Prevention and management of stress at work

Chapters

About the Health, Safety and Wellbeing Group

The Health, Safety and Wellbeing Group (HSWG) is a sub-group of the NHS Staff Council. It is a tripartite group involving staff side representatives from healthcare unions, management side representatives from NHS organisations and specialist members, such as the Health and Safety Executive, and the Institute of Occupational Safety and Health with a remit to do the following:

to raise standards of workplace health, safety, and wellbeing in healthcare organisations
to promote a safer working environment for all healthcare staff
to promote best practice across both the NHS and the Independent sector.

This guidance was produced through effective partnership working between unions, management, and specialist advisors. The group wishes to ensure this guidance is implemented with the same partnership approach. The HSWG recognises that partnership working ensures best outcomes for patients and staff in protecting their health, safety, and wellbeing.

Find further HSWG resources to support you in your organisation.

Download this chapter: About the Health, Safety and Wellbeing Group

Introduction

There is increasing evidence that work-related stress is on the rise. This has been identified through various studies and surveys. For example:

In 2020, the Chartered Institute of Personnel and Development (CIPD) found that over two fifths of public sector organisations reported that stress-related absence (most commonly caused by heavy workloads) had increased over the last 12 months. With 70 per cent, stating it is the most common cause of long-term absence.
The 2020 Labour Force Survey found rates of work-related ill-health due to stress in the health sector is statistically significantly higher than that for workers across all industries (HSE 2020).
The annual NHS Staff Survey (2020) reported that 44 per cent of staff reported feeling unwell as a result of work-related stress in the last 12 months, a steady increase from 36.8 per cent in 2016. Increases were sharpest in acute/acute and community trusts and acute specialist trusts.
The Health and Safety Executive (HSE) publication Work-related Stress, Anxiety or Depression Statistics in Great Britain, 2020 identified that figures for stress, depression or anxiety in 2019/20 was statistically significantly higher than the previous period.

There are moral, financial, legal, and quality reasons for managing stress in the workplace. This guidance uses various sources including good practice information drawn from a useful 2013 study titled Health and Wellbeing in Healthcare Settings, commissioned by the NHS Staff Council.

More recently a study by the Royal College of Nurses Foundation and the Society of Occupational Medicine (2020) The Mental Health and Wellbeing of Nurses and Midwives in the United Kingdom report calls on urgent action to properly address the organisational causes of poor mental health and wellbeing in nurses and midwives (e.g., high work demands, poor leadership, lack of resourcing and workplace bullying).

The authors found that many staff were reluctant to disclose mental health difficulties and avoid asking their managers for support. They recommended that to avert a mental health crisis among staff, more healthy working environments were needed for nurses and midwives, with the stigma of disclosing mental health problems to be reduced, and managers and leaders being training to identify and alleviate stress in staff.

The HSE (2020) statistics, identified professional groups, and associate professional and technical groups as having the highest prevalence rate of work-related stress, depression or anxiety, with the predominant causes being workload, particularly tight deadlines, too much work or too much pressure or responsibility, with lack of managerial support, organisational changes and violence and role uncertainty.

The aim of this guidance is to enable employers within health organisations to work in partnership with trade union bodies and employee representatives to identify the signs of stress and put in place measures to prevent and reduce the causes and risks associated with workplace stress.

The key aspects of this guidance are:

identify signs of stress
identifying how management behaviours impact on the health of staff
demonstrating how, by working in partnership on stress risk assessments, the impact on health and wellbeing can be positively improved
providing resources for future use.

Download this chapter: Introduction

Who is the guidance for?

The guidance is aimed at managers and employees at all levels within the organisation.

For executive and non-executive board-level members – the guidance provides information to demonstrate the best practice all organisations should be working towards. This will support the requirement of The NHS People Plan (2020/21) in England where the promise includes 'we are safe and healthy' where wellbeing has been identified as a priority.

Northern Ireland

Health and Social Care Workforce Strategy 2026 This Northern Ireland Health and Social Care workforce strategy outlines a number of actions which, when implemented, will support our people to deliver world class health and social care.

Scotland

Health and social care: integrated workforce plan sets out our future workforce requirements in a national context and provides revised workforce planning guidance to health and social care employers.

Wales

A Healthier Wales: our Plan for Health and Social Care, recognises that a key factor in delivering high quality health and social care is the wellbeing and engagement of colleagues, with one dimension of the quadruple aim: ’to enrich the wellbeing, capability and engagement of the health and social care workforce’.

The Stevenson Farmer report Thriving at Work suggested a framework for employers to encourage open conversations about mental health and what support was available, provide good working conditions with a work life balance and routinely monitor employee mental health and wellbeing to promote a positive role in improving the mental health of the workforce (Stevenson/Farmer 2017).

Having a joint approach between all parties, will ensure that duties under the NHS Constitution, health and safety legislation are met and any civil activities minimised.

For senior HR, occupational health and health and safety practitioners – it provides a benchmark to audit current practices against. It also promotes the benefits of working in partnership to increase trust, benefit employees and improve the organisation as a whole. For organisational learning practitioners, it demonstrates the behaviours, cultures and practical approaches that can lead to improvements in employee health and wellbeing through management intervention.

For trade union safety representatives – it enables further opportunity to work in partnership with management to improve the health, safety, and wellbeing of members in the workplace. It represents an opportunity for dialogue to feed into policies, procedures, health, and wellbeing initiatives that can be monitored through the appropriate committees.

Download this chapter: Who is the guidance for?

Defining stress

Work-related stress is defined by the Health and Safety Executive (HSE) as:

“The adverse reaction people have to excessive pressures or other types of demand placed on them at work.” (HSE 2021)

Work-related stress develops because a person is unable to cope with the demands being placed on them. It is not in itself an illness, but physical or mental illness may manifest if the causal factors are not addressed.

Two people can be subject to the exact same experience and have very different physical responses. Within a workplace each and every situation can bring a different reaction to different individuals. Stress is subjective and is all about how the individual perceives and interprets the factors which could cause stress. It is not the same as stimulus. Therefore, there is no suggestion that ‘stress can be good for you.’ Stress is caused by a stimuli and can be either positive or negative that prompts an action.

Stress is often missed because it is not visibly evident. Individuals can be suffering from the effects of stress, which could be caused by a number of different factors, but their tolerance can become reduced by factors in the workplace. This could result in a sudden and unexpected reaction to a certain event or events. Like many issues which cause a reaction in an individual, the event which causes a stress reaction or illness may only be a contributing factor, not the only factor.

Ultimately if an individual is continually exposed to an environment (work or non- work) over a long period of time, or as a result of a sudden traumatic event stress-related ill health can present itself. Some of these ways are listed in the signs of stress section below.

The use of the HSE Stress Management Standard as part of the risk assessment process provides the organisation with examples of suitable control measures that can be put in place to assist the manager and the employee.

The Talking Toolkit provides a simple and practical framework to enable teams and managers dealing with issues, to engage in constructive conversations to identify the causes of stress, anxiety, or concerns. The toolkit also includes proven solutions that may resolve or prevent identified workplace stress related problems.

The talking toolkit for:

England
Scotland
Wales (in English and Welsh)

Download this chapter: Defining stress

Signs of stress

Stress can manifest in individuals in many ways, including physical symptoms, changes in normal behaviour and emotions. These symptoms can develop into health conditions including depression and anxiety, heart disease and digestion conditions such as irritable bowel syndrome.

If you notice employees start acting differently it can be a sign that they are stressed.

Signs of stress in teams:

arguments
higher staff turnover
more reports of stress
more sickness absence
decreased performance
more complaints and grievances.

This could have an impact on the delivery of quality care.

Signs of stress in an employee:

A change in the way someone acts can be a sign of stress, for example they may:

take more time off
arrive for work later
be more twitchy or nervous.

A change in the way someone thinks or feels can also be a sign of stress, for example:

mood swings
being withdrawn
loss of motivation, commitment, and confidence
increased emotional reactions – being more tearful, sensitive, or aggressive.

The NHS lists the following as symptoms of stress:

Physical symptoms

Headaches or dizziness.
Muscle tension or pain.
Stomach problems.
Chest pain or a faster heartbeat.
Raised blood pressure.
Tightness of chest/chest pains.
Abdominal cramps.
Nausea.
Sleep disturbance/tiredness.

Mental symptoms

Difficulty concentrating.
Struggling to make decisions.
Feeling overwhelmed.
Constantly worrying.
Being forgetful.

Changes in behaviour

Being irritable and snappy.
Sleeping too much or too little.
Eating too much or too little.
Avoiding certain places or people.
Increased alcohol, nicotine, or drug intake.
Working longer hours – not taking breaks.

Download this chapter: Signs of stress

Identifying the causes of stress in the workplace

The HSE has developed six standards, known as the ‘management standards,’ to help organisations manage stress. The standards are based on factors which are recognised to be the key causes of workplace stress. If not properly managed, these factors can lead to ill health, absence, and reduced productivity.

HSE’s management standards

1 Demands

Includes issues such as workload, work patterns and the work environment.

2 Control

How much say do the people have over the way they work?

3 Support

Includes encouragement and resources provided by the organisation, line management and colleagues.

4 Relationships

Includes promoting positive working to avoid conflict and dealing with unacceptable behaviour.

5 Role

Do people understand their role within the organisation, and does it ensure roles are not conflicting?

6 Change

How is organisational change (large and small) managed and communicated?

One, or a combination of these factors, can result in an employee feeling stressed in the workplace. For example, an employee with a high work demand, with little support or information about how to do the job following a recent organisational change, could be experiencing high levels of stress due to the complexity of factors that it involves.

The workplace health and safety standards, produced by the HSWG outline the legal requirements to risk assess stress.

Download this chapter: Identifying the causes of stress in the workplace

Impact of organisational change on stress

The NHS has seen unprecedented levels of change over the past ten years.

The potential health impact on the workforce of major organisational level change such as restructuring is well recognised, (Kings Fund 2018). Whilst change can be positive, staff may be particularly vulnerable to stress where:

there is a risk of redundancy
there is a risk of down banding or de-banding
The services are being outsourced or transferred to another employer
continuous change of service to offer greater efficiencies.

Higher levels of presentism – going to work despite being unwell – have been observed in workers going through restructuring as there is a perception and sometimes a reality that employees with poor attendance records are more at risk of being made redundant (CIPD 2020, RCN /SOM2020).

Organisational change has also been linked with an increased risk of bullying. Bullying from a manager or a colleague has been found to increase symptoms of stress (HSE 2013b).

There is also evidence that people not made redundant, so called ‘survivors’, suffer from health problems, report less job satisfaction and have higher absence (Burke 2003). Employees that remain may experience feelings of guilt towards their dismissed colleagues, increased job insecurity and associated anxiety. There is also evidence that pre-existing health problems, such as musculoskeletal disorders can worsen. Working in an unfamiliar environment with increased demands may also cause stress.

All these are subjective to the individual and their tolerance to factors. Some change can be positive, but managers should be aware that stress will occur in individuals where they no longer feel in control and unsupported. The HSE’s standards on stress outlines the states to be achieved in order to reduce the impact of organisational change.

To manage the risks of stress from organisational change the employer should be able to demonstrate that:

employees indicate that the organisation engages them frequently when undergoing an organisational change
systems are in place locally to respond to any individual concerns.

To achieve this, the organisation should:

provide employees with timely information to enable them to understand the reasons for proposed changes
ensure adequate employee consultation on changes and provide opportunities for employees to influence proposals
ensure that employees are aware of the probable impact of any changes to their jobs and if necessary, employees are given training to support any changes in their jobs
ensure that employees are aware of timetables for changes
ensure that employees have access to relevant support during changes.

Managers need to ensure that there is regular and quantifiable measurement of departmental susceptibility to workplace stress.

Download this chapter: Impact of organisational change on stress

Effectively measuring stress in the workplace

The HSE has developed a stress indicator tool that can be used to measure how an organisation is meeting the stress standards. Alongside the HSE indicator tool, there are a range of measures that a manager can use to assess the health of a department in relation to workplace stress. It is important to consider that there is no definitive calculation or formula to do this. Instead, managers should consider a range of measures, which suggest that there may be stress in the workplace. These can be individual to the particular service, the department or organisation wide.

Managers should also consider the frequency and timing of looking at information. Consideration of baseline data can be taken at a time of relative calm and used in comparison to other periods to identify potential greater risk of staff being susceptible to workplace stress. Equally, conducting an assessment at the onset of and immediately after sizeable organisational change can give an indication of the stress felt by staff as a result of the change.

One NHS organisation case study on the HSE website assessed and managed the risk of stress and decided to take a more proactive, preventative approach to managing stress-related ill health.

Below are examples of the type of information which should be considered holistically to indicate a department’s prevalence to workplace stress.

Sickness absence information

Managers could use information from the electronic staff record (ESR) to identify possible areas where there may be high levels of stress.
Managers should not assume that sickness absence relating to stress or anxiety is necessarily as a result of workplace stress unless there is evidence that the absence is caused by pressures of work.
Managers should look for workplace trends of high sickness absence or spotted absence to indicate where there is a risk of stress. These absences could be indicative of high levels of fatigue or burnout, or indicators of an increased risk of bullying or harassment in an area.
Organisations might find it useful to analyse its sickness absence data by age, disability, ethnicity, religion or belief, sex, and sexual orientation to see whether there are any trends which merit further investigation.

Occupational health referrals / counselling statistics

Due to the confidential nature of occupational health referrals, managers will not always be aware of when staff self-refer or access services for support. However, this information when gathered at a high level will provide an important guide to identifying risk in an organisation. Anonymised numbers of self-referrals or access of occupational health services from a particular area can provide an indicator of high risk of stress.

Critical incidents / errors / trauma

Within a health care setting, there may be times when employees, experience potentially distressing and traumatic situations which may have causal factors relating to stress. Repeated exposure to such events, can affect the mental health and wellbeing of employees and the team, for example, a high number of deaths in a short period.

Certain professions may make employees more vulnerable to post traumatic stress for example midwives (20-33 per cent) and emergency nurses (39 per cent). (SOM/RCN 2020).

Undertaking a risk assessment identifies key causes of stress, such as excessive demands and/or control factors, where there is lack of resources, human or physical to do the job. The assessment can introduce measures that can assist the manager and employee/s to identify actions required to resolve any concerns.

Workforce information

Workforce information and analysis of statistical data regarding vacancy rates in departments may provide information of where the risk of work-related stress may be a concern.
Vacancy rates can impact directly on demand where there are not enough people to do all of the work.
Turnover of employees can be an indicator of dissatisfaction with a manager, as it is often that people do not leave jobs, colleagues, or specialties, rather they leave their manager. Therefore, a review of the reason for leaving is crucial to understanding if there are any concerns within a department.
Disciplinary, grievance or bullying and harassment figures demonstrate where a department may be dysfunctional or have weak leadership, leading to increases of stress through loss of control.
Organisations are strongly recommended to analyse these areas of workforce information by age, disability, ethnicity, religion or belief, sex, and sexual orientation to see whether there are any trends which are concerning or merit further investigation.

Incidences verbal abuse / aggression and violence at work

Where the risk of violence or verbal aggression is not monitored, and if staff are not actively supported after an incident this could affect the moral of a team and the mental health of employees.

Therefore, monitoring and reviewing incidents of verbal abuse, aggression, and violence within specific departments against sickness absence could identify where control measures or where additional security measures may be required to reduce and prevent incidents.

NHS Staff Survey data

The 2021 NHS Staff Survey reported that work-related stress in registered nurses and midwives in England increased significantly to 53 per cent from 44 per cent in 2020 and 43 per cent in 2019. Midwives, mental health nurses and district and community nurses reported the highest levels of work-related stress.

NHS Staff Survey data cannot be analysed to departmental level, but at a directorate or clinical service unit level it can indicate where employees have anonymously expressed opinion on what they feel about a number of factors.

Based on the above information, facilitated focus groups can be set up to test opinion on a qualitative basis which may indicate where there is significant risk of stress at work. Analysis of this data by various protected characteristics (for example, ethnicity, sex, or sexual orientation) may also reveal some useful information in terms of trends or patterns which may merit further investigation.

Download this chapter: Effectively measuring stress in the workplace

Effective stress management policy implementation

Organisations need to ensure all employees are aware that it takes the management of workplace stress seriously. A key way of achieving this is to effectively implement a workplace stress policy. Not only will this help to assure employees that managers take the issue seriously, but it also provides an effective tool to identify, assess and tackle possible causes of stress in the workplace.

The policy needs to be under constant and active implementation. To ensure this, a stress at work policy group consisting of management and staff side working in partnership can help to ensure that departments are regularly assessing the risks of stress in the workplace and are taking action to address this. The group could:

act as a focus group for best practice
work as a discussion forum for organisational events which support the organisation to manage stress more effectively
consult with any staff support networks that may exist within the organisation, for example, disabled employees’ network, lesbian, gay, bi-sexual, and transgender (LGBT) network, black, Asian, and minority ethnic (BAME) network to get their insights/perspective on the implementation of the policy.

Care should be given to which parts of the policy are around process and which parts are around advice. There is a risk that guidance is seen as ‘policy’ in that it becomes an instruction to be followed. It may be useful to separate the document into policy and guidance:

the policy part can deal with the process which needs to be followed to identify and manage stress
the guidance can be around what departmental interventions can be put in place to reduce or prevent particular risks caused by specific occurrences.

Checklist: What to include in the policy
To make a strong statement and to have an effective process to identify, assess and manage stress in the workplace, policies need to reflect the following:

Statement of intent
Include a statement at the beginning of the policy making a commitment to preventing, managing, and reducing the causes of stress.

Context
Ensure the policy reflects the legal implications of why organisations have to manage stress in the workplace.

While there is no specific legislation on stress, the Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulations 1999 require all employees to be protected from risk and harm, so far as is reasonably practical, and for employers to assess the risks of workplace hazards. As stress can cause harm to individuals, stating the statutory requirements of organisations contextualises the need to have an effective stress at work policy.
National Institute for Health and Care Excellence (NICE) guidelines on promoting mental wellbeing at work also provide context for work on stress and should be implemented by NHS organisations (NICE 2009).

Definitions
Define stress, as this is key to understanding what it is and how it can occur. Citing HSE’s six management standards is key to understanding how stress can manifest and where it can be controlled in order to prevent it from causing harm.

Process for identifying stress
By following the HSE’s Plan / Do / Check / Act approach all aspects of the process may be evaluated.

The risk assessment is to be reviewed on an annual basis and a year-on-year analysis on improvements and feedback for ongoing learning will provide information and reassurance to employees that management of stress at work is being discussed and actioned.

Ensure there is an effective way for identifying where stress is likely to occur. This could be through an annual audit, or through sporadic audits which could be targeted at specific departments, for instance who have been involved in critical incidents or significant change.

Identifying priorities
Ensure that once the data has been collected, it can be assessed and prioritised to identify where the greatest risk exists.

If the Stress Indicator Tool is used, data can be downloaded into the HSE analysis tool to produce a report.
The policy should state the process for implementing action and ensuring progress on priorities. Procedures should be put in place to monitor and review the effectiveness of the policy.

Staff involvement in action planning
Ensure processes which look to prioritise key areas for action are agreed and implemented with staff involvement.

Once the data shows which departments and which factors are of highest concern, hold a time-out or action planning meeting with staff and their safety representatives to identify clear priorities with methods of evaluation and timescale for review.

Cascade action plans through team briefings for information and make them available to health and safety committees, workforce committees and stress at work policy groups for performance management and assurance purposes.

Available resources
Make reference to what internal and external support is available to staff who suffer from stress on an individual basis, including:

where to go in order to seek support
which websites can offer advice on dealing with stress
who to speak to within the organisation. Individuals should be able to self-refer to occupational health services.

The policy should avoid giving advice on how an individual may self-diagnose stress. There is a risk that employees may think themselves as stressed, which itself becomes a source of stress.

Responsibilities
Make reference to who is responsible within the organisation for implementing and supporting the policy:

the chief executive to reference the need for top-level support for ensuring policy practice is embedded within the organisation
senior manager and line manager responsibilities – to implement at departmental level
human resources – usually as the lead for the policy and to monitor effectiveness
health and safety team – to support development and implementation of policy
occupational health – to support the development and implementation of policy
safety representatives – to act in a collegiate way and escalate concerns
employees – to act in a way which ensures their behaviours do not cause stress within others.

Cross reference to policies which already exist
Ensure that the policy references other policies, such as the prevention of bullying and harassment or flexible working policies and practices. Stress is not in itself a single condition caused by a single factor.

Download this chapter: Effective stress management policy implementation

Management behaviours which impact on stress at work

Business Psychology Consultancy, Zeal Solutions commissioned by the NHS Staff Council, HSWG subgroup, (Zeal Solutions, 2013) looked at which management behaviours have positive and negative impacts on health and wellbeing in the workplace.

In this section, managers can use their research findings as a toolbox to reflect whether they demonstrate the positive management behaviours which impact on health and what they could do differently that would have a positive outcome.

In partnership with the Chartered Institute of Personnel and Development and Investors in People, HSE has developed a self-assessment tool to help managers reflect on their behaviour and management style.

Managers should also consider whether unconscious bias is affecting their behaviour or decision making in any way.

Workplace features having a positive impact on health.

Listed below are some of the recommended behaviours which are seen to have a positive impact on employee perceptions of support.

Supportive management behaviour

According to the HSE one of the six factors influencing stress at work is support. Business Psychology Consultancy - Zeal Solutions’ research findings (commissioned by the NHS Staff Council), indicated that managers provide an important role in offering support. The research shows how employees look to managers for approval, appreciation, and information.

Management support was also seen as crucial at a time of organisational change, which is another of the HSE’s six factors.

Recommended behaviour impact statement from research	Impact statement from research based on staff feedback
Managers should provide feedback and communicate openly on actions/ decisions taken.	“It’s not just the communication. It’s actually being honest... and answering the questions. And being open.”
Managers should use the knowledge, skills, and expertise of their staff.	“Managers should involve the team in how to find solutions to problems. Staff have a great deal of experience, knowledge and expertise that can help to make a difference."
Managers need to consider how best to protect staff from increasing and competing demands.	“We feel like we are fighting a constant battle because there are different demands coming in from different people.”
Managers need to keep staff updated and provide a rationale for actions and decisions taken.	“Managers need to keep you updated on what’s going on, so you know what’s happening and you’re fully aware.”
Managers should be given the training as well as protected time to carry out performance reviews that are considered high-quality, effective, and supportive of staff development opportunities.	“More needs to be made of performance appraisals. This is a good source of feedback but rarely used appropriately. It is used as a tick-box exercise, but it needs to be monitored and used properly not just as a once-a-year exercise. We should also consider 360-degree appraisals, so we can appraise our managers.”
Managers should be offered training which makes them aware of the critical role they have to play in employee health and wellbeing.	“Managers need to lead by example and to be made more aware of the impact of their behaviour on others.”

2. Positive interpersonal collegiate relationships

Another one of the six factors in influencing stress at work, according to the HSE, was relationships. Having positive relationships builds resilience within staff. For instance, staff groups experiencing a major or critical incident can share the experience through debrief with colleagues, which helps to control and manage the stress caused by the event.

Having positive working relationships across teams is also important for building teamwork outside the department. Having trust and appreciation across specialty and department supports more effective patient care as well as generating a feeling of wellbeing within individuals. These both produce positive feelings which helps manage the perception and resilience towards stress. Once again, consultation with relevant staff support networks can also help to engender trust and confidence across the wider organisation.

Below are some recommended behaviours, which managers can implement which will increase the likelihood of people perceiving positive interpersonal collegiate relationships.

Recommended behaviour	Impact statement from research
Ensure all are aware of the true value of effective teamwork and the impact organisational change can have on performance.	“We are looking at relocating... and I think anxiety levels have just shot through the roof, because that is beyond our control, but that would be an example of such a devastating impact on team culture, because we rely on each other so much.”
Provide appropriate and tailored team training and team working events, this includes increasing the level of interaction between and within specialties.	“Teamwork is pretty good in some parts, but we need more of it. We are not trained to work in teams but just expected to be able to do this. Some people are more natural at team working than others and this should be acknowledged and managed in some way.”
Make use of pre-existing services that assist with staff development.	“We’ve got a mediation service which has been used quite a bit and that’s been brilliant.”
Wherever possible, ensure policies, procedures and practices are applied consistently.	“It is often because different application of policies and procedures leads to conflict between people. You find that whispering cultures start to develop and issues escalate. Some staff are treated differently. For example, some are able to obtain annual leave when they like, for others it is a great deal more difficult.”
Utilise the most appropriate medium of communication when delivering messages.	“People do everything by email now so you’re losing the personal touch... the email doesn’t portray emotions and is so impersonal.”
Managers should be offered training which makes them aware of the critical role they have to play in employee health and wellbeing.	“Managers need to lead by example and to be made more aware of the impact of their behaviour on others.”

3. Positive contribution
Giving people information and feedback is central for supporting health and wellbeing in the workplace, as identified within both the role and support. Ensuring appraisals are carried out, and ensuring a balance between praise and constructive criticism, will support employees to understand and relate more effectively to their organisation.

Below are some of the recommended behaviours, with impact statements, which supports staff who took part in the research feel this adds benefit.

Recommended behaviour	Impact statement from research
Make use of performance appraisal and supervision sessions to acknowledge positive contributions.	“Although there are some improvements in places, more emphasis needs to be made on the importance of the performance appraisal system. This emphasis should not be put just on managers; all staff have a role to play here. Supervision doesn’t have to be formal it can also be informal. It becomes important that you can also chat about difficulties you are facing with colleagues who can help you to reflect and see a way through sometimes.”
Provide more positive feedback to staff.	“At the end of the day for somebody – just anybody – to come to you and say, ‘thank you.’ It’s a big word, thank you. Sometimes that’s just all you need.”
Ensure positive contribution is acknowledged within management development and training.	“At the end of the day for somebody – just anybody – to come to you and say, ‘thank you.’ It’s a big word, thank you. Sometimes that’s just all you need.”
Share positive feedback or customer/client satisfaction with staff.	“You rarely hear anything positive, all we hear is ‘we’ve had a massive complaint today’ but you rarely hear ‘we’ve had a lovely message that that says thank you very much.’ Hearing positive feedback is good for our morale.”
Utilise the most appropriate medium of communication when delivering messages.	“People do everything by email now so you’re losing the personal touch... the email doesn’t portray emotions and is so impersonal.”
Managers should be offered training which makes them aware of the critical role they have to play in employee health and wellbeing.	“Managers need to lead by example and to be made more aware of the impact of their behaviour on others.”

4. Participation/kept informed
Ensuring staff are kept briefed on key issues fits in with the role and support aspects of the HSE stress at work factors. The impact statements below illustrate the importance of ensuring staff have regular updates and feedback. Highlighted is the need to measure staff opinion, but to also give staff feedback on what managers plan to do with this information. This also gives an element of control, another factor regarded by the HSE as key to influencing stress.

Therefore, keeping staff up to date and working through issues identified within the annual staff survey to improve their workplace is an effective way of helping staff increase resilience against stress.

Recommended behaviour	Impact statement from research
Keep staff up to date and in the picture.	"I think if there was a bit more honesty about what was actually happening that would help. It seems as though we are given little snippets of information rather than the full picture. You often hear comments and things being said that can actually be interpreted in many different ways; it is unnerving and upsetting."
Improve access to information through web-based technology.	We have an intranet site, but it is too complicated and difficult to navigate to find anything of use or meaning.”
Hold regular feedback sessions with staff groups so views can be shared, and questions asked and answered.	“We would welcome the opportunity of meeting with senior managers at specific times throughout the year so we can raise our issues, share ideas and ask questions.”
When collecting data from staff (for example, through surveys), ensure staff understand how this has benefited them.	“We seem to complete lots of surveys or forms but yet no one ever tells us what they are for or how they are being used or if anything has changed as a result of them.”
Prevent staff from hearing messages from other sources first rather than receiving information from credible sources within the organisation.	“There is nothing more demoralising than hearing about change in your place of work through the local paper or from other sources. We are not children, although the news is not always easy to say, we would rather know than find out through a third party.”
Managers should be offered training which makes them aware of the critical role they have to play in employee health and wellbeing.	“Managers need to lead by example and to be made more aware of the impact of their behaviour on others.”

Workplace features having a negative influence on health.

This section discusses where management action can have a detrimental impact on stress in the workplace. Managers should consider these suggested behaviours in a positive manner, in that taking that approach can lead to a reduction in the negative factors which can increase feelings of stress.

1. Work overload

Stress is more likely to occur when there is a loss of control in managing demand – another one of the HSE factors which is seen to influence stress. Where that is often felt most acutely in organisations is through workload pressure. Where an individual perceives that they do not have control over the workload, this increases the risk of burnout. The recommended behaviours suggest more management control in managing workflow and ensuring appropriate staffing with the required skills, but it also recommends that staff can escalate concerns and feel they are being addressed.

Recommended behaviour	Impact statement from research
Understand team workload and strengths and effective management of work tasks and teams.	“Part of the solution is about managers knowing their staff, how much their staff have got on and how they are coping. Often staff are just so committed to doing a good job that they skip lunch or other breaks because time is so tight, and they don’t want to let people down.”
Support staff in terms of prioritising tasks.	“I don’t personally know which tasks I can just leave and which ones I can’t, but my manager does. It is important that they give you guidance and feedback and say ‘actually, that one’s important, get that one done, don’t do that one.’ ’’
Develop a culture whereby staff feel confident about raising concerns about workload.	“It is about engendering an open culture of communication at all levels. If staff feel they can communicate when they feel work is too much, then it allows them to share their feelings rather than holding on to them which cannot be good for their health.”
Encourage teamwork and skill mix.	“Everyone should work as a team; you should all be doing your bit. It impacts on our workload because someone else hasn’t done their part.”
Review and reduce any unnecessary paperwork and administration.	"Whilst it is important to record our practice, we sometimes have to record the same information/tasks on numerous occasions. I'm sure there are ways in which the amount of paperwork we have to complete can be reduced a little."
Managers should be offered training which makes them aware of the critical role they have to play in employee health and wellbeing.	“Managers need to lead by example and to be made more aware of the impact of their behaviour on others.”

2. Poor equipment and resources
Not having the right tools for the job is something which heightens the perception of stress in the areas of control, particularly where there is increased demand. It is recognised that there is always challenge in ensuring enough appropriate equipment within NHS resources, but if managed effectively, the research shows that this has a positive effect on feelings of resilience, as the impact statements below show.

Recommended behaviour	Impact statement from research
Improve access to resources and standardise resources.	"It is important for us to have the right equipment to do the job. This can range from simple bits of equipment to more complex things. Sometimes it can be difficult to access equipment; we also have different pieces/types of equipment for certain jobs which can make life very difficult and confusing."
Ensure staff are kept up to date with equipment faults, maintenance, and repairs.	“There can be a major problem, but it takes two weeks to fix and nobody tells you anything, they just don’t act. There’s no communication.”
Ensure knowledge and learning is managed across the organisation.	"We need to get better at capturing lessons and ensuring learning is shared and acted on. Staff are very innovative and have lots of ideas on how to save resources by, for example, working smarter and more effectively."
Adopt a more strategic approach to asset management.	"There are constant pressures across the trust to save on resources. The better the processes are for monitoring and managing our assets, the better we will be at managing and meeting our pressures to save money. This does not just apply to our hospital; this is about the NHS in general."
Review and reduce any unnecessary documentation administration.	"Whilst it is important to record our practice, we sometimes have to record the same information/tasks on numerous occasions. I'm sure there are ways in which the amount of documentation we have to complete can be reduced a little."
Managers should be offered training which makes them aware of the critical role they have to play in employee health and wellbeing.	“Managers need to lead by example and to be made more aware of the impact of their behaviour on others.”

3. Difficult home-life balance

Another area where control and demand come in to conflict is around work-life balance. Where there is a perception that work impacts on home life or prevents someone leaving on time to care for a dependent, there can be a perception that work has crossed a boundary which can lead to heightened perceptions of stress. Insisting on challenging timescales where they do not need to exist is another management behaviour which can be amended to improve the perception of health and wellbeing.

Recommended behaviour	Impact statement from research
Monitor staff working hours.	“I think that managers should speak to people who do work beyond their hours. It is important to get a real understanding of what is possible to achieve in the time we actually work. This is because those who stop when they are supposed to stop are then made to look bad.”
Ensure the impact of additional duties and/or tasks are considered appropriately.	“There is a need for forward planning. instead of dropping things on people, to have that foresight and forward planning to do the instruction correctly in the first place.”
Consider the added value or benefit of flexible working.	“There needs to be an education shift on the whole approach to flexible working.”
Empower/enable staff to feel confident about asking questions and raising issues.	“Managers need to encourage people to ask more questions. So, if someone says to you ‘it’s 4:55pm, can I have this tomorrow?’ you ask the question as to when it’s actually needed: ‘When are you actually going to use this information?’ ‘Well actually, 5pm tomorrow’ So you think, actually I can do it tomorrow morning. But sometimes people don’t feel empowered to ask someone questions.”
Managers should be offered training which makes them aware of the critical role they have to play in employee health and wellbeing.	“Managers need to lead by example and to be made more aware of the impact of their behaviour on others.”

Homeworking on work-life balance

With the change in the workplace during 2020 and more employees are working from home, the HSE recommend the following key areas are reviewed on a regular basis as part of a risk assessment.

Lone working, and the importance of regular contact and information on whom to contact.

Working with display screen equipment and a home working assessment.

Stress and mental health, due to being away from managers and work colleagues, which could make it difficult to get appropriate support.

4. Work-related aggression and violence

Violent and aggressive incidents are the third biggest cause of injuries reported under RIDDOR from the health and social care sector. Employers and employees should work together to establish systems to prevent or reduce aggressive behaviour.

Being treated with dignity and respect is a key to managing stress in the workplace. Staff are likely to have less resilience if they are subjected to behaviour which they feel undermines their sense of value and self-worth.

Employers have a duty of care to protect staff from threats and violence at work. Having a clear risk-based management approach on how staff report violence at work enables data to be built up identifying trends, providing opportunity for feedback. Where further action is required, it enables employers to provide follow-up support, and where required criminal proceedings against the individual. These steps could enable staff to feel they will be protected from disrespectful behaviour.

The following publications provide further guidance:

It is important to recognise that feedback to employees on any reports encourages employees to continue to report issues as they will feel their concerns have been noted and recognised.

Recommended behaviour	Impact statement from research
Heighten awareness of the organisational response to tackling work-related violence and verbal abuse and aggression.	“More needs to be done in terms of the organisation’s response to violence and aggression. We know that letters are sent to patients, but the organisation needs to make staff more aware of the action it is taking to deal with this issue.”
Assess staff needs for workplace aggression and violence management training and ensure training is available to all staff and is well attended.	“We are provided with conflict resolution training every three years as it is mandatory. However, you quickly lose the information you were taught. We also need to have more appropriate levels of training that help to tackle the problems – for example, internally staff need to be aware of the impact they have on each other. It is about being aware of each other’s perceptions.”
Making greater use of the court system/prosecutions/behaviour orders against aggressors and where successful prosecutions have occurred, ensure staff are aware of this.	“If it’s actual physical violence they should be taken through the court system rather than an individual having to take it through the civil courts. It should be organisational… it’s the way the law works though, as opposed to the way the organisation works.”
Improve public education about the impact of workplace aggression and violence.	“As a trust, we don’t actually publicise ‘what’s happening’... we don’t work particularly well with the press.
Raise awareness of the importance of management support when dealing with workplace aggression and violence.	“They’ve got better nowadays in terms of management coming in and seeing how you are… but that’s only up to local security management (LSM) level, there’s nothing above that. It is important that staff feel they have the support and backing of their managers. Managers are important for helping staff to deal with incidents as well as trying to work out what happened and how it might be avoided in the future.”
Managers should be offered training which makes them aware of the critical role they have to play in employee health and wellbeing.	“Managers need to lead by example and to be made more aware of the impact of their behaviour on others.”

Burnout

Burnout is a term often used when talking about overwork and stress. It can occur when experiencing long periods of very demanding workloads that typically include long and stressful hours. Staff suffering from burnout often experience lower energy levels, difficulty dealing with others and may have some trouble completing tasks on the job, in part because they find it difficult to concentrate. They may also experience feelings of helplessness, powerlessness, and isolation. Burnout can have a detrimental impact - not only the individual but for the organisation and service users as it can lead to absenteeism or extended time away from work in order to recover from physical and mental exhaustion. If pro-active measures are not taken to prevent burnout, employers run the risk of losing highly committed and skilled employees.

Supporting return to work

Organisations should support individuals to work towards a return to work following a spell of absence with stress, anxiety or depression or any other mental health condition. A flexible approach may be required, specifically to extending a phased return period for longer than a standard policy allows. This can include the exploration of modified shifts, reduced and flexible hours. When supporting a phased return, the NHS Terms and Conditions of Service handbook (Annex 26) makes provisions for staff to receive their normal pay.

You should explore whether the individual’s existing duties could be reduced or amended (temporarily or permanently, taking into account the needs and wishes of the individual) to facilitate a return to work. Conversations to explore how duties may be adapted to enable individuals to work from home for a specified period may be required. Temporary changes should be reviewed intermittently in consultation with the worker and occupational health to consider a return to normal duties.

Stress can affect all levels within an organisation from clinical to non-clinical staff.

Work related stress is not limited to clinicians and professionals. Initial findings from a 2021 Health Foundation study on the health and wellbeing of lower paid NHS staff on Band 4 or below, found higher rates of workplace stress, sickness absence, along with job insecurity, discrimination and working more than one job.

Download this chapter: Management behaviours which impact on stress at work

Working in partnership

A key requirement of managing stress is to consult with safety representatives and use resources which already exist, both within and outside of NHS organisations.

A safety representative is someone appointed by a trade union and recognised for collective bargaining purposes.
Trade union safety representatives can work in partnership with employers to support improvements in staff health, safety, and wellbeing. Partnership in health and safety (H&S) should go further than this, for example, H&S policy should, wherever possible, be agreed with safety representatives as part of formal arrangements at an H&S committee.
Safety representatives offer access to valuable insight and research from their own main trade unions and through contact and networking with colleagues from other trusts and staff side organisations. They can support organisations in delivering best practice in the provision of stress management in the workplace and carry out workplace assessments and audits to identify potential risks of stress.
Working in partnership with staff side representatives increases the trust between management and individuals that the organisation takes the issue of stress management in the workplace seriously and is committed to having a positive approach to it.

Occupational health and wellbeing

The occupational health team has knowledge and experience of supporting members of staff with health and wellbeing issues caused by stress in the workplace.
Occupational health can support employers with workplace assessments to ensure underlying health conditions are not exacerbated and can ensure reasonable adjustments are put in place which support the employee to sustain an effective level of attendance at work.
Occupational health can also assist in leading initiatives which can support employee’s health and wellbeing. By organising events such as stress management workshops, massage, and relaxation therapy sessions or ’money matters’ advice in liaison with the Citizens Advice Bureau, the team can offer employees advice, guidance, and therapy to help support manage the demands of their working and personal lives.
Occupational health may also support with organising and supporting with self-help and support groups for employees who have experienced workplace stress and how they have managed to cope with that situation. Knowing other employees have experienced but successfully managed to deal with issues in the workplace which caused stress, supports other employees by recognising they are not alone and that it can be overcome.

Mindful Employer

Mindful Employer is a charter mark which organisations can apply for to demonstrate that they are working towards standards and pledges which recognise the willingness to be better employers to employees with mental health problems.
The mark ensures that organisations have positive statements in employment literature, that managers are trained in employment practice around recruiting and employing people with mental health issues and that there is support for staff who experience stress, anxiety depression or other mental health conditions.

MIND

• MIND is the mental health charity which supports individuals with mental health issues with support and guidance. It also provides organisations with advice and guidance on how to support employees in the workplace.

The Samaritans

The Samaritans provides a 24/7 service via telephone, text, or email.

The Samaritans latest suicide data UK and ROI.

CALM

CALM, the Campaign Against Living Miserably, is leading a movement against suicide. According to CALM, every week 125 people in the UK take their own lives, and 75% of all UK suicides are male CALM exists to change this.

Survivors of Bereavement by Suicide, offers support to those who have been bereaved or affected by suicide.

Download this chapter: Working in partnership

Stress and the workplace - webinar recording

Watch the Health, Safety and Wellbeing Group's 2022 webinar discussing more details on how to manage stress in the NHS workplace and outlining the key focus and considerations for this Prevention and management of stress at work guidance.