CUMULATIVE TRAUMA AND STRESS IN THE WORKPLACE

Marion D Tyler, RGN, RHV, FAETC.

Introduction and Author Profile

My thanks to the NRAH and the Swindon PTSD working group team for inviting me to talk to you today. I feel privileged to be part of the conference amongstsuch highly qualified speakers.

I am now almost retired, after 30 years of working as a ‘stress consultant’. My background is in nursing, being a Registered General Nurse and a Registered Health Visitor.

My work in Stress Management began in ‘Primary Care,’ when I was based at a Health Centre in Dorset. During this time we became aware of the problems associated with ‘stress’ and its poor management.

Research undertaken by MIND found that more than 50% of patients attending GP surgeries were there because of stress related symptoms. I developed and launched a programme for patients, who wereidentified and referred by their GP’s to attend an eight week course. We had great success with patients showing positive benefits by reducing their anxiety and depression. Just as important was that they also reduced their need for medication and the need to repeatedly see their GP’s.

For the past 15 years I have been a stress management consultant and trainer, working in both the public and the private sectors.

Today my subject is:

Cumulative Trauma and Stress in the Workplace

I intend to firstly:-

  • Define Cumulative Trauma Disorder (CTD) and outline the costs to the UK. Identify some of the causes, signs and symptoms. We will then look at prevention of CTD and the legal responsibilities.

and secondly:-

  • Define stress and the difference between pressure and stress. Increase awarenessof problems associated with stress in the workplace and the employer’s legal responsibilities.

Cumulative Trauma Disorder may be defined as:-

‘A broad category that includes many common diseases that affect soft tissues of the body. CTD in itself is NOT a disease, but may result in injuries to one or more tissues. These tissues include muscles, joints, cartilage, ligaments, and or bone.’

Other terms often used to describe the concept of CTD include:-

  • Repetitive Strain Injury (RSI)
  • Overuse Strain (OS)
  • Occupational Overuse Syndrome (OOS)
  • Work Related Upper Limb Disorder (WRULD)

Causes of CTD

There are perceptions of many different causes, and not all experts agree. However some theories include:-

  • Over use of Muscles
  • Repetitive actions
  • Awkward or Static positions
  • Insufficient recovery time
  • Stress

How does CTD affect the UK industry?

According to the statistics released by;-

  • the Health and Safety Executive (
  • the Trades Union Congress, ( and
  • the Chartered Society of Physiotherapists, the costs to the UK are as follows:-
  • 1 in 50 of all workers in the UKreports a Cumulative Trauma Disorder.
  • Each affected person takes an average of 18.3 days off work.
  • Every day 6 people in the UK leave their jobs, due to CTD or a Repetitive Strain Injury condition.
  • It has been estimated that the cost to the UK industry could be up to £20 billion annually.

Signs and Symptoms of CTD

Like many illnesses, early intervention can be very beneficial, so seeking professional advice at the earliest possible signs may bring about a cure. Quite often there may not be any visual signs, but professional advice is still recommended. These are a few common symptoms:-

  • Aches
  • Pain
  • Swelling
  • Numbness
  • Tingling
  • Weakness
  • Cramp

Prevention and who is responsible?

The best possible solution is to prevent the problem from arising in the first place. Employers and employees are both responsible for managing cumulative trauma disorders, its prevention and the impact this has on the costs to the UK Industry.

Employers can:-

  • Improve employees’ working areas and ensure that they are comfortable.
  • Recognise a legal obligation to ensure safe working conditions under their duty of care.
  • Provide professional work place assessments to ensure safe working conditions.
  • Take appropriate and prompt action to change or improve workplace situations identified as being liable to result in CTD problems for employees.

Employees can:-

  • Follow good work/station guidelines to prevent problems relating to:
  • Eyes
  • Head, neck and shoulders
  • Back
  • Forearms/wrists/hands
  • Legs/feet
  • Environment

Guidelines can be accessed through If doubt whether a situation exists, a work station assessment can be requestedfrom the designated person or the health and safety representative at work.

Rest and Relaxation

Rest and relaxation have recently proved to be very effective in preventing problems associated with CTD. Techniques as simple as controlled breathing, regular walking, taking naps and light exercise have shown benefits in reducing the effects of CTD.

The following ideas may be consideredfor use in the work place:

  • Be relaxed. Work with relaxed muscles. Pace your workload, and try to stay ahead of deadlines. Take frequent breaks, (10 minutes every 60 minutes), or change the task.
  • Exercise. Gentle exercise performed routinely during the day helps to keep soft tissues flexible and ease tension.
  • Change positions. Plan different ways to change the working position, e.g.using a chair rather than standing.
  • Rotate jobs or share work duties. This can be fun.
  • Avoid alcohol, caffeine, excess sugar and tobacco. These can heighten stress, reduce blood flow and elevate the perception of pain.

Which neatly brings us to the second part of my presentation;-

Professor Cary Cooper based at LancasterUniversity is a leading expert on Stress Management. He has written and publishes many books and papers. One paper he has published is on Cumulative Trauma and Stress in the Workplace.

This paper looks at legal developments in the United States. Professor Cooper writes in an abstract from this paper:-

“Cumulative trauma is a form of worker compensation claim in which an employee contends that a major illness or disability is the cumulative result of minor job stresses and strains extending over a period of years”

Tackling Stress in the Workplace

Work related stress problems seldom occur overnight.Stress is often the result of cumulative factorsoccurring over a short or prolonged period of time.

Domestic and social events can contribute topersonal pressures and anxiety. Employers may not be able to intervene in an employee’s private life but employers need to safeguard their employees from work related stress as equally as they do from the risks of physical injury.

The Health and Safety Executive (HSE) has now established guideline workplace management standards to reduce the levels of work related stress, thus reducing the number of employees who go off sick and who cannot return to work because of stress.

It is recommended that organisations adopt a team approach to work with employees and their representatives in order to implement the stress management standards.

Definition of Stress

‘The adverse reaction people have to excessive pressures or other types of demand placed upon them.’

It happens when they worry (or fear) that they cannot cope.

(HSE 2000)

It is a person’sperception of a situation that will affect his/her ability to cope or not. The best way to describe this is by describing the fight or flight response, also called the ‘stress response,’ or the ‘challenge response’

What is meant by the Stress Response?

  • When a person is under pressure, the stress responses can act as a spur.
  • The pressure to meet deadlines can increase energy & drive.
  • In the face ofcompetition thismay enhanceperformance.
  • Where responsibility for the safety and care of others this response can improve the powers of concentration.
A Brief Physiology of the Stress Reaction

The fight/flight response is the body's primary reaction to a challenge; the secondary responses vary with a person’s emotional state.

If a person is in a life-threatening situation, or feels, (or imagines), he or she is in danger, a reflex action is triggered to prepare for the emergency. This is called the "Fight or Flight" or Alarm Reaction.

There are immediate physiological changes, which are brought about by the activation of the Sympathetic Nervous System.

The MIND becomes alert.

ThePUPILS of the eyes dilate.

The JAW clenches tight and makes one appear more aggressive.

MUSCLES stiffen ready for action.

HAIR stands on end, (to make one appear fiercer).

The MOUTH goes dry and the DIGESTIVE SYSTEM slows down.

The SKIN sweats and this is absorbed to keep the body cool during vigorous activity.

The HEART beats faster, to increase the blood supply to the vital organs and muscles. The blood pressure increases and the blood vessels dilate.

The LUNGS are stimulated to breathe faster to increase oxygen supply and expire carbon dioxide.

The LIVER releases glycogen, which is stored in the liver.

The PANCREAS releases extra insulin.

The ADRENALGLANDS produce adrenalin, to keep the reaction going.

The DIGESTIVESYSTEM slows down as gut mobility decreases, because blood is directed to the limbs and vital organs that are active in the fight/flight reaction.

FATTY ACIDS are also released into the bloodstream.

The NERVOUS CO-ORDINATION predominates in the SHORT-TERM response to stress, and the CHEMICAL CO-ORDINATION

predominates in the LONG-TERM stress reaction.

The MUSCLES of the body are also co-ordinated to prepare the body for the emergency reaction.

The Stress Responses
Alarm Reaction
  • Adrenaline increase
  • Raised blood pressure
  • Heart Rate increases
  • Increased alertness
  • Reduced blood flow to essential organs
  • Tightening of sphincters
  • Sweating
/ / Resistance Reaction
  • Stimulate adrenal cortex
  • Produces cortisone causing salt and fluid retention
  • Raises blood pressure
  • Reduces glycogen stores
  • Nor adrenaline production
  • Dilates peripheral blood vessels
  • Relaxes sphincters
  • Retains homeostasis

Note demonstration with bio-feedback machine

There is a clear difference between pressure and stress!

If pressures become too intense, or are too prolonged, or we are “working against the grain”, work suffers as well as the individual – causing distress.

There is much that can be done to relieve stress. Good management, good support systems and the creation of a caring culture can prevent many of the undesirable effects.

It is important that stress is not confused with pressure!

Remember - a certain amount of pressure is necessary to function well. It helps people reach their peak efficiency.

Having too little pressure or challenge is bad for us, resulting in boredom, frustration or even depression. Too much pressure can result in exhaustion and even breakdown, if prolonged and intense.

The Performance Curve is an excellent way to chart individual performance or efficiency in achieving certain tasks and undertaking responsibilities.

The vertical axis measures performance and the horizontal axis indicates the appropriate amount of arousal, or pressure, that is perceived by the individual.

The curve indicates the relationship between performance and arousal that is typical for most people.

What is Burnout?

“A loss of concern for the people for whom one is working”

or

“The psychological withdrawal in response to excessive stress and strain”

Burnout may happen to those people who have good intentions but often unrealistic goals, ending up with loss of energy, losing touch with themselves and others.

The onset is often slow. It may start with feeling emotional and physical exhaustion. Other indications are becoming cynical, impatient or detached, often ending up with resentment towards work and all people involved with work, including customers.

EARLY SIGNS OF STRESS AND ITS

MANAGEMENT

The early signs of stress can vary considerably from individual to individual, with the most frequent signs listed overleaf. These are grouped into three distinct types:

Physical – these are physical changes to the individual’s normal body functions.

Emotional or mental – these are changes to the individual’s normal emotional or mental state.

Behavioural – these show up as different patterns of behaviour to the normal.

If the stress problems are not resolved, there can be long term effects, and these are also listed.

Learning to manage excessive pressures effectively may improve the quality of our lives. In fact we may even live longer. Some people may tend to “blow their tops,” becoming angry, hostile and taking frustrations out on others.

Externalising their feelings in this way over a period of time will increase their risks of developing heart disease and/or arterial damage.

Alternatively, internalising,or “bottling feelings up,” may increase the risks of developing auto- immune diseases, reducing resistance to infections and even cancer, which is linked to the reaction to excessive pressures over a prolonged length of time.

What are the costs of stress?

  • About 1 in 5 people say that they find their work either very or extremely stressful.
  • Over half a million people report experiencing work related stress at a level they believe has actually made them ill.
  • Each case of stress – related ill health leads to an average of 29 working days lost. A total of 13.4 million working days were lost in 2001.
  • Work related stress costs society between £3.7 billion and £3.8 billion a year.

The HSE completed a six month trial of the new stress management standards, which were introduced across the country in 2004. Elizabeth Gyngell, the head of health strategy, when first unveiling the draft standards, warned that firms breaching the rules could be prosecuted under the Health and Safety at Work Act.

The HSE Guidelines, called “Tackling Work Related Stress,” identify six stressors, or causes of stress in the workplace. These are:

  1. Demands on staffsuch as workload, work patterns and the environment.
  2. Control – such ashow much say each person has in the way he/she does the work.
  3. Support – such as the encouragement, sponsorship and resources provided by the organisation, line management and colleagues.
  4. Relationships – such as promoting positive working to avoid conflict and dealing with unacceptable behaviour.
  5. Roles – such as whether people understand their role within the organisation and whether the organisation ensures that they do not have conflicting roles.
  6. Change – such ashow organisations (large or small) manage change and how it is communicated within the organisation.

Gyngell states that to meet the standards, employers will need to survey their staff, to measure how they feel they are affected by these six areas, and then provide feedback.

The Legal Position

Employers have a legal duty of care. The Health and Safety at Work Act 1974 states that every employer has a legal duty to provide a safe and healthy workplace andto ensure,

“….so far as is reasonably practicable the health, safety and welfare of their employees at work”.

This duty of care includes taking steps to prevent reasonably foreseeable risks.

Under the Management of Health and Safety Regulations 1999 employers have a statutory duty to regularly assess potential risks to the health of their employees.

Within this legislative framework the HSE Guidelines emphasise to employers that:-

“…ill health resulting from stress caused at work has to be treated the same as any other health hazard and should be borne in mind when assessing possible health risks in the workplace”.

This means that employers need to be aware of any situations where employees could be harmed, to assess the risk and to take action if deemed necessary. The Act does not require employers to take action to eradicate every perceived risk at whatever cost, but they do need to weigh up the degree of risk in the workplace against the time, trouble, cost and physical difficulty of taking measures to avoid or reduce the risk.

An employer who is taken to court for breach of duty under the Act will need to satisfy the court, (beyond reasonable doubt), that action wasn’t practicable or reasonable under the specific set of circumstances at his workplace.

N.B. Employees also have a degree of responsibility for their own safety.

Some of the main causes of stress

Stress is not just something that occurs overnight. There is usually a cumulative effect, involving a number of contributing factors, some of which we may be unable to control.

Common ‘stressors’ may fall under one or all of the following headings;-

  • People pressure. These are people from whom there is no escape. They may be people in our work place or in our private life.
  • Unacceptable time pressuresTrying to pack 36hours into 24. No time to relax, too much work and not enough play.
  • Sleep Deprivation. Sleep is the most restorative function of the body. When we are not getting the quantity or quality of sleep tiredness and exhaustion become an early symptom of stress.
  • Many Life Change Events that occur too close together. (See following list)

1

Life Change Events or Social Readjustment Rating Scale

Often people become stressed when there is a major change in their life or when they have to adapt to a new situation, whether that situation is good or bad. If several changes occur at once a person may then find it harder to cope, and suffer some degree of mental or physical illness. Researchers Holmes and Rahe in 1968 devised a Social Readjustment scale, which listed events in our lives, which are rated according to the amount of adjustment, required.

EVENT LIFE CRISIS UNIT SCORE

Death of wife or husband100

Divorce73

Marital separation65

Jail term63

Death of a close family member63

Personal injury or illness53

Marriage50

Getting the sack from work47