work related stress2

8/8/2019 Work Related Stress2

1/19

WO RK RELA T E D

STRESS INITIATIV ES S E T 2

THREE CASE STUDIES


2/19

Acknowledgements

Thank you to Liz Sheppard, Carole Hunter and Heather Kelly at East Yorkshire Hospitals NHS Trust,

Julia Macmillan, Sylvia Carter and Sandy Gaskins at Poole Hospital NHS Trust, and Geoff Howsego,

Bob Waterhouse and Sue Holmes at South Yorkshire Metropolitan Ambulance and Paramedic Service

NHSTrust for making this publication possible, and to Andrew Cole for his development of t he original

case studies.

For further information on any of the initiatives outlined in this publication contact:

Carole Hunter, Occupational Health Service Manager, East Yorkshire Hospitals NHS Trust on 01482 623054.

Julia Macmillan, Head of HR Development, Poole Hospital NHS Trust on 01202 442896.Geoff Howsego, Director of HR, South Yorkshire Metropolitan Ambulance and Paramedic Service NHS Trust

on 01709 820520.

For further information on these initiatives, or any other aspect of mental health at work contact:

Sarah Katz, Project Officer, Health at Work in the NHS on 020 7413 2056.

Vivienne Rangecroft, Health at Work in the NHS Administrator on 020 7413 1873

Health Education Authority, 1999

Health Education Authority

Trevelyan House

30 Great Peter Street

London SW1P 2HW

www.hea.org.uk

ISBN 0 7521 1747 5/001

2m 10/99

Further copies of this publication are available from:

HEA Customer Services

Marston Book Services

PO Box 269

Abingdon

Oxon OX14 4YN

Tel: 01235 465565

Fax: 01235 465556


3/19

Foreword v

Forewords by the Trusts vi

East Yorkshire Hospitals NHS Trust 1

The initiative: organisational stress survey 1

What the study revealed 1

Putting the findings into practice 2

The results 3

Lessons learnt 4

Poole Hospital NHS Trust 5

The counselling service 5

The initiative: counselling service evaluation 6

The results 6

Lessons learnt 8

South Yorkshire Metropolitan Ambulance and Paramedic Service NHS Trust 9

The initiative: critical incident debriefing 9

Putting it into practice 10

The results 10

The future 11

Lessons learnt 12

Contents


4/19

I am delighted to introduce the third of the series of stress management case-studies to be published by

Health at Work in the NHS. This publication follows North East Essex Mental Health Trust organisational

stress pilot: A case studypublished in 1998 and Work related stress initiatives: three case studies

published in March 1999. This third set of case studies again demonstrates how NHS Trusts can take

positive action to prevent stress, with senior managers focusing on the organisational influences on

staff health. The three projects have very different aims and approaches, but I believe the issues they are

tackling and the solut ions they come up with will have resonance with many other NHS Trusts.

East Yorkshire Hospitals NHS Trust opened a new womens health unit which was extremely successful,

but with repercussions for staff because of the increased demand. The pressure this created was the

incentive for an organisational stress survey.

Poole Hospital NHS Trust has a well-established counselling service. An evaluation of the service was

undertaken to assess its effectiveness in both individual and organisational terms.

South Yorkshire Metropolitan Ambulance and Paramedic Service NHS Trust instigated critical incident

debriefing as part of their work related stress programme. The initiative has had significant outcomes

both in terms of individual staff members abilities to cope with trauma and in influencing the culture

of the whole organisation.

The three Trusts have undertaken these challenging projects at a time of rapid change within the NHS,

and we very much appreciate their willingness to share their experiences. It is through innovative work

of this kind that we can build a knowledge base of good practice in the prevention of work-related stress.

Jane Greenoak

Acting Chief Executive HEA

v

Foreword


5/19

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.

Simon Pleydell

Chief Executive

East Yorkshire Hospitals NHS Trust

vi

Forewords by the Trusts


6/19

At Poole Hospital NHS Trust we have recognised the need to make extra effort to support our staff.

Our Staff Support Steering Group has been established and has facilitated many initiatives.

One of the first was to set up a counselling service which we at Poole are very proud of. By auditing

and undertaking a comprehensive evaluation of this service we have been able to demonstrate a

positive impact on staff and the healthcare we deliver.

We do not see this as the end of our work but merely the start of trying to address some of the issues

and problems staff face both personally and at work. Through this understanding of our staff and the

difficulties they face we can continually improve our services to patients, as well as the working lives of

our employees.

L. Adams

Chief Executive

Poole Hospital NHS Trust

vii


7/19

As I start to write this foreword, I was conscious of the many documents and papers issued by the

Government in support of the White Paper The new NHS: modern, dependable. One of the most

important of these for all colleagues in the NHS is the document Working together: securing a quality

workforce for the NHS.

The White Paper, in paragraph 6.30 makes it clear that it wishes to address a number of issues, the first

of which is to promote health at work. A further one is to address stress. The whole theme of the

White Paper is to focus on the needs of patients. It is easy to forget that those who work within todays

NHS, are also people who have needs and, sadly for many, who become patients.

Human resource issues are dealt with directly in Working together: securing a quality workforce for the

NHS. The Governments aim to make the NHS a better place in which to work is clearly stated. Many ofus know that this is easier said than done. In operational services such as the ambulance service, where

front-line colleagues are regularly exposed to serious trauma, discussion of doubts and worries can be

seen to be a stigma.

At SYMAS we have tried over a number of years to introduce change and developments by a process

of evolution rather than revolution. It is really important for managers to both know and respect the

fact that the body called the NHS is made up of individual people with individual needs. The size of

the present agenda sometimes makes us forget this. The gradual introduction of good staff policies in

a caring way can do much to improve the overall health of the organisation.

Ken Threlfall

Chief Executive

South Yorkshire Metropolitan Ambulance and Paramedic Service NHS Trust

viii


8/19

When East Yorkshire Hospitals Maternity Unit

moved from its old buildings in Beverley to

brand new purpose-built premises at Castle Hill

Hospital in Cottingham 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 tothe 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 re-

grading exercise which had caused unforeseenproblems.

Unfortunately, in tandem with this, two

significant but unrelated clinical incidents took

place which impacted on morale within the unit.

The initiative: organisational stresssurvey

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 long-termsickness 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.

What the study revealed

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

1

East Yorkshire Hosp ita ls NHS Trust


9/19

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 fullyfit 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 andprofessional 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 off ice 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 emphasises

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 developmentnurse 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.

2


10/19

The results

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 stress-related

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 CaroleHunter. 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 staff s stress levels. But, she

warns, this approach will only bear fruit if seniormanagers 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.

3


11/19

4

Lessons learnt

q It is important that a neutral outsider is seen to be conducting the survey if it is to have

credibility with staff.

q The unit manager must be prepared to act on the findings of the survey, however

uncomfortable.

q 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 publicising the results.

q 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 energised

to act.

q It is vital that managers feed back survey findings to staff and keep them posted on

developments.

q 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.

q 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 opennessabout stress.

q The rights of patients have to be balanced against the needs of staff.

q 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.


12/19

Poole Hospital NHS Trust has introduced a range

of measures to combat stress in the workplace

over the past five years. Among a host of

initiatives are a subsidised massage service,

a support group for new parents, a counselling

service, a system of quiet days allowing

harassed staff to get away from it all, and a

working well programme which aims to help

staff who have short-term sickness problems.

All of this is co-ordinated by the staff support

steering group a small but high-poweredcommittee consisting of a number of senior

managers which meets every quarter to

monitor how the various elements of the anti-

stress campaign are working, to consider new

ideas and to feed back information to the board

and staff .

The latest initiative, which aims to pull together

many of these issues, is a staff support policy

document which will be distributed to all 3500

employees within the acute Trust over the next

few months. The purpose of the document is toprovide a framework for the huge range of

stress initiatives currently in operation within the

Trust, says Head of HR Development Julia

Macmillan. It tells staff all the things that are

available. But it is also trying to get them to sign

up to being aware of their responsibilities.

Yet the question remains: is all this making a

difference? Judging by their uptake, most of the

schemes are clearly popular. But there are few

objective measures of their overall impact. The

Trust is planning a wide-ranging staff attitudessurvey later this year which will provide

important baseline data. It is also beginning to

break down its sickness absence data to analyse

the proportion that is stress-related.

In the meantime, however, it has been involved

in a detailed evaluation of its counselling

service, which has thrown up some

fascinating results.

The counselling service

Pooles counselling service was set up four and

a half years ago with the specific aim of

reducing sickness absence and improving staff

turnover. The service, headed by staff

support co-ordinator Sandy Gaskins, has a

number of distinctive characteristics:

q it is an in-house service staffed by external

counsellors who have no connection with

the organisation;q it works on the basis of self-referral, which

probably helps to account for the fact that

its DNA (Did Not Attend) rate is extremely

low at 4-5%;

q staff can seek counselling for either personal

or work problems;

q staff are not limited to a specific number of

sessions and, owing to the large number of

part-t ime counsellors, they are seen shortly

after referral usually within a fortnight;

q the service is completely confidential no

records are kept of sessions apart from theinitial referral form so there is no chance of

any information filtering back to

management;

q it is very well advertised within the Trust so

everyone is aware of its existence.

The service has been able to handle 120 new

referrals and provide a total of between 1600

and 1800 hours of counselling each year.

Sandy Gaskins estimates that around two-thirds

of the problems she and her colleagues

encounter relate primarily to personal issues, but

this is always a fine line: If people find they are

being taken advantage of in their personal lives,

for example, then youll often find theyve got

the same kind of thing happening in their

working life. Equally, notes her fellow

counsellor Sylvia Carter, some individuals find

they are unable to deal with work issues until

they have sorted out their personal problems.

5

Poole Hosp ita l NHS Trust


13/19

The most common causes for seeking

counselling help in the first place are general

anxiety and depression followed by relationship

problems, either at home or at work and

often both.

The service receives most referrals from the

Medical Directorate. However, Sandy Gaskins is

wary of drawing any firm conclusions about

stress levels from this. It may well be, she points

out, that some Directorates are over-represented

because they tend to encourage staff to seekhelp, while others bottle it up. Its not a bad

thing at all that a lot of people are coming from

certain Directorates. They are dealing with their

stress, and often the problems are resolved

more rapidly than in some other Directorates

such as Theatres, Obstetrics and Paediatrics. The

lower levels of uptake elsewhere may mean

there is a culture of coping on your own and its

considered weak to go for help.

The initiative: counselling service

evaluation

So the counselling service is well thought of.

But is it effective? Over the past two years Sylvia

Carter has been undertaking a wide-ranging

evaluation to try to answer that question.

All staff who have used the service during that

time have been asked to fill out detailed

questionnaires before they begin their

counselling, and then again three months and

six months after starting counselling sessions.

The results show a dramatic decline in both the

number and severity of symptoms of stress staff

experienced over this period. The questionnaire

listed a total of seven common stress symptoms,

including anxiety, depression, phobias and

obsessive behaviour. Before counselling

individuals exhibited an average of 4.08 of

anxiety, by three months this had fallen to 2.79

and by six months it was 1.87. The severity of

these symptoms was similarly reduced. The

symptoms of depression followed the same

pattern of reduction as those of anxiety

and were halved by three months and again

at six months.

The qualitative evaluation was equally

impressive with 85% of staff feeling that the

counselling had helped and a similar proportion

saying that they respected themselves more as a

result. Also, 90% were satisfied with the service

and 95% felt it was professional.

The service had allowed me to be myself,

said one satisfied client. Others talked of beingheard, being able to t rust and be trusted,

not being judged and helping me to focus.

Another commented: If it wasnt for my

counselling I would have had a lot of time off

work. Clients perception of their quality of

life and self-esteem had also improved.

Most criticisms related to the physical

environment in which the counselling took

place. Some were worried they could be

observed by others in the waiting room, others

criticised the rooms in which counselling tookplace and there were also concerns about the

fact staff were occasionally expected to return

to work immediately after a counselling session.

These issues have now been addressed.

The results

All this offers strong evidence that the

counselling service is working, says Sandy

Gaskins. It also suggests it is having an impact

on sickness absence. This is difficult to confirm

but it is well known that depression and anxiety the stress symptoms that were reduced most

dramatically in the study are major causes

of sickness.

Not that this is a simple equation. As Sandy

Gaskins points out, while some people with

stress will take time off, others will simply throw

themselves more energetically into their work.

Most of the time we are helping people not to

have to take time off. But occasionally were

suggesting they should take time off, because

otherwise they could be working dangerously.

6


14/19

However, the effects have gone well beyond

sickness absence and turnover figures. Concerns

voiced in counselling sessions over shift systems

and inappropriate placing of patients, for

instance, have led to organisational changes

on the ward.

Again, after receiving a number of visits from

ITU staff, Sandy Gaskins decided to take the

counselling service to the unit. One of the

counsellors now holds a two-hour session on

the ward each week, the first hour beingdevoted to group reflective practice and the

second to one-to-one sessions with staff who

have particular issues to raise.

The counselling service has also helped trigger

changes for staff who become pregnant. One

of the things I noticed fairly early on was that

I was seeing a lot of people returning from

maternity leave and not coping either as

mothers or as employees. Out of this came the

parent network group which provides a forum

within the hospital for new mothers to discusstheir experiences and exchange information.

In addition, some staff told counsellors they

were scared to tell colleagues they were

pregnant because of the resentment about

having to cover for them. Others were

concerned they would lose touch while they

were away. As a result several changes have

been introduced, including sending relevant

newsletters and minutes to those on maternity

leave who wanted them and arranging a

mini-induction for them on their return.

Another message that came through time and

time again in counselling sessions was the

problem many people had with aspects of

relationships, both at work and at home.So Sandy Gaskins has been asked to run a

course which helps staff deal with conflict

and confrontation. This goes beyond

simple assertiveness training, helping people

to understand their emotions in a way that

makes them more effective when they employ

these skills.

Much of this feedback on organisational issues

happens through the staff support steering

group. Its never going to be perfect, she

acknowledges, because its always aboutresources, but at least we are able to show

where the difficulties arise and hopefully this

will reduce the number of people leaving the

profession.

7


15/19

8

Lessons learnt

q Initially staff were anxious about the counselling service being based in occupational health as

they feared it would not be confidential. This has proven to be unfounded. The positive aspect

is that Sandy Gaskins and occupational health advisor Di Ford can share knowledge of any

concerns or difficulties reported by staff generally within the organisation.

q Counsellors need to be from outside the Trust. People want to see someone who is outside

the organisation but who understands the organisation, says Sandy Gaskins.

q People should be seen quickly once they have been referred and offered as many sessions as

required to deal with the problem. An artificial limit on the number of sessions can be

counter-productive.

q Staff must be able to self-refer both for their own sake and the efficiency of the service.

Sandy Gaskins ascribes her services very low Did Not Attend rate to this. The number of

non-attendances are far higher when staff have been referred by their manager.

q Staff should be seen after work or out of work wherever possible.

q There must be a mechanism for counsellors to feed back information on organisational issues

to management and for changes then to be made. None of this should compromise the

principle of confidentiality.

q It is important to feed back relevant information to staff.

q Good administrative back-up is crucial.

q The environment in which counselling takes place is important. In addition to being

comfortable and without distractions, it needs to be sufficiently private not to be observed

by others. The booking area also needs to be discreet.


16/19

When Geoff Howsego commenced working for

South Yorkshire Ambulance Trust he suggested

introducing a critical incident stress debriefing

programme. He was told the culture of the

organisation did not support such things and

that staff had no need for it in South Yorkshire.

Geoff Howsego, who is now director of HR

at the Trust, admits he was surprised by the

reaction. He had previously worked with the

Armed Forces where debriefing and counselling

after a traumatic incident was standardprocedure and no-one thought any the less

of you.

But in some parts of the ambulance service, it

seemed that a macho culture persisted which

stated that stress was part and parcel of the job

and that any sign of emotional weakness was

an indication you were incapable of doing

the job.

Just how wrong these assumptions were quickly

became apparent once Geoff Howsego took uphis new job and within months was fielding

calls from staff seeking help. This in turn led to

the setting up of a team of 10 volunteers who,

over the last two years, have offered a

confidential debriefing service to any member

of staff who needs it. The service has been so

successful it is now to be expanded.

South Yorkshire Metropolitan Ambulance and

Paramedic Service NHS Trust current ly employs

a total of 671 staff , of whom nearly two-thirds

are frontline staff, and another 40 work in A&Econtrol with most of the rest in ancillary,

management and technical back-up roles. The

crew operate from 13 different locations within

the Trust.

Most of these jobs are potentially highly

stressful. Front line emergency staff face the

most obvious traumas. But the staff in the

control room who receive the initial emergency

call can also be subject to enormous stress.

And all staff face a range of pressures such as

organisational change, ever more demanding

performance targets and an increase in violence

and aggression.

Geoff Howsego accepts unpleasant experiences

are inevitable if you work on A&E vehicles. But

what you can do is minimise their effect by

training in awareness and providing support and

care. Were saying there should be a mechanism

to help staff deal with this. Critical incident

debriefing, combined with the other stress

initiatives that have been introduced, offers thisemotional safety net. And hopefully in the

process it can prevent long-term emotional

damage and the onset of post-traumatic stress

syndrome.

The initiative: critical incidentdebriefing

Geoff Howsegos proposal for a critical incident

debriefing team was given board approval

approximately two years ago on condition that

it incurred no extra cost in terms of training orimplementation. He was also aware that the

scheme would be watched. There was a

perception among some that it would open up

a Pandoras box, with many staff using this as

an excuse to be absent.

It was against this background that he put

together a team of 10 experienced staff

members who would talk to any individuals

who had been through a traumatic or stressful

episode at work. All members of the team

agreed to give their time voluntarily. Theirtraining was also carried out in their own time.

One of the key features of the process from the

start has been the fact that the debriefers are

from a range of areas who, wherever possible,

have first-hand experience of the type of work

being undertaken. Another crucial ingredient is

confidentiality. Staff are given a contract before

they begin, signed by the chief executive, which

assures them the information divulged in the

meeting will go no further without their

9

South Yorkshire Metropolita n Ambulanc e

and Paramed ic Service NHS Trust


17/19

permission. The only exception is where an

individual has clearly transgressed his or her

contract or the law.

The team also agonised for some time over

precisely what constituted a critical incident

before deciding this should be a matter for the

individual. We now say it is anything that

causes the individual distress, no matter what

that is, says Geoff Howsego. Staff, all of whom

receive a pamphlet about coping with the

effects of a traumatic event, are automaticallyoffered debriefing after any serious incident.

The types of incidents which the team has to

deal with vary enormously. One crew, for

instance, was forced to remain longer than

usual at the scene of a particularly gruesome

traffic accident in which several people died.

Another crew was deeply traumatised by

dealing with an incident where a young boy

suffered a cardiac arrest during a dental

operation.

But other situations can be more prosaic.

For one member of staff the f irst symptoms

of stress emerged when he became depressed

on holiday. It was only when his wife contacted

the Trust that it became clear that accumulating

work pressures were responsible for this

mood change.

Putting it into practice

Debriefings are usually conducted by two

members of the team and, where this involvesfront line staff , will normally focus on both crew

members involved. The team makes it a rule not

to debrief within the first 48 hours when

emotions are still high, but try to organise a

meeting as soon as possible afterwards.

The session usually lasts around an hour and

a half, w ith as few interferences as possible.

We tell staff that if they need to go to the toilet

they should do so now, which sets the scene,

says debriefer and Head of Health and Safety

Sue Holmes. But we also say that if they need

to walk out at any point because of the

emotions of the situation then they can do so.

The session focuses on three principal areas

facts, feelings and the future, explains Bob

Waterhouse, Assistant Director of A&E, who is

another member of the debriefing team. It is

process-orientated and has a relatively

straightforward goal, which is to allow

individuals to talk through the incident and

make some sense of their thoughts and

feelings. They are also encouraged to talk aboutthe future, to consider how they can support

each other and what coping strategies they

can employ.

But the process does not end there. The team

always tries to follow up individuals within a

couple of weeks to see how they are managing

and to provide extra support if necessary. There

is a real danger you can do more harm than

good without this, emphasises Bob Waterhouse.

In most cases, however, the individuals aresimply seeking a safe place to discuss their

feelings and reassurance that they did their

best. People tend to wonder if they could have

done more in these situations, says Bob

Waterhouse. Usually the situation has gone

far beyond what one person could reasonably

be expected to do. But people need to be

reassured there was nothing more they could

have done.

Equally, says Sue Holmes, individuals are hugely

relieved to discover that reactions to events likethis, such as bursting into tears while walking

down the street, are completely normal. You

could say we are helping to normalise an

abnormal situation.

The results

Initially, admits Geoff Howsego, many staff were

fairly cynical about the initiative, but over the

past two years that seems to have changed.

Between 30 to 40 staff have now been through

the debriefing process. Most have been able to

10


18/19

return to work afterwards, though a handful

have been referred for additional counselling.

The anecdotal feedback is also positive. Most of

those who have completed evaluation forms

have been highly enthusiastic. Only one was

critical but the complaint was that this scheme

should have been introduced 10 years earlier!

What is more difficult to assess is the schemes

overall impact on the health of the Trust. Geoff

Howsego is convinced the scheme hasprevented instances of more serious illness.

Nevertheless, sickness absence and turnover

rates have remained largely constant during this

period. Bob Waterhouse suggests this may itself

be a mark of success. Given that levels of stress

generally are rising and are cause for concern,

how much would our sickness levels have gone

up if we hadnt been doing this? he wonders.

The fact we have held our position could, in

those circumstances, be interpreted as an

actual reduction.

Perhaps the biggest impact, though, has been

on the culture of the organisation. The

introduction of debriefing and other stress

measures has allowed staff to talk more openly

about stress for the first time and to accept that

showing your emotions is not a sign of

weakness.

The future

Debriefing is only one element in a wide

programme of stress initiatives within the Trust.

Most significantly, it is now launching a stress

awareness programme which is to be made

available to all staff, either as part of the

standard Continuing Professional Development

for clinical staff or on a voluntary basis for all

others. The aim is to explain to staff what stress

is, how it manifests itself and what coping

strategies can be employed to prevent it.

Geoff Howsego is now examining how to

expand the debriefing programme to enable

more operational staff to become debriefers and

to allow every level of the service to be properly

represented. At the same time it is hoped the

original team will take on a more managerial

and facilitative role, providing mentoring, back-

up and support to the new, larger group of

debriefers rather than only doing it themselves.

He accepts there is still a long way to go intackling stress within the Trust. But, given the

low baseline from which they began three years

ago, progress has been signif icant. And perhaps

the clearest indicator of this is that critical

incident debriefing, once regarded with such

suspicion, has now become part of the

organisations culture. In fact, says Geoff

Howsego, there would now be an outcry if

it were discontinued.

11


19/19

12

Lessons learnt

q The softly, softly approach, in which debriefing was introduced almost surreptitiously and

only publicised to staff once it was established, has been crucial to its success, Geoff Howsego

believes. Because we did it subtly to begin with, it had become almost accepted by the time

we announced it officially. So those people who might have wanted to cause problems

couldnt because it was already done.

q Selecting the right debriefers is critical to the whole process. If you get the people wrong, the

process will fail, says Geoff Howsego. And the bigger we made the team, the more chance

there was for something to go wrong.

q South Yorkshires experience is that debriefers working in pairs tend to be most effective.

This may be because they are usually counselling teams of two crew members.

q Administrative and secretarial support is essential.

q A co-ordinator or manager of the process is advisable. In South Yorkshire the debriefing team

managed things collectively but, now it is expanding, a co-ordinator will need to be appointed.

q It is vital to follow up the initial debriefing to find out how an individual is coping.

q Critical incident debriefing cannot operate in isolation. It should be linked to other stress

initiatives. In particular it needs to be complemented by preventive approaches, such as the

stress awareness scheme.

work related stress2

Documents