This document discusses work-related stress among district nurses and strategies for managing it. It notes that district nursing presents a unique caring environment but can also offer multiple sources of stress, including unmanageable workloads, lack of staffing, and inability to take breaks. The Health and Safety Executive's Management Standards approach provides a framework to identify and address stressors in the work environment through a staff survey tool and focusing on areas like demands, control, and support. Implementing solutions identified by staff like reorganizing caseloads or allowing more flexible time off could help reduce stress. Overall stress must be proactively managed through organizational changes to support staff wellbeing and allow district nurses to provide quality patient care.

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Michelle Burke
Michelle Burke is Tutor, Florence Nightingale School of
Nursing and Midwifery, King’s College London
Email: [email protected]
Managing work-related stress
in the district nursing workplace
AbstrAct

2. This article aims to highlight the issue of work-related stress
within the district
nursing workplace. It will acknowledge how the management of
work-related
stress has previously been discussed within nursing literature
and will consider
the emerging relationship between staff working conditions,
staff wellbeing
and quality of patient care. It will reintroduce the Health and
Safety Executive’s
(HSE’s) Management Standards approach to tackling work-
related stress,
which provides management support to reduce environmental
work stressors
and encourage enabling work environments and a positive
workplace culture.
Key Words
w District nursing w Work-related stress wStaff health and
wellbeing
w HSE Management Standards w Quality care
Work-related stress is defined as ‘the adverse reaction people
have to excessive pressures or other types of demand placed on
them at work’
(Health and Safety Executive (HSE), 2007:7). Under UK law,
employers have a duty of care to protect the health, safety and
welfare of their employees and to assess the risks arising from
hazards at work, including work-related stress (HSE, 2007).
Stressful work environments place high demands on a person,
without giving them sufficient control and support to man-
age those demands, with a perceived imbalance between the
effort required and the rewards of the job (National Institute
for Health and Care Excellence (NICE), 2009). NHS staff are
almost four times as likely to be absent from work with stress
compared with other occupations (Clews and Ford, 2009)

3. and the rate of sickness absence within nursing and mid-
wifery averages 4.87%, the third highest in the NHS (Health
and Social Care Information Centre, 2012).
environmental work stressors
In 2012, a national survey of nearly 3000 nurses captured
aspects of the working conditions of nurses in 31 acute hospi-
tals across England (Ball et al, 2012). Some 42% of the nurses
surveyed were classified as suffering from emotional exhaus-
tion; 70% of the respondents felt there were insufficient num-
bers of staff to get work done; 80% reported that at least one
aspect of care was not done in their last shift due to lack of
time and 44% said that they would leave their current job due
to job dissatisfaction. These results are supported by previous,
smaller studies (Zeytinoglu et al, 2006; Laschinger, 2010).
Although district nurses were not represented in the survey
by Ball et al (2012), the findings could be tentatively applied
to the district nursing setting, as smaller-scale research has
identified similar outcomes. A descriptive study by Evans
(2002) explored district nurses’ experiences of stressful work-
related events and found that the primary cause of stress for
district nurses was an inability to complete work in sched-
uled hours, with respondents regularly working over their
scheduled hours, taking work home and working through
their lunch breaks. Storey et al (2009) found that 36% (172)
of the district nurses surveyed identified workload and staff
shortages as the top barrier to continuing working in nurs-
ing. Haycock et al (2008) also highlight the culture of long
hours that is evident within district nursing. The study par-
ticipants likened district nursing to a ‘ward without walls’, a
care environment that is constantly expanding, with no limit
on the number of patients and little influence on the number
of referrals. The district nurses in the study described over-
whelming time pressures and a conflict between workload

4. and contracted hours that caused them to use other areas of
time, particularly their lunch break, to complete their work.
Haycock et al (2008) highlight that this lack of relaxation
time does not allow nurses to cope with stress. Witkoski and
Dickson (2010) explored nursing working hours from an
occupational health perspective and concluded that work-
ing without adequate rest breaks results in serious declines
in functioning, which can lead to safety issues for patients
and nurses.
the district nursing landscape
It is evident that although the workplace for district nurses
presents a unique caring environment, it can also offer
a multiplicity of sources of stress. The Health and Social
Care Act heralded the shift towards a more community-
focused NHS, and the NHS care objectives (Department
of Health (DH), 2012a) mirror the challenges community
health and social care services are facing. An ageing popu-
lation produces complex health and social care needs and
an enduring and increasing focus on long-term conditions
management, complex care management and end-of-life
care, which are the principal elements of the district nurs-
ing role. District nurses undertake multifaceted interven-
tions and assessments in a non-clinical environment, which
require a high level of responsibility and risk management
(Queen’s Nursing Institute (QNI), 2009). Add to this the
increase in the number of older people living alone and
the societal changes that have impacted on the availability
of family or social network support and the challenges are
British Journal of Community Nursing Vol 18, No 11 535
TOPIC HEADER PROFESSIONAL

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compounded. However, at the same time as the need for
skilled district nurses is steadily rising, district nursing num-
bers are dwindling and teams are working within a climate
of restructuring, organisational uncertainty and financial
constraint (Royal College of Nursing (RCN), 2012).
The shift in the configuration and focus of the NHS
will inevitably result in changes to nursing career pathways,
with a potential increase in the number of newly quali-
fied nurses entering the community nursing workforce.
Supporting both the existing and future workforce is piv-
otal to ensure high-quality autonomous care in the home
setting (QNI, 2009).

6. stress-management strategies
Work-related stress management in nursing has predomi-
nantly been researched from the perspective of reducing
its effects, rather than tackling actual stressors in the work-
place (Jordan at al, 2003). Within the nursing literature,
an emphasis has been placed on the different strategies or
coping mechanisms available to counteract stress in nursing:
w Problem-focused strategies (time management,
clinical supervision)
w Emotion-focused strategies (reflection, peer support)
w Lifestyle changes (diet, exercise) (RCN, 2005; 2009;
Fearon and Nicol, 2011; Por et al, 2011).
While emotion- and problem-focused strategies clearly
play a part in stress management, there is now increased
interest in investigating stress from an organisational per-
spective, with primary intervention strategies aiming to
attempt to eliminate the sources of stress by focusing on
changing the physical or sociopolitical work environment
(Jordan et al, 2003; McVicar, 2003; Fearon and Nicol, 2011).
recent reports
A recent large-scale cross-sectional survey of nurses and
patients in hospitals in the US and in 12 countries in
Europe was undertaken with the objective of determin-
ing whether good organisation of care (improved work
environments and nurse staffing) affected patient care and
nurse workforce stability (Aiken et al, 2012). Although the
findings varied considerably by country, it was found that
improved work environments and staffing levels were asso-
ciated with increased care quality and patient satisfaction.
It is of note that the research by Aiken et al (2012) in the
US showed that
‘investment in staffing improved patient

7. outcomes only if hospitals also had a good
working environment.’
In the Nursing and Care Quality Forum’s report, Brearley
(2012) also notes that the facilitation of quality nursing care
is not only an issue of resources (i.e. staffing levels), but also
of leadership and organisational workplace culture.
NHs health and wellbeing report
Four years ago, the Boorman Report (DH, 2009) set out
the case for the active promotion of a positive workplace
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The nurse’s working environment can offer a multiplicity of
sources of stress.
536 British Journal of Community Nursing Vol 18, No 11
PROFESSIONAL
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British Journal of Community Nursing Vol 18, No 11 537
TOPIC HEADER PROFESSIONAL
w Demands—includes workload, work patterns and the
work environment
w Control—how much say a person has in the way they
do their work
w Support—includes the encouragement, sponsorship
and resources provided by the organisation, line manage-
ment and colleagues
w Role—whether people understand their role within
the organisation and whether the organisation ensures that
they do not have conflicting roles
w Change —how organisational change (large or small) is

9. managed and communicated in the organisation
w Relationships—promoting positive working to avoid
conflict and dealing with unacceptable behaviour.
A key part of the approach is the employee ‘stress sur-
vey tool’ (Figure 1). This is based on a taxonomy of the
culture and made clear links between staff wellbeing and
three dimensions of service quality: patient safety, patient
experience and the effectiveness of patient care (DH, 2009).
It identified that when NHS staff support services were
proactive rather than reactive, and prioritised staff health
and wellbeing, staff performance was enhanced, patient care
improved, staff retention was higher and sickness absence
was lower.
The Boorman Report (DH, 2009) recommended that
all NHS organisations give priority to implementing the
NICE (2009) public health guidance, Promoting Mental
Wellbeing through Productive and Healthy Working Conditions:
Guidance for Employers, as a sign of their commitment to staff
health and wellbeing.
In turn, the NICE (2009) guidance recommended that
employers should consider adopting a structured approach
to promoting their employees’ mental wellbeing at work,
by using frameworks such as the HSE’s Management
Standards for Work-related Stress (2007).
Hse’s Management standards
approach to work-related stress
The Management Standards approach to work-related
stress evolved from extensive research carried out on behalf
of the HSE. Three theoretical models underpin much

10. of the evidence on work-related stress: the effort-reward
model; the demand-control model; and the model of
organisational justice (NICE, 2009).
The Management Standards refer to six areas of work
that can lead to stress if not properly managed (HSE, 2007):
Figure 1. The Health and Safety Executive employee stress
survey tool (HSE, 2007).
LeArNING PoINts
w The district nursing workplace is unique, but can offer a
multiplicity of
sources of stress
w Emotion- and problem-focused strategies play a part in stress
management, but there is now an increasing interest in
investigating stress
from an organisational perspective
w A Health and Safety Exectutive stress survey tool has been
designed to
capture employee’s perceptions of their work environment
w Pervasive work stressors must be acknowledged and
proactively
managed if the Government’s future vision of the NHS is to
become a reality
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538 British Journal of Community Nursing Vol 18, No 11
PROFESSIONAL
six identified work stressors and was designed to capture
employees’ perceptions of their work environment (HSE,
2007). The stress survey tool aims to help managers focus
on the underlying causes of stress in their workplace and
subsequently develop proactive stress prevention interven-
tions. The HSE’s website (HSE, 2012a) offers a variety of
resources aimed at managers and also employees. It outlines
the key Management Standards message, the person’s role
in the Management Standards and their next steps in the
process. Case studies provided by NHS trusts that have
employed parts of the Management Standards approach are
also available to view on the website (HSE, 2012b). One
trust used the stress survey tool and found that 32% of their
staff were experiencing work-related stress and this was
identified as being the main cause of staff absence. Nurses
in the trust identified that among the potential causes of
their stress were workload (demands), not being able to
take breaks (control) and levels of staffing (demands). The

12. trust responded by implementing face-to-face briefings at
the end of each shift to raise any workplace issues. Staffing,
recruitment and training needs were also addressed. The
RCN (2009) also presents examples of solutions identi-
fied by NHS trusts following implementation of the HSE
Management Standards approach, including appointing
more staff to a team when there was evidence of excessive
workloads and improved communication during a period
of change.
Gupta and Woodman (2010) describe a solution-focused
stress intervention which was implemented in a children’s
community palliative care team and which could be used
in district nursing teams. The nine nurses in the team
identified their stressors and were then asked to consider
solutions, which were divided according to what the nurses
thought they could do to reduce stress from an individual,
team, and service perspective.
Solution
s included:
w Fewer meetings
w Reorganisation of caseloads
w Active discharge
w An ‘achievable’ time-off-in-lieu system.
conclusion
District nursing team leaders could consider making use of
the HSE’s stress survey tool to capture their team’s percep-

13. tions of their work environments, to identify, with their
staff, the areas where improvements could be made and also
to communicate to commissioners the issues that affect staff
in their roles.
Team leaders are fundamental to creating a workplace
climate that enhances staff wellbeing and delivers quality
patient care. The Government (DH, 2012a) has called for
nursing leaders to be empowered and encouraged to man-
age resources to deliver safe, effective and compassionate
care—and interventions such as the Management Standards
approach are central to achieving this purpose. Investment
in a positive workplace environment that allows a skilled
district nursing workforce to develop, and in which staff
are enabled to provide quality patient care, is essential.
Achieving the government’s vision of an NHS in which
quality and outcomes are the best in the world (DH,
2012b) and in which district nurses play an important role
(RCN, 2012) will be a challenge if pervasive work stressors
are not acknowledged and proactively managed. BJCN
Aiken H, Sermeus W, Van den Heede K et al (2012) Patient
safety, satisfaction,
and quality of hospital care: cross-sectional surveys of nurses

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