2.3. The Participatory Organizational-level Intervention
This study is based on the INAIL’s methodology for the assessment and management of psychosocial risks tailored to the Healthcare sector [26
]. The INAIL’s methodology provides four main phases: 1. Preparation, 2. Preliminary Assessment, 3. In-depth assessment, and 4. Actions and monitoring [26
]. In this study, a fifth phase was added, named Evaluation, to investigate the effectiveness of the POI by answering the questions of what works for whom in which circumstances. A full description of each phase is provided below.
Phase 1: Preparation
Preparation is a starting phase for the POI where organizations plan the intervention process and develop strategies for how to ensure commitment to the process at all levels within the organization. This involves some essential steps useful for process, such as identifying persons and roles involved, planning activities, and procedures. The main steps of this phase can be summarized as follows:
Establishment of the Steering Group for the assessment and management of psychosocial risks. The employer, or in the case of hospitals, senior management, formally establishes a Steering group consisting of key stakeholders with a stake in worker health and working conditions, such as OSH professionals, human resource managers, and occupational psychologists. The key function of the Steering Group is to plan, monitor, and facilitate the process, to determine key milestones and to inform employees about intervention progress. A project champion should be identified who can coordinate the different activities and roles [43
Identification of the Homogeneous Groups of employees. Following Italian recommendation [30
], organizations with more than 30 employees must set the assessment and management of work-related stress risks at the group level. As the hospitals involved in the present study have more than 3000 employed each, the Steering Committees in the respective hospitals identify Homogeneous Groups. Such groups consist of employees who share similar aspects of work organization, thus experiencing similar working conditions and work environment, who are within the same chain of command, and who receive communication through the same channels.
Development of a POI plan with a formal timesheet of each action to be taken, roles, resources, and responsibilities.
Development of a strategy of communication to inform employees about the POI, its phases and framework, surveys/questionnaires used in the assessment, figures involved, and timesheet. Communication should happen using the organization’s formal communication channels to disseminate information in the organization. Moreover, employee representatives for health are involved to improve informal communication, too [43
Phases 2–3: Risk Assessment
Two assessment phases are conducted: (1) a preliminary assessment based on objective indicators related to the work content and context, as well as organizational record data as main indicators of work-related stress named sentinel events; (2) an in-depth assessment based on employees’ perceptions of psychosocial risks. For such risk assessment phases, the “standard methodology” offers two validated tools, respectively, an organizational Checklist (I-Check) [31
] and a standardized questionnaire (the Italian version of the Management Standards Indicator Tool) [32
]. At a glance, the I-Check measures trends in some organizational data named sentinel events that may be signal of work stress (such as sickness absences, turnover, injuries at work, etc.) and verifiable indicators of the work content and context. The Management Standards Indicator Tool measures seven dimensions of the psychosocial work environment.
The tailored methodology for the healthcare sector adds some organizational data (e.g., concerning patients) and scales to capture the sector-specific psychosocial risks. These are based on a preliminary proposal developed by the University of Bologna in a project led by INAIL and financed by the Ministry of Health in 2016 [41
]. Risk assessment was developed after a literature review and based on the findings of a workshop involving main stakeholders of OSH management in this sector using a participatory approach. This included: (1) adding to the risk assessment further and tailored indicators and dimensions to catch distinctive psychosocial risks of the healthcare work; (2) developing specific indications and procedures to apply the methodology in a healthcare context; (3) providing tools to translate assessment findings in fitting actions and interventions; and (4) developing procedures to evaluate the effectiveness of the whole POI process. After a first test, the proposal received a revision, and the final version is object of this study. A full list of standard and integrative indicators and measures tailored to healthcare sector are reported in Table 1
and Table 2
A measure of satisfaction with job [45
] was included as baseline of the outcome evaluation. Data will be collected at group level and analyses at group and organizational levels.
Phase 4: Actions Plan and Implementation
This phase provides two main actions: the identification and planning of corrective and preventive actions and the implementation of actions identified.
The identification of best and fitting actions is based on findings of the assessment phases where psychosocial risks are identified as a way to improve working conditions and job satisfaction. Moving from assessment to action is a crucial step that requires a reflection on which changes the way work is organized, designed, and managed may improve working conditions.
The Steering group has the responsibility for the planning of corrective actions on the basis of assessment findings but can involve other key stakeholders in light of the participatory approach to ensure the use of relevant expertise to understand which changes are needed and most efficiently implemented.
Steps recommended for moving from the assessment to the identification and plan for actions are detailed below. For each step, practical tools and templates for moving from one step to the next of the process will be developed to support the Steering group in the identification, planning, and implementation of actions and to ensure a consistent approach across units.
Identifying corrective/improvement action priorities based on the assessment results. The Steering Group examines and discusses the results of the assessment in order to establish the priority areas in which to intervene, especially in the event of multiple critical aspects requiring different actions.
Verifying the need for any in-depth analysis or additional information. At this stage, participation is crucial. The involvement of the workers from the group, through focus group and workshops, can be helpful to better interpret the results of the assessment phases and to gather suggestions for effective and appropriate solutions. Focus groups can be conducted to inform the work of the Steering group in identifying corrective actions, particularly in those groups where it is not immediate to link actions to the risk areas emerged.
Establishing improvement actions with regard to the priorities identified. The Steering Group establishes the actions to be implemented by evaluating their relevance and feasibility. At this stage, involvement of line managers with operational meeting is suggested. Line managers have a decision-making power over work processes and procedures requiring changes. They have also a role in promoting and communicating changes to employee. They can support and facilitate the implementation of the improvement actions defined by the Steering Group.
Once actions have been identified, the Steering group agrees a plan of actions including how these may be realistically integrated into existing work practices and procedures. Action plans will detail who will be responsible for implementing actions and other key stakeholders who may support the implementation of corrective actions (human resource, line managers, specific employees, internal psychologists, etc.). In the action plan, activities and tools identified for monitoring and evaluating the effectiveness of corrective actions must be set out. The plan for actions will be shared and discussed with line managers, and employees must, in turn, be informed about which changes will be introduced, why, and how to ensure they buy into and are ready to change their work behaviors that actions require.
The implementation phase mirrors the action plans identified in terms of time, roles, and responsibilities identified and plan for monitoring and evaluating the effectiveness of corrective actions.
According to the recent development in occupational health psychology, we focus on the Individual, the Group, the Leader, and the Organizational level model (IGLO model) [46
]. This model calls for actions to be developed at all the four levels and for the active involvement of each level in the intervention activities. Taking as its starting point the risk assessment findings, an action plan will be developed that identifies which actions need to be taken at each level to improve working conditions and job satisfaction but also what support is needed at each level to ensure sustainable change.
At the Individual level, employees should consider which actions they can take as individuals. Employees and their representatives for health (which are the union representatives, too, in Italy) are active involved in the assessment activities, actions plan, and process evaluation, through questionnaires and focus groups. At the Group level, actions may be implemented to promote a good social climate. Risk assessment and process evaluation are analyzed at group level. At the Leader or line manager level, training line managers in how to promote good working conditions at work may be necessary. As described above, line managers has also an active role in action plan and contribute to the implementation supporting the changes. Finally, at the organizational level, actions can be taken to develop supportive policies, e.g., flexible working or rotas, that promote work-life balance. Actions will also consider the existing organizational resources, procedures and facilities to hinder the implementation of the organizational intervention. Moreover, an evaluation of the process will also be conducted at the organizational level through an audit tool, including all the steps favoring the effective development of the POI.
Phase 5: Evaluation
To ensure that evaluation will inform future POIs and policy making, the pilot project employs a realist evaluation approach. This approach seeks to answer not only the question of whether an intervention worked, but answering the questions of what worked for whom in which circumstances [48
] through the examination of Context-Mechanisms-Outcome (CMO) configurations. These configurations examine what the contextual factors are that may either facilitate or hinder that a mechanism is being triggered and what the outcome is when a mechanism is being triggered [48
Mechanisms are the working ingredients in terms of the intervention process (e.g., participation, management support, and intervention fit) and the content of the intervention (actions taken at the IGLO levels), and outcomes are any improvements in working conditions and job satisfaction. We include three contextual factors, which may influence whether the intervention’s mechanisms will be triggered. First, the extent to which the intervention fits with the goals of the healthcare organizations. If the intervention does not align with the goals of patient care and is not seen to be appropriate for successfully addressing the psychosocial risks [49
], then employees and managers are unlikely to engage in the intervention process. Second, an important precursor to change is the extent to which employees and managers understand the goals of change. Previous research has found that poor communication about an intervention’s goals and objectives prevents employees and managers engaging in the participatory process [50
]. Third, participants’ readiness for change is crucial for mechanisms to be triggered. The extent to which participants are confident that their engagement in the intervention can lead to improvements in working conditions and that they are ready to accept changes introduced as a result of the intervention [51
] will determine their actual making changes and engaging in the intervention process, thus enabling the mechanisms to be triggered.
At baseline, the preliminary assessment and the in-depth assessment will be conducted (see Figure 1
) together with measures of context on all employees from each group. Around 6 months into the project, process measures of participation, line management support, and intervention fit will be measured on managers, 10% of employees, and their union representatives (see Figure 2
). At follow-up, around 4–6 months after baseline, the in-depth assessment will be repeated together with measures of the process and the actual actions at the IGLO levels that have been implemented (see Figure 2
). Structural equation modeling will enable the test of CMO-configurations [52