Published: 02/09/2004, Volume II4, No. 5921 Page 33

Dr Jan Hill-Tout outlines the need for a 'whole-systems' approach to staff well-being in the NHS

Health workers score higher than the rest of the working population in surveys of stress.

Following a period of organisational change and low staff morale in the late 1990s, the critical care directorate in Cardiff and Vale trust decided to employ a part-time clinical psychologist to support staff well-being.

A confidential staff counselling service was established, along with a staff educational programme on psychological aspects of their work.

It was also apparent that workplace processes like team-working, change management and communication often caused staff considerable difficulties.The management team decided to find out which organisational factors caused greatest problems, and if changes could be made.

Senior medical, nursing and management staff worked with the clinical psychologist to identify an efficient and reliable way to monitor staff health regularly.

Representations of staff stress are useful, but more information was needed on local difficulties.

In the absence of an appropriate 'off-the-shelf 'measure, an organisational health monitoring tool was developed. It starts with a 48-item questionnaire that gives a quantitative picture of individual and team stress, morale, atmosphere, effectiveness and support.

The second section gives staff a structured opportunity to describe why they perceive things as they do, eliciting a rich qualitative picture of workplace issues.Questionnaires are anonymous, though staff are asked to give a professional grouping and work location.

The questionnaires were analysed by the clinical psychology department and results given to the management team so that themes and problems were identified.

Staff responded positively about a range of things.However, comments suggested that workload was becoming insupportable and that relationships suffered as a result.Out of all groups, G grade nurses showed most evidence of disenchantment.Results were fed back to all staff, so that everyone would feel engaged in reflecting on areas of good practice, problems and possible solutions.

The most prominent finding of the exercise was the organisational 'ill health'of the 17 G grade nurses.This group of staff consistently rated themselves more stressed, less supported and less effective than any other staff group.

So the G grades were randomly allocated among four small discussion groups, created to reflect on the systemic causes of the problems.These culminated in a presentation to the management team, which demonstrated the inter-dependence and complexity of service systems.

The results were not only a list of action points for G grades, but also changes for the wider system. In addition, boundaries for responsibility were revisited and changes made to the organisation of meetings between doctors and nurses.Changes were also needed to the way G grades and consultants interacted in the clinical environment.G grades also acknowledged that the pressures were such that actions were required to manage workflow at an organisational level.

In the 12 months since the first survey, G grades from all areas continued to work on projects and to support team coherence.Although they are no longer seen as having difficulties, the directorate is committed to taking the 'organisational temperature'annually and the survey has recently been repeated.While stress for G grades remains high, all other ratings have moved in a positive direction and they no longer stand out as 'different'.

Individual comments suggest the group feels much better supported.The G grades cited the team development process described here as an important contributory factor.

Work on this project shows that the senior team can be out of step with everyone else in their understanding of how it feels to work in the service.Making time to find out engages all staff in a dialogue, so that possible solutions to problems can be achieved.

However, this approach needs commitment: having asked staff how they feel, senior staff are then obliged to do something about it - offering support, or developing whole systems interventions.

Dr Jan Hill-Tout is a consultant clinical psychologist in the critical care directorate, University Hospital of Wales.