A paper containing the presentation to NHS Employers 2008

1. I do like Mondays
A summary of a presentation made to
the NHS Employers Conference,
November 2008.
Professor Derek Mowbray
derek.mowbray@orghealth.co.uk

2. We spend a very large amount of time at work, sometimes as much as 210 days a year. Over a 24
hours cycle we allocate our time as illustrated, showing that a third of our time is at work, and the
proportion of time not at work, but at leisure, is very small compared to the time we have
available to us.
Hours at work and at home
Work work
leisure
preparing for sleep
sleep
preparing for work
Proportion of work and leisure p.a.
33% 33%
Work
Leisure
Home
16%
Working time, therefore, is a major part of our lives. In theory, at least, work should provide us
with the ingredients that make us contented and happy. It is doubly important that work should
provide us with positive experiences because we spend so much time at work, and because we
2|Page

3. spend so little seeking the experiences outside of work that should contribute to our general
health and wellbeing.
Why is work so good for us?
• It can provide the things that make us contented and
happy:
»Good physical health
»Clear purpose
»Effective relationships
»Challenges
»Motivation
»Confidence
»Self esteem
These are the reasons why work is so good for us. Work should enable us to maintain good
health because it should provide us with a clear purpose in life, provide us with the opportunity
for making good and effective relationships with others; it should provide us with the challenges
that give us motivation. This, in turn, increases our own confidence to do interesting and exciting
things and cope well with the routine of life, and with this comes our self-esteem – making us feel
good about ourselves. Research tells us these are the characteristics that make us feel contented
and happy.
So often, however, work seems to provide the opposite. There is a sustained high level of
sickness absence and staff turnover due to psychological distress. The triggers for this distress
are many and varied, and for a large number of people work can be a misery – and worse – many
people keep this misery to themselves until such time as they cannot cope any longer, and need
to escape, despite the provision of employee support service of various kinds, such as employee
assistance programmes, and occupational health services. We call this period of misery and
unhappiness the ‘Iceberg Effect’, as it is often kept out of sight and beneath the surface.
3|Page

4. At this point I would like you to complete the Health and Wellbeing at Work questionnaire. I
should explain that this is not a psychometric instrument, and has, therefore, not been tested for
reliability and validity. Completing it is entirely voluntary. I use it as a very quick way of opening a
conversation as it provides immediate ideas of how employees currently think about their work.
4|Page

5. Health and wellbeing at work
questionnaire
We want to find out if you are feeling good about your work, and about your working situation. To help us
find out we would like you to complete this questionnaire. It focuses on how you feel now and over the
recent past (say a couple of weeks). Please try and complete all the questions.
Thank you very much for your co-operation.
Have you recently:
Been unclear about what you are supposed to do at work? Not at all no more Rather more Much more
than usual than usual than usual
Found that others have been taking decisions that prevent you Not at all no more Rather more Much more
from performing at your peak? than usual than usual than usual
Not at all no more Rather more Much more
Become irritated by the behaviour of your manager? than usual than usual than usual
Not at all no more Rather more Much more
Found yourself idling the time away?
than usual than usual than usual
Been spoken to by someone you thought Not at all no more Rather more Much more
than usual than usual than usual
was being rude, unhelpful and thoughtless?
Found it difficult to get involved in your work? Not at all no more Rather more Much more
than usual than usual than usual
Felt under pressure at work? Not at all no more Rather more Much more
than usual than usual than usual
Spent longer than your normal time at work? Not at all no more Rather more Much more
than usual than usual than usual
Experienced sexual innuendo or verbal abuse at work? Not at all no more Rather more Much more
than usual than usual than usual
Felt you have been unfairly treated? Not at all no more Rather more Much more
than usual than usual than usual
Been feeling energized at work? Not at all no more Rather more Much more
than usual than usual than usual
Taken a decision that has been acknowledged
as a major step forward at work? Not at all no more Rather more Much more
than usual than usual than usual
5|Page

6. Thank you. It seems that all of you would like to have a conversation with me!
Recent research has uncovered the costs of the ‘Iceberg Effect’. Taking the total costs of
psychological distress, including the ‘visible’ costs of staff sickness absence and staff turnover,
the costs of the ‘Iceberg Effect’ are a staggering 58% of the total costs, with the ‘visible’ costs
being a small proportion of the whole. The impact on organisation and personal performance is
huge, and in the public sector, is a key area where cost savings are to be found.
Costs of the ‘Iceberg Effect’ as a
percentage of total costs of
psychological distress at work
32%
58%
sickness absence
‘Iceberg effect’
10% staff turnover
reduced productivity at work
What is stress? It is the stage beyond pressure and strain, and when left un-treated can become a
serious physical as well as psychological problem for the sufferer. However, there is a widespread
and continuing belief that stress is fairly trivial. It is not!
6|Page

7. What causes psychological distress? There are three main causes with the prime cause being the
behaviour we show towards each other, in particular the behaviour that managers show towards
their staff. The secondary causes of stress are life events we all experience at some stage.
Research shows that these, well recognised, triggers of psychological distress occur to all of us at
some time, and are, therefore, foreseeable. Some are constantly present, such as change, and
yet the attention needed for different people with different personality types is often not
provided. Put simply, a MBTI type J has preferences for an ordered future, planning well in
advance and J’s don’t easily cope with uncertainty, whilst P’s can get on a plane without knowing
where it is going! I exaggerate, of course!
The tertiary causes are categories of events that have been categorised for legal as well as HR
purposes – they are identifiable, and can be dealt with under various regulations and procedures.
The regulations and procedures can, also, add to the psychological distress. These categories of
events tend to emerge from the prime and secondary causes, and they crystallize and possibly
camouflage the underlying causes.
Tertiary
Secondary causes
causes Effects
Harassment
Primary Change Bullying
Increased costs
causes Adverse life events Autocratic leadership
Under performance
Mergers Intimidation
Leaders High sickness and absence
Acquisitions Insecurity
Managers High staff turnover
Growth and expansion Lack of personal control
People Reduced profits
Downsizing Job insecurity
Poor quality
Collapse Fear
Lower market share
Uncertainty Unexpected events
Recruitment difficulties
Loss and bereavement
Negativity
Poor performance
Isolation
Excess demands
There are five main reasons for being concerned about psychological distress at work. These
include the requirement to comply with the Health and Safety Management Standards, the
possibility of legal action, the interest of insurance companies and the effect of increased
premiums, the haemorrhaging of money as well as the misery of individuals.
7|Page

8. Management Standards
The Health and Safety Executive Inspection
Prosecution under several
The Courts and Tribunals Acts
Increased premiums for
company
The Insurance Companies
health insurance schemes
Haemorrhaging money
through
The Business
sickness, absence and
staff turnover
The Individual Misery
So, what can be done to address the effects of psychological distress at work, and to ensure that
we derive the contentment and happiness we should expect from work, leading to improved
performance, less errors, more energy and greater achievement?
The starting point for me is to establish a framework within which we can develop strategies for
addressing the issues. The following framework was developed by me sometime ago to provide a
context in which health strategies could be defined. It translates well to a number of different
issues, and is presented here in relation to psychological distress. There are five strategies – 1) to
prevent and promote 2) to manage stress and reduce its impact 3) the get people back to work
4) to support people with chronic psychological distress and 5) to sustain a psychologically
healthy workplace.
8|Page

9. Strategy for health and wellbeing at work
Promote
Reduce the
Psychological
impact
health and
of stress at work
wellbeing
Sustain
Psychological health
and wellbeing at
Support work
Help
chronically ill
people
people back to
back to work
work
Focusing attention on the first strategy – the promotion of psychological health and wellbeing at
work. I think most organisations find it useful to see what this means. I have constructed the
following characteristics of a psychologically healthy organisation from research into globally
successful organisations.
Psychologically healthy organisations have:
•a clear, unambiguous purpose, expressed as a simple ‘big idea’, an idea which all the staff
relate to closely, and are proud to discuss with friends and colleagues.
•an atmosphere of confidence, where all the staff are interested in each other, support
each other, and project this confidence towards clients and customers.
•staff who behave respectfully towards each other, value each other’s views and
opinions, work in teams which are places of mutual support, where anything is
debated without a hint of humiliation, where the critique of individual and team
work is welcomed, discussed and where lessons are learnt and implemented.
•staff who ‘go the extra mile’ by providing unsolicited ideas, thoughts, stimulus
to each other, and where their interest in their customers offers something
more than is expected, beyond courtesy, and beyond service, offering
attentiveness and personal interest.
•challenges for their staff, that provide opportunities for personal
development through new experiences, and which treat everyone with
fairness and understanding.
•staff who are personally driven towards organisation and personal
success - intellectually, financially, socially and emotionally.
9|Page

10. You may think this is like Motherhood and Apple Pie, but let’s see how many of you work in this
kind of organisation. Once again, completing this questionnaire is entirely voluntary. It is,
however, another very quick way of finding out how employees and managers feel about their
workplace and their relationship to it. It provides a pointer towards the kind of organisational
dynamic that requires attention.
10 | P a g e

11. Organisation aspirations -
assessment
Assess your own organisation by marking your answer to each statement on a scale
of 1 (we have this aspiration in place) to 5 (we don’t have this aspiration in place
anywhere).
My organisation is one:
1 2 3 4 5
with a clear, unambiguous purpose, expressed as a simple ‘big idea’, an idea which
all the staff relate to closely, and are proud to discuss with friends and colleagues.
that has an atmosphere of confidence,
where all the staff are interested in each other, support each other,
and project this confidence towards clients and customers.
where staff behave respectfully towards each other,
value each other’s views and opinions,
work in teams which are places of mutual support, where anything is debated
without a hint of humiliation, where the critique of individual and team work is
welcomed, discussed and where lessons are learnt and implemented.
where staff ‘go the extra mile’ by providing unsolicited ideas, thoughts, stimulus to
each other,
where their interest in their customers offers something more than is expected,
beyond courtesy, and beyond service, offering attentiveness and personal interest.
that challenges staff,
provides opportunities for personal development through new experiences,
treats everyone with fairness and understanding.
where staff are personally driven towards organisation and personal success –
intellectually,
financially,
socially,
emotionally.
11 | P a g e

12. Ahrrrr – none of you! Of course, there will be some of these characteristics in your
organisation, and, hopefully, all of them. Too often, however, organisations do not
measure up completely
I hope the following cartoon, which is now quite old, doesn’t ring bells for you.
The time has come to press on with the actions that can be taken to promote
psychological health and wellbeing at work. I have provided a benchmark against which
your current situation can be measured. We will now move on to see how your
organisation can achieve that benchmark.
In the same way that there are three principal causes of psychological distress, I have
identified from research three principal steps to be taken that achieve the prevention of
psychological distress and the promotion of psychological health and wellbeing.
They are: First, and most significant – the training of managers/leaders in the
organisational characteristics and behaviours that promote commitment, trust and
engagement. Second - the construction of a context within which behaviour takes place
at work – the organisation and its ‘rules’, and how these can be developed to foster a
culture of commitment, trust and engagement. Third, the behaviour characteristics
required to promote commitment, trust and staff engagement.
12 | P a g e

13. Tertiary steps
Secondary
steps
Manager – Outcomes
employee relationships
Primary ‘big idea’
steps Architecture Manager encouragement Improved productivity
Training and Increased profit
development Manager discretion Improved quality
Leaders Recruitment
Improved market share
Pay Employee discretion
Managers Performance
Lower costs
Appraisal Lower sickness and absence
People Job satisfaction
Career opportunity Improved retention
Job security Employee attitude
Work life balance
Openness Team work
Involvement
Job challenge
At this stage I think most people find it difficult to envisage what is meant by the behaviours
needed to promote commitment, trust and employee engagement. Personally I find metaphors
useful, so I have chosen the dance as my metaphor. The dance has a context in terms of type of
dance, those who take a lead, the ‘rules’ of the dance, the culture of the dance in terms of the
music appropriate to the type of dance and the purpose of the dance itself. Finally, the
behaviours of the dancers are critical within the context. Communication is essential, and as the
dancers get to know the dance and each other, trust, commitment and engagement become the
distinguishing features between a fluid and effective demonstration of a dance and a dance
where the fluidity does not exist, but the steps are followed.
Anyone witnessing Strictly Come Dancing will see before their eyes the gradual growth in
commitment, trust and engagement between the contestants over several weeks, until
seemingly ordinary dancers, at the beginning, turn into highly effective dancers of almost any
type of dance, at the end.
Effective communication
13 | P a g e

14. Another metaphor I use is that of the role of conductor of an orchestra or chorus. The conductor
has the ‘rules’ – the score; he has the context (organisation) in terms of the range of instruments
and choral voices, and his job is to obtain the perfect sound by encouraging the different parts to
blend together in an interpretation the conductor creates. The conductor need not know how to
play an instrument, nor be able to sing (although it helps), but he does need the skills to engage
the performers in the way he wishes them to perform (behaviour).
So, what are the skills that leaders and managers require? Research relating to commitment,
trust and engagement shows that the following attributes are central to adopting the behaviours
needed to promote commitment, trust and engagement:
Skills required to create and
sustain commitment and trust
Someone who addresses Attentiveness
individual needs
Someone who creates stress Being able to offer
and deflates it direction with
committed
ambition
Assertiveness
Someone who possesses
intelligence Being someone who attracts
with psychological status
humour
The critical attribute is attentiveness. If someone is attentive to you a natural response is for you
to be attentive back. This has to be genuine attentiveness – if there is any doubt then the
strength of the relationship is broken, and takes time to be re-established. The other attributes
are: providing a clear direction with a committed ambition to achieve it; being sufficiently wise
(psychological status) that people will defer to your opinion and decisions even if they don’t
agree with them personally; intelligence with humour is highly seductive and helps to create a
stress free interaction (you cannot feel stressed if you are laughing!); assertiveness that has no
signs of aggression but a clear message of what is required; the ability to create degrees of
pressure and stress combined with the ability to deflate the stress; and the ability to address
individual needs.
Of course, the behaviours that demonstrate the attributes are complex. Just how complex is
shown in the following slide. We all tend to behave according to how we judge a particular
situation and the reaction we anticipate from the behaviour – at least we do this if we are
attentive to each other. We can train people to demonstrate the attributes in ways that provide a
supportive and positive response. We are constantly adapting to different situations. The classic
14 | P a g e

15. demonstration of this is my presentation today. I don’t do this at home, yet I need to
demonstrate the skills and attributes to you as a large audience in order for you to go away
thinking about what I am saying.
I will behave according to my interpretation of this
situation and how I expect you to respond
I will also behave according to my interpretation of this situation
and how I anticipate you will respond to me
Now, let’s see whether you have some of these attributes. The Quick Leadership Q is quick, and
provides an instant idea of how you judge yourself. Simply place a cross somewhere along each
line, and this will show where you need some training in acquiring the skills and attributes. Of
course, you will score yourself more favourably than others will, so we tend to ask people who
know you to complete the same questionnaire and then compare the results. Again, completing
this is entirely voluntary, but it does start the conversation.
Quick Leadership Overall
Assessment Q performance
© Derek Mowbray 1
Leading change 1
through others 1 Trustworthiness
10
10 10
Intellectual 1 10 Trust 10 1 Collaborative
flexibility working
and
10 commitment 10
1 Decision making
Attentiveness 1
skills
10 10
10
Ability to
1 1
1 = not good empower others
10 = good 1
Humour
Effective at
influencing
15 | P a g e

16. The process of training people in the skills, attributes and behaviours needs to adopt a triple loop
learning process. Simply providing a presentation of ideas hardly ever brings about change. The
ideas need to be reinforced at least twice after the presentation in order to bring about change.
We, therefore, adopt any learning technique to provide the triple loop learning experience.
•Workshops
•Learning sets
•Action research
•Coaching
Turning now to the context within which leaders and managers behave towards their employees,
it is necessary to construct an environment that promotes commitment, trust and staff
engagement. I have developed a simple organisation development framework which helps to
map out the features that need reviewing and developing. The framework focuses on four main
areas – the purpose of the organisation, its architecture (structure), the ‘rules’ by which the
organisation is meant to work, and ‘how to play the game’ – the behaviours that are required to
achieve the organisational purpose, whilst following the ‘rules’.
Organisation Development
Organisation purpose
Organisation Organisation Organisation
architecture ‘rules’ ‘how to play the game’
Organisation
development
Derek Mowbray 1994
16 | P a g e

17. The interplay between the different areas is expressed below:
The interplay between
organisation and psychological wellbeing
Purpose Trust
Architecture Interaction commitment Psychological
Rules between and the wellbeing
‘Playing the Leaders and psychological at work
game’ followers contract
I have introduced here the concept of the psychological contract. This is the idiosyncratic
personal sense of fairness that we all experience at work, which is an essential aspect of
engagement. If we feel that we are being treated fairly we tend to be engaged with the
organisation. The strength of the engagement is determined by other factors that I have been
talking about. Once that sense of fairness is broken, we start to dis-engage. Once dis-
engagement starts it is extremely difficult to restore.
Drawing everything together can be achieved by following the diagram below. It includes the
issues of context, the structure, the ‘rules’ and ‘how to play the game’. Research shows that the
items in the diagram are critical in achieving commitment, trust and engagement, and each item
has a particular slant that promotes commitment, some of which I have been describing today,
others requiring another presentation at another time.
17 | P a g e

18. Factors that influence trust and commitment
Purpose
The ‘Big idea’
Manager – employee Architecture
relationship
Employee attitude Structure
Manager discretion
Employee discretion
Attentiveness
Rules of the game
Management encouragement Job
Leadership ability Recruitment
Performance appraisal Pay
Teamwork Challenge
Involvement Secure
Openness
Communication
Work life balance Career opportunity
Responsiveness
Citizenship
How to play Training and Behaviour
Procedures
the game development Policies
By undertaking a systematic approach to organisation and management development, adopting
the ideas I have been presenting, organisations will achieve the characteristics of psychological
health and wellbeing at work. Instead of the slide about individual misery we can substitute the
following slide that shows health and wellbeing at work.
18 | P a g e

19. Whilst I have been focusing on psychological health and wellbeing, the picture is broader than
this as there is a direct interplay between physical health and psychological health. Organisations
that adopt a programme that achieves psychological health will also find that the physical health
and wellbeing of employees improves, and the other way round. Whilst good physical health
does have an impact on our ability to cope with psychologically challenging events, it is not the
complete answer. There is an urgent need for all organisations to focus on the psychological
health and wellbeing of everyone at work, to achieve high performance and effectiveness.
Thank you.
19 | P a g e