Stress resource for managers

To understand if your staff are able to cope with the demands of their job, you may wish to ask the following questions

• Do you feel involved in how decisions about your job are made? 
  Think about whether you feel listened to, trusted, and valued
  Are you consulted and given opportunities for input?
  
• Do you feel you have a say in how your work is organised and undertaken?
• What improvements or support could be put in place to help with any of the issues you have talked about? 
  Think about you, your manager, your department, your organisation

Workload

• Develop and maintain adequate systems to be able to effectively monitor staff overtime and bank shifts worked.
• Carry out regular meetings, both individually and with your team to discuss anticipated staffing arrangements
• Develop systems to be able to notify nursing staff in advance of unplanned or exceptional need to work longer hours.
• Identify sufficient time to allow genuine collaborative planning between nurse managers and nursing staff.
• Understand your team’s current workload when discussing the allocation of additional tasks.
• Provide training and support (formal or informal) to help staff prioritise.
• Ensure you and your team have a clear understanding of your escalation procedures where staff or patient safety is at risk, and actively encourage that these procedures are followed
• Encourage flexible working wherever possible

Working patterns

• Allow and actively encourage nursing staff to take regular breaks away from their working area, especially when their workload is complex or emotionally demanding.
• Consider how flexible working can be used to enable staff to balance their work and personal commitments, while meeting the needs of services.
• Learn to say no to work if your team is already at full capacity.

Physical environment and violence

• Assess the risk and impact of other potential hazards in your area of responsibility and take steps to deal with them by consulting with employees and others. This may include planning for nursing staff not to be alone with previously aggressive patients, or community nurses visiting in pairs.
  
• Provide suitable and sufficient training to help nursing staff deal with and defuse difficult situations to prevent escalation.
  
• Take steps to reduce unwanted distraction, disturbance, and noise levels in the working area.
  
• Review systems and procedures to avoid frustration, for example queuing and triaging policies.

The demand standard also aligns with the following RCN Nursing Workforce Standards:

• Standard 3  Up-to Date business continuity plans must be in place to enable staffing for safe and effective care during critical incidents or events.
• Standard 8  When calculating the nursing workforce Whole-Time Equivalent (WTE) an uplift will be applied that allows for the management or planned and unplanned leave and absence
• Standard 9 If the substantive nursing workforce falls below 80% for a department/team this should be an exception and should be escalated and reported to the board/senior management
• Standard 11  Rostering patterns for the nursing workforce will take into account best practice on safe shift working. Rostering patterns should be agreed in consultation with staff and their representatives
• Standard 13  The Nursing workforce is entitled to work in healthy and safe environments

To understand how much say your staff have in their work, you may wish to ask the following questions:

• Do you feel involved in how decisions about your job are made? 
  Think about whether you feel listened to, trusted and valued - how you are consulted and given opportunities for input?
• Do you feel your skills are used to good effect? How could your existing skills be used more effectively? 
• Do you feel you have a say in how your work is organised and undertaken? 
• What improvements or support could be put in place to help with any of the issues you have talked about? 
  Think about you, your manager, your department, your organisation.

Communication

• Help staff to have a say about the way their work is organised and carried out, for example at team meetings, handovers, one-to-ones and performance reviews.
• Hold regular discussions during the planning stage of any changes to talk about the anticipated methods of working.
• Where possible, allocate responsibilities to teams rather than individuals. 
• Allow staff employees to have some control over the pace of their work and when to their take breaks. 
• Talk about training needs. 
• Involve a range of staff members in any projects or change initiatives.

Decisions

• Talk about the way decisions are made, ensuring staff understand how the organisation, department and team make decisions. 
• Allow and encourage people to participate in decision making, especially where it affects them.

Skills and Training

• Talk about the skills people have and if they believe they are able to use these to good effect. 
• Talk about how people would like to use their skills. 
• Consider personal development/training plans, where you ask employees to think about the skills they would like to develop. 
• Explore the continuous professional development (CPD) requirements of your team members and how these can be met.

The control standard also aligns with the following RCN Nursing Workforce Standards

• Standard 4  The nursing workforce should be recognised and valued through fair pair, terms and conditions
• Standard 7  The time for all elements of practice development must be taken into consideration when defining the nursing workforce and calculating the nursing requirements and skill mix within the team
• Standard 13  The Nursing workforce is entitled to work in healthy and safe environments

Managers provide an important role in offering support to their staff. Employees tend to look to managers for approval, appreciation, and information
To understand how your staff feel, you may wish to ask the following questions with an individual member of your staff or team:

• Do you feel that your team/organisation is a positive place to work and that you are valued? Think about the working environment, the support available and the opportunities to talk about support you may need.
• Do you know who to talk to and where to go when you need support? Think about where you would go for help if you were experiencing an issue and whether you would feel comfortable doing so.
• Do you feel there are enough opportunities to discuss any emerging issues or pressures?
• What improvements or support could be put in place to help with any of the issues you have talked about? Think about you, your manager, your team, your department, your organisation
• Set a date to revisit any proposed changes and agree an action plan

Support

• Hold regular one-to-one and team meetings to talk through any emerging issues or pressures.
• Include work related stress or pressures as a standing item for meetings with staff and/or performance review.
• Explore any concerns raised with you in an open, transparent manner.
• Provide timely and constructive feedback.
• Consider buddying systems or work shadowing to improve understanding of roles across the team and to foster peer support.
• Share examples of good practice.

• Share information on support available to your staff, for example employee assistance programmes, trade union support, occupational health and external organisations.
• Talk about the ways your organisation can provide support if someone is experiencing problems outside work, for example, relationship difficulties, bereavement or a health concern.

• Regularly consult with your staff and HR to ensure training is up to date.
• Managers should be given the training as well as protected time to carry out performance reviews that are considered high-quality, effective, and supportive of staff development opportunities.
• Hold local induction session for staff new to your department, including staff who are temporarily deployed from another area, agency staff and new starters.

Environment

• Assess the risk of physical violence and verbal abuse by consulting with staff and others.
• Raise awareness of initiatives already in place.
• Provide training to help employees deal with and defuse difficult situations.

The support standard also aligns with the following RCN Nursing Workforce Standards

• Standard 3  Up to date business continuity plans must be in place to enable staffing for safe and effective care during critical incidents or events.
• Standard 4  The nursing workforce should be recognised and valued through fair pair, terms and conditions.
• Standard 7 The time for all elements of practice development must be taken into consideration when defining the nursing workforce and calculating the nursing requirements and skill mix within the team.
• Standard 12 The nursing workforce should be treated with dignity, respect, and enabled to raise concerns without fear of detriment, and to have these concerns responded to.
• Standard 13  The Nursing workforce is entitled to work in healthy and safe environments.

To understand how your staff feel, you may wish to ask the following questions with an individual member of your staff or team:

• Have you experienced or witnessed unacceptable behaviour at work? Do you feel satisfied with how this was dealt with?
• Do you feel that honest, open communication is encouraged in your organisation?
• Do you feel that you know where to go and what to do if you experience or witness unacceptable behaviour? Do you feel confident that steps will be taken to stop this behaviour?
• What improvements or support could be put in place to help with any of the issues you have talked about? Think about you, your manager, your team, your organisation.

• Have an agreement with employees and senior leaders on which behaviours are unacceptable.
• Have a written policy for dealing with unacceptable behaviour and procedures for reporting incidents.
• Regularly communicate these policies and procedures to staff and make sure that they are understood.
• Have a confidential system for people to report unacceptable behaviour.
• Encourage good communication and provide training to help, such as listening skills, confidence building and assertiveness.
• Encourage and provide opportunities for employees to socialise together.
• Make sure that you are providing the same level of support and communications for staff who work in isolation such as like lone workers or those in separate locations.
• Find ways to celebrate personal, team and organisational successes.
• Ensure that as a manager you role model the values and behaviours of the organisation and develop positive cultures within your own team.

The relationship standard also aligns with the following RCN Nursing Workforce Standards:

• The nursing workforce should be treated with dignity, respect, and enabled to raise concerns without fear of detriment, and to have these concerns responded to.
• The Nursing workforce is entitled to work in healthy and safe environments.

To understand how your staff feel, you may wish to ask the following questions with an individual member of your staff or team

• Do you feel clear on what your responsibilities are?
• Are you clear on what your performance objectives are and what success looks like for you, your area/department and the organisation? Do you feel that they are achievable?
• Do you feel you understand how work is structured in your department and in the wider organisation?
• Do you know who is doing what and why, and how your role fits in?
• What improvements or support could be put in place to help with any of the issues you have talked about? Think about you, your manager, your organisation, your profession, your staff/union representative.

New starters

•  Give all new staff a thorough induction into your organisation and its policies and procedures. Include details of where to get support or who to speak to about stress or mental health issues

Communication

• Provide clear work objectives.
• Define work structures clearly so that all team members know who is doing what and why.
• Hold regular one-to-one meetings to ensure people are clear about what is planned for the coming months.
• Agree specific standards of performance for individual tasks and review regularly.
• Hold regular team meetings to enable staff to discuss any issues.
• Display departmental/organisational targets and objectives.
• Introduce or revise job descriptions with the involvement of staff to ensure the core functions and priorities are clear.

Role

• Introduce personal work plans which are aligned to the objectives of the team/organisation.
• Introduce or revise job descriptions to ensure the core functions and priorities are clear.
• Review job descriptions regularly, especially following change and discuss training/retraining regularly too.

The role standard also aligns with the following RCN Nursing Workforce Standards

• Standard 7  The time for all elements of practice development must be taken into consideration when defining the nursing workforce and calculating the nursing requirements and skill mix within the team.
• Standard 12  The nursing workforce should be treated with dignity, respect, and enabled to raise concerns without fear of detriment, and to have these concerns responded to.
• Standard 13  The Nursing workforce is entitled to work in healthy and safe environments.

To understand how your staff feel, you may wish to ask the following questions with an individual member of your staff or team

• Do you feel that your organisation handles change well?
• Do you feel you are properly consulted when changes are made which affect you and your role? Do you feel the reasons for the change are explained well? 
• Do you feel that you are involved in the planning process when changes are made?
• What improvements or support could be put in place to help with any of the issues you have talked about? Think about you, your manager, your organisation, your profession your staff/union representatives

Consulting with staff

• Keep staff up to date and in the picture
• Defne and explain key steps of changes being made.
• Consult employees early and throughout the change process.
• Build in engagement and support as key elements of any change process.
• Involve employees in the planning process.
• Provide a system for staff to comment and ask questions before, during and after the change.
• Review how the change will impact on departmental and individual objectives and workloads.
• Include training/retraining needs as part of your change process.

Communication

• Start communication early and, as far as possible, make it a two-way conversation.
• Explain what the organisation wants to achieve and why it is essential that the change takes place.
• Explain the timescales of changes and how changes will impact directly on staff.
• Have an agreed system for communicating to staff why a change is happening.
• Have agreed methods of communication (such as meetings, notice boards, newsletters, email and feedback forms) and agree their frequency.
• Don’t rely on a single communication route – most people may have access to a computer in work but what about those who don’t, or those who work off-site or out in the community?
• Make sure that employees are aware of the impact of the change being made on their jobs.
• Talk about the potential need for (re)training.
• Include people on long term sickness, maternity/paternity leave or career breaks, where possible.

The change standard also aligns with the following RCN Nursing Workforce Standards:

• Standard 7  The time for all elements of practice development must be taken into consideration when defining the nursing workforce and calculating the nursing requirements and skill mix within the team.
• Standard 12  The nursing workforce should be treated with dignity, respect, and enabled to raise concerns without fear of detriment, and to have these concerns responded to.
• Standard 13  The Nursing workforce is entitled to work in healthy and safe environments.

As a manager, you might notice someone is:

• taking more time off
• arriving for work later
• appearing nervous or twitchy
• having difficulty concentrating
• struggling to make decisions
• avoiding certain places or people
• working longer hours or not taking breaks.

Their behaviour might show signs of:

• mood swings
• being withdrawn
• loss of motivation, commitment, and confidence
• Heightened emotional reactions like being more tearful, sensitive or aggressive.

You might notice or suspect that there is increased alcohol, nicotine or drug intake.

For a fuller guide to the signs and symptoms of stress, see our Stress and You resource [add link]

You might find that, as a team

• Arguments are becoming more frequent
• There are more complaints which might escalate to grievances.
• The performance of the team as a whole has decreased
• Staff turnover is higher than usual
• Sickness absence is on the increase
• There are more formal or informal reports of stress

Employers have a duty of care to protect the health and welfare of all their employees and should therefore develop ways for individual employees to raise their concerns. This could include the following:

• Creating an environment where nursing staff are encouraged to talk, both formally and informally, to their line manager or another person in their management chain.
• Reminding nursing staff they can speak to their RCN representative and/or human resources.
• Encouraging nursing staff to talk to someone in the organisation or seek advice from occupational health advisors, or their GP if they are concerned about their own health. 
• Introducing mentoring or other forms of worker support. 
• Providing or referring to employee assistance (counselling) services. 
• If the staff member is an RCN member, they can access Member Support Services.

Where stress is ‘foreseeable’, action must be taken to limit the problem, so far as is reasonably practicable. For example:

• Speak to the individual to find out what has led to their concern and identify what can be done about it. 
• Always take concerns seriously, and do not belittle or make light of the individual. 
• Where distress is serious, fault is cited, and things have clearly gone beyond what you as manager can deal with, ask for expert assistance, for example, your occupational health team or human resources team. You can also contact the RCN for advice if you yourself are a member.
• Where the concern involves relationship issues, for example with the individual’s immediate manager, or other team members, it is useful to involve human resources, occupational health and a representative for the employee (for example RCN representative, trusted colleague, etc) when working through the issue. 
• Where it is possible to identify a clearly work-related problem, it is essential to rectify the situation as swiftly as possible, even if this involves compromise on either side.
  -  Follow this with a wider formal appraisal of the working conditions in the relevant area, which should include other employees and, where appropriate, their representatives. 
  -  This should be documented. 
• The risks of stress should be controlled, and an action plan agreed. 
  -  Where ‘home’ influences are impacting on the employee’s performance and perceptions of their work, it is generally in the employer’s interest to support the employee, rather than dismiss the problem as irrelevant to the organisation.

There are a variety of approaches to clinical supervision, and it is worth spending some time thinking about the approach you want to take to clinical supervision for your team or service if you do not have a process in place.  

One approach that is gaining momentum is resilience-based clinical supervision, offered by the Foundation of Nursing Studies. This approach is well structured, whilst creating space for personal connection and understanding other viewpoints related to the situation presented.

• Think about who else you can work with. It is possible to implement clinical supervision across services or departments, which will support the development of clinical supervisors across sites and services. Do you have a practice development team or practice educator that can support you to implement clinical supervision?
• Review what is working well and what could be better. Engage key stakeholders and your team especially if you have been doing clinical supervision for a while. If your just starting, consider what needs to be in place for you to successfully implement clinical supervision. Don’t be afraid to seek support from others who have implemented clinical supervision, it could save you some time and fosters collaboration and wider connection outside of your work area.
• Raise awareness in your team. Make sure your team knows what clinical supervision is, how you are going to maintain a consistent approach and ensure all staff have access. Getting your team involved is key to the success of implementation. They may have positive and negative experiences of clinical supervision and it's important not to dismiss these. Use them to inform and shape your vision. Linking clinical supervision to the vision for the team as it gives a sense of the whole team working together, creating a cohesive culture
• Provide good training. All team members will have a role, either as a supervisor or a supervisee. Training for both roles is incredibly important and will aid your long terms success. Spend time making sense of these roles and providing insight moments for staff to underpin your success.
• Do what works best. There are multiple ways in which you can implement clinical supervision, the key is to do what works best for you, your team, and your organisation.

Finally, remember to celebrate! Often we move on from projects without really reflecting and reviewing what went well and what we might have done differently.  

Setting up a task and finish group, with representation from across the organisation, is a way of steering the organisational risk assessment process forward and securing involvement and commitment.
It allows for wider representation for decision making, including input from employees or others with specific/specialist knowledge. It also allows for the workload, to be shared, enabling the risk assessment process to be completed in an organised and timely manner.

When setting up a group make sure there is satisfactory representation. For example, the group could include representation from the following roles:

• Senior Nurse Manager
• Health and Safety Lead
• RCN Safety Representative and/or Steward
• Staff Nurse
• Human resources manager
• Occupational Health

Following the setting up of the group, a project plan with a timeline, should be developed.

The availability of senior managers to attend meetings

• Identify whose input is needed and when.
• Ask yourself if they need to attend the meeting.
• Don’t have a meeting for the sake of it.
• Have an agenda with a timetable and keep to it.
• Look if something can be read or presented to the group and be included in the minutes.

Getting people together at the same time

• Avoid setting times when attendance will be difficult. 
• Agenda - who needs to be there to take things forward?
• If can’t attend – can the person nominate a deputy to represent them and put their ideas forward.

The group loses motivation

• Keep communication flowing.
• Encourage managers to motivate teams, encourage responses and to get involved in the process.

There is too much work to be undertaken

• Avoid duplication of work.
• Review planning and timescales.
• Integrate into existing management systems.

Senior Managers aren't visibly demonstrating their support and participating in communication activities

• Get senior managers to lead communications with all health and social care employees.
• Try to get in-house publications to feature stories about the work with supporting quotes from senior staff.
• Make sure meetings are led by senior staff.
• Encourage senior staff to promoting material to remove the stigma of stress and/or mental health conditions.

The work will need resources (both funding and time)

• Secure commitment for the time others will spend taking part in the process.
• Ensure there is available funding to implement proposed interventions.
• A  commitment to ongoing resources must be secured as there will need to be periodic reassessments and monitoring of control measures.

Who has authority? 

• Authority should be delegated either to an individual (smaller organisation) or steering group (larger organisation) and that should be clearly communicated.
• Oversight should be maintained to ensure co-operation from other senior managers.