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Employee perspectives on mental health in the workplace

Contents:	Summary Introduction Methodology Findings Discussion Recommendations References Appendices

Discussion

The study has explored the perspectives of employees from a range of employment settings and backgrounds on mental health in the workplace. It has included the experiences of people who have identified mental health problems and had recently been in employment, as well as employees who were not known to have had mental health problems.

The difficulties encountered by the research team in identifying employees to take part in the focus group element of the research have important implications for future work on mental health in the workplace. Approaches through employer organisations, firstly to secure agreement and access to employees and secondly, to recruit a group of employees in that workplace to take part in a group discussion hit against several barriers:

• employer reluctance to get involved, variously ascribed to pressures of work and time required to set up focus group or recent involvement in other HEBS activities. In some instances support from HR and from Occupational Health was not matched by support from management (and vice versa)
• employee reluctance, on grounds of lack of interest, concerns about confidentiality of research findings and about talking on this topic with a peer group. In one instance, staff were advised by the employer that participation would have to be in their own time.

Taking an overview of the perspectives and experiences reported through the focus groups and the one to one interviews, a number of key points stand out for consideration.

Perceptions and understandings

Mental health and well-being
Employees in this study shared an understanding of mental health and well-being that echoed findings from other research on perceptions and understandings of mental health and well-being in general (SDC, 1999) and of mental health at work (MHF, 2002). Employee perceptions of mental health and well-being were largely consistent with those of employers according to the earlier study by Lee in 2002.

For employees, mental health was an internal state of emotional health and was also associated with the capacity to fulfil roles and expectations satisfactorily. Employees' understandings of the relationship between work and well-being ascribed value to the following: a sense of purpose; the opportunity to feel useful and valued; fulfilment and satisfaction; social contact and support; stimulation and activity; material benefits and status.

These views on work's contribution to well-being are strongly supported by the literature. It is well recognised that work offers a social identify, social contacts and relationships, a means of structuring time, a sense of purpose, meaning and involvement (Jahoda, 1933; Shepherd 1989; Grove, 1999).

Mental health problems
Employees tended to regard mental health problems as a spectrum of difficulties which extended from the relatively mild to more severe difficulties that manifested as mental illness. Mental health problems were thought to interfere with the capacity to undertake everyday roles, tasks and relationships. It was commonly held that mental health problems were linked to the emotional distress brought about by difficulties in personal relationships or in the workplace.

Stress
Stress was considered by employees to arise from the mismatch between perceived demands and expectations on the one hand and perceived capacity and ability to cope on the other. The main sources of stress identified by employees included: workload and control; role clarity; performance and feedback; relationships at work; working environment, including job security and continuity.

While stress was regarded as distinct from mental health problems, the factors that generated stress at work were regarded as contributing to or exacerbating mental health problems.

Finding a balance at work between a level of stress that is motivating and a level of stress that creates unhealthy anxiety was considered to be unique to each individual employee and their own life circumstances including their family and social life and career ambitions.

Work and mental health and well-being

Contribution of work to mental health and well-being
Employees considered that balancing the demands of work and home life was crucial to their sense of well-being at work. This supports the findings of a recent Mental Health Foundation survey (MHF, 2003) which suggested that, as a result of working long hours, employees may be neglecting those aspects of their lives which them make more "resistant or resilient to mental health problems".

The work life balance is not static, but can fluctuate with different jobs and life circumstances. From the accounts of employees, there was evidence that people can learn to establish a balance that suits them, insofar as the workplace provides the flexibility to accommodate this.

It was clear from the findings that relationships at work were perceived as key, both as a protective influence in the face of stress and to promote a sense of well-being at work. However relationships at work could also contribute to or exacerbate experiences of mental health problems.

Overall employees' accounts of the factors that influenced well-being in the workplace were largely consistent with other sources:

A TUC survey of 900 respondents identified workload as the most detrimental factor affecting mental well-being at work, followed by the scale of change and the pace of work (TUC, 1998)

The UK Whitehall II study showed that how work is designed can affect employee mental well-being and physical health. The key factors highlighted were control and communication; effort / reward balance; support and understanding from managers (Stansfield et al, 2000)

The HSE has core management standards on work related stress (HSE, 2001). These seven standards cover:

• demands, including workload
• control: how much say the person has in how they do their work
• support from peers and line manager, and training to equip the person for their job
• relationships, covering harassment and bullying
• role, to ensure clarity and avoid role conflict
• change, to ensure effective management and communication of change
• culture, to address the organisation's overall approach to stress

The most recent CIPD sponsored annual survey (Guest and Conway, 2002) asked 1,000 employees about workplace stress and found evidence of several different effects. Firstly workload, working hours and job content were more likely to be perceived by employees as having harmful effects on their health and well-being. Secondly, the social context of work, including help support and relationships at work, tended to be experienced as beneficial. In addition control over work and opportunities to use skills tended to act as forces for positive well-being.

Impact of mental health on work performance
Employees considered that there was a link between people's mental health and their work performance; however, the nature of the impact on work was perceived to be contingent on whether the conditions and relationships in the workplace were such that it was possible for the person’s difficulties to be identified and for timely support to be provided. Employees with experience of mental health problems tended to attach more weight than other employees to feedback and support to manage anxieties about performance at work.

These observations concur with evidence from elsewhere that people with mental health problems can gain and retain work, if the right support is provided (Crowther et al, 2001). In a comparison of people with a mental illness who had retained employment with those who had not retained employment, the factors that distinguished the two groups were organisational climate and person-environment fit. There were not differences between the two groups in individual characteristics, including diagnosis and history of illness (Kirsch, 2000).

Impact of mental health on work attendance
There were some difference in views among the two groups of employees about work attendance. Employees with personal experience of mental health problems considered that work attendance would not be affected by their mental health, as they had a strong sense of needing to pull their weight with colleagues and because attending work was of direct therapeutic benefit. Other employees were tended to the view that mental health problems probably would lead to absence from work.

As with work performance, it appears that the availability of support is a crucial factor and can reduce prevent sickness. One NHS Trust with a well established vocational support service for employees with mental health problems reports lower rates of sickness absence among this set of staff, compared with the rate for all direct care staff within the Trust (Rinaldi and Perkins, 2003).

Promoting mental health and well-being in the workplace

Employees were able to describe a range of ways in which their employers had been contributing to mental health and well-being at work and supporting people with problems. Often these actions or activities were mainstream and were not designated as mental health or targeted specifically at employees with mental health problems. This may have important implications for future action.

Employees harboured some scepticism about the integrity of intention behind polices, regarding policies primarily as a veneer. Discussion at the stakeholder workshop suggested that formal policies in the workplace specific to well-being, such as flexi-time or stress policies, would be unlikely to promote well-being unless they were part of a wider organisational approach. To work, it was contended that such policies needed to be supported by the organisational culture with commitment from all levels of the organisation and with clear accountability for employee well-being. It was considered that employees feel supported despite the absence of any formal polices for mental well-being, when they perceive there to be a healthy and supportive workplace culture.

Both sets of employees - those with and without identified personal experience of mental health problems - shared similar views about the workplace features that were indicative of good and supportive employer practices in contributing to employee mental health and well-being:

• ethos and culture within the organisation that set the tone for relationships and experiences at work
• working practices that valued and fostered peer relationships
• accessible and supportive management structures and relationships
• policies and procedures to ensure that good practice was established
• flexibility and adaptation of role and workload to accommodate individuals
• management of transitions and changes to support people moving into new roles or returning after absence

The perceptions held by employees concerning the workplace features that are important for employee mental health and well-being illustrate the importance of a whole organisational approach. A recent review of the evidence on mental health improvement in the workplace concludes that many of the factors that influence both physical and mental health of staff are psycho-social and relate to style of management and working culture. For this reason, the review concludes that mental health needs to be addressed systematically at an organisational, rather than an individual, level (Mentality, 2003).

Getting help and support with mental health problems at work

Employees considered that attitudes amongst the general population regarding mental health and mental health problems and how to support people with mental health problems filtered through into the workplace. Of note here therefore is evidence of the ambivalence of public attitudes in relation to mental health problems (Scottish Executive, 2002) and the persisting stigma associated with mental health problems in the workplace (Blackwell et al, 2001).

From the findings of the employee study and the study on employer perspectives (Lee, 2002), the initial identification of situations where an employee may be developing a mental health problem remains problematic, for both employees and employers. There appears to be uncertainty about how and when to raise the issue in the first instance and how best to deal with it. Employees were alert to the ambiguities associated with intrusiveness on the one hand and respect for the individual employee on the other.

Employees felt that a supportive working culture would engender expectations of a positive response when someone discloses a mental health problem and also be sufficiently flexible to accommodate and support both the employee and their manager. There is an evident need for tools to enable managers to identify employees at risk, before a crisis occurs.

It is important to note that the strongest factor associated with successful job retention is support from and active involvement of management. There are strong indications that without support of the supervisor or manager, return to work after sickness absence and job retention is seriously jeopardised (Gates, 2000).

A whole organisation approach to improving mental health and well-being in the workplace

The experiences of employees who took part in the study and their recommendations to improve mental health at work point to the importance of an integrated approach. The findings reinforce the interconnections between strategies and efforts to:

• improve the well-being of all employees
• retain and support people in work when they develop or experience mental health problems
• facilitate the return to work of people who have or have had experience of mental health problems.

Set out below are the components which the findings of this study suggest make up a whole organisation approach to promoting and improving mental health and well-being at work, by considering the implications for organisations, for management and Human Resources functions within organisations and for individual employees.

Organisation wide responsibilities
According to participants in this study, to gain employer attention and commitment, there is a need to heighten employer awareness that the mental health of their workforce is a key asset for business success and for effective, quality service delivery and that the costs of not addressing this are high. It was also considered that employers stand to gain from enhanced workforce retention and from being recognised as an employer of choice.

The experiences and views of employees suggest that resource packs and tool kits are only one element of what employers need, and should be accompanied by training, support and advice to utilise resources and tools and contacts and connections with local networks of services and resources that can provide support to employees.

Employers require recognition if they are to strive to be employers of choice and need plaudits for good practice relevant to mental health and well-being. This might include acknowledging that a great deal is happening already and this need not always entail new or special initiatives. There is opportunity to make use of Scotland’s Health at Work scheme (SHAW), Investors in People and other routes to draw attention to well-being and ensure it is on the agenda of items that senior managers attend to.

According to the views of participants in this study, core factors that have a bearing on employee well-being are:

• ethos and culture within the organisation: peer support and informal networks are a crucial resource that flourish in supportive organisations
• employer commitment to the values of diversity and non discrimination, both in combating stigma and achieving heightened awareness of mental health and mental health problems
• respect for employees, manifested by commitment to consultation and communication with staff and by promotion of flexible working arrangements

Establishing a whole organisation approach sets a framework for improving mental health and well-being and supporting employees, within which individual teams, divisions and departments can develop appropriate policies, procedures and practices. It is important to ensure that focus is on well-being at all levels within organisation to achieve equity and synergy of effort. It is also important to ensure that promotion of well-being and support for staff extends to staff at all levels, including senior managers and executives. Responsibility for employee mental health and well-being needs to be woven into an organisation's structures of accountability.

Management functions
Line managers are a key resource for employers in promoting the mental health and well-being of the workforce. The line manager role is well placed to provide support to assist employees with the factors that may affect well-being. They also need to be alert to early indications that employees are experiencing difficulties in order to take timely action to stop situations reaching crisis point. This means that managers need competence and confidence in communication and listening skills. Managers' job descriptions can be used to reinforce responsibility for employee well-being, by building this in as a performance indicator.

Organisations need procedures to facilitate access to information, advice and support for employees and for their managers. Policies and practices with regard to induction, return to work, appraisal, support and supervision all provide opportunities to maximise mental health and well-being. Working practices that value and respect employees and that give employees choice and control over their work as far as possible, contribute to employee mental health and well-being and support people with mental health problems.

Human Resources and Occupational Health functions
Staff turnover is costly in terms both of the expense of recruitment and of the experience and skills lost when people leave. Employers stand to gain by investing effort in measures to promote retention in work of people who develop mental health problems. These can include effective policies for dealing with sickness absence and return to work for people with mental health problems.

Methods of auditing well-being and stress at work can be useful to track trends and to pinpoint where attention needs to be directed. Occupational Health have a key role in this.

Communication and consultation with staff remain central to encourage dialogue and create a climate where it becomes easier to discuss problems, including mental health problems that affect work. Until this is possible, problems associated with mental health will remain hidden, to emerge when a crisis is reached.

Working practices with individual employees
Employees need to be made aware from when they are first recruited that they can talk about mental health issues and need to know how to access this type of support. Open door policies encourage accessibility. It helps to have options in addition to the line manager. There will also be sources of help in the local community if these are signposted appropriately.

Where an employee with a mental health problem is experiencing difficulty coping at work, looking with them at what changes can be made is an important first step. This can mean agreeing a change to workload or hours, setting and reviewing goals and providing feedback, arranging for gradual return to work after sick leave, arranging mentoring or buddying.

Inhibiting and facilitating factors

Taking action in the areas identified by employees in this research has to be informed by the features of the employer's world that are likely to stand in the way of or facilitate the desired changes.

Barriers to overcome
Undoubtedly the main barrier remains that of awareness, interest and commitment. As in previous work, this study points to the need to convey to employers that mental health and well-being are areas which would repay their attention (Mindout for Mental Health, 2002). The employee research and the earlier study by Lee on employers concur that the lack of understanding of mental health and mental health problems stands in the way of both employers' and employees' addressing mental health problems at work.

The employee study suggests collusion in workplaces, where employees are very wary of talking about problems they may experience, even when these problems have a direct bearing on their work performance and attendance, and employers appear not to register the mental health consequences (both positive and negative) of their policies and practices.

In addition, the perspectives of many of the employees in this study would indicate that the prevailing culture in many workplaces sets up a tension between the employer's duty of care on the one hand and a business ethic on the other that judges success in terms of performance and output, rather than seeing these as inter-dependent. This contrasts starkly with the strong ethical, legal and economic arguments, supported by an evidence base, which the Health and Safety Executive presents for employer action to address work-related stress (HSE, 2001).

Enablers and opportunities
There is scope, utilising the arguments put forward by the HSE and others to bring renewed attention to workplace mental health and well-being, not least on the utilitarian grounds of workforce retention and the enhanced performance that may flow from contented and supported employees.

The legislative framework to tackle disability discrimination requires employers to make reasonable adjustment to accommodate employees with a disability (Disability Discrimination Act 1995, HMSO). It has been argued that employers need to recognise the diversity of people who have a long term illness and disability to develop a range of responses which reflect the workforce profile (McLean, 2001). From the evidence presented here, for people with mental health problems, reasonable adjustments would entail flexibility of working arrangements and the provision of support. Broadly, what is required is a consolidation of those features of employment which tend to be recognised as good practice. It can be contended that in making the reasonable adjustments required to accommodate people with mental health problems in the workplace, employers could not only help to prevent recurrence of ill-health for people with pre-existing mental health problems but also, through the same courses of action, promote mental health and well-being for all staff and thus improve retention (Carr, 2003).

The employer research by Lee indicated that these cumulative messages have not yet been transmitted forcefully enough to employers to make the case. Lee suggested that employers were looking for a clear unequivocal rationale and a robust framework to guide their actions and to acknowledge effort.

The employee study included employees from a range of employment sectors, working in a variety of workplaces across Scotland. The particular challenges for small employers are evident in seeking to address the agenda set out here. What may be encouraging is the conclusion that much of what employees are looking for in the way of supportive workplaces (ethos and culture, working practices and supportive relationships, management of change, flexibility and workload management) is indicative of good employment practice, rather than necessitating special initiatives.