It has been well-documented that the cost of work-related is significant, and rising all the time. As Tholakele Sindisiwe Gcumisa and Anne Harriss show in this case study, managing and addressing work-related stress needs to be a collaborative process involving managers who carry out risk assessments and OH practitioners who can offer advice as well as signpost to supportive mechanisms.
Stress has been identified as one of the main issues currently affecting employee health (Black and Frost, 2011; Hassard and Cox, 2011; Joyce, 2013; Kinnunen-Amoroso and Liira, 2016). The Health and Safety Executive (2017) reports that there were 526,000 workers affected by work-related stress, anxiety or depression in 2016/2017 resulting in a loss of 12.5 million working days, a significant cost to the UK economy.
Indeed, stress is one of the main causes of long-term absence in the workplace and it has been found to be one of the main concerns raised by half of public health workers (Black and Frost, 2011).
Stress has the potential to negatively affect industries and organisations in several ways. Stress can result in employee turnover (Bridger et al, 2013) and the World Health Organization (2004) highlight that the inability of the employees to undertake work-tasks to expected levels, can result in fiscal issues for organisations and industries.
About the authors
Tholakele Sindisiwe Gcumisa is an occupational health clinic nurse and Professor Anne Harriss is professor in occupational health and course director in occupational health nursing at London South Bank University
Stress is defined as a reaction that results when people are unable to effectively manage hazards that they are presented with. This results in physiological changes that may impact the body negatively if the effect is long-term (Randall, 2011, Richards, 2009).
When the body is presented with stress, the limbic system of the brain (a group of structures that control stress and anxiety) will initiate a response (Howard, 2004). This response, initiated by the sympathetic nervous system and the adrenal medulla, is designed to equip the body to deal with the stressor (Howard, 2004).
Richards (2009) outlines the physiological effects of stress on the main body systems that include a raised pulse, an increased respiratory rate increasing the body’s oxygen uptake, the slowing down of digestive action while increasing the production of stomach acids and a change in muscle rigidity.
With prolonged exposure there is an increase in energy required to mitigate the damage to the body that triggers the hormonal release of corticotrophin (Howard, 2004). The release of corticotrophin leads to the secretion of adrenocorticotrophic hormone enabling the adrenal cortex to maximise the production of cortisol (Howard, 2004).
Need for proactive preventative strategies
An increase in cortisol facilitates the breakdown of glucose ensuring that there is a sufficient supply of energy available for the body to manage the stress. (Randall, 2011). Randall (2011) emphasises that cortisol, described as a stress hormone, can affect multiple areas in the body including memory and the immune system. The World Health Organization (2004) acknowledges that stress can therefore result in individuals being more susceptible to infections when the immune system is suppressed.
Prolonged exposure to stress leads to exhaustion, a process that produces ill-health (Howard, 2004; Bridger et al., 2013). Prolonged and unmanaged stress can possibly progress to other mental health conditions such as depression and anxiety (Ingham et al, 2015).
Causes of stress are wide-ranging and result from the presence of illness, social difficulties and can also be work-related (Howard, 2004). The Health and Safety Executive (2017, p4) describe work-related stress as: “A harmful reaction that people have to undue pressures and demands placed on them at work.” Work-related stress can result from interpersonal relationships to poor management of aspects of work processes and responsibilities (World Health Organization, 2004).
Key factors include job demands and control, managerial support and role ambiguity. Black and Frost (2011) identify that significant organisational change, particularly when poorly planned and managed, can be a primary cause of workplace stress. With knowledge of these underpinning factors, organisations can develop strategies to manage work place stress with positive outcomes for employees, organisations and society (Hassard and Cox, 2011).
This results in a healthier and more content workforce, increasing productivity and reduces employee absence (Advisory Conciliation and Arbitration Service, 2018). There are legal obligations for employers to be proactive and safeguard against excessive levels of stress in the workplace. They should ensure there are measures available to assist those employees who are negatively impacted by their work (World Health Organization, 2004; Kloss, 2010).
Organisations should be proactive in developing preventative and management strategies to combat work-related stress. Occupational health (OH) should be involved in organisational policy development such as those relating to dignity at work. The referral of employees to OH for advice relating to managing the health effects of stress is an appropriate, but reactive, approach (Hassard and Cox, 2011).
This case study relates to Stacey (a pseudonym), an administrator, who was referred to the OH department by her manager on account of her frequent short-term absences. Stacey had worked as an administrator for a large healthcare organisation for over nine years. She was based in a healthcare centre where her work activities included undertaking desk-based tasks, face-to-face interactions with service users and arranging team activities and meetings.
Stacey was currently at work when reviewed by OH. On reviewing her notes, it was noted that Stacey had been seen in OH three months previously because of similar frequent short-term absences associated with minor and self-limiting illnesses. Her manager had stipulated on this referral that Stacey was now seeking advice on her diet, which she thought was contributing to her frequent minor ailments such as colds and flu-like symptoms to which she attributed her frequent short-term absences.
She was observed to be withdrawn and reluctant to speak to the OH nurse who was undertaking her assessment. Litchfield (2013) acknowledges that an OH referral may be a difficult experience for some employees and a source of distress. With this in mind, the referral, the outline of the consultation, confidentiality issues and the fact she could have access to the report were discussed at the start of the consultation to reassure her and alleviate any concerns she may have had about the consultation. Her consent to proceed was agreed.
A full clinical history including her current and past medical and occupational history was taken. Although no significant medical conditions were disclosed, Stacey reported an increasing number of minor ailments in recent months and thought that her diet may be the cause. It appeared she ate a healthy diet and there were no concerns requiring further referral to other members of the multi-professional team. Stacey provided detailed information when asked about her work issues.
Asking employees direct questions regarding work stressors establishes any underlying work issues impacting on their wellbeing (World Health Organization 2004). To gain a full picture of her mental health and ascertain a presence or rise in anxiety levels, Stacey was asked to complete a hospital anxiety and depression scale (HADS) questionnaire.
Her score did not indicate the presence of depression but indicated a borderline score on the anxiety scale. She revealed work had been stressful over the past year stating that this mainly resulted from a difficult relationship with a recently appointed senior team member that had led to a breakdown in effective working relationships.
She revealed this was distressing and she indicated she was being prevented from carrying out work tasks she had previously undertaken with ease. She considered her work was no longer valued and attributed this to this poor relationship. She expressed anger that this had escalated the conflict. She also reported being temporarily relocated to another healthcare centre making her feel that she was being blamed for the conflict.
Conflict, work-related stress and sickness absence
Conflict in the workplace resulting in significant discord or disagreement can result in hostility between work colleagues (Martinez-Corts et al, 2015). This may be associated with ill treatment and unacceptable behaviours such as lack of courtesy and disrespectful behaviour (Sliter et al, 2011).
Differences of opinion can have positive or negative benefits, it may result in positive outcomes when expressed in a courteous way if it encourages members of the team to carefully consider different opinions raised by colleagues thereby resulting in better outcomes (Brinkert 2010).
Conversely, a dysfunctional team results if conflict is not addressed effectively. Both absenteeism and presenteeism, attending work when an individual is affected by illness (Niven and Ciborowska, 2015), may ensue (Buon, 2008). The Advisory, Conciliation and Arbitration Service (2013) points out that conflict can result in financial loss for organisations due to employee absence, poor productivity and time spent in its management.
It is therefore unsurprising that Stacey reported that prior to her relocation, she had found it easier to be away from work allowing her not to deal with or be in contact with the work colleague with whom she was having difficulties.
People respond to stress differently, past experiences affect how individuals react to situations (Franklin, 2008). Personal traits such as anger can influence how people respond when under pressure or facing difficult situations (Sliter et al 2011). Individual characteristics combined with work aspects can have a major role in how work-related stress is managed (Moustaka and Constantinidis, 2010).
Stacey could avoid the conflict when absent from work. Such avoidance behaviour is recognised as a frequently used coping strategy (Franklin (2008). To prevent further work absences Stacey needed to consider and adopt different coping strategies.
Absence from work has implications not only for the individual absent from work but also for the employer and other members of the team. Niven and Ciborowska (2015) observe that employees may anticipate experiencing difficulties on their return to work if their usual workload has not been effectively processed during their absence. If they are aware that other team members have been unhappy to take on these additional responsibilities the returning employee may anticipate relationship problems with these colleagues due to their increased workload (Bridger et al, 2013).
A survey carried out by Niven and Ciborowska (2015) involving 1,205 pharmacists concluded that presenteeism was associated with increased anxiety and error rates amongst participants highlighting that presenteeism may result in a degradation of work efficacy. Attending work while ill is necessary for some individuals where being at work can be more beneficial than being absent. Work can provide remedial benefits and facilitate the recovery process (Wadell and Burton,
2006). Schultz and Edington (2007) assert that the maintenance of employee well-being is the most efficient measure in combating presenteeism. It was paramount that Stacey received support and skills to prevent further short-term absences helping her remain at work and be productive whilst there.
Dealing with workplace conflict
Having an illness or a health issue need not be a barrier to attending work (Black and Frost 2011). The decision as to whether to attend, or return, to work can be attitudinal and influenced by factors including a fear of losing their job or their perceived lack of support from their colleagues or their manager (Mellin and Harriss, 2010).
The National Institute for Clinical Excellence (2009) highlights measures that can be utilised to assist employees affected by work-related stress. These can include signposting of employees to OH services and the use of employee assistance programmes. Bridger et al (2013) advocate counselling as one of the measures that can be utilised to effectively support employees to manage stress.
Although interventions such as counselling can assist the employee with regaining their well-being, they fail to effectively address what employees identify as triggers of work-related stress (Ingham et al (2015) and pro-active effective management is essential.
Although Stacey was referred to the OH counselling services to help her develop adaptive strategies to build resilience. Stacey recognised that the causal factors of her stress must be addressed. Adaptive strategies with positive health benefits include activities such as sourcing assistance, undertaking forms of exercise and both were encouraged.
Stacey had not developed any maladaptive coping strategies harmful to health such as reliance on alcohol or drugs (Holton et al, 2016). She had been using avoidance to deal with stress which resulted in absenteeism, the adoption of adaptive coping strategies such as emotional resilience were recommended to help her better cope with workplace adversities as this would assist her to handle hardships successfully (Jackson et al, 2007).
Successful adaptation strategies can focus on both micro and macro elements, that is with individuals or at an organisational level (Chartered Institute of Personnel and Development, 2011). Business in the Community (2009) advocates that measures aimed at sustaining resilience should seek to adopt a biopsychosocial approach and consider both general health and well-being and should avoid focussing only on the psychological aspects.
Building resilience can encompass adopting a new perspective when dealing with diversity in the workplace and the expansion of the sources of support in the workplace (Jackson et al, 2007). Organisational resilience measures can include the availability of operational strategies geared towards managing stress in the workplace (The Chartered Institute of Personnel and Development, 2011).
In a systematic review undertaken by Ruotsalainen et al (2015) examining 58 studies assessing the efficacy of different measures utilised in combating work-related stress revealed that measures such as cognitive behavioural therapy were found to produce positive outcomes, it was essential to tackle causal issues that trigger stress.
As a breakdown in interpersonal relationship issues led to conflict that led to Stacey’s psychological distress it was important that this was addressed and mediation was a suggested strategy. Mediation is the use of a neutral third party to resolve conflict (Advisory Conciliation and Arbitration Service, 2013). The primary goal is to understand and effectively resolve disputes (Ingham et al. (2015).
Focusing on the root causes of stress at work can assist with its effective management (National Institute for Health and Care Excellence, 2017). Furthermore, the Advisory Conciliation and Arbitration Service (2013) recommends utilising mediation to assist all team members, including managers, and advocates its use at any stage of the conflict.
Mediation has been utilised by a local authority on the advice of OH to address work disputes and improve communication between employees and managers (Ingham et al 2015). Stacey was willing to engage in the mediation process as she could see the benefits.
Stacey was referred for counselling but failed to attend her first appointment. Despite this initial barrier, the appointment was rearranged. She remains under the care of the counselling service within the OH department and is participating in mediation.
Although conflict is sometimes unavoidable, it is important that when it occurs it is managed early and effectively. Managing and addressing work-related stress should be a collaborative process involving managers who carry out risk assessments and OH practitioners who can offer advice and signpost supportive mechanisms including mediation in order to facilitate positive outcomes for all.
Advisory, Conciliation and Arbitration Service (2013) Mediation: an approach to resolving workplace issues. Available from: http://www.acas.org.uk/media/pdf/n/n/Mediation-an-approach-to-resolving-workplace-issues.pdf
Advisory, Conciliation and Arbitration Service (2018) Dealing with stress in the workplace. Available from: http://www.acas.org.uk/index.aspx?articleid=6062
Black, C and Frost, D. (2011) Health at work-an independent review of sickness absence. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/181060/health-at-work.pdf
Bridger, R S, Day, A J and Morton, K. (2013) Occupational stress and employee turnover, Ergonomics, 56 (11), pp. 1629-1639. DOI: 10.1080/00140139.2013.836251.
Brinkert, R. (2010) A literature review of conflict communication causes, costs, benefits and interventions in nursing, Journal of Nursing Management, 18 (2), pp. 145-156. DOI: 10.1111/j.1365-2834.2010.01061.x
Business in the Community (2009) Emotional resilience toolkit. Available from: https://www.mentalhealth.org.uk/publications/emotional-resilience-toolkit/
Buon, T. (2008) Perspectives on managing workplace conflict, in: Kinder, A; Hughes, R and Cooper C L (ed.) Employee well-being support: a workplace resource. Chichester: John Wiley & Sons, pp. 251-268.
Chartered Institute of Personnel and Development (2011) Developing resilience: a guide for practitioners. Available from: https://www.cipd.co.uk/knowledge/culture/well-being/resilience-guide
Franklin, A. (2008) Mental health and stress, in: Oakley, K. (ed.) Occupational health nursing. 3rd ed. Chichester: Wiley, pp. 197-252.
Hassard, J and Cox, T. (2011) Work-related stress: nature and management. Available from: https://oshwiki.eu/wiki/Work-related_stress:_Nature_and_management
Health and Safety Executive (2009) How to tackle work-related stress: A guide for employers on making the management standards work. Available from: http://www.hse.gov.uk/pubns/indg430.pdf
Health and Safety Executive (2017) Work-related stress, depression or anxiety statistics in Great Britain. Available from: http://www.hse.gov.uk/statistics/causdis/stress/
Holton, M K, Barry, A E and Chaney, J D. (2016) Employee stress management: an examination of adaptive and maladaptive coping strategies on employee health, Work-A Journal of Prevention Assessment & Rehabilitation, 53 (2), pp. 299-305. DOI:10.3233/WOR-152145.
Howard, D. (2004) Stress, relaxation and rest, in: Mallik, M, Hall, C and Howard, D. (ed.) Nursing knowledge & practice: foundations for decision making. 2nd ed. Edinburgh: Elsevier Limited, pp. 175-198.
Ingham, S, St Romaine, J and Brearley, D. (2015). Mediation helps tackle stress at work at Bradford Council. Available from: https://www.personneltoday.com/hr/mediation-helps-tackle-stress-at-work-at-bradford-council/
Jackson, D, Edenborough, M and Firtko, A. (2007) Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review, Journal of Advanced Nursing, 60 (1), pp. 1-9. DOI: 10.1111/j.1365-2648.2007.04412.x
Joyce, J. (2013) Facing the challenge of mental ill health in the workplace, Journal of Public Mental Health, 12 (2), pp. 93-97. DOI: 10.1108/JPMH-01-2013-0003.
Kinnunen-Amoroso, M and Liira, J. (2016) Work-related stress management between workplace and occupational health care, Work, 54 (3), pp. 507-515. DOI: 10.3233/WOR-162317.
Kloss, D. (2010). Occupational Health Law. 5th ed. Oxford: Wiley-Blackwell.
Litchfield, P. (2013) Ethics in occupational health, in: Palmer, K, Brown, I and Hobson, J. (ed.) Fitness for work the medical aspects. 5th ed. Oxford: Oxford University Press, pp. 88-101.
Martinez-Corts, I, Demerouti, E, Bakker, A B and Boz, M. (2015) Spillover of interpersonal conflicts from work into nonwork: a daily diary study, Journal of Occupational Health Psychology, 20 (3), pp. 326-337. DOI: 10.1037/a0038661.
Mellin, T and Harriss, A. (2010) Sick and tired. Occupational Health, 62(8), pp.24-26.
Moustaka, A and Constantinidis, T C. (2010) Sources and effects of work-related stress in nursing, Health Science Journal, 4 (4), pp. 210-216. Available from: http://www.hsj.gr/medicine/sources-and-effects-of-workrelated-stress-in-nursing.pdf
National Institute for Clinical Excellence (2009). Promoting mental wellbeing at work. Available from: https://www.nice.org.uk/guidance/ph22/resources/mental-wellbeing-at-work-pdf-1996233648325
National Institute for Health and Care Excellence (2017). Healthy workplaces: improving employee mental and physical health and wellbeing. Available from: https://www.nice.org.uk/guidance/qs147/resources/healthy-workplaces-improving-employee-mental-and-physical-health-and-wellbeing-pdf-75545484547525
Niven, K and Ciborowska, N. (2015). The hidden dangers of attending work while unwell: a survey study of presenteeism among pharmacists, International Journal of Stress Management, 22 (2) pp. 207-221. DOI: 10.1037/a0039131.
Randall, M. (2011), The physiology of stress: cortisol and the hypothalamic-pituitary-adrenal axis. Available from: https://dujs.dartmouth.edu/2011/02/the-physiology-of-stress-cortisol-and-the-hypothalamic-pituitary-adrenal-axis/#.Wvt-t_ZFzIU
Richards, M. (2009) Stress pocketbook. Alresford: Management Pocketbooks Ltd.
Ruotsalainen J H, Verbeek, J H, Marine, A and Serra, C. (2015). Preventing occupational stress in healthcare workers, Cochrane Database of Systematic Reviews, pp. 1-155. DOI: 10.1002/14651858.CD002892.pub5.
Sliter, M T, Pui, S Y, Sliter, K A and Jex, S. M. (2011). The differential effects of interpersonal conflict from customers and co-workers: trait anger as a moderator. Journal of Occupational Health Psychology, 16 (4), pp. 424-440. DOI: 10.1037/a0023874.
Schultz A B and Edington D W. (2007) Employee health and presenteeism: a systematic review, Journal of Occupational Rehabilitation, 17(3), pp.547-579. 33p. DOI: 10.1007/s10926-007-9096-x.
Waddell, G and Burton, A K (2006) Is work good for your health and well-being? Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/209510/hwwb-is-work-good-for-you-exec-summ.pdf
World Health Organization (2004) Work organization and stress. Available from: http://www.who.int/occupational_health/publications/pwh3rev.pdf