Interventions to improve employee health and wellbeing ...€¦ · Web viewIn response to an increasing body of evidence on the importance of employee health and wellbeing (HWB)

Interventions to improve employee health and wellbeing within

healthcare organisations – a systematic review

Williams SP1,2, Malik HT1, Nicolay CR1,3, Chaturvedi S2, Darzi A1, Purkayastha S1

1Department of Surgery and Cancer, St Mary’s Campus, Imperial College London, W2 1NY, UK

2Imperial Business School, South Kensington Campus, Imperial College London, SW7 2AZ, UK

3Department of Surgery, Chelsea and Westminster Hospital, London, SW10 9NH, UK

Corresponding author:

Mr Stephen P Williams, Research Fellow, Academic Surgical Unit, St Mary’s Campus, Imperial

College London, W2 1NY, UK

Email: [email protected]

Tel: +442033126666

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mailto:[email protected]

Abstract

In response to an increasing body of evidence on the importance of employee health and

wellbeing (HWB) within healthcare, there has been a shift in focus from both policy makers

and individual organisations towards improving healthcare employee HWB. However, there is

something of a paucity of evidence regarding the impact and value of specific HWB

interventions within a healthcare setting. The aim of this paper was to systematically review

the literature on this topic utilising the EMBASE, Global Health, Health Management

Information Consortium, MEDLINE and PsycINFO databases. Forty-four articles were

identified and, due to a large degree of heterogeneity, were considered under different

headings as to the type of intervention employed: namely those evaluating changing

ways of working, physical health promotion, complementary and alternative

medicine, stress management interventions and those utilising multi-modal

interventions. Our results consider both the efficacy and reliability of each intervention in

turn and reflect on the importance of careful study design and measure selection when

evaluating the impact of HWB interventions.

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Introduction

In their 2010 document Healthy Workplaces: A Model For Action, the World Health

Organisation outlines the importance of improving employee health and wellbeing (HWB) on

a global scale.1 The HWB of healthcare employees is a particularly pertinent issue since they

have been found to be at significantly increased risk of exhaustion and burnout.2 Indeed, data

from the United Kingdom show healthcare employee sickness rates, at 10.7 days a year per

person, to be four times higher than that seen in other sectors.3 This issue is compounded by

strong links between low levels of employee HWB and poor job performance – though it

should be noted that when healthcare organisations prioritise employee HWB, not only do

they demonstrate improvements in sickness absence, staff retention and agency cost, but they

also show improvements in both productivity and patient care.3 To this end, there is an

increasing commitment, by the vast majority of hospitals, into schemes aimed at improving

the HWB of their employees. However, there is a paucity of evidence regarding the impact and

value of specific HWB interventions within a healthcare setting and this has been considered

to present a definite risk for healthcare organisations who continue to invest in HWB

interventions.4 It also limits the further development and refinement of a given intervention

programme.

The lack of evidence as to the effectiveness of specific HWB interventions extends to the

published literature. Moreover, many of the studies which are found are often small in scale

and employ a range of different evaluations – making any potential meta-analysis unsuitable.

Given these problems, our aim is to systematically review the literature regarding HWB

interventions for healthcare employees to assess whether we are able to draw any

conclusions as to which interventions are most effective in a healthcare setting.

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Methods

Data sources and search strategy

A systematic review was performed following current best practice in close adherence to the

guidelines set out in the Preferred Reporting Items for Systematic reviews and Meta-Analyses

(PRISMA)5.

A literature search was carried out using the electronic databases of EMBASE (1947 to

29/01/16), Global Health (1973 to 2016 Week 04), Health Management Information

Consortium (1979 to November 2016), MEDLINE (1946 to January Week 4 2016) and

PsycINFO (1806 to January Week 4 2016). Search terms included both MeSH terms and free

text words (truncated as required) in combination with Boolean operators ‘AND’ and ‘OR’.

The full search strategy can be found in Appendix A.

Eligibility criteria

The search was limited to English language studies involving humans and duplicates were

removed. Additional articles were located through hand searching the reference lists of

included studies. No year of publication restrictions were imposed. We included all articles

seeking to evaluate interventions to improve employee HWB within the context of a

healthcare organisation. Articles were required to have made an attempt at measuring the

efficacy of the intervention, though the manner in which they did so was left open to allow

inclusion of a variety of different types of interventions. Conference proceedings and editorial

articles were excluded due to a lack of data provision preventing any further analysis. Full

eligibility criteria can be found in Appendix B.

Article review process

Once duplicates were removed, search findings were reviewed by a panel of two independent

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reviewers. Search findings were initially screened by title, then by abstract. If an abstract was

unavailable, the full-text version was sourced. The remaining articles were then held against

the eligibility criteria, as found in Appendix B. Any disagreements were resolved by consensus,

involving the senior authors as required.

Data extraction

Raw data extracted included administrative data (including date of publication and country of

origin), topic-related data (including the intervention modality itself and the number of

participants in a given study) and research-related data (including study methodology and

results). Data was tabulated on to a spreadsheet under predefined column headings

(Microsoft Excel for Mac, Version 15.17, Redmond, USA).

Synthesis of results

A descriptive synthesis of results was performed with consideration as to the

risk of bias and quality of the studies. Studies were contextualised under

different headings as to the type of intervention broadly evaluated (namely

those evaluating changing ways of working, physical health promotion,

complementary and alternative medicine, stress management interventions

and those employing multi-modal interventions). Studies showed considerable

heterogeneity in both design and the relevant outcomes reported. As such, a

quantitative synthesis of the data (such as meta-analysis) was not performed.

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Results

Study selection

The most recent search was 31/01/16. A PRISMA flow diagram depicting the search results in

full can be seen in appendix C. Applying the search strategies found in Appendix A within the

EMBASE, MEDLINE, PsychINFO, HMIC and Global Health databases produced 2938 results.

The removal of duplicates left 2651 records for screening which yielded 60 full-text articles to

be assessed for eligibility. Twenty-six articles were excluded at this point (14 did not report

outcome data (many of which were written in the style of an editorial piece), 4 gave only

qualitative outcomes, 3 reported outcomes but did not outline an intervention, 3 were review

articles, 1 publication was a study protocol and a further study included participants from a

variety of job roles in addition to healthcare). Close scrutiny of the reference lists of included

articles produced a further 10 publications. In total, 44 publications met both the inclusion

and exclusion criteria. Of these, the majority were published in the USA (59%), with others

originating from Sweden, Australia, Canada, the Netherlands, the UK, India, South Korea and

Taiwan (see bar chart 1). An increased focus within the peer-reviewed literature for

publications on HWB interventions is reflected by an increasing number of publications over

the last 28 years. (see bar chart 2).

Data extraction

Summary information, from all 44 studies, is presented in Table 1. Publications differed

markedly not only in the choice of intervention used but also in their size, design and which

outcome measures they utilised. This makes any kind of meta-analysis all but impossible. We

have considered publications by the theme of the intervention assessed in each case.

Quality rating

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All studies were independently rated for quality by two reviewers (SPW and HTM) using the

Study Quality Assessment Tools developed by the National Institutes of Health (part of the

U.S. Department of Health and Human Services).6 Initial agreement was 91%. 100%

consensus was achieved after face-to-face discussion of the two reviewers. The majority of

studies were rated as Fair (n=25, 57%), with 9 (20%) studies rated as Good and 10 (23%)

studies rated as Poor.

Studies adjudged as Fair or Good will be considered, in turn, under the theme of the

intervention assessed in each instance. Studies adjudged as Poor will not be discussed at

length due to the significant flaws in their design.

Changing ways of working

Five studies explored adopting different work patterns or practices as a method of improving

psychological wellbeing.7-11 None of the studies included control groups in their design and

none were rated as Good, though three were rated as Fair.7-9 Two studies were rated as

Poor.10,11

Sluiter et al.7 report the introduction of biweekly structured work shift evaluations for staff

within a paediatric intensive care setting, evaluated over a 2-year period. Though the number

of participants in the pilot study was small (n=61) and outcome measures were only

completed by 55%, they found a significant improvement in emotional exhaustion (Maslach

Burnout Inventory, MBI12) but no change in work health fatigue (Need for Recovery After

Working Scale).13

Bergman et al.8 looked at physician dialogue groups involving team meetings to discuss

potential issues and negative experiences at work and foster a forum for creative solutions to

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help generate an improved psychosocial work environment. The intervention was reviewed

in concert with data from the institution’s yearly HWB staff survey (Quality Work Competence

Questionnaire, QWCQ14). The overall score was noted to improve significantly following the

intervention but the authors note that given outcomes are measured essentially by way of

natural experiment, causality cannot be presumed.

Dunn et al.9 also report on the implementation of a similar series of meetings amongst a group

of clinicians to generate ideas around improving working patterns and practice. This led to

the introduction of a series of systematic improvements and over the 5 year study period they

report significant improvements in emotional exhaustion (MBI12) and work related exhaustion

(QWCQ14) but no change in work/life balance (Physician Wellbeing Survey: unvalidated15).

Conclusions from this study are limited by the small number of participants and a high

turnover rate of staff during the study period.

Physical health promotion

A total of ten studies report the impact of interventions to improve the physical health of

healthcare employees.16-25 One study was rated Good16 and another five were rated as Fair in

quality.17-21 Four studies were quality assessed as Poor.22-25

Lemon et al.16 evaluated the impact of a multi-modal set of interventions, all aimed at

improving physical health, with a cluster-randomised-controlled trial design across 6

different hospital sites, with employees at 3 of these sites acting as controls. Interventions

included the provision of health education, a series of incentivised challenges and the revision

of cafeteria menus: however, there was no change in BMI between control and intervention

groups on intention-to-treat analysis.

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Stein et al.17 offered a monetary incentive, with the financial contribution of staff to the

hospital’s cafeteria plan weighted according to annual measurements of a range of physical

health parameters including blood pressure, tobacco use and serum cholesterol levels. This

was a large study conducted over a three-year period but showed no significant changes in

any of the health quotients measured.

Hewitt et al.18 report a pilot study exploring the impact of a progressive aerobic exercise

programme using an randomised-controlled trial (RCT) with those in the intervention group

assigned to regular exercise classes over an 8-week period. Significant improvements were

observed in the intervention group in peak O2 consumption and peak heart rate but not

systolic blood pressure nor body mass index (BMI).

Rather than utilising exercise-based interventions, Lemaire et al.19 report the impact of a

nutrition-based intervention in a pilot study where participants acted as their own controls

and took in significantly higher amounts of calories and fluid on their ‘intervention day’ in

comparison with a baseline assessment. The primary outcome, however, was cognition,

measured using a variety of software programs and showed significant improvements in

reaction times for both simple tasks and complex tasks.

Thorndike et al.20 report the effects of an intervention aimed at both improved nutrition and

physical activity. The intervention ran over 10 weeks and combined group sessions

promoting strategies to improve physical health with increased access to both gym facilities

and improved nutrition via the hospital cafeteria. Overall, programme completion was 82%

and significantly positive results were found in terms of weight loss, mean cholesterol level

and blood pressure, both at the end of the programme and maintained at 1 year.

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Following on from this study, Thorndike et al.20 then randomised participants to test an online

intervention aimed at facilitating healthy nutrition and physical activity. No significant

differences were found in weight at 1 year between the two groups.

Complementary and alternative medicine

Ten published studies report various forms of complementary and alternative medicine as

potential interventions to improve staff HWB.26-35

One study was rated for quality as Good.26 In this study, Tsai and Swanson-Crockett used an

RCT-design to assess the efficacy of an intervention based on a form of relaxation training,

combining the cognitive-behaviour model of relaxation with elements of imagery and

meditation. The intervention comprised a number of training sessions over a 5-week period.

Wellbeing (as measured using the Nursing Stress Checklist36) was noted to be significantly

improved immediately afterwards.

Seven studies were rated as Fair.27-33

McElligott et al.27 carried out a pilot study of the effects of touch therapy. A blinded RCT design

was adopted with those in the intervention group receiving an hour of therapeutic massage

per week for a four-week period but no significant differences were noted in the outcome

measures considered.

Staples and Gordon28 evaluated the effectiveness of a seven-day mind-body skills training

course. Existential wellbeing (Spiritual Wellbeing Scale37) was significantly improved at 1 year,

in comparison with baseline, though the authors do note that the vast majority of participants

had undergone similar training already limiting causality.

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Brathovde29 reported a pilot study (n=10) where level one Reiki energy therapy was taught to

nurses as a self-care technique to improve HWB. Self-care (Caring Efficacy Scale38) was

assessed as significantly improved versus baseline.

Oman et al.30 conducted an RCT, utilising a waiting-list model, to assess the impact of an 8-

week training course in passage meditation. This is a mediation based intervention where an

‘inspirational’ passage is memorized and then slowly mentally recited. The passage itself can

be religious or can avoid any such references. Outcomes were mixed with sustained

improvements in Perceived Stress Score39 (PSS) but no demonstrable changes in emotional

exhaustion (MBI12).

In a similar manner, Yong et al.31 provided a training programme based around spirituality

which again involved the repetition of ‘holy’ words. Significant improvements were noted in

MBI12, Spiritual Integrity40, Spiritual Wellbeing41 and Leadership Practice42 after the 5-week

training course was completed.

Palumbo et al.32 looked specifically at the HWB of older nurses when given training in Thai

Chi. Outcomes measured after the intervention period found no statistically significant

differences in HWB on any of the outcome measures utilised (SSF-3643, Nursing Stress Scale36,

PSS39).

Tarantino et al.33 report on an intervention programme utilising a variety of complementary

and alternative medicine techniques such as Reiki, prana yoga, meditation, guided imagery

and intuitive body scanning. Participants completed a number of different HWB assessment

tools at baseline, intervention conclusion and at 1 year. Significantly improved scores were

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found in PSS39 and the Coping Self-Efficacy Scale44 but, unfortunately, this study makes no

assessment of the level utilisation of techniques by participants, nor whether they were

continuing to be practised at the 1-year time point.

Two further studies were assessed as Poor in quality and so will not be discussed in greater

detail.34,35

Stress management interventions

Seventeen studies provide evidence for a variety of different interventions focused at

managing stress and thereby improving HWB.45-61 Six studies were rated as of Good quality all

of which explore the implementation of mindfulness-based stress reduction (MBSR) and are

indeed variations on the same protocol.45-50

MBSR is the single intervention type with the greatest amount of reports in the literature,

with all of these in the last decade.45-53 The earliest report of MBSR as an intervention to

improve the HWB of healthcare staff was by Cohen-Katz et al., in 2005.45 MBSR was first

standardised as a psychological intervention by Kabat-Zinn and broadly focuses on increasing

one’s attention and awareness to moment-to-moment experiences.62 The intervention in this

report was an 8 week MBSR course with 2.5 hours a week of teaching in addition to a 6-hour

long day-retreat. Randomisation to a waiting-list allowed a control group to be formed, with

volunteers in each group. The study size was admittedly small (intervention group n=14,

control group n=13) but outcomes were measured both at baseline and following

intervention. Significant improvements were found in emotional exhaustion (MBI12) and on

the Mindfulness Attention Awareness Scale63. There were no significant changes in the

proportion of those with elevated scores on Brief Symptom Inventory (BSI64) however.

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Using a similar study design (minus a control group), Foureur et al.46 tested an 8 week MBSR

course in a quasi-experimental study of 40 volunteer nurses and midwives. Compared to

baseline measurements, there were significant improvements in overall score on both the

General Health Questionnaire-1265 and the Sense of Coherence Survey66. Results from the

Depression, Anxiety and Stress Scale67 showed a significant improvement in the stress

subscale but not the depression or anxiety scales. No longer term data was included in the

report.

Krasner et al.,47 also considered an 8 week MBSR course but included monthly maintenance

sessions (each of 2.5 hours in duration, delivered over 10 months) in their intervention

design. A quasi-experimental methodology was used with assessments at baseline, 8 weeks

and 15 months. There were significant improvements at 8 weeks in emotional exhaustion

(MBI12), total empathy (Jefferson Scale of Physician Empathy68), total mood disturbance

(Profile of Mood States Survey69) and results from the Physician Belief Scale70. All

improvements were maintained at 15 months.

Other groups have trialed shortening MBSR training, including Mackenzie et al.,48 whose

intervention was a 4-week course. Otherwise applying the same study design as Catz-Cohen et

al. above,45 they again found a significant improvement in emotional exhaustion (MBI12). This

study was limited both by its small size (intervention group n=16, waiting-list control group

n=14) and limited follow up.

The same group published a further study in 2008, as Poulin et al.,49 comparing this 4-week

MBSR course with a course in imagery and progressive muscle relaxation. A control group

was also included in the study design but there was no randomisation and numbers were

again very small. No significant changes were noted following either intervention in any of the

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MBI12 subscales but there were significant improvements in the Satisfaction with Life Scale71

and the Smith Relaxation Disposition Inventory72 for both interventions.

A shortened 4-week MBSR course was also explored by Pipe et al.,50 who used an RCT design

to test this in a group of nursing leaders. A number of outcomes were looked at both pre- and

immediately post-intervention showing significant improvements in obsessive-compulsive

symptoms, anxiety type symptoms, global severity index and positive distress index within the

SCL-90-R (Symptom Checklist-90-Revised73). No significant changes were noted in results

from the Caring Efficacy Scale38. It was noted that 73% of the cohort randomised to the

intervention group attended at least three-quarters of the course.

Ten studies were rates as Fair in quality.51-60

Shaipro et al.,51 used an identical study design to the Cohen-Katz et al. study above,45 and

found a significant improvement in scores on the PSS39 but only a non-significant

improvement in MBI12 and BSI64. This study was again small in size (intervention group n=8,

control group n=18) and suffered from a considerable number of drop-outs in the

intervention group (56%) raising concerns about how onerous such a prolonged MBSR

training course is for healthcare employees to commit to.

Again utilising a very similar methodology, Geary and Rosenthal52 tested an 8 week MBSR

course in a group of healthcare professionals and considered outcomes at baseline, 8 weeks

and 12 months. A non-randomised control group was used in analysis but was drawn from a

different healthcare population. Significant improvements were however noted in the PSS39,

SSF-3643 and the SCL-90-R symptom checklist73 for self-reported psychological distress and

these were maintained at 12 months.

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Barzarko et al.53 tested an 8 week ‘telephonic’ MBSR course, comprising an initial full-day

retreat but with each session thereafter delivered via teleconference calls rather than in

person. Significant improvements were seen at both 8 weeks and 4 months in scores on the

PSS39, Copenhagen Burnout Inventory74, Short Form-12v275, Brief Serenity Scale76 and the Self-

Compassion Scale77 but results are clouded by noting that participants were offered incentives

for completion of the course.

Gardiner et al.,54 published the first report of a stress management intervention designed to

improve the HWB of healthcare staff, among a group of general practitioners (GPs) in

Australia. All participants were volunteers and a non-randomised control group (of GPs

attending other personal development courses) was incorporated for comparative analysis.

The intervention itself was a 5-week cognitive behavioural training (CBT) course, including

15 hours of dedicated teaching time. A number of self-reported outcomes were taken at

baseline, immediately after intervention and at 12 weeks thereafter. Significant

improvements were seen in the General Health Questionnaire65 and also the domains of

quality of work, work-related stress and work-related morale within the Queensland Public

Agency Staff Survey78 both immediately after intervention and at 12 weeks.

Walker55 explored the effects of training in HeartTouch technique (a method of intentionally

changing one’s thoughts and feelings towards stress and health) in a waiting-list model. Both

the intervention and control group received an initial education session, with further training

in the practice of the technique itself given to the intervention group. Both intervention and

control groups showed significantly improved scores in PSS39 suggesting the additional

session conferred little benefit with regards to this outcome domain. There was, however, a

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significant improvement in the Spiritual Wellbeing Scale41 within the intervention group, not

seen in the control group.

Codier et al.56 explored the impact of training in emotional intelligence in a quasi-

experimental study amongst 24 volunteer nursing managers. Unfortunately, only 15

completed the study but those that did had significant improvements in scores taken recorded

using the Mayer-Salovey-Caruso Emotional Intelligence test79 compared to baseline.

Saadat et al.57 utilised an intervention entitled ‘Coping with work and family stress’80 based on a

risk factor/protective factor model and focusing on the elimination of sources of stress,

training in stress management exercises and formulation of individual stress management

plans. The programme involved 1.5 hour sessions delivered weekly over a period of 16 weeks.

The impact of this intervention was assessed in an RCT with the control group released from

normal work activities for the same time period to minimise bias. When comparing outcomes

in the intervention and control groups there was a trend towards significance in the decreased

use of avoidance coping (Coping Strategy Indicator81) but no significant differences were

noticed when comparing scores from the Center for Epidemiologic Studies Depression Scale82.

Pipe et al.58 delivered a programme of behavioural interventions to self-regulate physiological

responses at times of stress. This required 7 hours of workshops in total and its effects were

assessed through a quasi-experimental study with pre- and post-intervention measurements.

Participants were recruited as volunteers and were divided, for the purposes of analysis, on

the basis of job role into a group of nurses (n=29) and those in clinical management (n=15).

Outcomes were measured through completion of the Personal and Organisational Quality

Assessment-Revised survey83, both at baseline and on completion of the intervention. From

the survey results, a number of stress indicators significantly improved included positive

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outlook, anxiety, resentfulness and stress for the nurses group. Only resentfulness showed a

similar improvement in the leadership group. No significant improvements were found in the

domains of morale or intention to quit in either group.

Irin-Light and Bincy59 designed an intervention based around a series of seminars covering

stress management, job stress awareness, progressive muscle relaxation and training in

conflict management and assertiveness. This was delivered to a group of 30 intensive care

nurses who were assessed at baseline and following the intervention using the Work Stress

Inventory84, with a significant decrease in the proportion of participants who scored overall as

severely stressed.

Ketelaar (i) et al.60 explored replacing the role of occupational health services with a series of

online self-help modules. This study cluster-randomised staff to either an occupational health

(control) arm or an e-mental health (intervention) arm. All participants received screening as

part of a routine HWB assessment within the institution. At this point, those which would

normally be referred to occupational health who were in the intervention arm were instead

offered access to a series of online interventions: Psyfit85, Colour your life86, Don’t Panic Online87

and Drinking less88. Both groups were assessed at baseline and following intervention using

the Nurses Work Functioning Questionnaire89. Significant improvements were noted in both

arms and whilst those in the control group under the direct care of occupational health

showed greater improvement (than the intervention group) there was no significant

difference between the two.

This group also conducted another study (in Ketelaar (ii) et al.61), which was rated as Poor and

so will not be discussed further.

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Multi-modal interventions

Two studies report the simultaneous implementation of an array of different interventions

aimed at a variety of aspects of HWB.90,91 It is impossible to consider the effects of each

intervention separately given they were all implemented within the same time frame and

outcome data reflects their summated effects.

One study was adjudged to be Good: Blake et al.90 designed a multi-model set of interventions

including increased provision of facilities for physical activity, dietary interventions, regular

health campaigns and screening checks as well as complementary and relaxation therapies.

Outcomes were measured at baseline and after the end of the 5-year study period, showing

significant improvements in sickness absence levels, job satisfaction (General Health

Questionnaire-1265) and physical activity levels (Physical Activity Questionnaire92).

The multi-modal HWB programme reported by Parkinson et al.91 was rated as Poor.

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Discussion

Summary of main results

This is the first systematic review evaluating the impact of HWB interventions for employees

within healthcare organisations. We identified forty-one such studies and found that nearly

two-thirds of these originate from the USA. There has been an increasing trend in the

publication of studies into HWB interventions with time, with more than three times more

studies published in the years 2000-2009 than 1990-1999 and almost as many studies

published in the last five years as the entire decade before. This echoes the recognition of both

the importance of HWB interventions and the clear need to expand the available evidence

base.

The diverse variety of HWB interventions found precluded any analysis en masse. As such, for

the purposes of analysis, studies were grouped as to the type of intervention they employed.

Considering first interventions centered around changing ways and patterns of working,7-11

there is evidence to support the introduction of facilitated forums for the discussion of

solutions to problems around the workplace and this comes from both a study with a natural

experiment design8 and a second pre/post intervention study, albeit one with a small study

size.9 A further report on the implementation of similar meetings showed positive changes in

only one of the two HWB outcomes measured.7

Of the ten interventions aimed at improving the physical health of healthcare employees,16-25

seven considered only volunteer participants and so are open to considerable selection bias. 17-

19,21-23,25 Positive findings were found by studies offering progressive exercise programmes and

improved nutrition, though results are tempered by small study sizes in each case. 17,18,25

Additionally, results from Hewitt et al.18 may also be skewed by participants all being drawn

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from the cytology department, a more sedentary role in comparison with others within a

hospital, and therefore potentially not representative of healthcare employees in general. Two

studies offered both nutrition and exercise based interventions in combination together but

results differed, with one study reporting significantly positive long-term results,20 and

another reporting no significant benefit.16

Complementary and alternative medicine techniques have been employed by many groups as

interventions to improve HWB,26-34 though all use only volunteer participants who will,

undoubtedly, demonstrate a higher level of engagement than would be seen across the

workforce of an entire healthcare organisation. Additionally, the majority employ small

sample sizes, further limiting the conclusions that can be drawn from studies.26,27,29,30,32 The

most encouraging evidence within this theme, however, comes from a group evaluating

relaxation therapy through a five-week training programme in imagery and meditation.26

MBSR is the intervention type with the greatest number of reports in the literature, all of

which are from the last decade.45-53 Delivery of an 8-week MBSR course has been found to lead

to significant improvements in an array of different HWB outcome measurements and, whilst

such improved scores are not found with every outcome tool, improvements have been noted

by a variety of groups suggesting a degree of robustness.45,46,51 Significant improvements have

also been noted in more long-term outcome data.47,52 Shortening MBSR training to 4 weeks

has been shown to generate similar improvements to the 8-week course, though no long-term

data is available following such a shortened course.48-50

Other stress management interventions evaluated include a CBT based 5-week course which

was found to result in significant HWB improvements in a quasi-experimental study of 110

volunteers.54 Delivering similar CBT based interventions online also led to significant

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improvements in a number of HWB outcomes but was limited by poor uptake by

participants.60 More generic stress and management training workshops have yielded mixed

results, with some groups reporting no significant improvements in HWB,57 and others

reporting improvements in only a subset of measured outcomes.58

Intervention programmes which harness a variety of different modalities are not easily

classifiable, due to their combination approach. Whilst a large study evaluating concurrent

interventions in physical health, complementary medicine and relaxation therapies found

significant improvements in HWB,90 it is impossible to determine the effects of each individual

modality singularly given outcome data collected reflect the summative effects of all

modalities together.

Applicability of evidence

Whilst a number of other reviews have considered HWB interventions on a broader level,

within other organisational spheres,93,94 this is the first review systematically evaluating HWB

interventions specifically for healthcare employees and, as such, could be considered directly

applicable to those within healthcare organisations.

The studies reviewed here, however, are from a variety of different healthcare settings, within

a variety of different countries. Implementing any HWB intervention, as with any other aspect

of organisational change, is dependent on both resources and need within a particular

organisation, and thus it could be argued that the transposition of an apparently successful

HWB intervention from one healthcare organisation to another might not confer similar

benefits given the differences inherent between the two settings. If one subscribes to this

belief, then only studies with positive results across a variety of different settings could be

considered in any way robust. The best case for any HWB intervention remains MBSR which

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has shown positive outcomes, both in the short and long-term, when delivered in a variety of

ways across a host of different institutions.45-53

Potential biases in review

There are a number of limitations in the studies reviewed here. The majority of studies lack a

control group and many of those that do have no randomisation between study arms. A

considerable proportion of the studies are pilot programmes and are therefore small in size.

Crucially, a high proportion of the studies use volunteer participants. Given we are

considering HWB, one could easily suggest that volunteers for a HWB intervention would be

those that were particularly motivated and engaged and therefore a considerable source of

selection bias. Such limitations have also been noted by authors appraising HWB

interventions in other settings.95

As with all systematic reviews, our searches remain open to publication bias – though it

should be noted that a number of studies in this review presented non-significant

results.10,16,17,21,27,32,57 Additionally, despite adopting a wide-ranging search strategy, we are also

limited by the confines of our approach and accept that there will be articles which escaped

our study design. Specifically, none of the HWB interventions reviewed above consider second

victim support services for healthcare employees experiencing distress following adverse

clinical events.

Implications

Changing the ‘health culture’ within an organisation has long been presented as a strategy

with which to improve employee HWB, reduce sickness absence and thereby improve cost-

effectiveness.96

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To do this there are a number of different interventions available to employers, many of

which have been reviewed here. A detailed comparative analysis of the impact of each

intervention is precluded by the lack of standardisation regarding both the particular facet of

HWB being targeted and the measurement tool(s) being utilised when considering outcomes.

If a degree of uniformity in such measurements were to be adopted it would allow the efficacy

of HWB interventions to be weighted far more accurately.

A recent review into healthcare employee HWB outlined a number of potential barriers

preventing the accurate evaluation of a given intervention and these can be seen in Box 1.4

Chief among these is data collection and evaluation criteria and generating better quality

evidence will allow us to make more informed decisions regarding the choice of HWB

intervention to be implemented.

Conclusion

There is an increasing recognition of the importance of employee HWB in healthcare

organisations. The majority of interventions reviewed here led to measurable improvements

in HWB but methodological shortcomings and a lack of standardisation cloud our ability at

this point to directly compare specific interventions with any clarity. There is an ongoing need

for further research into the efficacy of HWB interventions and this should be done with

consultation to both the existing evidence base and contemporary advisory reports.

23

Acknowledgements

This article represents independent research supported by the National Institute for Health

Research (NIHR) Imperial Patient Safety Translational Research Centre. The views expressed

are those of the author(s) and not necessarily those of the National Health Service, the NIHR

or the UK Department of Health.

24

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35

Bar Chart 1 – Publications by country of origin

Bar Chart 2 – Publications by decade

36

Box 1: Barriers to HWB interventions4

- the lack of time for evaluation

- the lack of appropriate baseline or benchmark data

- the lack of appropriate evaluation criteria

- the lack of focus on the process of an intervention

- the lack of skill to design appropriate data collection methods

- evaluation perceived as a complex and technical activity

- poor use and communication of evaluation evidence

37

Appendix A – Search strategiesMEDLINE In-Process & Other Non-Indexed Citations and Ovid MEDLINE® (1946 to January

Week 4 2016)

1. exp intervention studies/

2. exp Health Promotion/

3. Health Education/

4. (intervention* or method* or program* or health promotion or prevention* or activit*

or exercis* or meditat* or mindfulness).mp.

5. 1 or 2 or 3 or 4

6. (wellbeing or wellness or (health adj5 wellbeing) or (health adj5 wellness)).mp.

7. exp Health Personnel

8. 5 and 6 and 7

EMBASE Classic + Embase (1947 to 2016 January 29)

1. intervention study/

2. health education/



4. 1 or 2 or 3

5. wellbeing/


7. 5 or 6

8. hospital personnel/ or health care personnel/ or medical staff/

9. 4 and 7 and 8

Global Health (1973 to 2016 Week 04)

1. intervention/

2. health education/

3. health promotion/



5. 1 or 2 or 3 or 4

6. wellness/


38

8. 6 or 7

9. health care workers/

10. 5 and 8 and 9

PsycINFO (1806 to January Week 4 2016)

1. exp Intervention/

2. exp Health Education/

3. exp Health Promotion/



5. 1 or 2 or 3 or 4

6. exp Well Being/


8. 6 or 7

9. exp Medical Personnel/

10. 5 and 8 and 9

HMIC - Health Management Information Consortium (1979 to November 2015)

1. exp Health education/

2. exp health promotion/



4. 1 or 2 or 3


6. exp health service staff/

7. 4 and 5 and 6

39

Appendix B – Eligibility criteria

Criterion Definition RationaleStudy is published in the peer-reviewed literature

Accessible via MEDLINE, EMBASE, Global Health, PsycINFO or HMIC databases

To ensure search strategy robust and repeatable

Study is available in English language Study is available in English language Primary language of research teamPrimary participants are healthcare employees

Hospital employees include those in full and part time employment within a healthcare setting (including doctors, nurses and allied health professionals)

Studies reporting staff from other organisational contexts may not be truly representative of healthcare organisations

Hospital employees hold a substantive contract

Studies involving only students excluded The experience of student-level employees in the workplace may not be truly representative of more permanent work in that organisation

Study is reported as a full-text research article

Conference abstracts and editorials excluded Lack of data provision limits analysis of findings

Study reports on the efficacy of the intervention

The study makes a definite attempt to report on the efficacy of the intervention (though the manner in which they do so is left open provided they use quantitative means)

An appraisal of the intervention’s effect is required in order that we can collate and review all interventions

The intervention reported in the study specifically aims to improve employee HWB

At least one of the outcomes reported by the study can be considered to fall within the domain of employee HWB

To ensure the remit of the review is adequately met

40

Appendix C - PRISMA flow diagram depicting search strategy

Records identified through database searching

(n = 2938)

Records screened(n = 2651)

Full-text articles assessed for eligibility

(n = 60)

Studies included in qualitative analysis

(n = 44)

Duplicates removed(n = 287)

Full-text articles identified from reference lists

(n = 10)

Full-text articles excluded(n = 26)

Editorial / no outcomes (n=14)

Qualitative outcomes (n=4)Review article (n=3)

No intervention (n=3)Protocol only (n=1)

Mixed participants (n=1)

Records excluded, based on title/abstract

(n = 2591)

41

Documents

Interventions to improve employee health and wellbeing ...€¦ · Web viewIn response to an increasing body of evidence on the importance of employee health and wellbeing (HWB)