Mental health impact and fitness on return to work
Background: The incidence of work related mental health problems and sickness absences are increasing. The most vulnerable group are health care workers. The majority of health care workers are employed by the National Health Service.
Aims: To identify rates and degree of anxiety, depression and stress at work amongst National Health Service employees in five trusts attending the occupational health department. To describe the demographics of employees returning to work and characteristics of their work patterns, and what interventions were used if needed.
Methods: A retrospective observational study on 226 employees from October 2000 to November 2007 was carried out.
Results: Stress at work was associated with either anxiety or depression or both. Age, number of years in the NHS, past psychiatric history and shift work also influenced stress at work factors. Nurses were the most vulnerable group followed by administrative staff. With effective intervention, nearly 86% of employees were able to return to work.
Conclusions: The study supports that intervention by multiple approaches has a significant role for a successful fitness and early return to work.
Self-reported work-related illness in 1995 showed that 279,000 individuals in Britain were suffering from work related stress, depression or anxiety and 6.5 million working days were lost in Britain that year as a result . The incidence of work related mental health problems (as reported by occupational physicians and psychiatrists) appears to be increasing in the UK . The highest rates of stress, depression or anxiety are amongst nurses and teachers, with over 2% suffering from these. The second highest groups were care workers, managers and professional occupations at over 1%. At any one point in time, approximately 1 in 6 workers experiences anxiety, depression or other stress-related mental health problems . It has been reported that there is a low awareness amongst employers about the level of mental health problems in the workplace, and treatment for them is inadequate .
It seems that health care workers (i.e. nurses, doctors etc) form the majority group who suffer from mental health problems and large numbers are employed by the National Health Service (NHS). In almost all studies, prevalence rates of minor psychiatric disorders amongst health care staff are higher than in the general population with rates comparable with that of the unemployed . Some mental health problems are work-related and others are not. Whatever the source of anxiety and depression, mental illness has an impact on work performances, sickness absence and return to work.
The longer a person is off sick from work with mental ill health related absence, the less their chance of a successful return to work . It is therefore important to investigate which groups of people become ill and why, so that effective treatments can be targeted. Knowing more about the types of people who are off work, and the characteristics of their work patterns may enable targeted and more focused preventative and supportive strategies for them to continue working.
Data were collected retrospectively from 236 participants who presented to the Occupational Health department of North Hampshire Hospital, UK (now Basingstoke and North Hampshire NHS Foundation Trust) with mental health or stress-related issues in the period between October 2000 and November 2007. They were seen as a part of a) return to work after sickness absences or b) having long term sickness (prolonged sickness absences) or c) poor work performances or d) work related mental health issues. They attended as self-referrals, or were referred by their managers. The diagnosis of mental health or stress-related issues was made via a structured clinical judgement; in other words, mainly based on clinical interview and history taking between the employees and the Occupational Health Consultant and, and supported by the following self-administered questionnaires as described.
The self-administered questionnaire consisted of three parts:
1) General information – Demographic, occupation and work details, health-related questions including, psychiatric disorder and physical illness, smoking and alcohol history. We also gathered information on treatment management (medication, counselling, anxiety management, cognitive behaviour therapy or any other types of psychotherapy or intervention).
2) Anxiety and depression – Levels of anxiety and depression were measured by the Hospital Anxiety and Depression Scale . The HADS comprises statements which the patient rates based on their experience over the past week. The 14 statements are relevant to either generalized anxiety (7 statements) or 'depression' (7 statements). Even-numbered questions relate to depression and odd-numbered questions relate to anxiety. Each question has 4 possible responses. Responses are scored on a scale from 3 to 0. The maximum score is therefore 21 for depression and 21 for anxiety. A score of 11 or higher indicates the probable presence of the mood disorder with a score of 8 to 10 being just suggestive of the presence of the respective state .
3) Work related stress factors – These included; job demands, decision authority, skill discretion, terms of employment, and supervisor and co-worker support. These were measured by questions based on the Stress at Work Site questionnaire . Appendix 1 contains further details including how it is scored.
The validity of this stress questionnaire is well established. The questionnaire is found in the official publication for the European communities, which is used as a guide for small and medium sized enterprises . However, this is the first time that this stress questionnaire has been tried for NHS staff.
Each employee with stress-related issues completed the full questionnaire along with its’ consent form at the time the individual attended the clinic. The participant was then assessed face-to-face clinically with the completed questionnaire in the clinic by the Occupational Health (OH) Consultant, where a diagnosis was made again using the structured clinical judgement as described above. The clinical assessment included :
a) Reason for referral
c) Present illness
d) Personal history
e) Family history
f) Physical examination
g) Psychiatric examination
On the basis of trust policy, once the individual employee’s general practitioner had provided medical certification for the sickness absence, he or she had to see the OH Consultant before their return to work. Assessments or support for early return to work were provided where necessary. It was the OH Consultant who decided whether the individual was fit to return, or unfit with adjustments. Where applicable, further information was also obtained by the OH Consultant from psychiatrists and general practitioners with the participant’s consent. Thus the mental health stress–related issue was identified individually on the basis of clinical examination, supported by Questionnaire and medical or psychiatric records. The OH Consultant then recommended participants for work-related fitness, adjustments, rehabilitation programme, or remedial or other relevant intervention measures. The rehabilitation programme and workplace adjustments included the following: a phased or stepwise return to work, placements, flexi-hours, reduced hours, working from home, no shift or night shift duties, less responsible jobs or to work under supervision, and case conferences.
The employees’ line managers were also involved. If it was felt necessary, the participants were then followed up in clinic by the OH Consultant. This was especially important for those who were unfit for duties.
All participants were existing employees of 5 NHS trusts – North Hampshire hospitals (NHH), London Alliance (LA), Primary Care (PCT), Surrey Hampshire Borders (SHB) and Hampshire Partnership (HP). The Occupational Health department is responsible for approximately 4850 employees (3500 from NHH, 850 from PCT and LA, and 500 from SHB and HP).
Data were obtained from 226 people out of 236 eligible participants (96%). 69% of the participants worked for NHH trust.
Table 1 shows the demographic information of the participants.
Table 1: Characteristics of study population (n=226)
Figure 1 shows the distribution of participants by their occupation.
Figure 1: Occupational categories of 226 employees
The majority of participants were nursing staff. The majority of the participants were female (87%). The peak age group was between 41-50 years for both sexes. Females accounted for a higher percentage in each age group except for the 60+ age group. 62% were employed on full time basis and 40% were on shift duties.
The length of participants’ current job ranged from 0.25 years to 27.50 years (mean 5.91, SD 6.11). The length of time working for NHS was from 0.25 to 39 years (mean 11.70: SD 9.8). 133 (59%) participants had a history of existing or past psychiatric difficulties and 21 (9%) had a history of substance abuse.
The mean anxiety score was 8.8 (SD 5.17) and the range was from 0 to 20. Similarly, the mean depression score was 6.4 (SD 5.15) and the range was 0 to 20.
Table 2 shows the comparative values of work related, non-work related or a combination of both types of stress, anxiety and depression.
Table 2: Comparative results of the work-related (WR), non-work related (NWR) and both (WR & NWR) types of stress, anxiety and depression (n=226) (Means and SDs)
The occupational health recommendation for fitness to work on initial assessment showed 54 (24%) were fit, 90 (40%) were fit with workplace adjustments, and 82 (36%) were unfit. Of the 54 fit employees, 34 (63%) were on drug treatment, 13 (24%) were having supportive treatment like counselling, and 2 (4%) were on psychotherapy, which included cognitive therapy (CBT). The remaining 5 employees did not require any specific treatment.
Of the 90 subjects who were fit with workplace adjustments, 59 (66%) were on drug treatment, 29 (32%) were having counselling supportive treatment, 7 (8%) were on psychotherapy, which included CBT, and 2 (2%) were having therapies such as group therapy, day hospital therapy or attending alcohol anonymous group. Their workplace adjustments showed that 17 (19%) subjects had redeployment or placement. 36 (40%) had workload and duties adjustments which included working from home, less responsible jobs or to work under supervision, etc. 20 (22%) had working hours adjustments such as flexi-hours, reduced hours and overtime; 5 (6%) subjects were adjusted for shift duties including night shifts. Shift and working hours were adjusted for 3 (3%) subjects but shift and workload were adjusted for one (1%) person. 8 (9%) had working hours as well as workload/duties adjustments.
Of 82 unfit employees, 59 (70%) were on drug therapy, 22 (27%) were having counselling, (2%) psychotherapy or CBT and 16 (20%) were having another kind of therapy, as above. 82 unfit employees were followed up in clinic and gradually 19 (23%) became fit, 31 (38%) were fit with workplace adjustments. Of the 31 persons who had workplace adjustments, 13 (42%) had placements or redeployment, 11 (35%) had workload and duties adjustments. Working hours were adjusted on 2 (6%). 3 (10%) had shift adjustments. 2 (6%) had both workload and work hours adjustments. Of the remaining 34, 30 (37%) were found to have left the organisation, i.e. resigned, termination, ill health retirement, and 2 (2%) were still off sick. Of the 226, 58 (26%) completed the phased return rehabilitation programme. Remedial intervention measures showed that 150 (66 %) were on drug therapy, 64 (28%) were on counselling, 11 (5%) were on psychotherapy or CBT and 18 (8%) were having another kind of therapy (group therapy, attending day centre, alcohol anonymous group, etc.) Table 3 describes the participants in each group described above (fit, fit with adjustments and unfit) and what types of therapy they were on.
A limitation of this study is that it is based entirely on volunteers that completed the questionnaires. Ten cases did not participate, but they represent less than 5% of the overall numbers. There might be some cases that were not referred to. Despite this limitation, approximately 1 in 5 of the participants sampled had work related stress. When combined with non-work related stress this figure increased to over 1 in 2. However, 46.02 % did not have work related stress but might have pre-existing mental health related issues including stress and depression, which were identified by past or present histories and/or by anxiety and depression stress questionnaires.
A meta-analysis from 1994–2005 looking at psychosocial work stressors and mental health9 found that predictors of common mental health problems included job strain, low social support, high psychological demands, effort-reward imbalance, and high job insecurity. In particular, high job strain (defined as high psychological demands combined with low job control)  and high effort-reward imbalance (defined as high effort at work combined with low reward) were prospective risk factors for common mental health disorders. These results were backed by Clays et al. although they also found a significant independent association with low job control amongst women. In our study women formed the largest group. Nurses were the most vulnerable group (the smallest group was doctors) followed by administrative staff. We offer some potential reasons why this may be the case. One explanation for the small number of doctors is that, either fewer doctors volunteered for the study, or that doctors are less vulnerable to stress due to introduction of European Working time directives. Of course, an explanation for why more nurses presented with issues could simply be that there were more nurses than doctors.
Doctors in training are now protected by the European Working Time Directives, stating a maximum 48-hour week and ensuring adequate breaks and sleep during shifts. Harma concluded that continuously working more than 50-hour weeks, or long total working hours (both at work and at home) were associated with objective and self-rated health problems . Many doctors work a 1 to 3 consecutive night shift, whereas nurses tend to spend longer periods doing night shifts, and many do overtime/ bank shifts to top up pay. The risk of accidents has been shown to correlate with the number of consecutive night shifts in a shift system . All this might affect work performances and our study supports that shift working practice is associated with stress related decision making. It does not explain however why such a large proportion of administrative staff attend occupational health departments. It may be argued that compared to doctors, nursing and administrative staff have a higher job insecurity, which is one of the factors found to correlate with long term (>3 days) sickness. Interestingly, in our study, apart from workplace adjustments, most referrals were due to sickness absences.
Most individuals, however, are able to perform effectively with appropriate medications and workplace adjustments. Some require supportive treatment or psychiatric supervision along with regular follow up. There were also cases that were not able to retain their jobs.
What measures according to the literature can be put in place to help? Harma  concludes that the most promising measures would be to regulate overtime and excessive working hours, introduce sleep promoting principles in shift rotation, and increase the individual’s control on work time.
In our study, this was done on the basis of work adjustment in the form of placements, flexi-hours or reduced hours duties, overtime regulation, restriction on shift or night shift duties and supports. Case conferences involving individual and manger were helpful. In this respect, the line mangers’ role is no doubt crucial.
There is also evidence that stress intervention programmes improve psychological as well as physiological health . Relaxation techniques, counselling and cognitive behavioural programmes can be used. In our study, most intervention programmes were based on counselling services, with very few on CBT. The importance of CBT is growing and the Occupational Health department should have more excess to full CBT services. There are books available specifically for detailing how to use CBT for occupational stress in health professionals. These approaches appear to be effective in preventing, as well as aiding, recovery in some mental health problems . Busy health care professionals may prefer to use computerised CBT. A randomised controlled trial in UK that looked at treating stress related absenteeism from work showed significant reductions in anxiety and depression after an eight week computerised CBT programme compared to conventional care alone. The Hospital Anxiety and Depression scale was used as an outcome measure, as in our study, and the results were sustained after 1 month .
A systematic review looked at the effectiveness of interventions that help prevent mental health problems or helped people return to work for those that suffered from them . The most effective programmes for staff retention focused on personal support, individual social skills and coping skills training. Multiple approaches had the longest lasting effects. Other interesting findings that emerged from the review were that the line manager had a key role in managing common mental health problems, and perhaps they need to be trained with specialist skills.
Re-iteration of healthy lifestyle factors can be used (for example, promote more fruit at work, give incentives to use gym facilities, provide massages after work/ during breaks etc.). Other effective alternative therapies include music relaxation with visual imagery, muscle relaxation and social support group sessions, and brief massage therapies . One study has shown that as little as 15 minutes of Swedish massage at a time could be very useful in reducing stress and improving mood . Although advice was given for healthy lifestyle during face-to-face consultations, such interventions were limited because of costs and degree of motivation involved.
NICE guidelines on long-term sickness absence make reference to the key role of the general practitioner . It is essential that they feel confident in recognizing mental health problems early on and knowing the range of effective treatment currently available.
We suggest that perhaps during the induction for new staff (especially targeting nurses and administration staff), specific psycho-education could be delivered to increase awareness of the signs and symptoms of common mental health problems, simple techniques on how to deal with them, and where they can go for help. This would be fairly cheap to implement. This service is not available for most of the trusts.
Specifically targeting NHS Trusts with campaigns that raise awareness and reduce stigma of mental health issues is another way that can certainly help. To that end the government’s “Open your Mind Campaign” should be applauded .
Utilising some of the multiple approaches described above, 85.54% employees were able to return to work. Unfortunately, despite all these measures, nearly 12% were not able to hold the jobs. Undoubtedly a successful and early return to work requires the support of general practitioners and line managers, also. This is most important when the individual or manager does not agree with Occupational Health recommendations.
This descriptive study provides more information about the types of people and characteristics of those who are being assessed for return to work after absences. This can add to the literature and we feel this is useful information enabling certain groups at more risk to be potentially targeted for extra support.
The authors acknowledge the help of the staffs of Occupational Health Department; especially Diane Pittard (manager), Carol Henderson and Thelma Ennis, Senior Occupational Health Nurse Advisor. We are also extremely grateful to Bernard Higgins, Academic Research and Development Unit, School of Postgraduate Medicine , University of Portsmouth for his statistical help and advice, and to Dr Rachel Pearson for copy editing this manuscript.
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