This case study on workplace stress shows how the evidence base for occupational health underpinned a successful intervention. Anne Donaldson and Anne Harriss explain.
Stress, anxiety or depression underpin much work-related ill health, accounting for 9.9 million days of sickness absence in 2014-15, with, on average, 23 days lost per person. It resulted in 35% of all days missed from work due to ill health. Industries reporting the highest prevalence of ill health from work-related stress included health and social care, teaching, public administration and defence (HSE, 2015).
The Mental Health Foundation claims 12 million adults consult their GP each year due to mental illness, much of it stress related; one in six of the population experiences anxiety (MHF, 2014).
The main causes of work-related stress reported to GPs (THOR – GP) were workload pressures, interpersonal relationships, including bullying, harassment and difficulty with superiors, and work changes, including responsibilities and reduction of resources (HSE, 2014). A YouGov survey (2012) found 48% of the British workforce said they were stressed most of the time and 47% cited performance issues as key reasons.
Impact of workplace stress on individuals and work colleagues
Stress wanes when stressors are reduced. Conversely, anxiety can persist without a clear cause to the individual.
Anxiety and stress are closely linked with similar signs and symptoms; anxiety may be associated with depression as the most common mood disorder seen in primary care (Kumar and Clark, 2012). People with low psychosocial resources are more likely to succumb to mood disturbance when stress levels increase despite experiencing few stressors (DeLongis et al, 1988).
Colleagues often undertake the work responsibilities of absent staff. This may lead to spiralling absences among co-workers, who are stressed because of the additional responsibility (HSE, 2014). This case study presents the assessment of an employee, Norman, in order to ensure his fitness to return to his role without impacting on his health (Palmer et al, 2013).
The objectives of the consultation were two-fold:
- evaluating whether work had adversely affected Norman’s health and whether it may continue to do so; and
- providing impartial advice to management regarding his sickness absence, suggesting modifications for their consideration in order to support a successful return to work.
Norman’s referral by management was precipitated by a four-week absence related to stress and anxiety. There had been four further single-day absences in the preceding six months attributed to gastrointestinal upsets.
Norman, a 22-year-old part-time receptionist and administrative assistant, had been employed in this role for 10 months working 30 hours per week. He had been absent from work for a month on the day of the consultation and was preparing to return to work. On entering the department, his mobility difficulties and an obviously awkward gait and altered balance were noted. He disclosed treatment by his GP for stress, anxiety and depression.
He described previous short-term absences resulting from nausea and vomiting, relating these to his anxiety at attending work. In the previous five to six weeks, in addition to nausea he also referred to difficulty sleeping, restlessness, loss of appetite, palpitations and rumination on his low self-esteem. Rumination can be a negative effect of stress. Genet and Siemer (2012) claim that rumination moderates the relation between unpleasant daily effects and negative mood.
Although excessive rumination is maladaptive, McFarland et al (2007) agree that some limited self-focus can be beneficial. Norman felt anxious about returning to the same situation and was accessing counselling support to help anxiety management. Hunsley et al (2014) suggest that psychological treatments are of at least equal benefit to medication for common mental disorders.
He had been prescribed 75mg of Venlafaxine a day with good effect. Venlafaxine is a serotonin and noradrenaline re-uptake inhibitor used to treat depression or generalised anxiety disorder. His GP also prescribed 5mg of diazepam – a long-acting benzodiazepine anxiolytic – to be taken as required. Recently he had not taken this as he felt better.
Past health and social history
Norman had cerebral palsy and experienced difficulty walking during his early years. Achilles tendon surgery in childhood improved this, although surgery left him with residual lower leg discomfort if he walked too far or stood for sustained periods without resting. The orthopaedic team monitored him every 18 months.
Norman described excellent family support. A non-smoker and non-drinker of alcohol, he took no formal exercise but walked as much as he felt able. Increasing physical activity within his ability was advised as it is found to improve mental health (Crone & Guy, 2008; McArdle et al, 2012).
Norman generally enjoyed his role, shared with an able-bodied colleague with whom he alternated his reception duties. He indicated the interface with the public could be challenging and stressful. His workload had increased in the previous four months following the resignation of a colleague who indicated that he too found this role stressful. Financial constraints resulted in this position remaining unfilled, increasing Norman’s responsibilities. Stress is recognised as contributing to high staff turnover and low morale (Wolever et al, 2012).
Although working primarily at the reception desk, Norman frequently got up from his chair to deal with customers and to undertake photocopying duties. On one occasion he spent an afternoon mostly standing, which resulted in leg discomfort. No workplace adjustments had been effected to support his disability.
On recruitment, his manager had enquired whether he required any adjustments. Norman declined this offer, not wanting to “make a fuss”. He had not disclosed his disability at pre-employment screening (PES) as he did not consider himself disabled.
Many of Norman’s perceived stressors are normal daily occurrences of reception duties, but his physical disability exacerbated this. As he had not requested adjustments, there was nothing in place to support him in relation to his mobility difficulties.
Although his disability had not been disclosed at PES, under s.2 of the Health and Safety at Work etc Act 1974, Norman’s employer has a duty of care to him. Withholding information at PES that later comes to light could lead to disciplinary action but Norman considered that declaring his disability may have precluded his employment.
Cerebral palsy describes a group of childhood syndromes, apparent from birth or early childhood, characterised by abnormalities in motor function and muscle tone caused by genetic, intrauterine or neonatal insults to brain development. Resulting disabilities, of varying degrees, may be physical and mental.
A full functional capability assessment should have been performed at the start of his employment, facilitating adjustments enabling him to function effectively (Palmer et al, 2013). This had not been undertaken.
Norman usually managed his leg discomforts but occasionally had been unable to rest them at work. A study of workers with rheumatoid arthritis suggested that the workers reported greater discomfort on the days when they experienced more undesirable work events or job “strain” (Fifield et al, 2004).
Although this study looked at rheumatoid arthritis, issues concerning chronic pain and discomfort are relevant in this case. Although ultimately a legal decision, Norman was likely to be covered under the Equality Act 2010 as he had a long-term disability.
Withholding information at PES was fundamental to the case of Cheltenham Borough Council v Laird (2009). The council accused Laird of lying on her PES questionnaire by not disclosing her mental health history. She had been taking long-term antidepressants that kept her depression under control, but after some work problems her health deteriorated and she retired on health grounds. The judge confirmed there was no general duty of disclosure of information that was not specifically requested.
Thus, if a PES form does not directly ask about cerebral palsy, disclosure was not required. Kloss (2010) mentions these types of dilemmas are often only answered through the courts, but unless the employer is given information regarding disability, he cannot reasonably put adjustments in place. In the case of Hanlon v Kirklees Metropolitan Council and others, the employee declined to consent to the disclosure of medical records, arguing this would contravene his right to privacy, and subsequently lost his case of disability discrimination.
The Health and Safety Executive (HSE 2007) defines stress as: “The adverse reaction people have to excessive pressures or other types of demand placed on them at work.”
The stress response
Stressors initiate physiological responses, evolved to protect and preserve the individual in times of threat by ensuring a reaction (Alexander et al, 2006).
This response is triggered by the limbic system within the brain. This is a series of centres controlling emotions, reproductive and survival behaviours (Blows, 2011). When survival is threatened, the system is instantly triggered into action to protect the individual, regardless of the threat magnitude.
A chain reaction occurs: the hypothalamus mediates the autonomic nervous system (Alexander et al, 2006), resulting in a sequence of physiological changes. The initial reaction is very fast, and only when the information reaches the cerebrum can the urgency of the situation be determined and responses modified (Blows, 2011).
The initial flight-or-fight response acts on the sympathetic division of the autonomic nervous system. Noradrenaline from the adrenal medulla immediately prepares the body for physical activity, mobilising glucose and oxygen to the heart, brain and skeletal muscles, preparing for flight or fight.
Non-essential functions, including digestion, are inhibited. Reduced bloodflow to the skin and kidneys promote the release of rennin, triggering the angiotensin – aldosterone pathway leading to fluid retention and hypertension. The resistance reaction results from corticotropin-releasing factor from the hypothalamus, stimulating the release of adrenocorticotropic hormone from the pituitary. This effects a release of cortisol from the adrenal cortex.
Cortisol effects are far-reaching, including lipolysis, gluconeogenesis and reducing inflammation. (Tortora and Grabowski, 2003). The body compensates for the effects of stress as long as possible. Three phases of stress are described as the general adaptation syndrome: alarm phase, resistance and exhaustion (Blows, 2011). The resistance and exhaustion phases may lead to immunosuppression and consequent disease (Tortora and Grabowski, 2003).
There is a reciprocal feedback link between the thalamus and amygdala. When the amygdala becomes overactive, fear and anxiety result. While adrenaline keeps the stress response active, endorphins protect the brain from the effects of fear (Blows, 2011). With so many physiological responses, there are numerous symptoms of stress that vary with each individual.
Significantly, stress causes muscle tension (HSE, 2007), exacerbating Norman’s discomfort, influencing his quality of life. As Kumar and Clark (2012) note, this is associated with depression.
The HSE (2007) management standards for work stress cover six main areas of primary work design that can contribute to stress if not properly managed. These include:
- Demands – including work patterns, workloads and work environment.
- Control – the extent of the worker’s job control.
- Support – provided by the organisation, management and colleagues.
- Role – understanding of their role and avoiding role-conflict.
- Change – management and communication of organisational change.
- Conflict – avoiding conflict, unacceptable behaviour and promoting positive working.
Fitness to work
The fitness-for-work assessment was based on a phenomenological appraisal as the effects of stress vary with each individual and their resilience (Alexander et al, 2006). A bio-psychosocial model informed the assessment. Norman stated that his condition was improving and he was ready to return to work. He no longer experienced symptoms that had taken him to the GP, but he was concerned at ending up in the same situation as before.
A patient health questionnaire (PHQ-9), providing an indication of depression, could have been used to assess Norman. Arroll et al (2010) found that the PHQ-9 is unreliable for diagnosing depression, whereas Manea et al (2012) refutes this assertion. At the time it seemed to be of limited value as he was making good progress.
Norman was advised to discuss his work concerns with his manager. With Norman’s consent, his manager was contacted and advised to carry out a comprehensive stress risk assessment as per the HSE management standards. It was suggested to Norman that he contact the organisation’s employee assistance programme and Access to Work, which offers grants for practical support for individuals with disabilities/health conditions to assist them with starting and staying at work. A phased return to work was formulated assisting Norman back into work and supporting him to stay at work. The following work regime was recommended:
- Week 1: Four hours on two days.
- Week 2: Four hours on four days.
- Week 3: Six hours on four days.
- Week 4: Full working week with the option of a review should Norman struggle.
Norman was to meet with his manager at the end of each week to review his progress, with the option to delay the next stage if this programme proved ineffective. In general, Norman had indicated that he had let his concerns take over without making any attempt to talk with his managers. He realised he should have discussed his work issues with his managers at an earlier stage. As Waddell and Burton (2006) note, early interventions are more effective at reducing long-term sickness absence and keeping workers at work.
Norman’s case illustrates how lack of control and apparent excessive demands and change can influence stress at work to negatively affect health. It reached a successful conclusion, but Norman’s case may have been prevented from requiring OH intervention had he been able to discuss his concerns and feelings with his manager in the first instance and a proactive approach, including the use of HSE stress management standards, been used at an earlier stage.
Anne Donaldson is an occupational health adviser. Anne Harriss is associate professor and course director, London South Bank University.
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Cheltenham Borough Council v Laird  IRLR 621.
Hanlon v Kirklees Metropolitan Council and others  EAT 0119/04 (IDS Brief 767).