Between stress and health

Why we now need more assessments of workplace hazards and resilience training

The current discussion about the introduction of sick days forms the background for this article, in which I would like to shed light on the effects of gainful employment on the health of employees as well as the associated tasks in corporate management practice.

The Job Demands-Resources Model

The Job Demands-Resources (JD-R) model is a framework that can be applied to any job. The characteristics of all jobs can be categorised into two categories:

• job demands and
• job resources.

Job demands are physical, psychological, social and organisational aspects of work that require a usually prolonged physical and/or psychological strain. Job resources are the physical, psychological, social and organisational working conditions that are functional to achieving work-related goals and initiate personal development and growth. These include, for example, task variety, participation in decision-making, opportunities for advancement, performance feedback from superiors, and interpersonal relationships between employees and between employees and superiors. (cf. Schulte et al 2021)

Each of the two categories sets a separate process in motion. ‘In the first process, confrontation with high or poorly designed work demands leads to the development of exhaustion in the longer term.’ (…) ‘In the second process, a lack of sufficient work resources makes it more difficult or impossible to achieve work goals (…).’ (Demerouti/Nachreiner 2019 :121).

In this context, an individual’s resilience can also be mentioned, as the ability to deal constructively with work demands on the basis of internal or socially mediated resources while remaining capable of action. Risk assessments can be understood as a process ‘in which, on the basis of an assessment of the hazards associated with the work, necessary measures to protect the health of employees are systematically identified, implemented and reviewed for effectiveness.’ (Beck/Schuller 2021 :14). When conducting a risk assessment, mental aspects of work that could pose a potential risk to employees must also be considered as working condition factors.

A dual perspective must therefore be adopted here; on the one hand, building and promoting (individual) resources and, on the other hand, reducing work demands that have an impact on mental health as stressors.

‘To maintain or promote health, it is necessary for an individual to be able to cope with external and internal demands with the help of external and internal resources (Backer 2017, cited in Unkrig 2021 :19).

The German National Prevention Conference (NPK), with its sponsors GKV, DGUV, SVLFG and Deutsche Rentenversicherung, states (somewhat simplistically): ‘Gainful employment plays an important role in the health of employees: On the one hand, it has great potential to promote health, as work positively shapes the personal identity of the individual, creates meaning and social cohesion (…). On the other hand, working conditions can also have a detrimental effect on the health of employees.’ (NPK n.d. :n.p.)

Impact of working conditions on health

The link between (‘poor’) working conditions that have a direct or indirect negative impact on the health of employees is undisputed. The Federal Institute for Occupational Safety and Health has analysed and described the links between more than 20 working conditions and mental disorders, musculoskeletal disorders and cardiovascular diseases as part of a scientific inventory. Consistent links were found in particular between (individual) working conditions and mental health.

Figure 1: Basic assumptions about the effect of work factors on mental health. (Rothe et al 2017: 23)

The working conditions that have a particularly strong impact on mental health include, above all, work intensity, (atypical) working hours, disturbances/work interruptions, emotional labour and ‘destructive leadership’ (characterised by a lack of appreciation of employees, little consideration or employee participation), which plays a central role in conjunction with other working conditions. (cf. Rothe et al 2017)

Physical stress at work can ‘cause strain on the musculoskeletal and cardiovascular systems. In the short and long term, these demands can lead to uncompensated stress on individual conditions (excessive demands) and thus pose a risk to health.’ (Kittelmann et al 2023 :3).

The ‘risk factors’ of musculoskeletal disorders include not only physical stress at work (specific physiological-biomechanical stress constellations) but also ‘changes in the organisation of work, such as the design of work content, psychosocial factors such as social structures, development opportunities in the company and leadership behaviour’, which ‘favour the progression of work-related MSDs’. (Holzgreve et al. 2023 :183). For years, there has also been a clear link between stress and back pain.

What are work-related illnesses?

The European Agency for Safety and Health at Work (EU-OSHA) includes both musculoskeletal disorders and mental disorders, along with work-related cancers, skin diseases and diseases caused by biological agents, in the group of so-called work-related illnesses. (EU-OSHA n.d. : n.d.).

The term ‘work-related illnesses’ was introduced into German legislation as early as 1973, more than 50 years ago, by the legislator in the Occupational Safety Act. ‘It takes particular account of the cumulative causation of illnesses through occupational influences.’ (Arbeiterkammer des Saarlandes 2018 :2).

‘Work-related illnesses are understood to mean all illnesses whose occurrence is related to work’ (Landesinstitut für Arbeitsschutz und Arbeitsgestaltung Nordrhein-Westfalen, n.d. :n.p.) – “without a certain legal quality having to be achieved. The connection does not have to be causal in the legal sense.” (Arbeiterkammer des Saarlandes 2018 :2)

‘A work-related illness can be assumed if the potential for stress and danger at the workplace has influenced, in part caused or worsened the health disorder. It is also irrelevant whether an individual’s physical predisposition, age-related wear and tear or non-occupational causes have contributed significantly to the development of the illness.’ (Landesinstitut für Arbeitsschutz und Arbeitsgestaltung Nordrhein-Westfalen n.d. :n.p.)

Development of sickness absence

Since sickness absence due to illness or accident is a key indicator of work-related influences on health and the incidence of incapacity to work is of great importance to the economy as a whole, it is worth taking an honest look at the current situation in 2023 (compared to the pre-coronavirus year of 2019).

Figure 2: Comparison of sick leave in 2019 and 2023 (according to BAuA 2020 and 2024)

The Federal Ministry of Health states that the average annual sick leave (sick compulsory members unable to work as a percentage of all compulsory members) was 4.35% in 2019 and 6.07% in 2023. (cf. Institute for Work and Qualification at the University of Duisburg-Essen (2024) :2)

No consolidated figures are yet available for 2024. Since the average number of sick days per employee in the first 11 months of 2024 was 0.1 days higher than in the same period in 2023, according to the Techniker Krankenkasse for its policyholders, and the total number of employees has risen slightly again, the total number of sick days is likely to have exceeded 900 million sick days.

Employers’ expenses for continued pay in the event of illness will increase from €64.9 billion to €76.6 billion (by 18%) in the period 2019-2023, doubling within 14 years. (cf.: Pimpertz 2024:2)

However, anyone who assumes that the increase in employers’ expenses for continued remuneration in the event of illness is primarily due to the increase in the number of sick days and calls for the introduction of a waiting day in order to sustainably reduce labour costs is mistaken. Rather, there are three reasons for the increase:

1. increase in gross wages

Gross wages in Germany have increased annually by 3.1 – 5.1% since 2009-2021, with the exception of 2020 (minus 0.7%) (and 2022 / 2023 again significantly by 6.1 / 7.4%). (cf. Statista Research 2024: n.p.) Even with a constant AU rate, this development would have already led to a significant increase in the costs of continued remuneration in the event of illness.

2. Increase in the number of employees:inside

The number of employees (as a subgroup of the domestic labour force) has increased by more than 10% since 2014, reaching a peak in 2023 (which was exceeded again in 2024) (see Federal Statistical Office 2025: n.p.). This development would also have led to a mathematical increase in wage bill costs for employers if the AU rate had remained constant.

3. Increase in the number of AU days per employee

It should be noted here that the average number of sick days taken by employees (also) increases with age. Among those over 60 years of age, the average duration of sick leave in 2023 was 20.2 days, twice as high as the average duration of sick leave across all age groups. (cf. Radtke 2024: n.p.). Compared to 2009, the proportion of people aged 60 and over in employment in 2022 has roughly doubled (to 5.45 million), while the number of 15- to 25-year-olds has fallen slightly (to 4.49 million). (cf. Federal Ministry of Education and Research 2023: n.p.).

Finally, the health insurance funds point out that the increase in sick days is due to a statistical effect, since all ‘sick notes issued by doctors’ have been recorded in full by the health insurance funds since 1 July 2022, when the mandatory introduction of the electronic certificate of incapacity to work (eAU) came into force. According to a study by the DAK health insurance fund, the so-called reporting effect is around 60 per cent or more, depending on the diagnosis (see DAK press release dated 7 January 2025).

The assumption of Allianz SE CEO Bäte regarding the predicted effect (at best, a halving of employers’ expenses for continued pay-roll in the event of illness) when a one-day waiting period is introduced is more than doubtful.

Prof. Ragnitz, an economist at the ifo Institute, comments: ‘To be honest, I cannot understand this high figure he mentions at all. If you do the rough calculations, depending on how many people are actually sick and how often they are sick, you come up with an amount in the range of less than 10 billion euros – so it is far from the figure he has come up with.’ (MDR Sachsen interview with Ragnitz on 15 January 2025).

The question of whether employees could ‘go to work sick’ in the event of a day of absence due to the loss of income (presenteeism) and the resulting consequences have not yet been considered here.

Mental illnesses – a detailed description

In 2023, mental illnesses were the third most common group of illnesses causing the most days of absence from work (337 AU days per 100 insured workers). The number of days of absence in this diagnosis group (including depression, stress-related illnesses and adjustment disorders) has increased by 52% in 10 years. In 2023, working women had around 60 per cent more days of absence due to mental illness than men (per 100 insured persons). The number of sick leave certificates with a mental diagnosis has increased in 2023 in all age groups. Younger workers were on sick leave more often due to mental illness, but for a shorter period of time. (see IGES Psychoreport for DAK policyholders 2024)

According to BAuA data (see table above), the increase in per capita sick days for the diagnosis group of mental and behavioural disorders in the period 2019–2023 was 18.2%. ‘The increase in sick days due to mental illness is one of the most striking developments in terms of sick leave figures in recent years.’ (Dehl et al 2024 :19).

‘This is not surprising when you look at how psychological stress for employees has increased in recent years.’ (Baumgart 2024)

Also, “(according to) Professor Volker Nürnberg, an expert in occupational health management, the changed parameters in the world of work, among other things, may be reasons for this increase.” (DAK Gesundheit press release 2024: 2)

The BAuA stated as early as 2017: ‘Overall, it can be assumed that there is a great need for action in the area of mental health in the world of work, which addresses the design and implementation deficits at the company level.’ (Rothe et al 2017 :119)

Tasks in the management practice of companies

‘Estimating the production losses (wage costs) and gross value added losses (loss of labour productivity) due to inability to work indicates, from an economic point of view, a prevention potential and possible benefit potential.’ (BAuA 2024 :1)

The motto of consultants in the face of rapidly increasing absenteeism due to mental disorders seems to be: ‘Make your organisation more resilient’ (Unkrig 2021:3). I have published an article on this topic here in the t2informatik Blog: Leadership and individual resilience.

Resilience training and workshops for employees with and without management responsibility undoubtedly represent an important building block in this context for strengthening the mental resilience and adaptability of individuals in the face of far-reaching changes in the world of work (and against the background of the current polycrisis). Resilience helps to actively cope with stress and challenges and thus protect mental health. In this context, managers must be aware that their leadership behaviour makes them either part of the problem of employee health or part of the solution.

However, the idea of placing the responsibility for stabilising mental health solely on individuals (employees) is more than questionable if it were to release employers from their responsibility for the health of their employees.

What companies need now is to develop and expand a health-oriented corporate culture (health incentive system) and a health-oriented form of leadership instead of a blanket culture of mistrust towards employees who are ill.

In the area of occupational health and safety, the primary concern is the complete and sustainable implementation of the employer’s prevention mandate. The Occupational Safety and Health Act obliges employers to organise work in such a way that health hazards are avoided as far as possible. This also includes taking into account the risks posed by mental stress at work.

In fact, only a maximum of 50% of companies carry out the risk assessment required by Section 5 of the Occupational Safety and Health Act. When asked about the reasons for non-compliance with this legal requirement, the entrepreneurs surveyed do not respond by pointing out possible implementation problems or the associated effort, but with the (lapidary) remark that ‘there are hardly any hazards’ or that employees would recognise safety deficits themselves without any indication. (Sommer 2019 :n.p.) However, even in companies that do carry out risk assessments, ‘the handling of psychosocial risks at work is still far too rarely taken into account.’ (Beck/Schuller 2021 :13)

Many employers are thus also failing to adequately fulfil their mandate to protect the health of their employees from psychological stress and to investigate and prevent the causes of work-related illnesses in accordance with §3 para. 1 of the Occupational Safety Act.

But: ‘Constant restructuring of corporate structures, teams, tasks and requirements places enormous demands on the mental robustness of the individual. (…). In addition to constant availability, excessive workloads and poor leadership culture, it is above all the climate of constant insecurity that increases employees’ vulnerability to exhaustion disorders.’ (Graefe 2022 :56)

Accordingly, the Joint German Occupational Health and Safety Strategy (GDA) has determined that the ongoing digital transformation in the world of work is also leading to changes in mental stress at work and has declared mental stress to be a priority for the third GDA period 2021-2024. Against the background outlined above, it will certainly be interesting to see the results and how they are implemented in companies.

Notes:

Do you want to remain capable of acting in complex and uncertain situations? Do you want to strengthen your resilience? Stephan Pust offers an interesting skills training programme (in German).

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Literature (in German):

Arbeitskammer des Saarlandes (2018) Arbeitsbedingte Erkrankungen und Berufskrankheiten. Saarbrücken

Baumgart (2024) Krankheitsfälle: Neuer Höchststand 2024; https://www.zdf.de/nachrichten/wirtschaft/krankheitsfall-fehlzeiten-beschaeftigte-aok-100.html

Beck/Schuller (2021) Psychosozialen Risiken wirksam begegnen mit Hilfe der Gefährdungsbeurteilung; in: DGUV-Forum 11/2021, S. 13-15

Bundesanstalt für Arbeitsschutz und Arbeitsmedizin (Hrsg.) (2020) Sicherheit und Gesundheit bei der Arbeit – Berichtsjahr 2019. Dortmund

Bundesanstalt für Arbeitsschutz und Arbeitsmedizin (2024) Volkswirtschaftliche Kosten von Arbeitsunfähigkeit 2023. Dortmund

Bundesministerium für Bildung und Forschung (2023) Erwerbstätige nach Altersgruppen und Geschlecht (Tabelle 0.25a); https://www.datenportal.bmbf.de/portal/de/K04.html

DAK Presse (2025) DAK-Analyse zeigt Ursachen für Rekordkrankenstand. https://www.dak.de/presse/bundesthemen/politik-unternehmensnachrichten/dak-analyse-zeigt-ursachen-fuer-rekordkrankenstand-_88050

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Demerouti/Nachreiner (2019) Zum Arbeitsanforderungen-Arbeitsressourcen-Modell von Burnout und Arbeitsengagement – Stand der Forschung; in: Zeitschrift für Arbeitswissenschaft Band 73, Seiten 119-130

EU-OSHA (o.J.) Arbeitsbedingte Erkrankungen. https://osha.europa.eu/de/themes/work-related-diseases

Graefe (2022) Warum Resilienz allein nicht ausreicht (Haufe News 29.09.2022) https://www.haufe.de/personal/hr-management/warum-resilienz-allein-es-nicht-richtet_80_556976.html

Holzgreve et al (2023) Allgemeine und arbeitsplatzbezogene Risikofaktoren von Muskel-Skelett-Erkrankungen und ihre Bestimmungsmethoden; in: Zentralblatt für Arbeitsmedizin, Arbeitsschutz und Ergonomie Jahrgang 73, Seiten 182-189

IGES Institut (o.J.) Psych-Report 2024. https://www.iges.com/kunden/gesundheit/forschungsergebnisse/2024/psychreport-2024/index_ger.html

Institut Arbeit und Qualifikation der Universität Duisburg-Essen (2024) Entwicklung des Krankenstandes 1970-2023. Sozialpolitik-aktuell.de pdf-Datei zum Download)

Kittelmann et al. (2023) Handbuch Gefährdungsbeurteilung Teil II (Hrsg.: Bundesanstalt für Arbeitsschutz und Arbeitsmedizin) Dortmund.
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MDR Sachsen (2025) Kein Lohn am ersten Krankheitstag – Dresdner Ökonom lehnt Vorschlag ab. Interview mit Joachim Ragnitz am 15.01.2025.

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Rothe et al (2017) Psychische Gesundheit in der Arbeitswelt (Hrsg.: Bundesanstalt für Arbeitsschutz und Arbeitsmedizin) Dortmund.

Sommer (2019) Warum führen Betriebe keine Gefährdungsbeurteilungen durch? Arbeitsschutz digital; https://www.arbeitsschutzdigital.de/ce/warum-fuehren-betriebe-keine-gefaehrdungsbeurteilungen-durch-1/detail.html

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Schulte et al (2021) Ressourcen und Anforderungen in der Arbeitswelt; in: Zeitschrift für angewandte Organisationspsychologie Band 52, S. 405-415

Unkrig (2021) Resilienz im Unternehmen – den Faktor Mensch fördern. Springer Gabler Verlag Wiesbaden

Stephan Pust has published more articles in the t2informatik Blog, including: