Assessed Coursework for Applied Psychology Postgraduate Courses
Module Title: Workplace Health and Wellbeing
Module Code: C84SRR
Grade Awarded: Merit
It should be noted that general absence is not included in this report, e.g. non-attendance at work because of annual leave, attending a funeral, or public transport issues. Consideration will only be given to ill health that affects the individual’s ability to work effectively, stay in work, or has caused them to be absent from work. Key words: rehabilitation, sickness absence, general absence (refers to absence not caused by illness), return to work, case management, wellbeing.
Absence From Work: The Extent of the Problem
Sickness absence costs the UK economy approximately £15 billion per year. The indirect costs of managing absence burden employers, estimated to be £9 billion annually, while the state incurs costs of £13 billion. This accounts for 140 million working days lost because of illness. However, a large proportion of these absences result in a swift return to work (hereafter referred to as RTW). Of concern is the number of absences that last longer than necessary, since 300,000 people leave employment annually and become dependent on state benefits.
Absence from work because of sickness is often avoidable, but when little or no constructive action is taken to return the person to work, the consequences are damaging to individuals, families, and wider society. Many causes of absence are the result of mild conditions which, if treated correctly, can allow individuals to stay in work or RTW as soon as it is possible after a period of sickness absence (Black & Frost, 2011).
In the UK, even though the employment rate is at an historic all-time high of approximately 75%, only half of people with disabilities are in work yet many would like to be employed if the appropriate support was made available. This inequality is a consequence of historic injustices and obstacles, which have developed and evolved over time (Department of Health on Improving Lives, 2017). Despite this, and to address the imbalance, the Government is committed to helping one million disabled people into work by 2028, which includes retaining those who are already in work (Improving Lives. The Future of Work, Health, and Disability, 2017). Black and Frost (2011) suggested that absence levels fluctuate considerably in relation to demographics and the type of organisation. For example, higher absences are associated with older workers, women, lower paid workers (£15,600 to £20,799 per annum), and those in unskilled occupations. Furthermore, public sector employers, larger firms, and organisations where trade unions function tend to have higher levels of reported absence. For example, the average (mean) number of sickness days taken by employees in 2016 equated to 3.5 in the private sector and 7.2 in the public sector. In contrast, the self-employed tend to take far less sickness absence compared to all sectors (Hussey, Turner, Thorley, McNamee, & Agius, 2012).
Possibly one of the most important issues of our generation is the impact of poor mental health on individuals, society, the economy, and Government. The annual costs are staggering; for employers, the burden is estimated to be £42 billion while the Government absorbs approximately £27 billion. Furthermore, the cost to the economy totals more than both figures combined because of lost output and productivity (Department of Work and Pensions, 2017).
It is recommended that specific focus is given to musculoskeletal disorders and mental ill health which accounts for 53% and 31% of reported sickness respectively by general practitioners. The evidence suggests that the health of the population will continue to deteriorate in the coming decade, particularly diseases linked to unhealthy lifestyles. The ageing workforce also poses a considerable dilemma for health professionals, since the population is expected to work longer. The challenge for all stakeholders is to find ways of reducing the burden and costs. This includes individuals, healthcare professionals, employers, official agencies, and the state (Black & Frost, 2011).
Interventions for Attendance Management, Rehabilitation and Return to Work
A 2009 public health report by the National Institute for Clinical Excellence (NICE) emphasised the need for organisations to develop and implement effective vocational rehabilitation interventions. A distinction should be made between ‘treatment’ and ‘vocational rehabilitation’, with the former achieving the goal of treating pathology and/or relieving symptoms, while the latter’s primary purpose is to improve capability for work and to transform that into actual working and effective productivity (Waddell, Burton, & Kendall, 2008).
First and foremost, the development of an effective absence policy is vital to the process of managing absence and effective rehabilitation. While there is no definitive answer on what should be included, it should ideally incorporate:
- A definition of roles, responsibilities and expectations
- Support for genuine absences
- The promotion of health and wellbeing in the workplace
- Reduction of obstacles which may affect an RTW
- Methods for preventing and deterring ‘illegitimate’ absences
(Grieve & Harrison, 2007)
Further recommendations regarding the implementation of a rehabilitation policy is stated in later in this paper.
Additionally, the Health and Safety Executive (n.d.) emphasised the importance of implementing robust recording and monitoring mechanisms, which have demonstrated success in reducing overall sickness. It is imperative that the correct process is followed when an employee is either absent from work, returning to work after a period of illness, or still in work and experiencing ill health. This should involve effective communications, consultation, planning, and delivery to ensure the person returns to work as quickly as possible or stays in work with the necessary adjustments.
The key question to be faced is “why do some people with common health conditions continue to work while others with similar conditions leave their workplace and seek a medical certificate?” (Black & Frost, 2011, p.16). While there is no conclusive answer to this question, experts suggest an individual’s response to illness is likely to be shaped by a wide combination of social and circumstantial factors. Indeed, while illness may originate from a health condition, the development of chronic problems can often depend on biopsychosocial factors. Consequently, a holistic approach must be adopted to consider all the influences which have previously, or are currently, causing the condition (NICE, 2009). A broad view expands upon the obvious conclusions which are often reached regarding causes of absence and encompasses attributes such as biological factors, e.g. genetic, psychological influences such as mood or ill mental health, and social issues such as cultural and familial matters.
Rehabilitation strategies must be tailored to meet the needs of the employee, to accommodate their multifaceted needs and complex histories, as opposed to adopting a generic method (Waddell, Burton, & Kendall, 2008). For example, a worker who is recovering from cancer treatment can RTW on full duties with temporary restrictions and thereafter progress to full duties with no restrictions.
Early intervention is vital to prevent prolonged periods of absence, since the longer the person is off work, the harder it is to encourage them back to work. In the first 6 weeks or so, low cost, low intensity interventions are appropriate for common health problems and thereafter can be adapted to more intensive and focused programmes for complex illnesses. To prevent a drift into long-term absences, short-term absences should be managed with effective and constructive RTW interviews to identify the underlying problems causing the absences. It provides an opportunity to identify patterns of absence and, if necessary, can lead to a formal caution (Waddell, Burton, & Kendall, 2008). Managing day-to-day sickness absence and RTW can be done by line managers, however for complex issues, managers need to obtain advice from human resources and health specialists (Institute of Occupational Safety and Health, n.d.).
Indeed, NICE (2009) recommends that planning and development should include consideration of the person’s age and gender, the circumstances which led to the condition, prognosis for returning to work, and the nature of the work they are employed to do. The organisation’s culture is a key element of this process, while the principles of equality, diversity, and inclusion should not be overlooked, e.g. race, ethnicity, disability, or sexual orientation. Circumstantial dynamics which may influence a RTW should be considered, including alternative options for employment, whether inside or outside of the organisation.
Once the evidence has been carefully considered, activities can be tailored to the individual’s condition. A multi-agency approach will ensure that the timing, extent, regularity, and intensity of the intervention is effectively agreed upon by all parties. It is imperative that the employee has confidence in the person delivering the intervention. Timing is key in case management, for example, musculoskeletal disorders require early intervention to prevent further damage and injury, e.g. referral to a physiotherapist, whereas following a nervous breakdown, for example, initial contact should primarily be to ascertain the person’s wellbeing and welfare and whether the employer can do anything to help.
Thereafter, rehabilitation can be considered should it become evident that a long-term absence is likely, for example after a fit note has been received or the employee has been absent for a month. The employer may need to take medical advice and can refer to an occupational health adviser, GP, or specialist for more information regarding the seriousness of the illness, how long a return to full health may take, and what adjustments or allowances are recommended in the interim. For example, if the employee is on an NHS waiting list for treatment, the employer may opt to arrange private treatment. This information can facilitate a programme of rehabilitation. (Institute of Occupational Safety and Health, n.d.).
Models help to broaden our view on this topic. Regarding exposure to pressure in the workplace, Bakker, Demerouti, De Boer, and Schaufeli, (2003) looked at job demands and resources as predictors of absence and duration. Furthermore Demerouti, Bakker, Nachreiner, & Schaufeli, (2001) proposed the job demands-resources model (JD-R) whereby working conditions can be categorized into 2 broad categories, job demands and job resources. The central hypothesis is that accumulated excessive work-related stress is a unique predictor of exhaustion, low morale, and burnout and can be referred to as health impairment. In contrast, job resources (job control and participation in decision making) can determine absence spells, including the worker’s level of motivation, for example improved morale, confidence, and engagement. These models highlight the essential role of line managers who have the authority and accountability for managing staff in ways which effectively reduce absences (NICE, 2009).
Critique of a Qualitative Return-to-Work Intervention for Workers with Common Mental Disorders
In Denmark, Andersen, Nielsen, and Brinkmann (2014) conducted a study to investigate how 17 workers who were suffering from common mental health disorders experienced a multi-disciplinary RTW intervention. The RTW programme was executed in 22 Danish municipalities with approximately 13,000 workers on sick leave irrespective of their medical diagnosis. The principles of interpretive phenomenological analyses (IPA) guided the study, which sought to capture the complex processes workers experience when returning to work. IPA is a psychological process which aims to offer insights into how a person makes sense of a phenomenon within a particular context. This method differs to most interventions which focus on the time to RTW, severity of symptoms, and ability to engage in work-related tasks (Andersen, Nielsen, & Brinkmann, 2014). Initially, the inclusion criteria required that the participant was absent from work because of stress or depression so a homogenous sample of participants could be selected.
However, in the recruitment process, the researchers failed to provide an official definition of stress. Subsequently, several sick listed workers who reported stress as a disorder were also experiencing symptoms relating to anxiety and adjustment disorders. This meant the researchers had to re-define the participants more broadly as being on sick leave because of common mental health issues and not narrowed down to stress or depression. This error demonstrates the importance of implementing the correct terms of reference and definitions when planning an intervention to prevent costly mistakes and possible reputational damage.
A multi-disciplinary team coordinated the RTW programme which consisted of municipal sickness benefits offers, psychologists, physiotherapists, psychiatrists, and physicians. Based on the information gained by the benefits officer, the worker was referred to an appropriate specialist. This approach concurs with Black and Frost (2011) who emphasised the benefits of capitalising on the knowledge and expertise of professionals from different disciplines so the ‘full picture’ can be established regarding the worker’s illness, thus allowing for more informed and accurate assessments and recommendations. In fact, several participants of the study stated the multi-disciplinary team made them feel confident that all the aspects of their cases were being fully considered (Anderson et al., 2014).
Participants found the psycho-educational group sessions to be helpful in providing insights into their symptoms and helped to reduce anxiety and fear. Spending time with others who were experiencing the same symptoms helped to normalise the condition, restore confidence, and alleviate feelings of loneliness. Shin and Lukens (2002) utilised the same intervention in a randomised controlled trial with 48 adults diagnosed with schizophrenia. The group responded very well and reported a reduction in perceived stigma and an enhanced understanding of the condition, which alleviated feelings of helplessness. These results suggest that a psychoeducational programme may be a viable intervention for workers experiencing ill mental health.
Despite this, the RTW activities proved to be problematic. One participant complained the RTW activities were ineffective and that no one asked how he felt to be back at work. This lack of care, empathy and attention by the line manager may have contributed to the worker contemplating suicide, which led to a referral to a psychiatric unit. As previously mentioned, line mangers should be adopting effective management processes vis-à-vis staff who have returned to work and require the appropriate support (NICE, 2009).
Several participants complained the interval was too long before returning to work which led to feelings of insecurity and the lack of a daily structure. This is concerning and illustrated serious failures in the organisation’s intervention programme which was not tailored to meet individual needs. Waddell and Burton (2006) provided extensive evidence to suggest work meets essential psychosocial needs in society where working is the norm and it is vital to individual identity, social roles, and social status.
By delaying the workers’ RTW, the mental health conditions deteriorated, however it is not stated to what degree. In addition, the 10 hours per week mandatory RTW activities caused additional stress for some who felt their health and energy levels were not up to it. Again, this feedback from the participants illustrated that the intervention was having a negative impact in some respects. This led to the authors concluding that the RTW professionals did not (whether because of mandatory requirements or not) consider the wide variation in the participants’ needs, timing, and extent of the intervention (Anderson et al., 2014).
Critique of a Workplace Intervention to Improve Heart Health in Women
Jones, Weaver, and Friedmann (2007) conducted a study in Alabama to evaluate the effectiveness of a workplace intervention designed to improve awareness of heart disease risk factors among 48 female ethnically diverse, lower income municipal employees. The project was aligned with various governmental strategies which targeted health awareness and all participants were required to have at least one risk factor for heart disease.
A quasi-experimental design was employed with one group with repeated measures. The intervention was based on the Health Belief Model (HBM), which suggests behaviour change to improve health is more likely to occur when the person was aware of the impact which risky behaviours may have. Perceived susceptibility and accrued accurate knowledge has the potential to bring about behaviour change (Janz & Becker, 1984).
The project was conducted over a period of 5 weeks and participants attended a 1 hour per week session during the lunch period to improve their knowledge of heart disease and how to reduce the risk of personal susceptibility. Each 1 hour session focused on a subject, specifically (and in sequential order); awareness of heart health, heart disease risk factors, nutrition, physical exercise, and stress management. A factual 33 item multiple choice questionnaire was used to measure their knowledge. Perceived susceptibility to heart disease was measured using a simple vertical visual analogue scale with 10 indicators, i.e. ‘no risk’ at the bottom and ‘high risk’ at the top, and the participant was asked to select a perceived level of risk in relation to developing heart disease. Scores on knowledge pre-test ranged from 30% to 70% (M=48.7%; SD=10.2). Post-test, scores ranged from 24% to 79% (M=52.1%, SD=11.4%). Average increase in knowledge was not significant before or after the intervention [t (47) = 1.536; p=.069). Perceived susceptibility scores were 4.03 (SD=2.0) pre-intervention and 4.47 (SD=2.0) post intervention. Average susceptibility was inclined to increase, albeit not significantly from before to after the intervention [t(47)=1.64;p=.055). The researchers suggested that the benefits realised from the project were modest but notable. Understandably, participants who had less knowledge and perceived susceptibility pre-test tended to improve more post-test compared with those who had higher levels of perception in these two areas.
A significant point has been overlooked, i.e. for what period after the intervention were the benefits still being realised by the participants? When one considers the demographic profile of the sedentary prone participants, who hailed from underprivileged obesogenic environments, it is likely that the accrued benefits were unsustainable.
Regarding use of the HBM, self-efficacy was not mentioned or seemingly considered. In 1988 this component was added to the model to better explain individual differences in health behaviour (Glanz, Rimer, & Viswanath, 2008). It may have been beneficial to add one more sessions to the programme on this topic since it is a key component in behaviour change. The researchers did not mention why only women were recruited to the programme. Their bias, which excluded men in this case, could present opportunities for future research if ‘men only’ programmes were conducted in tandem to analyse trends, tests of relationships, and probability theories. Regarding attendance, no data was collected on why participants did not attend some sessions. This information could have been useful in the design and implementation of future programmes to increase participation. Vis-à-vis healthy eating, the key topic of the third session, health and wellbeing practitioners in the workplace must embrace a holistic approach to improving workers’ diets. This should include heathier food offerings in the company’s canteen and food outlets, which encourage lower calorie diets and ‘nudging’ tactics that steer customers towards more nutritious meals and snacks.
Indeed, according to the Institute of Medicine, “it is unreasonable to expect that people will change their behaviour easily when so many forces in the social, cultural, and physical environment conspire against such change” (Kushi, Doyle, McCullough, Rock, Demark-Wahnefried, & Bandera, p.32). Despite these suggested shortcomings, the impact which the intervention had on the participants’ colleagues, friends and the wider community should not be overlooked (albeit minimally), since they were likely to have shared the knowledge gained from the Healthy People 2010 Heart Disease Educational and Community-Based Programme.
Critique of a Worksite Intervention Using Individual Counselling to Help Reduce Sick Leave
Proper, Van der Beek, Hildebrandt, Twisk, and Van Mechelen (2004) aimed to investigate the outcome of a worksite intervention which hoped to reduce staff absences from work by utilising individual counselling. A total of 299 civil servants from three municipal services were measured at baseline and randomised in clusters into the intervention (n=131) or control group (n=168). The intervention group and control group received the same written information on ways to improve lifestyle. This would have been to ensure that, at baseline, both groups had access to the same rudimentary information. Over a period of 9 months, the participants of the intervention group received a total of 7 20-minute consultations aimed at increasing physical activity and improving dietary habits. The sessions were conducted by a physiotherapist trained in the use of PACE (Patient-centred Assessment and Counselling for Exercise and Nutrition) protocols and materials (Patrick, Sallis, Long, Calfas, Wooten, Heath, & Pratt, 1994). This type of intervention utilises the Transtheoretical Model (TTM) which assumes that behaviour change takes place through various stages – namely precontemplation, contemplation, preparation, action, maintenance, and termination. Counselling and learning materials are tailored to match the person’s stage (Prochaska & Velicer, 1997). It was hypothesised that the counselling sessions would encourage persistent regular activity, improve eating habits, lead to less illness, and a reduction in sickness absence.
The mean sickness rate increased for both groups during the intervention, however the median value decreased. A multi-level analysis indicated no statistically significant effect, i.e. sick leave rate and frequency of sick leave. The author of this paper suggests that several intervention shortcomings resulted in a failure to reduce absence significantly. A maximum of 7, 20-minute long counselling sessions were offered over a period of 9 months.
Considering the ultimate objective of the intervention, which was to reduce sickness absence, it is reasonable to suggest that the sessions were not frequent enough or long enough. Positive effects were found for physical activity, cardiorespiratory fitness, percentage of body fat, and blood cholesterol. These findings partially concur with previous studies on the effectiveness of PACE interventions (Calfas, Long, Sallis, Wooten, Pratt, & Patrick, 1996).
At the start of the intervention, a large firework disaster occurred in the town of Enschede. A total of 22 deaths ensued and 1,500 houses were damaged, which led to a parliamentary enquiry. One of the municipal services who had participants in the intervention was involved in the disaster relief programme, including being accountable for the storage of the fireworks and issuing of permits. The authors of the paper suggested this interference did not adversely affect the outcome of the intervention. However, the mean number of sick days increased in the group, albeit not significantly. It may have been useful to ask each participant in the counselling session whether they felt the disaster had adversely affected their morale, which in turn could have influenced their enthusiasm and motivation to improve lifestyles.
Proposal for an Improved Attendance Management and Rehabilitation Policy
The Organisation
For this paper, the author reviewed the ‘Sickness Absence Policy and Procedure – a guide to sickness absence management, June 2017’ and related sickness data for the periods 01/04/2016 and 31/03/2017, of a large university in central London (thereafter referred to as the university). The primary campus is in central London with a smaller one located in north east London. A total of 1,700 staff are employed in the university’s 7 schools and 9 professional service groups (PSGs) with a total of 15,000 students engaged in higher education study.
The Current Primary Policy
The university’s primary and only policy fulfils all the legislative requirements and basic criteria for managing absence such as defining its purpose and principles, procedures for reporting and referrals to occupational health, protocol on RTW meetings, disability, and reasonable adjustments and trigger points. When a pattern of absence is a concern, first and second formal sickness meetings are compulsory as well as the final stage hearing. Long-term sickness absence is defined as more than 20 working days in one single period and guidance is given on the process to be followed by the employee for keeping in touch and providing evidence. Grounds of appeal must be in writing and a dismissal can only be authorised by the vice chancellor.
Nevertheless, several weaknesses are evident in the primary policy; the Bradford Factor formula has been excluded and can be an effective tool to highlight those employees who have a poor record of taking numerous short-term absences (Grieve & Harrison, 2007).
There is no reference to the process line managers and employees should follow regarding short and long term absences and long-term conditions which may require workplace adjustments. Specific guidance should be given on these matters to prevent ambiguity and confusion and, as discussed in the previous section, tailored interventions are necessary for the benefits of the individual and organisation. Failure to comply with the rules as set out in the policy is stated in two sections, specifically ‘purpose and principles’ and ‘sickness absence reporting and monitoring’. However, it is recommended that a dedicated section be entitled ‘misconduct’ which further clarifies the consequences of contravening the rules vis-à-vis notifying the university of an absence, keeping in contact and complying with the timeframes for producing medical evidence etc.
This standalone policy is inadequate for managing absences. The opportunities for implementing a proactive business model which focuses on vocational rehabilitation and retention has been overlooked. The university needs to take a more reactive approach to responding to ill employees, which includes strategies to make them healthier. ‘Rehabilitation has two main aims: To help employees return to work after an illness or disability and help employees with chronic health conditions stay in work’ (Institute of Occupational Safety and Health, n.d., pg.3).
Recommendations for Two New Policies
Consequently, the author of this paper recommends that two additional policies accompany the one mentioned above. The first policy should be for a guidance document for line managers, on how to utilise and get the best results from the primary policy. The provision of tangible guidance, specific advice, and realistic suggestions will ensure consistent decision making, which is compliant with the law, for example, when to obtain medical reports or which health professionals to consult.
The second policy should define a formal occupational health and rehabilitation programme that can help to keep employees in work, reduce short-term sickness, minimise long-term disabilities and get employees back to work as quickly as possible (Institute of Occupational Safety and Health, n.d.). It is recommended that a distinction is made between the disciplinary procedures which tend to have a more negative, authoritative tone (that is, the existing policy) and the rehabilitation processes which should be encouraging, helpful, and positive.
Moreover, employee wellbeing programmes can be an effective mechanism for developing resilience, morale, motivation, and a positive approach to life: “Organisations that achieved their absence targets were significantly more likely to manage (long- and short-term) absence through promoting health and wellbeing than those that did not achieve their target” (CIPD Annual Survey Report Absence Management, 2015, pg.26).
Supplementary recommendations and observations regarding an additional policy are specified below (hereafter referred to as the policy). Importantly it should be noted that, traditionally, rehabilitation focused on severe medical conditions and permanent impairments which required overcoming, adapting, or compensating for the impairment.
However, vocational rehabilitation for common health issues focuses more on the biopsychosocial factors which are preventing a return to work (Waddell et al., 2008).
Consequently, the policy should increase awareness by making specific reference, possibly in the form of appendices, to common health issues, which when combined account for approximately 75% of sickness absences from work, i.e. musculoskeletal disorders, mental health issues, and stress (Health and Safety Executive, n.d).
Effective case management is integral to the policy. Definitive guidance must be provided for line managers, as this will give them the confidence to uphold the policy and related procedures. RTW meetings must systematically fulfil certain criteria with the objective of establishing a rapport between both parties, while the needs of the employee and the organisation must be met. Early intervention is crucial to the whole process to prevent the absence becoming long-term.
Cases should be viewed holistically, through a biopsychosocial lens which encompasses biological, social, and psychological factors that are causing sickness absence (Institute of Occupational Safety and Health, n.d.). Furthermore, a proactive approach (rather than reactive) must include the promotion of wellbeing, for example use of the free yoga classes or the employee assistance programme.
It is recommended that a distinction is made between short- and long-term absence, since both require a different approach in terms of rehabilitation and retention, albeit the same principles are applied (Grieve & Harrison, 2007).
Implementation Issues for Consideration
During the development of the policy, high level buy-in by senior management is crucial to ensure the correct absence measures are in place, and these must provide a realistic snapshot of reported sickness absence at any given time. Reporting of sickness absence to the board must be mandatory, and a culture of accountability should trickle down to middle and junior managers to ensure they are taking attendance seriously in their departments. In implementing the policy, cooperation is required from all stakeholders who must understand the importance of meeting business targets, for example occupational health professionals and health and safety representatives. Trade unions and employee representatives should be consulted through focus groups or surveys to gauge opinion and help shape the policy (Grieve & Harrison, 2007).
It is recommended that the two new policies be introduced initially by the vice chancellor at a high-profile event and thereafter via the university’s formal communication channels and department meetings. The organisational development team should offer training sessions for staff, to help them become acquainted with the new protocol and guidance. Additionally, human resource representatives, deans of schools, and heads of 19 department have a key role to play in embedding the policy and developing a culture that is aligned with the effective rehabilitation and retention of staff who are experiencing ill health.
An analysis of the absence data being recorded for the university indicates accurate measurements pertaining to the 7 schools and 9 professional service groups (PSGs), (in relation to the data source). The data is filtered into specific PSGs and schools in relation to short- and long-term absences. According to the Chartered Institute of Personnel Development (CIPD), the average annual level of employee absence is 6.3 days and since the university is classified as a large organisation, this figure is expected to be higher. However, across the organisation there is clearly underreporting (particularly in the schools) in that the average number of sickness days for PSGs is 5.6 and schools is 3.4 per full time equivalent (FTE).
This evidence clearly indicates that line managers are not following best practice and the issue must be addressed to prevent further financial losses. Black and Frost (2011) emphasised the essential role of managers in ensuring that absences are accurately recorded to better inform decision making.
It is recommended a section provides sickness absence data and related direct and indirect costs so employees can gain a full picture of the impact of ill health including trends, hot spots, and the adverse effect on service delivery, including those workers who are left to pick up the additional workloads. It can help senior managers and line mangers identify priorities for action and implement robust strategies which focus on accountability, thus helping to achieve organisational effectiveness (Grieve & Harrison, 2007).
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