The impact of stress amongst health professionals

It is a truism to say that a defining characteristic of modern life is ‘stress’, though its subjective nature and the many meanings attached to it both by lay people and within clinical literature (see an example of the challenges in measuring such individualised perceptions in Witteman et al.'s paper on illness perception in this edition) can make its study a complex undertaking (Bergman et al., 2009). Nevertheless, the experience of ‘stress’ can have a significant negative impact on health (Nako, 2010). This edition of the Journal of Mental Health has a special focus on what is increasingly becoming a significant societal issue work-related stress, interventions to address it and the promotion of mental well being.

Occupational stress or work-related stress is undoubtedly a major cause of mental ill health in populations and is a world-wide phenomenon (Nako, 2010). For example, in Canada 28% of workers report that they find most days at work either ‘quite a bit’ or ‘extremely stressful’ (Bergman et al., 2009). In the United Kingdom, the recent Labour Force Survey (Office for National Statistics et al., 2010) estimates an annual incidence rate of work-related stress, depression or anxiety of 760 cases per 100,000 workers.

An individual insecurity is often not clearly defined and may be drawn from a wider societal sense of dislocation. Sudden changes to the certainties provided by particular working environments can be one such mechanism for promoting individual insecurity even when the previous working environment itself might be judged by those outside it to have been stress inducing and uncertain. Thus, soldiers fighting in places such as Afghanistan being returned to the uncertainties of civilian life, particularly in a dislocating context of high unemployment, may find a loss of certainty as to role and previously experienced social relations stressful. An example of difficulties associated with this adjustment is provided in this edition by Jones et al.,'s report on a clinical study of demobilised reservists with post-traumatic stress disorder (PTSD) and other common mental health difficulties.

The current general negative discourse around the economy, reinforced by increasing unemployment in many European countries is likely to be a complicating factor in dealing with work-related stress for society in general. In this context, how those in work feel about general employment conditions in terms of occupational stress is as significant as what they directly experience (Zeytinoglu et al., 2009).

As indicated earlier, changes in the direct experience of work are significant in that they serve to confirm a general sense of insecurity that arises where the demands on individuals in their jobs are not fixed or are subject to sudden change – what is sometimes called ‘flexible working arrangements’. Such flexible arrangements include non-permanent contracts; changes from full time to part-time working hours; being on call at short notice, or having to work split shifts (Burchell, 2002). A significant body of research reveals that temporary workers, who have been traditionally subject to such ‘flexible’ employment conditions, have reported chronic work-related stress for years (Nako, 2010).

Within this broad context of employment insecurity, those working in the public sector may feel particularly vulnerable since much national discourse is currently focused on how the public sector needs to be both reduced and made more productive. In the United Kingdom, for example, despite government assurances that the National Health Service (NHS) budget will be protected, changes in structures and service delivery will inevitably impact on employment. In this regard, occupational stress amongst health care workers is likely to be as much a feature of employment as any other part of the public sector that hasbeen specifically targeted to be cut, such as local councils. Indeed, it might be more so since it is well recognised that health care workers experience considerably higher levels of work-related stress compared to the wider working population as part of their day-to-day work (Harvey et al., 2009; Mimura & Griffiths, 2003), with physicians and registered nurses experiencing the highest levels stress of all.

The costs of such work-related ill health to the ability of health services to function effectively can be considerable. For example, it has been argued that reducing work-related stress in the UK NHS would result in an annual saving of £555 million and a gain of an extra 3.4 million working days (Boorman, 2009).

Two papers in this edition deal with issues pertinent to this. The first by Onyett returns to the issues he first raised in 1997 on job satisfaction, stress and burnout in community mental health teams (CMHT). Onyett emphasises that in the current climate effective team working to protect workers in CMHTs is even more important. In the second paper, Svedberg explores the costs of poor mental health and attitudes to health promotion interventions among patients in mental health services. Svedberg's findings indicate that female patients find health promotion more important than males, which in a context of constrained resources and reported patient satisfaction could lead to health promotion efforts with patients being down graded in relation to other interventions.

The emotional, intellectual and physical labour involved in day-to-day health care differentiates those working in health services from many other sectors (Michie & Williams, 2003). For example, Maunder (2004) highlights the psychological impact of dealing with SARS on health care workers. Therefore, the nature of interventions to manage the psychosocial impact of such labour is likely to be different from more generalised interventions to manage work-related stress. Yet, there is a surprisingly small body of work focused on interventions and programmes to lessen the psychosocial impact of stress on health care workers, both at an environmental and individual level.

Of the work that does exist Harvey et al. (2009) reports that the majority focuses on doctors with a ratio of papers published about doctors and stress compared to a range of health care professionals, such as nurses, of 8:1. Perhaps this level of reporting reflects the fact that doctors are perhaps significantly disadvantaged in terms of recognizing when they need help and being able to seek it.

A Cochrane review identified 51 studies specifically focused on health care workers ofwhich only 19 were sufficiently robust to be included for review (Marine et al., 2009), these were divided between work-directed interventions and person-directed interventions. The review found that the evidence for the effectiveness of either type of intervention was limited, with studies in general either being too small from which to draw any firm conclusions, poor quality evidence or poor in terms of reporting. However, the authors did identify one good quality study which seemed to indicate that cognitive-based intervention strategies were more effective than ones based on behavioural interventions alone.

Two papers in this edition explore issues around intervention, both by Chalder et al. One, through an exploration of the literature, makes the case that doctors unique circumstances as this relates to seeking help and accepting treatment mean that they need specialist services to deal with work-related stress. The second, reports on such a specialist service and intervention – the Practitioner Health Programme.

The lack of clear evidence to support the efficacy of current approaches to interventions to manage and reduce the impact of work-related stress on the lives of employees is significant in the light of the recent report of the Health and Safety Executive (HSE) in the United Kingdom on psychosocial working conditions in general (Packham & Webster, 2009). This stated that there has been no discernable improvement in psychosocial working conditions in the United Kingdom. The HSE further reports that few workers are aware of initiatives onthe management of stress in their workplace or report feeling able to discuss with their manager feeling stressed.

What the HSE report makes clear is that despite the clinical literature on work-related stress and intervention programmes, popular media coverage of issues of day-to-day stress and political initiatives through legislation to address it, we seem to be making little headway in its reduction, perhaps because of a combination of a lack of awareness and a lack of easily accessible support for workers in general. Chald and Ridge, therefore in this edition, report on the development of a web-based stress management intervention for occupational support workers (part of the Reducing Occupational Stress in Employment (ROSE) project; which, though targeted at a particular group of workers is freely accessible to the general public across Europe in English, German, Italian and Romanian.

The fact that the HSE in the United Kingdom actually reports on work-related stress indicates, perhaps, that the issue is not primarily one that can be addressed through psychological management alone but has a significant policy dimension. The significance of the policy dimension is illustrated by the high level conference on mental health held in Brussels in June 2008, entitled ‘Together for mental health and well-being’ (World Health Organisation Europe, 2008).

This conference resulted in The European Pact on Mental Health (World Health Organisation Europe, 2008), which identified five priorities for the improvement of the mental health of the European population. A linking theme in all five priorities was the needto address individual and societal stressors to improve mental health and well-being, perhaps most significantly articulated in Priority Three which emphasises the importance of improving mental health in workplace settings.

The Pact calls upon stakeholders to: ‘Improve work organisation, organisational cultures and leadership practices to promote mental well-being at work, including the reconciliation of work and family life;’ and ‘implement mental health and well-being programmes with risk assessment and prevention programmes for situations that can cause adverse effects on the mental health of workers (stress, abusive behaviour such as violence or harassment at work, alcohol, drugs) and early intervention schemes at workplaces (World Health Organisation Europe, 2008, p. 3).

It is clear from the areas identified in Priority Three that these are principally affected by changes in legislation, changing the societal climate in which people experience work and changing the structures of their working environment. Thus the clinical component, though important, is not the most significant in terms of developing a strategic approach to the issue of work-related stress. Indeed, Harvey et al. (2009) point out that by emphasising the clinical aspect of stress at work one might exacerbate the problem by medicalising normal stress and thereby encourage further staff sickness and work absence.

Two papers in this edition deal with the European policy context for dealing with work-related stress and promoting mental well being. One is by Ozamiz on the presence or lack of mental health promotion policies in Europe. The other is by Wells et al., which explores European policy and guidelines on dealing with work-related stress and the degree such policy is reflected on ‘on the ground’ in the vocational and rehabilitation support sector in five European countries.

In 2001, a UK study of depression, coping and turnover among NHS and private sector staff caring for people with dementia (Margallo-Lana et al., 2001) found that levels of stress amongst health care workers in NHS homes were considerably lower than those amongst health workers in private care homes (16% versus 22%). The study found that there were higher rates of staff turnover in the private sector homes compared to the NHS, which theauthors attributed to a greater sense of ‘community’ amongst NHS staff. Taken in the context of the European Pact on Mental Health, this study and the limited findings of the Cochrane review (Marine et al., 2009) on the efficacy of cognitive approaches, the way forward in managing work related stress seems to be to change the perceptions of workers creating an inclusive environment that generates a sense of belonging. This is a societal rather than clinical task.

Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.