Health Business

There can be little doubt that many staff in the NHS are experiencing serious pressure in many areas of their work and it is a management responsibility to explore this and work with staff to reduce the pressure to a manageable, motivational level. There are many factors at play here, however, including staffing levels, staff competencies, staff expectations, patients expectations, remuneration, professionalism, resources, politics, and so on.
    
According to the NHS Employers (2008), stress is believed to account for over 30 per cent of sickness absence in the NHS, costing the service £300-400 million per year. The Healthcare Commission's 2007 staff survey found that 33 per cent of staff questioned said they had felt unwell because of work-related stress over the past 12 months.

What is stress?
The first thing most of us need to clarify is the meaning of the term ‘stress’. Stress is one of those words that everyone uses but it seems to mean something different every time it is used. People talk about experiences being ‘stressful’ – everything from getting up late to getting divorced. They describe themselves as ‘stressed’ when they often mean busy or being prevented from doing what they want to do.
    
The International Stress Management Association (ISMA) in conjunction with the Health & Safety Executive (HSE) defines stress as “the adverse reaction people have to too much pressure.” The key word in this definition is ‘adverse’. An adverse reaction is not good, especially when related to health.
    
Therefore, stress is not good for you. In ISMA training sessions delegates are asked if they think stress is good for them and around 80 per cent think it is – until they read the definition. This poses the question of what they think is good for them? The answer to this is ‘pressure’.

That’s life
Challenges and pressures are part of life and we need them to motivate and stimulate us. Interestingly, some people really thrive on pressure and feel low and below par (stressed) if they are not being pushed or pushing themselves. We can, however, all experience too much pressure and this is what is meant by stress.
    
The work of Yerkes and Dodson (1908), indicates how this works:

• Not enough pressure: limited coping/stressed
• Just the right amount of pressure and challenge: coping and enjoying life
• Too much pressure: limited coping/stressed/ill.
  

Legal compliance
There is no specific law relating to stress. In 1974, the Health and Safety at Work Act placed duties of care on employers and employees. For example, section 2 (1) placed the duty on employers to ensure the health and safety of all employees at work, as far as is reasonable and practicable. In 1988 a further amendment to this stated: “ill health resulting from stress caused at work has to be treated the same way as ill health due to other physical causes present in the work place.”
    
1999 saw The Management of Health & Safety at Work Regulations, which required all employers of five or more people to carry out regular risk assessments, identify hazards and take action. In 2001, HSG 218 was produced which offered practical advice on dealing with workplace stress and identified the key workplace hazards that would become the basis for a risk assessment.
    
Responsibility for managing stress was placed on managers. This means that managers need to be aware of the effect of too much pressure on their staff. The Management Standards were introduced in 2004 and act as guidance and best practice for managers at all levels to focus on the six workplace risk factors. Further guidance and clarification was issued in 2007 HSG 218 revised.

The cost of stress
From the NHS Employers statement above, the HSE and CIPD it is clear that absence due to stress cost organisations like the NHS. Public sector organisations have a higher absence rate than the private sector and at an average of ten days per annum, sickness absence among the 1.3 million NHS employees is significant. Not all sickness is due to stress but typical symptoms of stress are susceptibility to minor ailments like headaches, migraines, irritable bowel, anxiety and musculoskeletal problems as well as high blood pressure and heart conditions.

Pressure v stress
Make no mistake – pressure and work are good for you. There has been much research to validate this statement.
    
The workplace should be a stimulating, positive environment, where employees work with their managers to enable the work to be done. Too often it is a place of strife, excessive demands, limited control and unclear lines of communication. This leads to dissatisfaction and negativity, which in turn lead to stress, ill health, unproductive staff and reduced retention of all levels of staff.

Tackling the problem
The HSE has clearly indicated how work related stress (WRS) should be tackled in its publication HSG 218. A strategy is planned from the top and cascaded throughout the organisation based on a sound stress management/wellness policy. A risk assessment is initiated based on the six workplace risk factors identified:

• Demands – include workload, work patterns, environment
• Control – the amount of involvement an employee has in the pace and method of work 
• Support – includes level of encouragement, sponsorship and resources provided by the organisation, line management and colleagues 
• Relationships – include promoting positive behaviour to avoid conflict and dealing with unacceptable behaviour 
• Role – clarity of role and responsibilities 
• Change – how organisational change is managed and communicated within the organisation. 
  

An audit or questionnaire can provide an indication of how these risk factors are perceived by staff and from November 2008 this can be benchmarked against the similar sized organisations in the country using the HSE audit or similar tool.
    
Examination of absence records, retention levels, accidents and other HR/H&S records all add up to a clear picture of the well being of the staff and the organisation. The audit is anonymous so it can be useful to initiate focus groups to validate and explore issues pinpointed by the audit. Once all the information has been gathered actions are planned with staff and implementation is begun and reviewed after a suitable period of time.
    
In 2007, Donaldson-Fielder, funded by the HSE, produced a useful set of management competencies for preventing and reducing stress at work. These provided clear guidelines for managers on how to deal with issues that arise from any of the six risk factors above. These can be found in HSG 218 revised.

Absence management
Absence management procedures have become very popular recently with useful guidelines being produced by the CIPD. It is important not to demonise sickness but to provide support and encouragement towards health and wellness. Unfortunately, this is not always the outcome when a computer runs the procedure.
    
Employee assistance programmes or crisis telephone lines provide confidential support to all staff, however, the usage of such a provision needs to be monitored to ensure value for money. Referral to occupational health/counselling is another effective route of support for members of staff that are showing signs of stress. It is important that such professional help is focused on coping outcomes and developing staff resilience – helping them to change the way they think and act to enhance their wellbeing. Stress awareness training for all staff enhances knowledge and hopefully results in the use of the word stress to mean regularly experiencing excessive pressure and not a description of every day life hassles.

In a nutshell
In summary, the way forward is to:

• train managers to apply the Management Standards (based on the six risk factors)
• train managers to employ coaching techniques – sometimes just a discussion about perceived pressures is enough to clarify a situation
• encourage managers at all levels to take stress seriously and look at the work factors that may be causing too much pressure. 
• have a good, clear Stress Management/Wellbeing policy
• regularly carry our a Risk Assessment for stress, communicate the results, devise an action plan and work the plan
• listen to staff – even minor adjustments in work load, flexibility in timing and personal encouragement can reduce perceived pressures and enhance commitment
• refer staff to professional support systems that are focused on coping outcomes and resilience.
  

For many years stress has been seen as a weakness, but the many case studies and legal cases clearly indicate it can happen to anyone in the pressurised workplace of the 21st Century.

For more information
Web: www.isma.org.uk