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Whole-system approaches to improving the health and wellbeing of healthcare workers: A systematic review

  • Sarah L. Brand ,

    Roles Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

    brands@cardiff.ac.uk

    Affiliations European Centre for the Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall, England, United Kingdom, Y Lab Public Service Innovation Lab for Wales, School of Social Sciences, Cardiff University, Cardiff, Wales, United Kingdom

  • Jo Thompson Coon,

    Roles Conceptualization, Methodology, Project administration, Supervision, Writing – review & editing

    Affiliation University of Exeter Medical School, South Cloisters, St Lukes Campus, Exeter, Devon, England, United Kingdom

  • Lora E. Fleming,

    Roles Conceptualization, Funding acquisition, Project administration, Resources, Supervision, Writing – review & editing

    Affiliation European Centre for the Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall, England, United Kingdom

  • Lauren Carroll,

    Roles Formal analysis, Writing – review & editing

    Affiliation Y Lab Public Service Innovation Lab for Wales, School of Social Sciences, Cardiff University, Cardiff, Wales, United Kingdom

  • Alison Bethel,

    Roles Data curation, Methodology, Writing – review & editing

    Affiliation University of Exeter Medical School, South Cloisters, St Lukes Campus, Exeter, Devon, England, United Kingdom

  • Katrina Wyatt

    Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

    Affiliation University of Exeter Medical School, South Cloisters, St Lukes Campus, Exeter, Devon, England, United Kingdom

Whole-system approaches to improving the health and wellbeing of healthcare workers: A systematic review

  • Sarah L. Brand, 
  • Jo Thompson Coon, 
  • Lora E. Fleming, 
  • Lauren Carroll, 
  • Alison Bethel, 
  • Katrina Wyatt
PLOS
x

Abstract

Background

Healthcare professionals throughout the developed world report higher levels of sickness absence, dissatisfaction, distress, and “burnout” at work than staff in other sectors. There is a growing call for the ‘triple aim’ of healthcare delivery (improving patient experience and outcomes and reducing costs; to include a fourth aim: improving healthcare staff experience of healthcare delivery. A systematic review commissioned by the United Kingdom’s (UK) Department of Health reviewed a large number of international healthy workplace interventions and recommended five whole-system changes to improve healthcare staff health and wellbeing: identification and response to local need, engagement of staff at all levels, and the involvement, visible leadership from, and up-skilling of, management and board-level staff.

Objectives

This systematic review aims to identify whole-system healthy workplace interventions in healthcare settings that incorporate (combinations of) these recommendations and determine whether they improve staff health and wellbeing.

Methods

A comprehensive and systematic search of medical, education, exercise science, and social science databases was undertaken. Studies were included if they reported the results of interventions that included all healthcare staff within a healthcare setting (e.g. whole hospital; whole unit, e.g. ward) in collective activities to improve physical or mental health or promote healthy behaviours.

Results

Eleven studies were identified which incorporated at least one of the whole-system recommendations. Interventions that incorporated recommendations to address local need and engage the whole workforce fell in to four broad types: 1) pre-determined (one-size-fits-all) and no choice of activities (two studies); or 2) pre-determined and some choice of activities (one study); 3) A wide choice of a range of activities and some adaptation to local needs (five studies); or, 3) a participatory approach to creating programmes responsive and adaptive to local staff needs that have extensive choice of activities to participate in (three studies). Only five of the interventions included substantial involvement and engagement of leadership and efforts aimed at up-skilling the leadership of staff to support staff health and wellbeing. Incorporation of more of the recommendations did not appear to be related to effectiveness. The heterogeneity of study designs, populations and outcomes excluded a meta-analysis. All studies were deemed by their authors to be at least partly effective. Two studies reported statistically significant improvement in objectively measured physical health (BMI) and eight in subjective mental health. Six studies reported statistically significant positive changes in subjectively assessed health behaviours.

Conclusions

This systematic review identified 11 studies which incorporate at least one of the Boorman recommendations and provides evidence that whole-system healthy workplace interventions can improve health and wellbeing and promote healthier behaviours in healthcare staff.

Introduction

Healthcare professionals throughout the developed world have markedly high rates of sickness absence, burnout, and distress compared to other sectors [17]. With the added pressure on healthcare systems, and thus on healthcare staff, of rapidly aging populations and burgeoning chronic disease burdens [8], there is increasing interest in improving both the mental and physical health and wellbeing of healthcare professionals [9, 10]. There is a growing call for the ‘triple aim’ (improving patient experience, patient outcomes, and efficiency) to become the ‘quadruple aim’, with the inclusion of improving healthcare staff experience of care delivery [11, 12]. In the United Kingdom (UK) the National Health Service (NHS) in England’s Five Year Forward View [9] identifies NHS staff health and wellbeing as a priority for the NHS.

Sub-optimal health behaviours of healthcare practitioners in the workplace are linked to stress, illness, increased healthcare costs, obesity, high staff turnover, errors, and poor quality healthcare delivery [4, 13]. However, despite concerted policy and research efforts in the last decade designed to support and improve their health and wellbeing (for example [9, 10]), the acute and long term sickness absence of UK healthcare deliverers remains high [14].

Interventions to improve healthcare staff health and wellbeing have primarily focused on supporting or improving individual coping skills rather than affecting the workplace environment such that it promotes healthier behaviours. Whilst personal coping skills mediate the effects of stressors at work on health and wellbeing, i.e. the ability to deal with environmental stressors at a personal level [5, 7, 15], research points to the potential preventative benefits of targeting the workplace at a system-level (including organisational, cultural, social, physical aspects) in creating sustainable and effective health and wellbeing interventions [16].

The Boorman review [17], commissioned by the UK Department of Health to specifically address the health and wellbeing at work of healthcare staff, highlighted the need for whole-system interventions which incorporate input from staff regarding their local needs and contexts and the involvement of management staff at all levels of the organisation. The review proposed five system-level changes for healthcare workplaces to improve staff health and wellbeing: understanding local staff needs, staff engagement at all levels, strong visible leadership, support for health and wellbeing at senior management and board level, and a focus on management capability and capacity to improve staff health and wellbeing. In the United Kingdom, these healthcare workplace improvement plans are supported by the National Institute for Health and Care Excellence (NICE), and are incorporated into the NHS Health and Well-being Improvement Framework [18].

In this systematic review, we sought to identify healthy workplace interventions in health care settings which used elements of this whole system approach and to determine whether they improve the health and wellbeing and promote healthier behaviours in healthcare staff.

Methods

The systematic review was conducted following the general principles published by the NHS Centre for Reviews and Dissemination (CRD) [19] and is reported in accordance with the PRISMA guidelines [20]. A pre-defined protocol was developed following consultation with topic and methods experts, and is available from the Peninsula Collaboration for Leadership in Applied Health Research and Care (PenCLAHRC) website (http://clahrc-peninsula.nihr.ac.uk/est-projects.php). This study has been reviewed and approved by the Peninsula College of Medicine and Dentistry Research Ethics Committee, now under the auspices of the University of Exeter Medical School Research Ethics Committee.

Literature search and eligibility criteria

The search strategy was constructed using a mixture of controlled vocabulary terms and free text terms after consultation with topic experts and examination of key papers. The master search strategy is shown in S1 Fig. No language or date restrictions were applied. This search was applied to AMED, CINAHL (via NHS Evidence), Embase, Medline, PsycINFO (all via OVID), SportDISCUS (via EBSCO), the Cochrane Library (via Wiley), Science Citation Index expanded and Social Sciences Citation Index (all via the Web of Knowledge interface). All databases were searched from inception. The main search was run in July 2011, and updated in October 2013 and September 2016. The bibliographies of systematic reviews identified during the screening process and of all papers meeting the inclusion criteria were scrutinised for any additional studies cited. The following websites were searched: UK Department of Health http://www.dh.gov.uk/en/index.htm; UK Department of Work and Pensions http://www.dwp.gov.uk/; US Department of Health and Human services http://www.hhs.gov/; Health Canada http://www.hc-sc.gc.ca/index-eng.php; Australian Government Department of Health and Ageing http://www.health.gov.au/internet/main/publishing.nsf/Content/Home. In addition, the online contents of the American Journal of Health Promotion and International Journal of Workplace Health Management were hand searched for additional articles. These were selected because they were identified as key journals by an expert stakeholder.

Inclusion criteria

Studies were included if they reported interventions which were targeted at all staff within a healthcare setting (for example a whole hospital, health centre, or unit), were predominantly delivered as group rather than individual activities, and measured the impact on health behaviours or psychological wellbeing in healthcare professionals (outcomes chosen a-priori). Studies in which the intervention was solely aimed at a subgroup of the population (e.g. those with high cholesterol or smokers) were excluded.

Randomised controlled trials (RCT), before and after studies (with or without control), case control, cohort studies and survey designs were included.

Study identification

Inclusion and exclusion criteria were applied to all titles and abstracts by one reviewer (JP, SLB, AB or JTC) and double screened by a second (JP, SLB, AB, KW, LC, or JTC). Duplicates were identified, checked, and excluded. Discrepancies were resolved by discussion with a third reviewer (LF or KW) where necessary. The full text of potentially relevant articles was retrieved and screened independently by four reviewers (four of: JP, SLB, KW, LC, and JTC); discrepancies were resolved by discussion with a third reviewer (as appropriate, one of: AB, LF or KW).

Data extraction and quality assessment

A data extraction and quality assessment tool was developed and piloted for suitability on four papers by SLB and KW. Data extraction and quality assessment were undertaken by SLB and checked by KW; any disagreement was resolved through discussion.

Assessment of study quality was carried out using the Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [21] and the EPOC guidance for randomized controlled trials, controlled before and after studies and interrupted time series (Cochrane Effective Practice and Organisation of Care Review Group [22]).

The following data were extracted from each eligible article (S2 Fig): study design; geographic location of study (country); numbers eligible to participate, numbers participating, loss to follow up; summary characteristics of the study population; details of the intervention; whether the intervention was designed to address a local need; whether and which stakeholders were involved in the development and implementation; whether senior management were involved and in what way, including whether there was visible leadership from or upskilling of management staff; treatment of any control group; duration of follow-up; primary and secondary outcomes, outcome measures and intervention effects. Details on whether the intervention was going to be continued at the site after the initial evaluation were also looked for.

Data analysis

As the studies as well as the workplace health and wellbeing interventions reviewed were heterogeneous in their design, implementation and outcomes, an overall meta-analysis was not appropriate, rather we aimed to describe the nature of the interventions, whether they engaged staff, and the outcomes. Study and intervention details were put in to tables, with columns for the whole-system recommendations and rows for description of the study/intervention. This supported us to identify patterns in relation to whether and how the studied intervention aimed to 1) engage staff at all levels of organisation in activities and be responsive to local need and context (relating to whole-system recommendations 1 & 2 [17]) and 2) engage, involve and up-skill leadership staff (whole-system recommendations 3, 4, & 5 [17]).

We provide a narrative review of overall patterns of whether and how we believe the interventions in the included studies take a whole-system approach as described in the Boorman recommendations [17], commenting on whether and how the groups of interventions improved the health and/or wellbeing and/or increased health behaviours of healthcare staff.

Results

Identified studies

While the original searches retrieved a total of 14,526 records, the review process identified eleven studies to be included (Fig 1). After removing duplicates, 11,908 unique records were downloaded into the reference manager software Endnote to form the master library. The full texts of 379 papers were retrieved for closer examination. Three hundred and seventy five papers were excluded (Fig 1). Update searches (Oct 2013 and Sept 2016) identified a further 7 studies (6 from update searches and 1 from hand searching). A total of eleven studies [6, 2332] were included, and are summarised in Tables 13.

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Table 1. Summary of design and quality of studies in the systematic review.

https://doi.org/10.1371/journal.pone.0188418.t001

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Table 2. Design, outcomes measures, analysis and results of the eleven included studies.

https://doi.org/10.1371/journal.pone.0188418.t002

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Table 3. Summary of interventions in included studies including whether they address aspects of the five whole-system recommendations and their effectiveness at improving healthcare staff health and wellbeing and/or health behaviour change (yes, partial, no).

https://doi.org/10.1371/journal.pone.0188418.t003

Study characteristics and quality

Outcomes.

All reviewed studies included self-reported measures of individual health behaviours and health outcomes, and four studies [6, 23, 28, 29] included self-reported measures of the psychosocial workplace environment (see Table 3). Two studies [28, 32] reported Body Mass Index (BMI).

Study design and quality.

The overall quality of included studies was considered to be poor (Table 1). The main reasons relate to the outcome measures, which were generally low in reliability, variable in validity, and heterogeneous; lack of controls; variable follow-up length; and high attrition rates.

Reliability and validity of outcome measures: Six [6, 2325, 27, 28, 31] out of the eleven studies had partial or low reliability of outcome measures. Three studies [6, 23, 24] did not use validated outcome measures. Petterson and colleagues [6] used self-report scales based on the findings of a factor analysis. They report that in general these scales have high internal consistency, though two (job demands and work pressure) had lower internal consistency, leading them to question the ability of these scales to measure unitary dimensions. Some studies used self-report measures. Sorenson and colleagues [23] used self-report survey and process tracking measures (including self-reported number of activities taken part in). Jasperson and colleagues [24] constructed and used a health questionnaire that measured self-reported physical activity and diet and a survey measuring self-reported walking event attendance.

Heterogeneity of outcome measures: Three studies [25, 27, 28] used an objective outcome measure of health (BMI). The other nine studies used subjective self-report measures, and no two of them used the same subjective self-report measures.

Study design: In addition (see Table 1) five of the eleven studies lacked a control group [6, 24, 25, 27, 30], two had no follow-up [24, 31], and one did not report follow-up information because baseline and follow-up questionnaires were not linked by person [23]. Follow up periods varied considerably; in six studies [2326, 2931] follow-up (or single time-point) data were collected immediately post intervention. In the remaining studies follow-up data were collected at between 3 months [26, 32] and 5 years [27] after the start of the programme. Follow-up rates also varied as the workforce itself changed over the follow-up period.

Attrition rates: Five of the eight studies reporting follow-up had attrition rates higher than 20% (ranging from just over 20% to 50%) [6, 2527, 32]. One study reported no attrition; two studies reported 20% attrition (Lemon, Uchiyama); four studies [6, 2527] reported attrition rates varying from 22 to 33%; one study reported 50% attrition, one [23] did not report attrition rates; and two did not have baseline measurements [24, 31].

Participation: Nine studies [6, 23, 24, 2632] offered the intervention to all hospital/unit/health centre staff; one study [25] offered the intervention to everyone, but operated on a first come first served basis as there were only 400 places available to the 2900 staff; one study [31] offered the intervention to all staff working in a work area that had a workplace wellness champion working in it. Given the nature of the included interventions (i.e. aiming to affect whole-system change), it is hard to estimate overall participation rates other than in the specific activities which were delivered within the intervention programme.

None of the studies described the interventions in sufficient detail to allow replication. One study [30] offered the manual for their brief MBSR intervention upon request.

Effectiveness of interventions

Included studies.

All interventions were deemed by their authors to be at least partly effective (Table 2). Two studies reported statistically significant improvement in objectively measured physical health (BMI; [27, 28]) and eight in subjective mental health [6, 2431]. Six studies reported statistically significant positive changes in subjectively assessed health behaviours [2328].

Due to the heterogeneity of types of study and measures used, it is difficult to make meaningful comparisons between the studies. We describe the interventions in relation to the degree to which they included the whole-system recommendations for healthy workplace interventions in healthcare settings [17].

Included interventions.

Interventions varied in terms of whether and how they incorporated the five whole-system recommendations [17] (Table 3) and their overall effectiveness (as reported by the authors of each study) in improving healthcare staff health and wellbeing and/or health behaviour change (Table 3: yes = O; partial = I; no = —).

Recommendations 1&2: Identifying and responding to local need and engaging staff at all levels

The eleven studies varied considerably in how they tailored their interventions to local need and engaged staff at all levels (Table 3; [17]). Interventions were: 1) pre-determined and fixed from the outset without choice of activity [25, 30]; 2) pre-determined with choice of activity [26]; 3) had choice of a wide range of activities and some adaptivity of the programme, with further activities added in response to take-up [23, 24, 27, 32]; and, 4) adaptive and responsive workplace programmes, taking a participatory approach from the beginning and creating programmes responsive and adaptive to staff needs, in which the implementation process was part of the intervention [6, 28, 29, 31].

1) Pre-determined interventions with no choice of activities.

Two studies offered a fixed set of activities, including some element of group activities, to all staff in one workplace. These activities were not created in response to local need, and nor was there choice about which activities to participate in [25, 30].

An eight-week Mentalisation-Based Stress Reduction (MBSR) intervention for staff in a 12 bed mental health inpatient unit (MBSR practice focuses on individual coping but the team delivery design of the intervention also enabled whole-system change; Table 3) resulted in a significant decrease in self-reported psychological distress, including reduced levels of self-reported anxiety [30]. There was no overall increase in the Kentucky Inventory of Mindfulness Skills, suggesting that these changes in distress and anxiety may have resulted from the increased communication and activity-sharing between the work unit [30].

Implementing a pre-determined 12 week intervention to improve physical activity and nutrition behaviours across a hospital site using a team-based approach and peer support (Table 3) resulted in those completing the intervention reporting significantly higher physical activity, fruit and vegetable consumption, water intake, and feeling less stressed than the non-completers [25].

2) Pre-determined interventions with some choice of activities.

One study [26] had a fixed set of activities and some choice about which activities to participate in. In response to an identified need, a self-care plan and holistic learning programme on one hundred and three nurses’ health-promoting behaviours in intervention units over twelve months resulted in a significant difference pre- and post- intervention in nurses in intervention versus control units in overall Health Promoting Lifestyles Promotion (HPLP) II scores, and the sub-scales of stress management, nutrition, and spiritual growth [26].

3) Choice and some adaptivity of the programme (supplementary activities).

Five interventions [23, 24, 27, 28, 32] offered an initial range of activities for the workforce to participate in, as well as providing supplementary activities during the implementation of the interventions.

Three of the five interventions involved “Workplace Champions” whose roles were delivery as well as gathering feedback and planning further activities [23, 24, 27]. In one intervention [23], the role of the workplace champion was to further refine and adapt the intervention activities delivered depending on identified need and context. Employee leadership and advisory boards were also created to develop site-specific strategies and approaches.

Three interventions [23, 28, 32] had an explicitly participatory approach both in the design and the delivery. Two [23, 28] included External Advisory Boards at each intervention site to engage the workforce and tailor activities to their needs and two had a strong emphasis on engagement of leadership and staff in the development and tailoring of intervention activities [28, 32]. The latter two contained activities designed to engage the whole worksite and develop relationships to support healthy behaviours, e.g. a directors’ team-building course, and activities for all staff (including leadership) to improve team coordination, communication and stress management [32].

Uptake of the intervention was not determined for any of the studies, probably as all offered a variety of activities as well as making some environmental changes; one study [24] reported that a third of all the employees participated in a competition organised as part of the intervention.

Four of the five studies [23, 24, 26, 27] reported an improvement in health and wellbeing behaviours (Table 3); increase in fruit and vegetable consumption (three-arm randomised controlled trial [23]); increased physical activity (before and after study with no control [27]; self-report, survey design, no control [24]); increase in healthy eating post-intervention [26]; and improved self-reported nutrition post-intervention in a controlled before and after study [26]. Two studies found no change in BMI [27, 28].

Three studies found improvements in employee mental health: improved job satisfaction (but no effect on mood or work perceived work performance [27]); more self-reports of staff satisfaction in post-intervention survey [24]; improvements in stress management and spiritual wellbeing post-intervention compared to controls [26].

One study [28] observed improved employee perception of worksite commitment to their health and wellbeing and that changes in perceptions of co-worker norms changed outcomes for participants: higher perception of co-worker normative healthy eating behaviours was associated with greater fruit and vegetable consumption and less fat consumption; and higher perception of co-worker normative physical-activity behaviours was associated with greater total physical activity. Perceived co-worker support also increased in the intervention arm in another study [23].

One study [28] observed a significant participation dose-response effect: When intervention exposure was used as the independent variable BMI decreased for each unit increase in intervention participation at 24 months (Table 3).

4) Adaptive and responsive workplace programmes.

Three large hospital studies [6, 29, 31] viewed the process of developing the intervention to be a part of creating a healthy workplace: a before and after study involving over three thousand employees from thirty seven regional hospital departments in Sweden [6]; a cluster-RCT in twenty four hospital departments in two hospitals in Japan [29]; and a cohort study comparing people exposed and not exposed to a workplace wellness champion intervention (self-reported) within a large academic medical centre [31]. The three interventions were adaptive and responsive to local needs and context from development and implementation, right through until the end of the study and beyond. This responsivity provides the opportunity for sustainability after the end of the study, and for processes involved in the intervention to become part of the workplace culture.

All three: aimed to improve the psychosocial work environment by utilising a participatory approach, asking each department or work area to identify the enablers and barriers to workplace wellbeing, and to set goals and identify areas for improvement; appointed key people or “champions” to support the interventions and to act as communicators within and across departments; and used feedback to develop activities responsive to local need (two [6, 29] fed back survey results to local staff and one [31] had workplace wellness champions (Table 3)design activities based on local feedback)

Two studies showed some evidence of a dose-response effect in which greater participation produced greater benefits. When a notice of staff cut-back was announced between baseline and follow-up staff in departments rated as highly active in improvement activities did not deteriorate during the follow-up period in work pressure, organizational climate and coping whereas staff in departments rated as less active did deteriorate [6]. Similarly, participants in a local work area who did versus did not participate in activities rated their overall health and wellness as significantly higher and significantly more of participating versus not participating in a local area agreed that their co-workers support one another in practicing a healthy lifestyle [31].

One [29] found varying levels of participation across the departments, with staff citing “realising that change was possible” and responding to identified needs as positive ways of improving the psychosocial work environment; concomitantly, the lack of time and common understanding, staff changes, and a feeling that activities were not responding to staff needs were given as reasons why the environment did not change. They observed no overall effect on mental health status, but significant increases in participatory management, co-worker support, and job control versus control.

Recommendations 3, 4, & 5: Engagement, involvement and upskilling of management and board-level staff

Three of the five recommendations involve the engagement and support of management and board-level staff in intervention activities, including strong visible leadership, support for the health and wellbeing of staff, and the targeting of resources on improving management capability and capacity to deliver this increased visible leadership and support. Despite this emphasis in the recommendations these activities were notably lacking in seven interventions reviewed. Promisingly, five focused considerable resource on engagement, involvement and upskilling of management staff [6, 28, 29, 31, 32]. Two significantly improving mental health and wellbeing of healthcare staff [29, 31], one reducing deterioration in mental health measures for people with high versus low participation rates [6], one significantly improving physical health (BMI) and health behaviours [28]. The fifth found no significant effect on mental health and wellbeing [32].

Four interventions involved extensive management involvement as champions [28, 29, 31, 32]. Sun and colleagues [32] Engaging higher management staff in local staff activities and creating opportunities for increased communication, group solidarity and group coordination, alongside intervention activities to improve leadership and management and communication skills of higher levels of management (e.g. directors of intervention centres were engaged and educated about the importance of activities in groups for staff, and then were involved in implementing and taking part in the group activities, having the responsibility to plan, coordinate, and monitor the group’s activities and to convey a vision, inspiring team collaboration) resulted in no significant impact of their intervention on workplace social capital, the measures of which included items on vertical and horizontal trust and communication. In another intervention [31], following efforts to involve management, supervisors and HR in supporting the workplace wellness champions to deliver and implement their locally adapted intervention, twenty-three percent of people engaging with the intervention reported an improved work atmosphere, and significantly more of those participating strongly agreed or agreed that the organisation provides a supportive environment to live a healthy lifestyle compared to those not familiar with the wellness champions. Enthusiastic“buy in” at the upper level of administration and visible strong leadership support, when it improves cooperation by other staff to implement changes [28], produced a significant association between perception of stronger organisational commitment to employee health and a reduction in BMI. When local leadership staff were directly supported to develop their capability and capacity to improve staff health and wellbeing (Table 3) [29], the intervention group showed a statistically significant increase in the psychosocial work environment questionnaire sub-scale of ‘participatory management’, along with self-reports of improved work environment in the process evaluation; however, there was no significant difference in the intervention groups’ scores on the depression scale pre- to post- intervention.

When there was a focus on management visibility and involvement in the feeding back of local results and the active implementation of changes related to locally raised needs, and improving vertical communication between managers and staff, staff in departments that actively participated showed significantly less deterioration in perceived organisational climate compared with staff in departments with low participation [6].

Discussion

This systematic review identified eleven studies of workplace health promotion interventions which sought to enhance the health and wellbeing of healthcare staff by using a whole-system approach to interventions. The low number of identified studies highlights that the impact of whole-system healthy workplace interventions for healthcare workers, as recommended by Boorman [17] is under-researched, and we feel this gap is important for future research to address.

Although the studies were of mixed (mid to low) quality and the intervention designs varied considerably, the reported results suggest that interventions taking a whole-system approach can improve physical and mental staff health and wellbeing and promote healthier behaviours.

Interventions that incorporate at least one of the five whole-system recommendations for improving healthcare worker health and wellbeing [12] resulted in improvements in physical and/or mental health and promoted healthier behaviours in healthcare staff. However, one study [32] incorporated all five of the recommendations in their workplace social capital intervention and did not find any significant change in measures of mental health (workplace social capital measure, see Table 2). It is not possible to draw conclusions regarding the specificity of the interventions as they varied widely in terms of their context, development, design, and implementation, but it is interesting to note that there seems to be no relation between the greater number of recommendations incorporated in interventions and the effectiveness of the study. However, heterogeneity in outcome measures makes this a tentative comparison.

Four studies of interventions offering choice of a range of activities to participate in [6, 23, 28, 31] individually offer some evidence that the greater the level of participation, the greater the individual benefit: greater participation improved: resilience to organisational change [6]; self-rated overall health and wellness [31]; BMI [28]; and fruit and vegetable consumption [23]. The latter study also found enhanced effect of a worksite intervention when there was family participation suggesting that widening activities beyond the workplace to include family and friends may further enhance engagement and improvements to wellbeing.

The suggestion of potential individual “dose-response effect” in these four studies (i.e. more benefit derived from more participation [6, 23, 28, 31] has several implications: firstly, it suggests that attention needs to be given to creating intervention activities that healthcare staff want to engage in and offering a selection of a range of activities, some team- and some individual-based, for participants to choose between. Interestingly, some workplace interventions [28] had the least take-up of team-based activities, whereas others [24] found this the most participative aspect of the intervention.

The four studies that reported findings from their process evaluations [23, 25, 28, 29] all suggested that time was one of the greatest barriers to employee participation in workplace health and wellbeing interventions. Understanding the barriers to participation (such as time, resources, and poor communication about activities) should be part of the process of evaluating any workplace intervention, and having an intervention able to adapt to allow different times and ways of participating should be beneficial.

Although it is hard to make any meaningful comparisons regarding effectiveness, the studies which assessed intervention activity participation [23, 25] suggest that the interventions in which staff were involved from the beginning in determining the activities had greater participation. There was lower participation in interventions with more pre-determined activities, even when there was an opt-in process for staff and hence potentially had a more motivated workforce participating. One study [25] invited 400 of 2900 staff to participate in a 12 week intervention and had 61% participation, compared with the 81% participation in the workplace intervention implemented by another study [23] where employees were involved in the development and implementation of their workplace intervention.

Implications for policy/practice

The Boorman Review [17] called for healthcare workplaces that: support local staff needs; have staff engagement at all levels; have strong visible leadership and support at senior management and board level on health and wellbeing; have a focus on management capability and capacity to improve staff health and wellbeing. Our systematic review shows that interventions incorporating these whole-system approaches can improve healthcare staff health and wellbeing and increase health behaviours.

Only five of the eleven studies focussed on management capability and capacity. There was some evidence from subjective author reports that this focus resulted in enthusiastic engagement from leadership [28, 29, 32]. Of these five interventions, four involved management-level staff as healthy workplace champions. It is interesting to note that the findings of these four studies all involved perceptions of improved workplace culture or atmosphere in participants: improved work atmosphere and environment, more supportive environment to live a healthy lifestyle, more ‘participatory management’, less deterioration in perceived organisational climate, and stronger organisational commitment to employee health (the latter of which was significantly associated with reductions in objectively measured BMI). However, the fifth study found no significant impact of their intervention on measures of vertical trust and communication. These findings provide some evidence that interventions including efforts to engage and involve management staff, such as in the feedback of local results of health and wellbeing surveys and involvement in discussions with local staff of how they would like to address the, in being workplace champions themselves, to make their leadership on health and wellbeing more visible, and to provide training on skills to support the health and wellbeing of their staff, can impact the perception by those staff that management are on their side and that they work in a place with a positive workplace environment.

The finding of potential “dose-response” effects in the four studies that report participation rates suggest that participation and engagement are important in designing and implementing healthy workplace interventions: A flexible intervention with continuous employee involvement and an ongoing evaluation to highlight facilitators and barriers to participation has greater potential to positively affect and sustain health and wellbeing for the healthcare workforce and thus to improve staff health and wellbeing.

Strengths and limitations

The review was conducted according to the principles published by the NHS Centre for Reviews and Dissemination (CRD) and is reported according to PRISMA guidelines (S3 Fig). The review was comprehensive, searching across electronic and grey literature sources to identify studies. There were no language or date restrictions in the searches.

Due to the nature of the topic under consideration, the inclusion criteria in this review were open to a degree of subjective interpretation. For this reason we took all reasonable steps to ensure that eligibility criteria were applied consistently across all identified articles by 1) piloting the criteria on a subset of papers, 2) having two reviewers independently assess the eligibility of all articles with discussion of all disagreements, and 3) involvement of a third reviewer to resolve disagreements where necessary.

Comparison across the approaches utilised to improve health and wellbeing of healthcare professionals was challenging due to the lack of detail provided regarding the specific nature of the components and the mechanisms making up the interventions.

Variable methodological quality, mostly related to the outcome measures used, which were in general low in reliability, variable in validity, and heterogeneous, along with the nature of the study designs prevented any conclusions related to the effect on health and wellbeing outcomes of incorporating more versus less of the five whole-system recommendations being made. Nor were we able to compare the effectiveness of different patterns of whole-system recommendation implementation.

Recommendations for future research

Despite extensive and systematic searching of the literature, we were only able to identify eleven studies that met our inclusion criteria. The low number of identified studies highlights that there is currently limited evidence regarding the effectiveness of whole-system approaches to enable staff health and wellbeing for healthcare professionals in healthcare settings, as recommended by Boorman [17]. Ten out of eleven included studies provide evidence that whole-system approaches to healthcare workplace health interventions that include at least one of the five whole-system recommendations [17] improve physical and/or mental health and promote positive health behaviours in healthcare staff, suggesting this is an area of potentially fruitful inquiry.

The methodological quality of the studies was mostly low, with only five out of eleven studies included being rated as “medium” quality. This systematic review clearly identifies a need for good quality primary research using similar and validated outcome measures to evaluate whole-system approaches to health and wellbeing interventions in healthcare worker populations. Comparative studies of the effectiveness of individual-focused versus whole-system-focused approaches would clarify their relative effectiveness and cost-effectiveness. Long-term follow-up is necessary to evaluate the sustainability of observed change. More systematic reporting would allow more definitive conclusions about how the conditions for sustainable healthy workplaces for healthcare workers can be created.

The low number of studies and heterogeneous intervention designs and outcome measures used in those studies, makes it challenging to pin down whether and in what way whole-system approaches improve healthcare worker health and wellbeing. Realist reviews of the literature, in which context-mechanism-outcome configurations rather than whole interventions are the unit of analysis, would be of use in establishing what it is about whole-system interventions that works to improve health and wellbeing for healthcare workers, who for, under what circumstances, and in what way.

Conclusion

This systematic review identified 11 studies which incorporate at least one of the Boorman recommendations and provides evidence that whole-system healthy workplace interventions can improve health and wellbeing and promote healthier behaviours in healthcare staff.

Acknowledgments

Funding provided in part to the European Centre for Environment and Human Health (part of the University of Exeter Medical School) by the European Regional Development Fund Programme 2007 to 2013 and European Social Fund Convergence Programme for Cornwall and the Isles of Scilly; and by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

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