**4. Step-by-step procedure**

**•** Organizational culture–Poor communication, low levels of support for problem-solving and function personal development, lack of definition of, or agreement on, organizational

**•** Interpersonal relationships–Social or physical isolation, poor relationships with superiors, interpersonal at work conflict, lack of social support, harassment, bullying, third-party

**•** Career development–Career stagnation and uncertainty, under-promotion or over-promo-

**•** Home-work interface–Conflicting demands of work and home, low support at home,

A large number of data were obtained by employees' stress self-assessment, according to which 60% of the participants regard responsibility due to their line of work as stressful; 52% participants consider stressful situation interruptions at work; for 46% of employees, stressful situations are short notice deadlines; for 45% of employees, repetitive movements are stress inducers; and for 40% of employees, new tasks are stressful, especially for older working population [9]. A number of questionnaires are offered for self-assessment of the increased stress results, that is, burnout syndrome. In the Netherlands, 22% of the cases of burnout syndrome were caused by a job organization (too few or too many tasks, unclear duties, etc.), while the interpersonal relations at work hold the sec-

In the Netherlands, specifically among most stressful jobs is work behind a counter followed

With regard to mental disorders in working population, three big groups of patients can be recognized. The first group of employees is the ones who have work-related mental health problems, while the second one has similar problems that are not work-related. Workplace is of great importance to both groups because of their rehabilitation process. The third group includes the unemployed suffering from mental disorders for a longer period of time, but it is

"European Pact for Mental Health and Well-being of 2008" gives workplace a central role underlying the necessity for improvement in workplace setting by creating a good work environment to contribute to mental health well-being by including reconciliation of work and family life, introducing stress prevention program at work, promoting health at workplace and support to employment, rehabilitation and return to work of employees with mental problems and mental ill health [12]. Luxembourg Declaration points out the importance of workplace health promotion since a considerable number of population spend significant

**•** Role in organization–Role ambiguity, role conflict, responsibility for people

problems relating to both partners being in the labour force (dual career).

tion, poor pay, job insecurity, low social value to work

objectives

240 Occupational Health

violence

ond place (21%) [10].

by the job of a teacher [10].

**3. Mental disorders, work and cost**

also important to integrate them in the working process [11].

Chart gives a detailed review of the step by step representing a number of procedures conducted in a company in order to assess psychosocial risks and select measures for risk reduction in a workplace. Step by step was created on the basis of available directives, algorithms of the procedure, experience in antistress procedure implementation in some developed countries and evaluation of the results of the measures taken, adjusted to tradition, resources and legal provisions, published in Croatian [23] and presented on Final Conference of the EU Joint Action on Mental Health and Well-being (JA MH-WB) [24]. Based on available guidelines, protocol, etc., of the EU countries as well as evaluated results of the taken measures step-by-step procedures are proposed as well as the tools of occupational medicine specialist for identification of stressors and measures that should be taken to reduce stress at work.

The most important is the implementation of risk-at-work assessment, selection of measures and their control, primarily by employer along with employees and the assistance of an expert/ employee in charge of safety at work and occupational medicine doctors/specialists [7, 14, 15, 25, 26].

The developed world and Europe apply several strategies and models that are focused on organization's analysis and its existing activities, mainly those with regard to prevention and safety at work, health conditions of employees, selection of the most suitable tools for identifying psychosocial risks and stressors. One of the best known for all types of workplace risk assessment is SOBANE strategy which includes four levels: screening, observation, analysis and expertise level

(*S*–.*screening*, *OB*–.*observation*, *AN*–.*analysis and E–.expertise*) [27]. With regard to the stress level according to Karasek's model (demand/control), organizations are divided into four types: active (high job demands and high control), passive (low job demands/low control), high strain (high demands/low control) and organizations with little strain (low demands/ high control) [28].

Each workplace risk assessment especially psychosocial risk assessment, requires employer's support and employees' active participation. Therefore, "fight against stress" should become **organization's policy** (the first step–**Figure 1**). Along with the awareness of the necessity to fight against stress and employer's support, it is necessary to motivate the employers and employees alone to participate in the workplace psychosocial risk assessment, as the primary goal is satisfaction of employees at their work. Healthy workplace environment and satisfaction at work have as a result a higher productivity and a better quality work. According to the latest indicators for organization's management in fighting stress, the most important motive is complying with legal duties, meeting the employees' and their representatives' expectations avoiding the inspection fines but also maintaining the organization's reputation and increase in its productivity [5].

The second step is establishing of a **committee for stress reduction in the workplace, that is**, a team to identify and analyse indicators, risks stressors, identify groups or individuals exposed to high risks, the so-called focus groups and select and propose measures for psychosocial risk reduction at work and at the same time, stressreduction. The committee carries out an action plan and makes decisions about measures to take, who takes measures, how the action is financed, who is responsible and the time needed for the action to be done. So, the owner and/or employer, that is, the authorized person is the key member of the committee for stress reduction in the workplace.

Step-By-Step Procedure and Tools to Reduce Work-Related Stress http://dx.doi.org/10.5772/66181 243

**Figure 1.** Step-by-step procedure and tools to reduce work-related stress.

algorithms of the procedure, experience in antistress procedure implementation in some developed countries and evaluation of the results of the measures taken, adjusted to tradition, resources and legal provisions, published in Croatian [23] and presented on Final Conference of the EU Joint Action on Mental Health and Well-being (JA MH-WB) [24]. Based on available guidelines, protocol, etc., of the EU countries as well as evaluated results of the taken measures step-by-step procedures are proposed as well as the tools of occupational medicine specialist for identification of stressors and measures that should be taken to reduce stress at work.

The most important is the implementation of risk-at-work assessment, selection of measures and their control, primarily by employer along with employees and the assistance of an expert/ employee in charge of safety at work and occupational medicine doctors/specialists [7, 14, 15,

The developed world and Europe apply several strategies and models that are focused on organization's analysis and its existing activities, mainly those with regard to prevention and safety at work, health conditions of employees, selection of the most suitable tools for identifying psychosocial risks and stressors. One of the best known for all types of workplace risk assessment is SOBANE strategy which includes four levels: screening, observation, analysis

(*S*–.*screening*, *OB*–.*observation*, *AN*–.*analysis and E–.expertise*) [27]. With regard to the stress level according to Karasek's model (demand/control), organizations are divided into four types: active (high job demands and high control), passive (low job demands/low control), high strain (high demands/low control) and organizations with little strain (low demands/

Each workplace risk assessment especially psychosocial risk assessment, requires employer's support and employees' active participation. Therefore, "fight against stress" should become **organization's policy** (the first step–**Figure 1**). Along with the awareness of the necessity to fight against stress and employer's support, it is necessary to motivate the employers and employees alone to participate in the workplace psychosocial risk assessment, as the primary goal is satisfaction of employees at their work. Healthy workplace environment and satisfaction at work have as a result a higher productivity and a better quality work. According to the latest indicators for organization's management in fighting stress, the most important motive is complying with legal duties, meeting the employees' and their representatives' expectations avoiding the inspection fines but also maintaining the organization's reputation and increase

The second step is establishing of a **committee for stress reduction in the workplace, that is**, a team to identify and analyse indicators, risks stressors, identify groups or individuals exposed to high risks, the so-called focus groups and select and propose measures for psychosocial risk reduction at work and at the same time, stressreduction. The committee carries out an action plan and makes decisions about measures to take, who takes measures, how the action is financed, who is responsible and the time needed for the action to be done. So, the owner and/or employer, that is, the authorized person is the key member of the committee for

25, 26].

242 Occupational Health

and expertise level

high control) [28].

in its productivity [5].

stress reduction in the workplace.

Occupational medicine specialist is obliged to assess working environment and to work on risk prevention which is in accordance with the signed Convention 161 of *International Labour Office* (ILO) [29]. Employer is due to provide occupational medicine service and health monitoring corresponding with dangers, risks, health damages and strain at workplace with the aim of protecting employees' health.

Furthermore, in some countries have legally established the Committee for Safety and Health Protection and its members including: employers or employer's authorized person, representatives of employees, an expert for safety at work and an occupational medicine specialist [30]. Personnel administration employees and psychologists may be also included in the work of the committee.

Different **methods of the problem analysis and identification** (the third step) are applied in business analysis and work so-called stress indicators, not only of the organization but also of the occupational medicine specialist. Risk assessment of an organization is a legal obligation for employers and has a particular importance in getting the insight into safety and protection at work.

Along with the data obtained from an organization and obligatory riskassessment, data and occupational medicine specialist findings, there are a number of tests to enable a better insight into psychosocial risks in the workplace.

Employer alone can identify work stressors of his employees by means of work stressor questionnaire but there is a possibility for external assessor to do that.

A number of questionnaires are offered for self-assessment of the increased stress results, that is, burnout syndrome.

Employees who have already had disorders or problems should be sent to occupational medicine specialist who would, together with a psychologist as a member of occupational medicine team, take necessary measures, for example, direct the employee to the secondary and tertiary health services.

**Analysis** of all collected data done by the Committee members (the fourth step) can have many outcomes and the most favourable one is a **low stress-risk**, when no measures should be taken.

A group or individuals in which stress identifiers and analysis showed a high stress risk, the so-called **focus group** will probably require additional analysis and testing as well as interviews with high stress risk employees. Some individuals will need occupational medicine specialist service, in some cases even psychologist, which is secondary, that is, reactive action against stress in case of an individual under stress or exposed to stressrisk. Primary or proactive action against stress at work cannot be and need not be removed since in a lower degree it can positively affect creativity, quality, concentration and productivity. Usual steps in removing the danger, harmfulness and strain at work are undoubtedly their elimination, reduction, isolation, control, information and consultation.

**After analysis, the committee chooses the measures** (the fifth step) for stressogenic factors reduction according to the so-called SMART criteria (*S*–*specific*; *M–measurable*; *A–attainable*; *R–* *realistic*; *T–time-bound*) [31]. EU studies point out that the measures taken to reduce psychophysiologic strain in the workplace and health promotion that result in changes of lifestyle increase productivity and profitability and reduce fluctuation as such workplaces are regarded as the "chosen workplaces" [21]. Health promotion at work is a *primary measure for psychosocial risk reduction in the workplace*. European network for health promotion at work gives support to professionals and non-professionals in the field, at the national level [32].

Occupational medicine specialist is obliged to assess working environment and to work on risk prevention which is in accordance with the signed Convention 161 of *International Labour Office* (ILO) [29]. Employer is due to provide occupational medicine service and health monitoring corresponding with dangers, risks, health damages and strain at workplace with

Furthermore, in some countries have legally established the Committee for Safety and Health Protection and its members including: employers or employer's authorized person, representatives of employees, an expert for safety at work and an occupational medicine specialist [30]. Personnel administration employees and psychologists may be also included in the work of

Different **methods of the problem analysis and identification** (the third step) are applied in business analysis and work so-called stress indicators, not only of the organization but also of the occupational medicine specialist. Risk assessment of an organization is a legal obligation for employers and has a particular importance in getting the insight into safety and protection

Along with the data obtained from an organization and obligatory riskassessment, data and occupational medicine specialist findings, there are a number of tests to enable a better insight

Employer alone can identify work stressors of his employees by means of work stressor

A number of questionnaires are offered for self-assessment of the increased stress results, that

Employees who have already had disorders or problems should be sent to occupational medicine specialist who would, together with a psychologist as a member of occupational medicine team, take necessary measures, for example, direct the employee to the secondary

**Analysis** of all collected data done by the Committee members (the fourth step) can have many outcomes and the most favourable one is a **low stress-risk**, when no measures should be taken.

A group or individuals in which stress identifiers and analysis showed a high stress risk, the so-called **focus group** will probably require additional analysis and testing as well as interviews with high stress risk employees. Some individuals will need occupational medicine specialist service, in some cases even psychologist, which is secondary, that is, reactive action against stress in case of an individual under stress or exposed to stressrisk. Primary or proactive action against stress at work cannot be and need not be removed since in a lower degree it can positively affect creativity, quality, concentration and productivity. Usual steps in removing the danger, harmfulness and strain at work are undoubtedly their elimination, reduction,

**After analysis, the committee chooses the measures** (the fifth step) for stressogenic factors reduction according to the so-called SMART criteria (*S*–*specific*; *M–measurable*; *A–attainable*; *R–*

questionnaire but there is a possibility for external assessor to do that.

the aim of protecting employees' health.

into psychosocial risks in the workplace.

isolation, control, information and consultation.

is, burnout syndrome.

and tertiary health services.

the committee.

244 Occupational Health

at work.

**A-organizational measures** are primary measures for stress reduction at work. Employer and managers should stimulate and be a role model for using a holiday and break at work, discourage overtime and insist on reconciliation of family life and work. Bigger organizations invest their money in building kindergartens and its equipment, centres for physical training, which, along with health promotion, have positive impact on employees' work.

**B-organizational** measures are primary and secondary measures for stressreduction in the workplace. Strictly speaking "organizational measures" refer to a suitable workplace, work conditions and methods of work of the employees, for example, working hours, work post, lighting, noise and clear work instructions. Bigger organizations in developed European and US states have introduced the employee assistance program (EAP). It enables the employees with the family problems and problems at work to turn to professional assistants for help for free [33].

**Individual** measures include changing the attitude, methods of work and code of conduct. The contribution of management is seen in education of employees in conducting a conflict, team building and education of team leaders. In Denmark, managers have longer sick leaves and more claims for recognition of professional stress [10]. Education and exercises teach the employees the techniques of stress reduction, relief and relaxation. Efficiency of individual measures for absenteeismreduction is proved [34]. Considerable number of jobs, especially in growing service industry, require emotional strain at work. These jobs require "empathy and sensibility", and emotional stress does not end with finishing work [33, 35]. They are jobs which cause frustration and the feeling of helplessness, jobs in which the employees are faced with extreme situations, so they need some time to move away from their job. Traumatic events like accidents and attacks in the workplace demand special measures starting from step-by-step procedure for incidents. It was found that traumatic experience caused post-traumatic stress syndrome in 87% of the employees [10]. Individual techniques for stressreduction and frequent 15 min breaks at work to do some physical exercises turned to be very efficient [33]. Individual measures at work help in reduction of home-related stress, such as divorce, moving a house and death of a close relative. Not only employers with mental illnesses or disorders should be included in the working process regardless of the cause being at work or outside work, but also the unemployed with chronical mental disorders.

**Return to work** of the employees with mental illness or disorders requires a number of adjustments, from working hours to education of managers and from trainings of the group of the employees to which such employee would join, to psychological support.

**Evaluation of measures** (the sixth step) will show if the committee has selected and worked out suitable measures and if their implementation has led to the desired goal, that is, to the reduction in psychosocial risks at work and reduction in stress in the workplace or workrelated stress.

**Committee analysis** of the results of the measures taken the seventh step should answer the question of profitability of the measures.

All those results will define **a new term to start evaluation of psychosocial risks/stress at work** (the eighth step).

Tradition and experience in safety at work of occupational medicine specialist are exceptionally powerful element in fighting stress at work, which is recognized in EU project "*Jointaction*WP6 mental health at work (personal data)". Also, it should be mentioned that mental health is obligatory part of education of occupational medicine specialist. Considering all obtained results and experience from other countries, we can say that by implementing all mentioned methods, measures and procedures for stress reduction at work and the acquired experience as well as education and evaluation of all results and within the existing legal framework, occupational medicine specialist can make a big step forward towards the stress reduction at work and achieve its primary goal.
