Health and Well-Being in Healthcare Settings › - › media › Employers › ... · October 2012 - A POSHH Group publication produced by Zeal Solutions Limited HEALTH AND WELL-BEING

Partnership for Occupational Safetyand Health in Healthcare

Publication produced by Zeal Solutions Limited: October 2012

Health and Well-Beingin Healthcare Settings

Contents

October 2012 - A POSHH Group publication produced by Zeal Solutions Limited

HEALTH AND WELL-BEING IN HEALTHCARE SETTINGS Contents

2

Foreword 3

Participant feedback and acknowledgements 3

Acknowledgements 4

Section 1:

Project overview and objectives 5

Section 2:

Making the most of the report 5

Section 3:

The health and well-being audit approach 7

Overview 7

The health audit using ORATM 7

The rationale for using ORATM 12

Section 4:

Assessment and Feedback 13

Workplace features identified as key for health and well-being 13

Section 5:

Taking Action 34

How to use the evidence to improve health and well-being 34

1. Review and Reflection 35

2. Agree and Plan Prioritised Action 35

3. Decision Feedback 37

4. Evaluate Action 37

Section 6:

Reflections and Best Practice Principles 38

Some common challenges to the promotion of health and well-being 38

Best practice principles for increasing the chances of delivering a

successful health and well-being management project 40

Section 7:

Summary and Close 45

Section 8:

Useful resources to support health and well-being management 46

Foreword


HEALTH AND WELL-BEING IN HEALTHCARE SETTINGS Introduction

3

The moral and legal case for effectiveoccupational health, safety and wellbeingin NHS organisations has been well madeover a number of years. This is recognisedwithin the NHS Constitution, which statesthat staff have a right to work within ahealthy and safe workplace.

Stress is one of the major causes ofsickness absence in the NHS and thelatest NHS annual survey found that 30%of NHS staff reported that they hadsuffered from work related stress. TheHSE define stress as an adverse reactionto people have to excessive pressures orother types of demands placed on them.

Stress can happen in different ways indifferent NHS organisations but there arecommon factors that can lead to stress

Why have we done this?

and poor health. Some NHS staff haveto deal with violent and unpredictablepatients. Others deal with traumatic andharrowing circumstances. Others have alack of support or are not receivingenough communication about changesaffecting them. The most important fact isthe impact on the individual and how theyfeel able to manage those feelings.

What is of most significance is howorganisations support their staff to copewith this. This is not only about providingprotective equipment or appropriatetraining, but how as an organisation itenables its managers to support staff ona day to day in terms of its peoplemanagement, engagement, consultationand communication.

Introduction

The Partnership for Occupational Safety and Health in Healthcare (POSHH) is theoccupational health and safety sub-group of the NHS Staff Council. It consists ofmanagement representatives from NHS organisations and staff side representativesfrom healthcare trade unions. The Health and Safety Executive and NHS Protect areadvisory members of the group. By working in partnership, the group producesguidance to promote health, safety and wellbeing within the NHS workforce.

POSHH commissioned Zeal Solutions to conduct research in a variety of healthcaresettings within the NHS in order to see what increased and decreased stress within theworkforce. This report provides the summary of that research.

Thanks should go to Julian Topping, Programme Lead, Health and Wellbeing at NHSEmployers for commissioning this research and seeing it completed prior to hisretirement in July 2012.



4

This research is valuable because it highlights,in practical terms, in real organisations and indifferent settings which managementinteractions, policies and organisationalculture helps or hinders workplace stresswithin its workforce.

How will this help NHSOrganisations?

NHS staff are its most important resource. Noone should be made ill by work. The health,safety and welfare of staff directly contributesto organisational success and poor workforcehealth has a high cost.

By knowing which workplace factors arelikely to increase or decrease stress, NHSorganisations can use the informationcontained within this report to review its riskassessments, management behaviour,cultures and processes. This report alsochallenges myths. Firstly, that “stress is goodfor you”. The study suggests that anadrenalin rush can help anyone in a givensituation, but having that feeling constantly isnot good for the long term health of anyone.The second myth is that sickness absence canbe managed down through effective sicknessabsence management policies. This reportdemonstrates that the long term health ofindividuals is best managed by a holisitic,proactive and engaged approach to health inthe workplace as opposed to mechanisticabsence policies which fail to tackle the mainissues. Work is generally good for health butthat work has to be well-designed, organised,safe and managed.

How can this report be used?

This report is aimed at directors, managerswith health and safety responsibilities,occupational health advisers, humanresources advisers, health and safetyprofessionals and trade union safetyrepresentatives. They can be used inexamining which management behavioursand cultures have a positive effect onattendance and engagement. This can beused for developing improvementprogrammes, management and competencetraining, reviewing risk assessments or foruse through self audit or self assessment.

The report can be used alongside the HSE’sstress management standards to help NHSorganisations assess levels of compliance.This could inform a gap analysis of workrequiring to be done before legal and NHSLAcompliance is achieved.

Where can I find moreinformation?

Support around managing stress, along withother occupational health, safety andWellbeing information can be found on thePOSHH web pages.

http://www.nhsemployers.org/HealthyWorkplaces/POSHHnew/Pages/POSHH.aspx

James Tracey,Leeds Teaching Hospitals NHS Trust,Management Side Chair of POSHHKim Sunley,Royal College of Nursing,Staff Side Chair of POSHH

There was a real

added value in terms

of expertise, guidance

and knowledge. We

have learned so much

about monitoring and

managing workplace

health and well-being.

We are able to do

so much more about

it now.

Organisation 3

“

”

Participant feedback



5

Within a short period

of time we obtained so

much information on

the health and well-

being of our workforce

and we were able to

prioritise action on the

basis of the evidence

we received.

Organisation 1

“

”

The process used

meant that we were

able to follow a

framework for health

and well-being

management. At no

point did we become

overwhelmed or unsure

about where we were

heading and what

needed to be done.

Organisation 2

“

”

What was the added value of being involved?

What was the single biggest lesson learned?

Health and well-being

and health promotion

must be integrated

into the broader

development of the

organisation for it to

be successful.

Organisation 3

“

”

The importance of

securing senior

management support

from the word go.

Organisation 1

“”

The culture of the

organisation is a key

factor in improving

health and well-being.

Organisation 2

“”

Acknowledgements



6

The team at Zeal Solutions would like tothank each of the participating Trusts andall of the employees who took part in thehealth and well-being audits; without yourinput it would not have been possible tocomplete this project. We would also liketo thank the NHS Employers, and inparticular the Partnership for OccupationalSafety and Health in Healthcare (POSHH)group, for sponsoring this work. Particularthanks are provided to Joanne Wanje,Kim Sunley and James Tracey of the POSHHexecutive group for their support andguidance. Finally, we must offer a special

thanks to Julian Topping from the NHSEmployers for commissioning this report,and for his support and foresightthroughout the project life-cycle.

It should be acknowledged that during thewrite up of this report, Julian announcedhis retirement. In light of this news wewould like to commend Julian for all hiswork and commitment to improving healthand well-being across the healthcaresector. We wish Julian the very best forthe future and hope this report is asuitable contribution to his legacy.

Project overview and objectives


HEALTH AND WELL-BEING IN HEALTHCARE SETTINGS Section 1

7

Specifically, this project set out to:

1. Develop and use a tailored auditto assess health and well-being withinhealthcare settings;

2. Establish a valid and useableevidence base on the impactof working practices on healthand well-being;

3. Identify the workplace featuresthat have a positive and/ornegative impact on health andwell-being;

4. Support organisational decisionmakers in their actions to promotehealth and well-being; and

The remit of this project

This project and report was commissioned in direct response to the Boorman review by thePartnership for Occupational Safety and Health in Healthcare (POSHH) – a sub group of theNHS Staff Council. The aim of the project was to a) identify specific workplace features withinthe healthcare sector that influenced employee health and well-being, and b) identify practicalsolutions that would promote the development of health and well-being at work.

5. Present case study information ofthe experience of some participatinghealthcare organisations.

Overview

The business case for the promotion of health and well-being within healthcaresettings is well documented within a number of seminal reports and publications.In essence, the message is simple and clear, poor health and well-beingsignificantly limits individual achievements and organisational performance.In contrast, positive health and well-being promotes sustainable, resilient, andhigh quality service delivery.



8

This report does not provide:

An up to date summary of the latestresearch on health and well-being at work;nor does it provide general researchevidence on the link between employeehealth and outcomes such as performanceand productivity. Research publicationsdocumenting such findings are rich andextensive.

Following this report

This report will be supported with a number of general as well specific resources (e.g. tools,articles, networking opportunities, etc.) that will help all readers to take local action toprotect and promote employee health and well-being. The resources that will be madeavailable will be developed over time and accessed via the NHS employers website.

This report does provide:

Access to the combined findings froma number of healthcare organisationsthat have participated in a healthand well-being audit. The audit wasdesigned to understand the natureand impact of working conditionson valued health outcomes.A summary of eight commonworkplace features that were foundto have positive and/or negativeimpacts/associations on individual andorganisational health and well-being. Suggested / recommended actionfor improving each of the identifiedworkplace features. A summary of actions that havebeen taken by each participatingorganisation.

The overall aim of this report is to providethe reader with tangible evidence as wellas realistic recommendations on how tobring about improved health and well-being at work. Evaluating the impact ofany action is the subject matter of a secondreport that is due for publication in 2013.

What this report is and is not about

It is important to state at the outset what that this report does and does not provide.

Making the most of this report



9

There are many ways in which all readers can make use of the information includedwithin this document over and above any additional support and action that will beoffered by the NHS Employers. The following suggestions should help to ignite action:

Section Three: Should be used as a basis for reviewing practice as well asunderstanding health - All readers can and should consider what actions are takento assess and monitor the health and well-being of staff. Are the assessments used,accurate, valid and meaningful? More often than not, the success of any action forhealth promotion is evaluated in terms of the impact on absence (e.g. a reduction insickness absence). However, and as shown in Table 1, health has various individualand organisational indicators, greater awareness of the breadth of health indicatorscan be used to develop a more robust business case for investing in health protectionand promotion.

Section Four: Should be used as a basis exploring working conditions- All readers can and should consider the extent to which employees experience thepositive and negative workplace features. For the positive workplace features, what isbeing done to protect and promote these? For the negative workplace features, whatis being done to prevent and reduce these? The illustrative suggestions can be used as a basis for comparing and contrasting local action for improving health as well asfor informing current or planned action. All readers are reminded that these are notthe only workplace features that will influence individual and organisational healthand well-being.

Overview

This report has been written so that it can be accessed and shared by all who readit. It has been produced to establish a common understanding of what stress isand is not, and to help support a fuller understanding of what health and well-being at work actually looks like.

As will be seen, there are eight common workplace features that have beenidentified as either having positive or negative impacts on employee health andwell-being. These workplace features should not become the sole focus ofattention when considering how best to protect and promote employee healthand well-being; however, they do represent important workplace features that allorganisations should consider when reviewing action that is taken.



10

Section Five: Should be used as a basis for monitoring progress - All readerscan and should consider how and whether the factors identified are influencingprogress. The action planning process can also be used to ensure action is wellcoordinated and health and well-being becomes an integrated part of organisationalreality.

Section Six: Should be used to inform individual and organisationaldevelopment - All readers can and should reflect on the challenges that arehighlighted. The principles of best practice should be used to inform local actiontaken to promote health and well-being.

The information contained within this report can also be converted into check lists andactions plans that can form the basis of local team based discussions.

This document has been written so that it offers some tangible results as well as practicalsuggestions for those who wish to effect positive change with regards to individual andorganisational health and well-being. The evidence that has been collected has followeda methodology that approaches health as a dynamic process. The very fact that health isa dynamic process should remind everyone that health and well-being is as much amatter of concern for the individual employee as it is for the employer. Employers mustalso ensure employee health is seen an integrated and positive aspect of theorganisational culture, as it is the employer that creates the work conditions whichultimately impact, for better or for worse, employee health, well-being and performance.The dynamic nature of health also requires all to remain proactive and vigilant.Organisations must ensure they use adequate and continuous assessments of theworkplace and invest where necessary in appropriate interventions that can be shownto protect and promote individual as well as organisational health and well-being.

The health and well-beingaudit approach



11

The valid and accurate assessment ofemployee work experience is integral toinforming successive action taken toimprove individual as well asorganisational health and well-being. It is for this reason that theOrganisational Risk Assessment (ORATM)tool was used as a basis for completinga series of health and well-being auditswithin the participating organisations.

ORATM is a proven, reliable and realistictool for diagnosing and identifyingaspects of the workplace – whetherpositive or negative - that contributeto important outcomes such as jobsatisfaction, employee engagement,performance, sickness absence, as wellas other valued outcomes.

The principles, themes and processesinvolved with ORATM also provide a robust

The health audit using ORATM

framework for taking practical actionfor improving health and well-being,motivation and ultimately theperformance of the workforce. In linewith best practice, the process isparticipative from the outset and ensuresthat all employees have an opportunityto contribute.

In its simplest form, the ORATM processfollows four basic procedural steps asshown in Figure 1 (See Page 12).

Overview

In this report, the combined results of six health and well-being audits arediscussed. The audits were completed within general hospitals, ambulanceservices, and mental healthcare Trust settings. The audit process was guided by theuse of a risk management (problem solving) approach to health and well-being.Risk management is a systematic, evidence-based, approach which seeks toprovide participating organisations with an accurate understanding of theissues/risks impacting on employee health and well-being. This information is thenused to guide decision making and action.



12

Step 1: The diagnosisThe diagnosis comprised of three stages.

1. Audit – this involved speaking toa representative sample of staff todevelop a good understanding of theirwork experience. On the basis of thisunderstanding a health auditinstrument was designed thata) suitably reflected the local workingenvironment, and b) enabledcomparisons to be made with otherorganisations across the sector.

2. Data collection – audit data wassubsequently collected using bothonline as well as paper copies of thehealth audit instrument.

3. Data analysis – the data wasanalysed, modelled and presented ina manner that enabled theorganisation to recognise thoseaspects of the workplace that had

ORATM - PROCEDURAL STEPS

Figure 1: The ORATM procedural steps to health and well-being management

Each procedural step shown in Figure 1 was carried out with the participatingorganisation and is explained further below.

1

Diagnosiscompletion of a tailored, systematic and rigorous health and well-being auditto identify issues in a reliable and valid manner

2

Feedback engaging employees in feedback processes to help make sense of the findingsand inform action

3

Actionusing the findings and the feedback to take direct and coordinated action to improvehealth and well-being

4

Evaluationestablishing a systematic and rigorous process for evaluating the impact, value andeffectiveness of actions taken



13

the greatest positive and/or negativeimpact on health and well-being.It is important to understandthat the analysis approach adoptedthrough ORATM is different to thestandard opinion survey or thosecommonly used with off-the-shelftools. Whilst this is not to deny therole of such tools within organisationalsettings, they tend to provide a verysimplistic picture of what is a complexprocess. Instead, the ORATM analysis ispremised on understanding thatindividual and organisational healthand well-being is an outcome of the

dynamic interplay betweenenvironmental/workplacedemands and the resources that areavailable to assist with meeting thesedemands (as shown in Figure 2).1

This analysis provided eachparticipating organisation with aunique insight regarding the dynamicinterplay between variousaspects/work conditions and theirimpact on the individual andorganisational health and well-being.The health and well-being indicatorsused in this project are shown inTable 1.

1 The analysisperformed by ORATM isa uniquely modelledprocess which takesinto account variousweighted factors in theprocess of identifyingimportant aspects ofthe workplace. Theoverview presented hasbeen simplified for thepurposes of this report.

Within an organisational context, healthand well-being can and should bedetermined by examining indicators thatpoint both to individual as well asorganisational health. Appreciating thecomplexity of establishing the mostappropriate indicators to utilise for anysingle organisation, each audit projectutilised both common as well as unique

indicators of individual and organisationalhealth. It is the common health indicatorsthat are reported here. The healthindicators measured in this project havebeen grouped under the three categoriesof 1) work attitudes; 2) health andstress symptoms; and 3) withdrawal& performance (see Table 1 on page 14).

THE AUDIT PROCESS

TABLE OF HEALTH AND WELL-BEING INDICATORS

Figure 2: The audit process – examining the relationship between workplacefeatures and health and well-being indicators

The outcomes from the audit are discussed in Section 4.

WORKPLACEFEATURES

HEALTH ANDWELL-BEINGIMPACT



HEALTHINDICATOR

JOB SATISFACTION

ORGANISATIONALCOMMITMENT

WORKENGAGEMENT

STRESSSYMPTOMS

BURNOUT

PATIENTNEGATIVITY

INTENTIONSTO QUIT

ABSENCE

PERFORMANCE

DESCRIPTION

Levels of satisfaction with various aspects ofthe job.

Extent to which staff identify with the employingorganisation and feel a strong emotional bondto it.

Extent to which staff feel motivated andinvigorated by their job.

Symptoms of anxiety, depression and feelingshyper tension.

The extent to which the person feels tired,worn out and emotionally exhausted withspecific reference to their work.

The extent to which the person feels negativeand tired of working with patients.

Attitudes towards leaving the organisation atthe first available opportunity.

Self-reported days and periods of self- andmedically-certified absences.

Levels of perceived performance quality andconfidence.

CATEGORY

WORK ATTITUDES

HEALTH ANDSTRESSSYMPTOMS

WITHDRAWALANDPERFORMANCE

Table 1The common indicators of health and well-being

14



15

Step 2: Feedback

Following the completion of the audit,the findings were then fed back to eachorganisation. Here, employees wereinvited to take part in a series of focusgroups and were asked to reflect on theresults and validate the findings as well asassist in identifying practicable solutionsfor improving health and well-being.Illustrative solutions offered by employeesare summarised in Section 4 (See Page 17).Further information on any of thesuggested interventions can also be madeavailable on request.

Step 3: Action

Following the feedback, each participatingorganisation was provided with a series ofORATM health and well-being reports. Aspart of the reporting process, participantswere coached and encouraged to adopt acoordinated and strategic response tomanaging the health and well-being oftheir workforce. The aim of this processwas to ensure action was guided byevidence and directed towards protectingand promoting health, well-being and thequality of working life.

Step 4: Evaluation

The impact, effectiveness, value andsuccess of any action taken is an integralpart of the health and well-beingmanagement process. In reality, theevaluation process starts during Step 1 andcontinues throughout the health and well-

being management process. In addition,and where action to promote health andwell-being has been taken, the evaluationmust continue to determine if and/or howthe intervention is taking its effect. At thetime of writing this report, there seemed tobe general lack of useful evaluationevidence regarding the value and impactof health promotion interventions. It is forthis reason that the primary focus of thisreport is on Steps 1 to 3 of the healthmanagement process. The fourth step(evaluation) will be the focus of a secondreport scheduled for publication in 2013.

Participative – at all stages of theprocess, there was involvement andparticipation from staff at all levels,from members of the board to frontline employees;

Tailored – the health managementprocess was tailored to eachparticipating organisation ensuringcontext specific workplace featurescould be identified to promoteindividual and organisational healthand well-being;

Outcome focussed – the processis centred upon showing how ‘workingconditions’ impact upon outcomesthat are important for individual andorganisational development andcontinuous improvement. It is alsoabout guiding and demonstrating howaction taken on the basis of theprocess supports the achievement ofdesired strategic objectives.

Educational – the ORATM process wasused to support learning anddevelopment within the organisationabout employee health and well-being;

and

Driven by evidence – the successof the health management processis dependent upon the participantshaving confidence in the evidencethat is collected and offered.In addition, the process aims todevelop confidence and capabilitywithin the organisational context sothat employees are able to criticallyappraise and work with evidence.This process ensures decision makingand investment in action to improvehealth and well-being is informed,systematic, optimal and efficient.

The underpinning rationale for usingthe ORATM process was also to ensureorganisational members were able todiscuss health and well-being managementusing a common framework and language.Finally, and although the audit was tailoredto each participating organisation, theprocess also ensured common workplacefeatures/themes that had positive and/ornegative health impacts could beidentified. These common workplacefeatures are the central focus of this report.



16

The rationale for using ORATM

In summary, the aim of the approach adopted in this project was to provide eachparticipating organisation with a very practical and accurate process for assessingthe health and well-being of their workforce. The ORATM process is underpinned bythe following principles:



17

Assessment and Feedback Workplace features identified as key for healthand well-being

In this section, and for the purposes of simplicity, we do not document all ofthe relationships that were established between the workplace features and theindicators of health and well-being. Instead, the results are shown for thoseworkplace features found to have a consistent impact across all participatingorganisations, as these findings will represent the most meaningful areas of focusfor all readers. Further information on the findings documented in this report canbe made available on request.

Workplace features having a positive impact on health

The ORATM process showed four workplace features which individually and collectivelyinfluenced all of the health outcomes. Although for each participating organisation therewere a variety of other workplace features that had a beneficial impact on health, the fourworkplace features shown below in Figure 3 were found to have a consistent and positiveimpact on all health indicators (i.e. they were associated with improved health) across allparticipating organisations.

Information about each of the above positive workplace features is provided below tosupport the reader in considering these features within their own work environment.

Figure 3: The four workplace features found to improve health and well-being

HEALTH AND STRESSRELATED SYMPTOMS

WITHDRAWAL ANDPERFORMANCE

WORKATTITUDES

POSITIVETEAM

CULTURE

SUPPORTIVEMANAGER

BEHAVIOUR

POSITIVECONTRIBUTION

PARTICIPATION/ KEPT

INFORMED

POSITIVE EFFECT

Stress, Burnout, Patient Negativity Intentions To Quit, Absence, Performance Satisfaction, Commitment, Engagement

The role of the line manager was found tohave a profound impact on employeeexperience of work as well as on theirhealth and well-being. Managers are oftenemphasised as important sources ofsupport since they tend to be the mostreadily available. Managers are oftenthought of as the primary source of work-related social support since they have themost influence over employee perceptionsof the work environment.

There were numerous comments fromemployees to suggest that their linemanagers played a key role in passing onrecognition, appreciation and accurateinformation, as well as providing important

support to staff during difficult times. Many staff also commented that a goodline manager was someone who wouldmake notable efforts to protect or ‘shield’staff from the demands of more seniormanagers within the organisation. Within the NHS, support from managershas become even more critical as a resultof the actual and planned changes inorganisational structure which has led to,for example, decreased visibility of seniormanagement, increased fear and anxietyover job security as well as substantialincreases in work demands. All thesefactors increase the influence of theimmediate manager on employee healthand well-being.



18

Supportive Manager Behaviour

When you have a

poor or ‘non

supportive’ manager,

things not only feel

worse it just brings

everyone down, it is

de-motivating.

“

”

Our manager is a

great people person,

they treat us firmly

but fairly, they are

there when you

need them. Just by

being the way they

are they breed

confidence, this

confidence helps

bring the team

together and

transfers between

us all. We find that

work becomes less

heavy and

cumbersome because

we are able to work

together better.

“

”



19

Illustrative suggestions on how this can be improved:

ILLUSTRATIVE QUOTE FROMPARTICIPANT SITE

“It’s not just the communication. It’s actuallybeing honest...and answering the questions. Andbeing open.”

“The higher management need to come and talkto the people that actually do the job.”

“Wherever possible, management should applyrules consistently across staff, avoiding situationswhere staff believe that there is one rule for oneand another rule for another."

“Managers should involve the team in howto find solutions to problems. Staff have a greatdeal of experience, knowledge and expertise thatcan help to make a difference."

“We feel like we are fighting a constant battlebecause there are different demands coming infrom different people.”

“The best manager I’ve ever worked with...sheknows the department so well, I know for afact...it’s the understanding of the job that’s themost important thing.”

“Managers need to keep you updated on what’sgoing on so you know what’s happening andyou’re fully aware.”

“More needs to be made of performanceappraisals. This is a good source of feedback butas mentioned rarely used appropriately. It is usedas a tick box exercise but it needs to bemonitored and used properly not just as a once ayear exercise. We should also consider 360 degreeappraisals, so we can appraise our managers.”

“Managers need to lead by example and to bemade more aware of the impact of theirbehaviour on others.”

RECOMMENDEDSUGGESTION

Managers should provide feedback andcommunicate openly on actions/decisions taken

Managers need to increase theiravailability and visibility

Managers should be consistent andequal in their treatment of staff, andshould lead by example

Managers should utilise the knowledge,skills and expertise of their staff

Managers need to consider how bestto protect staff from increasing andcompeting demands

Managers need to demonstrate aclear understanding of the job rolesof their staff

Managers need to keep staff updatedand provide a rationale for actions anddecisions taken

Managers should be given the trainingas well as protected time to carry outperformance reviews that areconsidered high quality, effective andsupportive of staff’s developmentopportunities

Managers should be offered trainingwhich makes them aware of the criticalrole they have to play in employeehealth and well-being

The quality and efficiency of the serviceprovided within the NHS is dependentupon close working (interdependent)relations between staff. When staffperceived themselves as working as partof a positive team culture, they reportedbeing happier at work, feeling supportedand valued, and having importantopportunities to discuss problems through‘informal problem solving’ sessions atwork. Supportive colleagues were thoughtto provide support through difficult times,to demonstrate understanding of theircolleagues, to share work when one is

away on annual leave, to understand eachother’s roles and to provide recognitionand reward for a job well done.

When relationships with colleagues werenegative, this was found to be detrimentalto work attitudes, health and stress aswell as towards withdrawal. Staff werealso mindful of the fact that within theNHS there is a diverse workforce andthere will be individual differences in howpeople complete or perform their dailytasks/duties.



20

Positive Interpersonal Colleague Relationships


It’s a massive thing,

a massive thing...

my team are friends

as well as work

colleagues to me.

“

”


"Managers need to make time to understandthe strengths of the staff they have around them.In situations where staff are not pulling theirweight, managers should be quick to challengethis type of behaviour."

“It is important that appraisals are used tosupport managers and the staff themselves inmonitoring and managing workload.”

“We are looking at relocating...and I thinkanxiety levels have just shot through the roof,because that is beyond our control, but thatwould be an example of such a devastatingimpact on team culture, because we rely oneach other so much.”


Improve the management of teamdynamics and take advantage of thediverse skill mix and team strengths

Extend the focus of performanceappraisals so that they are concernedwith collective values of team work

Ensure all are aware of the true value of effective team work and the impactorganisational change can have onperformance



21

If you do not get along with the people that you work with ... people will not want

to perform at work.” Another person expanded on this, saying: “People stop

sharing ideas, stop talking about anything that’s bothering them, avoid contact with

the group and ... can become quite insular, they just stop enjoying coming to work.

“”


“Team work is pretty good in some parts, but weneed more of it. We are not trained to work inteams but just expected to be able to do this.Some people are more natural at team workingthan others and this should be acknowledgedand managed in some way.”

“Employees need to understand each other’sroles...we understand that every department hasgot exactly the same problem. We all haveknowledge, ideas and experiences to share butno one is sharing.’’

“We’ve got a mediation service which has beenused quite a bit and that’s been brilliant.”

“It is often because different application ofpolicies and procedures leads to conflict betweenpeople. You find that whispering cultures start todevelop and issues escalate. Some staff aretreated differently. For example, some are able toobtain annual leave when they like, for others itis great deal more difficult.”

“Director level managers should go out withstaff to see what it's actually like. However, staffalso need to understand what life is like fromthe management side. I don’t know how thiscould be achieved but it would help us all tounderstand each other better if it happened.”

“People do everything by email now so you’relosing the personal touch...the email doesn’tportray emotions and is so impersonal.”


Provide appropriate and tailored teamtraining and team working events -this includes increasing the level ofinteraction between and withinspecialties

Improve systems and practices forcapturing and sharing lessons identified

Make use of pre-existing servicesthat assist with staff development

Wherever possible, ensure policies,procedures and practices are appliedconsistently

Explore opportunities for familiarisationof roles and duties

Utilise the most appropriate mediumof communication when deliveringmessages

The more that staff reported feeling thatthey experienced a sense of positive workcontribution, the better they were acrossall health outcomes. Indeed, in all ofthe participating Trusts, this workplacefeature was found to be the mostconsistent and positive contributor tohealth outcomes. That is, if staff felt thattheir work was making a difference tosomeone or something, or they couldsee others benefit from their actions, orindeed felt that they had achieved a jobwell-done, they also reported significantlymore positive levels of attitudes towardspatients, lower levels of stress andwithdrawal behaviours and higher levelsof perceived performance.

Although the actions that staff needed totake in order to make a positive contributiondepended on their specific job role, theimportance of feeling that they were doingsomething worthwhile was universalacross all groups. Many staff memberscommented that although they get paid fordoing their jobs, they would sometimes

like to get something more than monetaryrecognition in acknowledgement of theirhard work and effort. Amongst otherthings, staff commented that this wasimportant for building their own sense ofconfidence and capability within their jobrole. Three specific groups were mentionedas important sources of recognition:managers, patients and colleagues.

There was a general suggestion that whenpositive feedback occurred, it tended to befrom colleagues giving one another a“boost”: colleagues were generallyconsidered to be the most likely sourceof positive feedback. The greatest concernfor staff was the general lack of positivefeedback, particularly from management.When feedback was received frommanagers, some people felt that this wastoo often focused on negative feedbackrather than commenting on a job welldone. Some individuals even suggestedthat the best way of knowing they weredoing a good job was by making sure thatnobody was complaining.



22

Positive Contribution

There’s no

appreciation...

I suppose we’re

getting paid for it

and it’s our job

and everything,

but just a little bit of

recognition would

be welcomed.

“

”

As healthcare

professionals, we

don’t expect a lot in

the way of reward:

there are no

incentives, we don’t

get performance

related pay or a

bonus at the end of

the month. But it can

be as simple as

a...thank you.

“

”



23


“Although there are some improvements inplaces, more emphasis needs to be made on theimportance of the performance appraisal system.This emphasis should not be put just onmanagers; all staff have a role to play here.Supervision doesn’t have to be formal it can alsobe informal. It becomes important that you canalso chat about difficulties you are facing withcolleagues who can help you to reflect and seea way through sometimes.”

“At the end of the day for somebody – justanybody – to come to you and say ‘thank you.’It’s a big word: thank you. Sometimes that’s justall you need.”

“I don't know if this is part of managementtraining, but managers should be made awareof the fact that when staff are made to feelvalued this has a massive impact on their healthand motivation.”

"It really helps when a manager takes time tounderstand our job/role. It is really useful whenwe are under pressure as they understand whenwe really need their help."

“You rarely hear anything positive, all we hear is‘we’ve had a massive complaint today’ but yourarely hear ‘we’ve had a lovely message that thatsays thank you very much.’ Hearing positivefeedback is good for our morale.


Make use of performance appraisal andsupervision sessions to acknowledgepositive contributions

Provide more positive feedback to staff

Ensure positive contribution isacknowledged within managementdevelopment and training

Improve awareness of the importanceof role understanding

Share positive feedback orcustomer/client satisfaction with staff


Staff who felt that they were kept informedand consulted in matters relating to theorganisation were also more committed tothe organisation and less likely to be absentfrom work. In particular, many participantsdiscussed the impact of recent changeswithin their local Trust, and how this wasgenerally followed with a constraint onresources. Several participants indicatedthat they had been asked for their viewsduring change processes, but that theopportunities to participate could not betaken advantage of due to workloadpressures. Many of those who didparticipate felt as though their views thenappeared to have been set aside whensubsequent decisions were made.

Some staff also suggested that it wasdifficult to differentiate between thevalidity of different pieces of informationthat became available during times oforganisational change, because differentmessages were being conveyed throughdifferent forums. Similarly, there appearedto be inconsistency in how people feltabout these issues, dependent on theirindividual managers. Some people hadmanagers who were considered “very good at communicating” whereasother people felt as though their managerdid not keep them informed of any of theorganisational changes.



24

Participation/Kept Informed

There were a lot of

focus groups that

happened when

things were

changing, but no

one had time to go.

I definitely didn’t

and no one from our

team attended.

“

”

There’s always

‘merger talk’ going

on at the minute, and

we hear different

things...that’s scary,

that’s really scary.

“

”



25


"I think if there was a bit more honesty aboutwhat was actually happening that would help.It seems as though we are given little snippets ofinformation rather than the full picture. You oftenhear comments and things being said that canactually be interpreted in many different ways;it is unnerving and upsetting."

“We have all these surveys and things, butI do wonder – will there be an outcome?”

“We have an intranet site but it is toocomplicated and difficult to navigate to find anything of use or meaning.”

“We would welcome the opportunity of meetingwith senior managers at specific timesthroughout the year so we can raise our issues,share ideas and ask questions.”

“We seem to complete lots of surveys or formsbut yet no one ever tells us what they are for orhow they are being used or if anything haschanged as a result of them.”

“There is nothing more demoralising thanhearing about change in your place of workthrough the local paper or from other sources.We are not children, although the news is notalways easy to say, we would rather know thanfind out through a third party.”


Keep staff up to date and in the picture

Provide staff with feedback on howtheir views are utilised

Improve access to information throughweb-based technology

Hold regular feedback sessions withstaff groups so views can be shared,and questions asked and answered

When collecting data from staff(e.g. through surveys), ensure staffunderstand how this has benefitedthem

Prevent staff from hearing messagesfrom other sources first rather thanreceiving information from crediblesources within the organisation




26



27

Workplace features that have a negative impact on health

For each participating organisation there were also a variety of workplacefeatures that had a consistent and negative impact on health and well-being. Four of these workplace features that proved to be particularly important areshown below in Figure 4.:

Each of the above workplace features will now be discussed and examples of eachwill be provided to support the reader in considering these features within their ownwork environment.

Figure 4: The four workplace features found to damage health and well-being

HEALTH AND STRESSSYMPTOMS

WITHDRAWAL ANDPERFORMANCE

WORKATTITUDES

WORKOVERLOAD

POOREQUIPMENT/RESOURCES

DIFFICULTHOME-WORK

BALANCE

WORKRELATEDVIOLENCE

DAMAGING EFFECT

Stress, Burnout, Patient Negativity Intentions To Quit, Absence, Performance Satisfaction, Commitment, Engagement

The audit has demonstrated theimportance of the link between feeling andbeing overloaded at work and the healthand well-being of healthcare workers. Although in some cases work overload was associated with improvements in self-reported absence, this tended to come at a cost to other aspects of staff health.This is also known as a ‘negative spill overeffect’, where the commitment andpressure that one feels to complete theirprimary tasks spills over into other areas(e.g. health and work attitudes) in anegative way. The more that staffexperienced ‘work overload,’ the lesscommitted they often felt towards theorganisation and the less inspired/enthusiastic they felt about their job. In many cases, overloaded employees were also more likely to report increasedsymptoms of stress, less enthusiasm forcaring for patients and lower levels ofjob performance.

There was a perception among someparticipants that the work load wasincreasing in line with financial cuts, whilemany felt that the number of people or theamount of time to do the work was notsufficient for the level of demand. A number of people suggested that theyfelt they were doing the work of more thanone person, but were not being recognisedfor their additional efforts. There was asuggestion that individuals who took onadditional workloads to meet their targetswere not any better thought of by theirmanagers than the people who did nottake on these tasks.

One additional common problem wasrelated to the duplication of tasks(e.g. being asked to do the same worktwice by different people, or beingasked to do the same work again in adifferent way).



28

Work Overload

Demand is increasing.

Anyone leaving isn’t

replaced, which then

puts pressure on the

people who are

left...The demand is

constantly increasing

and targets don’t

change much.

“

”

We find the best way

to deal with the

increasing demand

is to openly discuss

our concerns and

work through the

issues as they occur.

We are lucky we can

do this as we have

a really good team

and a manager that

supports this type

of approach.

“

”



29


“Part of the solution is about managers knowingtheir staff, how much their staff have got on andhow they are coping. Often staff are just socommitted to doing a good job that they skiplunch or other breaks because time is so tightand they don’t want to let people down.”

“I don’t personally know which tasks I can justleave and which ones I can’t, but my managerdoes. It is important that they given you guidanceand feedback and say ‘actually, that one’simportant, get that one done, don’t do that one.’”

“We need to ensure we have better bank staff.We have to improve the admin bank staff butalso look at the skills we take on into the bankto ensure it is right for what we need. Often thestaff we bring on are not skilled at the right leveland that causes even more pressure.”

“It is about engendering an open culture ofcommunication at all levels. If staff feel they cancommunicate when they feel work is too muchthen it allows them to share their feelings ratherthan holding on to them which cannot be goodfor their health.”

“Everyone should work as a team, you should allbe doing your bit...It impacts on our workloadbecause someone else hasn’t done their part.”

"Whilst it is important to record our practice, wesometimes have to record the sameinformation/tasks on numerous occasions. I'm surethere are ways in which the amount of paperworkwe have to complete can be reduced a little."

“It would just be nice for us to have one systemthat would give us everything we needed. On aday to day basis we’re flicking through differentsystems on our screen.”


Understand team workload andstrengths and effective managementof work tasks and teams

Support staff in terms of prioritisingtasks

Review and improve the quality ofbank staff

Develop a culture whereby staff feelconfident about raising concerns about workload

Encourage team work and skill mix

Review and reduce any unnecessarypaperwork and administration

Standardise requests/data recordingprocesses to avoid task duplication


Two key categories of problems were raisedin relation to equipment: the first was a lackof appropriate or required equipment; thesecond was the amount of time it takes forbroken or faulty equipment to be repaired.Staff complained that it takes so long forthings to be fixed, that things often gounreported because people assume thatnothing will be done to fix the problems,or at least that any actions taken will takeso long to implement that they are notworth waiting for.

Staff also mentioned that they tend toreceive little or no information on thecurrent status of faulty or brokenequipment, making it very difficult to assesswhether or when things will improve.In some organisations, there was a generalperception that senior members of staff

failed to see the urgency or importanceof good equipment. Many focus groupparticipants reported feeling verydisappointed when they were asked toperform tasks that they could not perform,due to a lack of appropriate equipment.Related to a lack of appropriate equipment,many participants focused specifically onthe difficulties they experienced whentrying to access a computer.

The research has demonstrated that havingpoor resources (e.g. information, trainingor equipment) can have a negative impacton staff job satisfaction and organisationalcommitment, and also increased stresssymptoms, intentions to quit and absence.Furthermore, the lack of resources was alsolinked to reduced levels of performance andconfidence in care delivery.



30

Poor Equipment and Resources

The equipment we

have to use is

substandard and

is often broken.

Patients sometimes

complain that we do

not care for them but

sometimes we just

don’t have the right

type of equipment to

offer them the speed

and quality of service

they expect and

rightly deserve.

“

”We have a fantastic

resource manager who

is on the ball when it

comes to equipment

problems, faults and

the expected arrival

of equipment.

Knowing that you

have such a person

around or behind

you helps you to plan

and gives you the

confidence when you

are communicating

to others.

“

”



31


"It is important for us to have the rightequipment to do the job. This can range fromsimple bits of equipment to more complex things.Sometimes it can be difficult to accessequipment, we also have different pieces/types ofequipment for certain jobs which can make lifevery difficult and confusing."

"When we have to work with the faultyequipment you start to lose confidence. You canoften work around the faults or issues butsometimes you don't know whether something isgoing to work or not, or whether you or someoneelse needs to re check you work."

“There can be a major problem but it takes twoweeks to fix and nobody tells you anything, theyjust don’t act. There’s no communication.”

“Response times for faults are so long thatequipment problems are not reported.”

"We need to get better at capturing lessons andensuring learning is shared and acted on. Staffare very innovative and have lots of ideas onhow to save resources by, for example, workingsmarter and more effectively."

"There are constant pressures across the Trust tosave on resources. The better the processes arefor monitoring and managing our assets thebetter we will be at managing and meeting ourpressures to save money. This does not just applyto our hospital this about the NHS in general."


Improve access to resources andstandardise resources

Raise awareness of the impact of faultyequipment and prioritisation of repairs

Ensure staff are kept up to date withequipment faults, maintenance andrepairs

Encourage reporting of faultyequipment

Ensure knowledge and learning ismanaged across the organisation

Adopt a more strategic approachto asset management


In all participating organisations, therewere some participants who spoke aboutthe difficulties in creating an appropriatebalance between their work life and theirhome life. This is not to say that allindividuals experienced this problem,because a number of people commentedthat they “would not allow” their work-lifeto interact with their home-life.

Despite this, the occurrence of tensions inthis area appeared to be relatively high.Often, comments overlapped with the moregeneral ideas and suggestions related towork overload (i.e. it was because of heavyworkloads that staff felt they had to carrytheir work over into their ‘personal time’).

Some individuals talked about their lackof work life balance as being somethingthey struggled with, because they feltobliged to take on extra work because

it was ‘expected’ by their managers.This expectation led to some discussionaround the need for managers to bemade aware of the impact of staff takingwork home with them, and also of thesometimes inconsistent application offlexible working practices.

This audit has demonstrated that the linkbetween the workplace and home isimportant for individual and organisationalhealth. For NHS employees who wereinvolved in this research, tensions betweenwork life and home life were linked withincreased levels of stress and a decreasein perceptions of performance.

In addition, conflict between home andworking life was linked with increasedlevels of withdrawal (e.g. higher levels ofintentions to quit and sickness absence).



32

Difficult Home-Work Balance

I would never take

work home, but what

happens is ... I’m

consistently staying

back … half an hour,

an hour, couple of

hours later on a night

time to do my notes

at work, so that is

then impacting on

my home life.

“

”

A lot of staff will

work shifts but the

key here is how their

managers arrange

their shifts. Our

manager steps

in if they notice staff

are going beyond

their shifts. This is

common sense and

good practice.

“

”



33


“I think that managers should speak to peoplewho do work beyond their hours. It is importantto get a real understanding of what it is possibleto achieve in the time we actually work. This isbecause those who stop when they are supposedto stop are then made to look bad. For example,some people work on electronic patient recordsat home and late at night. I would question howthey can effectively write up notes late at night.Although it appears as if some people are betteror more efficient than others this is not alwaysthe case.”

“There is a need for forward planning...instead ofdropping things on people, to have that foresightand forward planning to do the instructioncorrectly in the first place.”

“There needs to be need an education shift onthe whole approach to flexible workingdepending on the need.”

“Managers need to encourage people to askmore questions. So if someone says to you ‘it’s4:55pm, can I have this tomorrow?’ you ask thequestion as to when it’s actually needed: ‘whenare you actually going to use this information?’‘well actually, 5pm tomorrow’ So you think,actually I can do it tomorrow morning. Butsometimes people don’t feel empowered to asksomeone questions.”

“The practicalities are, we are getting a biggercaseload. We are not getting more staff...whatyou will be seeing from a job point of view isincreasing demands on your time.”

“As a case in point, the way that the sicknessabsence policy is implemented can sometimes bevery restrictive and cause problems. Sometimesmanagers feel or believe that they have nodiscretion over managing an issue when theyhave. Other policies are really good for employeehealth, such as flexible working.”


Monitor staff working hours

Ensure the impact of additional dutiesand/or tasks are consideredappropriately

Consider the added value or benefitof flexible working

Empower/enable staff to feel confidentabout asking questions and raisingissues

Review caseload and support caseloadmanagement

Consider the impact of various policieson health and well-being


For some staff, work-related violence isa very common everyday occurrence:although some members of staff statedthat they had not received any violence oraggression from within the organisation,others claimed that dealing with violenceor aggression had become part of their job(particularly for participants in clinicalroles). Some staff acknowledged that, evenwhere violence or aggression felt like ‘partof the job’, this sometimes made them feelsomewhat anxious about coming into workwhen they knew they would be dealingwith particularly difficult patients.

In each participating organisation, theaudit examined the impact of work-relatedaggression from within the organisation(i.e. between employees) as well as fromexternal service users (patients andrelatives of patients). In most cases, theexposure of staff to such instances wasuncommon (particularly in relation toviolence from internal colleagues) but when

violence and aggression of any kind didoccur, the links to health and well-beingwere clear and significant. Instances ofviolence were related to all healthoutcomes measured within the audit.The damage that can be done by work-related violence was clearly illustratedthrough some of the comments thatemerged during the feedback sessions.

Existing initiatives aimed at tackling work-related aggression were acknowledged bymany participants (e.g. training, incidentrecording, lone worker devices, etc.).NHS organisations have policies in placefor tackling work-related aggression, andsome staff commented on existingreporting procedures and training that theyhad received to help them to cope with‘difficult patients.’ However, despite thisthere were various suggestions putforwards regarding improvements thatcould be made in this area and these areconsidered below.



34

Work-Related Aggression and Violence

The violence and

abuse that we get

from patients has

a really negative

impact on you.

It makes it hard to

carry on. We take

so much abuse,

sometimes from

patients, sometimes

their families and

sometimes just the

public out on the

street. It can be

tough.

“

”



“More needs to be done in terms of theorganisation’s response to violence andaggression. We know that letters are sent topatients, but the organisation needs to makestaff more aware of the action it is taking todeal with this issue.”


Heighten awareness of theorganisational response to tacklingwork-related violence



35


“We are provided with conflict resolution training every three years as it is mandatory.However, you quickly lose the information youwere taught. We also need to have moreappropriate levels of training that help to tacklethe problems – for example – internally staffneed to be aware of the impact they have oneach other. It is about being aware of eachother’s perceptions.”

“If it’s actual physical violence they should betaken through the court system rather than anindividual having to take it through the civilcourts. It should be organisational…it’s the waythe law works though, as opposed to the way theorganisation works.”

“As a Trust, we don’t actually publicise ‘what’shappening’ ...we don’t work particularly well withthe press.”

“They’ve got better nowadays in terms ofmanagement coming in and seeing how you are…but that’s only up to Local Security Management(LSM) level, there’s nothing above that. It isimportant that staff feel they have the support andbacking of their managers. Managers are importantfor helping staff to deal with incidents as well astrying to work out what happened and how it mightbe avoided in the future.”

“We are now encouraged to record incidents.However, for some of us this has only just beenbrought to our attention. However, the incidentreport form is quite a lengthy document and itdoes take up a great deal of your day, however,it is important that this is encouraged.”


Assess staff needs for workplaceaggression and violence managementtraining and ensure training is availableto all staff and is well attended

Making greater use of the courtsystem/prosecutions/behaviour ordersagainst aggressors and wheresuccessful prosecutions have occurredensure staff are aware of this

Improve public education about theimpact of workplace aggression andviolence

Raise awareness of the importance ofmanagement support when dealingwith workplace aggression and violence

Review the incident reporting processand ensure the value of the system isbeing realised



36


“You can raise it as an incident and thenthere’s counselling and things…there’s a 24hour helpline.”

“The introduction of lone worker devices hasbeen very positive. They are very user friendlyand you know staff at your organisation canhear what is happening. We are limited onnumber so they are not available to everyone –but not everyone needs one.”

“In reality, the training I attended was not thatgood. It actually made me feel a lot worse andconcerned about the problem of violence atwork. I don’t think anyone has ever looked atwhether or not what is being offered is fit forpurpose or even safe.”

“When I was attacked by a patient I wasrelieved to know that I had the support of mycolleagues, I don’t think I would have returnedto work without them to be honest.”


Ensuring counseling / support systemsare available to staff and increasingtheir awareness of it

Consider the availability of appropriatedevices against an informed riskassessment

Where training is provided, ensure it isevaluated for its validity, impact andeffectiveness

Develop a supportive culture to limitthe impact of exposure to aggressionand violence

I was a victim of violence at work. The thing that really helped me was the level of

support that I received from my manager. I was not made to feel as if I was the

problem. I was provided with the time to talk things through and I was supported

in reporting the incident. This really helped me to stay on top of things.

“”



37

The Positive Spiral:Supportive Management Having a supportive manager provides staffwith a number of personal as well as task-based resources. On a personal level, having a manager that is considered‘supportive’ can, for example, enhanceindividual levels of confidence as well asself-esteem. This heightened sense ofpersonal worth is in itself motivational andcan spur people on to perform at higherlevels (a positive behaviour spiral). In turn,this heightened level of performance canhave a positive impact on the quality ofthe relationship between the employee andtheir manager, and so on.

The Negative Spiral:Workplace Aggression and Violence The negative impact of being exposed toworkplace aggression and violence is welldocumented. On a personal level,aggression and violence is known toincrease, amongst other things, levels offear, anxiety, stress and burnout as well asreduce levels of confidence, motivation andengagement. These outcomes are a drainon resources and impair health. If we takethe concept of burnout alone, one primarysymptom of patient burnout is withdrawaland a reduced sense of wanting to engagewith patients. This sense of withdrawal canoften be interpreted by patients (as wellas other staff) as a lack of due care andattention, this perception of a healthcareemployee can potentially ensue in negativeand heated interpersonal interactions(a negative behaviour spiral).

WORKPLACE FEATURES AND POSITIVE AND NEGATIVEBEHAVIOUR SPIRALS

In addition, the presence or lack of resources at work can influence healthand well-being through positive and negative behaviour spirals (see examplesand Figure 6 below).

Figure 6: Example of behaviour/performance spiral

DECREASED PERFORMANCE

INCREASED PERFORMANCE

POOR HEALTH

NEGATIVEWORKPLACE FEATURES

POSITIVE WORKPLACEFEATURES

IMPROVED HEALTH

EMPLOYEE

POSITIVE SPIRAL

NEGATIVE SPIRAL



38

Taking Action How to use the evidence to improve health and well-being

More often than not, interventions for the promotion of health and well-beingwithin the participating organisations tended to focus on the individual employee,whilst ignoring the pivotal role that the workplace itself has to play in shapingemployee health and well-being.

These individually targeted healthpromotion activities are those which tendto focus on, for example, health relatedknowledge, improved coping styles,increasing physical activity and so on.Whilst individual level interventions arenot of themselves under question - whenselected and targeted appropriately theseinterventions can be very effective – but asthe only approach to health promotion,their impact and value is likely to be shortlived if realised at all. In addition, an overreliance on individual level interventions,suggests that health management at workis an issue to be managed by, and withinthe total control of, the individualemployee. Furthermore, the focus on theindividual implies ‘poor’ health is a directresult of human incompetence or weakness.

In line with best practice and the ORATM

principles, it was recommended that a‘holistic’ approach was considered whenprioritising action for health promotion.The holistic approach encourages decisionmakers to move beyond individuallytargeted interventions and explorealternative levels of health promotionactivity. As shown in Figure 5, the holisticapproach requires consideration of at leastfour levels of intervention. These includefactors associated with the individualemployee(s) (e.g. skills, competencies,coping styles, etc.), the job task/rolecompleted (e.g. the role performed, thecontent of the job, etc.), the organisationalcontext (e.g. culture, structure, etc.) andthe external influences (e.g. performancetargets, financial climate, etc.).

INDIVIDUALFACTORS

JOB TASKSOR ROLE

ORGANISATIONAL CONTEXT

EXTERNALFORCES

HEALTH ANDWELL-BEING

Figure 5: The factors that influence workplace health and well-being



39

Using the holistic approach outlined inFigure 5, participants were directed toconsider how any agreed actions wouldeither protect or promote health and well-being. They were also encouraged to thinkthrough any forces that would help and/orlimit the impact of any action. To facilitateholistic action planning, the following stepswere followed:

1. Review and Reflection2. Agree and Plan Prioritised Action3. Decision Communication 4. Evaluate Action

Each step is briefly outlined below:

1. Review and Reflection Those responsible for managing stress andpromoting health within each participatingorganisation were invited to attend anaudit feedback meeting. At this meetingparticipants were encouraged to reviewand reflect on the evidence summarisedin their local report. They were alsoadvised to commit to a response thattargeted both individual and organisationalhealth. It was also recommended thatrepresentatives from each participatingorganisation work in unison with other keystakeholders to ensure a coordinated,balanced and strategic approach to healthmanagement was adopted.

2. Agree and Plan Prioritised ActionEach participating group was subsequentlyencouraged to prioritise and focus oncollective and practicable action thatwould enable the health improvementsto be realised. Participants attended anaction planning presentation and weresupported in how to consider the evidence

as well as prioritise the areas of actionthat required further follow-up work.Additional tools/proformas were alsoprovided to guide decision making. Eachworkplace feature was provided with astatus indicator to help focus attention2:

1. Priority – This workplace feature hasbeen found to have a number ofassociated links with health outcomesand therefore should be given priorityconsideration.

2. Important – This workplace featurewas found to be associated with somehealth outcomes and is consideredimportant.

Participants were assisted in constructinga plan of action. Amongst other things,it was recommended that each plandocumented the following information:

The workplace feature of concern

The action(s) to be taken to tacklethe workplace feature

The rationale for the action

The level of action (individual, team,division, organisation)

The anticipated resources requiredfor taking action

The forces working for and againstthe intervention

The links with existing or plannedactions across the organisation

The anticipated implementation date

The anticipated duration

The evaluation approach

The owner of the action(s)

The communication plan for sharinginformation about the action(s)

2 In reality, the identifiedworkplace featureswere not mutuallyexclusive and positivechanges in one area(e.g. team working)is likely to have aconcomitant andbeneficial impactin another area(e.g. work overload).



40

Organisation 3

Table 2A sample of the health promotion actions agreed with each of theparticipating Trusts.

The audit report was reviewed by thehealth and well-being steering group.

Members of the steering group wereallocated a priority area for review.The task was to establish what ifanything was being done about thisissue, and whether what was beingdone was being evaluated and shownto be working. A business case wasproduced on what else needed to bedone to tackle the workplace feature.

The findings from the audit weredistributed to all members of staff invarious formats – full report andshort reports.

An example of some of the healthpromotion activities that are beingimplemented as a direct result of theORATM process include:

Enhancing reward andrecognition scheme.Supporting staff withMusculoskeletal disorders.Introducing a supportivemanagement behaviourprogramme.A health and well-being areawas developed on the intranetand the information wasconverted into an interactiveintranet resource. Presenting the findings fromthe audit to the board and other senior management groups. Implementing an evaluationof health promotion.

Organisation 1 Organisation 2

How did the each organisations approach the health and well-being audit data

The audit results were presented tothe board and other seniormanagement groups.

A coordinating group took ownershipof the health promotion aspect of theORATM audit.

Events were held with staff to discussthe core themes from the audit andto prioritise action areas.

Areas for action were prioritised sothat action would be taken where thegreatest risk to health was identifiedand/or the greatest benefit fromtaking action could be realised.


An integrated staff engagementstrategy that focuses on healthand well-being as a key criterionof success.Implemented a new rewardsand recognition scheme forstaff contributions.Improving communicationabout work-place violenceand aggression.Introduction of a managementbehaviour training programme.Evaluation of key initiativesfor promoting health andwell-being.

Following receipt of the audit report,the results were presented to varioussenior management groups to ensurethere was broader awareness of themain issues impacting on the healthand well-being of the workforce.

A health and well-being steeringgroup took ownership of the results.

The findings were subsequentlyaligned to an integrated HumanResources (HR) and Workforcestrategy.

The core workplace features resultingfrom the audit were used to guideaction and intervention.


Development of a reward andrecognition scheme for staff.Publication of good news stories.Sharing of patient satisfactionletters with staff.Improving team leader training.Cascading value basedmanagement training.Improving the performanceappraisal process.Improving communicationmethods to all staff.Introduction of othermethods/mechanisms formonitoring employee healthand well-being

The list of actions is illustrative rather than exhaustive and not all actions shown have been implemented.



41

3. Decision Feedback Throughout the feedback process,employees from each participatingorganisation raised concerns aboutwhether or not any action would arise asa result of the health audit. The followingcomment by one member of staff helps tosummarise the issue very succinctly:

“We are always completing surveys and itfeels like nothing is ever done or changedas a result of our feedback. Does anyoneactually acknowledge or listen to thefeedback we provide?”

The concerns raised by staff are verylegitimate and reflect the general apathyfelt by employees in many organisationswhere annual opinion surveys are a regularpart of corporate life.

To help overcome and tackle theseconcerns each participating Trust wasencouraged to communicate the findingsfrom the health audit to all employees. Inaddition, action that was planned was alsoannounced to all staff.

4. Evaluate Action It was also recommended that the localproject coordinating group monitor andrigorously evaluate any action taken as adirect result of the health and well-beingaudit. At the time of writing this report,action was still being planned andimplemented within the respectiveorganisations. Each local group will besupported in how best to evaluate theirhealth and well-being promotion activities.The overall aim of the evaluation will be toestablish a valid evidence base and enablequestions to be answered about the impact,effectiveness and value of the action takento promote health. The findings from theevaluation will be published in 2013.

The Management Behaviour Programme:Organisation 1

As part of the intervention phase for this organisation, amanagement behaviour programme was commissioned anddesigned by the research team. The programme is built around anumber of scenarios that serve to enhance the behaviours thatmatter for individual as well as organisational health, well-beingand performance. This programme has been implemented acrossthe entire organisation and has been classified as a mandatoryprogramme for all managers. The training is being continuouslyevaluated with evidence being collected on the impact and theeffectiveness of the programme on both individual as well asorganisational outcomes.

The Engagement Approach: Organisation 2

Along with other outcomes, the audit identified a number ofworkplace features that were important for improving employeeengagement; a priority health promotion area for this organisation.Endorsed by the board and the senior management team, theorganisation has now used the audit findings to structure and designan integrated employee engagement strategy. Actions have beenprioritised and an evaluation process is being designed to increasethe chances that any actions taken will improve employee health andwell-being as well as levels of employee engagement.

An Integrated Strategy : Organisation 3

The findings from the audit were considered by a health and well-being steering group. The decision was taken to use outcomes of theaudit to inform organisational development by integrating andaligning the actions with the workforce development and HRstrategy. A number of other specific interventions associated withimproving health and well-being were also identified including, forexample, values and behaviour change workshops, team feedbacksessions, leadership development as well as specific initiatives forimproving physical health and exercise. A series of evaluation studiesare being planned with the organisation to help demonstrate impactand effectiveness of these interventions.

The outcomes of the evaluation will be shared in the evaluation report scheduled for 2013.



42

Reflections and BestPractice Principles

Some common challenges to the promotion of health andwell-being

An underpinning philosophy for this project has been to identify and reportpositive messages that provide an indication of where and how improvements canbe made to enhance health and well-being.

Throughout the project a number of common perspectives or challenges were identified inall participating organisations, each of which has a role to play in limiting action to improvehealth and well-being. In addition, we have also identified best practice principles that willincrease the chances of successfully delivering a health and well-being managementproject/programme.

Challenge 1:Develop an accurate understandingof health and well-being There continues to be a general myth orbelief that some ‘stress’ is good for you.The confusion seems to be related to the factthat in research and more general terms theword stress has come to represent distress(i.e. experiencing an imbalance betweendemands that are made of someone andtheir beliefs that they are able to copeeffectively with these demands). Eustress isa term that is used to represent what someterm ‘good’ stress (i.e. a positive response tojob demands and a sense that one is able tocope and deal with these demands). In thisproject, stress is seen as representing anegative process and leading to ill healthand other negative consequences.

Challenge 2:Using accurate and adequateassessments of health and well-being Stress and/or health and well-being is acomplex process, understanding this

process is fundamental to informing actionand intervention for achieving positiveindividual and organisational healthoutcomes. The ubiquitous employeeopinion survey provides only part of thepicture in understanding individual andorganisational health and well-being. Asidefrom some of the psychometric shortfalls,there is also a real danger that standardopinion surveys over simplify what is acomplex issue and can unwittingly misleaddecisions taken to allocate resources forimproving health and well-being. Modernworkplaces are becoming increasinglycomplex and multiple factors interact thateither serve to enhance or diminish healthand well-being. Understanding thisinteraction underpins effective stress and/orhealth and well-being assessments.

Challenge 3:Acknowledging the impact ofexternal forces on leader behaviour As has been argued throughout this update,the way that staff are managed and/or led



43

by those around them is inextricably linkedto their health, well-being, performance andeffectiveness. The NHS is an extremelycomplex and highly pressured workenvironment. Leaders and/or managershave often commented on the change thatis generally being imposed upon them andhow this can sometimes conflict with thepressures that exist for delivering quality. As a result of such conflicting pressures,there is a real danger of healthcareorganisations suffering from negative healthand behavioural spirals (i.e. performancemonitoring pressures force managers/leadersto use their authority to demand increasedperformance which can lead to poorreactions in staff, ill health and poorperformance which in turn leads to greaterdemands for performance).

Challenge 4:Raising awareness of theimportance of health and well-being There continues to be a general ‘under’appreciation of the importance of health andwell-being for individual and organisationaleffectiveness. This lack of appreciationstems, in part, from a poor understanding ofthe health process and in demonstrating thelink between poor health (e.g. fatigue, lowjob satisfaction, etc.) and reducedperformance outcomes that are ofimportance to the organisational setting(e.g. efficiency, absence, quality of care,patient satisfaction, etc.). This lack ofappreciation also stems from ‘silo thinking’(e.g. stress at work being seen solely asa Human Resources (HR) or OccupationalHealth (OH) issue) which consequently

results in poor integration of the health andwell-being agenda with more generalcorporate objectives (i.e. demonstrating thelink between health and organisationaldevelopment, strategic thinking, patientsatisfaction and outcomes, and so on).

Challenge 5:Improving the evaluation of actionto promote health and well-being There is a great deal of action andinvestment being undertaken across the NHSto reduce the impact of stress and improvehealth and well-being. Unfortunatelycoordinated effort for evaluating theseinterventions is lacking. Without appropriatesystematic and rigorous evaluationorganisations are in danger of investingresources without understanding if theirresources have been used wisely or indeedwhether or not any resulting intervention hashad the desired impact. In addition, withoutcoordinated effort on how to evaluateinterventions there is likely to be limitedopportunity for real learning to be sharedabout how to effectively implement healthand well-being interventions.



44

Best practice principles for increasing the chances of deliveringa successful health and well-being management project

PRINCIPLE 1:

Integrate health and well-being management into the everyday behaviour

Adopt a realisation that health and well-being management is a collective matter. The natureand quality of the relationships that exist within an organisation are a key determinant of bothindividual and organisational health and well-being. The behaviours and values adopted andexpressed between workers plays a key role in creating a healthy workplace. Encourage positivebehavior and limit exposure to negative behaviour.

PRINCIPLE 2:

Gain a demonstrable commitment from top leaders to health and well-being

Health and well-being management must be supported from the top down. The viability andsuccess of any programme for assessing and improving health and well-being will be dependentupon senior managers sending clear signals that demonstrate their intent and long-term supportfor health promotion.

PRINCIPLE 3:

Set up a project/programme structure to ensure action is coordinated

To be effective, health and well-being management requires a systematic project/programmebased approach. This approach must follow principles of effective project management including,planning, delegating, monitoring and controlling all aspects of the project. Adopting a projectbased approach also helps ensure that expectations can be managed, risks monitored and thebenefits of the project realised.

PRINCIPLE 4:

Seek high levels of staff engagement in health and well-being projects andparticipation in the selection/design of action

Employee involvement at all stages is critical. This should also involve engagement andconsultation with trade union representatives and other key stakeholder groups. A participativeapproach to the health management process should be applied, from assessment and feedback,through to selecting actions and evaluation.



45

PRINCIPLE 5:

Undertake systematic evaluation of the need, impact and effectiveness of action

The need for evaluation cannot be stated strongly enough. However, evaluation is much more thanjust a collection of participant perspectives following their involvement in an intervention. There arevarious questions that must be answered to help inform a suitable evaluation of an intervention.For example, two important questions surround what should be measured to demonstrate theeffectiveness of any action taken (a question of criteria)? And how should the evaluation evidencebe collected to confirm the intervention brought about the change (a question of design)?In addition, there are many reasons why an intervention may or may not work; exploring if/howan intervention was implemented influenced its success or failure is also an important question forany evaluation exercise (a question of process).

PRINCIPLE 6:

Ensure health is considered a continuous process that requires monitoringand vigilance

As with personal health, health and well-being at work requires vigilance and continuousmonitoring and management. The audit and action steps for health and well-being are a cyclicalprocess whereby the evidence that is collected on the health profile as well as on the impact ofany action is regularly reviewed to ensure lessons are learned and health gains are being realised.

PRINCIPLE 7:

Holistic evidenced based interventions for improving health and well-being

Action for improving health and well-being should be broad and holistic. There must be ahealthy balance between interventions that target the organisation with those that seek toenhance individual skills and competencies for dealing with workplace demands. In addition,the selected interventions must necessarily be informed by the evidence that has been collectedthrough the health management process. The evidence will help to identify the common causesto health symptoms and therefore the best solution for tackling the cause.



46

PRINCIPLE 8:

Avoid simplistic summaries of ‘organisational life’ as accurate indicators of healthand well-being

One of our challenges is also one of our principles. The workplace is complex and multiple factorsinteract that either serve to enhance or diminish health and well-being. With the changes occurringacross the healthcare sector, new and emerging risks or challenges to health are likely to occur.Simplistic frequency counts or assessments often under estimate the impact of certain workplacefeatures and over inflate the importance of others. Accurate and high quality diagnostic assessmentsshould form the basis of any health and well-being audit. In essence, they are there to provide asound diagnosis of the health of the workforce. It is important to use the right tool for the job.

PRINCIPLE 9:

Support managers in understanding the importance of their role in shaping thehealth and well-being of the workforce

Managers often find themselves struggling to manage the various demands that are made of them.The healthcare context is one that is often described synonymously with concepts such as pressure,change, measurement, innovation, productivity, performance and quality. Managers often raiseconcerns that they themselves are lacking the appropriate support for monitoring as well asmanaging the health and well-being of their staff. It is vital that managers are offered additionalresources to support them in promoting health. They must also be shown through evidence the rolethey have to play in shaping the health and well-being of their workforce.

PRINCIPLE 10:

Health and well-being is a strategic corporate issue

It is important that organisational stakeholders see health and well-being as part of the broaderorganisational agenda. Health and well-being is often approached with a silo mentality (orattitude) where it is often aligned to occupational safety and health or as an ‘add on’ to thehuman resource function. In reality, health and well-being is a continuous exercise inorganisational development. The health of the workforce is determined by multiple factors andin turn health influences multiple outcomes. Health and well-being must be an integral part ofthe corporate agenda as a healthy workforce is a workforce that can offer more and deliver more.Individual and organisational health is an asset to be protected, monitored and enhanced. Healthis a resource that will enable the organisation to deliver against its performance objectives.In simple terms, what is good for employee health is good for the organisation.



47



48



49

Summary and CloseHealth and well-being at work is ultimately about employees having at theirdisposal the right type and level of resources to help them deal with their workdemands. The presence or absence of these resources can serve to enhance ordiminish individual as well as organisational health and performance as theyassist staff in completing their day to day tasks. These resources can be personal(e.g. self-confidence, self-esteem, emotional, physical and psychological, etc.),social (e.g. interpersonal relationships with work colleagues) and physical(e.g. material artefacts).

The workplace features identified in thisproject were shown to either have positiveor negative impacts on health. In short, eachworkplace feature serves to either increaseor reduce the level of ‘resources’ that areavailable to staff. When resources areincreased health and well-being to tends tobe improved and when decreased it to tendsto be impaired. These findings help toestablish a clear path way for tackling andpromoting both individual andorganisational health and well-being.Resources (time, focus, energy and attention)must be given towards the development andpromotion of the positive workplace featuresas well as the prevention and reduction ofexposure to the negative workplace features.

As a close to this report, we are reminded ofthe messages that need to be extracted andcommunicated to others namely:

Achieving organisational performanceoutcomes must be matched by a concernfor the well-being of those employeeswho directly affect these practices. Accurately understanding how workconditions and the work itself influenceshealth is an important starting point forachieving wellness at work. We need to improve the mechanismsfor identifying and monitoring healthand well-being as well as theaccessibility of these mechanisms for employees to make their needs known

in a safe, valid and reliable manner. Health is a complex process whichrequires continuous attention, evaluationand action to maintain, improve anddemonstrate the importance of healthboth for individual as well asorganisational effectiveness.Individual health and well-being existswithin - and is a consequence of - thebroader ‘organisational’ cultural context.Support, fairness and safety are threecentral determinants of establishing ahealthy workforce. This broader contextmust be considered when taking actionto promote health.

Creating a healthy workplace andworkforce ultimately relies on constantcommunication with employees andthe availability of effective resources(physical, personal and social) within the organisation. There needs to be arealisation that health and well-beingmanagement is as much about individualresourcefulness and action as it is aboutorganisational responsibility, values andcommitment. There needs to be a newapproach to health and well-beingmanagement that is driven by integratedpolicies and practices that can bothpromote the health and well-being ofindividual employees while at the sametime strengthening organisationalhealth, performance and effectiveness.



50

Useful resources to support healthand well-being management

Below we offer a list of useful websites which have a wide range of resources(e.g. information, tools, advice and guidance) for assessing, protecting andpromoting individual as well as organisational health and well-being. Along withthis report, these resources can and should be used to support local action forimproving health and well-being.

The resources listed below are not exhaustive; they solely represent a starting point.

Resource Description:The NHS Employers - is the voice of employers in the NHS, supporting them to put patientsfirst. The NHS Employers promotes well-being at work, with advice and information onhealth and safety, stress, sickness absence and more.

Website Address: http://www.nhsemployers.org

Resource Description:The Health and Safety Executive (HSE) - is the national independent watchdog for work-related health, safety and illness.

Website Address: http://www.hse.gov.uk

Resource Description:The Department of Health (DH) - provides strategic leadership for public health, the NHSand social care in England. The DH has responsibility for standards of health care, includingthe NHS. They set the strategic framework for adult social care and influence local authorityspend on social care. They also set the direction on promoting and protecting the public’shealth, taking the lead on issues such as environmental hazards to health, infectiousdiseases, health promotion and education, the safety of medicines, and ethical issues.

Website Address: http://www.dh.gov.uk

Resource Description:GOV.UK – is an online portal for finding government services and information. It deliversinformation and practical advice about public services, bringing them all together in one place.

Website Address: http://www.gov.uk



51

Resource Description:National Institute for Health and Clinical Excellence (NICE) - guidance supports healthcareprofessionals and others to make sure that the care they provide is of the best possiblequality and offers the best value for money. Their guidance is for the NHS, local authorities,charities, and anyone with a responsibility for commissioning or providing healthcare,public health or social care services.

Website Address: http://www.nice.org.uk/guidance/

NOTES

Partnership for Occupational Safetyand Health in Healthcare

If you have queries regarding this publicationor the services provided by Zeal Solutions Ltdplease contact:

Tel: 01159 932 324Fax: 01159 932 354

Email: [email protected]

www: zealsolutions.co.uk

Zeal Solutions LtdAntenna15 Beck StreetNottinghamNG1 1EQ

Documents

Health and Well-Being in Healthcare Settings › - › media › Employers › ... · October 2012 - A POSHH Group publication produced by Zeal Solutions Limited HEALTH AND WELL-BEING