Brief summary of the problem The case study from East Yorkshire Hospitals NHS Trust shows an approach

taken to dealing with stress in one department following a move into a purpose built centre on the main hospital site. It is generally acknowledged that delivering healthcare can be in itself stressful, and must be a key concern for managers and staff. The case study shows how occupational stress was compounded by organisational change resulting from a change in service location together with an unprecedented increase in workload. The case study demonstrates how the reasons for the unacceptably high level of stress were identified and the action taken to deal with the concerns expressed by staff. When East Yorkshire Hospitals Maternity Unit moved from its old buildings in Beverley to brand new purpose-built premises at Castle Hill Hospital in Nottingham two and a half years ago, hopes were high of a new era for womens health in the area. The new womens health unit is now situated close to intensive care and other acute facilities, and covers not only maternity but also gynaecology. For mothers-to-be it has proved an instant success. Large numbers have come to the new unit, and have generally been delighted with the care they received. Due to the popularity of the unit, the number of deliveries significantly rose despite a projected fall in the birth rate. As staffing levels were based on this projected fall in birthrate, the increase put a strain on the midwives. In addition, staff were adapting to a new working environment, and the effects of a regarding exercise which had caused unforeseen problems. Unfortunately, in tandem with this, two significant but unrelated clinical incidents took place which impacted on morale within the unit. The initiative: organizational stress survey

At this point in the autumn of 1998, Liz Sheppard, the newly appointed head of womens health services at the hospital, approached occupational health service manager Carole Hunter to see if something could be done about what she perceived to be worryingly high levels of stress on the unit. Having worked on the unit for some time, she was well aware of the growing concerns about staffing shortages and high workload. But, in addition, four senior midwives had been off sick with work-related stress in a short space of time. I was concerned about these staff but I also had a general feeling that a lot was going on within the unit, she explains. Although I knew it was stress, I wanted to find out the reasons. The approach came at an opportune time. The occupational health department had carried out a detailed organisational stress survey in another department earlier that year. The surveys findings had led to increases in staffing, reorganisation of some roles and a new training programme among other things. When Carole Hunter suggested a similar survey into the womens health unit, Liz Sheppard accepted enthusiastically. Most importantly, from Carole Hunters point of view, she Committed herself in advance to act on the organisational issues that might emerge from the study. The two women agreed a number of changes to the original questionnaire, which had focused principally on the major sources of stress. Bearing in mind the problem of longterm sickness on the unit, they included questions about the physical and psychological effects of stress on individuals. They also added questions on violence and aggression.

The questionnaire designed to take no more than 15 minutes to complete was sent out in January 1999 to 180 staff on the unit, from nurses and midwives to ancillary workers. The only group not included were medical staff. Propose and appraise solution to the problem The response rate of nearly 58% was good. However the results showed that 94% of respondents said they were working under stress. More than half said this was a combination of home and work factors, while over a third attributed it to work alone. The biggest source of stress was workload combined with stretched staffing levels. There was also frustration about the amount of paperwork and computer work many staff were having to complete which, they felt, was taking them away from direct patient care. At the same time, especially on the maternity wards, staff did not feel they had time to offer support to each other. There were also issues relating to the layout of the new unit. Although acknowledging the improved environment for patients, some staff experienced difficulties in adapting to the new working environment. The effects of all this on individuals gave cause for concern. Reported levels of anxiety, depression, tension and frustration were high. In addition, a significant number reported physical symptoms which could be attributed to stress such as headaches, muscle tension, bowel disorders and disturbed sleeping patterns. This did not necessarily mean they were reporting sick. Some staff said they remained at work when they were ill due to the pressure of work. Others returned to work when not fully fit because of guilt that colleagues would suffer if they werent there, says Carole Hunter.

Staff had a number of positive comments about their work. The camaraderie of colleagues came out top of this list, followed by the pleasures of the job itself and the opportunity to work one to- one with patients and their families. In addition, many clearly appreciated the chance to say what they really thought. A number poured out their troubles both personal and professional when asked for their comments on the unit. One ended a long catalogue of complaints by saying: Thank you for this opportunity to write down our concerns. Putting the findings into practice The hospital is now in the process of implementing a number of changes which, it believes, is helping to increase morale on the unit. First, it has been agreed to raise the number of staff on the unit by six. There has also been an increase in the number of F grade posts available. Liz Sheppard is looking at creating a new post of ward administrator to relieve frontline staff of some of the clerical workload. She is also hoping to expand teamworking into areas such as maternity and special care following evidence from the survey that this manner of working was popular where it operated. The unit has also taken steps to further improve the physical environment and plans are afoot to convert an office into a staff quiet room. Staff are actively encouraged to report all incidents of verbal or physical abuse and a staff charter has been drawn up which emphasizes patients obligations as well as rights. Midwives are also receiving training sessions on how to defuse potentially violent situations. With the agreement of the local Health

Authority, it was decided to review the appropriate level of maternity bookings to the unit. This involved taking a balanced view of the needs of staff and the quality of care they provided. Liz Sheppard defends the move. She acknowledges the importance of patients choice: But we had to look at the best service we could provide, and to do that we had some difficult decisions to make. Following input from professional development nurse Heather Kelly, staff are to be offered training in assertiveness, stress and time management, communication skills and, for some, clinical leadership. One of the problems in the past, says Liz Sheppard, is that these types of courses were given low priority compared to professional development. That is now set to change. The Outcomes Implementing the changes is at an early stage at the moment. However, both Liz Sheppard and Carole Hunter are convinced they are already having an effect. The message were getting back is that things are improving, says Liz Sheppard. Morale will always go up and down in this unit, but at least staff acknowledge that were doing things and were giving them a chance to be heard. It may also be significant that two of the staff who had been on long-term sick leave with stress-related problems have returned to the unit and had no further problems. Interestingly, the incidence of stressrelated sickness reported to the occupational health department has actually gone up. But this is more a reflection of the fact that staff are now encouraged to admit to stress and to make use of occupational health services, believes Carole Hunter. We are also now seeing staff before

they actually go off sick, whereas before we werent seeing them until theyd been off for a number of weeks. The impact on the overall health of the organisation must be beneficial in the long run, she says, and I have no doubt the result will bring major benefits to the Trust. It is still too early to assess fully the results of the changes, but Carole Hunter and Liz Sheppard are hoping to repeat the survey early next year to measure the effects more accurately. In the meantime Carole Hunter is hoping that other units in the hospital will be encouraged to follow the womens health example and invite the occupational health department to investigate their staffs stress levels. But, she warns, this approach will only bear fruit if senior managers within the unit are genuinely signed up to the process: If you raise all these issues without any commitment to take anything forward, then it is a wasted exercise. Outcomes and impact of future It is important that a neutral outsider is seen to be conducting the survey if it is to have credibility with staff. l The unit manager must be prepared to act on the findings of the survey, however uncomfortable. l Assuring staff of anonymity when doing the survey is vital if they are to say what they think. But is also important to stress that these anonymised findings will be made public. A misunderstanding about the status of the first occupational health survey meant staff were opposed to publicizing the results.l It is important to encourage positive as well as negative comments from staff. Without this, the overall tone can be so negative that people feel overwhelmed rather than energized to act. l It is vital that managers feed back survey findings to staff and keep them posted on developments. l

Speed of feedback is also important. In Castle Hill Hospitals case the gap between questionnaire and feedback was nearly six months, which was too long. l Sickness absence figures should be treated cautiously as a measure of stress levels. The figures may actually go up at least in the short term as a result of encouraging greater openness about stress. l The rights of patients have to be balanced against the needs of staff. l Evaluation of any changes made is essential. Equally, there is little point in a one-off survey. Ideally surveys and evaluations should be carried out at regular intervals.