Cardiff and Vale University Health Board is one of the largest NHS organisations in the UK, providing day to day health services those living in Cardiff and the Vale of Glamorgan who need emergency and scheduled hospital treatment and mental health care, delivering care in people's own homes and community clinics and for the delivery of NHS primary care services in Cardiff and the Vale of Glamorgan, including general practitioners, community pharmacists, dentists and optometrists.
Cardiff and Vale has an established Employee Wellbeing programme that has operated for a number of years. Managers of the programme recognised that the organisation would benefit from taking a more preventative approach to managing stress related ill health. This was introduced alongside existing services to provide a more rounded approach.
It was also recognised that stress can be an unnoticed and gradual build up of the many pressures experienced in work, at home and in everyday life. Most people are able to cope with the big issues in life and can find them exciting and motivational, but for some they can be too demanding, or when combined, they can become overwhelming, resulting in stress and illness.
Cardiff and Vale takes a 'hot spot' approach to pick out departments where action is most needed. In order to identify such departments it uses management information, including rates of sickness absence, amount of sickness due to stress/ anxiety, staff turnover etc, as well as Employee Relations data - including details of any recorded violent incident against a member of staff, grievance, disciplinary, or dignity at work complaint. The existence of organisational change is also a factor used to assess risk. The organisation, using a steering group, looks at the collected ‘stress data’ on at least a quarterly basis.
The core activities are delivered in-house by the Employee Wellbeing Service Organisational Health Psychologist. There is also a contracted Employee Assistance Programme (EAP) which can be accessed via self referral for staff and, where appropriate, bespoke psychological training courses (e.g. Assertiveness, Stress Resilience, Relating under Pressure training) were provided in house.
Specific organisation wide targets were not set; the aim of the programme was to reduce the level of stress related ill health across the organisation and thereby reduce the cost to the business and the cost to the individual.
There was commitment at the highest level of the organisation to see the project succeed. The Director of Workforce and Organisational Development is very much in favour and was, initially, part of the steering group. Trade Unions are also part of the steering group, which works with Consultant Clinical psychologists in activities with individual directorates. All staff in the directorates chosen for intervention are involved in identifying the issues, using the Management Standards Indicator Tool, giving feedback at ‘coffee table sessions’, and generating solutions.
Based on Systemic Psychological theory, the coffee table sessions involved the Organisational Health (Consultant Clinical) Psychologist talking to staff, discussing potential solutions and what changes would produce positive change; staff shared their ideas using a large sheet of paper that was made available to everyone. Other staff could then comment on these potential ideas and add to or suggest a further solution. . The neutral position of the psychologist is vital to the success of the activity to allow everyone to contribute in a comfortable, non-judgemental environment.
The actions identified from this exercise were discussed between the staff and managers and changes made based on these staff suggestions. Having the Psychologist involved as a neutral facilitator was seen as vital in this exercise. It allowed staff to feel that changes are self-generated rather than imposed upon them. This was an equivalent of the focus group approach used in the Management Standards.
More in depth qualitative surveys were also completed to give additional data on which to base the risk assessment and assist in the psychological evaluation, thus informing the plan for intervention.
The unions have been involved at every stage, their contribution has been invaluable and given the project added credibility with staff; it ensured that staff feel they have a voice and can participate in discussions about the process as well as in the process itself.
Previous attempts to implement an Organisational Health Review process became focused on linear issues such as dignity at work. This highlighted the need for an independent practitioner, with an understanding of Systemic and Psychological issues to lead the process, who could identify all the issues, both organisational and systemic, and the causes that could be related to them.
Senior and HR Managers had identified hot-spots for intervention, which had higher than average levels of sickness absence and staff turnover. The preventative approach was seen as very much an extension of the existing Employee Wellbeing service building on the knowledge and expertise of the counsellors, but offering a separate, level of intervention at a purely organisational level.
A particular intention of the exercise was to improve the emotional wellbeing of staff and thus to improve the quality of patient care. This was measured by hard outcomes such as sickness absence and staff turnover rates. It was also measured using softer outcomes, such as improved communication, cultural change around the giving and receiving of positive and negative feedback and reports of dignity at work issues.
Engagement with staff and managers is always a challenge. Most people are very busy and it is difficult to find time to give them an opportunity to present their views and learn about stress and how it affects people. To overcome this staff and managers were given a number of opportunities to feed in to the work, through surveys, team meetings and in the coffee room. This enabled them to contribute at a time suitable to them.
Throughout the work the Organisational Health Psychologists ensured they remained neutral, independent of HR and ‘management’ enabling them to engage in conversations with all sides. Taking this approach was labour intensive, the psychologist attended meetings, job shadowed, was present at 1:1 sessions and had informal conversations in the coffee room, in order to gain insight into the Directorate and explain the activity to staff and managers. However, this paid off as it led to good engagement rates for the survey and allowed them to introduce new ideas and practices from outside pre-existing relationships, relational patterns or historical behaviours.
The Systemic Psychological Theory and practice used, including a ‘multi-partiality’ approach allowed them to position themselves neutrally, not taking sides. The technique aims to give people new physical and emotional positions so that they experience things differently. For more information see Anderson & Goolishian (1992)
There are some positive indications where preventative interventions have taken place. However, the intervention stage of the process was implemented at different times and this is why, in the following section, one Directorate shows a better ‘improvement’ result.
Managers were given a toolkit for managing work related stress in the workplace and everyone was offered stress resilience training. This was part of a full range of other support including training and development, coaching and counselling and access to web based self help information developed in conjunction with the EAP.
Available quarterly stress mapping data shows that during the course of this work so far so benefits that include:
There are signs of cultural changes in directorate 1 including;
There was also a very positive impact on the delivery team who won the ‘Healthcare People Management Award’ for preventing work related stress.
Advice to Others:
Anderson, H & Goolishian H (1992) The Client is the Expert: a Not Knowing Approach to Therapy in S. MacNamee & K. Gergen Therapy as Social Construction. Sage Publishers