Appendix C
Stress Assessment Tool
CONFIDENTIAL
Stress Assessment Tool
For the purpose of assessing a person’s level of perceived stress this template can be used as a guide for initial assessment, possible
actions to be taken and as a precursor to trigger a referral to Staff Support and Counselling Service at Occupational Health.
The form can be completed either by:

An individual member of staff can complete this form at any time s/he feels they are experiencing signs or symptoms of stress.

Should a manager feel that a member of staff is displaying signs/symptoms of stress, they should encourage him/her to complete this
form.

This risk assessment should not be seen as a one-off exercise but should be incorporated as part of Supervision and Appraisal.

The Appraisal may trigger completion of this risk assessment where stress issues have been identified.

It is the manager’s responsibility to ensure that this form is completed for all members of staff returning to work following a period of
absence due to stress.

It may be beneficial for the member of staff to involve/obtain advice from his/her Trade Union safety representative. If it is the member of
staff’s wish, this form is to be made available to his/her Trade Union Safety Representative.
The first part should be completed by the individual member of staff experiencing signs or symptoms of stress.
The second part can be completed individually and/or with the line manager. Further advice can be sought from Mark Abbotts, Health and
Safety Manager on 01392 208642.
Devon Partnership NHS Trust Stress Policy can be found on the intranet web site for information:
http://www.devonpartnership.nhs.uk/uploads/tx_mocarticles/HR52_Reducing_Stress.pdf
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To Be Completed in All Assessments
Name:
Directorate / Section:
Job Title:
Date of Assessment :
Manager :
Present at the Discussion:
Name:
Role:
Name:
Role:
Name:
Role:
Reason for completion of the risk assessment
Devon Partnership NHS Trust Policy on Reducing Stress at Work?
You should read the policy before completing the form
Yes
Return to work following absence due to stress
Have you read the DPT Policy on Stress Management?
At any point where the staff member is experiencing stress
Does the staff member have a copy of the Policy?
Incorporated as part of the Appraisal
Copy of assessment to go to the Manager for personnel file?
Information will only be shared with the Trade Unions with the consent of the staff member. If you wish to share the information
contained in this form with your Trade Union, please do so. Do you agree to this?
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CONFIDENTIAL
How to use this assessment tool / Scoring
To ascertain a guide to the level of stress a person maybe experiencing, complete pages 4 & 5 by circling the closest answer as indicated
with the agree / disagree guide. Try to answer this as honestly as possible, as just circling the middle figure throughout may result in
inaccurate results.
Please Circle most appropriate answer – Where 1 = Strongly Disagree and 5 = Strongly Agree
ACTIONS
I have been avoiding my normal tasks
I have been withdrawing myself from
company
PHYSICAL
1
2
3
4
5
1
2
3
4
5
I’ve been suffering from increased aches
and pains
Do you suffer from high blood pressure?
1
2
3
4
5
1
2
3
4
5
Then total up the results, ie. 4 + 5 + 3 + 4 = 16 and repeat this for the whole table on pages three and four. Then when you have the total,
transfer this to the corresponding box below to give an indication of levels of stress.
Guidelines to perceived level of stress
Low Stress
Date Completed
Date Completed
0 - 55
Medium Stress
56 - 110
High Stress
111 - 166
Very High Stress
167 +
Date Completed
Action
Identify triggers / monitor
Discuss triggers / refer to management
standards to resolve / complete part B
of the assessment to identify areas of
concern. Resolve locally.
Refer to Staff Support and Counselling
Service
As above
4
CONFIDENTIAL
Please Circle most appropriate answer – Where 1 = Strongly Disagree and 5 = Strongly Agree
FEELINGS
THOUGHTS
I have been feeling uptight
1
2
3
4
5
My memory seems worse than normal
1
2
3
4
5
I’ve been finding myself more upset
than usual
1
2
3
4
5
I have been experiencing a loss of self
confidence
1
2
3
4
5
I have been more easily embarrassed
than usual
1
2
3
4
5
I’ve been feeling more self-conscious
1
2
3
4
5
I have been feeling low most days
1
2
3
4
5
I feel cut off from others
1
2
3
4
5
I have been feeling more angry than
usual
1
2
3
4
5
I am at the end of my tether
1
2
3
4
5
I’ve been feeling more tense than
normal at home
1
2
3
4
5
My concentration is worse than normal
1
2
3
4
5
I have been feeling insecure
1
2
3
4
5
I am easily confused
1
2
3
4
5
I feel like I have lost my sense of
humour
1
2
3
4
5
I don’t feel motivated anymore
1
2
3
4
5
I feel more anxious than normal
1
2
3
4
5
I have difficulty in switching off
1
2
3
4
5
I have been feeling helpless
1
2
3
4
5
I’ve been less interested in day to day
activities
1
2
3
4
5
I have been feeling out of control
1
2
3
4
5
Things seem worse than they really are
1
2
3
4
5
5
CONFIDENTIAL
ACTIONS
PHYSICAL
I have been avoiding my normal tasks
1
2
3
4
5
I’ve been suffering from increased
aches and pains
1
2
3
4
5
I have been withdrawing myself from
company
1
2
3
4
5
Do you suffer from high blood
pressure?
1
2
3
4
5
I have been making more mistakes than
usual
1
2
3
4
5
I have been losing / gaining weight
1
2
3
4
5
I have been avoiding responsibility
1
2
3
4
5
I have been suffering from frequent
headaches
1
2
3
4
5
I’ve been drinking more alcohol to help me
to relax
1
2
3
4
5
I have been feeling unusually tired or
fatigued
1
2
3
4
5
I have been smoking more than normal
1
2
3
4
5
I have difficulty relaxing
1
2
3
4
5
I have been more argumentative than
normal
1
2
3
4
5
I seem to be suffering from more
infections
1
2
3
4
5
I have had more time off sick
1
2
3
4
5
I have been experiencing chest pains
and / or palpitations
1
2
3
4
5
I find myself comfort eating
1
2
3
4
5
I find myself sweating / shaking more
than normal
1
2
3
4
5
My sleeping patterns have changed
1
2
3
4
5
I have been suffering from indigestion /
nausea / diarrhoea
1
2
3
4
5
I have been seeing my GP more frequently
1
2
3
4
5
I have been feeling short of breath (at
rest)
1
2
3
4
5
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Control Measures Guidance Notes
The following section of this assessment tool (Part B) has been developed for Managers and Staff members to identify areas of particular
difficulty which may have preceded the member of staff experiencing stress in the work place. It will also facilitate the assessment of what
control measures have been used or can be used to help reduce the staff members stress. This can be kept and reviewed periodically at
agreed times or during supervision to identify any changes that may have occurred over the previous given period. Additionally it may help
to identify changes that were agreed previously that still require attention to facilitate the reduction of stress for any individual (where this is
realistically achievable).
Managers and staff can complete this part of the assessment as a joint initiative.
If it is found that there are particular areas that can be identified and dealt with by the individual or with the support of their manager, then
this should be addressed in the first instance and action planned with realist achievable target dates and reviewed at these times.
Should Some of these concerns raise further discussion issues or are not changeable due to local arrangements or DPT guidelines then
advice should be sought from the next appropriate line manager. The Health and Safety Manager, Business Partner or Occupational Health
may also be approached for further advice / guidance. They can be contacted via the following means;
Mark Abbotts, Health and Safety Manager, Wonford House
Hospital, Dryden Lane, Exeter, EX2 5AF
Tel: 01392 208642
Business Partner, via the HR Helpdesk, Wonford House
Hospital, Dryden Lane, Exeter, EX2 5AF
Tel: 01392 403442 or
403425
Peninsular Occupational Health Network – Counselling
Service
Exeter
Plymouth
Torbay
Barnstable
Tel:
Tel:
Tel:
Tel:
01392 217555
01752 437222
01803 655023
01271 322791
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Email: [email protected]
CONFIDENTIAL
Please Circle most appropriate answer – Where 1 = Strongly Disagree and 5 = Strongly Agree
Demands
Control
Support
DPT Provides me with adequate &
achievable demands in relation
to the agreed hours of work
1 2 3 4 5
Where possible I have control over the pace of
my work
1 2 3 4 5
DPT has policies &
procedures to adequately
support me
1 2 3 4 5
My skills & abilities are matched to the
job demands
1 2 3 4 5
DPT encourage me to use my skills and
initiative to do my work
1 2 3 4 5
I feel supported by my
manager or line manager
1 2 3 4 5
I feel empowered to use my full skills
and potential abilities at work in the
day to day tasks
1 2 3 4 5
Where possible I am encouraged to develop
new skills to help me undertake new and
challenging pieces of work
1 2 3 4 5
I feel able to support and
encourage my colleagues
1 2 3 4 5
I do not feel my skills and abilities are
used to their full potential
1 2 3 4 5
I have a say when I can take my breaks
1 2 3 4 5
In general jobs are designed to be
within the capabilities of employees
1 2 3 4 5
I am consulted over my work patterns and
annual leave
1 2 3 4 5
My Concerns about my work
environment are addressed
1 2 3 4 5
I feel supported by DPT in line with friendly
family policies???
1 2 3 4 5
I regularly work over and above my
contracted hours
1 2 3 4 5
I have opportunities to express my ideas and
points of view
1 2 3 4 5
Total
8
I know what support is
available and how and when
to access it
I know how to access the
required resources to do my
job
I have regular supervision
and appraisal from my
manager
I have the right equipment to
do my job well
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
CONFIDENTIAL
Please Circle most appropriate answer – Where 1 = Strongly Disagree and 5 = Strongly Agree
Change
I am provided with information to
enable me to understand the reasons
for proposed changes
Role
1 2 3 4 5
Relationships
DPT provides information to enable
employees to understand their role and
responsibilities
DPT ensures that the different
requirement it places upon employees
are clear and that these are compatible
with their role
There are adequate opportunities to raise
concerns about any uncertainties or
conflicts concerning role and
responsibilities
I have a good understanding of my role
and what is expected of me during my
duties
1 2 3 4 5
DPT promotes positive
behaviours at work to avoid
conflict and ensure fairness in the
workplace
1 2 3 4 5
1 2 3 4 5
I share information relevant to my
work with colleagues
1 2 3 4 5
1 2 3 4 5
DPT has policies / procedures to
prevent or resolve unacceptable
behaviour
1 2 3 4 5
DPT ensures adequate employee
consultation regarding changes and
provides opportunities for open
discussion
1 2 3 4 5
I am made aware of the probable
impact of any changes to my job
1 2 3 4 5
I am given training to enable me to
facilitate changes within my job
1 2 3 4 5
I am made aware of time tables for
change
1 2 3 4 5
My current job role adequately reflects
my current job description
1 2 3 4 5
I have access to relevant support
during change
1 2 3 4 5
I know the standards I have to meet in my
job
1 2 3 4 5
When change is implemented, I feel
equipped to deal with it
1 2 3 4 5
I know what I am expected to achieve in
my job
1 2 3 4 5
Total
9
1 2 3 4 5
Managers are enabled and
encouraged to deal with
unacceptable behaviour
There is a supportive team
atmosphere and dynamics
between the team are good
If I had a problem I feel that I
would be able to approach my
manager
There are unresolved conflict
issues within the team
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
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FINAL CHECKLIST OF POSSIBLE ACTIONS / OUTCOMES (To be considered during the discussion, with the Manager)
Identified Issues Raised
Training - Examples for Guidance
1.
2.
3.
4.
5.
Assertiveness Training
Changing Patterns of Work
Conflict Management Training
Stress Management Training
Examples of Internal Support Services Available
Agreed Action
Counselling (Occupational Health)
Occupational Health Unit advice and support
Stress Management Service (Adult and Community
Services only)
1.
2.
3.
4.
5.
Review Date
Examples of External Support Services Available
_______________________________
Signed Manager
_______________________________
Signed Staff Member
_______________________________
GP – Family Doctor
Citizen’s Advice Bureau
Consumer Credit Counselling Service
Trade Union
Example of Management Action
Review job description
Review work load/role
Review staffing levels
Review of general risk assessment
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