One of the necessary developments from the traditional risk management model is the “translation” phase, where identified risk factors are discussed, prioritised and targeted by means of specifically designed actions. Usually, the discussion and exploration of likely risk factors involved in any case allows the discovery of any underlying organisational pathology—major problems that may be hidden. A medical analogy can be made where, by exploration of a patient’s symptoms, a doctor discovers the underlying disease. This often facilitates intervention planning, since the underlying organisational pathology can be targeted, rather than symptoms (the likely risk factors). Often, more than one risk factor (several symptoms) may be targeted by one intervention: improving communication processes, for example, often deals with many specific problems.
A response to a risk assessment can be integrated into existing management plans for change, and this is shown clearly in our case studies. Risk reduction interventions need not be disruptive, nor need they be “different”, or even revolutionary, when compared with everyday management practices. Primary prevention is about good management practice. It is about well-designed, organised and managed work in well-designed, organised and managedworkplaces. This is clearly reflected in the nature of the interventions implemented. Most are simply examples of imaginative good management practice.
Evaluation, Feedback and Organisational Learning
The key question in this phase is “did the actions achieve what was intended?”. However, evaluation is a thread that runs though the entire risk management process. The evaluation of organisational interventions is not straightforward and this question is dealt with elsewhere in this volume. However, I-WHO researchers have explored various methods of evaluating organisational interventions, with the stated aim of identifying a method that is good enough, yet also straightforward enough, for non-researchers to use. As well as documenting quantitative change in key outcome variables (well-being, for example), qualitative approaches such as stakeholder interviews are often found to be a cost-effective and satisfactory technique. In addition, because organisational interventions are not an “all-or-nothing” event, it is useful to explore how far any planned action was actually implemented, and whether or not it reached its intended audience. Exploring subtle variations in implementation (evaluating process as well as outcome) can provide a useful technique for evaluation research (Randall et al., 2001).
The evaluation of interventions is an important step, but one that is often overlooked or avoided. Not only does it tell the organisation how well actions have worked in reducing stress but it allows the reassessment of the situation, providing a basis for organisational learning. Essentially it establishes a process for continuous improvement. Managing workrelated stress is not a one-off activity but part of an ongoing cycle of good management at work and the effective management of health and safety. In many ways, good management is stress management.
There are parallels between the risk management model and organisational intervention processes developed by other researchers around the world. When looking at the health effects of work design and management, and particularly when attempting to understand, to explain and to intervene (rather than simply describe), many applied psychologists have independently formulated an approach and have identified issues which have much in common (Goldenhar et al., 2001; Hugentobler et al., 1992; Israel et al., 1996, 1998; Kompier & Kristensen, 2000; Kompier et al., 1998; Landsbergis & Vivona-Vaughn, 1995; Lindstr¨om, 1995; Nytrø et al., 2000; Schurman&Israel, 1995). The major development with the I-WHO risk management approach is that it overtly attempts to construct a process based on legal requirements. With the data thus provided, employers should be able to help promote the improvement and management of working conditions towards better employee and organisational health, provide opportunities for organisational development, reduce the likelihood of claims against organisations for breach of duty of care, and improve their defence against such claims, and strengthen the organisation’s position with regard to employer liability insurance.
In Britain, the Regulations require employers to undertake a risk assessment that is “suitable and sufficient”. Employers need to comply with legislative requirements within a feasible yet scientific and defensible framework, and are not charged with complying with the requirements of the more pedantic researcher. This is not to deny that several scientific challenges have been identified during the development of a risk management approach (Cox & Rial-Gonz´alez, 2000) but there is not space in the current post to cover them in detail. There is a debate, for example, as to whether self-report data on working conditions are better predictors of behaviour and (stress-mediated) health outcomes than objective measures (Bosma et al., 1997; Jex & Spector, 1996; Spector, 1987). Many would argue that they are, but this is not to deny that perceptions can be inaccurate or moderated by other factors. It is also far from straightforward deciding what constitutes a psychosocial hazard. Further, psychosocial hazards, unlike physical hazards, can often be conceptualised as part of a factor that is health-endangering at one end of its continuum, and health-enhancing at the other (for example, participation in decision making). It is also not easy to achieve a reliable classification of harm, or to measure degrees of harm when dealing with psychological and social outcomes. A further challenge is presented by estimating risk at the group level, although the objective of risk assessment is to identify the main risks for the majority of employees. This is not to deny that individual differences exist, or that employers have a duty of care to individuals.
We propose that it is unlikely that the average research-based “stress audit” would be regarded as good enough in law as a genuine attempt to assess and improve employee health and safety. However, the question is, do the actions as outlined above, within the risk management framework, constitute a good enough approach to the management of work stress? Is the process likely to identify the major stressors faced by any particular working group and assist managers to reduce them? The answer,wepropose, is “yes”. In the following section, several case studies are presented that demonstrate the risk management approach in action.
CASE STUDY EXAMPLES
Over the past ten years, I-WHO has undertaken a series of case studies in various types of organisation, with various groups of workers; for example, chemical manufacturing process operators, railway station supervisors, call centre operatives, nurses, doctors, senior managers, engineers, researchers, teachers, utility company field operatives, and supermarket, catering and warehouse staff. Space only permits a very brief account of some of these case studies here, but full accounts are available elsewhere (Cox et al., 2000a, 2002). These case studies have been published in a “warts-and-all” fashion. It has usually been the problems that have proved the most useful learning experiences and have promoted newdevelopments in the process.
Call Centre Employees
This case study was carried out with employees in the call centre of a large water utility dealing with telephone enquiries and written correspondence from customers. Many staff wanted to leave the company, their job satisfaction was low and well-being poor. Absence levels were fairly high, and a relatively large proportion of employees reported workrelated musculoskeletal pain. The risk assessment stage identified the following risk factors: unrealistic performance targets and a lack of praise and recognition, poor communication with senior management, lack of support from line managers, slowmovement of information around the organisation, lack of guidance on the prioritisation of tasks, lack of time to complete tasks, and inadequate time for taking breaks during the working day. An extensive package of interventions was implemented that targeted risk factors and their underlying pathologies. The interventions included changes in the management of performance targets, the instigation of more regular, structured and purposeful team meetings, measures to improve organisational communication, the introduction of new training initiatives, the design of “Best Practice” guidelines in working procedures, a review and updating of staffing levels to meet increased public demand, formal break-taking arrangements and innovations in IT systems.
A number of positive findings emerged from the subsequent evaluation, with staff generally reporting that the interventions had improved their working life. Although some problems remained, fewer staff reported problems overall, fewer risks were identified, absence levels reduced and staff well-being improved.
Accident and Emergency Nurses
This case study focused on a group of 35 nursing staff working in the Accident and Emergency Department of a medium-sized hospital. The department dealt with both minor and major injuries and disease conditions. The staff faced a number of problems. Once stabilised, patients were not being moved into the wards quickly, and this resulted in extra work for the department’s staff when workload was already heavy. Many staff indicated that their “peripheral” workload (e.g., organising community-based work and dealing with paperwork) was a problem. Although communication was strong, staff indicated that consultation about change was weak. The availability of support for staff involved in distressing situations was rated as poor. There were some vacant posts in the department, and many staff reported that they were not notified of their working hours far enough in advance. Problems with training were also cited by the majority of staff. These problems appeared to impact on well-being of staff: although most found their job satisfying, they indicated that they were worn out and tense.
Interventions focused on addressing problems with staffing, reducing the peripheralworkload placed on staff, and improving communications, training and the organisation of shifts. These included the recruitment of staff to fill vacancies, the introduction of an administration coordinator (to deal with many of the administrative tasks taken on by nurses) and the relocation of specialist and support staff into the unit (nurses who organised after-care for patients attending theward such as places in residential homes), the introduction of in-house training sessions (run by the more highly qualified nursing staff), more regular and inclusive departmental meetings and the reorganisation of the off-duty rota. Interventions designed to reduce the peripheral workload placed on staff were seen as particularly effective, as was the recruitment of staff. The impact of the other interventions was more modest, but nonetheless important for a number of staff. It did appear, however, that persistent problems with the movement of stabilised patients to wards and its impact on workload, as well as problems in providing support for staff, tempered the impact of some of these interventions.
Hospital-Based Outpatient Department Staff
This case study involved approximately 40 staff: nurses, health care assistants (direct staff) and administration staff. These groups of staff worked closely together to deliver outpatient care (treatment that does not involve overnight stays in hospital) in eye, ear, nose and throat departments. Risk assessments revealed that direct care staff regarded communication with administration staff as poor. Clinic time was pressured, clinics were over-booked and insufficient time was allocated for each patient. Treatments were often interrupted by administrators’ requests to access patients’ notes and test results, or to complete paperwork. There were problems with aggression from patients (staff also considered that patients were not given enough information when clinics were running behind schedule) and many reported that there was inadequate appreciation and recognition from consultants. They reported difficulties caused by covering the work of absent colleagues and problems with the physical working environment. There also appeared to be a specific problem with the inequitable distribution of late working hours. Nonetheless, staff well-being was relatively good. Administration staff identified a significant number of problems that suggested they were under real pressure. Staff turnover was high and this was having a significant impact on workload, ability to take up training opportunities and the overall ability of the section to deliver an effective service. Working relationships between administration staff and direct care staff were strained. The group reported poor well-being, low job satisfaction and high levels of intention to leave.
In response to the risk assessment a number of major interventions were implemented in the administration that led to fundamental change in thewayworkwas organised. Staff were allocated to work with named consultants on the booking and management of particular clinics—thiswas designed to increase the ownership of information and to raise their level of expertise. A programme of training was set up to teach staff about the full capabilities of the patient administration computer system. A new management structure was implemented to give the section a more “hands-on” and influential management team. Regular staff meetings were also instigated. Special projects were run to help track down missing notes and files—a source of significant problems for all staff in the department.
A more modest package of interventions was implemented for direct care staff, whose good general well-being indicated a lower priority for action. A series of team-building sessions were introduced to allow direct care staff to meet and discuss issues with administration staff. A departmental clerk was appointed to ease the administration load placed on nursing staff. Some new clinics were run with a smaller number of patients. To improve the management of clinics and the information given to patients, one member of nursing staff was assigned to work as a clinic liaison nurse (to keep patients informed of delays and organise their passage through the clinic). Specific training courses were offered to help staff deal with aggression from patients.
Across the board, these interventions were well received. Problems with communication between administration staff and other staff in the department were virtually eliminated. Time pressures eased for many direct care staff as a result of a reduction in their peripheral workload—the introduction of the administrative coordinator was seen as particularly effective. Although many clinics remained very busy, restricting the sizes of clinics was seen as making a significant difference. Staff also indicated that late working was more equitably distributed. It was reported that the use of a clinic liaison nurse helped to make clinics run much more smoothly and eased a number of problems. The strong well-being of nursing staff was maintained. The administration section of the department responded well to the package of interventions. They reported significant improvements in communications and consultation (particularly with nursing staff), better working relationships with management and improved training. Job satisfaction had improved, absence dropped, and fewer staff indicated that they wanted to leave the department. Despite these improvements, the administrative staff’s well-being had not improved significantly, the department was still very busy, new staff were being recruited, and managers were seeking to improve the situation further.
Supermarket Staff
The study was carried out with two groups of employees from a major supermarket chain: customer services staff and staff working on night and evening shifts. Customer services staff reported relatively satisfactory levels of general well-being, but they had high levels of musculoskeletal disorders.Anumber of risk factors for health were identified that concerned excessive time pressures, concerns about performance monitoring, lack of support and lack of appreciation by management, and lack of training. The health profile of the night and evening shift staff contrasted sharply with that of the customer services staff. A relatively large proportion of these staff reported poor well-being, musculoskeletal disorders, a lack of sleep, job dissatisfaction, intention to leave the company and recent involvement in a workplace accident. A number of risk factors were identified: time pressures, unfair pay, poor communication with management, high demands from management, colleagues and cover staff, poor quality equipment, lack of support from store managers, absence among colleagues, lack of flexibility in hours, lack of communication about new procedures and intimidation at work.
Many of the interventions were broad-brush actions designed to impact upon more than one group of employees, more than one risk factor and on their underlying pathologies. These included the introduction of staff and management meetings, open surgeries with store managers, store newsletters, overlapping shifts, increased access to email, information on methods of best practice, harassment awareness and management training, “return to work” interviews for absentees, swap sheets for shift staff, flexi-hours for supervisors, separate customer services desks managed by an experienced member of staff, improvements in store equipment, and changes in customer complaints policies.
Although most case study interventions were evaluated some six months or a year after their implementation, due to the research funding arrangements, the interventions in this particular case study were evaluated less than six months after their implementation began. Inevitably, some stressors remained, but there were encouraging signs that where interventions had taken place, staff responded very positively to them, their perceptions of working conditions had improved and they reported better levels of general well-being.
There has been an increase in concern aboutwork-related stress in relation to both individual and organisational health. Part of the experience of such stress and related health outcomes arises from the exposure of employees to psychosocial hazards at work. Organizations are required in law to assess the risks to employees arising from these hazards as well as those arising from the more tangible and physical hazards of work.
This post has introduced a framework, a methodology and procedures for conducting assessments for psychosocial hazards in the workplace, and for reducing them. These are based on the published work of the Institute of Work, Health and Organisations (I-WHO) at the University of Nottingham. This approach is set firmly within the risk management paradigm that is central to current European health and safety legislation and practice. It provides a positive framework for action, focused on the organisation as the generator of risk, and on prevention. The complex aetiology of work stress represents a major scientific challenge, and its mechanisms may never be fully understood. Nonetheless, there is a moral and legal imperative to act to reduce the harm caused by stress in the workplace. The assessment procedures and supporting instruments required to achieve this are still under development, most notably in an attempt to take the process forward out of the hands of researchers or consultants for use by workers themselves.
Tags: Evaluation Feedback and Organisational Learning, evaluation of interventions, Primary prevention, risk assessment