NHS managers are more prone to stress than those in other sectors and suffer from it more than doctors or nurses.

Explanations for, and causes of, ineffective management are many and varied, but one of the most plausible and proven reasons is that managers are suffering from psychological ill-health - stress, in other words.

The costs to organisations if managers do not function effectively in their role could be considerable.

Research suggests that the prevalence of stress is higher among managers working in the NHS than their counterparts in the private sector, and that the prevalence of stress is higher among NHS managers than other groups of health service staff.

Increasing pressures have resulted in considerable structural changes in organisations and in the role of the manager as empowerer, facilitator and co-ordinator.

The result is increasing diversity in management functions, less clarity about the manager's role, less certainty about sources of authority and lines of responsibility, and career paths which have become idiosyncratic and confused.

1Thus, managers have become increasingly important for organisational effectiveness, but are operating in a more challenging and complex organisational context.

Some researchers argue that the organisational context in the public sector is even more challenging and complex - characterised by discordance, disjunction and conflict - which, they argue, promotes uncertainty and 'alternative agendas, and prevents managers from managing'.

2Stress among NHS managers Private and public sector managers operate in different organisational contexts which may expose the latter to a wider range of organisational and work-related sources of stress than their counterparts. There is evidence to support this contention for NHS managers.

We compared data from our 1998 study of NHS staff, including 994 managers in 17 trusts, with other research, which includes managers.

Stress was measured using the general health questionnaire-12. Stress was found to be more prevalent (32.8 per cent) among NHS managers than among managers in the British household panel survey (21.3 per cent) and managers in the manufacturing industry (see box below). A breakdown of the different grades showed that stress prevalence is highest in junior managers (36.2 per cent), though senior managers still show high levels (29.1 per cent), especially when compared with other groups. There were no gender differences.

Comparing stress in managers with prevalence rates among other NHS staff groups shows that managers have the highest prevalence. Other research studies involving healthcare managers have reported high levels of stress.

Work-related factors The main factor identified by our research as the cause of stress for all staff in the NHS was work demands - the extent to which individuals perceive that they do not have the time or resources required to complete their work satisfactorily.

Managers reported higher levels of work demands than the other occupational groups. In addition, the relationship between work demands and stress was different; a reduction in work demands resulted in a significantly greater reduction in stress for managers than in the other occupational groups.

Lack of influence For all occupational groups, a perceived lack of influence over decisions made at work was a source of stress. Managers reported significantly higher levels of influence than all other groups.

But not being able to influence decisionmaking resulted in significantly greater increases in stress among managers than in other occupational groups.

An additional source of stress for all occupational groups was low levels of autonomy and control. Managers who report this experience significantly greater increases in stress levels than staff in the other occupational groups.

Low levels of social support was also a source of stress for all occupational groups. The relationship between social support and stress was, again, different for managers, with low levels of support reported by managers resulting in significantly greater increases in stress than in other occupational groups.

There were other important workrelated sources of stress for managers, including role conflict, where contradictory instructions and feedback from others is received, and lack of feedback.

Women managers For both women and men working as managers in the NHS, work demands, lack of influence over decision-making and role conflict were the main factors associated with stress. Lack of support from their own manager and professional compromise were additional sources of stress for men.

Among women managers, low levels of social support, lack of feedback on performance and lack of role clarity were additional work-related sources of stress. The relationship between role clarity and stress varied for women managers; a lack of role clarity resulted in a significantly greater increase in stress for women managers than men.

Conclusions

Research evidence suggests that the increasingly challenging and complex public sector organisational environment has consequences for the psychological health of managers working in the NHS, and that there are particular sources of stress in this environment. Action to increase managers' sense of control and support are needed.

Intervention is required to enable managers to recognise their own stress and help them develop coping strategies.

Given managers' key role in co-ordinating the activities of others, investing in them could have far-reaching benefits for other groups in the NHS. An organisation considering interventions to reduce stress would benefit from targeting managers first.

Key points

Stress is more prevalent among NHS managers than those in other sectors.

Managers suffer more stress than other groups in the NHS.

Perceived failure to influence decisionmaking was particularly stressful for managers.

Managers should be targeted first in any organisation's stressreduction programme.

A longer version of this article appears in Stress and Health Professionals , edited by Jenny Firth-Cozens and Roy Payne.

Published by John Wiley. Price£39.95 hardback,£17.99 paperback.

Carol Borrill is director, Aston Centre for Health Services Organisation Research, Aston University.

Clare Haynes is an independent consultant.

REFERENCES

1 Kanter R. The new managerial work. Harvard Business Review 1989a; November-December, 80-92.

2 Harrow I, Willcocks L. Public service management: activities, initiatives and limits to learning. J of Management studies 1990; 2 7:3.

3 Borrill C et al . Stress Among NHS Staff: final report.Institute of Work Psychology, 1998.

4 British Household Panel Survey, 1997.

5 West M, Lawthom R, Patterson M, Staniforth D. Still Far to Go: the management of UK manufacturing. Institute of Work Psychology. Sheffield University, 1995.