Managing Health at Work Partnership Information Network (PIN) Guideline

MANAGING HEALTH AT WORK

Guideline 1 Dealing positively with stress at work

1.1 Introduction

The organisation of work, communication and leadership styles have a significant effect on the physical, social and mental wellbeing of staff, and consequently on their performance. The characteristics of an 'unhealthy' workplace could include staff:

• frequently showing signs of stress;

• experiencing depression;

• with low confidence;

• behaving aggressively;

• suffering 'burn-out' or breakdown; and

• being absent a lot.

1.2 Promoting attendance by dealing positively with stress at work

Work-related stress has been defined by the Health and Safety Executive as 'the adverse reaction people have to excessive pressures or other types of demand placed on them' (HSE 1995). Stress exists where people see that they cannot cope with what is being asked of them at work or if they are not certain of their job or role. In principle, everyone can experience work-related stress, and no one is immune. However, there is an important difference between work-related stress, and the beneficial effects of reasonable pressure and challenge.

Work-related stress is not an illness, but if it goes on a long time, it can contribute to ill health.

The physical effects include:

• raised blood pressure;

• heart disease;

• back pain;

• stomach problems; and

• minor illnesses.

The psychological effects include:

• anxiety and depression; and/or

• displaying other behaviour which can be bad for health such as skipping meals, drinking too much caffeine or alcohol and smoking cigarettes.

Work-related stress also has consequences for organisations. It can lead to:

• increased levels of sickness absence, together with the associated effects on other members of staff;

• reduced staff morale;

• reduced staff performance; and

• staff looking for other employment.

The scale of the problem

• The Confederation of British Industry (CBI) has estimated that the direct cost of stress-related sickness absence is estimated to be 7 billion a year. This represents a cost of 310 for each employee each year (Parker, 1999). According to the CBI / PPP Healthcare report, stress was the second most significant cause of sickness absence, behind minor illness. The cost for each employee is 426 and a total annual cost of sickness absence cost (for everything) of over 10 billion.

• The Industrial Society (now known as The Work Foundation) stated that bullying accounts for nearly 2.3 billion in lost productivity due to stress-related problems (News item, 1999).

• The Chartered Institute of Personnel and Development said that the annual cost of job stress is around 224 million and the price paid by UK business, in terms of inefficiencies arising from stress, is as much as 10% of the gross domestic product (1998).

• A TUC survey said that five million people have been bullied at work, one in 10 employees claimed intimidation by managers and more than a quarter said they know of colleagues who had been similarly treated (1998).

As a result of these factors it is estimated that stress and stress-related problems account for over one third of every GP's caseload in Scotland (The Scottish Office, 1992). While workplace policies and regulations can do much to improve the working environment and to change unhealthy lifestyle practices among staff, other approaches are needed to tackle stress-related issues and to understand and respond to staff's concerns and needs.

This is especially true in NHSScotland where much of the work is inherently stressful, and where staff are under constant pressure to perform against a background of continuous change and uncertainty. One of the consequences of this pressure is that more and more NHSScotland staff are experiencing stress at work. As a result of this, their physical and mental health is being put at risk while the efficiency and quality of the service is also under threat.

In 1995, the HSE published a landmark document entitled 'Stress at Work: A Guide to Employers'. This clearly told employers about their duty of care for the mental as well as physical health of their employees. Included in the guide was the following warning.

"Ill health resulting from stress caused at work has to be treated the same as ill health due to other, physical causes present in the workplace. This means that employers do have a legal duty to take reasonable care to ensure that health is not placed at risk through excessive and sustained levels of stress arising from the way work is organised, they way people deal with each other at their work or from the day-to-day demands placed on their workforce."

In 1999, the HSE produced a discussion document, 'Managing Stress at Work', and carried out a major consultation exercise. In response to the results of the consultation process the HSE published two guidance documents in June 2001:

• Tackling work-related stress - A manager's guide to improving and maintaining employee health and wellbeing

• Tackling work-related stress - A guide for employees

1.3 Developing a stress policy which tackles organisational and individual issues (or including stress in a general health policy)

The parts of this type of policy might include the following.

• Making a commitment to a healthy workforce by placing a high value on the physical and mental health of staff.

• Acknowledging that stress problems have many causes - including in the workplace and the outside world.

• Identifying and listing the factors that may contribute to increased levels of stress in the organisation. (This should be based on the risk assessments for the organisation.)

• Recognising that domestic factors (housing, family problems and bereavement for example) may add to levels of stress experienced by staff.

• Stating that the organisation is committed to a course of action that may include:

  • increasing knowledge of the causes of stress in the organisation;

  • dealing with the causes of stress and helping staff to manage stress; and

  • managing health problems associated with stress through:

    • recognising symptoms early;

    • managing stress appropriately;

    • providing access to counselling;

    • providing advice and sources of help; and

    • managing the return to work of those who have suffered stress-related mental or physical health problems to make sure that their skills are not lost.

1.4 The benefits of an organisational stress policy

An organisational stress policy can lead to a number of benefits. These include:

• improved staff efficiency and effectiveness;

• improved morale;

• better working relationships;

• a reduction in the waste of trained staff; and

• a better image for NHSScotland.

1.5 The aims of the organisational stress policy

The policy should:

• encourage staff wellbeing within NHSScotland and discourage the stigma attached to stress;

• raise awareness of ill health associated with stress, its causes and associated factors;

• train managers to identify the causes of potential stress and the symptoms of stress;

• change those aspects of the workplace that have been identified (through risk assessment) as increasing the risk of stress;

• improve factors within the organisation that reduce the risk of stress;

• educate staff in techniques for coping with pressure and stress;

• provide staff with help if they have mental or physical health problems associated with stress;

• through information and education, encourage everyone to recognise stress-related problems;

• provide systems of support and make sure they are well publicised;

• encourage staff to get help at an early stage;

• offer easy access to counselling and other professional help;

• make sure there is confidentiality for those who want help (from whatever source);

• as far as possible, guarantee job security, sick leave, the retention of status and make sure that there is no blame attached to those using the support mechanisms;

• set up procedures for return to work, and rehabilitation in work; and

• make sure that these procedures are flexible enough to meet varying needs.

1.6 Putting the policy into practice

To help successfully put the policy into practice it is important to make sure that the policy:

• is part of the health and safety policy and structure within the organisation;

• is linked to other elements of health promotion within the organisation such as Scotland's Health at Work Award;

• is developed to suit the particular structure, organisation and ethos of the organisation;

• is developed by a working group that represents staff of all grades and from all sections of the organisation;

• applies to all staff no matter what their age, sex, ethnic origin or grade; and

• makes clear statements on the roles and responsibilities of each group of staff within the organisation including the following:

  • senior managers;

  • line managers;

  • HR;

  • Occupational Health Services;

  • Trade Unions/Professional Organisations; and

  • all staff.

1.7 Education and training needs

Due to the complex nature of stress, there is no simple education and training programme available to meet all the needs of an organisation. The organisation has to prioritise what action is needed. The type of issues which may need to be addressed include:

• general awareness-raising for all staff; and

• training managers to identify the potential causes of stress and the symptoms of stress.

1.8 Evaluation, audit and review

The activities stemming from the introduction of the policy and all its constituent parts should be constantly monitored and examined with regular revisions of the policy when appropriate. The risk assessment process should also be reviewed in the light of any changes to work activities. Regular monitoring and reviewing staff turnover, sickness absence and accidents may also help to evaluate the effectiveness of the policy.

1.9 The risk assessment process

• Managing risk involves controlling hazards at source rather than treating the effects of a hazard. This philosophy is also suitable for organisational stress.

• A stress audit can be viewed as a precursor to a risk assessment, which in turn enables intervention decisions to be made. This is consistent with an assessment of stress as a hazard along with the likelihood of an attendant risk of harm. Adoption of interventions driven by risk assessment is likely to bring maximum benefit to all by focusing on the key issues. Furthermore, a joint focus of data-gathering, interpretation, discussion and action is likely to be more meaningful for everyone involved (Baker and Saunder OHR 2000).

• Cox and others (2000) in an HSE-funded report ('Organisational Intervention for Work Stress, A Risk Management Approach') made the case for a new approach to assessing and managing stressful work situations. Previous studies have looked at links between what causes stress and health in terms of risks to the individual. This reflects a bias towards dealing with stress at a personal rather than organisational level. The authors argue that what is needed is an approach that looks at problems faced by groups of staff. In other respects the strategy they describe is firmly based on techniques for managing risk used for other hazards including:

  • identifying the hazard leading to characterising risks;

  • an audit of existing risk management systems; and

  • recommendations for new measures that tackle the risks that are still present.

• Risk assessments are used with most other occupational health and safety hazards.

1.10 The organisational stress audit (OSHA)

In order to begin to identify and assess stressors within an organisation it is necessary to look at the organisational structure and culture. A number of stress audit tools are available to help with this process. The main function of a stress audit tool is to investigate current situations within the organisation and will include gathering information on the following:

• organisational culture;

• management and social environment;

• communication;

• task environment;

• problem-solving environment; and

• staff development environment.

The audit will provide the organisation with information on the relevant issues. This should be followed by the introduction of a process of developing interventions to address the identified areas of risk.

One example of an audit tool was developed in 1996 by the Institute of Occupational Medicine (IOM) who adopted this risk-assessment framework and developed the Organisational Stress Audit (OSHA). This identified and categorised the known causes of workplace stress. The categories form a semi-structured interview that acts as the risk-assessment tool.

The OSHA is a three-staged approach that is similar to the methodology used for physical dangers, namely that the first line of enquiry is not targeted at the individual but rather focuses on the nature of the hazard and what procedures are in place for controlling risks. As a result, the specific investigations carried out (for example, the conventional monitoring and control actions) can focus on areas where hazards are thought to be presenting the highest risk.

Stage one identifies the hazards by carrying out semi-structured interviews with a representative sample of staff at all levels and functions in the organisation. This stage identifies and prioritises the risks and recommends an action plan.

Stage two involves detailed investigation of the priority areas in order to develop more wide-ranging strategies for reducing risk.

Stage three aims to evaluate the effectiveness of interventions.

More detail on this model is included at Appendix 1.C.

Other tools available include Work Positive - prioritising organisational stress. This resource was developed by the Health Education Board for Scotland and the Health and Safety Authority, Ireland.

APPENDIX 1.A
Model policy on stress at work

1 Introduction

1.1 [Name of organisation] is committed to a healthy workforce by placing value on both physical and mental health. We acknowledge that stress problems have many causes, including in the workplace and the outside world. In [Name of organisation], our risk assessments show that factors which may lead to increased stress in our organisation include [...]. We also recognise that domestic factors (housing, family problems and bereavement) may also add to levels of stress experienced by our staff.

1.2 [Name of organisation] is committed to a plan of action which includes:

• action to manage the return to work of those who have suffered mental or physical health problems associated with stress to make sure their skills are not lost;

• increasing knowledge of the causes of stress in the organisation;

• action to tackle stress and helping staff to manage stress; and

• managing health problems associated with stress by:

  • recognising stress early;

  • managing stress appropriately;

  • providing access to counselling; and

  • providing advice and sources of help.

1.3 This policy and its procedures have been developed and agreed through our Partnership Forum.

2 Scope

This policy applies to all staff in [Name of organisation] no matter what their age, sex, ethnic origin or grade.

3 Policy aims

Our policy aims to:

• encourage staff wellbeing within [Name of organisation] and discourage the stigma attached to stress;

• raise awareness of ill health associated with stress, its causes and associated factors;

• change aspects of the workplace which have been identified (through risk assessment) as increasing the stress risk;

• enhance the factors within [Name of organisation] that reduce the risk of stress;

• educate staff in techniques for coping with pressure and stress;

• provide staff with help if they have mental or physical health problems associated with stress;

• through information and education, encourage everyone to recognise problems;

• provide systems of support and make sure they are well publicised;

• encourage staff to get help at an early stage;

• offer easy access to counselling and other professional help;

• make sure there is confidentiality for those who want help (from whatever source);

• as far as possible, guarantee job security, sick leave, the retention of status and make sure that there is no blame attached to those using the support mechanisms;

• set up procedures for return to, and rehabilitation in work; and

• make sure that these procedures are flexible enough to meet varying needs.

4 Responsibilities

4.1 Senior managers are responsible for making sure that:

• stress, which is likely to lead to ill health, is eliminated from the work environment as far as possible;

• an organisational culture is developed where stress is not seen as a sign of weakness or incompetence and where seeking help in managing negative stress is seen as a sign of strength and good practice;

• suitable training and guidance is provided to managers to equip them to undertake the necessary risk assessments in relation to stress in the workplace, and effective control measures are implemented where appropriate;

• information is provided for staff on:

  • the effects of stress at work;

  • positive coping mechanisms; and

  • general health improving activities within the workplace;

• advice and information is provided for all staff on how to recognise symptoms of negative stress in themselves and others;

• advice and information is provided for managers on their duty of care to staff;

• a working environment is promoted where staff who feel they are at risk of suffering from the negative effects of stress can raise the issue in confidence, so that necessary support mechanisms can be put in place;

• suitable support mechanisms for staff suffering from the negative effects of stress are established; and

• good practice guidelines based on current evidence and knowledge are produced.

4.2 Line managers are responsible for:

• involving individual staff and staff teams in seeking solutions;

• encouraging a workplace culture where mental wellbeing and physical wellbeing are regarded as equally important;

• making sure, as far as is reasonably practicable, that the physical work environments for staff are safe and do not expose them to risks that may give rise to stress at work;

• considering the implications for staff of any changes to working practices, ways of working, work location, new policies or procedures, and the need for appropriate support and training;

• making sure that all new staff receive appropriate induction to and training for their job, including reference to support services other than at unit level, for example, OHS, HR, Staff Counselling Service;

• providing clear job descriptions (outlining lines of responsibility, accountability, and reporting), individual supervision and clear objectives with review;

• resolving work-related issues at individual level and at team level as appropriate, involving others outside the team as necessary;

• managing absence in accordance with the organisational policy, and linking to other policies as necessary, such as Dignity at Work;

• keeping in touch with any staff who are on prolonged absence and agree with the individual, OHS and HR how to support their return to work;

• reviewing regularly excess hours worked by staff, time back, monitoring absence monitoring and staff turnover, and carrying out exit interviews;

• making sure that staff teams take time to review and celebrate positive achievements and likewise less positive outcomes so that a sense of balance can be achieved; and

• agreeing with staff teams what can be actioned and how to improve things, promoting openness and discussion.

4.3 HR is responsible for:

• making sure that organisational policies and codes of conduct (professional and general) are adhered to;

• facilitating discussions within areas of conflict;

• monitoring staff conduct, attendance, turnover, etc.;

• advocating clarity of roles and responsibilities, advising on job descriptions and organisational structure; and

• promoting positive cultural change within the workforce.

4.4 Trade Unions/Professional Organisations are responsible for:

• encouraging members to speak up as soon as they feel that their working environment is beginning to affect their health;

• using the facilities laid out in the Safety Representatives and Safety Committees (SRSC) Regulations and Management of Health and Safety at Work Regulations to tackle work-related stress;

• investigating potential hazards and complaints from their members, receiving information they need from employers to protect members' health and safety;

• liaising with management to carry out risk assessments, including reviewing absence figures and linking these with other policies that may be available such as Dignity at Work; and

• encouraging members to keep a written record of any problems and to put things in writing to management, so that there is evidence of any problem and that management is aware of them.

4.5 OHS is responsible for:

• advising managers and staff on occupational stressors and the risk assessment process;

• delivering an education/training programme on stress risk assessment/awareness and management;

• providing support for staff at all levels who may be experiencing the negative effects of stress; and

• monitoring work-related stress in terms of sickness absence patterns and self/management referrals and providing appropriate feedback to the organisation.

4.6 Staff counsellors are responsible for:

• offering help to individuals in assessing the effectiveness of the coping strategies they currently use;

• offering help and ongoing support in identifying and maintaining any changes to current strategies;

• offering help in establishing a tailor-made programme of stress management which extends beyond work;

• being accessed by any individual experiencing problems which affect their ability to function; and

• offering an opportunity to talk in confidence about any problem or difficulty, whether work-related or not.

4.7 All staff are responsible for:

• talking to their manager if there is a problem, or accessing OHS, HR or their Trade Union/Professional Organisation;

• supporting their colleagues if they are experiencing work-related stress and encouraging them to talk to their manager, OHS, HR or Trade Union/Professional Organisation;

• seeking support or counselling from OHS and/or the staff counselling service;

• speaking to their GP if worried about health issues;

• discussing with their manager whether it is possible to alter the job if necessary, to make it less stressful, recognising all team members' needs;

• trying to channel their energy into solving the problem rather than just worrying about it, thinking about what may resolve any issues and discussing this with their manager;

• recognising that stress is not a weakness;

• regularly exercising their right to attend stress management courses; and

• being actively involved in the risk assessment process.

5 Education and training

To deal positively with stress at the workplace, [Name of organisation] recognises the importance of:

• the link between home and the workplace;

• identifying particularly vulnerable groups; and

• the effects of prescribed medication on work performance.

These key points will be highlighted in:

• health education for staff;

• induction programmes for new staff (as stress education);

• specific training for occupational health practitioners; and

• feedback (for sorting out any problems with the policy).

6 Monitoring and reviewing

• The activities which result from the introduction of this policy will be examined and the activities of each component part monitored. This review process will lead to a regular revision of the policy.

• As well as the policy itself, the risk-assessment process should be reviewed in light of any changes to work activities.

Regular evaluation of staff turnover, sickness absence and accidents will also contribute to the monitoring and reviewing of the policy.

APPENDIX 1.B

APPENDIX 1.C
Model Organisational Stress Audit (Developed by the Institute of Occupational Medicine)

Stage one

The aim of stage one is to identify:

• the presence or absence of recognised work-related stress factors within the organisation and provide recommendations for reducing risk; and

• areas considered as having the greatest effect on the health and wellbeing of individuals (and so the performance of the organisation) and to outline recommendations for detailed investigation.

Further investigations would use appropriate ways of carrying out testing chosen from published literature. The following are examples.

1 For psychosocial problems

• The Work Environment Scale (Insel and Moosl 1994)

• The Job Diagnostic Survey (Hackman and Oldham 1974)

2 For physical and environmental problems

• The Body Comfort Questionnaire (Corbett and Bishop 1977)

• or direct measurements, for example for heat or noise, may be needed.

Many of these instruments may be used in the assessment of an individual's circumstances, but by carrying out stage one of OSHA any action will be focused and guided by identified needs rather than stemming from a general 'trawling' operation.

In some circumstances the investigative tools may provide a quick response measure for evaluating the effect of change, giving an early indication of effect before more objective benefits such as reduced sickness absence become noticeable.

Using semi-structured interviews

It is important that the semi-structured interviews are tailored to the needs of the individual organisation but they should include questions related to recognised work-related stress such as:

• organisational structure;

• change;

• communication;

• management and supervisory skills;

• training;

• staff support facilities;

• policies;

• sickness absence;

• work characteristics; and

• contracts of employment.

The results of stage one should enable work-related stressors and measures for risk reduction to be recommended.

Stage two

The aim of stage two is to carry out a detailed investigation of the particular pressures being experienced by groups or individuals, or areas of organisational behaviour which, based on information from stage one, could have an effect on the wellbeing of several groups of staff. The method chosen must be appropriate for the organisation and must be specific to the causes of stress identified in stage one. Some of the survey tools that could be used include:

• the general health questionnaire;

• the anxiety stress questionnaire; and

• the work environment scale.

Other stage-two activities might include, for example, carrying out a needs assessment and training on stress awareness.

Stage three - Evaluation

This should revisit those involved in stages one and two to ask if they have noticed any change in levels or causes of stress at individual and organisational level.

Other measures might be changes in sickness absence and staff turnover.

APPENDIX 1.D
References

Cox T et al	Organisational interventions for work stress.A risk management approach. HSE Books, London, 2000, ISBN 0717618382
Health and Safety Executive	Stress at Work - A Guide for Employers. HSE Books, London, 1995, ISBN 071760733X (no longer available, see HSE Tackling work-related Stress)
Parker, Bill	High Anxiety. Occupational Health Vol 51, No 9, 1999
The "News" Section	Stress at work on the up. Occupational Health, Vol 51, No 12, 1999
The Chartered Institute of - Personnel Development	Tackling Work Related Stress - An employee guide to helping theiremployer improve and maintain healthand well-being at work, CIPD, London Available from: http://www.cipd.co.uk
The Institute of Occupational Medicine	Organisational Stress Audit OSHA, 1996

Recommended further reading

Corbett and Bishop	The Body Comfort Questionnaire, 1977
Hackman and Oldham	The Job Diagnostic Survey, 1974
Health and Safety Executive	Tackling work-related stress. A manager's guide to improving and maintaining employee health and well-being. HSE Books, London, 2001, ISBN 0717620506
Health and Safety Executive	Tackling work-related stress. A guide for employees. HSE Books, London, 2001, ISBN 0717620654
Insel and Moosl	The Work Environment Scale, 1994
Institute of Occupational Medicine	The Evaluation of OSHA, London, 1999