Principles of Quality Management - (2008) Volume 16, Issue 6
Lecturer, University of Nottingham School of Nursing, Queen’s Medical Centre, Nottingham, UK
Scott Lloyd BSc(Hons) MSc
Health Improvement Specialist, Public Health Directorate, Stockton on Tees Teaching Primary Care Trust, Stockton on Tees, UK
Received date: 30 June 2008; Accepted date: 11 September 2008
This article presents a discussion of the key issues in influencing organisational change in NHS settings, in the development of workplace wellness interventions to improve employee health and wellbeing. To tackle poor public health and associated rising healthcare costs, there must be a focus on the root cause of many preventable diseases – unhealthy lifestyle choices. Workplace wellness initiatives are now an important prevention strategy adopted by socially responsible organisations to target the health and wellbeing of working age adults. Lessons learned from initiatives in secondary care suggest that effective implementation requires change in organisational ‘health culture’, through a combination of education, behaviour change intervention, needs-based facilities, and services and strategies for developing supportive and health-promoting work environments. Most of all, employers must demonstrate a commitment to health and wellness that is fully integrated with their mission, values and long-term vision, paving theway for sustainable lifestyle changes. Evaluation systems must be in place to measure the impact and outcomes of wellness schemes.
behaviour change, culture change, health education, workplace health
In the context of the population decline in physical activity and health, this article outlines the govern-ment drive to improve health through workplaces as ‘healthy settings’, and the case for organisations to develop workplace wellness schemes. We argue that such schemes are particularly important in NHS settings, and use evidence from the literature, personal experi-ences and observations, with examples from initiatives in two acute hospital settings as ‘models of best prac-tice’ that may be adapted for primary care. The barriers to effectively implementing schemes within organis-ations are presented, together with suggestions for effecting positive change.health events. The social cohesion of workplace com-munities can provide positive peer support and, further, workplaces have established channels of com-munication which can be accessed for promoting inter-ventions, by publicising facilities, programmes and events, providing feedback, and encouraging partici-pation to assist with the process of change.
The public health context
Workplace wellness initiatives are becoming ever more important since the launch of the government strategy ‘Health, work and well-being – caring for our future’ in 2005. This initiated movements to improve the health and wellbeing of our workforce and all working-age people in the UK. Our nation is unhealthy, and recent data show that one-quarter of the UK population smokes, one-fifth is obese and one-fifth reports suf-fering stress from work. It is well established that physical and mental health can be improved with regular physical activity, although only 37% of men and 24% of women are sufficiently active to gain any health benefit. Sickness absence from preventable ill-health is a growing concern, and it has been estimated that the average cost of employee absence to UK businesses is £598 per employee, per year. There is an undeniable need to improve population health.
Settings approaches to workplace health
Individuals may spend up to 60% of their waking hours in their place of work, and with over half of the UK population currently in employment the work-place therefore offers a significant potential setting for physical activity and health promotion. Traditional images of workplace health centre around accident and injury prevention, yet the incidence of chronic diseases such as heart disease and stroke now far exceeds the rate of accidents (Janet Voute, CEO of the World Heart Federation, personal communication). Health and physical fitness are now a primary focus for workplace wellness to prevent key risk factors for disease and poor mental health. Government policy has acknowledged the importance of promoting the health and wellbeing of the population, encouraging a ‘settings’ approach to health promotion through prisons, schools, workplaces and community groups. The workplace has been identified as an ideal setting for health improvement for a variety of reasons. It allows access to large numbers of individuals, many of whom are at risk of adverse
Socially responsible organisations
Improving the health of the working population requires that organisations accept responsibility for workplace wellness, whether for altruistic, philanthropic or egotistical reasons. In practice, socially responsible organisations must provide workers with the facilities and opportunities to make healthy lifestyle choices during the working day. This can be achieved through partnership working, engaging with a diverse range of groups and communities, and actively encouraging people to participate in decisions about their health and lifestyle. This approach begins with ensuring the organisation has a statement, within its mission, aims or strategic plan that makes clear to employees (and others) that the goals of the organisation contribute to the greater social good of the population. What is more, in a climate of increasing sickness absenteeism and poor retention of staff, employers need to ensure they do all they can to recruit and retain a workforce, and it is widely accepted that embracing corporate social responsibility for workplace health is indeed profitable, through impacts on employee motivation and morale.
Organisational change: influencing health culture in the NHS
Our knowledge of the need to invest in population health, and evidence of the benefits of workplace intervention is longstanding. Action to implement workplace programmes is on the increase nationwide, although it is not yet universal. From the perspective of the employer, the benefits of workplace wellness programmes are significant, including improved physi-cal and mental health of employees, reduced absen-teeism and turnover, better retention of staff, reduced rates of accidents and injuries, improved morale, motivation and job performance/productivity, and reduced occupational healthcare costs. Optimising the health of the workforce in an NHS and primary care setting is particularly important since members of healthcare professions spend a significant amount of their time promoting health to others, although they do not always practise what they preach, with many NHS staff self-reporting low levels of physical activity, as well as smoking, poor diet, low mood and poor sleep. Yet we know that promoting health in an NHS setting is achievable since recent research has shown that moderate exercise, for example, can be successfully incorporated into working hours for NHS employees, to significantly improve capacity and cardiovascular health in this group. Improving health and wellbeing in this group is also important since employees in better physical and mental health are better able to provide quality care, safely and consistently, to their patients, with increased numbers of employees who are fit and able to work having a knock-on effect of reducing waiting lists, thus improving the NHS stan-dard of care. A fitter, healthier and happier workforce makes economic sense.
Surveys have been conducted with NHS employees and student nurses in an acute NHS trust in Nottingham, and these showed that a large proportion were not meeting government recommendations for physical activity, with many having a poor diet, suffering from low mood and having low levels of job satisfaction (Blake and Pisano, MNursSci disser-tation data). This highlights the need to provide facilities for individuals to make healthier lifestyle choices during the working day and to educate NHS employees about the importance of looking after their own health as priority. In practice, these local needs have now been addressed, with wellness schemes accessible to all NHS staff, and all healthcare students onsite, as described below.
A model of best practice: lessons from secondary care
Over the past three years, comprehensive workplace health projects have been implemented in two NHS acute hospitals in London and Nottingham. Both pro-jects adopted an ‘ecological’ approach to behaviour change (see Figure 1), with interventions aimed at the individual (e.g. structured indoor and outdoor exer-cise classes, holistic therapies, free employee health and fitness screening) supported by changes to the physical environment (e.g. enhanced cycle storage, posters encouraging stair use) and the development or amendment of relevant policies (e.g. ‘green travel’ plan). There are opportunities at both sites for employees to become ‘health champions’ for their workplace. The programmes include regular lifestyle initiatives such as loyalty schemes and health-promotion campaigns, with internal educational sessions to promote physical and mental health (e.g. nutrition advice, weight man-agement, stress management). Liaison with Trust managers has encouraged monitoring of the impact of certain work situations, such as lack of work breaks, shift work and sedentary roles, to facilitate flexibility in work patterns to accommodate personal health and wellbeing. Although these two Trusts are geographi-cally disparate, varying greatly in size (e.g. one has 11 000 members of staff, the other 2200), with each experiencing organisational restructuring during programme delivery (e.g. Trust mergers and redun-dancies), the successes and barriers identified were surprisingly similar, resulting in a unified outcome in our learning about the implementation of workplace wellness schemes in an NHS setting.
Most importantly, continued high-level managerial support from the outset is essential. As Donaldson accurately reported, ‘... better population health is the sum of better health of individuals, but needs more than individuals’ action to achieve it’. Ideally, a director-level individual would champion the cause, with endorsement from the Chief Executive and Trust Board. Without this, sustaining any such work that is needed for significant changes in employee health status and therefore business indicators is difficult and at risk of being rapidly discontinued. These observations are supported by a review in 2002, which highlighted the importance of employers as ‘visionary leaders’ in facilitating change.
We observed that stress is often viewed as a ‘badge of honour’ for certain groups, despite the inevitable negative health consequences of this standpoint. For instance, recent research has shown that stressed white collar workers in London are significantly more likely to develop chronic heart disease (CHD) when compared to their non-stressed counterparts. In this study, increased risk of CHD was mediated through the indirect effect of stress on healthy behaviours such as physical activity and healthy eating, both of which can be positively affected through the workplace.[11–13]
The existing ‘health culture’ and negative attitudes within organisations can be limiting. In practice, we observed that those members of staff who actively engaged with workplace health activities were often subject to criticism by colleagues and line managers for ‘not having enough work to do’. Disapproving attitudes were prevalent on both sites, yet are counter-productive given the government drive to encourage physical activity and improved health behaviours in the workplace, by incorporating them into the work-ing day.
Employees often cite a lack of time as the number one barrier to adopting and maintaining healthy behav-iours,[7,14] and recent publications have also shown this to be one of the main reasons why both white and blue collar workers do not engage in workplace health. However, the evidence points towards healthy workers having better job satisfaction, reduced absenteeism and increased productivity, so employers should view workplace health as an important and necessary in-vestment in efficiency.
It was also observed that the health and welfare of employees may not be a priority for external profit-making companies associated with the NHS, such as those providing food in hospital canteens and filling vending machines. While some may question the rele-vance for primary care trust (PCT) employees, in fact many PCT staff spend significant periods in an acute setting during their working week, and hence access the onsite catering. Lessons learned by both workplace wellness teams is that working with private caterers for whom health is not a priority can be exceedingly difficult in terms of making healthy changes to menus, and result in ‘lip service’ being paid to health promotion.
Both workplace wellness schemes identified diffi-culties in influencing health behaviours among certain employee groups within the NHS. Engaging nursing staff was challenging, and further investigation into barriers to workplace wellness in this group appears necessary, particularly since nurses are often subject to high levels of stress. Our own observations show that although the nursing role by nature involves promot-ing health to patients, this is not always transferred into their own lives (Blake and Pisano, MNursSci dissertation data). However, there is a strong case for improving employee health within the nursing pro-fession. Employees from non-professional job roles (e.g. portering services, domestic services, catering assistants) were also less likely to engage in health activities at either site, which demonstrates current difficulties in accessing these groups in the workplace. The government is committed to reducing health inequalities, and this agenda could be aided by specific targeting of such groups through workplace schemes. A promising NHS approach currently under way is to educate and train individuals in these professions to be ‘health trainers’, purported to promote health among their colleagues, although no published results of these pilot projects are presently available. The Royal Insti-tute for Public Health ‘Level 2 Award in Health Improvement’ is currently being delivered or developed at an increasing number of sites nationally, including our Nottingham site, to employees wishing to pro-mote health within their organisation as dedicated ‘health champions’.
Influencing positive change
While the evidence base for workplace health pro-motion is still relatively weak, we feel this is primarily due to a lack of investment in formal evaluation of such schemes, and a lack of relevant data collection and outcome measures, since a rising number of schemes are being implemented successfully, although findings do not always reach the academic literature.However, the published evidence is growing and there are positive findings appearing internationally.[13,19–21]
Innovative methods for workplace health promotion are also emerging, and have included the use of technology (e.g. internet, email) to encourage positive health behaviours among employees, such as healthy eating, physical activity and smoking cessation. Historically, one key setback has been in delivering the evidence to the most appropriate and influential individual or group that can provide the support needed to ensure that positive changes are self-sustaining. Nevertheless, the recent National Institute for Health and Clinical Effectiveness (NICE) guidance targets those at ‘top level’ by recommending that organis-ations develop policies and activities to encourage their employees to give up smoking and increase their physical activity levels.[11,23]
Such policy development and implementation of activities can be simplistic and low cost, although for significant changes to ‘health culture’ and health behav-iours and sustainability of the scheme, a more ‘eco-logical’ approach is required. Changes to the physical environment are especially important as these may be permanent; examples might include the provision of showers, secure storage for cyclists, and improvements to signage and the appearance of stairwells to encour-age people to use the stairs.
Trusts should also take advantage of the skills that they have in-house: occupational health staff, cardiac and diabetes nurses, physiotherapists, health-promotion specialists, human resources employees, and employee representatives or ‘health champions’ can all provide valuable input. It is also important that implemented activities engage employees and involve doing things with them, not to them.
Any workplace can take steps to encourage their staff to be healthy by promoting active transport to and from both home and any community commitments/ meetings, since this is known to confer real health benefits. For example, employees who walk or cycle to work decrease their cardiovascular risk by 11%, and are also exposed to less pollution than car drivers. Promoting active travel is a significant step in work-place health for employers, not least for encouraging positive health behaviours among individuals, but also for supporting and implementing national health policies and strategies related to physical activity and obesity, and reducing their carbon footprint.
One of our initiatives showed a statistically signifi-cant increase in the percentage of employees walking or cycling to and from work, with the second region still at intervention stage yet anticipating a similar increase. Increases in cycling to work were achieved by changes to Trust policy regarding car permit applica-tions, providing staff access to cheaper bicycles through a salary sacrifice scheme open to all UK NHS trusts, and investing in showers, secure cycle storage, onsite main-tenance workshops and cycling proficiency training.
A notable lesson learned in implementing work-place wellness schemes is that health-promoting be-haviours can be made convenient for employees, which in turn increases the likelihood that health behaviours will be easily adopted. For example, by accessing a 10-minute health check in the workplace, individuals may save time in visits to their general practitioner (GP) or practice nurse. Workplace health screens may also help to identify previously undiagnosed clinical issues such as high blood pressure, in which case the indi-vidual can be referred to their own GP for early follow-up. In our experience, while some of these individuals are then found to be normotensive at follow-up, a greater percentage require medical intervention to control their blood pressure, and treatment can be initiated early following workplace screening.
The future of employee wellness initiatives for primary care
Although many employers currently have programmes linked to wellness, these are often limited in scope and do not accurately measure improvements in health and productivity. By adapting established health pro-grammes that improve employee wellness, models of effective workplace wellness initiatives may be applied in the primary care setting. The importance of ‘set-tings-based’ health promotion in primary care has been acknowledged, and ‘creating a healthy working environment’ has been proposed as an important element of a ‘health-promoting general practice’. Nevertheless, while attempts are being made to intro-duce legislation and workplace health policy to improve employee health in this setting, to our knowledge, at present there are no published findings of PCT em-ployee wellness interventions, although anecdotal evi-dence suggests that interventions in this setting are emerging. The Health Development Agency Frame-work for Action in Primary Care provides a useful tool for planning, implementing and evaluating workplace health within GP practices. This model reflects the particular needs of primary care, and the processes outlined in this model include: setting up support structures, gathering information, developing a strategic action plan, implementing and monitoring the plan, and finally reviewing the plan and support structures. While the importance of workplace wellness is increas-ingly recognised, there is clearly scope for the devel-opment and formal evaluation of employee wellness schemes in primary care.
There should be an increased focus on creating a healthy working environment for primary care em-ployees. The real cost of poor public health will be felt by those organisations that do nothing about em-ployee health and wellbeing. Workplace health is not a short-term fix, but rather a long-term commitment or fundamental organisational strategy. However, to successfully initiate organisational change in ‘health culture’, a fresh perspective on transformational lead-ership is required. Healthy workplaces form part of our long-term vision for public health, and organis-ations that effect change are those that embrace the concept of corporate social responsibility for the health and wellbeing of the workforce. These organisations provide models of best practice that are transferable to the primary care setting.
Commissioned; externally peer reviewed.
The authors would like to thank the workplace health team at Newham University Hospital NHS Trust and the Q-active team at Nottingham University Hospital NHS Trust, in particular Dr Sandra Lee (Q-active Manager) and Professor Mark Batt (Q-active Director) for practical insights into workplace wellness imple-mentation.