A model of the stress process

There is accumulating research evidence for the stressful nature of the health and social care professions (Reference Guthrie and BlackGuthrie & Black, 1997) and consequently a growing interest in interventions that will decrease stress (Reference Carson, Kuipers, Hardy, Carson and ThomasCarson & Kuipers, 1998). This large and confusing literature often lacks a theoretical grounding. Fagin et al (1996) have put forward a three-stage model of the stress process (Table 1). External stressors, which comprise specific occupational stressors, minor ‘hassles’ and ‘uplifts’ and major life events, impinge on the individual. Mediating or buffering factors such as self-esteem, social support and individual coping skills determine the effect of the ubiquitous external stressors on the individual in terms of stress outcomes. These outcomes are generally measured in terms of psychological ill-health, burn-out and job satisfaction.

A model of the stress process needs to be an interactive one: the poorly-functioning doctor who lacks appropriate coping mechanisms and ends up working in an improverished service may well experience more occupational stresses than his or her more successful peer working within a well-resourced and professionally rewarding service (“Unto them that have more shall be given.”) Overwhelming personal or professional life events (e.g. a patient homicide) may lead to the decompensation of even the most resilient and best-supported professional. The model also requires modification to take account of a range of positive ‘motivating’ factors for workers – sources of job satisfaction for the individual. These will include recognition for work done, responsibility for others, personal advancement and salary (Reference Benbow and JolleyBenbow & Jolley, 1998), opportunity for working autonomously using specialist skills, variety in the job, physical security and a valued social position (Reference WarrWarr, 1987).

Stressors for psychiatrists

There are a number of broad categories of job-related stress: intrinsic characteristics of the job; organisational structure and climate; relationships within the work setting; and the demands of and opportunities for career development (Reference Benbow and JolleyBenbow & Jolley, 1998).

Drawing on the results of the NHS Workforce Study (Reference Borrill, Wall and WestBorrill et al, 1996), Thompson (1998) has identified a range of stressors experienced by psychiatrists, including: high work demands and insufficient resources; ambiguity of the consultant role, which is experienced as combining medical responsibility with lack of authority over non-medical colleagues; role conflict, when the perceived priorities of employers may conflict with the perceived interests of patients; poor social support, consequent on the dispersal of consultants into community teams; lack of feedback on job performance; and lack of influence over decisions at work.

These issues are reflected in the comments of consultant psychiatrists who retire prematurely (Reference Kendell and PearceKendell & Pearce, 1997) (see Box 1). Themes identified in a detailed qualitative study of sources of stress for mental health professionals working within a well-resourced community service were strikingly similar. In rank order, these were: administrative demands (79% of respondents); lack of resources (75%); work overload (58%); responsibility for patients (54%); patients relapsing (37%); fears of violence (33%); time management (33%); and working with demanding patients (29%) (Reference Reid, Johnson and MorantReid et al, 1999a ). Similar stressors were identified by Guthrie et al (1999) in a study that compared the sources of stress identified by trainee and consultant psychiatrists, although the impact of stressors was rated quite differently between junior trainees, specialist registrars and consultants. One striking finding was that 47% of consultants reported that their relationship with consultant colleagues was moderately or very stressful. Old age psychiatrists have reported their major stressors to be: overwork (56% of respondents); management issues (43%); resource issues (38%); personal stressors (33%); lack of time (30%); changes in the health service (22%); and changes in community care (17%) (Reference Benbow and JolleyBenbow & Jolley, 1997).

The day-to-day demands on the consultant psychiatrist are many and various. Community psychiatrists are expected to deal rapidly and effectively with a wide variety of clinical risks (Reference HollowayHolloway, 1997). The risks presented in one difficult but not atypical day to one of the authors are shown in Box 2. In addition to clinical risk, the consultant may experience a wide range of professionally adverse experiences: a set of such experiences directly or indirectly encountered by the authors is shown in Box 3. Each of these is likely to require formal or informal support for the average psychiatrist.

Mediating factors

Carson & Kuipers (1998) list mediating factors that might buffer the effects of occupational and life stresses. These include the individual's self-esteem, social support networks, hardiness, coping skills, mastery and personal control, emotional stability and physiological release mechanisms (such as humour, the ability to relax and the ability to let-off steam). Some of these appear to reflect temperament or personality traits which might be enduring or resistant to change. There is some evidence that psychiatrists differ from other doctors in terms of personality traits (Reference Deary, Agius and SadlerDeary et al, 1996) and that these differences have been apparent since before the initial choice of specialisation (Reference Firth-Cozens, Robertson and KatonaFirth-Cozens et al, 1997). Other mediating factors reflecting the environment or coping strategies, might be more amenable to change.

The one factor outstandingly and regularly referred to by mental health staff as being important in coping with work demands is talking with colleagues within the work setting, who are also perceived as the major source of support (Reference Reid, Johnson and MorantReid et al, 1999a ). The potentially isolated position of the consultant within a mental health team and the frequency with which consultants cite their relationship with their peers as a source of distress are both issues which deserve attention.

Managing workplace stress

Strategies to deal with the stresses of working life can be divided into those centred around the individual worker and those focused on the organisational characteristics of the workplace (Reference Carson, Kuipers, Hardy, Carson and ThomasCarson & Kuipers, 1998). Individually-based interventions include improving the coping skills of the worker (e.g. social skills training, stress management interventions, social support, training in time management and encouraging staff to alter their lifestyle, particularly the balance between work and home life). These ‘therapeutic’ interventions are reviewed in detail by Carson & Kuipers (1998), who quote Reynolds & Briner (1994):

One popular stress management technique in mental health services is the staff support group, although support groups are not necessarily perceived as valuable or even supportive by a significant proportion of staff (Reference Reid, Johnson and MorantReid, 1999b).

The occupational literature identifies a range of workplace interventions that might decrease stress. These consist of attention to a number of domains:

1. • role characteristics – issues of clarity of role and workload

2. • job characteristics – attending to the design of the job

3. • interpersonal relationships – improving communication systems within the workplace

4. • organisational structure and climate – encouraging decentralisation and participation by the workforce in decision-making

5. • human resource management – recruitment and selection policies that select staff for the task in hand, effective mechanisms for supervision, appraisal and performance management

6. • physical aspects of the work environment

All these are at least partially remediable within an effective management culture.

Support systems for psychiatrists

A range of support systems that might impact on the work experience and performance of consultant psychiatrists is presented in Box 4. Clearly, consultants going into post must have adequate training for the roles they will undertake. This will include both clinical and managerial skills (including the assessment and management of risk), specific training in the role of the doctor within a multi-disciplinary team and a firmer grasp of mental health law than is currently required. Trainees require a solid understanding of the principles and practice of health service management. Arguably, active engagement with the manifold ethical dilemmas that arise in psychiatric practice (Reference Szmukler and HollowaySzmukler & Holloway, 1998) might prepare the trainee for the pressures of the consultant role, which are ubiquitously experienced but rarely systematically analysed. ‘Calmanisation’, with its strict curtailment of the length of training, has, in these respects at least, done the aspiring consultant psychiatrist no favours.

Given that tasks, technologies and expectations within health services change rapidly, there is a clear central role for continuing professional development (CPD) and the opportunities it offers for the maintenance of knowledge, skills and professional attitudes, the acquisition of new skills and supportive contact with peers. There is a rhetoric of ‘lifelong learning’, which may be at odds with the reality of hard-pressed consultants reluctantly finding time for external and internal CPD events of dubious educational quality. There are financial implications for employers if CPD is to move from rhetoric to reality: good training costs professional time and, therefore, money.

To function effectively, the consultant psychiatrist requires his or her job to be designed appropriately. This requires a clear and achievable job description and adequate support to carry out the required tasks. A key role for the medical manager is to ensure that all consultants have a well-defined job description and person specification. One important managerial skill, which can be supported by the College, is to use a vacancy to review job descriptions and ensure that advertised posts have realistic expectations of the post-holder that reflect current good practice. Both the applicant and the employer must be clear that the job is the right one for the potential post-holder (a difficult rule to follow in a shortage speciality where some services face complete breakdown owing to difficulties in recruitment and retention).

It is clear that mental health workers in general derive most support from peers, although this is not necessarily the experience of consultant psychiatrists. The opportunities for the consultant to receive support from non-medical colleagues are real but rarely discussed in the literature, which tends to focus on the isolated ‘leadership’ role of the consultant. Informal support by consultant colleagues, which requires day-to-day contact, is highly desirable. We have encouraged the co-location of offices for consultants in a highly community-oriented mental health service on the hospital site. This does not have to undermine the consultant presence within the CMHT, particularly in urban catchment areas. Consultant colleagues may develop concerns over performance or health of a peer that cannot be resolved informally. In this case, they have an ethical duty to take appropriate action, which should usually be through the medical director, if necessary involving the GMC health procedures. Anecdotally, the first years of the consultant role are particularly difficult. Within a large trust in an inner-city area, we have successfully facilitated the formation of an informal group of new consultants who have met regularly for peer support: similar initiatives may be feasible on a multi-trust basis.

It is important that consultants participate in a formal meeting structure, which includes participation in regular clinical and non-clinical meetings. Non-clinical meetings should enable consultants to be active participants in the day-to-day running of their services and to be actively involved in the strategic direction of the services within which they work. Clinical meetings are traditionally focused on the training of junior medical staff, but they might usefully be structured towards addressing the emerging agenda of risk assessment and risk management, and in particular the neglected element of risk-sharing.

Consultants should have access to, and be prepared to make use of, second opinions in problematical clinical situations, if necessary using expertise outside the local provider trust. In the near future, access to teleconferencing may allow the consultant to obtain rapid access to specialist opinion.

One very significant support mechanism is the opportunity for wider professional contact outside the local service. Membership of College groupings and other professional organisations can offer the consultant vital opportunities for reinforcing professional skills, enjoyable contact with peers and clarifying issues of concern or difficulty with peers. Similarly, consultants are well-advised to maintain special interests, which might include specialist clinics, academic sessions or private practice.

It is important that consultants have the capacity to negotiate with management. This requires skills on the part of the clinician, particularly in the formulation of issues of concern and the development of potential solutions, but more importantly a commitment from management towards their workforce and an understanding of the reality of the problems that practitioners experience. Senior managers should be accessible to and respectful of consultants. There should be opportunities for clinicians to have contact with purchasers, possibly mediated via the Public Health Department.

Formal ‘appraisal’ and support

Management texts underline the value of formal mechanisms for supervision and appraisal. Community mental health staff experience supervision very positively (Reference Reid, Johnson and MorantReid et al, 1999b), although this is not available routinely to the consultant psychiatrist (or, for that matter, the consultant clinical psychologist). Benbow & Jolley (1998) have asserted that there is a need to review how consultant psychiatrists are supervised and supported, but without articulating a mechanism that could offer this to practitioners who are defined by and fiercely defend their clinical autonomy. Introducing supervision and appraisal may become less difficult as the current generation of trainees, who have been subject to the more thorough contemporary methods of scrutiny and appraisal, come into post. The clinical director role offers opportunities for a senior clinician who has the general support of colleagues to provide advice and support when the many practical hassles of the consultant role (identified, in part, in Box 3) threaten to become overwhelming.

Currently, appraisal and mentoring of senior doctors only comes into play when there is a perception that the doctor's functioning is unacceptable, within a framework involving the local employer (mediated by the medical director) and, if necessary, the GMC (Reference IrvineIrvine, 1997). It can be argued on general principles that similar mechanisms are required for all consultants, irrespective of performance, to maximise the individual's potential – although the evidence base for this assertion is not entirely clear. Perhaps more pressing is the expectation that professional self-regulation is failing, and it may be that the introduction of mentoring and appraisal will modify demands for re-accreditation of specialist status. Domains that should be covered within an appraisal system are the individual's knowledge, skills and attitudes (against current standards of good practice, which will be evolving continually) on the one hand and his or her performance, both clinical and non-clinical, on the other. The ultimate goal, within the overall context of clinical governance, is the not unreasonable one that professionals should be judged by their clinical outcomes. Mentoring, which is purely supportive, needs to be distinguished from the performance management aspect of appraisal.

Formal appraisal procedures for consultants are currently the subject of much discussion, and confusion. The clinical governance framework will demand their implementation. In our view, the difficulties around appraisal mechanisms turn on a lack of clarity of purpose. Appraisal is in danger of being an ‘overburdened’ concept. We can recognise at least five purposes linked to the term:

1. (a) Helping consultants continually to develop practice, improve performance, and achieve excellence: this is seen as a supportive process, occurring within a confidential relationship with the appraiser.

2. (b) Reviewing performance (e.g. using a set of indicators of minimum standards): this obviously needs to be taken into account in developing one's practice, but it raises the question of what should be done if standards are not met.

3. (c) Dealing with poor performance: here, standards are not being met. Remediation may be offered within a context of support, education and training, and perhaps it can be done within the same appraisal setting as that for continual development. However, if seriously poor performance is at issue, or ‘supportive’ remediation is not working (and someone needs to monitor this), and there is a threat of disciplinary proceedings, we believe it cannot be dealt with in the same ‘appraisal’ setting.

4. (d) Professional self-regulation and re-validation: there is a suggestion that local appraisal could be combined in some manner with external accreditation by a body such as a medical Royal College to form the basis for re-validation by the GMC. Results of appraisal must then to some extent become public.

5. (e) Reassuring the public that doctors are safe. It is not clear what would reassure the public; perhaps none of the procedures listed above would be effective.

A single annual ‘appraisal’ session with a clinical director or medical director cannot meet all of the purposes set out above. If we are serious about continuing development, it needs to be done in a supportive and essentially private setting (Standing Committee on Postgraduate Mental and Dental Education, 1998), more than once a year, and by someone whom the consultant trusts – perhaps a peer. Data about performance should be incorporated, as should a meeting with a service manager, so that the strategic direction of the trust and the business plan of the service are clear to both appraiser and appraisee. Dealing with performance failures and providing data for re-validation could be carried out by another type of ‘appraiser’, such as a clinical or medical director. Whatever the details, we would argue that if the supportive and developmental component is not to be lost, more than one type of appraisal procedure is required (with the consequent resource implications).