Under pressure: what employers must do to reduce workplace stress

It is reckless of healthcare organisations to ignore signs of stress in their workforce or offer only superficial support. With the pressures on nurses reaching dangerous levels, the legal, moral and financial case for action is overwhelming

It is reckless of healthcare organisations to ignore signs of stress in their workforce or offer only superficial support. With the pressures on nurses reaching dangerous levels, the legal, moral and financial case for action is overwhelming

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Nurses are used to showing resilience in a job that is always going to have its stressful moments. But over the past few years those stressful moments appear to have become more common, and the cracks are beginning to show.

A Care Quality Commission report last year revealed how a senior nurse at one hospital said they ‘can’t bear to see junior nurses crying anymore’. The acute trust’s report also detailed inadequate staffing levels, work left undone because of pressure, difficulties in escalating issues, and lack of training and support.

RCN senior employment relations adviser Kim Sunley says employers should be assessing the risk to their workforces and looking at ways to mitigate it. ‘There are regulations in place that require employers to assess the risk from workplace hazards. Stress is a hazard, just as working with chemicals is.’

Failure to protect

The Health and Safety Executive has in the past issued an enforcement notice to a trust for unsafe working practices, and trusts run the risk of claims from staff whose health has been affected by workplace stress.

Despite the risks to organisations that fail to protect their staff, employers’ efforts in this area can be superficial, suggests Ms Sunley. 'Trusts often seem to address the symptoms of stress – for example by providing mindfulness classes – but not the root causes such as work pressures. They will put in resilience training but not address the underlying factors.’

Simple steps to improve communication and engagement could help reduce stress at source, she says.

RCN professional lead for long-term conditions and end of life care Amanda Cheesley says: ‘Of course employers have a responsibility to staff. But I think often they are so busy juggling all of the other plates that they forget the importance of maintaining good staff morale and health.’

For some nurses, stress becomes a danger to their health. A majority of the nurses who contact the RCN’s counselling service have considered suicide, says the service co-ordinator Tanja Koch.

In 2016 268 of those nurses – 24% of the total number contacting the service – had acute suicide ideation, where suicide is actively planned or thought about, and 88 counselling appointments were prioritised because there was deemed to be an imminent risk of suicide.

‘The psychological need and distress our members are experiencing at the moment is a lot more than it was three years ago’

Tanja Koch

Office of National Statistics figures show female nurses have a 23% higher suicide rate than the population generally.

Ms Koch says the severity of the stress experienced by nurses has worsened over the past few years, and a higher proportion have contemplated suicide. Last year the counselling service saw waiting times begin to rise, and it had to put more resources into meeting the needs of distressed nurses.

‘The psychological need and distress our members are experiencing at the moment is a lot more than it was three years ago,’ says Ms Koch. She adds that she cannot see pressures on the workforce reducing.

Top requests for counselling

The top five work-related issues that led to members contacting the service were:

  • Nurses unable to become attuned to the job and workload, failing to settle for reasons ranging from overwork to under-commitment.
  • Bullying and harassment.
  • Work-life balance.
  • Formal proceedings such as investigations, disciplinary hearings or referral to regulatory bodies.
  • Work relationships.

Almost all of the nurses who contacted the service did so because of work issues.

Missed breaks

Nursing is inherently stressful. Nurses deal with the sick and dying every day, they are under time pressure and face conflicting demands. But many feel their work has become much more intense over the past few years.

Some of this may be due to dealing with sicker patients, some may be due to staffing shortages and working with more temporary staff who may not know the ward routines. This can lead to missed breaks and late finishes.

Nurses may also be concerned about changes to their working routine that can have a profound impact on their work-life balance, such as rotas being rearranged or services being centralised, meaning they have to travel further to get to work.

This is not just an ‘acute hospital’ problem, says Ms Cheesley. Nurses in other parts of the NHS and the private sector, including care homes, often face high levels of pressure as well.

‘The NHS has arguably led the way with more open conversations about psychiatric health and well-being’

Danny Mortimer, NHS Employers chief executive

In the latest NHS staff survey, conducted in 2016 and published last March, 37% of those responding reported feeling stressed. NHS Employers chief executive Danny Mortimer is quick to agree that this is too high, although it has actually fallen over the past few years.

‘That is positive but it is still 37% of the workforce,’ he says. ‘We all recognise that the demands that are made on our sector are increasing. Employers over the past 15 years have taken ever more seriously their responsibility to help people.’

Mr Mortimer says there have been attempts to address the causes and the manifestations of stress – increasing staff numbers, technological innovations and new ways of working can all help staff meet the demands on their time and talent. More employers are also offering employee assistance programmes, he says, and there is increased openness about psychological and mental health.

While the NHS may not be perfect, and there remains more to do, he says it is trying to create the right climate. ‘The NHS has arguably led the way with more open conversations about psychiatric health and well-being.’

Care in, care out

There are also financial drivers for trusts to address this, as stress is a major reason for sickness absence. ‘At its simplest, it is care in, care out. The business case is an utterly compelling one, and it chimes with the moral case,’ says Mr Mortimer.

There are plenty of tools that employers can use to tackle some of these issues.

The RCN’s healthy workplace toolkit is designed to be used by employers together with trade union representatives to carry out a check of where the organisation stands and identify areas for improvement. NHS Employers has its own toolkit, which was tested with nursing teams.

There are also Health and Safety Executive management standards – these say there is often insufficient attention paid to elements such as job design and management in work-related stress – and NICE workplace health guidance on mental health and management practices.

Performance rating fears

Employers could introduce a confidential occupational health service that nurses could contact without fear of it escalating into a performance management issue, suggests Ms Sunley. Ideally, staff should also be able to access counselling services.

‘There has to be more that organisations can do to keep an eye on their staff and recognise when there are things that may be escalating,’ she says. Triggers that employers can watch out for include rising sickness rates and more errors, which may be a sign of stress in the workforce.

As a first step, employers need to ensure nurses have breaks, can take holidays, and receive support such as debriefing after stressful events, says Ms Sunley.

‘There are wins if you look after your staff and you make the workplace as pleasant an environment as you can, where people feel genuinely valued’

Kim Sunley, RCN senior employment relations adviser

Mr Mortimer is hopeful that the government will take on board concerns about employee health and well-being. He would like to see a nationwide fast-track service through occupational health for healthcare workers experiencing mental health or psychological problems.

But Ms Sunley says nurses run the risk of their resilience being eroded to the point where they can no longer function. ‘We as nurses are not terribly good at saying enough is enough – the amount we are being asked to do under the conditions in which we work is no longer acceptable,’ she says.

‘There are wins if you look after your staff and you make the workplace as pleasant an environment as you can, where people feel genuinely valued. We are treating staff the way people were treated at Mid Staffs, and that is an incredible indictment.’

Stark figures reveal extent of stress at work

  • An RCN survey of more than 2,000 members in 2012, called Beyond Breaking Point, found a workforce struggling with a high workload and fast pace of work, while also feeling detached from the implementation of changes in the workplace. It highlighted safe staffing levels, shift patterns and lack of staff engagement in changes. More than four out of five nurses had gone to work feeling unwell in the previous 12 months. A third said work often or always had a negative impact on their health and well-being, with around half having felt unwell due to stress or workload in the previous 12 months.
  • Figures for 2016-17 from the Nursing and Midwifery Council show 45% more UK nurses and midwives leaving the register than joining it. Nearly 3,000 of them were under 30. Among the main reasons for leaving were working conditions, cited by 44% of those not retiring, and disillusionment with the quality of care provided to patients (27%).
  • A 2016 survey by the NHS found that 37% of staff had felt unwell due to work-related stress, the lowest figure since 2012. There was also a drop in the number who had come to work feeling unwell in the previous three months, because they felt pressure from managers, colleagues or themselves (56%, compared with 64% in 2012).
  • A BBC freedom of information request found that over 40,000 NHS staff took sick leave due to stress, anxiety or depression in 2014, double the 2010 figure.

NHS trust finds early intervention brings positive results

Rising levels of stress and sickness absence at Gateshead Health Foundation Trust prompted staff and the HR department to work together, using the RCN’s healthy workplace toolkit.

Deputy director of workforce Karen O’Brien says it had the highest level of absences among trusts in the north east. ‘There had been a steady increase in absences related to stress, anxiety and mental health over the previous 12 months,’ she explains.

‘We found that staff who were off work due to an issue related to mental health were five times more likely to return quickly if there was an intervention in the first few days.’

Now staff who are off sick for reasons thought to be related to mental health will be contacted and offered rapid access to the occupational health service.

Range of options

If they wish they can then be offered a range of options, from self-help suggestions to referrals to psychology services.

Sickness absences have gone down by about a fifth since this was introduced last year, partly due to the decline in long-term absences, she says. Many of the staff had issues at home rather than at work, says Ms O’Brien.

The trust has also introduced an internal mediation service to address work-related problems before they escalate.

Denise McLaughlin, who chairs the staff side committee, says the trust was keen to engage and there was a high level of support from management.  Ms O’Brien says input from Ms McLaughlin about her members’ experiences was important in shaping solutions.

Alison Moore is a freelance health journalist


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