Spotlight on Local Mental Wellbeing Practice: East Midlands Trains Tackles Post-Traumatic Stress Disorder (PTSD)
How is PTSD an occupational health hazard in rail?
PTSD is defined in the National Institute for Health and Care Excellence (NICE) guidance as a mental health condition that can develop following ‘a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone’.
People get trained and prepared for danger when they join professions such as the military or police. Exposure to potentially traumatic incidents is something we talk about less in rail. A new RSSB study surveyed 700 frontline staff with nearly 95% experiencing workplace abuse in the last year alone, with over 25% experiencing physical assaults.
There were 293 public fatalities on the railway in the 2017-18 financial year, 249 of these were suicides or suspected suicides, 36 trespassers, 6 occurred at level crossings and 2 at stations.
It is a unique situation as it is unpredictable and not related to a fault or to the driver’s professional competence. Whether you are a driver or station worker, the very nature of the interface between the railway and the public creates an occupational hazard. In addition, repetitive overexposure to other occupational hazards, such as physical hazards and fatigue which increase the risk of burnout, may have important health and wellbeing consequences. East Midlands Trains (EMT) have acknowledged the likelihood that an employee may experience such a potentially traumatic event and are taking a dual approach to hazard management through pre and post event measures.
Preparation is key
Risk factors for PTSD, particularly in occupational contexts, include feelings of helplessness over a traumatic situation, feeling out of control of personal reactions, guilt and shame. EMT have developed a formalised training module for its new drivers. Facts and figures on events provide context and understanding. They get information on how it might impact them, normalising acute stress reactions which re expected following an abnormal event. The aim of this knowledge is to tackle unhelpful appraisals of an event and understand the complexity of events that are outside of their control.
By thinking of PTSD as an occupational hazard in the same way as we think about trackside safety or slips and trips, then we can actually get to grips with preventing it and managing it. We need the equivalent of PPE for trauma. 'For me it’s how do we protect our people? The best way to protect them is to prepare them. If you know what you might be dealing with you’re better prepared.'
Attending the coroner’s court after a death can be significantly distressing for staff. Seeing the impact of their staff, EMT took the coroner on a ride out to help the them understand drivers’ unique working conditions. Not only has this increased the coroner’s understanding of a fatality, but it has reduced the need for drivers to attend the coroners court and the associated distress.
EMT also ensure that all their staff have attended the Samaritans Trauma Support Training which is free for rail staff to attend. This helps provide a base level of emotional literacy throughout their staffing.
Like many rail companies, EMT were well versed in the support that drivers needed following a potentially traumatic incident. Treating it as an occupational hazard led those processes to be formalised and has helped ensure that everybody gets the same standard of care. The formalisation has facilitated the process being rolled out to non-drivers.
Historically, it wasn’t uncommon for drivers to take time off and be left at home, isolated and worrying about what they were feeling. Tanya explained, 'For me, it felt like we weren’t supporting them. If someone was having a problem they were just being left to self-manage. You didn’t get the watchful waiting. If you have that contact, you are ready in case things aren’t progressing normally and you’re looking for the red flags.'
‘Watchful waiting’ involves active monitoring of how the staff member is doing by their line manager and support network in the company. In line with the NICE guidance, if after four weeks their distress has not reduced, EMT refer directly into specialist psychologists.
'Historically trauma support was over-medicalised and all employees were sent to Occupational Health without thinking. The training they get now explains they are having a normal reaction to a horrible event and they are followed up by their own managers for a year post incident using a standardised contact form. This gives control back to the individual as to whether they want to come to Occupational Health.'
Within the procedures there is flexibility to respond on a case-by-case basis. Tanya shared that they have had drivers who have struggled following a previous incident, or had negative experiences of how their healthcare was managed. OH work closely with managers to determine the best way forward in these sensitive cases, 'the managers can pick up the phone to me and ask can they be seen directly to the psychologist and we refer them instantly.'
'Driver function have the process for supporting someone after an incident down as they see more and deal with it more often. I think it’s starting to make a big difference in the non-driver function. They’re a group that historically might have been forgotten about. All employees deserve the same quality of service. It is important to keep training the new managers into the business about trauma support so there is consistency of practice across all functions.'
'One of the biggest initial challenges was getting people to understand it’s not just for the driver function and trying to make sure staff in all the different areas have the information. You don’t want to be the company that has all the lovely policies and procedures, and no one knows they are there. It’s about having materials that are easy to find, easy to use, and easy to implement.' Embedding these changes can be difficult in functions where there is higher turnover. EMT have utilised groups to support dissemination in other functions.
Returning to work
Tanya shared that people were initially concerned that they wouldn’t get the time off they need after an incident. Rather, they get clinically informed time off with a recovery purpose instead of being left at a loose end. Return to work and reasonable adjustments are given careful consideration. 'Can a person do all of their job? A part of their job? And if it’s only part of their job how do we support them? I think it’s important that people are in a productive role and not just attending the workplace to sit in a coffee room. I don’t think that’s meaningful for them. When you are structuring a rehabilitation plan it’s important that it’s a meaningful plan and that it can be supported by the business. There’s a positive to being at work so that even if you’re struggling with mental ill-health., having structure to your day, something to get up for is really positive.'
Complimenting line manager support, EMT have a buddy scheme. Peer support schemes have demonstrated promising outcomes in attenuating PTSD. George Campbell, the driver manager who has spearheaded this work alongside Tanya, explained that after putting up posters advertising the scheme, buddies volunteered themselves. Buddies haven’t necessarily been through a traumatic incident themselves, it’s their interpersonal qualities that count. 'It’s about having the right person who’s giving the right support at the right time. They’re someone to check in, you don’t always want your manager knowing everything about you'. There are buddies available at all depots, and they are available for everything from a chat, to supporting adaptation of rosters.
EMT have developed these procedures just with the resources they have in house. The primary cost is time. The OH knowledge came from the Trauma Support Working Group, and George Campbell put it together as a training package. The Trauma Support Working Group is made of up HR, driver managers, a rep, and OH, whose sole remit was to develop these procedures. They examined what their issues were and what they wanted to address. They reviewed it after three months and were then able to disband once it was in place.
Tanya emphasised the importance of having union input. Their rep acted as a conduit both to the employees and the union, ensuring that staff’s concerns were heard and communicating to them how and why changes were made.
Importantly, EMT have been sharing their post-event procedures with wider industry. 'We believe in sharing our practice to improve the health and wellbeing across the industry'
'Any company could do what we did.'
The evidence base for trauma-focussed therapy is well established and reflected in the NICE guidance. However, there is less known about the effectiveness of psychoeducation interventions for the primary prevention of PTSD. At the time of designing their new procedures around potentially traumatic incidents, EMT’s average days lost to sickness absence following an incident was at 66. After reviewing the procedures, they reduced this to a remarkable 13.5.
Tanya helpfully reflected, 'improvement hasn’t always been sustained. It crept up to 55. You must look at why. At that time, we identified we’d had a period of incidents involving people who hadn’t done well historically. You have to look at the figures and ask why it’s like that.'
Tanya emphasises, 'it’s about having better policies and procedures that support better working practices. That then has a financial benefit, but more than a financial benefit, it’s the benefit of having people feel looked after and cared for. I was brought up by my father to believe ‘look after your employees, your employees look after the business’.
Being on the journey
'Our process will never be perfect, because no system is perfect. You are trying to do the best with the evidence base you have in that moment in time. You must constantly be looking and asking how you can improve on things. Are we doing the right thing? Is someone else out there doing something that’s better? Rail can benefit from looking at other industries and what they do. There is plenty of good practice going on in other areas.'
'As a business we’re on the journey of ensuring health and wellbeing is embedded in every decision the business makes, and that includes mental health. A few years ago, safety made the transition that safety was everybody’s responsibility, well actually health and wellbeing is everybody’s responsibility too. It’s about looking after yourself, looking after your colleague, and taking that outside the business to your families.'