
DP
−.37∗∗
.26∗∗
.22∗∗
.20∗∗
.44∗∗
PA
−.13∗∗ −.13∗∗ −.05
−.19∗
.15∗∗
.25∗∗
Flu-like
.40∗∗
symptoms
.28∗∗
6. Gastro.16∗∗
enteritis
7. Problem.53∗∗
Focused
8. Emotionfocused
9. Social
support
10. Race
11. Caseload
size
12. Salary
13. Work
experience
14. Age
Variable
TABLE 1 Intercorrelations Among Study Variables (N = 591)
−.01
.03
−.03
.06
.06
.07
.08
−.03
.02
.01
−.05
.10∗
−.01
.02
−.07
−.11∗
−.18∗∗
−.05
.08∗
−.06
Salary
12
−.01
.14∗∗
−.07
Caseload
11
.01
.14∗∗
.02
.03
−.03
Race
10
.12∗∗ −.13∗∗
−.14∗∗
.09∗
−.02
.11∗∗
.03
−.00
−.10∗
07
SSP
9
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−.16∗∗
−.06
−.07
−.10∗
−.15∗∗
.17∗∗
−.08
Age
14
−.05
−.18∗∗
−.04
.58∗∗
.07
−.9∗∗
−.04
−.03
−.03
.01
−.03
.07
−.06
−.05
.00
.06
.04
−.01
.01
−.10∗
.04
−.08
Gender
15
−.01
−.17∗∗ −.28∗∗
−.08
−.04
−.09
−.09∗
−.14∗∗
.12∗∗
−.06
EXP.
13
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414
G. M. Acker
low positive correlation with social support, and statistically significant low
negative correlation with flu-like symptoms. Both coping styles had low positive correlations with flu-like symptoms and GA. Positive correlation means
that the two variables move in the same direction, and negative correlation means that the two variables move in opposite directions—that is, as
one increases, the other one decreases. White workers reported higher levels of DP and GA than non-White workers and also felt less competent in
the context of managed care than the non-White workers. The results also
indicate that the power of the correlations between the primary variables
including EE, DP, PA, flu-like symptoms, and gastroenteritis are sufficiently
independent to be examined separately.
Multiple regression analyses provided information on the influence of
the different coping mechanisms on burnout symptoms including EE, DP, PA,
flu-like symptoms, and gastroenteritis above and beyond the work-related
variables (i.e., CMC, social support, caseload size, satisfaction with the salary,
and work experience), and workers’ socio-demographic variables including age, gender, and race. Problem-focused coping was entered first into
the regression equation. The second step included the variable emotionfocused coping. Then, in the third step, the work variables were added
to the regression to examine whether there was an increase in predictability above and beyond the information provided by the coping strategies
variables. The fourth step included workers’ socio-demographic variables
to examine if those variables also contributed significantly to the outcome
variables (Table 2). To reduce the problem of finding significance that’s
actually produced by chance when multiple correlations are made with multiple regression analysis, the Bonferroni procedure calls for the researcher to
divide the .05 probability level by the number of statistical tests to be conducted, which in this case included 10 tests. This resulted in a new p value,
p = .005 (.05/10)(Montcalm & Royse, 2002).
The first analysis for predicting EE, which included the variable problemfocused coping in the first step, resulted in significant relationship: R2 = .05,
F (1, 378) = 20.86, p < .001. Step two, which included the variable emotionfocused coping, was also significant: R2 change = .12, F (1, 377) = 53.07,
p < .001. The third step, which included work variables (social support, CMC,
caseload size, satisfaction with salary, and years of experience practicing social
work), was not significant: R2 change = .03, F (5, 372) = 3.02, p < .011.
The fourth step with the socio-demographic variables (age, race, and gender)
was not significant, R2 change = .00, F (3, 369) =.537, p < .657. The first
step of the second analysis with problem-focused coping as the predictor
of DP was significant: R2 = .03, F (1, 378) = 11.36, p < .001. The second
equation, which included emotion-focused coping, was also significant: R2
change = .16, F (1, 377) = 76.70, p < .001. The third step, which included
the work variables, was not significant: R2 change = .02, F (5, 372) = 2.10,
415
∗
p < .005,
Step 4:
Age
Gender
Race
R2
F
∗∗
p < .001.
Step 3:
CMC
Social support
Caseload
Salary
experience
R2
F
Step 2:
Emotion-Focused
R2
F
Step 1:
Problem-Focused
R2
F
Variable
.07
.03
.02
.13
−.06
−.02
−.08
.02
.54
.23
β
1.124
.549
.363
.21
.54
2.867
−1.141
.520
−1.774
.422
.20
3.03
7.285
.17∗∗
53.07
4.568
.05∗∗
20.86
t
EE
∗
∗∗
∗∗
p
−.07
−.08
.04
.13
.02
.01
.00
−.07
.47
.17
β
−1.431
−1.674
.925
.23
1.57
2.942
.367
.136
−.005
−1.431
.22
2.10
8.758
.19∗∗
76.70
3.376
.03∗∗
11.40
t
DP
∗
∗∗
∗∗
p
.15
.09
.09
−.01
−.02
−.06
.08
.09
−.23
−.04
β
2.320
1.820
1.819
.10
3.76
−.1904
−.308
−1.168
1.486
1.644
.07
2.10
−3.898
.04∗∗
15.19
−.846
.00
.72
t
PA
∗∗
∗∗
p
.05
.03
−.02
.06
−.11
.02
−.08
−.02
.20
.16
β
.787
.630
−.307
.08
−.35
1.225
−2.225
.331
−1.616
−.439
.08
2.0
3.508
.06∗∗
12.31
−3.130
.03∗∗
9.80
t
∗∗
p
Flu–like symptoms
.04
.06
.01
.01
−.05
.03
−.05
.02
.26
.17
β
.585
1.161
.240
.09
.54
.124
−.895
.638
−1.018
.316
.09
.47
4.505
.08∗∗
20.29
3.434
.03∗∗
11.80
t
GA
TABLE 2 Results from Hierarchical Regression Analyses Predicting Outcome Variables (EE, DP, PA, flu-like symptoms and GA)
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∗∗
∗∗
p
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416
G. M. Acker
p < .064. The fourth step with the socio-demographic variables was not
significant: R2 change = .01, F (3, 369) = 1.20, p < .197.
The first step of the third analysis for predicting PA was not significant:
R2 = .00, F (1, 378) = .716, p < .398). The second equation, which included
emotion-focused coping, was significant: R2 change = .04, F (1, 377) = 15.19,
p < .001. The third step which included the work variables, was not significant: R2 change = .03, F (5, 372) = 2.10, p < .065. The fourth step
with the socio-demographic variables was not significant: R2 change = .03,
F (3, 369) = 3.76, p < .011.
The analysis for predicting flu-like symptoms resulted in significant relationship for the first step: R2 = .03, F (1, 377) = 9.80, p < .002. The second
equation was also significant: R2 change = .03, F (5, 376) = 12.31, p < .001.
The third step, which included the work variables, was not significant R2
change = .03, F (5, 371) = 2.00, p < .077. The fourth step with the sociodemographic variables was not significant: R2 change = .00, F (3, 368) = .35,
p < .790. The last analysis for predicting gastroenteritis resulted in a significant relationship for the first step: R2 = .03, F (1, 377) = 11.80, p < .001.
The second equation was also significant: R2 change = .05, F (1, 376) = 20.29,
p < .001. The third step including the work variables was not significant:
R2 change = .01, F (5, 371= .47, p < .800). The fourth step with the sociodemographic variables was not significant: R2 change = .00, F (3, 368) = .54,
p < .653.
Based on the results of the multiple regression analyses, EE, DP, and the
somatic symptoms were predicted by problem-focused coping and emotionfocused coping when controlling for the work and the socio-demographic
variables. PA was predicted only by emotion-focused coping when controlling for the work and the socio-demographic variables. The sets of the
work variables and the socio-demographic variables offered little additional
predictive power beyond that contributed by problem-focused coping and
emotion-focused coping.
DISCUSSION
The results of this study suggest significant relationships between competence in the context of managed care, coping, emotional exhaustion, somatic
symptoms, social support, and several demographic variables such as race,
age, and work experience. The data suggested that social workers that felt
competent in working with managed care organizations did not rely on
problem-focused coping. It is possible that, because of their good relationship and comfort working with managed care organizations, they did not
need to assert themselves with managed care staff and/or direct their energy
and efforts toward actions and activities that would eliminate problems. This
confirms previous research, which suggests that stressful work situations
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elicit those behaviors directly aimed at altering or managing the problematic
situation (Gellis, 2002; Lazarus & Folkman, 1984; Shikai, et al., 2007).
On the other hand, those who did not feel competent in working with
managed care organizations relied on emotion-focused coping and used
escape-avoidance behaviors. The study also found that competence in the
context of managed care did contribute negatively to emotional exhaustion
and flu-like symptoms. These findings are consistent with other researchers
(Bandura, 1989; Cherniss, 1993; Hall & Keefe, 2000; Harrison, 1980; Wagner
& Morse, 1975; White, 1967).
The findings of this study are in accordance with the coping strategies
literature, which suggests that the mere existence of stress is less important
than how individuals appraise and cope with stress (Aldwin & Revenson,
1987; Antonovski, 1979; Gellis, 2002; Lazarus, 1981). When controlling for
all the other variables in the hierarchical regression analyses, coping strategies had statistically significant relationships with all the burnout variables,
indicating that the internal psychological resources available to people are
the key component of how people deal with work stress. Contrary to
the burnout literature (Arches, 1997; Maslach, 1978; Maslach, Jackson &
Leiter, 1996; Pines, 1983; Rosenbaum, 1992), in this study work-related
stressors, such as those associated with lower levels of competence in the
context of managed care, social support, and caseload size, were not as
important in predicting burnout as the ways that people cope with those
stressors.
As some theorists state, the relationship between problem-focused coping and emotion-focused coping is not as simple, as people tend to use both
coping styles when dealing with the same source of stress. When dealing
with stressful encounters, people do not necessarily use either problemfocused coping or emotion-focused coping. They may wait for a while until
they react directly to the stressful encounter by first using emotional-coping
style. When people feel that they have not handled the stressful situation
well, they will expand the effort to reduce the impact of the stressful event;
one possibility is to switch to more effective coping styles such as those
that deal directly