Occupational health practitioners should always be on the lookout for psychosocial workplace hazards. Noreen Tehrani explains more.
Health surveillance and screening are a familiar part of an OH adviser’s role, involving a systematic approach to the identification of early signs of work-related ill health or injury. This article is concerned with the need for OH providers to undertake surveillance in relation to known psychosocial workplace hazards that have been shown to cause harm to workers.
The Management of Health and Safety at Work (1999) legislation provides the necessary framework, with a specific reference to the need for surveillance: “Every employer shall ensure that his employees are provided with such health surveillance as is appropriate having regard to the risks to their health and safety which are identified by the assessment.”
Surveillance falls within the wider risk control and management cycle in which organisations are required to undertake key five activities – see box below. The Health and Safety Executive (HSE) has also identified a number of psychosocial workplace hazards that are less extreme, including bullying, harassment and workplace stress (Rick et al, 2001).
While occupational surveillance shares some of the features and tools of clinical research, it is not designed to generate or create new scientific knowledge, but rather it uses existing knowledge and research to prevent disease or injury, enhance resilience and increase wellbeing in employees who may become exposed to an identified health hazard (Otto et al, 2014).
A review of the risks inherent in organisations (European Agency for Safety and Health at Work, 2011) identified a number of hazards in emergency services that included physical exposures such as musculoskeletal hazards, and radioactive, chemical and biological substances. However, in addition to these physical hazards, the agency identified psychological hazards including exposure to disasters, dealing with multiple deaths, body recovery, transport accidents, terrorism, fires, shootings and other threats to life.
Five steps of risk assessment
1. Identify the risks in the workplace: What hazards exist and how could these hazards affect the health and wellbeing of employees?
2. Find out who might be harmed and how this might occur: Who might be exposed? Which groups are particularly vulnerable? How could they become exposed? Which roles or tasks are particularly hazardous?
3. Analyse and evaluate the level of risk: What is the likelihood of an injury occurring? What could be the magnitude of harm caused? How can the risk be measured?
4. Establish ways to reduce the risks: What are the control measures? Are they proportionate? How should they be implemented? Who would be responsible?
5. Record, monitor, review and improve: How is the surveillance programme working? How do we compare with other organisations?
The surveillance of psychosocial hazards should be treated with the same importance and urgency as physical surveillance, in order to support organisations to meet their duty of care to their workforce (Acas, 2012).
1. Identifying the psychosocial risks to health
Many occupations involve activities that are known to have potential for causing psychological harm and therefore can be foreseen. The HSE has developed management standards that identified five potential hazards that should be monitored and controlled in organisations (HSE, 2009). These stress-related hazards include: lack of control and support; exposure to conflicting relationships; poorly defined roles; and organisational change. These can result in the workers suffering psychological injuries including anxiety and depressive disorders.
In addition to workplace stress, a large number of occupations are exposed to more extreme hazards as part of their work. These include: emergency services; social work; teaching; retail; humanitarian assistance; transport; engineering; and construction. These workers are exposed directly or indirectly to death, trauma and distress where the possibility of psychological injury is known and is therefore foreseeable under the law.
There is a significant body of evidence to demonstrate that workers directly exposed to traumatic events, including body handling, shootings, transportation disasters, physical attack, verbal abuse, harassment and accidents during the course of their work, have an increased risk of developing post-traumatic stress disorder (PTSD), major depression, anxiety, and/or alcohol or drug dependency (Breslau, 1998). The latest version of the American Psychiatric Association (APA) guide to psychiatric disorders provides descriptions of stress-related hazards that can lead to PTSD, acute stress disorder and adjustment disorder.
During this phase of the cycle, the employer, often assisted by the OH service, needs to be examining all the roles within their organisation to identify any known hazards to the psychological health of employees. The OH service can help by examining the research into work-related psychological injury; this may involve looking at claims for compensation, stress/trauma research and epidemiology.
2. Find out who might be harmed and how this might occur
After the risk assessment has been completed, the next stage of the control cycle is to identify which workers are at greatest risk and how they might be harmed. There is growing evidence to show that certain employees are at more risk than others; the Management of Health and Safety at Work Regulations identify a number of categories of employees who require particular attention, including new and expectant mothers and young people.
Research into anxiety, depression and traumatic stress has shown a wider range of vulnerability that includes gender, personality, level of education, pre-existing disorders and early life abuse. These factors have been shown to increase the impact of an exposure to a hazardous event and need to be considered in recruitment, task design and the provision of support. It is important for the OH service to identify which individuals may be at more risk, to introduce reasonable adjustments and to take account of these vulnerabilities when planning and undertaking a surveillance programme (Breslau, 2009; Alexander and Klein, 2003; McFarlane, 2004).
This phase of the control cycle requires employers to consider how particular employees are exposed to a hazard. Understanding their roles and how these roles are undertaken is important; this would generally mean interviewing workers to find out how they engage in hazardous tasks to identify what might be involved in increasing or mitigating the risks. For example, a traffic warden’s role is to identify dangerous and illegal parking and to issue parking tickets where appropriate. The traffic warden faces the hazard of being assaulted by an angry driver; this risk may be increased or mitigated by the level of the traffic warden’s training in the use of interpersonal skills.
3. Analyse and evaluate the level of risk
The most effective way to systematically analyse and evaluate the level of psychological risk within an organisation is through psychological screening. It is important to check the reliability and validity of the questionnaire and to make sure that the person administering and interpreting the results is trained and competent in psychometric testing. There are a number of questionnaires and screening tools that have been developed that can be used to help analyse and evaluate the level of psychological risk faced by workers. Research has been undertaken in clinical and organisational settings to create measures that assess the levels of symptoms and also identify vulnerability and protective factors implicated in the development of psychiatric disorders. Wilson and Keane (2004) provide a good review of assessment tools and gauge their reliability and validity in assessing trauma symptoms.
An effective surveillance programme also measures other relevant factors, including personal vulnerability where gender, introversion/extroversion and neuroticism/emotional stability have been shown to be important factors (Tehrani, in press). A number of psychometric tools can be used to measure personality, one of the earliest being the three-factor EPI (Eysenck and Eysenck, 1975) and more recently the five-factor NEO-PI (Costa and McCrae,1992). Both personality questionnaires measure the important extraversion/introversion and neuroticism/stability continuums. Personality tests can only be interpreted by a British Psychology Society (BPS) registered and qualified test user (BPS, 2014).
The effective use of coping skills and personal resilience factors can also be helpful in identifying vulnerability to harm. There are a number of valid and reliable measures that can be used to assess individual resilience, including measures such as COPE (Carver et al, 1989), hardiness (Bartone et al, 2008) and sense of coherence (Antonovsky, 1993). Some of these questionnaires can only be used by a registered psychologist (BPS, 2014), while others are more widely available (Brewin, 2005).
The OH service may be able to access a provider of electronic psychological screening or employ a suitably qualified psychologist to undertake the screening on their behalf (Association of Chief Police Officers (ACPO), 2009). Having undertaken surveillance screening, the OH service should then identify psychological “hotspots” where employees are experiencing above the expected levels of clinical symptoms. The OH service will need to discuss this with the managers and employees to identify what might have caused the change in symptoms, examining organisational factors including: recruitment training; procedures; workload; and control or changes in the nature, incidence or magnitude of the psychological hazard.
As the use of psychological surveillance increases, it should become possible to benchmark with organisations facing similar hazards.
4. Establish possible ways to reduce the risks
The control cycle involves three levels of risk reduction interventions: primary interventions, involving changes to working practices or procedures; secondary interventions, which help employees manage their responses to hazards without attempting to eliminate or modify them (training aimed at increasing resilience and coping skills are useful in reducing the impact of psychological hazards); and tertiary interventions, involving the provision of individual support (Jordan et al, 2003).
Primary interventions require management agreement and support as they will typically involve changes in ways of working, equipment or procedures. The use of benchmarking with other organisations can identify gaps and opportunities for improvements; this is a good way to highlight what might be done to reduce the primary risks.
Secondary interventions can involve the OH service in developing educational presentations to help the employee recognise how to reduce the risk of psychological harm and identify the early signs of distress. One of the more effective ways of reducing the risk of psychological ill health is the structured interview with employees, which combines secondary and tertiary interventions. Employees identified as experiencing difficulties in the screening should be offered a structured interview, which will help to identify the most appropriate intervention options. These options may include training to increase resilience or coping, an adjustment to the role, additional management support or redeployment to an alternative role. Employees suffering from clinical symptoms may require a referral for therapy or psychiatric treatment.
5. Record, monitor, review and improve
Organisations need to maintain records on how they are handling physical and psychological risks to employees. Not only is this important to the surveillance process but it also helps to demonstrate that the organisation is meeting its legal duties. OH departments should work with management to ensure that data is collected and that opportunities for improvement are taken.
It is important that the OH service maintains a risk register, which covers any significant psychological risk and a record of the results from the programme of surveillance. OH can then provide management with the information on the fitness of employees to undertake their role. Where an employee is currently unfit then the OH service will provide advice on any adjustments or need for redeployment in an alternative role. Management will then also be provided with information on the operation of the surveillance programme, the numbers of people engaging in the programme, number of roles assessed as needing to be part of the surveillance programme, levels of fitness, areas of concern and opportunities for improvement (Everton, 2013).
Discussion
By using these five steps, OH can support management in bringing about real change in psychological wellbeing within organisations. There will be a requirement to work with others where particular skills are needed to augment the standard OH provisions, but there is a lot that OH advisers can do using their existing skills and knowledge of the workplace to implement workplace surveillance with confidence.
In 2012, the Department of Health discussed a vision of the future where surveillance would play an important role in reducing the burden of ill health. However, to achieve the potential benefits there will be a need to bring together systems and expertise from organisations and public health to establish a minimum standard surveillance model, which could inform future directions in reducing the incidence of preventable morbidity and mortality. There is a rich seam of information available within organisations – all that is needed is a desire to gather it.
References
ACAS (2012). Defining an employer’s duty of care, downloaded 29 August 2014
Association of Chief Police Officers (2009). ACPO Combating Child Abuse on the Internet (CCAI): practice advice on the protection of workers engaged in identifying, investigating, tracking and preventing online child abuse (internal document).
Alexander D, Klein S (2003). “The epidemiology of PTSD and patient vulnerability factors”. Psychiatry; 2 (6), pp.22-26.
Antonovsky A (1993). “The structure and properties of the sense of coherence scale”. Social Science Medicine; 36 (6), pp.725-733.
APA (2013). Diagnostic and Statistical Manual of Mental Disorders, fifth edition, Washington DC: American Psychiatric Association.
Bartone PT, Roland RR, Picano JJ, Williams TJ (2008). “Psychological hardiness predicts success in US army special forces candidates”. International Journal of Assessment and Selection; 16 (1), pp.78-81.
BPS 2014. Psychological Testing Centre.
Breslau N (1998). “Epidemiology of trauma and post-trauamtic stress disorder”, in R Yehuda Ed, Psychological Trauma. Washington DC: American Psychiatric Association.
Breslau, N (2009). “The epidemiology of trauma, PTSD, and other post-trauma disorders”, Trauma, Violence and Abuse; 10 (3), pp.198-210.
Brewin C (2005). “Systematic review of screening instruments for adults at risk of PTSD”. Journal of Traumatic Stress; 18 (1), pp.53-62.
Carver CS, Scheier MF, Weintraub JK (1989). “Assessing coping strategies: A theoretically based approach”. Journal of Personality and Social Psychology; 56, pp.267-283.
Costa PT, McCrae RR (1992). “Normal personality assessment in clinical practice: the NEO personality inventory”. Journal of Personality and Assessment; 4, pp.5-13.
Department of Health (2012). Public health surveillance: towards a public health surveillance strategy for England. London: TSO.
European Agency for Safety and Health at Work (2011). “Emergency services: a literature review on occupational safety and health risks”. Luxembourg: publications office of the European Union.
Everton S (2013). “Health Surveillance”, in Greta Thornbory (Ed) Contemporary Occupational Health Nursing: A Guide for Practitioners. London: Routledge.
Eysenck HJ, Eysenck SBG (1975). Manual of the Eysenck Personality Questionnaire (Junior and Adult). Kent, UK: Hodder & Stoughton.
HSE (2009). “How to tackle work-related stress: A guide for employers on making the management standards work”. Sudbury: HSE Books.
Jordan J, Gurr G, Tinline G, Giga S, Faragher B, Cooper C (2003). “Beacons of excellence in stress prevention”. Sudbury: HSE Books.
Management of Health and Safety at Work (1999).
McFarlane A (2004). “The contribution of epidemiology to the study of traumatic stress”. Social Psychiatry and Psychometric Epidemiology; 39, pp.874-882.
Otto JL, Holodniy M, DeFraites RF (2014). “Public health practice is not research”. American Journal of Public Health; 104 (4), pp.596-602.
Rick J, Briner RB, Daniels K, Perryman S, Guppy A (2001). “A critical review of psychosocial hazard measures”. Sudbury: HSE Books.
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Tehrani N (in press). “Extroversion, neuroticism and secondary trauma in child protection investigators”, Journal of Forensic Practice.
Wilson JP, Keane TM (2004). Assessing Psychological Trauma and PTSD. New York: Guildford Press.
