workplace stress - chartered society of physiotherapy

Document type HEALTH & SAFETY INFORMATION PAPER Reference H&S 01 Issuing function EMPLOYMENT RELATIONS & UNION SERVICES Date of issue FEBRUARY 2009

Workplace Stress

THE CHARTERED SOCIETY OF PHYSIOTHERAPY 14 Bedford Row, London WC1R 4ED, UK www.csp.org.uk Tel +44 (0)20 7306 6666 Email [email protected]

THE CHARTERED SOCIETY OF PHYSIOTHERAPY

Workplace Stress INTRODUCTION ..................................................................................................................4

DEFINITION .........................................................................................................................5

CAUSES OF STRESS AT WORK ............................................................................................5

THE EFFECTS OF STRESS......................................................................................................9 Physical signs/symptoms..............................................................................................9 Psycho-social symptoms ..............................................................................................9 Emotional/Mental Health Symptoms .......................................................................10

The CSP..............................................................................................................................10

WHAT IS THE HSE DOING ABOUT STRESS? .....................................................................12

NHS LITIGATION AUTHORITY ..........................................................................................14

REGULATION/LAW AND STRESS ......................................................................................15 The Health and Safety at Work Act 1974.................................................................15 The Management of Health and Safety at Work Regulations 1999.......................15 Working Time Regulations .......................................................................................17 Disability Discrimination Act (DDA) 1995.................................................................17 Safety Representatives and Safety Committees Regulations 1977 (SRSC)..............18 Workplace (Health, Safety and Welfare) Regulations 1992 (WHSW).....................18 Protection from Harassment Act (PHA) 1997...........................................................18 Common Law Duty of Care.......................................................................................19

COURT OF APPEAL GUIDANCE ON STRESS CASES ..........................................................20

NEGOTIATING FOR PREVENTION OF STRESS...................................................................22 Our aims should include: ..........................................................................................22 Common Obstacles....................................................................................................22 Common Proposed Solutions....................................................................................23 What Employers Should Do ......................................................................................23

TACKLING STRESS – WHAT CSP SAFETY REPS CAN DO...................................................24

REFERENCES AND RESOURCES.........................................................................................25

APPENDIX 1 - Model Stress Policy....................................................................................27

APPENDIX 2 - Model Stress Surveys .................................................................................32

WORKPLACE STRESS – HEALTH & SAFETY BRIEFING NO. 1 – FEBRUARY 2009 2


APPENDIX 3: Stress At Work - Summary Report of the CSP Safety Reps Surveys undertaken during 2007 ..................................................................................................45

APPENDIX 4 - Stress Advice Sheets ..................................................................................48



Workplace Stress

INTRODUCTION The National Group of Regional Safety Reps (NGRSR) organised in April 2007 a national stress survey to be conducted by CSP safety reps in their workplace. The results from that exercise showed that around 76% of physiotherapists surveyed believe they are suffering from stress at work. A significant 37% consider the level of stress as unacceptable. And a quarter of our members considered they have been harmed by their experiences of stress. One finding of a research report for the Joint Trade Unions based on a 2007 survey of NHS staff found that overworked and overloaded health service workers are so stressed that six out of 10 of them had considered leaving their jobs in the past year. The Healthcare Commission National NHS staff survey for 2007 showed that a third of staff (33%) were suffering from work-related stress, which reflect CSP’s survey figures, conducted in the same year (see Appendix 3) on what has been an ongoing and persistent problem for the NHS workforce over many years. The NHS Employers’ publication “The Healthy Workplace Handbook: The NHS Reference Guide to Staff & Wellbeing” 2008 refers to information provided by the Health and Safety Executive (HSE) that workers in health and social care have some of the highest rates of self reported illness due to stress, anxiety and depression. NHS Employers state around 30% of sickness absence in the NHS is due to stress. Trade Union Approach Given this situation, organisations ranging from the HSE and International Labour Organisation (ILO) to the TUC and health service trade unions, are all taking steps to ensure that tackling stress at work is a priority. This briefing paper aims to advise members on how to tackle the issue of stress at work. It examines the causes of stress, its effects on health and the symptoms to look out for. It sets out the legal duties of employers to prevent stress and gives practical advice to safety representatives on how to use their legal rights to ensure that stress is taken seriously.



DEFINITION The HSE defines stress as: “The adverse reaction people have to excessive pressures or other types of demand placed on them”

CAUSES OF STRESS AT WORK In itself stress is not an illness, but if it is excessive and prolonged, it can lead to mental and physical ill health, including depression, nervous breakdown and heart disease. We feel stress as a result of demands that are placed upon the mind and the body. Factors that cause this response and make us experience stress are called stressors. Before examining these effects in more detail, it is important to first identify what the possible factors are that cause stress at work: Physical Conditions & Work Environment Noise – whether external (traffic etc), or internal (machinery, open plan working) Incorrect temperature – too hot or too cold Poor lighting and / or ventilation Overcrowding Badly designed furniture and equipment / dangerous equipment Poor maintenance Use of VDU’s Poor canteen, toilet, and rest facilities Exposure to possible violence/danger

Job Design Unrealistic targets Boring or repetitive work Incorrect use of skills Poor/insufficient training Inadequate rest breaks Lack of/too much supervision Shift work Too much/too little work Isolation Lack of direction Lack of decision making



Lack of control over the job Poor opportunities for peer support Work with VDU’s and other machinery Time pressures Responsibility for lives Uncertainty about responsibilities New technology

Contractual/Work Organisation Lack of job security/promotion prospects Too much unnecessary or badly planned change Poor communication from management Inadequate staffing levels Long hours culture Low pay Job insecurity Temporary/short term contracts Unsocial hours Continuous changes in work organisation Financial constraints Flexible working Rigid hierarchies Punitive disciplinary procedures Excessive overtime

Relationships Harassment/discrimination Bullying Poor relationships with colleagues/managers Conflict between home and work responsibilities Unsympathetic management Denial of training, assistance, support Complaints by patients Poor communication Social isolation Impersonal treatment



Balancing Demands Poor childcare/other care facilities Inflexible attitudes of management Need to take time off to care for children and other dependants

It is worth examining a few of the causes in more detail: 1. Violence

Workers who experience violence, threat of violence, or anxiety about violence show high levels of stress. Nationally, 13% of staff in the Healthcare Commission’s NHS staff survey 2007 reported that they had been physically attacked by patients or their relatives. 26% reported that they had been harassed, bullied or abused. The Healthcare Commission concludes that the levels of violence, harassment and bullying against staff in the NHS nationally appear remarkably high. They advise individual employers in the NHS need to examine their results and take action to address these high levels. Violence and aggression at work can take many forms, and originate from many sources, but lead to high levels of stress-related symptoms. The NHS Counter Fraud Security Management Service is responsible for overseeing strategies for tackling violence and aggression against health workers and information on their activities can be found at www.cfsms.nhs.uk

2. Excessive/Unsocial Hours

Physiotherapists & Assistants work considerable amounts of unpaid overtime on top of their daily on-call and weekend contractual commitments. They are also increasingly required to work flexibly with more and more employers looking to introduce flexible working arrangements i.e. 7 day working and extended shifts. There are demands to provide more on-call/emergency duty services. These can all cause stress due to overwork and juggling other non-work commitments.

3. Physical Hazards

Some physical hazards include noise, vibration, toxic substances, temperature, ventilation, and lighting. These can cause stress both by anxiety of serious damage, e.g. industrial deafness, eye strain, and by interfering with concentration and energy levels, e.g. persistent noise and excessively high temperatures.


http://www.cfsms.nhs.uk/


One of the most common physical hazards in physiotherapy departments associated with stress is space. In September 2002, the Employment Relations and Union Services department at the CSP conducted a survey via the safety reps network on the physiotherapy work environment, and found space to be the single most pressing work environment issue for members. Many physiotherapy departments are cramped, and there is inadequate space for storage, note-writing and for undertaking treatments. More information on the work environment can be found in the CSP Information Manual for Safety Representatives.

4. Harassment & Bullying

Workplace harassment and bullying is often characterised by employees being shouted at or chastised in front of colleagues. However it can also take on more subtle forms, such as being ignored by colleagues or managers, or being over managed or criticised, given excessive work loads or denied resources and discretion/responsibility to conduct your work as an autonomous practitioner. Bullying can also often come from other work colleagues whether they be on the same, lower or higher pay grade. An individual may also be targeted by a group in the workplace and bullying of this nature may often be in the form of threats, abuse, teasing and practical jokes designed to make the person feel isolated and rejected. Bullying will often lead to victims suffering from stress-related illnesses including anxiety, loss of self esteem, tension, depression, lack of concentration, headaches and deterioration in personal relationships. In some extreme cases the person may even become suicidal if no intervention or adequate support is provided. For further information, please refer to Health & Safety Information Paper No 5 – Bullying at Work.



THE EFFECTS OF STRESS The immediate effect of stress on the body is the fight-or-flight response. However, this leads on to a variety of other short and long term symptoms. As many of these symptoms are generalised, and may be caused by other factors, they have long been ascribed to the characteristics of a particular person, rather than to work-induced stress. However, mounting evidence now shows that workplace stress is the common thread linking a number of physical, emotional, and psychological symptoms. These can be characterised as follows:

Physical signs/symptoms Short Term Long Term

Headaches/migraine Heart Disease Colds & respiratory infections Hypertension Backache Ulcers Poor sleep High Cholesterol Indigestion Risk of Cancer Menstrual Disorders Diabetes Effects on pregnancy Asthma Lethargy Karoshi (death from overwork) Muscle tensions/cramps Neck Ache Chest Pains Racing Pulse Tooth/Jaw Pain Palpitations

Psycho-social symptoms

Short Term Long Term

Increased consumption of alcohol, drugs, cigarettes

Relationship breakdown

Increased sickness absence Society isolation Accidents Domestic violence Insomnia Alcoholism Loss of appetite Suicide Overeating



Emotional/Mental Health Symptoms

Short Term Long Term

Fatigue Withdrawal Anxiety Chronic depression Irritability Chronic anxiety Boredom Breakdown Depression Post Traumatic Stress Disorder (PTSD) Poor concentration Low self-esteem Emotional outbursts Fear and Panics Nightmares Obviously, not everyone under stress at work will exhibit all or even any of these symptoms, but managers should be aware of the early symptoms of stress, to enable them to identify individuals in need of assistance. The CSP During summer 2003, the Employment Relations and Union Services department conducted some primary research in to work-related ill health and musculoskeletal disorders (MSDs) amongst 10% of the CSP membership. Section B of the questionnaire asked questions around general injury/ill health (non-musculoskeletal) and found that 67 members said they suffered from stress which led to a diagnosed medical condition (eg clinical depression) and 100 members said although they did not receive a clinical diagnosis, their stress levels were so high that it necessitated taking time off work as a result. At the CSP’s 2007 Annual Representative Conference a motion was overwhelmingly endorsed by delegates for the CSP to continue to dedicate resources for monitoring and supporting members. The CSP is actively working to ensure through its networks with other unions and relevant organisations, such as the Health and Safety Executive, the Healthcare Commission and Security Management Service, to get the NHS and employers to properly address the problem. The NGRSR organised the safety reps network to conduct workplace surveys throughout 2007 and out of this work the main source of stress identified for the membership is demands of the job, in terms of too much work, insufficient time, long working hours and



not enough rest breaks. Dealing with constant change and the reduction of training/learning opportunities were also widely seen as other significant sources of stress for members. The NGRSR, on the back of these findings, has developed one page advice sheets on these key causes, giving practical tips and information on what members and their representatives can do to effectively challenge situations in the workplace that are creating these problems. (See Appendix 4, Stress Advice Sheets) In circumstances where an individual member has required to take sick leave from work through a stress related illness the CSP advises against the practice of asking your GP to put something other than stress on a sick note, as this masks the problem and lets your employer off the hook from addressing the problem. It also undermines your ability for seeking any legal remedy as you need to provide evidence of the employer’s knowledge of your illness at the time. (see section titled Court of Appeal Guidance on Stress Cases page 20)



WHAT IS THE HSE DOING ABOUT STRESS? The Health and Safety Executive (HSE) is the Government body which is responsible for advising employers and others on health & safety matters and for enforcing health & safety law. In order to help employers tackle this challenging issue in their own workplaces, HSE has developed stress management standards, which can be used as a simplified risk assessment tool for identifying and addressing various causes of stress in the workplace. In the HSE literature on the standards, the aims also include encouraging employers, employees and their representatives to work in partnership and for the standards to provide a yard stick by which organisations can gauge their performance in tackling stress. These standards however are not legally enforceable and it is up to the employer to decide whether they will adopt them or not. However, there is still a legal obligation on employers to conduct (and take preventative action following) risk assessments of all the risks that may affect their employees and this includes workplace stress, although it should be noted that, in the past, legal enforcement on this matter has been negligible. In 2007 the HSE began a series of workplace inspections targeting 200 Acute Trusts in England to check whether these standards or similar initiatives are being applied. The HSE management standards target six areas under the headings of ‘demands’, ‘control’, ‘support’, ‘relationships’, ‘role’, and ‘change’. The standards define the characteristics or culture of an organisation where stress is being managed effectively. For further details visit the HSE website www.hse.gov.uk/stress/standards HSE Stress Management Standards

Demands – include issue like workload, work patterns and the work environment The standard is that:

• Employees indicate that they are able to cope with demands of their jobs; and

• Systems are in place locally to respond to any individual concerns

What should be happening/states to be achieved: • The organisation provides employees with

adequate and achievable demands in relation to the agreed hours of work;

• People’s skills and abilities are matched to the job demands;

• Jobs are designed to be within the capabilities of employees; and

• Employees’ concerns about their work

environment are addressed.

Control – How much say the person has in the way they do their work The standard is that:

• Employees indicate that they are able to have a say about the way they do their work; and

• Systems are in place locally to respond to any individual concerns.

What should be happening/states to be achieved: • Where possible, employees to have control over

their pace of work; • Employees are encouraged to use their skills and

initiative to do their work; • Where possible, employees are encouraged to

develop new skills to help undertake new and challenging pieces of work;

• The organisation encourages employees to develop their skills;

• Employees have a say over when breaks can be taken; and

• Employees are consulted over their work patterns.


http://www.hse.gov.uk/stress/standards


Support – Includes the encouragement, sponsorship and resources provided by the organisation, line management and colleagues The standard is that:

• Employees indicate that they receive adequate information and support from their colleagues and superiors; and


What should be happening/states to be achieved:

• The organisation has policies and procedures to adequately support employees;

• Systems are in place to enable and encourage managers to support their staff;

• Systems are in place to enable and encourage employees to support their colleagues;

• Employees know what support is available and how and when to access it;

• Employees know how to access the required resources to do their job; and

• Employees receive regular and constructive feedback.

Relationships – Includes promoting positive working to avoid conflict and dealing with unacceptable behaviour The standard is that:

• Employees indicate that they are not subjected to unacceptable behaviours, eg bullying at work; and


What should be happening/states to be achieved

• The organisation promotes positive behaviours at work to avoid conflict and ensure fairness;

• Employees share information relevant to their work; • The organisation has agreed policies and procedures

to prevent or resolve unacceptable behaviour; • Systems are in place to enable and encourage

managers to deal with unacceptable behaviour; and • Systems are in place to enable and encourage

employees to report unacceptable behaviour.

Role – Whether people understand their role within the organisation and whether the organisation ensures that the person does not have conflicting roles The standard is that:

• Employees indicate that they understand their role and responsibilities; and



• The organisation ensures that, as far as possible, the different requirements it places upon employees are compatible;

• The organisation provides information to enable employees to understand their role and responsibilities;

• The organisation ensure that, as far as possible, the requirements it places upon employees are clear, and

• Systems are in place to enable employees to raise concerns about any uncertainties or conflicts they have in their role and responsibilities.

Change – How organisational change (large or small) is managed and communicated in the organisation The standard is that:

• Employees indicate that the organisation engages them frequently when undergoing an organisational change; and



• The organisation provides employees with timely information to enable them to understand the reasons for proposed changes;

• The organisation ensures adequate employee consultation on changes and provides opportunities for employees to influence proposals;

• Employees are aware of the probable impact of any changes to their jobs. If necessary, employees are given training to support any changes in their jobs;

• Employees are aware of timetables for changes; • Employees have access to relevant support during

changes.



NHS LITIGATION AUTHORITY The NHS Litigation Authority (NHSLA) indemnifies English NHS bodies against claims of clinical and non-clinical negligence. In addition to dealing with claims when they arise the Litigation Authority has an active risk management programme to help raise standards of care in the NHS and assist in the reduction of incidences leading to claims. NHS Trusts have a strong monetary incentive to complying with the NHSLA’s standards and assessment programmes because by successfully achieving these standards they can receive up to 30% discounts in their premiums. Under the NHSLA’s standard 3 titled “Safe Environment”, there are various criteria for s to ensure staff safety on key health and safety issues, including manual handling, prevention and management of violence, aggression and bullying as well as stress. For tackling work-related stress Trusts have to show they have approved documentation which describes the processes for managing the risks associated, including providing information to staff, identifying the key causes and undertaking appropriate risk assessments for the prevention, management & monitoring of work-related stress. For further information about the NHSLA and their risk assessment auditing procedures, including copies of their previous auditing reports for each Acute Trust (Primary Care Trusts begin undergoing NHSLA auditing from 2008 on) visit their website www.nhsla.com


http://www.nhsla.com/


REGULATION/LAW AND STRESS Although there is no specific law dealing with stress, existing laws, such as the Health and Safety at Work Act 1974 and other legislation are relevant to tackling work-related stress.

The Health and Safety at Work Act 1974 The main relevant legislation is in section 2 of the Health and Safety at Work Act 1974: “ It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare of all his employees”. This does not only mean physical health, but mental health as well. Occupational stress is a health and safety issue like any other workplace hazard.

The Management of Health and Safety at Work Regulations 1999 The most relevant regulations, which can be used to protect members are the Management of Health and Safety at Work Regulations 1999. These require employers to assess the nature and scale of workplace risks to health and ensure that there are proper control measures in place to firstly prevent/avoid these risks wherever possible and if that is not possible to reduce, isolate or control the risk. There is typically a five step approach that all risk assessments should follow: Step 1 – Identify the Hazard Step 2- Decide who might be harmed and how Step 3- Evaluate the risk and take action Step 4- Record your findings Step 5 – Monitor and review the action plan Every employer must conduct a suitable risk assessment in every workplace by law. These risk assessments are the key to preventing illness through stress. The HSE advises that ill health from workplace stress be treated the same as ill health due to the other, physical, causes when assessing possible health hazards. Employers have a legal duty to take reasonable care to ensure employees’ health is not placed at risk through excessive and sustained levels of stress arising from the way work is organised, the way people deal with each other at work (managerial styles, or harassment etc) or from the day to day demands (of work)’. As outlined in the previous section, the HSE stress Management Standards provides the employer with the necessary guidance and resources from which they can proceed with a risk assessment of this nature. HSE advises that



assessing the organisation’s performance against their management standards can be done by:

Using existing information to see how the organisation shapes up. Sickness absence or staff turnover data could help, as could any surveys that the employer has undertaken to get the views of staff. Using the HSE survey template (‘Indicator tool for work-related stress’) accessed from

their website (www.hse.gov.uk/stress/standards/pdfs/indicatortool.pdf) This survey provide an indication of performance against the standards and consist of 35 tick box statements that ask the individual staff member about working conditions known to be potential stressors. The results can then be put through the HSE’s Analysis Tool, (www.hse.gov.uk/stress/standards/pdfs/analysistool.xls) which computes an average figure for each of the six management standards for the whole workforce, or particular parts of the workforce. It provides a benchmark figure to compare the employer with others. To develop an action plan HSE has provided a template and an example for employers

on how to use - www.hse.gov.uk/stress/standards/pdfs/actionplan.pdf

If the employer is not prepared to conduct a survey they are advised by the HSE to do the following:

Go straight into discussions with employees Outline the importance of tackling stress and discuss the statements in the standards

(see pages 12 & 13) with a representative sample of their employees. Ensure employees are able to express their honest opinions, eg consider involving

someone else in the process so that employees are not afraid to say what they think. Record what employees say, to prioritise and give the employer a record to check back

on in the future. Continue to use existing methods to talk to employees about issues that affect them at

work, eg regular staff meetings, or performance reviews.

When employers are initiating or conducting a risk assessment they are advised under the Management of Health and Safety at Work Regulations, 1999, to consult with the accredited safety representatives. If CSP safety representatives participate in any employer group set up to oversee a risk assessment, it is important to clarify with management that the role of the rep in this context is to give advice or to receive information and that the risk assessment remains the employer’s responsibility. This is an important distinction because the CSP representative’s role is primarily to make representations on behalf of members and this may be required if the risk assessment proves to be inadequate or does not lead to the necessary action or resources being made available.


http://www.hse.gov.uk/stress/standards/pdfs/indicatortool.pdf

http://www.hse.gov.uk/stress/standards/pdfs/actionplan.pdf


Working Time Regulations Working long hours and shift work are both linked to stress. The Working Time Regulations 1998 limits working time and outlines rest periods and also makes paid holidays a legal entitlement. These may alleviate some of the worst causes of stress – long hours and lack of rest. The CSP has produced guidance on the Working Time Regulations – Information Paper No 22.

Disability Discrimination Act (DDA) 1995 The Disability Discrimination Act (DDA) 1995 makes it unlawful to treat a disabled (within the meaning of the Act) person less favourably, without a justifiable reason. The definition of disabled under the DDA is the person has to show they have a physical or mental impairment which has substantial and long term (i.e. at least 12 months) adverse effect on their ability to carry out normal day to day activities. If the employee’s condition doesn’t meet this definition then the provisions of the Act cannot apply. Review of legal cases taken to date would lead us to conclude that suffering from ‘stress’ alone is insufficient to meeting the definition requirements of disability as required under the Act. However, if the employee complaining of stress was also suffering from a stress-related psychiatric illness which is clinically well-recognised then this is more likely to lead to a successful claim under the Act. Two examples of such illnesses are clinical depression and post-traumatic stress disorder. However there is still the requirement to show how this mental impairment affects the person’s ability to carry out normal day to day activities. In relation to health and safety, section 4A of the DDA is particularly useful. This section of the Act requires employers to make reasonable adjustments to working conditions or to the workplace to avoid putting disabled workers at a substantial disadvantage. Failing to do so may be deemed as unlawful discrimination. Complaints about disability discrimination go to an employment tribunal which can award compensation and recommend action for the employer to take within a specified period. For more information, please see our Information Paper No 27 on the Disability Discrimination Act.



Safety Representatives and Safety Committees Regulations 1977 (SRSC) The SRSC Regulations give safety representatives extensive legal rights to investigate and tackle workplace stress. Where there is a recognised trade union, the members are legally entitled to elect a representative. Under the Regulations, safety reps have the right to: ♦ Investigate potential hazards; ♦ Inspect the workplace; ♦ Access to facilities/private room to talk to members; ♦ Take up members’ health and safety complaints; ♦ Be consulted by the employer about health and safety matters (including risk

assessments); ♦ Obtain health and safety documents held by the employer; and ♦ Take time off to carry out their functions. Safety reps will be able to gather information from management on issues such as sickness and accidents, which may be useful in identifying patterns of stress. They can conduct membership surveys, which is an inspection activity under the regulations to build up awareness of stress and reveal the extent of the problem (see Appendix 2 for safety rep survey templates).

Workplace (Health, Safety and Welfare) Regulations 1992 (WHSW) These regulations cover workplace conditions such as ventilation, temperature, lighting, cleanliness, space and drinking, washing and rest facilities. Failure to provide and maintain these facilities can be a source of workplace stress.

Protection from Harassment Act (PHA) 1997 This Act states that a person must not pursue a course of conduct which amounts to the harassment of another, and which they know or ought to know amounts to such. As a result of a House of Lords’ ruling employers can now be vicariously held accountable under this act for the actions of their employees while acting in the course of their employment. Claims taken under this Act can be pursued for up to six years after the incident in comparison to the



three months time limit to lodge an employment tribunal claim for unfair dismissal. The case that created this precedent is Majrowski v Guy’s and St Thomas’s NHS Trust. Mr Majrowski had endured 18 months of bullying from his line manager before he resigned and pursued his claim under the PHA. However while Mr Majrowski was successful there hasn’t been large increase in cases taken under PHA against employers, mainly because the complainant has to prove:

1. That the harassment is serious – capable to amounting to a criminal act 2. To have occurred on more than one occasion 3. Not simply about a disagreement between two work colleagues 4. Represents an intense connection between the conduct and the job of work 5. Not to be considered to be reasonable and proper criticism of poor performance.

Common Law Duty of Care This is an area of law concerned with compensation claims. Under Common Law the employer owes a general duty of care to each individual, for example to provide a safe system of work and protect employees from foreseeable risks. An employer’s common law duty also operates as an implied term of the contract of employment. There is a fundamental implied duty of mutual trust and confidence in every contract of employment. This duty may be breached as a result of serious or consistent abuse directed at an employee by the employer, or a failure by the employer to protect employees who are subject to abuse from other colleagues. In reality, however, pursing a stress case is difficult because of the different effects of pressure on individuals, and therefore the courts are not easily persuaded that an employer has breached this duty of care. For example, in the case of Walker v Northumberland County Council, the claimant, Mr Walker, was successful only because of the fact that he had a second breakdown due to stress caused by over-work and was able to show that his employers failed to act following his first breakdown (which was for the same reason), to prevent him further harm. What do you have to prove to take a stress case of this nature?

1. That you have a psychiatric illness (the injury) then 2. Your work posed a real risk of causing the illness and your employer knew (or ought to

have known) that you were exposed to that risk. 3. Given the foreseeable risk, what action did your employer take to address it and was it

reasonable in the circumstances to keep you safe from harm? 4. Requirement to show causation in that the harm you suffered was caused by your

work and your employer’s breach of duty to you.



COURT OF APPEAL GUIDANCE ON STRESS CASES A House of Lords ruling in April 2004 (Barber v Somerset County Council) confirmed that employees win damages for workplace stress only if their employer knew that they might suffer serious injury to their mental health, or had been warned that this might occur. The House of Lords also confirmed the Court of Appeal’s guidance to the lower courts on when to award damages for stress. This makes it clear that workers can win damages for stress at work only if: ♦ The employer knows the employee has suffered a previous mental breakdown; or ♦ The employee has told the employer that they think they are going to suffer ill health

through stress at work. The Court of Appeal guidelines are: ♦ Employers can usually assume that employees can cope with normal pressures of their

jobs unless they know that a particular employee is vulnerable. This highlights the importance of making employers aware of excessive demands and the effects these are having. The most obvious example of doing this is through certified sickness absence clearly identifying the cause to stress or depression. The employer is expected to make enquiry about the employee’s problems and what can be done to ease them. Employees should not be brushed off with instructions to reprioritise work without the employer taking further steps to consider the situation.

♦ Employers are only expected to take steps if indications are clear that an employee is likely to suffer harm from occupational stress. Once again this underlines how important it is that members are open about the causes of any problems or absence from work. However once they know the employer is under an obligation to do something about it. This duty continues until something reasonable is done to help the employee.

♦ If work stress is not the sole cause of the ill health, employers are only liable for the proportion, which is attributable.

♦ An employer who offers a confidential counselling service is in a stronger position of proving they have met their duty of care. However the Court of Appeal recently added a caveat that it only applies to a case where on the facts such advice or counselling services would have actually been effective to deal with the particular problem.

♦ An autocratic and bullying style of leadership, which is unsympathetic to complaints of occupational stress is a factor that courts can take into account in deciding whether there has been a breach of the employer’s duty to an employee.

♦ Employees who complain do not need to be forceful in their complaints and need not describe their troubles; and symptoms in detail. They may be suffering from depression, making it more difficult to complain. Their complaint should be listened to sympathetically.



♦ Monitoring employees known to be suffering from occupational stress is mandatory. If they do not improve, then more robust steps may need to be taken to help them

♦ There is a statutory duty to carry out risk assessments As with much case law and legislation it is often subject to change and it is important that if you are wanting to pursue a claim you should seek up to date appropriate legal advice first.



NEGOTIATING FOR PREVENTION OF STRESS First and foremost, stress is a trade union issue. Stress must be recognised as an organisational problem which affects individuals and not vice-versa. It is the result of poor work environments, job design, or work organisation, not of weak or incompetent individuals. Stress can be approached by trade unions in the same way as any other occupational hazard.

Our aims should include: a) Recognition by the employer that stress is an organisational problem. b) Recognition that employees are experiencing work related stress. c) Employer commitment to fulfilling their legal obligations and reducing occupational stress. d) Finding out the extent of the problem, usually by a joint management/union anonymous

survey (see Appendix 2). e) Negotiation of a prevention of stress policy (see Appendix 1). f) Clear identification of preventative measures g) Clear and ed reporting systems h) Clear and sympathetic ways of helping employees experiencing stress.

Common Obstacles a) Management will not acknowledge the problem within their workforce; this can

be dealt with by general or sample surveys, case studies, requesting risk assessments for stress, inspection reports etc.

b) Management see stress as an individual problem requiring individual solutions; refer the employer to the HSE Stress Management Standards & ACAS guidance for further information on the causes of stress at work and on why it should be addressed on an organisational level rather than as an individual’s problem.

c) Management claim lack of resources to tackle stress; the Health and Safety at Work Act 1974, and Management of Health and Safety at Work Regulations 1999, impose a legal obligation on employers to reduce risks of stress and, although they are only required to do what is “reasonably practicable”, the resource argument alone is not a “get out” clause. In addition, while cost benefit assessments should only be used to assess which preventative measures should be implemented first, there are strong “cost arguments” where stress is concerned. The obvious one is reduction in days lost through sickness absence, and this can be dramatic where root causes of stress are addressed. However, there are also savings on the “hidden” costs of high accident rates, inefficient and unproductive working, low morale, poor health amongst employees, high turnover rates, and recruitment and retraining costs. As mentioned in a previous section on the NHSLA and its activities (see page 14) there are savings that could be generated for Trusts when achieving discounts on their insurance premiums through having effective stress management mechanisms in place. However



there are savings in other areas such as locum costs for covering sickness absence. According to NHS Employers, one Trust reported a saving of £500,000 expenditure a year in agency cover costs when they invested in stress management.

Common Proposed Solutions Initial responses by employers to the issue of stress are often “person-based”. They include stress counsellors, help-lines, gym facilities, lifestyle advice, stress management techniques, relaxation, and looking at stressors outside the workplace. While these measures may not be harmful, and indeed some are helpful, they perpetuate the view that stress is an individual problem, and thereby the personal stigma that many still feel is attached to stress. Most causes of work-related stress are often outside the scope or the ability of an individual employee to resolve.

What Employers Should Do

• Good sickness absence data collection and monitoring is a key aspect of identifying the problems with stress at an early stage. If a particular team or unit demonstrates high sickness absence, the employer needs to investigate the causes to find out if staff are having to take time off due to stress.

• The key message is to talk to staff and safety reps and allow them to openly respond to what they see are the issues.

• Conduct exit interviews. If staff turnover is high, the employer needs to know why people are leaving.

• Improve communications (e.g. by introducing regular team meetings). • Have a comprehensive negotiated prevention of stress policy (See Appendix 1 for model

policy). • Conduct risk assessments and put risk control measures in place, preferably utilising the

HSE stress management standards and resources, which addresses the root causes of stress.



TACKLING STRESS – WHAT CSP SAFETY REPS CAN DO Raising the profile of stress with both members and management are important first steps.

1. Check what action management are taking to tackle stress by completing our Organisation Survey (Survey 3, Appendix 2, page 44);

2. Carry out a questionnaire survey of members (surveys 1 or 2 of Appendix 2) or talk to members to identify the specific work related causes which they consider important and to see if they have any suggested solutions;

3. If the employer has a policy on stress at work, ask for regular updates on the way the policy is being implemented;

4. Safety reps have wide-ranging rights under the Safety Representatives and Safety Committee Regulations 1977 (see section “Regulation/Law and Stress” page 16). You should use these rights to investigate and take up problems of work-related stress. For example, accessing details of sickness absence records to see if a particular area or department has higher or lower rates of absence;

5. Raise members’ awareness of workplace stress as a health and safety issue. Circulate information on stress, e.g. information contained in this paper, circulating the CSP Stress Advice Sheets (see Appendix 4, page 49);

6. Encourage members to discuss stress openly at meetings;

7. Let members see that the CSP believes that stress is not an individual problem but a workplace issue that can be dealt with collectively;

8. Make sure that individual members know how to contact you if they have a particular problem, which is causing them stress. Try to listen to the member without judgement as this in itself could assist them to feel better about a stressful and emotional situation;

9. Use your employer’s grievance procedure and /or other appropriate procedures to help individual members who are suffering as a result of stress;

10. Seek advice and assistance from the CSP, whenever necessary;

11. If the causes of stress also affect staff other than your members, liaise with their union representatives about joining forces to get the employer to address the problem. Consider raising the topic for discussion at the Trust’s health and safety committee.



REFERENCES AND RESOURCES ACAS, “Stress at Work”, advisory booklet October 2006, available at www.acas.org.uk The Andrea Adams , charity established to address work place bullying www.andreaadams.org/ CSP, “Safety News: November 2007, electronic newsletter to CSP Safety Representatives. CSP, “Information Manual for Safety Representatives”, June 2002 Healthcare Commission, “National NHS Staff Survey 2007: Summary of Key Findings Health and Safety Commission, “Management of Health & Safety at Work”, Regulations 1999 Health and Safety Commission, “Safety Representatives and Safety Committees Regulations 1977”, published by TUC, March 2005 Health & Safety Executive, ACAS & ISMA, “Managing the Stress Management Standards work: How to apply the Standards in your Workplace”, pamphlet 2005 International Stress Management Association UK. Health & Safety Executive, ACAS & ISMA, “Working together to reduce stress at work: A guide for employees”, 2005 International Stress Management Association UK Health & Safety Executive, Tackling Stress: The Management Standards approach”, Leaflet, March 2005 Health & Safety Executive, “Real Solutions, real people: A managers’ guide to tackling work-related stress”, (Book), 2003 Incomes Data Services, “NHS Staff Survey: A research report for the Joint NHS Trade Unions, August 2007 International Stress Management Association, “You can do something about stress”, pamphlet for managers Labour Research Department, “Stress at Work”, April 2006 London Hazards Centre. “Surveys and Questionnaires (1994) Hard Labour Part 3 – section 8”. http://www.lhc.org.uk


http://www.andreaadamstrust.org/


NHS Employers, Chapter 44: “Stress Management” from “The Healthy Workplaces Handbook: The NHS Reference Guide to Staff Well-being, 2008 Society of Radiographers, “Work-related Stress: Guidance for Health & Safety Representatives” March 2007 Thompsons Solicitors, “Stress at Work”, booklet, June 2007 TUC “Hazards at Work: Organising for Safe and Healthy Workplaces”, Chapter 39, 2005 TUC ”Health & Safety Executive’s Management Standards for Work-Related Stress: A guide for Safety Representatives” http://www.tuc.org.uk UNISON ”Stress at Work – a guide for Safety Reps” (undated) WorkStress.Net. http://www.workstress.net



APPENDIX 1 - MODEL STRESS POLICY

A stress policy demonstrates management’s intentions on stress. It can be used to lay out a progressive approach to tackle the issue. An agreement or policy will also help to communicate the message to managers and staff that stress is viewed as a problem for the organisation to tackle and not as a weakness in individuals. An effective policy on stress should: ♦ recognise that stress is a health and safety issue; ♦ recognise that stress is about organisation of work; ♦ be jointly developed and agreed with workplace unions; ♦ indicate commitment from top management; ♦ be signed by the employer ♦ guarantee a ‘blame free’ approach; and ♦ apply to everyone. Safety reps must be consulted on the contents of any stress policy and have the opportunity to comment and make suggestions for change.



Model Stress Policy Introduction The X NHS Trust is committed to protecting the health and safety and welfare of its employees. X NHS Trust recognises that workplace stress is a health and safety issue and acknowledges the importance of identifying and reducing workplace stressors. This policy will apply to everyone in the X NHS Trust. Managers are responsible for implementation and the Trust is responsible for providing the necessary resources. Definition of Stress The Health and Safety Executive defines stress as “the adverse reaction people have to excessive pressure or other types of demand placed on them”. This makes an important distinction between pressure, which can be a positive state if managed correctly, and stress, which can be detrimental to health. Policy ♦ The Management of Health and Safety Regulations 1999 require employers to assess

health and safety risks, including stress, and to introduce prevention and control measures based on those risk assessments.

♦ The X NHS Trust will consult with trade union safety representatives on all proposed action (including risk assessments) relating to the prevention of workplace stress.

♦ The X NHS Trust will provide training for all managers and supervisory staff in good management practices.

♦ Employees suffering from stress and stress-related illnesses will be offered paid time-off to attend stress counselling sessions, so that staff can make arrangements for counselling outside their working hours if they do not wish to draw attention to their need for counselling. The names of stress counsellors and how to contact them will be posted on notice boards.

♦ The X NHS Trust shall provide staff involved in “critical incidents” with an opportunity to debrief within a short period of the event. A critical incident may include an employee who has been subjected to physical or verbal abuse, or they have witnessed acts of violence. It would also include suicides, bereavement where the member of staff was involved in the care or knew the patient/client/colleague well.

♦ Counselling will be offered by independent and trained counsellors. This service will be strictly confidential between the counsellor and member of staff. No details or records will be disclosed without the written permission of the member of staff concerned.

♦ The X NHS Trust will provide adequate resources to enable managers to implement the Trust ’s agreed stress prevention and management strategy.



♦ Priority will be given to assessing the causes of stress at work and introducing measures to reduce or prevent it. The Health & Safety Executive Stress Management Standards to be utilised as primary resource or guidance.

♦ If stress causes deterioration in job performance, this will be treated as a health problem and the sufferer will be encouraged to seek help under the terms of this policy. There will be no discrimination against individuals suffering from stress.

♦ This agreement for dealing with stress at work forms part of the employer’s Health and Safety Policy, and should be read in conjunction to it.

♦ This policy and its effectiveness will be regularly reviewed jointly by the staff unions and management. The initial review will be undertaken by the Health and Safety Committee and take place 6 months after this policy comes in to effect and at intervals of not more than 12 months thereafter.

Responsibilities Manager ♦ Conduct and implement recommendations of risks assessments within their departments. ♦ Ensure good communication between management and staff, particularly where there are

organisational and procedural changes. ♦ Ensure staff are fully trained to carry out their duties. ♦ Facilitate or provide peer supervision/mentorship that encourages opportunities for staff to

discuss difficult problems and develop supportive action plans for addressing their concerns.

♦ Provide information and training to all employees, including: the causes of stress, a copy of this stress agreement, details on how to seek confidential help, and information on the arrangements for reporting causes of stress and work-related illnesses.

♦ Ensure staff are provided with meaningful developmental opportunities. ♦ Monitor workloads to ensure that people are not overloaded. ♦ Monitor working hours and overtime to ensure that staff are not overworking. Monitor

holidays to ensure that staff are taking their full entitlement ♦ Attend training as requested in good management practice and health and safety. ♦ Ensure that bullying and harassment is not tolerated within their departments. ♦ With respect to an employee who has been exposed to a “critical incident” (see main

policy section for definition) their line manager will be responsible for arranging within 24 hours of the event or from the time of when they were notified the debriefing and that this support will be provided by a suitably experienced and qualified person.

♦ Where a number of staff are involved in a “critical incident”, it may be appropriate for the debrief to be carried out on a team basis.

♦ Be vigilant and offer additional support to a member of staff who is experiencing stress outside work e.g. bereavement or separation.



♦ If an employee becomes ill through stress, identify the causes of stress and eliminate them through changing the post-holder’s duties or working environment. Employees unable to continue in their job because of stress-related illnesses will be offered alternative suitable posts, subject to agreed procedures for relocation, relocation will be considered as a last resort, unless requested by the member of staff concerned.

Occupational Health and Safety Staff ♦ Provide specialist advice and awareness training on stress ♦ Train and support managers in implementing stress risk assessments ♦ Support individuals who have been off sick with stress and advise them and their

management on a planned return to work ♦ Refer to workplace counsellors or specialist agencies as required ♦ Monitor and review the effectiveness of measures to reduce stress ♦ Inform the employer and the health and safety committee of any changes and

developments in the field of stress at work. Human Resources ♦ Give guidance to managers on the stress policy. ♦ Assist in monitoring the effectiveness of measures to address stress by, for example,

collating sickness absence statistics, conducting joint surveys. ♦ Advise continuing support to managers and individuals in a changing environment and

encourage referral to occupational workplace counsellors where appropriate. ♦ Advise managers and individuals on training requirements Employees ♦ Raise issues of concern with your safety representative, line manager or occupational

health department. ♦ Consider opportunities for counselling when recommended. In situations when exposed

to a “critical incident” (see main policy section for definition) staff should contact their line manager within 24 hours in order that debriefing arrangements can be made without unnecessary delay.

Function of Safety reps & Health & Safety Committees ♦ Safety representatives will be meaningfully consulted on any changes to work practices or

work design that could precipitate stress. ♦ Safety representatives will be able to consult with members on the issue of stress including

conducting any workplace surveys.



♦ Safety representatives will be meaningfully consulted and involved in the risk assessment process. However the employer will retain ultimate responsibility for the conduct and implementation of the risk assessment.

♦ Safety representatives will be allowed access to collective and anonymous data from HR. ♦ Safety representatives will be provided with paid time away from normal duties to attend

any Trade Union training relating to workplace stress. ♦ Safety representatives will be able to conduct joint inspections of the workplace at least 3

months to ensure that environmental stressors are properly controlled. ♦ Safety representatives are provided with reasonable facilities to enable them to in paid

time consult their members on stress including conducting or discussing the outcome of local stress surveys.

♦ Safety representatives may make representations to management on behalf of a member or group of members.

♦ The joint health & safety committee will perform an essential role in ensuring that this policy is implemented.

♦ The health & Safety committee will oversee monitoring of the effectiveness of the policy and other measures to reduce stress and promote workplace health and safety.

Signed by: Director of Personnel/Human Resources Date: Employee Representative



APPENDIX 2 - MODEL STRESS SURVEYS

Audits/surveys can help to show members that the problem of stress is being addressed. It is possible to analyse them in a way as to compare stress levels between grades, or jobs, areas of the organisation or between male and female employees. They can determine the stress level within an organisation as a benchmark to measure the effectiveness of a strategy. They are not, however, a solution in themselves and must only be used as part of a wider strategy to tackle stress. Included in this appendix are three model surveys for safety reps or members to utilise to determine the extent & causes of members’ stress levels. The first survey is very detailed and will generate the most information and data for analysis. The second survey is more concise but should provide sufficient information to assist a safety rep to make a case to their manager that intervention of some sort is required and to request for a risk assessment preferably utilising the HSE indicator tool. The risk assessment for this type of problem is likely to include a detailed questionnaire that the employer require individual staff to complete (see section on “The Management of Health and Safety at Work Regulations 1999”, page 14, for further information about the HSE indicator tool) The third survey is just for Safety reps only to complete. It is titled “Organisation Survey” and requires the rep to respond to a range of questions, giving either a ‘pass’ or ‘fail’ response regarding their employer’s performance for addressing stress in the workplace. Any of these questionnaires can be adapted to suit the requirements of a particular workplace. Safety reps may for example, want to add Department/Work Area or Grade if members work in a large hospital and they want to find out if stress levels differ in different departments and grades of staff. You should also always send the questionnaire with a cover letter, explaining the purpose of the questionnaire to members and emphasise that it is a confidential questionnaire and that under no circumstances will any personal details be released to the employer.



(Survey 1)

Confidential Questionnaire Symptoms of Occupational Stress 1. Do you suffer from any of the following?

Recurrent headaches/migraines/anxiety Muscle tension Chest pain/palpitation Indigestion or nausea Poor disrupted sleep Recurrent backache Recurrent neckache Irritability/loss of temper Gastro-intestinal disorders Feelings of guilt, fear or panic Skin problems Feelings of not being able to cope

2. Have you suffered from any of the above for a period of 12 months or over?

Yes No 3. Do any of the following cause problems for you at work? (please tick those which

make you uncomfortable, anxious, annoyed etc) The Work Environment

Noise Poor lighting Too hot Badly designed/inadequate/poorly maintained furniture Poor canteen/inadequate rest or changing facilities Poor ventilation Too cold Poor access to toilets/lack of staff-only toilets Dust or fumes



Poor maintenance of building Not enough space Inadequate equipment Non-applicable

Job Design

Exposure to violent/aggressive or traumatic incidents The under-utilisation of your skills Too little interesting work Pressure to perform (deadlines etc) Lack of decision-making Too much or too little supervision Working with VDU’s and other machinery Boring or repetitive work Too much work The pace of work Lack of feedback Lack of control Job isolation Change or the pace of change Non-applicable

Contractual problems

Job insecurity (fear of redundancy/temporary contracts/government targets etc) Unsocial hours Insufficient breaks at work Inadequate pay Excessive hours Excessive workload Insufficient holiday Staff shortages Threats of violence from patients Lack of breaks after on-call Non-applicable



Work Relationships

Harassment and/or discrimination and/or bullying Sexism Racism Bad relations with supervisors Bad relations with work colleagues Impersonal treatment at work Working with the public Patient complaints Lack of communication from management

4. At work do you feel? (please tick under never, sometimes or often) Never Sometimes Often Irritated Angry Frustrated Anxious Helpless Confused Depressed Unable to concentrate Bored Over tired Happy Enthusiastic/motivated 5. During the past 12 months, have you experienced any of the following?

(Please tick under Never, Sometimes or Often) Never Sometimes Often

Loss of motivation/ commitment Working increasingly long hours Erratic or poor time- keeping



Increase in error rates Poor decision-making Deterioration in planning and control of work Increase in sickness absence Poor relationship with patients Tension and conflict with colleagues Tension with managers Increase in complaints or disciplinary problems 6. Do you ever use the following to help with the symptoms above? Never Sometimes Often Tobacco Alcohol Drugs 7. Have any risk assessments been carried out in your work area? Yes No 8. Are risks of stress considered in those risk assessments? Yes No If yes, have measures to reduce stress been put in place as a result of the risk

assessment? Yes No



9. If yes, were/are these measures effective?

Yes No

Health effects 11. In your opinion, has the quality of your work suffered because of workplace stress? Yes No 12. In your opinion, has your job satisfaction declined because of workplace stress? Yes No Sometimes 13. In the 12 months, have the staffing levels in your work area or workplace:

Increased Decreased Remained the same Don’t know/can’t say

14. When staff are away from work because of holidays, sick leave or any other reason,

are replacement staff provided?

Yes, always Sometimes Rarely No, never Don’t know

15. Do you ever stay late or come in early to complete work (i.e. work unpaid outside of

your regular hours of work)? Yes No Sometimes



16. During the past 12 months, have you taken sick days because of stress (even if you didn’t identify those days as “stress related” on your leave forms)?

Yes No 17. If you have taken time off sick due to stress in the past two years, how many working

days were you away from work?

1-3 days 4-6 days 7-9 days 10-14 days 15+ days

18. During the past 12 months, have you taken time off using your annual leave due to

the health effects of stress? Yes No 19. If you have taken time off because of stress using your annual leave, how many

working days were you away from work?

1-3 days 4-6 days 7-9 days 10-14 days 15+ days

20. Have you had difficulty taking your holiday time off because of your stress levels? Yes No Sometimes Policy Issues 21. Does your workplace have a stress policy? Yes No Don’t know



22. In the past 12 months, have you raised stress concerns with any of the following? (please tick as many as apply to you)

Co-workers Safety rep Manager/Employer Family Occupational health GP Other

23. What measures do you think would help to reduce stress in your workplace?

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

General Information Anything written on this questionnaire will be treated with the strictest confidence. Please do not give your name. 24. Are you? Male Female 25. What is your age?

less than 20 years 20-29 years 30-39 years 40-49 years 50 or more years

26. Do you work?

Full time Part time Temporary Other ………………………



27. Please use the space below to write any remarks you might have about stress that you

feel have not been addressed in this questionnaire, or any other comments that you might have about stress as a health and safety issue.

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Thank you for completing this questionnaire. Please return the completed questionnaire to your CSP safety representative.



(Survey 2) CSP: STRESS SURVEY – INSTRUCTIONS TO THE SAFETY REP – GETTING IT FILLED IN Read the following instructions and if you have any queries on how to undertake this exercise don’t hesitate to contact your Senior Negotiating Officer or the National Health and Safety Officer for advice.

1. When sending the questionnaire out to individual members please include a cover letter, explaining the purpose of the questionnaire and stress that it is a confidential exercise and that no personal details will be released to the employer, or others without the member’s knowledge and consent.

2. Fill in the name of the part of your work place, which you are studying (at the start of the form), the date by which it should be returned and who to return it to (both at the end of the form) and then run off enough copies to give to everyone in the part of the workplace being surveyed. Remember to keep a record of the number of survey forms you sent out and where.

3. Distribute copies to CSP members in whichever part of your workplace you want to study. Remember to give the survey to as many people as possible, including agency and temporary staff. Remind them about the deadline for returning the form, and who to return it to. People may want to give the information completely anonymously so you may need to arrange a post box or similar system where members can drop off their survey sheets.

4. When the answers have come back, check what percentage of forms have been returned. A return rate of over 50% is very good, and should give you confidence in the results - the lower the rate of return, the less you can depend on the findings of the survey (and if hardly anyone returns the form, that may just mean there’s not a big problem).

5. If appropriate - make a workplace stress map -Draw a sketch of your workplace (it

doesn’t have to be to scale, or a work of art!) Write in each area surveyed the percentage of workers answering 'yes' to question 2.

6. Identify the main stressors. Count up the number of ‘yes’s’ for each stressor. If

more than a quarter of the people who responded have circled ‘yes’ for any stressor, that issue is a major problem, which needs to be addressed. For each part of the workplace where there are high levels of stress, work out what the main stressors is by listing the number of 'yes' for each stressor received. The more 'yes’s', the more of a problem that stressor is.



7. Once you have developed the stress map, and what the main causes of stress are, put

the results on a poster on notice boards, or produce a short report of the survey findings and give everyone a copy.

8. Then set up a suggestion box for people to make their own suggestions about how

their stress could be reduced - they might come up with ideas you haven’t thought of, and their views may help you to persuade management.

9. Report your findings to your Regional Safety Rep and cc to your Senior

Negotiating Officer and make it a point of discussion at your next regional training day or discuss on your local iCSP safety rep network.



CSP STRESS SURVEY (Survey 2 – read above instructions) WORKPLACE:……………………………………………………………… Circle either yes or no for your answer to the following questions Q1. Do you feel you are stressed by your work? YES / NO Q2. Is the level of stress unacceptable? YES / NO Q3. Is it causing you harm? YES / NO Q4. Which of the following do you feel contribute to your stress?

A. Demands of your job? e.g. too much work, insufficient time, long working hours, not enough rest breaks YES / NO

B. Lack of control? e.g. unrealistic deadlines, unremitting pressure to perform well, too much/little supervision YES / NO

C. Relationships at work? e.g. bullying, harassment, lack of communication

YES / NO D. Change? e.g. uncertainty about your future, lack of consultation over changes

YES / NO E. Working environment? e.g. temperature in the work place, lone working,

overcrowding or cramped work areas, poor eating and rest facilities, badly designed, unsuitable or uncomfortable equipment – such as computer workstations YES / NO

F. Learning opportunities? e.g. insufficient time or resources for CPD and courses

YES / NO Any Comments……………………………………………………………………………………………. ………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………….. Please complete this survey and return it by …………………………………………. To:……………………………………………………………………………………………………. All information is anonymous and will be used to help identify workplace stressors so that the CSP in partnership with management can produce an action plan to reduce workplace stress levels.



(Survey 3) Organisation survey (for Safety Rep to complete only) Write ‘Pass’ against questions where you are able to answer “yes” and ‘Fail’ against questions where the answer is “no”. Where you do not know the answer (do try hard to find out!) leave the question blank.

1. Does your employer have a policy for dealing with workplace stress?

2. Does your employer’s policy on workplace stress cover health and safety, equality and human resources issues?

3. Were safety reps or the union consulted in the development of your organisation’s stress policy?

4. Are audits or risk assessments carried out for workplace stress?

5. Does your employer utilise the HSE Stress Management Standards and processes for risk assessing stress in the workplace? (For detail see www.hse.gov.uk/stress/standards/index.htm)

6. Are safety reps involved in stress risk assessments?

7. Does your employer have/provide copies of HSE guidance on preventing work-related stress?

8. Are managers given training on managing workplace stress?

9. Are staff given information on workplace stress?

10.Are staff generally confident that they can report suffering from stress, or give stress as the reason for sickness absence, without fear of discipline?

11. Do/would managers act in a sympathetic way to people suffering from workplace stress?

12. Are confidential counselling or similar services available for workers suffering from workplace stress?

13. If someone took sick leave for stress-related reasons, would your employer attempt to identify whether the stress was work-related?

14. Would your employer be prepared to alter working conditions or practices (such as hours, workload or specific tasks) to help someone suffering from stress?

If you have five or more fails you should request for a proper risk assessment to be undertaken and ask that the HSE stress management standards is utilised for this process



APPENDIX 3: STRESS AT WORK - SUMMARY REPORT OF THE CSP SAFETY REPS SURVEYS UNDERTAKEN DURING 2007

Introduction In 2007, the following resolution was passed at the CSP annual representative’s conference: “In the present political climate health and safety issues are continually being undermined leading to increased stress in the workforce. We are aware of the Health and Safety Executive work with NHS employers to pilot management standards on stress. We call upon the CSP to direct adequate resources towards:

a) a proper assessment of stress across the membership, and b) to encourage employers to conduct risk assessments and implement the Health and

Safety Executive Management Standards.

The National Group of Regional Safety Representatives (NGRSR) was then delegated the task of considering the resolution and developing the necessary resources and support for the national network of safety reps to conduct surveys within their workplaces. After piloting a more detailed survey (see version 1 of Appendix 2) with the Eastern region safety representative the NGRSR decided upon a simpler version (see version 2 in Appendix 2) to be undertaken by safety reps in their workplace. Findings After comparing results in the regions the NGRSR identified the following trends: Around 76% of physiotherapists surveyed believe they are suffering from stress at

work. A significant 37% consider the level of stress as unacceptable. And a quarter of our members considered they had been harmed by their experiences of stress.

Key Factors – 92% of the responses cited ‘demands of the job’ as their primary or

one of their primary sources of stress. Examples of demands included too much work, insufficient time, long working hours and not enough rest breaks. Lack of learning opportunities in terms of lack of time or resources for CPD and courses was rated highly by half of the responses and over a third saw management of change as a significant cause of their stress.



Safety reps were also asked to complete an organisation survey (See version 3 of Appendix 2) regarding their employers’ policies and procedures for dealing with stress. Out of those that were returned most employers had policies in place. However there were a significant number of responses showing employers are not consulting safety reps when they conduct a risk assessment on workplace stress. On the back of these findings the NGRSR is developing resources to assist members in ways to get stress levels down such as:

• A series of one page Information Sheets with ideas and advice on dealing with specific causes of stress that came up such as what to do when the demands of the job are too much, the work environment is unacceptable, the employer doesn’t properly involve their staff in change, relationships between colleagues or with managers is difficult or when members have no control regarding their workload and how they work.

• An updated Briefing Paper on workplace stress to take on board recent developments

on this issue.

• During 2008 further regional training courses for safety reps and stewards on what to do beyond the survey in tackling the various causes of stress.

• An in-service training pack to assist safety representatives when informing members

about the process involved on assessing members’ stress through undertaking stress surveys.

Case Studies - Tackling Stress Below are some case studies of safety reps’ experiences on what happened after the stress survey was done.

• At one PCT when the safety rep shared her findings with her colleagues and management, it acted as a catalyst for change. Management started to address the problem of staff shortages, further training was offered for new staff coping with the transition of previously being locums to becoming permanent employees with the impact on their work arrangements that had entailed. The PCT is also now undergoing an audit of the working environment and plans are underway for members to be surveyed again in six months time to check on whether their stress levels have decreased.

• One safety rep shared her survey results with her Trust’s risk managers to assist in their

work on drawing up Trust policies for dealing with staff stress. Problems that came up



specific to a particular work area were circulated to the relevant team leader to resolve directly with their staff.

• At one hospital the survey exposed incidences of harassment, which is now being

addressed by management. Results of the survey were included as part of the employer’s risk assessment process on stress also underway at that time.

• Another Trust has taken action by employing a consultant psychologist to lead on

stress management and a staff counsellor to join their occupational health services.

• At another hospital the survey findings brought to management’s attention the need to address overcrowded work conditions. The safety rep got management to get a risk assessment underway and as a consequence staff have received 3 extra workstations, improved ergonomic chairs and more ‘staff friendly’ work arrangements in terms of how and where staff do their work.

• One safety rep advised that their survey results were used at a partnership forum set

up with the employer and other trade unions to assist in their development of an action plan to reduce stress levels.



APPENDIX 4 - STRESS ADVICE SHEETS

Following work developed with the National Group of Regional Safety Representatives (NGRSR) in 2007, the CSP developed a series of 6 advice sheets dealing with causes of stress.

Advice Sheet 1 – Demand - Facing members coping with staff shortages

Advice Sheet 2 – Change - Dealing with restructuring and job changes

Advice Sheet 3 - Role - Coping with conflicting priorities at work

Advice Sheet 4 – Support – How to access your workplace training/learning entitlements

Advice Sheet 5 – Bullying – Tackling individual or collective bullying behaviour

Advice Sheet 6 – Work Environment – Challenging physically uncomfortable or unsafe environment



Stress at work – demands of the job C Advice for members when overworked and stressed due to staff shortages 1. Ask your manager to develop an escalation policy --- i.e. what services get

withdrawn when short staffed. 2. Ask managers to advise ward staff/consultants/senior management that you

are under-staffed, what steps have been taken as a consequence and for how long the situation is likely to continue.

3. Develop a priority list of patients requiring physiotherapy in consultation and agreement with your managers.

4. Ask your employer to write to those who refer patients to your service, notifying of situation and give appropriate time frames for when realistically patients are treated.

5. If your employer runs an out of hours’ service --- ask for the service to be temporarily suspended during the staffing shortage.

6. Encourage staff to fill in clinical incident forms when they feel as a result of insufficient equipment or staffing patient care was compromised.

7. Remind patients to utilise the Trust’s complaints processes if they feel they have been denied access or experienced unreasonable delay in receiving treatment.

8. Contact Occupational Health --- ask them to undertake a risk assessment utilizing the Heath and Safety Executive’s Management Standards for Stress.

DO

• Take your breaks • Take your full lunch break • Start work on time • Leave work on time • Talk to your colleagues, CSP safety rep or steward about pursuing a grievance

if the problem has been ongoing and no solutions are forth-coming from your employer.

DON’T

• Suffer in silence • Work beyond your means • Work unpaid overtime • Ignore health and safety effects associated with overwork.

Produced by National Group of Regional Safety Reps 2008

STRESS AT WORK - DEMANDS OF THE JOB CSP MEMBER ADVICE SHEET 1 14 Bedford Row, London WC1R 4ED www.csp.org.uk Tel +44 (0)20 7306 6666 Email [email protected]


STRESS AT WORK – DEALING WITH CHANGE CSP MEMBER ADVICE SHEET 2 14 Bedford Row, London WC1R 4ED - www.csp.org.uk Tel +44 (0)20 7306 6666 - Email [email protected]

Stress at work – dealing with change Check list for members coping with change at work

1. Where significant changes are proposed for your work has all relevant information been provided to you, your colleagues and the CSP?

2. Have management’s proposals been provided with enough time to allow you

to be properly consulted with, or has the crucial decisions already been taken?

3. Does the information provided by your employer include exactly why, when, who is affected and how and what the claimed impact on your services will be?

4. If colleagues from other unions/professions are affected or have an interest

what sort of network or process been set up to ensure effective information sharing and support?

5. Have you and colleagues put management on notice that there must first be

clarity on the process – timescales, status of proposal, nature of consultation and staff involvement?

6. Have your steward or safety rep networked via CSP with members from other

Trusts where similar proposals have been introduced?

7. Does your employer have an organisational change policy and if so are they following it?

8. If there are potential redundancies looming, read up on your rights by

downloading CSP’s information paper titled “Redundancy: A Guide to the Law and NHS Provisions” – available to CSP members at www.csp.org.uk

DO

• Discuss with colleagues and the CSP the option of taking out a collective grievance if your employer is not following their policy, not giving enough information or enough time for you to effectively participate in their consultation process.

• Talk to family and friends about the situation and allow them to support you.

DON’T

• Suffer in silence. • Accept changes to the scope of your job or your responsibilities without

making sure that you know what is required of you and are able to do it. • Ignore health and safety effects associated with stress. If available utilise

your employer’s employee assistance programme or contact Occupational Health, or see your GP.


STRESS AT WORK- ROLE CONFLICT CSP MEMBER ADVICE SHEET 3 Email [email protected] - 14 Bedford Row, London WC1R 4ED, UK - www.csp.org.uk - Tel +44 (0)20 7306 6666

Stress at work- Role Conflict Advice for members facing conflict over priorities at work

From time to time situations can occur where your responsibilities as an employee appear to conflict with your responsibilities as a health professional. For example at times of staff shortages or rising waiting lists, staff can be over-loaded with unmanageable caseloads. It is important that patient care and staff safety aren’t compromised, so you need to assess the workload that you can safely manage. The key aspects to consider are: Your Duty of Care as a Health Professional

1. Your knowledge & skills must be kept up to date and you should be capable of providing a service of no less a quality than that to be expected based on the skills, responsibilities and range of activities within your profession.

2. To provide a safe service to patients 3. Keep accurate & contemporaneous records of your work as detailed by the CSP and HPC

standards and maintain confidentiality 4. With respect to patient care no delegation to others unless you know they are competent &

safe. You also don’t accept delegated duties if it is outside your scope of practise.

Your responsibilities to your Employer 1. Work in accordance with lawful orders 2. Serve your employer faithfully and honestly 3. Exercise skill and care in the performance of your work

In return your Employer should:

1. Take reasonable care for your safety through providing a safe working environment 2. Not act in a way that undermines the trust and confidence in your working relationship 3. Not cause you physical or psychological harm by reason of the volume or character of the work

they impose on you. 4. Not give you an instruction that conflicts with your professional duty of care as listed above.

DO When you think you are exposed to a situation or incident that you feel compromises you as a health professional seek advice from your steward or safety rep and enlist their support. Actions they may recommend are likely to include:

• Promptly writing to your manager bringing to their attention your concerns. (also keep a copy for your records)

• And/or complete your employer’s incident form/reporting procedures. • Access and follow your employer’s grievance and/or whistle-blowing/public interest disclosure

procedures where the urgency or the situation demands it or where informal approaches have been unsuccessful. (Note your silence may make you an accomplice if you don’t report).

• Encouraging other colleagues to support your safety rep or steward in getting the problem resolved.

• If people are at immediate and serious risk of sustaining a serious injury stopping the work/withdrawing from the dangerous area and notifying your employer immediately of the situation as well as contacting your safety rep.

DON’T Be apathetic or complacent. Remember under the terms of your HPC registration & as a chartered member of the CSP you are personally accountable for your practice regardless of your employer or others’ culpability. If the situation comes to the HPC attention they will prosecute the case relating to you on this basis. For further information – read CSP practice & development Information paper “Scope of Physiotherapy Practice 2008” and “Standards of Physiotherapy Practice” 2005 & “Rules of Professional Conduct” 2002. From the HPC, “Standards of conduct, performance and ethnics: your duties as a registrant “2004 and “Standards of Proficiency for Physiotherapists” 2007 .


STRESS AT WORK – SUPPORT CSP MEMBER ADVICE SHEET 4 Email [email protected] - 14 Bedford Row, London WC1R 4ED, UK - www.csp.org.uk - Tel +44 (0)20 7306 6666

Stress at Work- Support Advice on how to access your workplace training/learning entitlements

A major cause of stress for members identified from 2007 CSP safety reps’ stress surveys is the decline in workplace training or access to clinical education opportunities through employers slashing their learning and development budgets. This is disappointing as a major strand of the AfC agreement was implementation of the knowledge and skills framework (KSF) which recognises rights of NHS staff to be given adequate opportunity to develop the skills needed for the job. Two Key Reasons why continued education in the workplace is important: 1. NHS is constantly reorganising, and you need to up-skill and adapt to changes in your role. 2. To ensure you remain clinically safe HPC require all registrants to have continuous, up-to-date

record of their skills and knowledge. Did you know that under the terms of an Agenda for Change contract of employment (AfC

Terms & Conditions Handbook, Sections 6.11 & 31.29) you are entitled to: 1. Comprehensive induction when you start your new job. 2. An annual development review (ADR) and a personal development plan (PDP) (arising from

that review). 3. Sufficient financial support & appropriate time to fulfil your training and development

requirements where your training needs are identified & agreed with your employer. DO If there is a problem with your employer about arranging an ADR or receiving your PDP seek support from your safety rep or steward. Actions they may recommend are likely to include: • Seeking further information/action from your line manager on when you can expect your ADR or

PDP • If no action is forthcoming putting your concerns in writing to your line manager and asking when

(within a reasonable time frame) you can expect your ADR/PDP • Check with other physiotherapists and colleagues in your service on whether they have had

ADRs/PDPs. • If not, ask your safety rep or steward to take the issue up either at the local management level if

appropriate or at higher levels if required. Your safety rep or steward may have to lodge a formal individual or collective grievance if no satisfactory local resolution is reached.

• Support your safety rep or steward in any actions he/she take on your or other members’ behalf by attending meetings or reading information provided or arranged by your steward. Also give them your informed feedback on their activities and proposals.

• Encourage other colleagues to support your steward in getting the problem resolved. DON’T Be apathetic or complacent. You are entitled as an NHS employee to be given training and development on an ongoing basis and you should enforce this right. Remember as a health professional registered with the HPC it is you (not your employer) who is ultimately responsible for maintaining your continuing professional development and keeping an up to date record of your knowledge and skills.

Produced by the National Group of Regional Safety Reps 2008


STRESS AT WORK – BULLYING CSP MEMBER ADVICE SHEET 5 Email [email protected] - 14 Bedford Row, London WC1R 4ED, UK - www.csp.org.uk - Tel +44 (0)20 7306 6666

Stress at Work - Bullying Advice for members experiencing bullying (on an individual or collective basis)

Employers have a duty of care to you to ensure that your health, safety & welfare are protected, and this includes your mental as well as your physical health. Employers should have clear and well - publicised policies on bullying including expectations of appropriate behaviour and processes for making and investigating complaints. A Hostile Work Environment –An organisation that sets unrealistic service targets or budget constraints can develop into a strong management regime. This often tips over into unreasonable managerial demands or aggressive behaviour towards staff. Alternatively, employers not providing adequate intervention against abusive patients may lead to staff feeling stressed and unsupported. In such circumstances- DO • Notify your safety rep or steward of the situation. Participate actively in the strategy they develop.

This may include things like; - a meeting with CSP members to discuss the problem and set up an action plan to challenge the employer on attitudes or lack of action - or a survey on bullying or stress to provide information to assist in the CSP’s case to get the

employer to take action. • If a CSP formal collective grievance is pursued, support your union representative by attending

their meetings, keeping yourself informed on developments, and give feedback when asked which may assist in the collection of evidence or inform the CSP on how to argue their case on your behalf.

DON’T • Be apathetic or justify bad behaviour from patients as something you have to endure because of

your duty of care for them. Employers should display notices/posters in wards and treatment areas stating the organisation’s expectation of behaviour from patients, their relatives and friends including the consequences if they persist abusing staff. Managers should also write to abusive patients requesting an apology with a warning that services will be withdrawn if their aggressive behaviour continues. The NHS Security Management Service supply publicity material & policies for NHS Trusts promoting zero tolerance to abuse. Visit the website www.cfsms.nhs.uk to download posters etc.

Bullying by a colleague – It is important that behaviour by a colleague that causes you distress are appropriately challenged, and that your concerns are treated and responded to seriously by management and your union.

DO • Raise the issue with your CSP safety rep or steward – others may also be suffering. • Contact your employer’s employee assistant programme or occupational health services. These

should be confidential and can be a source of further support and advice. • Keep a written record/diary of incidents, including your own responses and feelings • If you feel able to, confront the bully, and if you can’t consider writing a letter explaining why you

object to their behaviour and ask them to stop • If the behaviour is continuing after the individual has been notified of your concerns then follow

your employer’s complaints process as outlined in their bullying or dignity at work policies. Your steward or safety rep will support you throughout this process.

DON’T Put up with it – you have the right to be treated with courtesy and respect, and your actions will ensure other work colleagues are not exposed to similar behaviour.

http://www.cfsms.nhs.uk/


STRESS AT WORK – WORK ENVIRONMENT CSP MEMBER ADVICE SHEET 6 Email [email protected] - 14 Bedford Row, London WC1R 4ED, UK - www.csp.org.uk - Tel +44 (0)20 7306 6666

Stress at work –The Work Environment Advice for members working in physically uncomfortable or unsafe environments

Many members in the 2007 CSP safety rep stress survey stated that their work environment was their key source of stress. Members are often expected to work in cramped, overheated and poorly ventilated treatment rooms and departments. As employers insist on members using computers or other electronic devices increasingly there is also a higher incidence of repetitive strain injuries or other upper limb/back pain. If you find yourself in such circumstances you should consider that:

1. You are unlikely to be alone in experiencing difficulties, so talk to colleagues and your safety rep to determine the extent of the problem. Ask your safety rep to set up a body map exercise for you and other members to do. Body or workplace mapping is a useful tool to identify common problems or ailments shared by staff undertaking similar tasks or operating in the same work environment. This will provide useful evidence during discussions with the employer to secure improvements. Your rep will be able to explain the process in more detail to you.

2. Your safety rep can approach your employer asking them to undertake a proper risk assessment to address the problems or hazards identified. Any employer proposals arising from the risk assessment should be discussed with staff first.

3. Sometimes employers try to get round their obligations to risk assess staff who use computer workstations on the basis they don’t consider them to be regular users. CSP strongly rejects this approach. If you are suffering pain or feeling uncomfortable when using your employer’s equipment they have a general duty of care to you to sort the problem out and not risk your health and wellbeing.

4. If your employer fails to undertake a risk assessment or to implement adequate precautions and it is agreed that a grievance is the best way of pursing the issue then support your safety rep or steward in doing so on your behalf. Again your representatives will be able to explain the process.

DO

• Challenge your employer about poor work conditions. In the CSP 2005 research study on physios’ MSDs, a significant 44% of the injured respondents identified awkward or cramped conditions as an important contributory factor.

• Fill in an incident report form if you are in pain or injured at work. Remember to keep a copy of your report and notify your safety rep.

DON’T • Be apathetic, if you or colleagues are injured, it may have unforeseen negative

consequences for your future career & wellbeing – Prevention is key.

Produced by National Group of Regional Safety Reps

workplace stress - chartered society of physiotherapy

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