Staff have a direct impact on the lives of patients with learning disabilities. They should therefore be considered one of the NHS’ most important assets. Their performance should be a prime concern in the light of scarce resources.
VOL: 101, ISSUE: 28, PAGE NO: 35
Christopher Hodgkins, BSc, is trainee clinical psychologist;
David Rose, BSc, MA, Clin.Psy.D, is clinical psychologist;John Rose, BSc, MSc, M.Clin.Psy, PhD, is divisional psychologist and lecturer; all at Dudley South PCT and The School of Psychology, University of Birmingham.
A number of authors have identified factors that influence stress levels. These include: resident behaviour (Jenkins et al, 1997), staff support (Harris and Rose, 2002), team functioning (Rose and Schlewa-Davis, 1997), organisational factors, and individual staff characteristics (Rose, 1997). Staff are also often subject to considerable changes in roles and responsibilities as a result of the reorganisation of care provision to patients with learning disabilities (Emerson and Hatton, 1994).
Staff can experience poor morale and high stress, with up to one-third reporting stress levels that are indicative of mental health problems (Hatton et al, 1999; 2004). Staff who are deemed to be highly stressed or burnt out are much more likely to give up their job or be absent due to sickness. Some research suggests that those who report lower levels of stress or strain provide a better quality of care. For example, Rose et al (1998) found that staff who reported lower stress levels gave patients more positive interactions. Some evidence is also emerging of a link between stress in staff and measures of job performance rated directly by people with a learning disability (Hatton et al, 2004).
Reducing the impact of stress may improve the psychological and physical health of staff. With this in mind, interventions should be designed to enable staff to identify and effectively manage the stresses that occur in the workplace (Rose et al, 1998). Interventions should assist them to:
- Identify individual and staff group stressors;
- Identify main environmental stressors;
- Identify support and resources that can be used to ameliorate the effects of stress;
- Devise collaborative strategies to manage stressors at individual and organisational levels.
As such, this emphasises that although individual members of staff should be enabled to maximise their personal coping resources, for any stress management programme to be effective in the longer term it has to be supported by the organisation in which they work.
Based on this evidence it was hypothesised that a collaborative intervention between the staff, management and psychology department could be designed that would be effective in producing a measurable reduction in staff stress levels.
The intervention had a pre/post-longitudinal design with a series of questionnaires given to staff prior to the intervention and a subset of questionnaires given at follow-up. Unfortunately, due to practical constraints, it was not possible to also include a control group.
The study was undertaken on a residential site containing four bungalows that house 36 clients with varying levels of learning disability. There are 82 full and part-time care staff (42.45 WTE), most of them female (88 per cent). They returned 46 pre and 36 post questionnaires, representing an overall return rate of 56 per cent (pre) and 43 per cent (post).
During the initial assessment, staff were asked to rate their perceptions of strain, demands and supports using the demands and supports questionnaire (Rose, 1999) (focusing on demand scales only) and the staff support questionnaire (Harris and Rose, 2002). They were also asked to indicate their perceptions of the team they worked in using the team climate inventory (Anderson and West, 1999). Additionally, the Maslach burnout inventory (Maslach, 1996) was used to measure the staff’s level of risk for burnout. A short scale measuring anxiety (Fletcher, 1991) was also included.
From this initial assessment, a report was produced and discussed with staff and management in a one-day workshop. The main aim of the workshop was to give staff space in which to discuss the difficulties they face in their jobs. It allowed the opportunity to work together as a team in order to develop practical plans and solutions to improve working lives. As part of the day, stress models were discussed, the most important influences on perceived stresses were examined, and stress-management and problem-solving techniques were introduced. Finally, a list of goals were set.
The different staff groups identified a wide variety of things as stressful. However, a number of recurring themes emerged in most of the bungalows. These included:
Excessive work pressure;
- New initiatives placing demands on staff, such as the implementation of person-centred planning;
- A lack of communication between staff on the bungalow and with management;
- Challenging behaviour of some residents;
- A lack of support both during and after incidents of challenging behaviour;
- Difficulties in the relationship between staff and some relatives of clients.
Goals set in response to these stressors included:
- Ensuring that staff had appropriate training and support to implement person-centred planning;
- Improving the exchange of information between management and staff;
- Implementing regular staff meetings and reviewing internal procedures and structures. For example, making sure the changeover period was structured and more effective use of communication books;
- Ensuring that care plans for clients were up to date and that staff were supported in their response to the challenging behaviour of clients;
- Staff were given training in counselling skills and how to respond to relatives in a sensitive and appropriate way, while ensuring that relatives understand their responsibilities.
It must be noted that these are only examples of responses and that interventions varied considerably between bungalows according to need. Particular individuals were identified to implement these changes.
Three months later, the same set of measures was administered, apart from the team climate inventory. The data were scored and the results discussed in a review meeting. Goals were again reviewed and changed as necessary, based on staff feedback and progress. Follow-up meetings were then arranged as part of a process of monitoring and review, to ensure the continuing development of interventions designed specifically to meet the staff groups’ needs.
The team climate inventory was analysed on an individual bungalow basis using the software supplied with the questionnaire. This provided a report on team functioning within each of the bungalows on a number of scales (participative safety, support for innovation, vision and task orientation), which was then used to stimulate discussion. The results from the other questionnaires were also collated and added to the reports. Scores were compared using an independent samples t-test. Table 1 summarises the results. The results indicated significant post-intervention reductions in levels of anxiety and emotional exhaustion. No significant changes were found on the remaining two factors of the burnout inventory.
Tables 2 and 3 summarise the results from the demands and supports questionnaire (Rose, 1999) and the staff support and satisfaction questionnaire (Harris and Rose, 2002). Results indicate a statistically significant reduction in the demands resulting from work pressure and resident interaction. The resident interaction result indicates that stresses perceived due to interaction with residents (for example challenging behaviour) were reduced. No significant changes were found in any other demands and support factor.
Reductions in anxiety and emotional exhaustion indicate that the intervention was successful in reducing the levels of stress experienced by the staff. However, there were no changes in the other subscales of the burn out inventory. This may be due to insufficient time between pre and postadministration of the measures. If more time had been allowed, the interventions might have produced a change in these measures.
Future projects could allow a longer time between initial assessments and follow-up or more frequent assessment.
Additionally, factors on other scales, which appear to show little or no change, may have been linked to areas that were regarded as initially less problematic by staff. Consequently they may have received less attention when operational and procedural changes were considered during the problem-solving stage of the intervention.
The reductions in work pressure and resident interaction suggest that, after the intervention, staff generally perceived that there was less pressure of work and fewer stresses from residents. This may have been due to the changes made during the intervention that helped staff to organise themselves more effectively or enlist support from others. For example, this may have resulted in the implementation of more effective behavioural management strategies for residents.
Evidence shows that stress-management programmes can improve work performance and quality of service. This study suggests that programmes focusing on individual and organisational factors, and utilising a problem-solving approach within the context of ongoing monitoring and review, may lead to positive changes.
This article has been double-blind peer-reviewed.