WO R K R E L AT E D

S T R E S S I N I T I AT I V E S S E T 2
THREE CASE STUDIES
Acknowledgements

Thank you to Liz Sheppard, Carole Hunter and Heather Kelly at East Yorkshire Hospitals NHS Trust,
Julia Macmillan, Sylvia Carter and Sandy Gaskins at Poole Hospital NHS Trust, and Geoff Howsego,
Bob Waterhouse and Sue Holmes at South Yorkshire Metropolitan Ambulance and Paramedic Service
NHS Trust for making this publication possible, and to Andrew Cole for his development of the original
case studies.

For further information on any of the initiatives outlined in this publication contact:

Carole Hunter, Occupational Health Service Manager, East Yorkshire Hospitals NHS Trust on 01482 623054.
Julia Macmillan, Head of HR Development, Poole Hospital NHS Trust on 01202 442896.
Geoff Howsego, Director of HR, South Yorkshire Metropolitan Ambulance and Paramedic Service NHS Trust
on 01709 820520.

For further information on these initiatives, or any other aspect of mental health at work contact:

Sarah Katz, Project Officer, Health at Work in the NHS on 020 7413 2056.
Vivienne Rangecroft, Health at Work in the NHS Administrator on 020 7413 1873

Further copies of this publication are available from:

HEA Customer Services
Marston Book Services
PO Box 269
Abingdon
Oxon OX14 4YN
Tel: 01235 465565
Fax: 01235 465556

© Health Education Authority, 1999

Health Education Authority

Trevelyan House
30 Great Peter Street
London SW1P 2HW

www.hea.org.uk

ISBN 0 7521 1747 5/001

2m 10/99
Contents

Foreword v

Forewords by the Trusts vi

East Yorkshire Hospitals NHS Trust 1

The initiative: organisational stress survey 1

What the study revealed 1

Putting the findings into practice 2

The results 3

Lessons learnt 4

Poole Hospital NHS Trust 5

The counselling service 5

The initiative: counselling service evaluation 6

The results 6

Lessons learnt 8

South Yorkshire Metropolitan Ambulance and Paramedic Service NHS Trust 9

The initiative: critical incident debriefing 9

Putting it into practice 10

The results 10

The future 11

Lessons learnt 12
Foreword

I am delighted to introduce the third of the series of stress management case-studies to be published by
Health at Work in the NHS. This publication follows North East Essex Mental Health Trust organisational
stress pilot: A case study published in 1998 and Work related stress initiatives: three case studies
published in March 1999. This third set of case studies again demonstrates how NHS Trusts can take
positive action to prevent stress, with senior managers focusing on the organisational influences on
staff health. The three projects have very different aims and approaches, but I believe the issues they are
tackling and the solutions they come up with will have resonance with many other NHS Trusts.

East Yorkshire Hospitals NHS Trust opened a new women’s health unit which was extremely successful,
but with repercussions for staff because of the increased demand. The pressure this created was the
incentive for an organisational stress survey.

Poole Hospital NHS Trust has a well-established counselling service. An evaluation of the service was
undertaken to assess its effectiveness in both individual and organisational terms.

South Yorkshire Metropolitan Ambulance and Paramedic Service NHS Trust instigated critical incident
debriefing as part of their work related stress programme. The initiative has had significant outcomes
both in terms of individual staff members’ abilities to cope with trauma and in influencing the culture
of the whole organisation.

The three Trusts have undertaken these challenging projects at a time of rapid change within the NHS,
and we very much appreciate their willingness to share their experiences. It is through innovative work
of this kind that we can build a knowledge base of good practice in the prevention of work-related stress.

Jane Greenoak
Acting Chief Executive HEA

v
 Forewords by the Trusts

The case study from East Yorkshire Hospitals NHS Trust shows an approach taken to dealing with stress
in one department following a move into a purpose built centre on the main hospital site.

It is generally acknowledged that delivering healthcare can be in itself stressful, and must be a key
concern for managers and staff. The case study shows how occupational stress was compounded by
organisational change resulting from a change in service location together with an unprecedented
increase in workload. The case study demonstrates how the reasons for the unacceptably high level of
stress were identified and the action taken to deal with the concerns expressed by staff.

Simon Pleydell
Chief Executive
East Yorkshire Hospitals NHS Trust

vi
 FOREWORDSBY THE T RUSTS

At Poole Hospital NHS Trust we have recognised the need to make extra effort to support our staff.
Our Staff Support Steering Group has been established and has facilitated many initiatives.

One of the first was to set up a counselling service which we at Poole are very proud of. By auditing
and undertaking a comprehensive evaluation of this service we have been able to demonstrate a
positive impact on staff and the healthcare we deliver.

We do not see this as the end of our work but merely the start of trying to address some of the issues
and problems staff face both personally and at work. Through this understanding of our staff and the
difficulties they face we can continually improve our services to patients, as well as the working lives of
our employees.

L. Adams
Chief Executive
Poole Hospital NHS Trust

vii
 FOREWORDS BYTHE TRUSTS

As I start to write this foreword, I was conscious of the many documents and papers issued by the
Government in support of the White Paper The new NHS: modern, dependable. One of the most
important of these for all colleagues in the NHS is the document Working together: securing a quality
workforce for the NHS.

The White Paper, in paragraph 6.30 makes it clear that it wishes to address a number of issues, the first
of which is to promote health at work. A further one is to address stress. The whole theme of the
White Paper is to focus on the needs of patients. It is easy to forget that those who work within today’s
NHS, are also people who have needs and, sadly for many, who become patients.

Human resource issues are dealt with directly in Working together: securing a quality workforce for the
NHS. The Government’s aim to make the NHS a better place in which to work is clearly stated. Many of
us know that this is easier said than done. In operational services such as the ambulance service, where
front-line colleagues are regularly exposed to serious trauma, discussion of doubts and worries can be
seen to be a stigma.

At SYMAS we have tried over a number of years to introduce change and developments by a process
of evolution rather than revolution. It is really important for managers to both know and respect the
fact that the body called the NHS is made up of individual people with individual needs. The size of
the present agenda sometimes makes us forget this. The gradual introduction of good staff policies in
a caring way can do much to improve the overall health of the organisation.

Ken Threlfall
Chief Executive
South Yorkshire Metropolitan Ambulance and Paramedic Service NHS Trust

viii
East Yorkshire Hospitals NHS Trust
When East Yorkshire Hospitals’ Maternity Unit
moved from its old buildings in Beverley to
brand new purpose-built premises at Castle Hill
Hospital in Cottingham two and a half years
ago, hopes were high of a new era for women’s
health in the area.
The new women’s health unit is now situated
close to intensive care and other acute facilities,
and covers not only maternity but also
gynaecology. For mothers-to-be it has proved an
instant success. Large numbers have come to
the new unit, and have generally been delighted
with the care they received.
Due to the popularity of the unit, the number of
deliveries significantly rose despite a projected
fall in the birth rate. As staffing levels were
based on this projected fall in birthrate, the
increase put a strain on the midwives.
In addition, staff were adapting to a new
working environment, and the effects of a re-
grading exercise which had caused unforeseen
problems.
Unfortunately, in tandem with this, two
significant but unrelated clinical incidents took
place which impacted on morale within the unit.
The initiative: organisational stress
survey
At this point in the autumn of 1998, Liz
Sheppard, the newly appointed head of
women’s health services at the hospital,
approached occupational health service
manager Carole Hunter to see if something
could be done about what she perceived to be
worryingly high levels of stress on the unit.
Having worked on the unit for some time, she
was well aware of the growing concerns about
staffing shortages and high workload. But, in
addition, four senior midwives had been off sick
with work-related stress in a short space of
time. ‘I was concerned about these staff but I
also had a general feeling that a lot was going
on within the unit’, she explains. ‘Although I
knew it was stress, I wanted to find out the
reasons.’
The approach came at an opportune time.
The occupational health department had
carried out a detailed organisational stress
survey in another department earlier that year.
The survey’s findings had led to increases in
staffing, reorganisation of some roles and a new
training programme among other things.
When Carole Hunter suggested a similar survey
into the women’s health unit, Liz Sheppard
accepted enthusiastically. Most importantly,
from Carole Hunter’s point of view, she
committed herself in advance to act on the
organisational issues that might emerge from
the study.
The two women agreed a number of changes
to the original questionnaire, which had focused
principally on the major sources of stress.
Bearing in mind the problem of long-term
sickness on the unit, they included questions
about the physical and psychological effects of
stress on individuals. They also added questions
on violence and aggression.
The questionnaire – designed to take no more
than 15 minutes to complete – was sent out
in January 1999 to 180 staff on the unit,
from nurses and midwives to ancillary workers.
The only group not included were medical staff.
What the study revealed
The response rate of nearly 58% was good.
However the results showed that 94% of
respondents said they were working under
stress. More than half said this was a
combination of home and work factors, while
over a third attributed it to work alone. The
biggest source of stress was workload combined
with stretched staffing levels.
There was also frustration about the amount of
paperwork and computer work many staff were
1

having to complete which, they felt, was taking
them away from direct patient care. At the
same time, especially on the maternity wards,
staff did not feel they had time to offer support
to each other.
There were also issues relating to the layout of
the new unit. Although acknowledging the
improved environment for patients, some staff
experienced difficulties in adapting to the new
working environment.
The effects of all this on individuals gave cause
for concern. Reported levels of anxiety,
depression, tension and frustration were high. In
addition, a significant number reported physical
symptoms which could be attributed to stress
such as headaches, muscle tension, bowel
disorders and disturbed sleeping patterns.
This did not necessarily mean they were
reporting sick. ‘Some staff said they remained at
work when they were ill due to the pressure of
work. Others returned to work when not fully
fit because of guilt that colleagues would suffer
if they weren’t there’, says Carole Hunter.
Staff had a number of positive comments about
their work. The camaraderie of colleagues came
out top of this list, followed by the pleasures of
the job itself and the opportunity to work one-
to-one with patients and their families.
In addition, many clearly appreciated the chance
to say what they really thought. A number
poured out their troubles – both personal and
professional – when asked for their comments
on the unit. One ended a long catalogue of
complaints by saying: ‘Thank you for this
opportunity to write down our concerns.’
Putting the findings into practice
The hospital is now in the process of
implementing a number of changes which,
it believes, is helping to increase morale on
the unit.
2
WORK RELATEDSTRESS INITIATIVES
First, it has been agreed to raise the number
of staff on the unit by six. There has also been
an increase in the number of F grade posts
available.
Liz Sheppard is looking at creating a new post
of ward administrator to relieve frontline staff
of some of the clerical workload. She is also
hoping to expand teamworking into areas such
as maternity and special care following evidence
from the survey that this manner of working
was popular where it operated.
The unit has also taken steps to further improve
the physical environment and plans are afoot to
convert an office into a staff quiet room.
Staff are actively encouraged to report all
incidents of verbal or physical abuse and a staff
charter has been drawn up which emphasises
patients’ obligations as well as rights. Midwives
are also receiving training sessions on how to
defuse potentially violent situations.
With the agreement of the local Health
Authority, it was decided to review the
appropriate level of maternity bookings to the
unit. This involved taking a balanced view of the
needs of staff and the quality of care they
provided. Liz Sheppard defends the move. She
acknowledges the importance of patients’
choice: ‘But we had to look at the best service
we could provide, and to do that we had some
difficult decisions to make.’
Following input from professional development
nurse Heather Kelly, staff are to be offered
training in assertiveness, stress and time
management, communication skills and, for
some, clinical leadership. ‘One of the problems
in the past’, says Liz Sheppard, ‘is that these
types of courses were given low priority
compared to professional development.’ That is
now set to change.
 E AST YORKSHIRE HOSPITALS NHS TRUST

The results It is still too early to assess fully the results of

Implementing the changes is at an early stage at
the moment. However, both Liz Sheppard and
Carole Hunter are convinced they are already
having an effect.
‘The message we’re getting back is that things
are improving’, says Liz Sheppard. ‘Morale will
always go up and down in this unit, but at least
staff acknowledge that we’re doing things and
we’re giving them a chance to be heard.’
It may also be significant that two of the staff
who had been on long-term sick leave with
stress-related problems have returned to the
unit and had no further problems.
the changes, but Carole Hunter and Liz
Sheppard are hoping to repeat the survey early
next year to measure the effects more
accurately.
In the meantime Carole Hunter is hoping that
other units in the hospital will be encouraged to
follow the women’s health example and invite
the occupational health department to
investigate their staff’s stress levels. But, she
warns, this approach will only bear fruit if senior
managers within the unit are genuinely signed
up to the process: ‘If you raise all these issues
without any commitment to take anything
forward, then it is a wasted exercise.’

Interestingly, the incidence of stress-related

sickness reported to the occupational health
department has actually gone up. But this is
more a reflection of the fact that staff are now
encouraged to admit to stress and to make use
of occupational health services, believes Carole
Hunter. ‘We are also now seeing staff before
they actually go off sick, whereas before we
weren’t seeing them until they’d been off for a
number of weeks.’ ‘The impact on the overall
health of the organisation must be beneficial in
the long run’, she says, ‘and I have no doubt
the result will bring major benefits to the Trust.’

3
 WORK RELATEDSTRESS INITIATIVES

Lessons learnt

● It is important that a neutral outsider is seen to be conducting the survey if it is to have

credibility with staff.

● The unit manager must be prepared to act on the findings of the survey, however
uncomfortable.

● Assuring staff of anonymity when doing the survey is vital if they are to say what they think.
But is also important to stress that these anonymised findings will be made public.
A misunderstanding about the status of the first occupational health survey meant staff
were opposed to publicising the results.

● It is important to encourage positive as well as negative comments from staff. Without this,
the overall tone can be so negative that people feel overwhelmed rather than energised
to act.

● It is vital that managers feed back survey findings to staff and keep them posted on
developments.

● Speed of feedback is also important. In Castle Hill Hospital’s case the gap between
questionnaire and feedback was nearly six months, which was too long.

● Sickness absence figures should be treated cautiously as a measure of stress levels. The figures
may actually go up – at least in the short term – as a result of encouraging greater openness
about stress.

● The rights of patients have to be balanced against the needs of staff.

● Evaluation of any changes made is essential. Equally, there is little point in a one-off survey.
Ideally surveys and evaluations should be carried out at regular intervals.

4
Poole Hospital NHS Trust
Poole Hospital NHS Trust has introduced a range
of measures to combat stress in the workplace
over the past five years. Among a host of
initiatives are a subsidised massage service,
a support group for new parents, a counselling
service, a system of ‘quiet days’ allowing
harassed staff to get away from it all, and a
working well programme which aims to help
staff who have short-term sickness problems.
All of this is co-ordinated by the staff support
steering group – a small but high-powered
committee consisting of a number of senior
managers – which meets every quarter to
monitor how the various elements of the anti-
stress campaign are working, to consider new
ideas and to feed back information to the board
and staff.
The latest initiative, which aims to pull together
many of these issues, is a staff support policy
document which will be distributed to all 3500
employees within the acute Trust over the next
few months. The purpose of the document is to
provide a framework for the huge range of
stress initiatives currently in operation within the
Trust, says Head of HR Development Julia
Macmillan. ‘It tells staff all the things that are
available. But it is also trying to get them to sign
up to being aware of their responsibilities.’
Yet the question remains: is all this making a
difference? Judging by their uptake, most of the
schemes are clearly popular. But there are few
objective measures of their overall impact. The
Trust is planning a wide-ranging staff attitudes
survey later this year which will provide
important baseline data. It is also beginning to
break down its sickness absence data to analyse
the proportion that is stress-related.
In the meantime, however, it has been involved
in a detailed evaluation of its counselling
service, which has thrown up some
fascinating results.
The counselling service
Poole’s counselling service was set up four and
a half years ago with the specific aim of
reducing sickness absence and improving staff
turnover. The service, headed by staff
support co-ordinator Sandy Gaskins, has a
number of distinctive characteristics:
● it is an in-house service staffed by external
counsellors who have no connection with
the organisation;
● it works on the basis of self-referral, which
probably helps to account for the fact that
its DNA (Did Not Attend) rate is extremely
low at 4-5%;
● staff can seek counselling for either personal
or work problems;
● staff are not limited to a specific number of
sessions and, owing to the large number of
part-time counsellors, they are seen shortly
after referral – usually within a fortnight;
● the service is completely confidential – no
records are kept of sessions apart from the
initial referral form so there is no chance of
any information filtering back to
management;
● it is very well advertised within the Trust so
everyone is aware of its existence.
The service has been able to handle 120 new
referrals and provide a total of between 1600
and 1800 hours of counselling each year.
Sandy Gaskins estimates that around two-thirds
of the problems she and her colleagues
encounter relate primarily to personal issues, but
this is always a fine line: ‘If people find they are
being taken advantage of in their personal lives,
for example, then you’ll often find they’ve got
the same kind of thing happening in their
working life.’ Equally, notes her fellow
counsellor Sylvia Carter, some individuals find
they are unable to deal with work issues until
they have sorted out their personal problems.
5

The most common causes for seeking
counselling help in the first place are general
anxiety and depression followed by relationship
problems, either at home or at work – and
often both.
The service receives most referrals from the
Medical Directorate. However, Sandy Gaskins is
wary of drawing any firm conclusions about
stress levels from this. It may well be, she points
out, that some Directorates are over-represented
because they tend to encourage staff to seek
help, while others bottle it up. ‘It’s not a bad
thing at all that a lot of people are coming from
certain Directorates. They are dealing with their
stress, and often the problems are resolved
more rapidly than in some other Directorates
such as Theatres, Obstetrics and Paediatrics. The
lower levels of uptake elsewhere may mean
there is a culture of coping on your own and it’s
considered weak to go for help.’
The initiative: counselling service
evaluation
So the counselling service is well thought of.
But is it effective? Over the past two years Sylvia
Carter has been undertaking a wide-ranging
evaluation to try to answer that question.
All staff who have used the service during that
time have been asked to fill out detailed
questionnaires before they begin their
counselling, and then again three months and
six months after starting counselling sessions.
The results show a dramatic decline in both the
number and severity of symptoms of stress staff
experienced over this period. The questionnaire
listed a total of seven common stress symptoms,
including anxiety, depression, phobias and
obsessive behaviour. Before counselling
individuals exhibited an average of 4.08 of
anxiety, by three months this had fallen to 2.79
and by six months it was 1.87. The severity of
these symptoms was similarly reduced. The
symptoms of depression followed the same
pattern of reduction as those of anxiety
6
WORK RELATED STRESS INITIATIVES
and were halved by three months and again
at six months.
The qualitative evaluation was equally
impressive with 85% of staff feeling that the
counselling had helped and a similar proportion
saying that they respected themselves more as a
result. Also, 90% were satisfied with the service
and 95% felt it was professional.
‘The service had allowed me to be myself’,
said one satisfied client. Others talked of ‘being
heard’, ‘being able to trust and be trusted’,
‘not being judged’ and ‘helping me to focus’.
Another commented: ‘If it wasn’t for my
counselling I would have had a lot of time off
work.’ Clients’ perception of their quality of
life and self-esteem had also improved.
Most criticisms related to the physical
environment in which the counselling took
place. Some were worried they could be
observed by others in the waiting room, others
criticised the rooms in which counselling took
place and there were also concerns about the
fact staff were occasionally expected to return
to work immediately after a counselling session.
These issues have now been addressed.
The results
All this offers strong evidence that the
counselling service is working, says Sandy
Gaskins. It also suggests it is having an impact
on sickness absence. This is difficult to confirm
but it is well known that depression and anxiety
– the stress symptoms that were reduced most
dramatically in the study – are major causes
of sickness.
Not that this is a simple equation. As Sandy
Gaskins points out, while some people with
stress will take time off, others will simply throw
themselves more energetically into their work.
‘Most of the time we are helping people not to
have to take time off. But occasionally we’re
suggesting they should take time off, because
otherwise they could be working dangerously.’

However, the effects have gone well beyond
sickness absence and turnover figures. Concerns
voiced in counselling sessions over shift systems
and inappropriate placing of patients, for
instance, have led to organisational changes
on the ward.
Again, after receiving a number of visits from
ITU staff, Sandy Gaskins decided to take the
counselling service to the unit. One of the
counsellors now holds a two-hour session on
the ward each week, the first hour being
devoted to group reflective practice and the
second to one-to-one sessions with staff who
have particular issues to raise.
The counselling service has also helped trigger
changes for staff who become pregnant. ‘One
of the things I noticed fairly early on was that
I was seeing a lot of people returning from
maternity leave and not coping – either as
mothers or as employees.’ Out of this came the
parent network group which provides a forum
within the hospital for new mothers to discuss
their experiences and exchange information.
In addition, some staff told counsellors they
were scared to tell colleagues they were
pregnant because of the resentment about
POOLE HOSPITAL NHS TRUST
having to cover for them. Others were
concerned they would lose touch while they
were away. As a result several changes have
been introduced, including sending relevant
newsletters and minutes to those on maternity
leave who wanted them and arranging a
mini-induction for them on their return.
Another message that came through time and
time again in counselling sessions was the
problem many people had with aspects of
relationships, both at work and at home.
So Sandy Gaskins has been asked to run a
course which helps staff deal with conflict
and confrontation. This goes beyond
simple assertiveness training, helping people
to understand their emotions in a way that
makes them more effective when they employ
these skills.
Much of this feedback on organisational issues
happens through the staff support steering
group. ‘It’s never going to be perfect,’ she
acknowledges, ‘because it’s always about
resources, but at least we are able to show
where the difficulties arise and hopefully this
will reduce the number of people leaving the
profession.’
7
 WORK RELATEDSTRESS INITIATIVES

Lessons learnt

● Initially staff were anxious about the counselling service being based in occupational health as
they feared it would not be confidential. This has proven to be unfounded. The positive aspect
is that Sandy Gaskins and occupational health advisor Di Ford can share knowledge of any
concerns or difficulties reported by staff generally within the organisation.

● Counsellors need to be from outside the Trust. ‘People want to see someone who is outside
the organisation but who understands the organisation’, says Sandy Gaskins.

● People should be seen quickly once they have been referred and offered as many sessions as
required to deal with the problem. An artificial limit on the number of sessions can be
counter-productive.

● Staff must be able to self-refer both for their own sake and the efficiency of the service.
Sandy Gaskins ascribes her service’s very low ‘Did Not Attend’ rate to this. The number of
non-attendances are far higher when staff have been referred by their manager.

● Staff should be seen after work or out of work wherever possible.

● There must be a mechanism for counsellors to feed back information on organisational issues
to management and for changes then to be made. None of this should compromise the
principle of confidentiality.

● It is important to feed back relevant information to staff.

● Good administrative back-up is crucial.

● The environment in which counselling takes place is important. In addition to being

comfortable and without distractions, it needs to be sufficiently private not to be observed
by others. The booking area also needs to be discreet.

8
South Yorkshire Metropolitan Ambulance
and Paramedic Service NHS Trust
When Geoff Howsego commenced working for
South Yorkshire Ambulance Trust he suggested
introducing a critical incident stress debriefing
programme. He was told the culture of the
organisation did not support such things and
that staff had no need for it in South Yorkshire.
Geoff Howsego, who is now director of HR
at the Trust, admits he was surprised by the
reaction. He had previously worked with the
Armed Forces where debriefing and counselling
after a traumatic incident was standard
procedure ‘and no-one thought any the less
of you.’
But in some parts of the ambulance service, it
seemed that a ‘macho’ culture persisted which
stated that stress was part and parcel of the job
and that any sign of emotional weakness was
an indication you were incapable of doing
the job.
Just how wrong these assumptions were quickly
became apparent once Geoff Howsego took up
his new job and within months was fielding
calls from staff seeking help. This in turn led to
the setting up of a team of 10 volunteers who,
over the last two years, have offered a
confidential debriefing service to any member
of staff who needs it. The service has been so
successful it is now to be expanded.
South Yorkshire Metropolitan Ambulance and
Paramedic Service NHS Trust currently employs
a total of 671 staff, of whom nearly two-thirds
are frontline staff, and another 40 work in A&E
control with most of the rest in ancillary,
management and technical back-up roles. The
crew operate from 13 different locations within
the Trust.
Most of these jobs are potentially highly
stressful. Frontline emergency staff face the
most obvious traumas. But the staff in the
control room who receive the initial emergency
call can also be subject to enormous stress.
And all staff face a range of pressures such as
organisational change, ever more demanding
performance targets and an increase in violence
and aggression.
Geoff Howsego accepts unpleasant experiences
are inevitable if you work on A&E vehicles. ‘But
what you can do is minimise their effect by
training in awareness and providing support and
care. We’re saying there should be a mechanism
to help staff deal with this.’ Critical incident
debriefing, combined with the other stress
initiatives that have been introduced, offers this
emotional ‘safety net’. ‘And hopefully in the
process it can prevent long-term emotional
damage and the onset of post-traumatic stress
syndrome.’
The initiative: critical incident
debriefing
Geoff Howsego’s proposal for a critical incident
debriefing team was given board approval
approximately two years ago on condition that
it incurred no extra cost in terms of training or
implementation. He was also aware that the
scheme would be watched. There was a
perception among some that it would open up
a ‘Pandora’s box’, with many staff using this as
an excuse to be absent.
It was against this background that he put
together a team of 10 experienced staff
members who would talk to any individuals
who had been through a traumatic or stressful
episode at work. All members of the team
agreed to give their time voluntarily. Their
training was also carried out in their own time.
One of the key features of the process from the
start has been the fact that the debriefers are
from a range of areas who, wherever possible,
have first-hand experience of the type of work
being undertaken. Another crucial ingredient is
confidentiality. Staff are given a contract before
they begin, signed by the chief executive, which
assures them the information divulged in the
meeting will go no further without their
9

permission. The only exception is where an
individual has clearly transgressed his or her
contract or the law.
The team also agonised for some time over
precisely what constituted a ‘critical incident’
before deciding this should be a matter for the
individual. ‘We now say it is anything that
causes the individual distress, no matter what
that is’, says Geoff Howsego. Staff, all of whom
receive a pamphlet about coping with the
effects of a traumatic event, are automatically
offered debriefing after any serious incident.
The types of incidents which the team has to
deal with vary enormously. One crew, for
instance, was forced to remain longer than
usual at the scene of a particularly gruesome
traffic accident in which several people died.
Another crew was deeply traumatised by
dealing with an incident where a young boy
suffered a cardiac arrest during a dental
operation.
But other situations can be more prosaic.
For one member of staff the first symptoms
of stress emerged when he became depressed
on holiday. It was only when his wife contacted
the Trust that it became clear that accumulating
work pressures were responsible for this
mood change.
Putting it into practice
Debriefings are usually conducted by two
members of the team and, where this involves
frontline staff, will normally focus on both crew
members involved. The team makes it a rule not
to debrief within the first 48 hours when
emotions are still high, but try to organise a
meeting as soon as possible afterwards.
The session usually lasts around an hour and
a half, with as few interferences as possible.
‘We tell staff that if they need to go to the toilet
they should do so now, which sets the scene’,
says debriefer and Head of Health and Safety
Sue Holmes. ‘But we also say that if they need
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WORK RELATEDSTRESS INITIATIVES
to walk out at any point because of the
emotions of the situation then they can do so.’
The session focuses on three principal areas –
facts, feelings and the future, explains Bob
Waterhouse, Assistant Director of A&E, who is
another member of the debriefing team. It is
process-orientated and has a relatively
straightforward goal, which is to allow
individuals to talk through the incident and
make some sense of their thoughts and
feelings. They are also encouraged to talk about
the future, to consider how they can support
each other and what coping strategies they
can employ.
But the process does not end there. The team
always tries to follow up individuals within a
couple of weeks to see how they are managing
and to provide extra support if necessary. ‘There
is a real danger you can do more harm than
good without this’, emphasises Bob Waterhouse.
In most cases, however, the individuals are
simply seeking a safe place to discuss their
feelings and reassurance that they did their
best. ‘People tend to wonder if they could have
done more in these situations’, says Bob
Waterhouse. ‘Usually the situation has gone
far beyond what one person could reasonably
be expected to do. But people need to be
reassured there was nothing more they could
have done.’
Equally, says Sue Holmes, individuals are hugely
relieved to discover that reactions to events like
this, such as bursting into tears while walking
down the street, are completely normal. ‘You
could say we are helping to normalise an
abnormal situation.’
The results
Initially, admits Geoff Howsego, many staff were
fairly cynical about the initiative, but over the
past two years that seems to have changed.
Between 30 to 40 staff have now been through
the debriefing process. Most have been able to
 SOUTH Y ORKSHIRE METROPOLITAN AMBULANCE
return to work afterwards, though a handful
have been referred for additional counselling.
The anecdotal feedback is also positive. Most of
those who have completed evaluation forms
have been highly enthusiastic. Only one was
critical – but the complaint was that this scheme
should have been introduced 10 years earlier!
What is more difficult to assess is the scheme’s
overall impact on the health of the Trust. Geoff
Howsego is convinced the scheme has
prevented instances of more serious illness.
Nevertheless, sickness absence and turnover
rates have remained largely constant during this
period. Bob Waterhouse suggests this may itself
be a mark of success. ‘Given that levels of stress
generally are rising and are cause for concern,
how much would our sickness levels have gone
up if we hadn’t been doing this?’ he wonders.
‘The fact we have held our position could, in
those circumstances, be interpreted as an
actual reduction.’
Perhaps the biggest impact, though, has been
on the culture of the organisation. The
introduction of debriefing and other stress
measures has allowed staff to talk more openly
about stress for the first time and to accept that
showing your emotions is not a sign of
weakness.
AND PARAMEDIC SERVICE NHS TRUST
The future
Debriefing is only one element in a wide
programme of stress initiatives within the Trust.
Most significantly, it is now launching a stress
awareness programme which is to be made
available to all staff, either as part of the
standard Continuing Professional Development
for clinical staff or on a voluntary basis for all
others. The aim is to explain to staff what stress
is, how it manifests itself and what coping
strategies can be employed to prevent it.
Geoff Howsego is now examining how to
expand the debriefing programme to enable
more operational staff to become debriefers and
to allow every level of the service to be properly
represented. At the same time it is hoped the
original team will take on a more managerial
and facilitative role, providing mentoring, back-
up and support to the new, larger group of
debriefers rather than only doing it themselves.
He accepts there is still a long way to go in
tackling stress within the Trust. But, given the
low baseline from which they began three years
ago, progress has been significant. And perhaps
the clearest indicator of this is that critical
incident debriefing, once regarded with such
suspicion, has now become part of the
organisation’s culture. In fact, says Geoff
Howsego, there would now be an outcry if
it were discontinued.
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 WORK RELATED STRESS INITIATIVES

Lessons learnt

● The ‘softly, softly’ approach, in which debriefing was introduced almost surreptitiously and
only publicised to staff once it was established, has been crucial to its success, Geoff Howsego
believes. ‘Because we did it subtly to begin with, it had become almost accepted by the time
we announced it officially. So those people who might have wanted to cause problems
couldn’t because it was already done.’

● Selecting the right debriefers is critical to the whole process. ‘If you get the people wrong, the
process will fail,’ says Geoff Howsego. ‘And the bigger we made the team, the more chance
there was for something to go wrong.’

● South Yorkshire’s experience is that debriefers working in pairs tend to be most effective.
This may be because they are usually counselling teams of two crew members.

● Administrative and secretarial support is essential.

● A co-ordinator or manager of the process is advisable. In South Yorkshire the debriefing team
managed things collectively but, now it is expanding, a co-ordinator will need to be appointed.

● It is vital to follow up the initial debriefing to find out how an individual is coping.

● Critical incident debriefing cannot operate in isolation. It should be linked to other stress
initiatives. In particular it needs to be complemented by preventive approaches, such as the
stress awareness scheme.

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