Work & Stress Vol. 24, No. 3, JulySeptember 2010, 234259 Conducting organizational-level occupational health interventions: What works? Karina Nielsena*, Raymond Randallb, Ann-Louise Holtenc and Eusebio Rial Gonzálezd a National Research Centre for the Working Environment, Copenhagen, Denmark; bSchool of Psychology, University of Leicester, Leicester, UK; cNational Research Centre for the Working Environment, Copenhagen, Denmark; dEuropean Agency for Safety and Health at Work, Bilbao, Spain In recent years, there has been an increasing interest in how organizational-level occupational health interventions aimed at improving psychosocial working conditions and employee health and well-being may be planned, implemented and evaluated. It has been claimed that such interventions have the best chance of achieving a significant impact if they follow an intervention process that is structured and also includes the participation of employees. This paper provides an overview of prominent European methods that describe systematic approaches to improving employee health and well-being through the alteration of the way in which work is designed, organized and managed. The methods identified are the Risk Management approach and the Management Standards from Great Britain, the German Health Circles approach, Work Positive from Ireland and Prevenlab from Spain. Comparative analyses reveal that these methods all consist of a five-phase process and that they share a number of core elements within these phases. However, overall the five methods have not been thoroughly validated. To examine the validity of the core elements, we review them in the light of current research in order to support their appropriateness in conducting organizationallevel occupational health interventions. Finally, we discuss where we still need more research to determine the working ingredients of organizational-level occupational health interventions. Keywords: occupational health interventions; participation; evaluation Introduction In recent years, there has been an increasing interest in organizational-level occupational health interventions aimed at improving psychosocial working conditions and employee health and well-being. Organizational-level occupational health interventions can be defined as planned, behavioural, theory-based actions to remove or modify the causes of job stress (stressors) at work and aim to improve the health and well-being of participants (e.g. Giga, Cooper, & Faragher, 2003; LaMontagne, Keegel, Louie, Ostry, & Landsbergis, 2007; Richardson & Rothstein, 2008). Ideally such organizational-level interventions should improve the working *Corresponding author. Email: [email protected] ISSN 0267-8373 print/ISSN 1464-5335 online # 2010 Taylor & Francis DOI: 10.1080/02678373.2010.515393 http://www.informaworld.com Work & Stress 235 environment and help democratize the workplace (Mikkelsen & Saksvik, 1998). It has been found that such interventions are complex and many factors may influence whether they succeed or not (Egan, Bambra, Petticrew, & Whitehead, 2009; Murta, Sanderson, & Oldenburg, 2007). It appears that occupational health interventions have the best chance of achieving a significant impact if they follow a structured and participatory intervention process. Nytrø, Saksvik, Mikkelsen, Bohle, and Quinlan (2000) defined process as ‘‘individual, collective or management perceptions and actions in implementing any intervention and their influence on the overall result of the intervention’’ (p. 214). The importance of intervention planning and implementation processes in determining intervention outcomes is now being widely acknowledged. For example, the Danish government initiated a consortium between the Danish Working Environment Authority and the National Research Centre for the Working Environment (NRCWE) that is working together towards identifying methods that organizations may employ in order to improve the psychosocial working environment. As part of this task researchers from the NRCWE have reviewed intervention methods from a number of European countries that describe the important features of organizational-level occupational health intervention processes. In this paper we summarize the key components of these methods and present a critical evaluation of the research that has examined the links between these components of interventions and occupational health outcomes. The main objectives of this paper are three-fold: (1) to highlight which components could be included in organizational-level occupational health intervention programmes to enhance intervention effectiveness, (2) review the empirical support for these components and (3) to discuss where we have yet to develop our knowledge on how to conduct successful occupational health interventions. Reviewing European methods for improving employee health and well-being To identify methods that describe organizational-level primary occupational health interventions, seven criteria were used. These were developed based on discussions in the consortium and within a wider circle of Danish labour inspectors specializing in the psychosocial working environment (The Psychosocial Taskforce). These labour inspectors conduct inspections in organizations with a special focus on psychosocial issues and therefore have in-depth knowledge of the needs of organizations. The seven criteria that were identified were as follows: (1) Interventions should focus on organizational-level solutions (primary interventions) aimed at changing the way work is designed, organized and managed. (2) Participatory principles should be a core component of intervention. (3) Methods for conducting interventions should systematically consider all phases during an intervention project, from planning to evaluation. (4) Intervention methods should include considerations of how organizational-level occupational health programmes may be integrated with existing procedures and organizational cultures and the management of occupational safety and health within the organization. (5) Communication/education in and raising awareness of the risks posed by features of work design, organization and management should constitute part of the methods. (6) Methods should take into account the organization’s existing experiences with dealing with psychosocial risk 236 K. Nielsen et al. factors. (7) Small and medium-sized companies (SMEs) should be able to use the method. We sought intervention methods meeting these criteria in a number of European countries (Norway, Poland, Great Britain, Ireland, Spain, Italy and Germany), thus providing a good geographical and cultural spread of potential data sources. In some of the countries, for example, Italy and Poland, no such methods were identified. For a discussion of approaches at the national level, see Leka, Jain, Zwetsloot, and Cox (2010). The following five methods (or models) that met the majority of the seven criteria were identified: (1) The Risk Management approach developed at the University of Nottingham, UK (Cox et al., 2000; Cox & Rial-Gonzalez, 2000). (2) The Management Standards, UK, developed by the UK Health and Safety Executive (Cousins et al., 2004; Mackay, Cousins, Kelly, Lee, & Mccaig, 2004). (3) Work Positive, developed by the Health and Safety Authority, Ireland and NHS Health Scotland (http://www.healthscotland.org.uk/workpositive/). The Management Standards and the Work Positive are closely related and are both based on the Risk Management approach. (4) The Prevenlab method, Spain, developed at the University of Valencia (Peiró, 1999; Peiró, 2000, 2006, 2007, 2008). (5) The Health Circles method, Germany, developed partly at universities in Düsseldorf and Berlin (Aust & Ducki, 2004; Schröer & Sochert, 2000). The Health Circles consist of two different schools that vary slightly with regard to the focus: In the Berlin model, health circles consist of employees only, while in the Düsseldorf model both employees and managers participate. In recent years, the distinction has become smaller and the Düsseldorf model now dominates. As a result we do not distinguish between the two methods in this paper (for a detailed review of the differences, see Aust & Ducki, 2004). Using these five methods we developed a model that presents the important phases of an occupational health intervention, together with the components that should be considered under each phase. The model can be seen in Figure 1. The methods differ slightly in terms of the number of phases and, to some extent, the components included in each phase. For the purpose of this paper, we chose to develop an overall model that focuses on five phases. Validation of the five reviewed methods In terms of their overall effectiveness, these methods have only been sporadically validated. Aust and Ducki (2004) identified 11 reports or papers about Health Circles. Only three studies used statistical analyses to review the outcomes but their review identified the potential for Health Circles to bring about improvements in the psychosocial working environment and reduce sickness absenteeism. Reports on the Risk Management approach show that it has the potential to improve working conditions, and result in a decrease in absenteeism, intention to leave and symptoms of stress (Cox, Randall, & Griffiths, 2002). Two doctoral theses have focused on the Risk Management method; one describing and discussing the scientific implications of the method (Rial-González, 2000), and another focusing on the evaluation of intervention initiatives (Randall, 2002). Both of these describe positive outcomes of the risk management approach. The AMIGO (Analysis, Management, and Intervention Guidelines for Organizations) model which forms the basis for the Prevenlab has been validated in a doctoral thesis (Chambel, 1998; Peiró & Martinez-Tur, 2008). Work & Stress 237 Figure 1. Model of occupational health interventions that shows the five phases of an intervention and their associated core elements, as derived from five major intervention methods. Employee participation is important at all stages. The results indicate that when changes are introduced that are perceived by employees to be a violation of the psychological contract, the responses are lower job satisfaction and higher intentions to quit (Chambel, 1998). To the best of our knowledge there have been no published evaluations of Work Positive and the Management Standards. Overall, there is little evidence of which elements in the methods may actually be important to ensure a smooth and effective intervention process. This lack of evidence should be seen in the light of three challenges. First, it is a lengthy process for organizations to conduct organizational-level occupational health interventions, and thus it will be some time before the results can be analyzed and evaluated. Second, organizations differ in terms of occupational sectors and within sectors in terms of organizational cultures, contexts and management structures. Therefore, a large number of intervention studies are needed in order to reach conclusions on generalizability of the methods. Third, currently many high impact journals are reluctant to publish intervention studies, as they seldom follow the ‘‘Gold Standard’’ of experimental design and/or have small sample sizes (Cox, Karanika, Griffiths, & Houdmont, 2007; Semmer, 2006). In the following, we move away from the overall evaluation of the methods to highlight the five phases of the intervention cycle and 238 K. Nielsen et al. their constituent elements as shown in Figure 1, and review the current research about those elements. Phases of intervention methods and their constituent elements A review of the five intervention methods revealed a number of common elements at the various stages of the recommended intervention process. These included, among others, the establishment of a steering group to ensure participation, using sophisticated risk assessment to identify psychosocial risk factors and the development of tailored initiatives to combat psychosocial risk factors. Some elements were not considered by all methods or the emphasis differed. These included the importance of considering the context of the intervention and of reviewing the existing culture and management systems in place to deal with occupational health issues. Therefore in the remainder of this review we have, for each component of the process, made it clear which methods emphasize that component. We also offer a brief review of the research that supports each component. The components are arranged under headings representing five phases. However, first we discuss employee participation, which is common to all phases. Employee participation as a guiding principle All the methods that we reviewed emphasized the importance of employee participation. Although participation may vary throughout the problem-solving cycle, this is vital to the success of occupational health intervention programmes (Aust & Ducki, 2004; Cox et al., 2000; Cox et al., 2002; Peiró, 1999; Peiró, 2000; RialGonzalez, 2000; Schröer & Sochert, 2000). All methods emphasize the importance of establishing a steering group composed of both employers and employees as a first step to ensure participation. The steering group has a number of tasks. These are to represent all interests in the organization, identify groups at risk (the parts of the organization that may be of particular need of occupational health interventions) and set the ethical boundaries (e.g. how anonymity is ensured). They also approve the assessment strategy, plan and implement a communication strategy, monitor the risk assessment process, discuss the results before they are fed back to employees and participate in feeding back information. Steering groups will be discussed further in the section on the preparation phase. Employee participation is important for three reasons. The first is that it can help to optimize the fit of the intervention to the organizational culture and context. This is because it provides a way of making use of employees’ job expertise and knowledge of the organizational context; this provides an important supplement to the expertise of intervention experts (LaMontagne et al., 2007). The second reason is that it can be viewed as an intervention in its own right. Several studies have identified that a participatory approach was one of several working mechanisms that explained the effects of an organizational intervention (Bond & Bunce, 2001; Heaney, Price, & Rafferty, 1995; Lavoie-Tremblay et al., 2005; Le Blanc, Hox, Taris, & Peeters, 2007; Mikkelsen, 2005). Participatory action research treats employees as co-learners in an empowerment process (Mikkelsen, 2005), adding an element of respect, esteem and reward for participants (Andersen & Work & Stress 239 Svarer, 2007). Participation by those directly involved is likely to increase worker control, sense of fairness and justice and support (all of which are working conditions that have been shown to be linked to employee health). Mikkelsen and Saksvik (1998) reported that participation led to a change in perceived responsibility; where employees had felt that ensuring a good working environment had previously been the responsibility of managers they now realized that they also themselves played an important role. In a study of two interventions to reduce burnout, Hätinen, Kinnunen, Pekkonen, and Kalimo (2007) found that a participatory approach minimized burnout whereas a traditional approach without employee participation had no effect. Hätinen et al. (2007) and Bond and Bunce (2001) found that increased job control seemed to be the working mechanism of their successful participatory interventions. The third reason is that participation can also smooth the change process and increase exposure to the intervention. Lines (2004) found that participation was negatively related to resistance to change, and positively related to achievement of goals and organizational commitment. Nielsen, Randall, and Albertsen (2007) showed that influence over the content of an intervention was an important part of the mechanism that predicted participation in intervention activities (and, in turn, intervention outcomes such as behavioural stress symptoms and job satisfaction). The theory underpinning the impact of participation appears strong (Rosskam, 2009). The impact of participation also extends beyond those directly involved in intervention decision-making. Park et al. (2004) found that after a participatory problem-solving intervention in a number of stores all employees in the participating stores reported improvements in social climate, organizational support and interaction with the supervisor. Participation can also have protective effects during turbulent times or difficult organizational change processes. The more involved that employees reported being during the change, the more their managers reported that the intervention had had an impact on daily work practices (Petterson & Arnetz, 1998). Although causality could not be established, it may be that engaged managers are better able to involve their employees or involved employees influenced the managers’ perceptions positively. Similarly, Lines (2004) found that participation was negatively related to resistance to change and positively related to the achievement of goals and organizational commitment. In a review of 18 organizational-level occupational health interventions using participatory methods, Egan et al. (2007) found that in 12 controlled studies, eight of these found improvements in health and well-being. Overall, it appears that the use of participatory approaches brings about positive effects through a number of different mechanisms across a wide variety of organizational contexts and intervention activities. Preparation phase All intervention methods emphasize the importance of the preparation phase. During this phase organizations become familiar with the method and consultants learn about the organizational structure and culture. The phase consists of a number of component elements, as follows. 240 K. Nielsen et al. Establishment of a steering group All methods recommend the use of steering groups. These steering groups should consist of both employer and employee representatives who are empowered to participate as equal partners in decision-making. Employees, managers, middle managers and outside experts (occupational health consultants) are all important members of the such groups because of the complementary skills and expertise they have (Cox et al., 2002; Schröer & Sochert, 2000). Establishing a steering group involves identifying key stakeholders and agents to drive all aspects of the intervention. The steering group should also determine how initiatives may be planned and implemented. Some methods indicate that, when appropriate, the development of initiatives will be carried out by the steering group. The steering group should also monitor the progress of implementation and plan the evaluation of initiatives and the program itself (Cox et al., 2000, 2002). There is some research on the importance of steering groups. The lack of an efficient steering committee to some extent explained disappointing results in a Norwegian study (Mikkelsen & Saksvik, 1999). Here the steering group failed to have regular meetings and project participants received little feedback on how to progress. In another study, Mikkelsen, Saksvik, and Landsbergis (2000) suggested that part of the reason the intervention programme had only limited impact was because the steering group failed to take responsibility for action, by sending problems back to the employee groups without making suggestions or providing help. This research provides examples of the consequences of malfunctioning steering groups; the benefits of well-functioning steering groups have yet to be explored. Employee readiness for change Most intervention methods describe the importance of taking into account the extent to which those involved want, and will accept, change, that is, their readiness for change. The importance of employee ‘‘buy in’’ is identified in most models. Developing readiness involves organizational stakeholders learning about the intervention method (Cox et al., 2000; Peiró, 1999; Schröer & Sochert, 2000). Pryce, Albertsen, and Nielsen (2006) found that it can take time for the potential benefits of an intervention (in that case an open-rota system) to be recognized by employees. In order for participants to welcome change they need to (1) perceive their current situation as being unhealthy, (2) be convinced that change is necessary and (3) of benefit, and (4) be motivated to actively work towards the implementation of change initiatives (Weiner, Amick, & Lee, 2008). Jones, Jimmieson, and Griffiths (2005) found that a perceived positive organizational culture predicted readiness for change which in turn predicted usage of a new computer system. Cunningham et al. (2002) found that a healthy work environment predicted readiness for change which in turn predicted employees’ participation and active contribution to re-organization activities. The importance of ‘‘buy-in’’ at all levels has been stressed from the top level to the shop floor worker (Bourbonnais, Brisson, Vinet, Vézina, & Lower, 2006; Cox et al., 2002; Kompier, Cooper, & Geurts, 2000b). Work & Stress 241 Organizational readiness for change The Risk Management and the Prevenlab approaches focus on the importance of organizations having a certain level of maturity (or healthiness) and experience with organizational-level interventions (Cox et al., 2000, 2002; Peiró, 1999). Organizations with low levels of employee stress and a good working environment (e.g. in terms of autonomy and social support combined with low demands) may have better opportunities to develop and implement intervention initiatives (Taris et al., 2003). Mikkelsen and Saksvik (1999) reported that employees experienced difficulties in developing action plans when they had little previous experience of addressing psychosocial risks: they knew they had a problem but had little idea what to do about it. A recent study by Nielsen and Randall (2009) found that pre-existing levels of role clarity, social support and a meaningful work among employees influenced the degree to which middle managers played an active part in implementing intervention initiatives. Also, Nielsen and Randall (2008) found that employees’ levels of role clarity, social support and involvement in the organization predicted the degree to which employees and middle managers were ready for change. In other words, the organizational structures and organization of work influence the perceptions and actions of the members of the organization and thus also intervention outcomes. This presents a paradox in intervention work: organizations in the most need of intervention are those least well equipped to design and implement them. Naturally, the opposite is also true: in a study of human service organizations, Dellve, Skagert, and Eklöf (2008) found that organizations with systematic occupational safety and health structures had higher levels of work attendance. They concluded that problems with occupational disorders must be visible and systematically dealt with in order to influence employee attendance. Senior management support There is also general agreement among the various intervention methods that in order for an organization to successfully plan, implement and evaluate an occupational health intervention programme there must be good management support (Aust & Ducki, 2004; Cox et al., 2000, 2002; Peiró, 2000). Some empirical studies have validated this recommendation. In a study of stress coping training, Lindqvist and Cooper (1999) found that when senior management released staff from their duties to participate in workshops, attendance was 100%, but at follow-up when staff had to participate during their leisure time, participation dropped to 66%. Most of the available research evidence focuses on the deleterious impact of lack of management support for interventions. In a qualitative process evaluation, DahlJørgensen and Saksvik (2005) concluded that lack of support from senior managers influenced the attitudes of employees. Because managers demonstrated the intervention was an intrusion to their daily responsibilities employees were also resentful. Saksvik, Nytrø, Dahl-Jørgensen, and Mikkelsen (2002) reported on inadequate possibilities to engage in participatory workshops due to senior management only allowing employees time to participate in two-hour workshops. They also reported on problems with getting temping staff to cover for staff on workshops. The lack of support from senior management had a ‘‘trickle down’’ effect on the commitment of middle managers, who reported being unenthusiastic about the programme as they 242 K. Nielsen et al. were allocated no resources to implement initiatives. In summary, there is considerable evidence about the negative impact that a lack of management support can have on interventions. There is less evidence about the positive impact of the management support component of intervention processes. Communication Communication and information are advocated by all the intervention methods as an important part of the preparation phase. Employees must be informed of the project in order to facilitate critical success factors such as participation and buy-in (Cox et al., 2000; Peiró, 1999; Schröer & Sochert, 2000). If good risk assessment evidence is not available to them, ill-informed middle managers and employees will try to make sense of events (Weick, Sutcliffe, & Obstfeld, 2005) and invent their own local theories of justifications for change. These local theories are seldom formally formulated but will nevertheless drive the behaviour of participants. A study by Mattila, Elo, Kuosma, and Kylä-Setälä, (2006) found that the participatory approach did not positively influence health and well-being of employees because employees were not adequately informed about the intervention programme and therefore did not see the purpose of participating in it. Laing et al. (2007) found that without improvements in communication, employees did not report increases in decision latitude and influence when they were exposed to an intervention. The positive benefits of adequate information and communication have also been identified. Nielsen et al. (2007) and Hurtz and Williams (2009) found that perceived levels of information about an intervention predicted employee participation in intervention initiatives. The Risk Management approach warns against making ‘‘empty promises’’ to dilute disappointment (Cox et al., 2002). If communication has raised high expectations among employees but they do not have the opportunity to participate in initiatives or see any real changes being implemented, employees may become cynical. This was confirmed in the study by Nielsen et al. (2007), who found that if employees had heard about the project but not participated in intervention activities they reported a decrease in working conditions at the follow-up. Laing et al. (2007) found that a participative approach increased expectations; where these were not met, decreases in decision latitude were reported. These results suggest that organizations need to carefully consider their communication strategies and ensure that there is realistic communication about expected outcomes and the employees’ role in bringing about these changes. Drivers of change The Risk Management approach, Prevenlab and Health Circles rely on consultants external to the organization as drivers of change at several stages of the process (Cox et al., 2000, 2002; Peiró, 2000; Schröer & Sochert, 2000). The role of external consultants may facilitate the process if they possess expertise in process consultation and knowledge about occupational health issues. Furthermore, as external to the organization they may be objective and avoid taking sides (Cox et al., 2002). There is only a small amount of evidence to support the validity of these mechanisms. Bourbonnais et al. (2006) found that the use of external consultants enabled participants to translate problems into higher-level constructs that could be dealt Work & Stress 243 with more easily. Others have, however, pointed to the dangers of using external consultants. Dahl-Jørgensen and Saksvik (2005) found that their use meant that the participants did not feel ownership for the intervention initiatives, making it difficult to ensure a long-lasting effect. The Prevenlab method has identified eight competencies that external consultants should have. These concern change management skills, expert knowledge of psychosocial risk factors, awareness of regulations and laws, and practical skills to conduct risk assessment and evaluation (Peiró, 2007). The Health Circles method requires facilitators to have an understanding of the method, knowledge about the occupational sector of the participating organization, knowledge of the organization’s structure and experience of process consultation (Aust & Ducki, 2004). To our knowledge, there has been no systematic mapping of the competencies required of internal or external consultants. Screening phase All methods prescribe that an assessment of the risks is conducted as a means of informing initiatives. This is to identify the psychosocial risk factors and to get an overview of the health and well-being of staff. Most often this risk assessment is quantitative, using questionnaire surveys. In the Risk Management approach, interviews are conducted with employees and managers and the results used to tailor the content of a questionnaire in order to make it relevant and usable. Respondents are then asked to rate whether specific aspects of the working environment are problematic; these are analyzed in terms of frequency and are also linked to health and well-being outcomes (Rial-González, 2000). The screening phase consists of the following elements. Selection of methods In the Prevenlab method, a questionnaire consisting of both quantitative and qualitative parts is used. Employees are asked to describe specific situations that are of concern and to rate their intensity and frequency (Peiró, 2008). This can be followed up by further investigations if the picture is incomplete. The Work Positive method and the Management Standards use a standardized questionnaire that is designed to apply to any employee regardless of their work situation or the organizational context. The Health Circles also include organizational absence data (Aust & Ducki, 2004). Alternative methods of risk assessment A vast majority of intervention studies have used surveys to assess psychosocial risk factors; however, problems with small samples, statistical power and ethical issues regarding anonymity and confidentiality mean that survey approaches may not be appropriate in small- and medium-sized enterprises (SMEs). Harris and colleagues employed cognitive mapping to assess the psychosocial risks in eight organizations using a card-sorting technique in which participants were asked about the causes and consequences of negative and positive emotions at work (Harris, Daniels, & Briner, 2002). They concluded that this technique was appropriate for revealing the negative 244 K. Nielsen et al. emotions experienced at work and their causes in the psychosocial working environment: it also encouraged employees to suggest ways of improving working conditions and their current individual coping mechanisms to handle risks. Auditing existing systems The Risk Management method also conducts a supplementary audit of the existing support and management systems (Cox et al., 2000, 2002). In this the activities of Human Resources, training, and the organization’s occupational health and related services are audited in order to reveal the activities that they offer to ensure the health of workers, and how they are used. If services are found to be malfunctioning these may be targeted for intervention. If they are working well, these systems may become models, exemplars or delivery mechanism for future intervention activity. Also, Prevenlab incorporates information on the existing systems, recurrent organizational changes and the integration of the core task and job design in their working model (Peiró, 2000; Peiró, 2008). However, the method offers little information about how this audit should be integrated in the preventive stages. Both the Risk Management and the Prevenlab models could be said to measure the organizations’ readiness for change and maturity level. To our knowledge, there has been no research explicitly examining the effects of conducting such systems audits. Feedback of survey and audit results For all methods a detailed description of how results of the risk assessment (and the audit of management systems and employee support) is provided that should be fed back to employees (Cox et al., 2000; Cox et al., 2002; Peiró, 1999; Schröer & Sochert, 2000). Some studies have focused on the effects of risk assessment and feedback in determining the scale and impact of intervention activity. Eklöf, Hagberg, Toomingas, and Tornqvist (2004) found that feeding back risk assessment results to employees led to more intervention activities; however, the effects on actual changes in the working environment and employee health and well-being were not examined. The authors themselves report that the number of activities does not mean that the most appropriate initiatives were developed. In a later study, Eklöf and Hagberg (2006) significant changes in social support were found where supervisors, and to a lesser extent work groups, had received feedback on risk assessment results. Bourbonnais et al. (2006) concluded that the success of a participatory intervention programme could be partly explained by the feeding back to employees the results of thorough risk assessment prior to developing action plans. Action planning phase Following the feedback to employees, all intervention methods describe a distinct phase of activity that focuses on the development and implementation of initiatives to improve the psychosocial work environment and employee health and well-being. All methods emphasize the importance of prioritization of the problems that have been identified so that efforts focus on a relatively small number of powerful and well-delivered initiatives. As already mentioned, most intervention models stress that Work & Stress 245 employees should play an active role in developing initiatives, to ensure the use of their local knowledge. Risk Management and Prevenlab both emphasize the importance of screening the factors that may facilitate or hinder the development and implementation of change initiatives (Nielsen, Cox, & Griffiths, 2002; Peiró, 2000, 2008). These two approaches also emphasize the importance of evaluating previous occupational health intervention programmes to learn from past successes and failures. This phase of an intervention includes the formulation of a clear action plan which clearly states the initiatives that are planned, the targets of initiatives, the deadlines and the people responsible for driving the initiatives. The Prevenlab and the Risk Management approach also emphasize that part of the action plan should include the criteria for success, that is, the examination of whether an intervention fulfilled its purpose and worked as intended (Cox et al., 2000, 2002; Nielsen et al., 2002; Peiró, 2008). Part of the action plans developed within the Management Standards framework and the Prevenlab includes information on how to communicate initiatives and their outcomes. As such communication forms an integrated part of these action plans. Developing activities The various intervention methods suggest that different types of interventions should be considered during the action planning phase, with the first priority being the identification of primary interventions whenever possible. The Risk Management approach and the Health Circles recommend a mix of primary interventions, secondary interventions (those aimed at giving employees the skills to respond to stressors) and tertiary interventions (rehabilitative interventions). Hunt et al. (2005) found that primary and secondary intervention initiatives supported each other such that when primary initiatives supplemented secondary interventions the uptake at secondary interventions increased significantly. Similarly, results by Larsson, Setterlind, and Starrin (1990) suggested that secondary interventions may release inner resources in employees that can be applied in the outer world, thus leading to better well-being. For instance, Leppänen, Hopsu, Klemola, and Kuosma (2008) found that formal training enhanced the effects of a work process knowledge (knowledge useful for work) intervention. Furthermore, research on action plans has found that their development may lead to participants questioning existing routines and ways of doing business and therefore may be effective in making changes happen (Lavoie-Tremblay et al., 2005). Saksvik et al. (2002) found that some initiatives were not implemented because action plans had not been properly developed. Participatory workshops The development of action plans is typically done in workshops (Risk Management approach), focus groups (Management Standards) or in Health Circles (groups consisting of managers and employees that meet about 610 times over a period of about 6 months) (Aust & Ducki, 2004; Nielsen et al., 2002;). The Risk Management (Nielsen et al., 2002) and the Health Circles (Aust & Ducki, 2004) approaches both emphasize the importance of structured workshops and meetings that are clearly 246 K. Nielsen et al. distinguished from daily work to allow participants the opportunity to reflect and concentrate on the development of action plans. Indirect support for this need for boundaries was found by Dahl-Jørgensen and Saksvik (2005). Management did not prioritize such meetings but instead held conferences in open rooms where people would walk in and out and this impaired the commitment of participants and the development of action plans. Implementation phase In the next phase, a number of initiatives are implemented, as follows. Monitoring The methods that we reviewed included the monitoring of intervention activities. However, they offer little description of exactly how this should be done (Cox et al., 2000; Schröer & Sochert, 2000), only that progress should be monitored and adjustments made if necessary. This is a problem, because the literature points to the importance of monitoring whether intervention initiatives are being implemented as planned. The various methods contain little information about how steering groups should hand over intervention plans to middle managers. Drivers of change: middle managers Kompier, Aust, van den Berg, and Siegrist (2000a) found that in 13 case studies across Europe, middle managers were responsible for implementing intervention initiatives. Nielsen and Randall (2009) found that employees’ reports of intervention outcomes were most likely to be positive when middle managers had taken responsibility for, and involved their subordinates in, the implementation of organizational-level initiatives. Laing et al. (2007) and Nielsen, Fredslund, Christensen, and Albertsen (2006) found that employing engaged and committed managers during the intervention programme enhanced the positive outcomes of the programme. Of course, middle managers can also ‘‘block’’ the process: DahlJørgensen and Saksvik (2005) found that middle managers prevented employees spending time on intervention initiatives. Communication Especially, the Risk Management approach emphasizes communication during implementation. There is some evidence to suggest the importance of communicating the ongoing progress of implementation of initiatives. Landsbergis and VivonaVaughan (1995) found that while members of the steering group felt the project had been moderately or very effective, this perception was not shared by those less close to the epicentre of the intervention and had been little informed about progress: they believed the intervention programme to only have been slightly effective or even ineffective. This points to the fact participation is important throughout all phases employees need to be made aware of progress and have their say in the appropriateness of interventions, including during implementation. Work & Stress 247 Evaluation phase All the intervention methods that we reviewed include some mention of the importance of evaluation. The Health Circles method includes evaluation of the views of those employees involved in health circle discussion groups. The Health Circles and the Risk Management approaches and the Management Standards include, as a first step, the importance of evaluating whether planned initiatives were actually implemented (Aust & Ducki, 2004; Cox et al., 2002). If initiatives only exist as plans that have not been implemented they are unlikely to improve the psychosocial working environment. Effect evaluation Effect evaluation receives less attention in the Health Circles approach than the satisfaction with health circles themselves (Aust & Ducki, 2004; Schröer & Sochert, 2000). The Prevenlab includes a comprehensive evaluation of the degree to which initiatives had the intended effect, how the process was perceived by participants, and organizational learning (e.g. the degree to which the organization has become better equipped to deal with psychosocial risk factors in the future; Peiró, 2008); it also considers whether the organizations are continually undergoing change, deliberate or not (Peiró, 2000). The Risk Management approach heavily emphasizes the importance of evaluation (Randall, 2002). This approach emphasizes the importance of effects being measured at several levels, including both proximal changes (in procedures and working conditions) and distal changes (in levels of absenteeism, turnover and employee health and well-being). Complex analyses of process and effect evaluation have been conducted and published in peer-reviewed journals (Randall, Cox, & Griffiths, 2007; Randall, Griffiths, & Cox, 2005). These include qualitative evaluation in smaller groups (Randall et al., 2007) and the use of emergent variability in quantitative research. Intervention initiatives tend not to be uniformly implemented across employees and therefore can only be expected to improve the health and well-being of those employees that actually were affected by them (Randall et al., 2005). It is important to evaluate not only the effects of the actual intervention initiatives but also the processes which may have facilitated or hindered their implementation. Process evaluation documentation The Management Standards, the Risk Management and the Prevenlab approaches also consider documentation of the processes. Combining the evaluation of both process and effect is increasingly being advocated (Egan et al., 2009; Murta et al., 2007; Semmer, 2003; Semmer, 2006). There is a body of research (primarily Scandinavian) that has provided evidence for the benefits of integrating process and effect evaluation to get an increased understanding of why and how interventions work (Dahl-Jørgensen & Saksvik, 2005; Mikkelsen et al., 2000; Nielsen et al., 2006; Nielsen et al., 2007; Nielsen & Randall, 2009; Nielsen, Randall, & Christensen, in press; Pryce et al., 2006). Nielsen, Randall, and Christensen (2010) presented an evaluation model which examined the intervention process at three levels: the importance of the organizational context, the documentation of initiatives 248 K. Nielsen et al. developed and implemented, and the importance of individual appraisals of the quality of intervention activities. The importance of evaluating the impact of context is well acknowledged (Egan et al., 2009; Murta et al., 2007). For the use of context in intervention research the concepts of omnibus and discrete context may be useful (Johns, 2006). Omnibus refers to the story told, for example, who are the participants? There is evidence that intervention activities form a transactional relationship with the intervention omnibus. In a study by Dahl-Jørgensen and Saksvik (2005), it was found that the actual requirements of the job (i.e. face-to-face relationships) bound service providers to the needs of the customer and hindered participation in intervention initiatives. Mikkelsen and Saksvik (1999) report that finding cover for staff involved in participatory intervention processes can use up more time and effort than the development of action plans themselves. Saksvik et al. (2002) found that being part of a larger organization or having a bureaucratic organization hindered the development of intervention activities. The discrete context, that is, specific events that took place throughout the intervention project, also receives little attention in established occupation health intervention approaches. Many concurrent events can facilitate or hinder implementation. For example, in one study the introduction of a non-smoking policy created resistance among participants (Nielsen et al., 2006). In another, threats of lay-offs distracted the participants’ focus on the intervention project (DahlJørgensen & Saksvik, 2005; Nielsen et al., in press). Egan et al. (2007) found in their review that where redundancies and downsizing took place at the same time as participatory intervention programmes, positive effects on employee health and wellbeing were diluted. Process evaluation emergent variability The Risk Management approach, the Management Standards and Prevenlab also consider how intervention activities have been received by participants. The impact of context raises the important issue of fidelity of implementation processes. Research shows that the degree to which interventions are actually implemented is imperative to the outcomes of the intervention. Nielsen et al. (2006) and Landsbergis and Vivona-Vaughan (1995) found that where few of the planned interventions were implemented, improvements in psychosocial working conditions and employee health and well-being were not detected. Nielsen et al. (2007) found that actual participation in intervention initiatives predicted whether employees reported that their working conditions had improved at time 2. Randall et al. (2005) demonstrated that unintended and unplanned variations in intervention exposure explained differences in health at the follow-up. Measurement of exposure to an intervention is not an explicit part of the risk management processes that we identified in our research. Linked to this is the important issue of participants’ appraisals of intervention initiatives. The way individuals perceive situations are likely to drive their behaviour (Johnson-Laird, 1983). Oreg (2006) found that the lack of trust in management and that others did not support change predicted behavioural resistance to change. Randall et al. (2005) found that the reason middle managers did not communicate changes in procedures were because they felt the changed procedures would make it difficult for them to Work & Stress 249 control their budgets. Nielsen, Randall, Brenner, and Albertsen (2009) found that employees who had participated in intervention initiatives and found them to be of value also reported improved working conditions. Bunce and West (1996) found that positive appraisals of initiatives were associated with higher levels of job satisfaction and lower levels of stress. In an extension of the study by Bond and Bunce (2001), Bond, Flaxman, and Bunce (2008) found that among employees who had flexibility (i.e. employees had the ability to persist with or change their behaviours in order to achieve their goals) the positive effects of a participatory effect were stronger. Cynicism due to previous failed projects has been found to hinder successful intervention projects (Nytrø et al., 2000). Saksvik et al. (2002) and Dahl-Jørgensen and Saksvik (2005) found that employees were resistant to change because they knew from experience that although interventions were initiated they were not followed through and failed to bring about the desired results. This has been termed ‘‘initiative fatigue.’’ Discussion This aim of this paper has been to provide an overview of the phases and their constituent elements as incorporated in major European approaches to organizational-level occupational health interventions. In collaboration with labour inspectors with a special expertise in psychosocial issues, we used seven criteria to identify methods with may bring about sustainable improvement in the psychosocial work environment and employee health and well-being. Shared components in the methods were identified and held up against current research in an attempt to validate the processes prescribed in these methods. These elements for the most part received support from research. Although this paper brings us one step further in how to conduct such interventions, it also highlights the significant gaps in our knowledge. Below we discuss where more knowledge is needed. Future directions In the following, we discuss some issues that we feel need to be addressed in order move the field of organizational-level interventions forward. Conducting occupational health interventions to reduce risk or to improve employee development? Organizational-level interventions are often referred to as stress management interventions (SMIs) (Murta et al., 2007; Randall et al., 2005, 2007, Randall, Nielsen, & Tvedt, 2009); however, in this paper we have adopted the term organizational-level occupational health interventions. This reflects a need for intervention goals to be set above and beyond the absence of ill-health (Linley & Joseph, 2004). Organizational-level interventions may not only reduce ill-health but can sometimes promote positive well-being at work (Jackson, Sprigg, & Parker, 2000; Mikkelsen et al., 2000; Sprigg, Jackson, & Parker, 2000). Approaches to interventions need to offer explicit guidance for organizations about how change may bring personal growth, engagement, and positive affective well-being (Bakker & Schaufeli, 250 K. Nielsen et al. 2008; Hackman, 2009; van Horn, Taris, Schaufeli, & Schreurs, 2004). Many of the methods examined in this paper provide some mention of the importance of the positive aspects of work, but give little information about how they can be incorporated into an intervention strategy (Cox et al., 2000; Peiró, 2008). This focus on problems with health and work is also reflected in the language of these methods such as ‘‘stress,’’ ‘‘risk assessment,’’ ‘‘risk analysis’’ and ‘‘prevention’’; more work is needed to test and describe intervention frameworks that include the positive aspects of work, and employee development and engagement. Employee participation While employee participation constitutes a central part in all methods, and is generally recommended in the literature (Egan et al., 2007; Rosskam, 2009), there is still a need to explore the form that participation should take. During the preparation phase employees should play a role in planning the project, whereas in the risk assessment phase participation may be limited to responding to questionnaires or, in the action planning phase, to prioritizing and planning interventions. However, although participation is generally thought to be a good thing, more research is needed to better understand why and when participation works. A recent study by Nielsen et al. (2006) found that where employees were unaccustomed to dealing with occupational health issues a more directive intervention process seemed to be more effective than a participatory approach. Joint ownership of problems and solutions is an important part of participation that is rarely discussed. When external consultants play a part in the intervention process, dealing with occupational health issues must become part of daily practice for employees to ensure that responsibility for the intervention is not shifted to the external consultants. This establishes a feeling of joint responsibility and minimizes the risk that the process will stagnate when the external consultant leaves the organization. This approach to participation also helps to ensure that empowerment and learning are integrated in the organizations’ daily practices. An over-dependence on ‘‘drivers of change’’ can also leave the intervention vulnerable. Intervention programmes that depend on middle managers are vulnerable to changes in management personnel, since newly appointed managers may not feel responsible for the project (Dahl-Jørgensen & Saksvik, 2005; Mikkelsen & Saksvik, 1999; Nielsen et al, 2006). Through the participatory processes, joint needs should develop so that intervention programmes will be less dependent on individuals and have a better chance of bringing about sustainable changes. The use of occupational health professionals The methods described in this paper focus heavily on the use of external consultants; however, it should be examined whether this is always necessary. Small and medium enterprises (SMEs) may have neither the resources nor the interest to employ such consultants and because large organizations may already have in-house resources that may take on the role as facilitator. It should be possible to map the competencies required by these facilitators so that those wishing to be involved in implementing an intervention can be trained. The ethical issues regarding bias, power and confidentiality are somewhat different and perhaps more challenging for those Work & Stress 251 working within the organization than external consultants, and may therefore require careful selection and training of those leading intervention programmes. Although both the Risk Management approach and Prevenlab point to certain competencies being needed, no research has been conducted to validate these suggestions. Validating which competencies are required should result in a mapping tool that organizations could use to identify people within the organization who might take on this role. Risk assessment Most screening methods focus on using questionnaires. Although these have many advantages, disadvantages, (e.g. their lack of suitability in SMEs) must also be acknowledged. For practical and ethical reasons, new tools should be developed that capture important data throughout the intervention process. Standardized questionnaires make it difficult to interpret the results since normative interpretation does not always identify the need for the intervention and fails to consider the specific organizational context. For example, white collar workers traditionally have more influence and control than blue-collar workers and therefore employees in a whitecollar organization may experience problems even if their questionnaire results compare favourably to the national average. For a discussion of which factors should be assessed see Nielsen, Taris, and Cox (2010). There is a need to explore alternative risk assessment tools for several reasons. First, problems exist with translating the results of standardized questionnaires to concrete initiatives. Second, many current questionnaires fail to consider the importance of individual appraisal. Harris and Daniels (2007) provide powerful evidence that it is not the objective working environment that influences employee well-being but how individuals appraise the working environment. The importance of appraisals is crucial in dominant theories of (1) work stress (Lazarus & Folkman, 1992), (2) sense-making in determining behaviour in organizations (Weick et al., 2005) and (3) theories of planned behaviour (Ajzen, 1991). Third, survey methods are not appropriate in SMEs for ethical and statistical reasons. Alternative methods that integrate dialogue methods may offer a way forward while also taking into consideration the social, regulatory and professional conditions of SMEs. And fourth, there is a need to explore the interplay between risks (problems) and resources (opportunities). Most of the above methods pay little attention to how the organizational and individual resources may be best employed to minimize risks and ensure individual well-being and growth. For example, the audits of organizational support systems have not been scientifically validated, nor has it been extensively discussed how such audits may be used in preventing risks and developing employees. Maturity and ceiling effects: intervening in sick or healthy organizations? Previous research has found that organizations with little experience of, and few formalized systems for, dealing with occupational health issues struggle to implement organizational-level occupational health interventions that bring about the desired outcomes. On the other hand, organizations where employees report good working conditions and employee health and well-being due to well-developed occupational 252 K. Nielsen et al. health practices in their daily business may benefit only marginally from organizational-level occupational health intervention programmes. While both the Prevenlab and the Risk Management approaches emphasize the importance of taking into consideration systems that already exist within the organization to deal with occupational health issues, they fail to consider whether organizations are ready for intervention programmes. It may be useful to develop an initial screening tool that determines whether or not an organization would benefit from participating in an intervention programme, and what measures need to be put into place to make it ready for intervention. The maturity of an organization is only likely to reveal itself during the risk assessment process, by which time researchers have already invested so much time and effort that they cannot turn away from the organization; expectations will have been raised among employees about the programme such that it may have negative consequences if risk assessment is not followed by initiatives to improve the working environment (Nielsen et al., 2007). This situation may require a re-consideration of the suitability of the criteria for success, with modest goals being set and more sensitive evaluation methods being used. Organizational-level occupational health interventions may take some time to exert a significant effect on working conditions and well-being (Landsbergis & Vivona-Vaughan, 1995; Mikkelsen, 2005). Before these effects are apparent, organizations may start communicating with employees in different ways and have a greater focus on occupational health issues, and employees may start feeling more empowered to deal with such issues. There is a need for researchers to evaluate these issues as well. Rather than concluding that an intervention was ineffective, programmes should include the evaluation of micro-level changes or proximal measures (rather than distal measures), such as improved communication to employees about occupational health issues and empowerment. Changes in distal measures should always be linked to changes in proximal measures; that is, the procedures targeted by intervention activities should change in such a way that changes in distal measures are in fact the result of the intervention. The lack of published evaluation of changes in empowerment is curious, considering the recommended use of participation in the methods we reviewed, where the aim is to empower employees. Occupational health and its links to daily performance To date too little attention has been paid to how we may integrate occupational health interventions into daily work practices. Occupational health interventions are often seen as something separate from running the daily business and ensuring high performance (that is, as a ‘‘nice to have’’ rather than as integral to the effectiveness of the organization). There are powerful arguments for organizations to pay special attention to occupational health issues. Bambra, Egan, Thomas, Petticrew, and Whitehead (2007) concluded in their review that where task restructuring interventions were implemented with the sole purpose of improving performance, they had no or detrimental effects on employee health and well-being. The effects of poor employee well-being on organizational performance have been confirmed (Taris & Schreurs, 2009; Wright & Cropanzano, 2000). Also, in many studies on occupational health interventions, organizational changes and restructuring have taken place that Work & Stress 253 have blunted the effects of the intervention. This is increasingly the case when the intervention is not integrated into daily business and as such becomes more vulnerable to organizational change. It is important to (a) develop tools that can evaluate the ‘‘true’’ effects of occupational health interventions and separate them from contextual ‘‘noise’’ and (b) develop strategies for better integrating occupational health intervention programmes into daily business. Improving employee health and well-being: the responsibility of the organization? Since the 89/391/EEC Framework Directive (EU-OSHA, 2002), employers across the European Union have a legal obligation to assess and manage all workplace risks, including psychosocial aspects. However, it is widely acknowledged that this is challenging. According to the European Survey of Enterprises on New and Emerging Risks (ESENER; EU-OSHA, 2010), only 26% of establishments in the 27 member states of the European Union (EU-27) report having procedures in place to deal with work-related stress. Higher prevalence is reported in larger establishments, and these more formalized procedures are widespread in only a few countries; the highest frequencies are reported in Ireland, the United Kingdom, the Scandinavian countries and Belgium. National and EU initiatives may increase organizations’ motivation and ability to conduct organizational-level occupational health interventions. It is precisely in three of the countries that report the highest prevalence of formal procedures that examples of these initiatives are found: the UK’s Management Standards and Ireland’s Work Positive initiatives, where inspection bodies have provided guidance on how to improve employees’ health and well-being, and the ‘‘Prevention Packages’’ that are currently being developed in Denmark. Following the work of the Danish consortium described in the introduction, the NRCWE and the Danish Working Environment Authority are jointly developing ‘‘Prevention Packages’’ that consist of occupational health intervention programmes. Organizations can apply for funding to conduct these interventions. The projects will be scientifically evaluated using process and effect evaluation. Such initiatives may provide financial incentives for organizations at the same time as providing structured guidance for the content and process of occupational health interventions. An added advantage is the built-in evaluation which ensures that initiatives are properly evaluated. The fact that national labour inspectorates are behind these initiatives should represent a significant incentive for organizations, given that among those establishments that report having procedures in place to deal with work-related stress, by far the most cited reason for addressing psychosocial risks, with an EU-27 average of 63%, is ‘‘fulfilment of legal obligation’’ (EU-OSHA, 2010). Limitations of this review In this paper, we have focused on five major approaches to improving the psychosocial work environment through organizational-level interventions. This has the advantage that we have been able to systematically review the various phases of those major approaches. However, this also has its limitations: First, we only reviewed four methods. It is likely that other approaches may also contribute to existing knowledge on how to improve the psychosocial work environment. For 254 K. Nielsen et al. instance, approaches from countries not reviewed by the Danish Consortium of the NRCWE and the Danish Working Environment Authority, or approaches that are less widespread, may provide valuable knowledge not covered here. That is, the approaches that we covered may have ‘‘blind spots.’’ Second, we used a number of criteria to select the methods that we reviewed, with the overarching principle being methods having a focus on participation and organizational-level interventions. It is likely that other methods exist that may also improve employee health and well-being that have not been covered here. Furthermore, the gold standard in organizationallevel occupational health intervention research is still the (quasi-)experimental study design. We chose not to engage in a discussion of research designs, as this has been extensively covered elsewhere in recent years (Semmer, 2003, 2006). Conclusions In this paper, we have presented the main phases of an intervention and their constituent elements as identified by five major European approaches to systematically planning, implementing and evaluating organizational-level occupational health interventions. We have also reviewed the existing research supporting the appropriateness of these elements and suggested avenues for future research. We believe that this paper has two important implications: First, the major approaches all share a set of core elements across the European borders that are emphasized in these approaches as being essential to ensure employee health and wellbeing. There seems therefore to be a certain consensus regarding the elements that constitute a systematic approach, even if these elements weigh differently across the approaches. Second, it would appear that although the approaches themselves have only been sporadically evaluated, current research supports these elements. We found support that a vast majority of the core elements identified are important in ensuring a good intervention process, leading to improvements in employee health and wellbeing. Some studies investigated the absence of these core elements (e.g. senior management support and the use of a steering group). Overall, our knowledge is developing as regards which processes of organizational-level interventions may help to ensure successful outcomes. However, more research is still needed to explore how these factors may be best exploited to improve the work-related health of employees. Acknowledgements The authors would like to thank José Marı́a Peiró for providing information on the validation of the Prevenlab method and also colleagues from the National Research Centre for the Working Environment and the Danish Working Environment Authority, who as members of that consortium have been involved in the discussions on the methods reported in the Danish reports. 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