Supporting our NHS people experiencing stress

It is important to act on stress early, before an employee becomes unwell, and ensure tailored, professional psychological support is readily available to support staff experiencing moral injury and provide informal support led by trained peer supporters. 

The best way to detect whether an individual might be experiencing stress is by being alert and aware of changes in your staff. Knowing and listening to staff members is essential, as this will enable you to recognise when they are acting out of character.  This might include:

• changes in work performance - inconsistent performance, uncharacteristic errors, lack of motivation, working longer hours, skipping breaks
• emotional signs - overreactions, crying, undue sensitivity
• aggressive behaviour - malicious gossip, temper outbursts, bullying
• withdrawal - absenteeism, limited social contact, leaving early
• physical signs - nervous speech, sweating, reporting/increase of headaches.

Other signs can include increased alcohol intake, smoking, lack of interest in appearance, and accidents at home/work.

The Chartered Institute of Personnel and Development (CIPD) has created factsheets to help detect changes in behaviour and performance that could be initial indicators that employees are suffering from excess pressure.

Employers can actively help to reduce the stress staff experience and support staff through stress.

Organisational support

• Educate all staff about the symptoms of stress, not only line managers, and encourage staff to look out for one another. In some cases, it may also be helpful to share information with families on symptoms to look out for in their loved ones.
• Use all available comms channels to promote internal support available to all staff, including staff with limited access to a computer and/or who work across different sites. You might consider sharing leaflets, posters, flyers, QR codes linking to information on your organisation’s wellbeing support on your staff intranet.
• Signpost to national and local offers on your intranet and share this information with line managers so they can direct their staff to support.
• Act on stress early, as evidence points towards early detection of stress and trauma being key in recovery and avoiding further mental illness. In some cases, it may be necessary in the longer term to actively monitor staff for traumatic stress reactions. 

Role of teams and line managers

• Encourage line managers to build positive relationships with staff and have regular open and honest health and wellbeing conversations. This includes taking the time to ask about colleagues' lives and circumstances beyond work, as well as asking after their wellbeing. See our guidance on how to get the most out of health and wellbeing conversations. Regular meetings with line managers can also help staff to navigate organisational change which might contribute to stress.
• Implement a buddying system that allows colleagues to connect with colleagues and share experiences, allowing time for essential reflection and decompressing following challenging work situations. This may be particularly beneficial for frontline shift or ambulance workers who rotate shifts frequently and may not have a group of colleagues they see regularly.  
• Offer training to line managers (e.g. TRiM and REACT – see below) to increase confidence when holding open and honest conversations where supervisors feel equipped to explore responses from their team a little further; this can reduce sickness absence by up to 90 per cent. 
• Encourage team huddles to help staff to process the day’s events and reduce stress. Huddle facilitators guide a single person, group or team through a discussion of the day’s shift and events, allowing employees to share any challenges and give people time to stop, think and be with their colleagues.

Training

• Trauma Risk Management (TRiM) is an early intervention, formal peer support system which aims to ensure employees exposed to trauma at work are supported.  It includes psycho-educational briefings, time after the traumatic event to decompress, and access to medical and psychological services.  
• REACT mental health conversation training empowers people to recognise, engage, actively listen, check risk, and talk about specific actions to support staff with their mental health and wellbeing and helps colleagues to identify people in their teams who may be struggling with stress.

Stress inside and outside of the workplace can contribute to people feeling like they are unable to cope with the pressures and demands of their role. 

This can include but is not limited to organisational change, changes to workload, homelife-related stress (including family and childcare responsibilities), significant life events (e.g. moving home, marriage, divorce), financial wellbeing, and illness. 

See below examples of the types of work-related stress often experienced by the health workforce

Burnout  

Burnout is the emotional, mental and physical state of exhaustion, caused by excessive and prolonged periods of stress. In a Keeping Well NHS article, burnout is described as a feeling of ‘not enough’, be that not enough energy, time, enthusiasm or ability, rather than the feeling of ‘too much’, which is typically associated with work-related stress. It can result in a poorer physical state (tiredness, poor immunity), poorer mental health (sense of failure and doubt and loss of motivation), reduced job satisfaction, absenteeism and professional errors.  

Visit our beating burnout page for further insight into burnout and resources to support staff.

Trauma  

Trauma is the emotional response to a stressful, frightening or distressing event. While it is normal to have an emotional reaction to a stressful and traumatic situation, in some cases, the effects can be long-lasting and severely impact an individual’s life. Employers should be mindful that staff may have experienced trauma from events stemming both inside and/or outside of work. 

Post-traumatic stress disorder 

Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by a traumatic event.  People experiencing PTSD may experience irritability, flashbacks, nightmares and feelings of isolation and guilt. Symptoms may occur soon after exposure to a traumatic event or may be delayed by months or years and are particularly common in occupations with a high risk of trauma exposure, such as people responding to emergency medical situations. It impacts how a person feels about their ability to cope with the demands of their work.

Moral injury 

Moral injury is ‘psychological distress which results from actions, or lack of them, that violate someone’s moral or ethical code’. In traumatic or unusually stressful situations, people may witness or fail to prevent unforeseen events that contradict their deeply held beliefs and morals or be required to make very difficult decisions. Someone experiencing moral injury may have feelings of anger, guilt, shame or disgust, which can lead to PTSD, depression, and in some cases, suicidal thoughts.

Employers can have a major influence on employee productivity and wellbeing, and can actively help to reduce the stress their colleagues may experience.  

As a HWB lead, you can support managers by making them aware of the following: 

• National and local offers – encourage managers to know about and use national and local offers that are available to support our NHS people.  
• Clearly signpost – It’s essential that all employees are aware of the help and services provided internally and externally to individuals requiring support. Ensuring that signposting is available in different mediums for instance leaflets, posters, flyers, web pages, QR codes, or documents. Ensure any channels used consider the reach to all clinical and non-clinical staff. 
• Back to basics – promote the value of investing in self-care. Support colleagues to recognise their own behaviours by encouraging them to integrate acts of self-care into their day to help with rising stress levels. Some suggestions could be to encourage staff to connect with friends/loved ones, go for meals, listen to music or stroke a pet.  
• Timely manner – evidence points towards early detection of stress and trauma to be key in recovery and avoiding further mental unwellness. This allows for a timely referral to support services before the individual becomes overwhelmed and impacts their perceived ability to cope at work.  
• Educate – it may be necessary in the longer term to actively monitor staff for traumatic stress reactions. It is normal to have an emotional reaction to a stressful and traumatic situation, but in some cases, the effects can be long-lasting and severely impact an individual’s life. This is best achieved by alert, sensitive and compassionate managers, and it could be beneficial for staff and their families to receive information on the symptoms and indicators to look out for.  

Peer Support 

• Buddying system – implementing a buddying system allows colleagues to connect and share experiences with team members, allowing for essential reflection and decompressing of challenging work situations. Having a buddy means your staff feel more connected, including and part of a team, as well as enabling colleagues to detect any early signs of work-related stress. This may be particularly beneficial for frontline shift or ambulance workers who rotate shifts frequently and may not have a group of colleagues they see regularly.  
• Positive relationship with line managers - Evidence from King's College London suggests that a positive relationship between staff and immediate managers is critically important. Offering your line managers training (e.g. TRiM and REACT – see below) to increase confidence when holding open and honest conversations where supervisors feel equipped to explore responses from their team a little further, can reduce sickness absence by up to 90 per cent. Meeting regularly with employees would be beneficial, where managers can help employees adapt and cope and communicate any changes.  
• Trauma Risk Management (TRiM) – this formal peer support system aims for any employee exposed to trauma at work to be properly supported. Acting in a timely manner, the system aims to put into place early intervention and appropriate support where early psychological symptoms are not resolved. It includes psycho-educational briefings, time after the traumatic event to decompress, and access to medical and psychological services.  
• REACT Mental health conversation training – Underpinned by psychologically sound principles, the technique comprises of Recognise, Engage, Actively listen, Check risk, Talk about specific actions. The REACT mental health training will help colleagues to identify people in their teams who may be struggling with stress, allowing for a supportive and compassionate conversation to be had.  
• Team togetherness – Team huddles are a quick, small and useful aid to regularly process the day’s events in order to reduce stress. Huddle facilitators guide a person, group or team through a discussion of the day’s shift and events. Allowing employees to share any challenges of their day, huddles give people time to stop, think and be with their colleagues during times of stress and/or trauma. 

Tavistock and Portman NHS Foundation Trust 

The trust piloted a stress and resilience framework, commissioned by Health Education England (HEE), which focuses on what organisations can do to support staff experiencing stress, rather than making the individual more resilient. The framework offers a new perspective to challenge colleagues and organisations to view stress differently, incorporating five key pillars: leadership/management style, structure and processes, psychological safety, beliefs, attitudes and behaviour and the nature of the work. 

Find out more on how your organisation can get involved with this framework by emailing workforce@tavi-port.nhs.uk 

Epsom and St Helier University Hospitals NHS Trust 

The trust offered training to health and wellbeing leads and staff on how to have wellbeing conversations to get to know the individual as a whole, as a way to support employees experiencing stress at work. They were encouraged to have these conversations at the start of the induction process to act as a prevention to unmanageable stress levels. Introducing Schwartz rounds gave staff members the opportunity to express their experiences, feelings and stories, allowing them to decompress and reflect on challenging events with colleagues that may increase stress or trauma levels.  

Chesterfield Royal Hospital NHS 

They use the ‘huddle’ approach as a useful aid to regularly process the day’s events in order to reduce stress. The trust also has more structured incident response tools such as REACT mental health training, one-to-one counselling and top-level psychological support, such as eye movement and desensitization and reprocessing (EMDR) options.  

Lincolnshire Partnership NHS Foundation Trust 

The trust has developed a tool called the ‘circle of wellbeing’. Taking a holistic approach, the tool focuses on eight different areas such as mental health, nutrition, sleep, work-life balance and connectedness. It enables an individual to self-assess how the areas are impacting their ability to cope with perceived stress through workshops and follow-up reviews. Feedback from employees has been very positive. They are finding it helpful to identify a couple of areas to focus on and subsequently make positive changes. In-house support and necessary signposting to various resources are available to staff following this, depending on the areas they need and want help with.   

South East Coast Ambulance NHS Foundation Trust

The trust has a wellbeing hub that provides employees with a single point of access to wellbeing support, including TRiM for stress management. The hub allows for managers and peers to contact them for support and advice if concerned about a colleague, which is particularly important when working on ambulance rotation shifts where an individual may not regularly see their line manager. The trust has also created the ‘backup buddy’ app, which provides a wealth of information to support wellbeing and is also available to family and friends who are crucial to supporting our NHS people. 

They have a range of stress resources provided at the wellbeing hub, including a Stress leaflet and a Depression and low-mood leaflet (PDF).

Sheffield Teaching Hospitals NHS Foundation Trust 

The trust shares a useful poster that clearly and succinctly identifies signs and symptoms that a colleague could be struggling with stress and could need further support.  

Signs that a colleague might need support poster (PDF) 

Wrightington, Wigan and Leigh NHS Foundation Trust 

The trust has approximately 30 trained people trained in critical incident stress management (CISM). They support staff who have experienced an event that causes significant emotional and physical distress. Briefing and defusing sessions are followed up and colleagues signposted to any necessary psychological support service, for example counselling for anxiety, bereavement and/or cognitive behavioural therapy. Embedding CISM into their service has resulted in a reduction in days lost due to sickness in both the short and long term.  

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust 

The trust introduced an onsite reiki practitioner who runs free stress-relieving sessions. The feedback shows sessions to be highly effective, with staff finding it to keep them at work rather than going off sick. The trust is exploring further holistic therapy options, such as reflexology and acupuncture.  

There are a wealth of resources, toolkits and information to help combat stress and mental health problems in the workplace make positive improvements to emotional wellbeing and reduce work-related stress. We have developed some tools as well as collated information for you to use in your NHS organisation.

• The Health and Safety Executive (HSE) Management Standards Indicator tool: This survey tool consists of 35 items asking about working conditions to identify potential causes of work-related stress based on the six management standards.
• Post-traumatic stress guidance: The National Institute of Clinical Excellence (NICE) has written guidance on recognising, treating and assessing PTSD in adults. It is aimed at professionals who work with people at risk of PTSD, specifically NHS trust managers. 
• Recovering at work (PDF): City Mental Health Alliance and Centre for Mental Health have produced a guide to help organisations become 'trauma-informed' so that they can support their people through psychological and emotional trauma experiences.
• Sickness absence toolkit: access our simple guide which aims to support and give NHS managers confidence, so that they can in turn support their staff and manage sickness absence well.  
• Stress in the workplace: The Chartered Institute of Personnel and Development (CIPD) has created useful factsheets to help you identify the signs of stress, address stress at work and distinguish between stress and pressure.  
• Supporting mental health at work: ACAS guidance on why it’s important to take good mental health seriously at work.
• Supporting Mental Health of Employees During and Beyond COVID-19 (PDF): AXA Asia and the World Health Organisation (WHO) have collaborated to produce a toolkit that helps managers to anticipate and act effectively to support employees’ mental health during COVID-19 and beyond.  
• Supporting our NHS People: NHS England has a suite of resources available to NHS staff to help manage your own health and wellbeing while looking after others. The web page contains lists of support services, free apps and events to support staff wellbeing.
• Talking Toolkit (PDF): The Health and Safety Executive (HSE) have produced a talking toolkit specifically for NHS Service Providers to support six conversational areas surrounding work-related stress.  
• Listen to Acas’s Work-related stress: lifting the pressure at work podcast where Acas Head of Mental Health and Wellbeing, Francoise Woolley and HSE Policy Lead for work-related stress and mental health, Rob McGreal talk about identifying the causes of work-related stress and supporting mental health and wellbeing at work.
• The Health and Safety Executive (HSE) and the Working Minds campaign have released a free online tool to help employers prevent stress at work and support good mental health. The interactive tool comprises six short modules, which cover everyday scenarios, possible causes of stress, minimising stress at work and how to comply with employment law in this area. It includes games and quizzes and is designed to take less than an hour to complete. Find out more here. 
• Unmind and Headspace currently offer free access to their apps for NHS staff.