MANAGING AND ASSESSING THE RISK FOR WORK-RELATED STRESS - Guide for companies, in compliance with Leg. Decree 81/2008 and subsequent integrations ...
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MANAGING AND ASSESSING THE RISK FOR WORK-RELATED STRESS Guide for companies, in compliance with Leg. Decree 81/2008 and subsequent integrations and modifications Research Area 2013 Edition - English Version
Publication developed by INAIL Research Area - Department of Occupational Medicine SCIENTIFIC COORDINATOR Sergio Iavicoli, Director of the Department of Occupational Medicine-INAIL, Research Area English Version TRANSLATION Massimo Miele1 EDITORIAL TEAM Cristina Di Tecco1, Alessandra Luciani1, Laura Medei1, Sara Vitali1 1 INAIL, Research Area - Department of Occupational Medicine Original Title Valutazione e gestione del rischio da stress lavoro-correlato. Manuale ad uso delle aziende in attuazione del D.Lgs 81/08 e s.m.i. Edizione 2011. ISBN 978-88-7484-197-4 AUTHORS Tiziana Castaldi1, Patrizia Deitinger1, Sergio Iavicoli1, Marco Mirabile1, Elena Natali1, Benedetta Persechino1, Bruna Maria Rondinone1, Antonia Ballottin2, Fulvio D’Orsi3, Luigi Perbellini4 IN COLLABORATION WITH Marina Catelli1, Monica Ghelli1, Alessandra Luciani1 (graphic development), Matteo Ronchetti1, Antonio Valenti1, Sara Vitali1 1 INAIL, Research Area - Department of Occupational Medicine 2 SPISAL ULSS 20 VERONA 3 SPRESAL ASL - C ROMA 4 Reg. Hospital UNIV. of VERONA CONTACTS INAIL, Research Area - Department of Occupational Medicine Via Fontana Candida, 1 - 00040 Monte Porzio Catone (Roma) stresslavorocorrelato@inail.it Free distribution. Not for resale. Reproduction is authorized, provided the source is acknowledged. © 2013 INAIL ISBN 978-88-7484-330-5 Printed by INAIL’s Typography - Milan, October 2013
Following the entry into force of the Law N. 22 of 30 July 2010, the integration
of IPSEMA and ISPESL into INAIL has started and the “Health and Safety
Centre” has finally been established. Today, in particular, it is necessary to
integrate the ISPESL research-related activity that INAIL was not supposed to
conduct, from both organizational and functional point of view.
It is essential to highlight the key role of research within the “Health and Safety
Centre” in improving general performances and qualitative standards of
services with a particular focus on prevention, insurance, treatment,
rehabilitation/reinstatement issues.
This is mainly due to the deep changes in the world of work that have caused
a radical transformation in the organization of production and introduced new
occupational risks and new preventive requirements.
The recent regulations and guidelines on the assessment of risks associated
with work-related stress laid down by the Permanent Consultative Commission
for Occupational Health and Safety pose new challenges that require the pivotal
role of the research to be faced.
The aim of this monograph is to provide organizations with a useful and
sustainable tool for assessing and managing the work-related stress risk.
Marco Fabio Sartori
President of INAIL“… Tackling stress at work can lead to greater efficiency and improved
occupational health and safety, with consequent economic and social benefits
for companies, workers and society as a whole…”
(European Framework Agreement on work-related stress, Brussels, 8 October
2004).
In the light of the European Agreement - implemented by the Italian Leg.
Decree 81/2008 and subsequent integrations and modifications – which aims
to provide employers and employees with a model to identify, prevent and
manage work-related stress issues, the Permanent Consultative Commission
for Occupational Health and Safety has recently issued “minimum” guidelines
to be used for the risk assessment of work-related stress.
It goes without saying that the role played by the research is central in making
rigorous contributions to address work-related stress issues, through the
development of useful and reliable instruments for risk management and
assessment as well as the identification and dissemination of “good practices”.
This work aims to illustrate a logical route resulting from a scrupulous and long-
lasting research process that provides both employers and health and safety
representatives with a “step-by-step” guide to managing work-related stress
risk, involving the same basic principles and processes as all types of risk
assessment covered by the current regulatory framework, through a simple
and, at the same time, rigorous approach to the use of validated instruments.
Giuseppe Lucibello
Director General of INAILPREFACE The current regulatory framework on health and safety at work as provided in the Italian Leg. Decree 81/2008 and subsequent integrations and modifications has specifically identified the “work-related stress” as a risk that must be assessed and adequately managed, also in pursuance with the European Framework Agreement of 8 October 2004. Furthermore, the Permanent Consultative Commission for Occupational Health and Safety has been asked to “define the necessary indications for the assessment of risks associated with work-related stress” which were laid down on 17 November 2010 as a “methodological path which represents the minimum level of implementation of the obligation...”(Communication from the Ministry of Labour published in the Official Journal No. 304 of 30 December 2010). Therefore, the definition of “minimum” procedural indications has, more than ever, reraised the role of the scientific research in making rigorous contributions in order to develop valid and useful instruments for managing and assessing the risks of work-re- lated stress, also through the identification and dissemination of good practices for health and safety representatives in the organization. Specific research activities, through national and international collaborations, have been conducted by the Department of Occupational Medicine (DML) of former ISPESL. In particular, starting from the PRIMA-EF and PRIMA-ET projects and after a scrupulous benchmarking analysis on work-related stress management approaches conducted in different EU countries, the Department has developed a methodological path based on the Health and Safety Executive (HSE) Management Standards Model whose “Indicator Tool” was validated in the UK and Ireland by more than 26.000 employees. This publication illustrates the methodological path borrowed from HSE whose “Indi- cator tool” has been validated in Italy through a process involving more than 75 organ- izations from different production sectors and more than 6.300 employees. This path has been adapted to the Leg. Decree 81/2008 and subsequent integrations and mod- ifications and merged with the experiences of the “Technical Interregional Coordination Commission for occupational prevention” and the “National Network for work-related Psychosocial Disorders” with a view to providing a “single and integrated method” aimed at enhancing the strong points of these three methodological experiences, all adapted to the HSE’s Management Standards approach. The main aim is to provide a systemic path which is the result of a long-lasting research process aimed at giving both employers and health and safety representatives with a “step-by-step” guide to managing work-related stress risk, involving the same basic principles and processes as all types of risk assessment covered by the current regu- latory framework, through a simple and, at the same time, rigorous approach to the use of validated instruments.
The present work, therefore, besides providing the employer with valid tools to assess
and, subsequently, manage the work-related stress risk, according to the “minimum
level of implementation of the obligation”, also permits to illustrate an efficient and sci-
entifically correct assessment and management path ensuring a shared, coordinated
and integrated involvement of workers and health and safety representatives.
Sergio Iavicoli
Scientific CoordinatorINDEX INTRODUCTION 11 1. REFERENCE REGULATORY FRAMEWORK 13 1.1 Regulatory evolution 13 1.2 Indications for the risk assessment for work-related stress 14 1.3 Remarks 17 2. PROPOSAL FOR AN INTEGRATED METHODOLOGICAL PATH FOR ASSESSING AND MANAGING WORK-RELATED STRESS RISK 19 2.1 Premise 19 2.2 Preliminary phase 21 2.3 Preliminary assessment 22 2.4 In-depth assessment 25 2.5 Planning your next actions 31 2.6 Role of the Company Physician 33 REFERENCES 34 WEBOGRAPHY 36 APPENDIX 1 Preliminary assessment checklist 37 APPENDIX 2 Indicator Tool (original version) 52 APPENDIX 3 Work-related stress risk assessment document in the Risk Assessment Report (RAR) 56 APPENDIX 4 European framework agreement on work-related stress 60 ACKNOWLEDGE 64
Managing and assessing the risk for work-related stress
INTRODUCTION
Investigations and research on stress can be traced back so many decades that defining
stress is still a challenge (according to H. Selye; the most stressful thing is to define stress).
Stress is the adverse reaction people have to excessive pressures or other types of de-
mand placed on them. There is a clear distinction between pressure, which can in some
cases be a positive and motivating factor, and stress, which can occur when this pres-
sure becomes excessive.
Work-related stress may produce adverse effects for organizations in terms of employee
commitment to work, employees’ performance and productivity, accidents caused by
human error, employees’ turnover and intention to leave, attendance rates, job satis-
faction, potential litigation (1,2).
These factors may represent considerable costs for the organizations that could be
sensibly reduced by adopting an aware and integrated assessment approach to work-
related stress which does not only reflect the application of regulatory procedures but
also a greater awareness on the part of employees and employers of the specific risk.
By taking action to assess and manage the causes of stress in workplace, through in-
volvement and awareness raising on the part of employees and employers, it is possible
to prevent or reduce the impact of these problems on organization and bring about
business benefits.
However, any action taken requires a comprehensive approach based on the culture
of prevention leading to the understanding that preventing the work-related stress risk,
like other types of risks, is not only a regulatory requirement but also an investment for
the organization and its workers.
This publication is designed to contribute to the identification of the main features of an
adequate and achievable assessment of work-related stress risk and provides a useful
tool for meeting risk assessment obligation, both public and private, based on the Man-
agement Standards approach and pursuant to the European Agreement of 8 October
2004 - acknowledged by the Italian Leg. Decree 81/2008 and subsequent integrations
and modifications - and, in particular, to the “indications” issued by the Permanent Con-
sultative Commission for Occupational Health and Safety (appendix 4).
So, this monograph aims to provide Employers, Senior Management, Line Managers,
Company Physician, Health and Safety Managers, Occupational Health Representa-
tives, Occupational Health Professionals employees’ representatives as well as employ-
ees themselves with useful methodologies for the implementation of a collaborative
planning process in risk assessment in terms of organizational benefits through a Ma-
nagement Standards-inspired approach adapted to the Italian context and based on
the indications of the Consultative Commission.
11Managing and assessing the risk for work-related stress
1. REFERENCE REGULATORY FRAMEWORK
1.1 REGULATORY EVOLUTION
One of the most relevant changes introduced by the Leg. Decree 81/08 is the definition
of “health” provided by the World Health Organization as a "a state of complete physical,
mental, and social well-being and not merely the absence of disease or infirmity” (art.
2, par. 1, let. o), which is good assumption about employees’ protection against psy-
chosocial risks too.
At the same time, the definition of the “health and safety promotion system” as “the
whole institutional subjects that, through the participation of the social partners, help
implement action plans aimed at improving health and safety of people at work” (art. 2,
par. 1, let. p), broadens the scope of health and safety issues at work and refers to the
definition of the “Corporate Social Responsibility” as “the voluntary integration of social
and ecological concerns of businesses in their commercial operations and in their deal-
ing with stakeholders” (art. 2, par 1, let. ff).
In the framework of prevention activities, a key role is played by the study of work or-
ganization as highlighted by the art. 15, par. 1, let. d of the Leg. Decree 81/08 dealing
with “… the respect of the ergonomic principles in the work organization… ” and by art.
3, par. 1, let. f of the Leg. Decree 626/94 stating that the “ergonomic principles as re-
gards the design of workplaces, the choice of work equipment and the choice of work-
ing and production methods, with a view, in particular, to alleviating monotonous work
and work at a predetermined work-rate and to reducing their effect on health”.
Furthermore, the art. 32, par. 2 of the Leg. Decree 81/08 highlights that Health and Safety
Representatives need to be trained also about “ergonomic and work-related stress
risks”. As for the “risk assessment”, the Leg. Decree 81/08 states that it must concern
“all risks posed to health and safety of people at work, including those groups of workers
exposed to particular risks, such as the ones associated with work-related stress, ac-
cording to the European Agreement of 8 October 2004” (art. 28, par. 1).
After subsequent integrations of the Leg. Decree 81/08 by the Leg. Decree 106/09, the
assessment of work-related stress must be carried out (art. 28, par. 1-bis) “in accor-
dance with art. 6, par. 8, let. m-fourth and the relevant legal obligation accrues from the
definition of the aforementioned indications and, in the absence of them, from 1 August
2010”, successively postponed to 31 December 2010 by the Law 122/10.
Permanent Consultative Commission for Occupational Health and Safety (later on re-
ferred to as Consultative Commission) aims at defining indications in compliance with
art. 6, par. 8, let. m-fourth of the Leg. Decree 81/08 in order to fully meet the risk as-
sessment requirements. On 17 November 2010, the Consultative Commission approved
the indications concerning work-related stress risk assessment, successively published
13Managing and assessing the risk for work-related stress
on the website of the Ministry of Labour and Social Policy - protocol newsletter
15/SEGR/0023692 - and disseminated through an Official Statement of the Ministry
(Official Journal 304 of 30 December 2010).
1.2 INDICATIONS FOR THE RISK ASSESSMENT FOR WORK-RELATED
STRESS
As stated in the notes of the Ministry of Labour and Social Policy, the indications on
work-related stress risk assessment relies on the following principles: a) “brevity and
simplicity”; b) “identification of a methodology applicable to all types of organization”;
c) “application of such methodology to all groups of workers exposed to work-related
stress risk; d) “identification of a more complex, but practicable, methodology” that
must be adapted if the consequent corrective measures fail to drive down the risks”; e)
“enhancement of the prerogatives and faculties of Health and Safety Managers and
Company Physicians”; f) “planning of a limited transitional period for the scheduling
and completing of all activities conducted by stakeholders”.
The Consultative Commission specifies that “the document illustrates a methodological
path for employers which represents the minimum level of implementation of the risk
assessment obligation for employers …”; this highlights that minimum limitations (min-
imum level) have been set out in the step-by-step approach to the assessment process
(methodological path) and, therefore, a more structured approach based on the specific
needs and critical issues of companies may also be considered.
According to the Consultative Commission, the evaluation of risks associated to work-
related stress is “part and parcel of risk evaluation” and employer has the obligation
(non-delegatable obligation, pursuant to art. 17, par. 1, let. a) to perform it in cooper-
ation with Health and Safety Representative and Company Physician (art. 29; par.
1,2). The effective date of the obligation - 31 December 2010 - is to be considered as
the “…assessment activity start date…”. Temporal planning and deadline of such ac-
tivity “…must be reported in the Risk Assessment Report (RAR)”. Furthermore, the
Consultative Commission indicates that the assessment process must be performed
“not on the single worker but on homogeneous groups of workers… exposed to the
same type of risk, identified independently by the employer depending on each spe-
cific organizational structure..” and “the assessment should cover all female and
male workers, including senior management and line managers”. The Consultative
Commission’s methodological path is illustrated in Fig. 1.
14Managing and assessing the risk for work-related stress
Figure 1 - Methodological path for the assessment of work-related stress risk
according to indications of the Consultative Commission
PRELIMINARY ASSESSMENT
(identification of objective and verifiable indicators)
NEGATIVE OUTCOME POSITIVE OUTCOME
REPORTING RESULTS in PLANNING Interventions:
the RISK ASSESSMENT and ADOPTION of examples
REPORT corrective measures organizational
technical
procedural
communication
training
MONITORING PLAN
FORECAST CORRECTIVE
MEASURES
EVALUATION
REPORTING RESULTS in
the RISK ASSESSMENT EFFECTIVE INEFFECTIVE
REPORT
IN-DEPTH ASSESSMENT
(assessment of the employees’ perceptions)
QUESTIONNAIRE example
Relating to
FOCUS GROUP example investigated
factors and
indicators
SEMI-STRUCTURED INTERVIEW example
In organizations employing up to five workers,
employer MAY use assessment method (e.g.
meetings) that ensure direct workers
involvement in order to identify solutions and
assess their effectiveness.
15Managing and assessing the risk for work-related stress Preliminary assessment In this phase, the Consultative Commission identifies “all objective identifiable and, if possible, quantitatively appreciable risk indicators for work-related stress”, and classifies them, by way of example, into “at least” three different categories: 1) sentinel events; 2) work content factors; 3) work context factors. At this stage, “checklists for occupational prevention representatives” may also be used. “With respect to the assessment of job content and context factors, employees’ repre- sentatives must be involved or, in wider organizations, a representative sample of work- ers may be used”; employers may decide how to get workers involved, “also on the basis of the evaluation approach which has been adopted”. The deep involvement of employees, or their representatives, in the risk assessment for work-related stress makes this approach different from other kind of risk assessment processes which, to date, only require the consultation with health and safety represen- tatives. If work-related stress risk factors are not detected in the preliminary step and thus a “negative outcome” is obtained, this must be reported in the Risk Assessment Report and a monitoring plan must be forecasted. If a “positive outcome” is obtained and risk factors are detected, “proper corrective interventions shall be planned and adopted...”; if they prove to be “ineffective”, the second step, referred to as “in-depth assessment”, will be undertaken. In-depth assessment As already stated, this step is undertaken if, after a monitoring process performed during the previous step, corrective measures prove to be ineffective for “homogeneous groups of workers affected by specific issues”. To this end, according to the Consultative Commission’s guidelines, “the assessment of workers’ perceptions on risk factors and indicators” investigated in the preliminary assessment must be performed and, in wider organizations, “a representative sample of workers” may also be involved in this process. Some of the instruments used for the assessment of employees’ perceptions are “ques- tionnaires, focus groups, semi-structured interviews” but, in organizations with up to five workers, “the employer MAY use evaluation methods (e.g. meetings) that ensure direct workers involvement in order to identify solutions and assess their effectiveness”. 16
Managing and assessing the risk for work-related stress
1.3 REMARKS
According to the Consultative Commission, the “methodological path” for the risk as-
sessment for work-related stress aims at involving workers and their Representatives
for Health and Safety especially in the assessment of job content and context factors
but also in the identification and assessment of the so-called “sentinel events”. The
“collaboration” of Company Physician and Health and Safety Representative in the risk
assessment, as provided in art. 29, par. 1 of the Leg. Decree 81/08, usually turns into
an active and crucial participation. At the same time, prevention representatives and
employees may fruitfully take part in the identification of “homogeneous groups” where
risk assessment must be conducted, although this could be “undertaken independently
by the employer”. As already stated, the indications provided by the Consultative Com-
mission are based on a methodological path that includes “minimum” prescriptions but
does not preclude more articulated and scientifically correct approaches from being
developed.
The indications outline a precise approach where the employer and prevention repre-
sentatives are the recipients of the risk assessment for work-related stress.
However, some considerations need to be made regarding specific indications of the
Consultative Commission because applicative and interpretative problems could arise
from the brevity and simplicity of some of them.
The preliminary step includes work-related stress risk assessment, identification of
causes and corrective measures. Due to its simplicity, the preliminary approach, involv-
ing a small number of actors, might not clearly indicate whether or which corrective ac-
tions need to be taken.
This is why the employer, together with those professionals who take part in risk as-
sessment, may choose whether to pass to the deeper analysis or limit it to specific or-
ganizational sectors.
In the case of a risk assessment for work-related stress, this preliminary work is critical
as the approach relies heavily on the active involvement and commitment of workers
and their Representatives for Health and Safety.
It is evident that, due to the peculiarity of job content and context indicators, accurate
information and training programmes must be provided to workers so that they are en-
abled to make a reliable contribution to the assessment process.
If there is no clear consensus among workers, their representatives and employers on
work-related stress issues or corrective measures to take, a deeper analysis ensuring
an elevated quality of the process can be considered.
Furthermore, the indications of the Consultative Commission appears extremely syn-
thetic on the monitoring plan forecast, appearing flawed with respect to the modalities
in which it must be performed, and on the evaluation of the effectiveness of measures
that have been adopted.
It is also worth mentioning that the indications of the Consultative Commission do not
set out a validity term for risk assessment and tacitly refers to the legal provision con-
tained in art. 29, par. 3 of the Leg. Decree 81/08 and subsequent modifications and in-
tegration stating that “Risk assessment must be immediately redeveloped, … when
17Managing and assessing the risk for work-related stress relevant changes in production processes and work organizations take place with re- spect to occupational health and safety issues or according to the level of technology, prevention and protection or when serious occupational injuries occur or when the health surveillance requires it…”; reasonably, every two/three years risk assessment should be re-performed. Undoubtedly, the complexity of “minimum” guidelines as well as the above-mentioned critical implementation issues, have led the Consultative Commission to plan a 24- month monitoring period on the effectiveness and implementation of the guidelines. 18
Managing and assessing the risk for work-related stress
2. PROPOSAL FOR AN INTEGRATED METHODOLOGICAL PATH
FOR ASSESSING AND MANAGING WORK-RELATED STRESS
RISK
2.1 PREMISE
The aims of the present methodological path is to perform a work-related stress as-
sessment, in accordance with the guidelines of the Consultative Commission, taking
into account the modularity and peculiarity of the Italian productive sector.
Benchmarks used in the present methodological path are based on the review of the
main scientific reference models, on the experience of other European countries
(3,4,5,6) and on the main methodological proposals put forward after the issue of the
Leg. Decree 81/08 and subsequent integrations and modifications (12,13,15) with a
view to initiating an integrated process that, through the simple and synthetic step-by-
step approach put forward by the Consultative Commission, ensures the irreplaceable
involvement of Health and Safety Representatives at the organizational level, all along
the process.
This process is the outcome of a research activity conducted by the Department of Oc-
cupational Medicine of ISPESL and completed by INAIL after the Leg. Decree 78/10
came into effect and converted into Law N. 122/10. The process is based on reliable
scientific experience aimed at testing and validating both the Management Standards
Model, illustrated in the introduction, and the tools used all along its phases (7,8,9).
The Italian translation, contextualization and adaptation of the HSE methodology (Fig.2)
as well as the validation of the Indicator tool are the result of a long research process
involving more than 6,300 workers from all parts of the country, numerous organizations,
universities and institutes of the Italian National Health Service. Results of the process
will soon be reported in scientific literature.
The methodological element of the Indicator tool are reported in Appendix 2.
19Managing and assessing the risk for work-related stress
Figure 2 - Flow chart on the Italian implementation of the HSE’s Management
Standards Model (10,11)
International Workgroup
consultative
group
Analysis of objective
assessment indicators Translation and
and contextualization back-translation of
the Questionnaire
Pre-testing Focus group
Translation, validation and
adaptation of the whole HSE Administration of
Italian validation of the
platform into the Italian Questionnaires by
Indicator Tool
context Italian National
Testing the HSE Dissemination of
Management the Model
Standards Model in
Italy
Following up the guidelines of the Consultative Commission and in order to provide the
users with a single procedure, this path has been contextualized also though the inte-
gration of some influential methodological proposals developed few months earlier, in
particular those issued by the “Interregional Technical Committee on Workplace Pre-
vention” (12) and the “The National Network for the Prevention of Psychosocial Stress
at Work” (13).
20Managing and assessing the risk for work-related stress
2.2 PRELIMINARY PHASE
In this phase, before starting the assessment, it is necessary to actually “prepare the
organization” which is key element of other forms of evaluation processes and, even
more, of the risk assessment for work-related stress. The preparation of the organization
is articulated in three different moments: Establishment of Steering Group; Development
of communications and employee engagement strategy; Development of a risk assess-
ment plan.
1) Steering Group
The Steering Group is established by the employer and includes: ah hoc manager as
delegate for the employer, line managers, Health and Safety Managers and, if nomi-
nated, the Company Physician. The Group aims at planning and coordinating the whole
evaluation process and modulating it according to the outcomes obtained.
In particular, the British HSE experience shows that the key role of Steering Group is to
monitor and streamline the implementation of the programme itself through:
- procedure planning;
- procedure management;
- procedure promotion within the organization;
- procedure supervision;
- action plan ratification;
- drawing up of management reports.
In medium and large organizations, an “assessment management responsible”, as proj-
ect manager, should be identified among the components of the group. His role is to
simplify and coordinate the meetings together with prevention representatives, formalize
decision-making processes in order to develop a result verification plan and control the
required timing and resources. All evaluation requirements and the time schedule must
be met: this is why this position could be held by a manager appointed by the employer.
2) Development of communication and employee involvement strategy
Besides providing clear information to the employees, including senior and line man-
agers, it is essential to integrate it with adequate training programmes with respect to
the specific activities/tasks that workers perform during the evaluation process. Accurate
information/training must be provided to workers and/or Health and Safety Represen-
tatives who, as stated by the Consultative Commission, have a say over job content
and context factors. Training, in particular, aims at enhancing the understanding of the
assessment methodology that is expected to be implemented.
3) Development of a risk assessment plan
Due to the specific nature of the methodological path elaborated by Consultative Com-
mission and to the direct participation of workers or their representatives required in
specific process’ phases, the “development of a risk assessment plan” appears fun-
damental, also taking into account that the risk assessment for work-related stress is a
step-by-step dynamic process punctuated by checkpoints. According to the Consulta-
tive Commission, “scheduling” is essential and timelines must be developed illustrating
21Managing and assessing the risk for work-related stress how long it will take to implement each phase and, in detail, which actions will be taken and which actors will be involved with margins for unforeseen circumstances. 2.3 PRELIMINARY ASSESSMENT In order to support the work of the Steering Group, a preliminary assessment tool has been developed. According to the Consultative Commission, the preliminary assess- ment must be the first step to take in a proper risk assessment for work-related stress. This instrument, referred to as “checklist” (Appendix 1), is the result of a critical review of the “National Network for work-related Psychosocial Disorders” (13) following the ex- periments conducted in 800 organizations by the SPISAL (Workplace Prevention, Hy- giene and Safety Service) of the ULSS 20 Verona (Veneto Region, Italy) and by the Chair of Occupational Medicine of Verona, also in the light of the specific indications is- sued by the Consultative Commission. On the basis of the current scientific literature, the checklist provides a number of indi- cators, apart from those laid down by the Consultative Commission, subdivided into three different “categories” (sentinel events, work content factors and work context fac- tors) and is the start of the preliminary assessment. According to the Consultative Commission, the approach to the preliminary assessment may include the use of checklists and is divided into two main phases: 1) The analysis of “sentinel events” (e.g. injury rates, sickness absences, turnover, liti- gations and sanctions, reports produced by the Company Physician, specifications and frequent formal complaints from employees) enable the characterization of such indicators and is conducted by the “Steering Group”. The applications of the indica- tors is based on homogeneous parameters identified within the organization, as stated by the Consultative Commission. Critical issues concerning the application of some of these indicators still affect recently established organizations or those which have undergone significant restructuring. 2) A more specific review of job content factors ( “… work environment and equip- ment; workload and pace of work; working hours and shift work systems; matching of employees’ skills to the job demands”) and job context factors (“… e.g. role within the organization; decision-making and control; interpersonal conflicts at work; career paths; communication (uncertainties concerning job demands)”) is conducted by the employer who has the obligation to consult and involve employ- ees and/or Health and Safety Representatives on the basis of the “assessment methodology adopted”. The checklist identifies a number of broad parameters which are typical stress indicators with respect to “sentinel events”, “job content factors” and “job context factors”. The section of the checklist related to the “sentinel events” is filled in by the Steering Group in collaboration with HR staff. 22
Managing and assessing the risk for work-related stress
As already reported above, employees and their Representatives for Health and Safety
should be involved in filling in the checklist related to job content and context factors to
guarantee their active participation and to include several views.
Subject to the obligation envisaged by of the Consultative Commission to perform the
“assessment process” on homogeneous groups of workers, one or more “checklists”
will be filled in, depending on the organizational complexity, while taking into account,
for example, different organizational partitions and/or homogeneous tasks.
A risk assessment may hence be performed through the analysis of indicators that have
been included (as shown below) in the “checklist”.
I - SENTINEL EVENTS II - WORK III - WORK
(10 organizational CONTENT FACTORS CONTEXT FACTORS
indicators) (4 indicators) (6 indicators)
Work-related Injuries Function and Organizational
Work Environment and Culture
Sickness Absences Work Equipment
Absences from work
Task planning Organizational Role
Left-over vacation days
Job Rotation Workload - Pace Career Path
of work
Turnover Autonomy in decision
making - job Control
Legal actions
disciplinary sanctions
Requests for extraordinary
Visits Work Schedule Interpersonal
Relationships at work
Formal records of
work-related stress Home/Work Interface -
Home/Work Balance
Notifications
23Managing and assessing the risk for work-related stress
A value is assigned to each indicator and their sum represents the score of the area in-
vestigated. The score of the three areas is then summed (following the instructions re-
ported in Appendix 1).
The sum of the scores of the three areas gives the indication of where the organization
collocates in the “risk level box” and is expressed as percentage of the maximal value.
Low Risk
RISK LEVEL NOTES
LOW RISK No conditions that could be causing work-related
≤ 25% stress are reported.
If case of “low risk” level, the result must be reported in the Risk Assessment Report
and a “monitoring plan” must be forecasted (e.g. regular monitoring of the evolution of
sentinel events).
Medium Risk
RISK LEVEL NOTES
MEDIUM RISK Conditions that could be causing work-related
>25% or ≤ 50% stress are reported; corrective actions need
to be taken with subsequent assessment of their
effectiveness; if they prove ineffective, an in-depth
assessment must be performed.
If case of “MEDIUM risk” level, suitable corrective actions are required (e.g. organiza-
tional, technical, procedural, communication and training interventions) with respect to
those content/context indicators with the highest risk levels. Successively, even through
the use of “checklists”, the effectiveness of taken actions must be evaluated and, if they
prove ineffective, in-depth assessment must be performed.
24Managing and assessing the risk for work-related stress
High risk
RISK LEVEL NOTES
HIGT RISK High risk of work-related stress is reported and
>50% urgent actions are needed. Corrective measures
are taken with respect to the critical issues
raised; successively, the effectiveness of taken
actions must be evaluated and, if they prove
ineffective, an in-depth assessment must be
performed.
If case of “HIGH risk” level, in a single area, suitable corrective actions are required
(e.g. organizational, technical, procedural, communication and training interventions)
with respect to those content/context indicators with the highest risk levels. Successively,
even through the use of “checklists”, the effectiveness of taken actions must be evalu-
ated and, if they prove ineffective, an in-depth assessment must be performed.
Example
An organization has a recognized whole “medium” risk level and findings identify the
“role within the organization” (high risk) and “interpersonal relationships” (medium risk)
as two critical areas. The “Steering Group”, through the indicators in the checklist, will
implement an action plan; with respect to the “role within the organization”, efforts will
focus on the understanding of the top-down organizational hierarchy, the definition of
roles and the management of overlapping roles in a single person (shift manager/line
manager/quality manager).
The required actions to address issues concerning the “role within the organization”
consist in a long-lasting cultural process. In response to this, the risk monitoring con-
ducted through the use of “checklists” every 2/3 years must be performed taking into
account that, despite the corrective measures, it is necessary to perform an in-depth
assessment to confirm that the result is “medium” risk.
2.4 IN-DEPTH ASSESSMENT
In-depth assessment consists in an “evaluation of the employees’ perceptions” of work-
ers aimed at identifying and characterizing the risk for work-related stress and its
causes. This process goes hand in hand with and integrates the analysis of the indica-
tors conducted in the preliminary assessment and, in any case, cannot replace it.
25Managing and assessing the risk for work-related stress The in-depth analysis represents a precious opportunity to improve understanding of the health of an organization and its employees and to better identify risks in those areas (e.g. helping professions, call-center agents, air-traffic controllers, etc.) where, due op- erational or technical reasons, risk characterization appears so complex that cannot be determined only through the use of “checklists”. It is worth reminding readers that the indications of the Consultative Commission consist in minimum measures and the employer can deliberately decide to conduct an “in- depth assessment”, irrespective of the outcomes obtained in the preliminary one. Due to the peculiarity of risks associated with work-related stress, regular analysis of workers’ individual perceptions is key element in the risk characterization. The Consultative Commission suggests some “instruments” designed to evaluate the workers’ perceptions such as “questionnaires, focus groups, semi-structured inter- views” that can help in providing scientifically based characterization of workers’ per- ceptions of “job context and content factors”. Compared to other instruments, the “Indicator Tool” developed by HSE, and on which re- lies the approach we have decided to adopt, has a number of strong points and they are: - it can be easily administered and guarantees the anonymity of workers; - it proves effective in all organizations employing 10 or more workers; - after a validation process in UK involving more than 26,000 workers and more than 6,300 workers in Italy, it enables the employer and the “Steering Group”, through an easy-to-use software application which can be found at www.inail.it, to get reliable results with respect to workers’ perceptions of the Management Standards (1. De- mands; 2. Control; 3. Support; 4. Relationships; 5. Role; 6. Change) and, therefore, to characterize the context/content indicators and to develop an action plan; - it analyses the results by comparing the responses to a benchmark. As stated in the HSE Methodology, the employer may have developed alternative ap- proaches that could involve professionals external to the organization and may use al- ternative tools also depending upon the characteristics of his own company; however, the involvement of the company’s prevention representatives must be assured even if the employer decides to outsource any of the work. In assessing risk perception, however, only scientifically validated tools must be used to investigate at least the six areas that the indicator tool is designed to cover; many outstanding psychometric tools used in occupational settings such as the Job Stress Questionnaire (JSQ) by Karasek (1979) or Effort Reward Imbalance (ERI) by Siegrist (1996) investigate only few areas. For a complete list of instruments, please refer to the review published by some authors of the present monograph (14). Ongoing research is being conducted by INAIL - Department of Occupational Medicine, former ISPESL - to experiment and validate modular tools that, if necessary, can provide a second level path in different production sectors. As already stated, the administration if the “Indicator Tool” may be confined to a limited and homogenous group of workers grouped according to their duties or section, on the basis of the outcome of the preliminary phase. 26
Managing and assessing the risk for work-related stress
In any case, anonymity must be guaranteed during compilation, collection and data
entry; data may be easily imported in a software application according to the instructions
illustrated in the section dedicated.
The “Indicator Tool” consists of 35 items measuring ‘working conditions’ recognized as
potential causes of work-related stress (Appendix 2). These working conditions corre-
spond to the six organizational factors of the Management Standards Model. The ques-
tionnaire also includes socio-demographic data so as to better identify homogeneous
groups of employees for a well-developed risk characterization by guarantying the
anonymity of workers. In order to maintain anonymity, the distribution of the tool is rec-
ommended in organizations employing more than 50 workers.
The six Management Standards cover six key area of work design, namely: 1. Demands;
2. Control; 3. Support; 4. Relationships; 5. Role; 6. Change. The Standard “Support” is
subdivided into “Manager Support” and “Peer Support” (7,8).
In each of the Standards the ‘What should be happening/States to be achieved’ section
defines a desirable set of conditions for organizations to work towards (Tab. 1). For further
information on Management Standards, please refer to the publication of 2010 (15).
27Managing and assessing the risk for work-related stress
Table 1
Management Standards and What should be happening/States to be achieved
KEY AREA STANDARD WHAT SHOULD BE
OF WORK (is that) HAPPENING/STATES TO BE
DESIGN ACHIEVED (examples)
1. DEMANDS
This includes issues such as Employees indicate that they are able to - the organization provides employees with adequate and
workload, work patterns and cope with the demands of their jobs and achievable demands in relation to the agreed hours of
the work environment. systems are in place locally to respond work;
to any individual concerns - jobs are designed to be within the capabilities of employ-
ees;
- employees’ concerns about their work environment are
addressed.
2. CONTROL
How much say the person Employees indicate to have autonomy in - where possible, employees have control over their pace
has in the way they do their the way they do their work and systems of work;
work. are in place locally to respond to any in- - where possible, employees are encouraged to develop
dividual concerns. new skills to help them undertake new and challenging
pieces of work;
- employees have a say over when breaks can be taken.
3. SUPPORT
This includes the encourage- Employees indicate that they receive ad- - the organization has policies and procedures to adequately
ment, sponsorship and re- equate information and support from support employees;
sources provided by the their colleagues and superiors and sys- - employees know what support is available and how and
organization, line manage- tems are in place locally to respond to when to access it;
ment and colleagues. any individual concerns. - employees receive regular and constructive feedback.
4. RELATIONSHIPS
This includes promoting Employees indicate that they are not sub- - the organization promotes positive behaviours at work to
positive working to avoid jected to unacceptable behaviours (eg. avoid conflict and ensure fairness;
conflict and dealing with un- bullying at work) and systems are in - employees share information relevant to their work;
acceptable behaviour. place locally to respond to any individual - systems are in place to enable and encourage employees
concerns. to report unacceptable behavior.
5. ROLE
Whether people understand Employees indicate that they understand - the organization ensures that, as far as possible, the dif-
their role within the organiza- their role and responsibilities and sys- ferent requirements it places upon employees are com-
tion and whether the organi- tems are in place locally to respond to patible;
zation ensures they do not any individual concerns. - the organization provides information to enable employees
have conflicting roles. to understand their role and responsibilities.
6. CHANGE
How organizational change Employees indicate that the organization - the organization provides employees with timely informa-
(large or small) is managed engages them frequently when undergo- tion to enable them to understand the reasons for pro-
and communicated in the or- ing an organizational change and sys- posed changes;
ganization. tems are in place locally to respond to - employees are aware of the probable impact of any
any individual concerns. changes to their jobs. If necessary, employees are given
training to support any changes in their jobs;
- employees have access to relevant support during
changes.
28Managing and assessing the risk for work-related stress
On the basis of the outcomes, the software determines the appropriate colour denoting
performance relative to a benchmark, as follows.
Table 2
Key to colour coding
Doing very-well and need to maintain performance
Represents those at, above or close to the 80th percentile
Good Performance but need for improvement
Represents those better than average (=>50%) but not yet at, above or
close to the 80th percentile
Clear need for improvement
Represents those likely to be below average (Managing and assessing the risk for work-related stress
The score relative to the Standard of Demands is below average (red colour) and equals
to 2.87. Therefore, urgent actions are required in this area; to better identify the correc-
tive measures to take, please consult the section “Demands” of Tab. 1.
The tool may also permit to develop an analytical approach to the Standard of De-
mands and to gain a better understanding of the risk level relative to the single items
the Standard is made up of in order to optimize the action plan and to schedule time
into them.
Average
Demands Items values
3 Different groups at work demand things from me 2.80
that are hard to combine
6 I have unachievable deadlines 3.20
9 I have to work very intensively 2.10
12 I have to neglect some tasks because I have too much to do 2.50
16 I am unable to take sufficient breaks 3.30
18 I am pressured to work long hours 3.40
20 I have to work very fast 2.60
22 I have unrealistic time pressures 3.07
Average 2.87
The monitoring on the effectiveness of the actions taken may be conducted through a
second administration of the indicator tool and subsequent review.
Although the tool proves effective for organizations with 10 or more employees, it may
be used also by smaller organizations employing 6 to 9 workers: it may be followed by
meetings held to discuss and focus on the outcome data or by a focus groups which
might include methodological adaptations due to the small size of the organization.
According to the indications of the Consultative Commission, smaller organizations with
up to 5 employees may find it useful to adopt a shared approach to discussion through
regular “meetings”.
It is worth noting, however, that no matter the approach adopted or the organizational
typology/size, the involvement of all actors must be ensured to enable them to take ac-
tive part in assessing and managing work-related stress.
30Managing and assessing the risk for work-related stress
Figure 3 - Indicator Tool and Focus Group for in-depth evaluation
Organizations Indicator Tool with
with more than socio-demographic data
50 employees
Focus Group
In depth assessment
Organizations Indicator Tool
with 10-50 without socio-demographic
employees data
Focus Groups run for
evaluation or
Organizations Indicator Tool
with 6-9 (methodological
employees limits posed by their
application must be
considered)
Organizations
with up to 5 Meetings
employees
2.5 PLANNING YOUR NEXT ACTIONS
The findings of the preliminary and in-depth assessment, if conducted, must be taken
into account for action plan and must be analyzed in the specific context of the work-
place in order to enable the employer to take the necessary corrective measures to
eliminate/minimize the risk and to develop a monitoring plan.
The employer may not find it easy to move from the risk assessment to the identification
of the required corrective measures to take. Focus groups, despite their methodological
limitations in small or very small organizations, may help transform the risk assessment
findings into programmatic and corrective actions; in facts, focus groups may prove ef-
fective in managing those steps where the direct involvement and participation of work-
ers must be guaranteed (e.g. in-depth assessment and/or analysis of results).
The focus group can be particularly helpful in raising specific issues relevant to the
organization and transforming data obtained in the previous phases. Ensuring ade-
quate employee consultation and providing opportunities for employees to direct take
part in the process remains essential. The appointment of a “moderator” will ensure
impartiality of roles and competences; for further information, please refer to the web
site section. As already stated, for the development of communications and employee
31Managing and assessing the risk for work-related stress engagement strategy, employers shall provide workers with effective information and training on the evaluation methods focusing on the six Management Standards Model and, in particular: - the six broad risk factors for work-related stress on which the Management Standards are based; - how the Management Standards translate to your organization; - how to compare your organization’s performance with the “good management prac- tice” of the Management Standards; - risk factors for work-related stress that may be specific to your workplace. The six key areas around which the Management Standards are based cover the pri- mary sources of stress at work. So, a very useful starting point is to become familiar with these. It is important that all parts involved understand the Management Standards approach and this includes having a clear understanding of how it is applied and adapted to the work-related stress risk assessment process. Successively, it is necessary to disseminate the findings of the evaluation and provide adequate information in order to focus on the process as a whole, including the data obtained in the preliminary phase, rather than only focusing on the survey results. Once you have conducted the work-related stress survey, it is important to accurately communicate the findings to the Steering Group, workforce and prevention represen- tatives as: - they are often closest to the issues identified; - they can be invaluable sources of knowledge of what will work and what will not work in practice; - employees who have taken an active part in developing and agreeing solutions as members of such a group are more likely to help ensure the success of any agreed actions. Yet, all process must be reported in the Risk Assessment Report including: the evalua- tion approach adopted and the results obtained, the corrective measures, timescales and monitoring plans. The evaluation approach used for the job content and context factors must reflect the involvement of the workforce and the employees’ consensus on the scores assigned to all sections of the “checklist” and on final results. Workers’ involvement in monitoring the effectiveness of corrective measures must also be recorded. 32
Managing and assessing the risk for work-related stress
2.6 ROLE OF THE COMPANY PHYSICIAN
Pursuant to the art. 25, par. 1 of the Leg. Decree 81/08 and subsequent integrations
and modifications, the Company Physician (CP) has the obligation to take part in the
risk assessment process; with respect to work-related stress, he must actively partici-
pate in the assessment process with peculiar contributions, due to the role he plays in
the management of health and safety at the workplace.
The CP contributes preciously to the identification of homogeneous groups or workers
in the risk assessment process and, even more actively, to the characterization of spe-
cific “sentinel events” or particular “job context/content factors”. His role in the review
and interpretation of the results of the preliminary phase of the risk assessment is also
irreplaceable.
The CP has also the obligation to carry out suitable health surveillance and he may,
therefore, know whether difficult situations must be dealt with at work, or whether
worker’s subjective elements of risk perception must be considered or unacceptable
behaviors such as the alcohol/drug use and psychotropic and psychoactive substance
consumption must be prevented or resolved.
It is worth noting that, although risk assessment for work-related stress primarily focuses
on issues that are likely to be potential sources of stress for groups of workers, respond-
ing to any emerging individual concerns is considered to be essential to reduce the
causes of stress. Some individuals may experience problems that the majority of em-
ployees do not and the solutions developed for the majority of the employees may not
address these problems.
With respect to the role of the CP in the management of work-related stress issues, the
approach developed by the Italian Institute of Occupational Medicine and Industrial Hy-
giene (SIMLII) (16) and the “Technical Interregional Coordination Commission for oc-
cupational prevention” seems effective. The involvement of the CP is required if, in the
absence of “residual risks”, problems are identified with single workers from different
sections of the organization; taking into account the peculiarity of psychological health
issues, the CP, in full respect of professional secrecy, plays key role in addressing work-
ers’ psychological problems.
In accordance with former art. 41, par. 2, let. c) of the Leg. Decree 81/08 and subsequent
integrations and modifications, workers may refer to the CP also through a request for
a physical examination.
Therefore, the CP takes positively part both in risk evaluation and health surveillance
and his role is central in indentifying useful indicators for risk management.
In the framework of “health and safety promotion system”, as provided in art. 2, par. 1,
let. p) of the Leg. Decree 81/08 and subsequent integrations and modifications, the CP
must be meaningfully involved in all organizational processes aimed at developing,
among other things, action plans for access to counseling services.
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