Psychosocial risk factors for MSDs – prevention approaches
Richard Graveling, Institute of Occupational Medicine
Psychosocial risk factors are a significant cause of ill-health in many workplaces. As well as their adverse effect on mental well-being they can also contribute to the development of musculoskeletal disorders (MSDs).
They have been shown to be a problem in all sectors including those as diverse as construction; the service sector; and agriculture amongst others. In addition, there are indications that the recent growth in remote (and especially home) working has added to these problems. The global COVID-19 pandemic is believed to have had a considerable impact on the prevalence of psychosocial risks, not only through accelerating the adoption of remote (home) working but also through widespread increases in pressures and demands. As well as the obvious impact on those working in essential services, many sectors have seen a dramatic change in the financial and other business pressures they face as a result of the worldwide disruption in trade.
- Risk factors in different sectors and workplaces
- Extensive research over many years has identified a variety of factors potentially leading to psychosocial risks to health in the workplace. Described in more detail on other OSHwiki pages these include:
- Excessive workloads (including high emotional pressure);
- Conflicting demands and lack of role clarity;
- Lack of involvement in making decisions that affect the worker and lack of influence over the way the job is done;
- Poorly managed organisational change, job insecurity;
- Ineffective communication, lack of support from management or colleagues;
- Psychological and sexual harassment, discrimination, third party violence.
There is research evidence to suggest that each of these, in conjunction with physical risk factors, can contribute to the development of MSDs in the workplace.
There are also concerns that, across many sectors, the digitalisation of the economy (including robotisation and other new forms of work such as remote working - including working from home - and telework) is creating new challenges and new forms of risk.
Although psychosocial risk factors can be present in any workplace, across a wide variety of sectors, there have been many studies and reviews of the specific nature of these factors in different sectors or occupational groups.
Excessive workload is probably the most commonly identified problem across multiple sectors and workplaces. However, the form that excessive workload takes, and the specific factors contributing to this workload can vary across sectors. For example, in the construction sector excessive workloads frequently emerge as the result of productivity pressures, especially when work is delayed by factors outside the control of workers such as adverse weather conditions. Job insecurity is also widespread, arising out of the fixed-term nature of many contracts. As a further factor in some parts of the sector, work-life balance and domestic issues can intrude because of the peripatetic nature of the work.
In the agriculture sector, although adverse weather conditions clearly have a potential impact, excessive workload often takes the form of long working hours and isolation while, in the retail sector, workload issues are more likely to arise out of the part-time, weekend, and shift working that is often a characteristic of work in this sector. In turn, the adverse effect of such factors contributes to the high turnover typical of much retail employment (which in itself compounds the workload issues).
Sectors such as Health care, Education and Retail, are particularly impacted by adverse social behaviour, including;
- suffering verbal abuse;
- unwanted sexual attention;
- threats or humiliating behaviour;
- physical violence, bullying and harassment.
As noted above, the recent COVID 19 pandemic has had an impact on many sectors, but probably none more so than the Health Care sector, not only through the obvious increase in physical work demands and psychological pressures on those in the ‘front line’ but in addressing the disruption to other parts of the sector.
However, although some psychosocial factors are more often encountered in specific occupations or sectors, there is no clear evidence to suggest that any specific risk factor can be related to a particular sector or to a particular type of MSD.
Nor is there clear evidence to suggest that male or female workers are more at risk. The exception to this may be bullying and harassment. Although the evidence for gender differences is not strong, there is evidence to suggest that, in most EU countries, women are more likely than men to report bullying and harassment. Some studies have suggested that, where a gender is in a minority in a work sector, that minority is more likely to be the target of harassment.
There is no evidence to suggest that any ethnic group is more susceptible than any other to psychosocially-related MSDs although some such groups might have a higher prevalence of MSDs by virtue of the sector they work in. An EU-OSHA report specifically explored the exposure to MSD risk factors of three specific groups of workers: women workers, migrant workers and lesbian, gay, bisexual, transgender and intersex (LGBTI) workers. The report noted that these groups were more likely to be employed in jobs and sectors associated with increased exposure to health and MSD risks (including psychosocial and organisational risks) and that they tended to be in poorer health as a result, including reporting a higher prevalence of MSDs.
Although more at risk by virtue of increased exposure to relevant risks, rather than any inherent increase in susceptibility, there is some limited evidence to suggest that cultural differences and expectations between some groups might play a role in the impact of psychosocial factors on MSDs. For example, there are suggestions that some cultures might foster a different attitude to others to factors such as workload and job control.
Despite efforts across Europe and beyond to manage the associated risks, MSDs remain a significant problem, both for individual workers and for their employers. A recent investigation into this persistent issue identified a number of problems, of which failing to take psychosocial risk factors into account played a part. A further investigation of the research literature found that, although physical risk factors presented the bigger risk, psychosocial factors could make a clear contribution to overall risk. As a consequence it recommended a holistic approach to assessing and managing the risk of MSDs, considering both physical and psychosocial risks.
It is clear from extensive research that psychosocial factors play a role not only in the initial causation of MSDs but also in exacerbating the extent of existing MSDs, either by aggravating the condition or by provoking symptoms. Evidence also suggests that they can present a significant barrier to the return to work/rehabilitation of those who have found continuing to work with an MSD difficult. Recognising and addressing these barriers should therefore be an integral part of the process of returning those with a chronic MSD to the workplace, or in working to retain those workers already working with a chronic MSD.
A number of key elements of a potentially effective strategy can be identified.
There needs to be recognition and commitment at all levels in the workplace for a requirement to address both physical and psychosocial risks of MSDs.
Many risks (both physical and psychosocial) have an organisational component. For example, poor planning and scheduling of work can increase both physical and psychosocial work demands and, in some sectors, can cause problems for the introduction and implementation of new ways of working. For example, there is widespread evidence that the uptake of mechanical patient handling devices is restricted by organisational failures to ensure the availability and accessibility of suitable equipment and by the failure to ensure that work schedules accommodate their use. As a further obstacle, many (especially but not exclusively) older buildings are not designed to accommodate the use of mobile patient transfer devices, presenting further challenges to their successful adoption. Experience has shown that these obstacles are not always recognised or acknowledged, and that the ‘blame’ for the non-use of such devices is placed on the individual workers.
It is essential therefore that, from the outset, all those potentially involved in agreeing and implementing change are committed and accept the need for action.
As a further example, in many industrial sectors piece-work working practices are common. These can result in an increased risk of MSDs through pressures to exceed targets (especially where financial incentives are included). Such risks can be physical, for example increasing work rates are likely to increase the rate of repetitive actions; but can also be psychosocial, especially where team working is involved creating pressures amongst the team to achieve and maintain work rates. There is often a reluctance to accept changes from such systems, by employers because of concerns regarding loss of productivity and by workers due to concerns about a reduction in pay.
This should be followed by a systematic, holistic approach to risk assessment, covering both physical and psychosocial risks. There are many aids to assessment available.
EU-OSHA guidance material provides a clear steer to the approach to be adopted in addressing (assessing and reducing) psychosocial and MSD risks in the workplace. It does not include specific risk assessment tools, directing the reader to the resources available either through EU-OSHA or (possibly) thought sectoral or national guidance.
On the issue of risk assessment tools, there are more than 200 such tools available through OiRA covering a wide range of sectors and types of work. They frequently start by emphasising the need for getting workers involved. In itself this will serve to enhance communication, a key aspect of reducing psychosocial risk factors.
Many of the OiRA tools are country and sector-specific, addressing those risks commonly encountered in that sector and enabling SMEs in that sector to assess risks quickly and in a straightforward manner. The extent to which psychosocial risks are addressed varies, with some (for example) citing the EU-OSHA e-guide on psychosocial risks as a general resource while others are more targeted, with specific questions examining issues such as task clarity, time pressures, work schedules and work-life management, etc. A key benefit of many of them is that they promote a holistic approach, addressing all the risks likely to be encountered in that sector. As such they are not therefore focussed on a single area of risk (e.g. MSDs).
In addition to the resources provided through OiRA many other tools are available, both nationally and internationally, although many of these primarily focus on physical or psychosocial risks alone.
While assessing the presence of psychosocial risk factors it is important to remember that some such factors can have a positive or a negative effect. For example, although poor social support (from co-workers or managers) can increase the psychosocial risks associated with high work pressures, good support can be beneficial and can offset some adverse effects of such pressures. The ‘Psychosocial work environment’ should therefore be considered as a whole. One way of accommodating these interactive effects is through the use of tools that provide an integrative measure of risk, such as those reflecting what is known as the Demand-Control-Support model (DCS) or the Effort-Reward Imbalance model (ERI), although these are currently mainly used in research.
Whatever the tools adopted, it is essential to ensure a holistic approach as the evidence indicates that specific physical and psychosocial risks rarely act in isolation and it is the combination of such factors that leads to the overall risk of harm.
Risk assessment should actively involve the workforce, and should ensure that actual work activities are assessed, not what is believed to happen.
Evidence from industry suggests that, in some instances, risk assessments are formulated on the basis of written systems of work, regardless of whether or not those systems are actually implemented. This has resulted in the development of a European Standards Technical Report that provides guidance on ensuring the correct assessment of working practices. In essence, assessments should focus on examining the work as actually carried out. If that deviates from the stated ‘system of work’ then the reasons for this should be investigated as experience suggests that such deviations might have developed in order to make the work easier. Alternatively, they might have developed because the workers did not fully appreciate the rationale behind the established system of work.
Adequately assessing psychosocial risk factors requires openness and honesty on the part of the workforce – and appropriate measures should be in place to safeguard and protect individual confidentiality.
Risk assessments are usually focussed at the workplace level, although there are legal requirements to consider ‘susceptible’ individuals. This is especially important in respect of assessing psychosocial issues where individual perceptions (and interactions between factors) tend to play a larger role.
Although the information collected can be anonymised, it is not always possible to ensure that personal comments and perceptions cannot be related to the individual worker. This is particularly the case in smaller businesses, or small departments in larger businesses. If workers are expected to be open and honest about their perceptions and feelings, they frequently need to acquire confidence that their comments will not be used to penalise them in any way and measures should be taken to provide the necessary reassurance. Some employers find the use of external agencies to manage the process can be helpful, although others develop means of providing the necessary reassurance within their own resources.
Assessing physical and psychosocial health and well-being will also be of value in identifying where action is most needed.
In relation to MSDs many employers and sectors have found it of value to assess the nature and extent of different MSDs amongst their workers as an aid to identifying priorities for action. For example, a high prevalence of upper limb MSDs will require a different focus to an excess of low back problems. Although knowledge of the impact of psychosocial risk factors is not so far advanced, practical experience has shown that adverse psychosocial factors can be particularly prevalent within a specific part or section of an organisation. Assessing psychosocial health and well-being can therefore provide a useful guide to where action is should be a priority. As with risk assessment tools there are many tools available for determining individual psychosocial health and well-being that can be used.
Don’t forget that psychosocial risk factors can have a direct negative impact on psychological health and wellbeing as well as MSDs.
The interactions between sources and types of risk, and their consequences, provide a strong rationale for taking a holistic approach. Psychosocial risk factors present a good example of this, as such factors can have an adverse effect on psychological health and wellbeing as well as contribute to the overall MSD burden that is the focus of this article. Addressing them will therefore potentially have a dual benefit by improving both physical (MSD) and psychological health. As well as any direct consequences, the inter-relationships between psychological health and MSDs will potentially lead to further health and wellbeing benefits.
As well as contributing to the development of MSDs, psychosocial factors can create barriers to returning to work for those with chronic MSDs.
Although not part of the usual workplace-related risk assessment process, it will also be necessary to consider both physical and psychosocial barriers on a one-to-one basis, either in respect of helping an individual worker remain at work when developing an MSD, or when a worker returns to work after a period of MSD-related absence. In many countries there are legal duties on employers to make adjustments to work and workplaces and such adjustments may involve both physical and organisational changes. The return to work process should involve clear collaboration between health professionals and workplace staff. Although clearly there are potential restrictions due to individual confidentiality it will be necessary for all involved to have a clear understanding of what the returning worker can (and can’t) do and what that worker might otherwise be required to do as part of their job. This should include discussion and involvement with supervisors and fellow workers as appropriate.
Risk assessment is a means to an end – not an end in itself – and requires the implementing of preventive and corrective measures.
Workplace investigations have suggested that, for a variety of reasons, many employers tend not to fully follow-through the findings of their risk assessments and do not translate them into action to reduce the risks identified. Clearly, simply identifying risks without such action will be ineffective in reducing those risks or the incidence of MSDs amongst the workforce.
As with risk assessment, identifying and developing any follow-up actions should involve the workforce.
Having assessed the risk, it is clearly important to take steps to remove (or reduce) the risks identified. Many of the EU-OSHA tools and guides referred to earlier provide valuable material relating to removing risks (as well as assessing them).
As with the risk assessment process, involving the workers is an essential aspect of identifying and implementing avenues for risk reduction. Apart from any legal obligations for consultation, there is clear evidence that solutions developed collaboratively are more likely to be successful. Involving the workforce in developing and applying interventions will help to gain acceptance of any changes to work and working practices amongst the workforce. Good communication and discussion is vital with workers potentially becoming dispirited and disinterested if they feel that their views and opinions are not being taken into account.
There is some evidence that a multifactorial approach to risk prevention is more effective.
As with risk assessment, adopting a holistic approach to risk management is essential as, without such an approach, measures can fail to be effective. As with the example of patient hoists referred to earlier, physical adaptations alone, in the absence of necessary organisational changes, might not be sufficient.
Addressing bullying and harassment.
Bullying and harassment at work (where identified) should be a priority as this can seriously impact both physical and psychosocial health. As with all hazards in the workplace, the elimination of risks should take priority. Thus a hierarchy of measures can be adopted starting, naturally, with making it clear to all workers that such behaviour is unacceptable and will not be tolerated. Strong, positive leadership will help to reinforce this, as will clear and decisive action against the perpetrators in response to reports of such activities.
Where such behaviour cannot be prevented (or at least reduced), such as in those segments of the public sector where verbal or physical abuse from the public can occur, then there is evidence to suggest that having a strong support network in place with support from co-workers, managers and, where appropriate, other support services, can help to mitigate the effects. Where physical violence is a threat, careful attention to workplace design characteristics can help to directly protect and safeguard the workforce as well as providing reassurance to workers. It is important to remember that the possibility of physical violence can itself be a psychosocial risk factor.
Some psychosocial factors can work positively.
Many of the risk factors identified above, that might be identified as a consequence of the risk assessment process, can be regarded in a positive manner. Creating a good psychosocial environment in the workplace is likely to boost health and wellbeing generally – as well as reducing the risk of MSDs and other health problems to which psychosocial risk factors can contribute.
While the consequences of some psychosocial factors such as the risk of violence and abuse are always negative, others can work in a positive manner and this fact can be used as part of a risk management programme. For example, support from co-workers and managers can help to offset the potentially adverse consequences of physically and mentally demanding work (where high work demands cannot be reduced. Fostering a positive and supportive working environment (with training provided where appropriate) can be beneficial. Organisational systems should be designed to promote such approaches and avoid adversarial attitudes.
Some relevant factors can work on both physical and psychosocial risks. For example, enabling greater individual freedom over scheduling work breaks (when possible) can act directly to reduce physical strain but also provide for a greater sense of personal control.
A number of other OSHwiki articles can provide additional help and guidance, especially in relation to psychosocial risks, which tend to be less well understood by many employers (and workers). EU-OSHA guidance on fostering wellbeing at work focusses on both psychosocial risks and MSDs and, in addition, the EU OSHA e-guide to managing stress and psychosocial risks is available in a limited number of languages. Although this e-guide is primarily focussed on psychological health outcomes, the principles are the same whatever the adverse impact. In addition to these EU-level sources, many countries offer help and guidance on recognising and addressing both physical and psychosocial MSD risks in the workplace. As yet, not all necessarily fully adopt a holistic approach reflecting all potential sources of risk, but the availability of such assistance is growing.
The potential effect of adverse risk factors on psychological health and well-being has been recognised for many decades. It is gradually attaining wider recognition, with action at EU and national levels. However, to date much of the attention directed towards this important cause of worker ill-health has been focussed on the direct psychological effects of such risks. In recent years, possibly as a result of the apparent intractability of many work-related MSDs, recognition has grown of the potential causal contribution made to these by psychosocial risk factors in the workplace.
There are a number of aids available to assist employers in different sectors to identify both physical and psychosocial risks.
Guidance on interventions and tools that enable the non-specialist to carry out holistic assessments of both physical and psychosocial MSD risks and identify measures to reduce risk and improve the working environment should be a key focus.
Once the factors relevant to a workplace have been assessed, then risk reduction becomes a priority. There is evidence that adopting a holistic approach, addressing all potential sources of risk and creating a positive psychosocial work environment will benefit workers and employers alike.
There is an urgent need to encourage and support the development of evidential material on the effect and effectiveness of focussed interventions providing a holistic approach to the prevention of MSDs.
There is a significant absence of evidence-based material based on properly conducted and evaluated interventions. Although there is a considerable body of evidence regarding what any intervention should include, and what form such interventions should follow (such as the advocacy of the participatory ergonomics approach) recent research has shown that there is little robust evidence of their efficacy. Clearly this is an evidence gap that should be addressed with a degree of priority to provide employers with the necessarily authoritative support and guidance to develop appropriate intervention strategies and interventions.
- EU-OSHA (2021, in press) The association between psychosocial risk factors at work and the occurrence and prevention of musculoskeletal disorders. Bilbao: EU-OSHA
- EU-OSHA (2021, in press) Psychosocial risk factors at work in the occurrence and prevention of work-related musculoskeletal disorders (WRMSDs) in the context of new forms of work and digitalisation. Bilbao: EU-OSHA
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