Psychosocial risks and workers health
Marlen Hupke, Institute for Occupational Safety and Health of the German Social Accident Insurance
In recent decades significant changes, closely related to the manner in which work is organised and managed, have taken place in the world of work; resulting in many emerging risks and new challenges faced by the field of occupational health and safety. Psychosocial risks have been identified as one of these key emerging risks. This article aims to give an overview on the theoretical background and current empirical findings regarding psychosocial risks, and their associated negative health outcomes for both the individual and the organisation.
The working environment and the nature of work itself are both important influences on the health and well-being of working people. Psychosocial risks have been identified as one of the key emerging risks facing worker’s occupatioanl health and safety today. Linked to psychosocial risks, issues such as work-related stress, workplace violence and harassment are widely recognised as major challenges to occupational health and safety, and more broadly public health. There is strong and growing evidence to indicate an association between work-related health complaints and exposure to psychosocial hazards, or an interaction between physical and psychosocial hazards, to an wide array of health outcomes for the individual worker and the organisation. The following section aims to provide the reader with a concise overview of the definition and nature of psychosocial hazards in the workplace.
Since the 1950’s, the psychosocial aspects of work have been increasingly the subject of research. This growing area of research gained further impetus in the 1960’s with the emergence of psychosocial work environment research and occupational psychology. During this time, there was a significant paradigm shift away from the individual perspective exclusively, to a greater examination of the relative impact and aetiological role of certain aspects of the work environment on worker’s health.
The International Labour Organization (ILO) defined psychosocial risks, in 1986, in terms of their interactions among job content, work organisation and management, and other environmental and organisational conditions, on the one hand; and, on the other hand, worker’s competencies and needs on the other. This interaction can prove to be hazardous to employee’s health through their perceptions and experience. Cox and Griffiths (1995) provide a simpler definition of psychosocial hazards: “... those aspects of work design and the organisation and management of work, and their social and environmental context, which may have the potential to cause psychological or physical harm” (pg. 69).
Exposure to psychosocial hazards can affect employee’s health, both psychological and physical, through a stress-mediated pathway. In addition, the health and resiliency of an organisation (e.g., absenteeism, high turnover, lower productivity and organisational commitment) can be affected. There is considerable evidence, and reasonable consensus among scientific community, of the nature of psychosocial hazards (see Table 1); but it should be noted that new forms of work give rise to new hazards – not all of which will yet be represented in the scientific publications. The following section aims to provide the reader with an overview of the prevalence of psychosocial risks and related issues, including, work-related stress.
Work-related stress is one of the health risks most frequently identified by workers in Europe, particularly in the new EU countries. The fourth European conditions survey revealed that an estimated 40 million people in the European Union are affected by work-related stress. The fourth European Working Conditions Survey (Parent-Thirion et al., 2007) showed that, in 2005, 20% of workers from the first 15 European Union (EU) member states and 30% from the new Member States believed that their health was at risk because of work-related stress (out of workers who reported that work affected their health). In the 15 member states (of the pre-2004 EU) the estimated cost of work-related stress and mental health problems was estimated to cost 3-4% of the gross national product; approximately EUR 265 billion annually (Levi, 2002). A report by the European Commission states that half of the workers in the European Union report working at high speed and to tight deadlines, 45% report having monotonous tasks, 44% no/ limited task rotation, and 50% short repetitive tasks.
A recent pan-European survey ESENER, conducted by European Agency for Safety and Health at Work (EU-OSHA), of enterprises opinions and practices in relation to the management of health and safety at work showed, that concerns in relation to psychosocial risks among managers were higher in countries such as Portugal, Norway, Turkey or Romania; whereas managers from Sweden, Denmark and Finland expressed lower concern. However, the results of the study related to the national situation have to be always interpreted within the wider cultural and legislative context. This survey also found that the main reasons for work related stress by managers were time pressure (52%), dealing with difficult customers, patients, pupils (50%), poor communication between management and employees (27%) and poor co-operation between colleagues (25%).
As aforementioned, there is a growing body to indicate an association between work-related health complaints and exposure to psychosocial hazards, or to an interaction between physical and psychosocial hazards, to an array of health outcomes: at both the level of the individual and the organisation. More specifically, exposure to work-related psychosocial risks has been demonstrated to have a possible detrimental impact on employee’s physical, psychological and social health; and, in turn, on the health and the resiliency of organisations.
Within the field of occupational health and safety, a generally expected aetiological model to understanding the association between exposure to occupational hazards, on the one hand, and employee’s safety and health, on the other, is the hazard-harm pathway. This model was adapted by Cox and Cox (1993) to include and account for psychosocial risks. The exposure to physical and psychosocial hazards may affect both psychological and physical health of workers. The evidence indicates that such effects on health may be mediated by, at least, two processes: firstly, a direct pathway; and second, an indirect stress-meditated pathway (see Figure 1). These two mechanisms yield complementary explanations of the hazard-harm relationship; and in most hazardous situations both, most likely, operate and interact in vary extents and in various ways. It is also, important to note, that the relationship between occupational hazards and employee health may be mediated by both biological and psychological processes and mechanisms. Such mechanisms include: neuroendocrine changes and alterations of autonomic, metabolic and immune functions, disturbances in blood coalguation; and psychological mechanisms, such as anxiety, hypervigilance and risk taking. As aforementioned, both physical as well as psychological health may be affected by these mechanisms.
The empirical findings on the relationships between each of the specified psychosocial hazards and the negative health and organisational outcomes are summarized in the following sections. While the impact of each psychosocial hazard is examined exclusively or in combination with only few others, several hazards may be present at the same time in a workplace. These hazards may interact with each other, or affect the variables under examination. Consequently caution is advised in generalising the findings.
Job content refers to jobs that lack of variety or short work cycles, fragmented or meaningless work, under use of skills, and high uncertainty. Numerous studies have found a significant relationship between jobs of this nature and poor worker health. For example, a review by Cox (1985) on the consequences of unskilled or semiskilled monotonous work found that workers who faced boredom at work were more likely to report negative psychological health reactions: such as, depression, anxiety, and resentment. In addition, poor job content has been linked with musculoskeletal pains and problems and substance abuse. Houtman and colleagues (1994) examined the relative impact of jobs with low intellectual discretion on the health of workers and organisations. Low intellectual discretion consists of monotonous work, poor possibilities for personal development, poor fit between the actual work and education or experience level, and poor promotional prospects. The study found that in jobs with low intellectual discretion, individuals were at a greater risk for general poor health and several specific indicators of ill health: specifically, psychosomatic and musculoskeletal complaints, and absenteeism.
Work overload and workplace
Workload, which may be conceptualised as work overload and work underload, was one of the first psychosocial risk factors to be researched. Workload may be divided into qualitative workload (referring to the difficulty of the task) and quantitative workload (referring to the amount of work that has to be completed within limited time). Workloads, as well as time pressure, are the two main indicators of demands in the demands-control-model. See the article on work-related stress for a discussion of the demand-control (support) model (Work-related stress: Nature and management). Consequently, most research on this model has focused on the impact of these specific demands and their interaction with control at work. Empirical results show that strain at work is particularly high when job demands are high, but situational control over work is low. Job demands have independently been shown to have a relationship with absenteeism, absence with a psychiatric diagnosis, self reported ill health, mental disorders such as depression and anxiety, burnout, coronary heart disease, and musculoskeletal complaints. De Rijk, Le Blanc, Schaufeli and de Jonge (1998) provide further evidence for these associations. However, the authors argue that due to conceptualisation and measurement differences across studies, results may not be easily comparable.
Job control refers to the extent to which a person is involved in decision-making relative to their job role. The basic assumption of the job-demands model is that the experience of work strain is reduced when job control is increased. However a high level of control, and the associated high demands to make choices may be a source of stress themselves. The “vitamine model” supports this approach by proposing that certain amounts of job control are necessary, but levels that are too high tend to be detrimental to the individual.
Relative to job control, Stansfeld (2002) provided evidence that low decision latitude is associated with depressive symptoms. An analysis by Duijts and colleagues (2007) combined the results of several studies, indicated that individuals showed a slightly elevated risk for absence behaviour when job control was low. Wieclaw and colleagues (2008) found a relationship between low job control and anxiety in men. In a review by Leka and Jain (2010), the authors present evidence for associations between low job control and depressive symptoms, cardiovascular disease, anxiety, poor general mental health, musculoskeletal complaints, hypertension and gastro-intestinal problems. High job control, conversely, has been shown to be related to positive health outcomes.
The impact of work schedule is mostly considered in terms of shift work, or long and unsociable working hours. Both Caruso and colleagues (2004) and Sparks and colleagues (1997) carried out an scientific review of several empirical studies, which showed a significant relationship between long work hours and health complaints; as well as injuries at work, and maladaptive health behaviours. Health risks are usually reported when the weekly working time exceeds 48 hours.
Shift work has been shown to be related to an increased risk of cardiovascular disease, hypertension, and atherogenic lipids. However, a recent study by Hublin and colleagues (2010) found no associations between shift work and cardiovascular morbidity. A review of several studies conducted by Wang and colleagues (2011) found a significant relationship between shift work and cardiovascular disease, metabolic syndrome, and diabetes.
Evidence for the relationship between shift work and ill mental health is scarce in the scientific literature. Bara and Arber (2009) found elevated risks for anxiety and depression in shift workers, but the risk to suffer from mental illnesses varied according to the type of shift work and gender. Results on association between shift work and cancer, particularly breast cancer in women, have frequently been reported; but further evidence is needed to further substantiate this relationship.
Environment and equipment
Factors relating to the work environment and working equipment refer, in general, to inadequate equipment availability, suitability or maintenance; and poor environmental conditions: such as, lack of space, poor lighting, and excessive noise. Factors belonging to this category of risks relate to the physical working environment, but this does not mean that the impact of these hazards relate to outcomes to physical health, exclusively. Exposure to poor working environment and equipment has been linked to stress and mental health impairments among workers. While there are only very few studies providing evidence on a hazard-stress-harm pathway, there exists broad empirical evidence on the direct link between physical risk factors and negative health outcomes; as well as on interactions between physical and also psychosocial risk factors and their impact on health.
Sickness absence and musculoskeletal complaints have been linked to strenuous physical work demands: such as, extreme bending or twisting of the neck or back, working mainly standing or squatting, lifting or carrying loads, and pushing or pulling loads. Aspects of the workplace layout (such as, distance between work places, open versus cellular office layout or desk sharing) have shown to be linked to worker health and performance in negative, but also positive ways. Noise is another factor of the work environment that has received continuous attention. Apart from damages to the middle and inner ears; excessive and chronic noise has been demonstrated to complicate communication, and be linked to stress, anxiety, irritability, tension, fatigue, impairments in performance and higher sickness absence particularly in men.
Role in organisation
The main factors that have been examined in relation to job role are “role ambiguity”, “role clarity” and “role conflict”. In addition, aspects that can affect individuals’ health are: role overload, role insufficiency and responsibility for other people. A study conducted by Väänänen and colleagues (2004) observed that when role clarity was low, the risk for absence behaviour was three times higher. In a study by Borritz and colleagues (2005), low role clarity and high role conflicts was observed to predict burnout at a 3 year follow-up. Lang and colleagues (2007) found that in a study of cadets, when high demands was present with high role clarity the participants reported less physical and psychological strain. An analysis by Jackson and Schuler (1985) found that role ambiguity was particularly related to affective reactions: such as, lower job satisfaction, tension/anxiety, commitment, involvement, and turnover intentions, and less to behavioural outcomes (e.g, absenteeism or job performance).
Organisational culture and function
The organisational culture and particularly management styles may be sources of stress in the workplace. Poor leadership and management,for example, in the workplace has been linked with numerous negative consequences for employees. A review of the evidence found a moderately strong relationship between the dimensions of leadership and enhanced employee well-being (ie., lower anxiety, depression, and job stress), decreased sick leave and reduced disability pension. In addition, numerous studies have found strong and effective leadership to have a positive impact on employee health and well-being. For example, a study by Nyberg and colleagues (2005) found a relationship between transformational and relation-oriented leadership and good mental health and well-being has been observed. These styles of leadership styles include behaviours: such as, showing consideration to subordinates, providing goals that workers may identify with, providing structure when needed and leave control over work to subordinates as much as possible. Aspects of the organisational culture have been identified to be hazardous by Kasl (1992). In particular, organisational size and structure (having a flat structure with relatively few levels), cumbersome and arbitrary procedures, and role-related issues have been linked to poor worker health.
Interpersonal relationships at work
Poor interpersonal relationships at work refer to social or physical isolation, poor relationships with superiors, interpersonal conflict, lack of social support, bullying, sexual harassment. Unsatisfactory relations at work may be a major source of stress, and can be related to both psychological and physical health complaints. Particularly the detrimental effects of conflicts, bullying and violence have recently received wide attention among researchers.
A major interpersonal source of stress at work is a lack of social support. A study by Siegrist and colleagues (2008) showed moderate relationships between low social support at work and the risk of depression. Further studies also suggest that low social support is related to anxiety, emotional exhaustion, job tension, low job satisfaction, and increased risk of cardiovascular disease. It has also been found to moderate the relationship between stressors and strain. Barth and colleagues (2010) analysis of several empirical study results demonstrated a moderately elevated risk to suffer from coronary heart disease when functional support (aid and encouragement provided to the individual by the social network at work) was low. However, the authors found no impact of low structural support (number of contacts, frequency of contact, membership of community groups, and marital status) on myocardial infarction in healthy populations. An analysis of empirical study results by Uchino, Cacioppo and Kiekolt-Glaser (1996) found protective effects of high social support at work on the cardiovascular, endocrine and immune system. Niedhammer and Chea (2003) demonstrated associations between low social support and poor self-reported health in women.
Risks related to career development refer to career stagnation and uncertainty, under promotion or over promotion, poor pay, job insecurity, and low social value to work. Job insecurity and a lack of further career opportunities have been identified as significant risk factor for physical and psychological health. Analyses of research results from several empirical studies carried out by Cheng and Chan (2008) and Sverke, Hellgren and Näswall (2002) showed that job insecurity was found to impact negatively on job attitudes, organisational attitudes and health; and to some extent, the workers behavioural relationship with the organisation. A strong relationship between turnover intentions, as a consequence of job insecurity, was found for workers with shorter tenure. In the study by Netterstrøm and colleagues (2010), observed job insecurity predicted ischemic heart disease and myocardial infarction in men. Stansfeld and Candy (2006) found associations between job insecurity and common mental disorders. A lack of career prospects was reported as a major job stressor in a large group of Taiwanese employees.
Home work interface
Risks related to home work interface refer to conflicting demands of work and home, low support at home, and dual career problems. Work tasks and private engagements interact with each other and may become a source of stress if conflicts are not resolved. It depends on the individual situation and the factors involved, if such interactions have a stronger impact on work or private life. Further details on the home-work interface are provided by the corresponding article (Work-life balance – Managing the interface between family and working life).
Several methods may be used to assess psychosocial risk factors in the workplace. The most common way to measure these variables is by self report questionnaires. This assessment method allows the researcher or health expert to assess a large amount of participants, and to analyse the data with relatively high cost-effectiveness. Examples for questionnaires used to assess psychosocial risks are the Job Content Questionnaire, the Effort Reward Imbalance Questionnaire or the Job Diagnostic Survey. However, results from questionnaire assessment may be confounded by personal or situational characteristics or states, and cannot be considered as fully objective. Measures enabling a more objective assessment are based on observational approaches, archival data (e.g. promotion policies, hours worked, grievances, sickness absence) or qualitative data. To achieve the most accurate measurement it is recommended to include several of the presented methods when assessing psychosocial risk factors or stress (Eurofound, 1997). On a national level, it is important to ensure surveillance of psychosocial risks to support programs and policies that promote the prevention of stress and ill health. See Bakhuys Roozeboom, Houtman & van den Boosche (2008) for more information on monitoring psychosocial risks at work. In addition, an overview of such systems in different EU countries is provided by Dollard and colleagues (2007). By using different assessment methods, as described above, the individual organisation has a good chance to identify those psychosocial factors that are most likely to be a risk to the health of the employees; and to implement actions, strategies and policies to address and prevent these risk factors.
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Links for further reading
Baumeister, R. F., Heatherton, T. F. & Tice, D. M., Losing Control: How and Why People Fail at Self Regulation, Academic Press, San Diego (CA), 1994.
Cox, T., & Griffiths, A., ‘The nature and measurement of work-related stress: theory and Practice’, In: J.R. Wilson & N. Corlett (Eds.), Evaluation of Human Work (3rd ed.), CRS Press, London, 2005.
EU-OSHA – European Agency for Safety and Health at Work, European Survey of Enterprises on New and Emerging Risks - Managing safety and health at work, European Risk Observatory Report, 2010. Available at: http://osha.europa.eu/en/publications/reports/esener1_osh_management
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