Stress in the NHS

In his report to the Department of Health on the health of the NHS workforce Dr Steve Boorman noted that while musculoskeletal problems accounted for 45 per cent of all staff absence the second highest cause was stress, depression and anxiety at 25 per cent.
    
The national Labour Force Survey shows over 35 per cent of NHS staff reporting stress as “illnesses caused or made worse by work.” These percentages are higher than in other sectors and, in a workforce of 1.4 million, indicate a huge problem for both employers and staff.
    
Sickness absence in the NHS is estimated to cost the service some £1.7billion each year of which a quarter is likely to be attributable to stress related sickness. And it is not just a question of cost. Time lost to sickness absence amounts to 10.3 million working days or the equivalent of having 45,000 whole time equivalent staff not at work – of these, a quarter are likely to be due to stress related sickness.

What is stress?
To start looking at the issue it is important to be honest. It has to be recognised that a major barrier to the implementation of good stress management, not only in the NHS but across the whole of the public and private sectors, is the fact that stress is a very individual thing.
    
Not only may staff be “stressed” by different things but their reactions may differ from day to day or week to week. An action that might cause stress and anxiety today may not even be noticed if it is repeated in a week’s time. Much of the impact is mitigated by the individual’s own personal state of mind at any given time.
    
It is very difficult to develop a policy framework for dealing with something which is so personal to each member of your staff. However all employers owe a duty to their staff to ensure that they do not arrange work and behave in such a way as to bring added stress to their staff which may cause them pain and distress.
    
And let us not forget that stress is not an illness itself – a common misconception held by both staff and employers – although it can lead to a wide variety of illnesses, some of which could be very serious, if it is not addressed. But it is not in itself an illness.
    
The Boorman report says that although stress is widespread in the NHS the reasons for it are not always work related; they include sleep deprivation, financial concerns, and caring responsibilities. However, there are work related factors apart from the general stress that comes from working in a busy and often demanding job. Staff who have been working in the NHS for a long time report higher levels of stress than colleagues who have joined more recently as do staff in managerial roles. Understandably those who cannot cope with their roles report being more stressed than those who can – twice as much in the research carried out by Boorman.

Cause of stress
The main cause of stress in staff in any organisation, public sector or private, is a feeling of lack of control. The Health and Safety Executive (HSE) in developing their Management Standards approach to stress recognised that the causes of stress could be defined as:

• Demands which includes issues such as workload, work patterns and the work environment.
• Control which is about how much say the person has in the way they do their work. 
• Support which includes the encouragement, sponsorship and resources provided by the organisation, line management and colleagues. 
• Relationships which is about promoting positive working to avoid conflict and dealing with unacceptable behaviour. 
• Role which is about whether people understand their role within the organisation and whether the organisation ensures that they do not have conflicting roles. 
• Change which relates to how organisational change (large or small) is managed and communicated in the organisation

In the NHS we were already a long way down the path of meeting some of these standards through development of flexible working, childcare provision, self-rostering and the improved staff engagement which flowed from the Improving Working Lives initiative that was rolled out between 2001 and 2006 and for which a revised Framework document can be found on the NHS Employers website.
    
Other areas identified by the HSE are not as easily addressed in a dynamic and fast-moving service like the NHS and need a more determined approach by employers and staff working together.

Identifying stress
Staff that work in the NHS need to recognise that life itself is not stress free and that no amount of hard work will ever totally eradicate workplace stress. They also need to recognise that very often they bring their stress into the workplace with them, as indicated in the Boorman research, reflecting problems with home, children, finance or mortgage problems – and that this means they need to develop coping strategies to help them to deal with them.
    
Boorman recommends that employers should give priority to implementing a policy, promoted by the National Institute for Health and Clinical Excellence, that covers the role of line managers, the organisation of work, managing the risks to employees mental well-being and identifying and implementing opportunities for improving staff mental well being. This would address the issues that cannot be covered by the actions already taken by most trusts.
    
NICE in its work on stress has identified a major influence on the incidence of stress in the NHS which is the role played by line managers. This is the group that can have a major impact on the way in which staff are affected – or not – by stress. They are also, ironically, the group that that has been identified in reports since the late 1990’s, including Boorman, as being major victims of stress and mental ill health. However, with their assistance we can reduce current levels of reported stress including theirs.

Advice available
NHS Employers has published advice for managers and staff on its website and has run a campaign aimed at identifying what part managers and staff could take in addressing this issue. Advice includes coping strategies for staff and tips for managers on identifying potential problem areas. Work carried out in Blackpool, Fylde and Wyre Hospitals NHS Trust has shown that a concerted effort by senior managers to address stress and its causes, which in this case meant looking at bullying and violence issues as well, can have good results.
    
Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust is a large General Hospital with 4,500 staff which in March 2007 had a sickness absence rate of 5.34 per cent with 55 per cent of sickness due to staff off for longer than 28 days, and with 40 per cent of staff seen in occupational health reporting mental health problems due to work. There was anecdotal evidence of high stress levels due to excessive working hours, restructuring and bullying.
    
The impact on individual staff was such that they were demotivated, disengaged and in the worst cases, absent. This left colleagues, frustrated, antipathetic to the trust and with an increased workload and the associated pressure that brought. For the organisation this meant increased grievances, high absence rates, inconsistent patient care and a resulting negative public image. This in turn led to reduced efficiency and performance, a workforce lacking in skills and competency and an adverse impact on service delivery to patients.
    
The Trust board made a decision to take an organisational development approach to transforming the performance culture through deep employee engagement with four key strands of work based around communication, management style, recognition, and continuous improvement. Key stakeholders in taking this forward were identified as being the chief executive, chairman, directors, staff-side representatives and the whole workforce. After focus groups, consultation and engagement with the workforce the causes of stress were identified and a senior manager was designated to lead a project, with robust timescales, to manage change.

A great deal of work was done by staff and management, and the results so far, on what is a continuing project, are that sickness absence is down, numbers presenting to occupational health with stress related problems are down by 40 per cent and the long hours culture that led to increased stress is now being tackled. (Further information on the Blackpool, Fylde and Wyre project can be found on the NHS Employers website under “Stress”).
    
Stress is a long way from being eradicated in the NHS workplace, and we should recognise that it probably never will disappear completely – which many would argue is a good thing. There is evidence from research that shows everyone needs some stress in their working lives in order to drive their work forward. However, as more organisations take on the sort of project that has been developed in Blackpool the situation is bound to improve. It may never be as stress free being a nurse or doctor in a busy accident and emergency unit as it is working in some other places but we can and will continue to work towards making that level of stress one which is more acceptable and towards eradicating it where it is not necessary.

For more information
Web: www.nhsemployers.org