Interventions to prevent and manage psychosocial risks and work-related stress

Introduction

Prevention is the cornerstone of the European approach to managing occupational safety and health. Prevention means anticipating and analysing the various aspects of work to identify short and long term risks, and then taking action to eliminate or mitigate those risks; that is identifying and addressing the source of the problem. The actions taken to eliminate or mitigate risks are referred to as interventions. This article presents the different levels of interventions that can be applied to manage psychosocial risks and work-related stress. It also describes the process of psychosocial risk management which outlines best practice on how to design, implement and evaluate interventions. The article primarily focuses on prevention, rather than on an extensive discussion on treatment or rehabilitation.

Interventions to prevent and manage psychosocial risks and work-related stress

Traditionally, interventions to prevent and manage psychosocial risk have been distinguished in organisational, task/job level and individual orientations and more recently in policy/legislative orientations ^[1] [2]. On the other hand, distinction is also made between the stage of prevention (i.e., between primary, secondary and tertiary level interventions). Table 1 presents a taxonomy of interventions as proposed by Murphy and Sauter ^[1].

Primary interventions are proactive in nature; the aim is in attempts to prevent harmful effects or phenomena to emerge. Secondary interventions aim to reverse, reduce or slow the progression of ill-health or to increase individual resources, while tertiary interventions are rehabilitative in nature, aiming at reducing negative impacts and healing damages ^[3]. Often interventions appear to bridge prevention stages. The following sections aim to provide the reader with an informed commentary on each intervention level.

Primary level interventions

Primary level interventions, also commonly referred to as ‘organisational level’ interventions ^[4] are concerned with taking action to modify or eliminate sources of psychosocial risks inherent in the workplace and work environment, thus reducing their negative impact on the and on the incidence of work-related stress ^[5]. The objective of these interventions is to target the problem at source. Most often primary level interventions are designed to deal with aspects of work design, organisations and management that are perceived to be problems by a significant proportion of employees (Randall & Nielsen, 2010). Primary interventions require changes in working practices. They are targeted at the group level, rather than the individual employee (e.g., actions may include increasing the number of staff meetings to tackle problems or redesigning job tasks and processes). It is rare to find primary level interventions that do not involve employees in intervention design ^[6]. Primary interventions can take time to work, and evaluation periods tend to be long as employees often need to become accustomed to new working practices ^[7]. Murphy and Sauter ^[8] suggest that employees may also need training and support to adapt to new working practices and in order for this be effective this requires commitment and support from the organisation.

Secondary level interventions

Secondary level interventions involve taking steps to improve the perception and management of psychosocial risks for groups that may be at risk of exposure. It is important to note, secondary level interventions are not a substitute for primary prevention interventions. They are concerned with the prompt detection and management of experienced stress, and the enhancement of workers’ ability to more effectively manage stressful conditions by increasing their awareness, knowledge, skills and coping resources (Sutherland & Cooper, 2000). These strategies, are thus, usually directed at ‘at-risk’ groups within the workplace (Tetrick & Quick, 2003). The common focus of these actions is on the provision of education and training. It is commonly believed that through training, employees can become more aware and knowledgeable about, work-related stress, harassment, bullying and third-party violence; and, hence, better able to address these issues. Issues that can be covered through training include: interpersonal relationships (between colleagues and with supervisors), time management, and handling conflicts, among others.

In short, “… the role of secondary prevention is essentially one of damage limitation, often addressing the consequences rather than the sources of psychosocial risks which may be inherent in the organisation’s structure or culture” (pg.9) ^[9]. Although these strategies are usually conceptualised as ‘individual’ level interventions, these approaches also embrace the notion that individual employees work within a team or work-group ^[9]; thus, these strategies often have both an individual and a workplace orientation.

Tertiary level interventions

Tertiary level interventions have been described as reactive strategies ^[10]. Tertiary level initiatives are concerned with minimising the effects that result from exposure to psychosocial hazards; through the management and treatment of symptoms of occupational disease or illness. The consequences of exposure can be either ^{[5] [11] [12]}. Thus, people who are suffering from psychosocial complaints (which can include burnout, depression or strain, can be provided with counselling and therapy; and those suffering from physical symptoms can benefit from occupational health services provision. When affected employees have been off work because of ill health, appropriate return-to-work and rehabilitation programmes should be implemented to support their effective re-integration in to the workforce.

Within organisations, tertiary level interventions are most common, with secondary level interventions following and primary level interventions being the most uncommon form of intervention ^[13] [11]. This is unfortunate as health and safety legislation requires employers to deal with all types of risk to workers’ health and safety in a preventive, and not in a reactive, manner.

Comprehensive multi-level interventions

Developing continuous and sustainable initiatives to promote employee and organizational health and wellbeing, requires practitioners and organizations to move beyond uni-model interventions (either individual or organizational approaches) to multi-model intervention (i.e., using a combination of such approaches ^[12] [14]. These approaches incorproate all three levels, and is evident in the healthy work programme of a Dutch hospital ^[15]. At the primary level, job rotation provided employees with a variety of work tasks; whilst the archiving system was redesigned to facilitate storage and retrieval of records, which reduced workload of employees. Support from colleagues was encouraged and managers were provided with supervisory training to be more supportive. At the secondary level, employees were provided with courses on stress management, while specific departments were targeted with additional training on dealing with death, violence, and aggression. At the tertiary level, supervisors were encouraged to participate directly in dealing with sick and absent workers, while changes in job roles were considered for those on long term absence in order to facilitate a quicker return to work

Policy level interventions

Policy level interventions in the area of psychosocial risk management and the promotion of workers’ health can take various forms ^[16]. These may include: the development of policy and legislation; the specification of best practice standards at national or stakeholder levels; the signing of stakeholder agreements towards a common strategy; the signing of declarations, for example at the European or international levels, often through international organisation action; and the promotion of social dialogue and corporate social responsibility (CSR) in relation to the issues of concern ^[17]. See policy interventions on psychosocial risks for more information on policies with regard to psychosocial risks at work.

Psychosocial risk management

As discussed previously, prevention is the cornerstone of managing occupational safety and health in Europe. The focus of European legislation on health and safety is on primary risk prevention targeted at the workplace; where the organisation is viewed as the generator of risk ^[3]. The risk management approach to dealing with health and safety problems is clearly advocated by European Legislation and is described in some detail in supporting guidance. It is, for example, referred to in the 1989 European Council’s Framework Directive 89/391 EEC on Safety and Health of Workers at work, and in the national legislation of member states. It is also implicit in official European, national and international guidance on health and safety management. This section aims to provide a concise summary and discussion of psychosocial risk management; in terms, of its development, key elements and process.

Development of the European framework psychosocial risk management

The use of risk management in occupational safety and health (OSH) has a substantive history ^{[18] [19]}. Risk management in OSH is a systematic, evidence-based, problem solving strategy. The risk management approach begins with the identification of problems and an assessment of the risk that these problems pose; and subsequently, uses this information to suggest interventions for reducing the identified risk(s) at the source. The developed and implemented risk management actions or interventions (informed by the risk assessment) are evaluated. Over the last two decades a number of approaches incorporating the risk management paradigm to prevent and manage psychosocial risks, and issues such as work-related stress, have been developed and implemented ^{[20] [21] [22]}.

One of the first models using the risk management paradigm to prevent and manage psychosocial risks and work-related stress was proposed in the UK in the early 1990s ^[23]. The proposed approach was based on a general summary of systematic problem-solving processes, commonly used in both applied psychology and in management science. The premise was that the risk management paradigm was already understood by managers, and one that had been widely in operation in many countries for some years with respect to the management of chemicals and other substances known to be hazardous to health ^[24]. The starting point for the development of the risk management approach for psychosocial risks was based on the changing nature of work and of work problems and work-related ill health ^[23].

To promote a unified approach, the European Commission funded the development of the Psychosocial Risk Management European Framework (PRIMA-EF), which incorporates best practice principles and methods of all existing and validated psychosocial risk management approaches across Europe ^[21]. According to PRIMA-EF, psychosocial risk management is a stepwise iterative process based on a variation of the Deming Cycle, consisting of the steps Plan, Do, Check and Act, as presented in Figure 1. Managing psychosocial hazards is not a one-off activity but part of the on-going cycle of good management of work and the effective management of health and safety. As such it demands a long-term orientation and commitment on the part of management and leadership. As with the management of many other occupational risks, psychosocial risk management should be conducted often, ideally on a yearly basis.

Key elements for psychosocial risk management

Psychosocial risk management should incorporate five important elements: (i) a declared focus on a defined work population, workplace, set of operations or particular type of equipment, (ii) an assessment of risks to understand the nature of the problem and their underlying causes, (iii) the design and implementation of actions designed to remove or reduce those risks (solutions), (iv) the evaluation of those actions, and (v) the active and careful management of the process ^[3].

The process of psychosocial risk management

There are five main steps in the psychosocial risk management process.

Risk assessment and audit

The model underpinning risk management for psychosocial hazards is relatively simple. Before a problem can be addressed, it must be analysed and understood; and an assessment made of the risk that it presents. Much harm can be done, and resources squandered, if abrupt action is taken on the assumption that the problem is obvious. The risk assessment provides information on the nature of the problem, the psychosocial hazards and the way they might affect the health of those exposed to them and the healthiness of their organisation. The risk assessment should focus on organisational level issues that have the potential to impact on group and possibly large numbers of employees, rather than individual employees. Useful risk assessment and management tools such as the British Health and Safety Executive Management Standards, Istas21 (CoPsoQ) Method, the SOBANE strategy applied to the management of psychosocial risks, and QPSNordic Questionnaire are used widely and focus on organisational issues such as demands, control, support, role, relationships and change (see further resources for links to tools).

Translation and development of action plan

Adequately completed, the risk assessment allows the key features of the problem to be identified - these have been called likely risk factors - and some priority given to them in terms of the nature and size of their possible effects or the number of people exposed. For example, there might be problems in relation to issues such as workload and work patterns which may be placing unreasonable demands on employees. The data from the risk assessment and other organisational data related to sickness absence, productivity, staff turnover etc., can be used to inform the development of an action plan to address the problems at source whenever it is reasonably practicable to do so. Usually, the discussion and exploration of the problems and likely risk, facilitates the discovery of any major problems that may be hidden but give rise to those problems and likely risk factors. This often makes intervention easier as the underlying problems can be targeted and not only its symptoms. For example, the Management Standards approach recommends that the outputs and conclusions from the data collection and analysis should be discussed with a representative sample of employees, involved also in identifying a preliminary action plan, containing suggestions and recommendations for action at different levels of the organisation.

Risk reduction: implementation of interventions

The development of the action plan and design of interventions also involves deciding on: what is being targeted, how and by whom, who else needs to be involved, what the time schedule will be, what resources will be required and how the action plan will be evaluated. If properly handled, planning to reduce risk in relation to psychosocial hazards is no different from any other management activity. The interventions are implemented as planned and its progress monitored and reviewed, and the processes involved and their outcomes eventually evaluated. It is important to work in partnership with employees and their representatives to not only develop actions to take but also to implement them.

Evaluation of interventions

It is essential for any intervention to be evaluated to determine how well and in what respects it has worked. Instead of solely examining whether the intervention worked, i.e. was it effective and what difference did it make, evaluations should also examined the underlying mechanisms and the contextual factors that might have influenced the outcome of the intervention ^[25]. This forms the foundation of ‘process evaluation’. Evaluation should consider a variety of types of information and draw it from a number of relevant perspectives (e.g. staff, management, stakeholders). A mixture of approaches may be used to gather these perspectives. For example, by setting up specific meetings with managers to review progress on major actions, by setting up regular sessions with staff to talk about sources of work-related pressure as part of team meetings or through informal meetings. The results of the evaluation should allow the strengths and weaknesses of both the action plan and the implementation process to be assessed. This information should not be treated as an issue of success or failure, praise or blame, instead should inform a reassessment of the original problem and of the overall risk management process, as well as providing feedback on the outcomes.

Organisational Learning

Evaluation not only tells the organisation how well something has worked in reducing psychosocial risks and the associated harm but also allows the reassessment of the whole situation, providing a basis for organisational learning and development. Essentially, it establishes a continual process for improvement that should be repeated within an established time frame in the organisational context. Lessons learned from the evaluation should be explicitly identified and used as the basis for organisational development.

What is in it for organisations? Evidence of effectiveness of the interventions

Knowledge on the outcomes of the risk management process is an important input for the continuous risk management and improvement process. A healthy organisation is defined as one with values and practices facilitating good employee health and well-being; as well as, improved organisational productivity and performance ^[26]. Managing psychosocial risks and workplace health relates to managing the corporate image of organisations ^[27] [28]. It can lead to a reduction of the cost of absence or errors, and accidents; and hence associated production ^[29]. In addition, it can reduce the cost of medical treatment and associated insurance premiums and liabilities. It can contribute to the attractiveness of the organisation as being a good employer and one that is highly valued by its staff and its customers. It can lead to improvements of work processes and communication, and promote work effectiveness and efficiency.

As such, best practice in relation to psychosocial risk management essentially reflects best practice in terms of organisational management, learning and development, social responsibility; and the promotion of quality of working life and good work. Bond, Flaxman and Loivette ^[30] in a review of the evidence on work related-stress in relation to beneficial business outcomes found improvements in relation to several dimensions of the psychosocial working environment (e.g., control, support, relationships, role, change, and demands) to be linked to positive outcomes in relation to business outcomes: such as, absenteeism, turnover, or performance (objectively measured and rated by others).

Although there is a growing and strong utilisation of interventions for the management of psychosocial risks in practice ^[10], the majority of these programmes are not systematically assessed or evaluated ^{[23] [31] [32] [33]}. The limited amount of scientifically rigorous evaluation data has resulted in a restricted evidence-base and limited knowledge on the effectiveness of prevention-orientated interventions. Many of the reviews conducted in this area are limited by the small number of studies that can be included: a consequence of the limited number of interventions that have been systemically evaluated ^[12]. Additionally, the varied focus of such studies (e.g., the diversity of outcome measures employed, duration of the intervention and its follow-up period, selection bias, and small sample sizes) makes it difficult to compare them and draw clear conclusions as to the overall effectiveness of such interventions, the mechanisms which underpin the sustainability and longevity of observed effects, and the interventions’ cost-effectiveness ^[34].

Despite the restricted evidence-base in this area, some general conclusions can be formulated; namely, that stress management programmes seem to be effective in improving the quality of working life for workers and their immediate psychological health (as derived from self-report data ^[26]). In a review of 90 interventions (43 of which were individual-orientated interventions), approaches with an individual-level focus were demonstrated to be effective at the individual-level (on a range of individual-level outcomes), while of the 47 organisational-level interventions reviewed, favourable effects were observed at both the individual and organisational level ^[12]. Similar results have been observed in earlier reviews ^[34] [35].

There is growing evidence of the economic argument and, moreover, cost effectiveness of interventions in the workplace aimed at psychosocial risk management. For example, a report published in 2013 ^[36] examined the cost-effectiveness of different types of interventions aimed at mental health promotion and mental disorder prevention. This report observed for every €1 of investment in workplace interventions there was an associated net economic benefit of up to €13.62 annually. It is important to note, these figures are based on selected European countries and, therefore, caution used be exercised in over generalising these findings. A comprehensive overview of the economic evaluation of workplace interventions aimed at managing and preventing work-related stress is presented and discussed in a recent EU-OSHA report ^[37]. The report concludes that there exists building evidence for the cost-effectiveness of workplace interventions; albeit more research is needed.

In addition, the cost-effectiveness of different types of interventions focusing on mental health promotion and mental disorder prevention, every Euro results in net economic benefits of up to €13.62 over a one-year period ^[37].

Conclusion

It must be reiterated that the assessment of psychosocial risks and the implementation of interventions to prevent and manage such risks is stipulated by European and national legislation. Although there is increasing use of interventions to deal with, and related issues of work-related stress, bullying, |harassment and violence, the focus has remained largely at the individual level. While such interventions are useful, the evidence also suggests that there are several advantages and a strong business case for implementing organisational level interventions aimed at prevention and addressing the problems at source. It is important to emphasise that the prevention and management of psychosocial hazards is not a one-off activity, long-term commitment and stewardship by management is critical to the success of implementation of interventions, as is an adequate analysis of risks, use of a combination of methods, tailoring to meet the specific needs of an organisation and the use of methods according to the competencies of those in charge of the process and thorough planning of interventions. Finally, interventions have traditionally focused on eliminating or reducing exposure to psychosocial hazards, and more work needs to be done to examine the development of positive working environments.