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ORIGINAL ARTICLES

Organizational Perspectives on How to Successfully Integrate Health Promotion Activities into Occupational Health and Safety

Biswas, Aviroop PhD; Begum, Momtaz MPH; Van Eerd, Dwayne PhD; Smith, Peter M. PhD; Gignac, Monique A.M. PhD

Author Information
Journal of Occupational and Environmental Medicine: April 2021 - Volume 63 - Issue 4 - p 270-284
doi: 10.1097/JOM.0000000000002087
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Abstract

Learning Objectives

  • Discuss the need for an “organizational voice,” with input from workers in managerial or leadership roles, to guide implementation of integrated worker health approaches.
  • Describe the workshop approach used to gain organizational perspectives on facilitators, barriers, and recommendations for successfully integrating health promotion activities into occupational health and safety.
  • Summarize and give example statements of key themes identified by stakeholders participating in the workshop.

Chronic diseases, which include heart disease, stroke, certain cancers, and diabetes, have long been leading causes of death and disability worldwide.1,2 In high income countries like Canada, three out of five people over the age of twenty live with a preventable chronic health condition, and four out of five are at risk of developing a preventable chronic illnesses.3,4 For workers, chronic health conditions have been linked to an increased risk of workplace accidents,5,6 more serious complications after an accident,7 prolonged recovery times,8 and decreased productivity.6 Workplaces are effective venues for chronic disease prevention efforts as they are where a large number of working people can be reached and also spend most of their waking day.9,10 The work environment, encompassing the physical, psychosocial, and organizational environments also can directly shape employee health, safety, and health behaviors.11,12 For example, shift work, long work hours, work stress, and physically demanding work have been associated with obesity,13,14 cardiovascular disease,15,16 and poor mental health.17,18 Many workers with unhealthy behaviours (eg, smoking, high alcohol use, and unhealthy diets) also are employed in hazardous jobs, thereby potentially amplifying their risks for injuries and chronic illness.19,20

Workplace health promotion programs typically operate separately from occupational safety activities in their aim to alter individual health behaviours. However, an integrated worker health approach recognises the role of the broader work environment in facilitating health behaviours and health promotion. Specifically, an integrated worker health approach focuses on altering workplace policies, programs and practices to protect workers from work-related health hazards, as well as advance their overall health and wellbeing.21 There has been a growth of studies in the last decade on the effects of integrated worker health approaches, helped by endorsements from the National Institute for Occupational Safety and Health's Total Worker Health® program and other health and labour agencies.22–24 Examples of implemented integrated worker health approaches include: a program to reduce smoking and exposures to job-related chemicals that synergize the cancer risks of smoking in trades workers,25 the extension of an occupational safety program to include exercise training, group participatory processes to plan/implement job redesign, and training on lifestyle issues as part of an occupational safety program,26 and a participatory intervention targeting job stress and mental health and wellbeing in blue-collar workers.27 Empirical evidence, while still emerging, provides initial support for the effectiveness of integrated worker health approaches in contributing to higher rates of worker participation for both safety and health promotion efforts,28–31 reductions in occupational injury and disability rates,32,33 and reduced healthcare and societal costs.34

Guidance to support the integration of safety, health, and wellbeing in organizational policies and practices is becoming increasingly available. For example, Sorensen et al developed a set of implementation steps through a review of the literature and discussions with researchers. The findings outlined seven indicators with accompanying measures of integrated worker health approaches, including: organizational leadership and commitment, coordination between health protection and health promotion, supportive organizational policies and practices, coordinated management and employee engagement strategies, benefits and incentives, integrated evaluation and surveillance, and comprehensive program content.35,36 Cooklin et al reviewed empirical evidence and Australian case studies in their recommendations.37 Guidance included the importance of collaboration and communication between occupational health and human resources departments, building an existing occupational safety infrastructure, and continual improvement based on ongoing program evaluation. The Campbell Institute also used case study evidence to provide organizations with a process for a systemic approach to coordinating workplace safety, health and wellbeing practices.38 Among the report's recommendations was a focus on how workplaces can identify, prioritize, and target for intervention the health conditions of highest risk to the worker population.38 These resources largely summarized evaluations of existing programs or official corporate reports from case studies. Accordingly, existing resources are useful for developing an understanding of the ways in which vanguard organizations select, adopt, and sustain certain integrated worker health approaches.39

Missing from existing guidance is the incorporation of input from workers in managerial or leadership roles (ie, an organisational voice) on whether integrated worker health recommendations were feasible and practical, as well as input on facilitators and barriers to implementation. Organizational input is particularly important as it can be challenging to gain organizational buy-in and convince workers to enroll and participate in voluntary workplace health promotion programs.39 This is in line with participatory action research in the workplace, which emphasizes participant engagement in part or all of the research process and involves critical dialogue, reflection, and discussion among participants to develop actionable evidence and guidance.40 Furthermore, the participatory action research process can advance implementation research by informing actionable guidance for what works for whom, why, and in which situations.41,42 The objective of this study was to identify implementation facilitators and barriers and recommendations when seeking to implement an integrated worker health approach based on the perspectives of organizational representatives.

METHODS

A series of sequential processes were conducted by the research team to develop recommendations informed by organizational perspectives (Fig. 1). Processes included the establishment of an advisory committee of relevant organizational stakeholders, a scoping review of the literature, a full-day workshop with the organizational stakeholder advisors and additional organizational representatives to discuss the scoping review findings, a thematic analysis of the workshop discussions, a web-based recommendation ranking exercise derived from the workshop discussions, and finalising the recommendations. The advisory committee was comprised of six key informants with knowledge of workplace safety and health promotion initiatives (ie, health and safety professionals, wellness consultants, academics). The committee were recruited to share their insights in guiding the study objectives and in the interpretation of findings. Five of the key informants were Canadian and one was from the United States and were already known to research team members. The study protocol was approved by the health sciences research ethics board at the University of Toronto (Protocol No.: 00036727).

FIGURE 1
FIGURE 1:
Outline of process identifying integrated worker health recommendations.

A scoping review was first performed to review the available peer-reviewed and grey literature of the facilitators, barriers, and recommendations that are relevant to the implementation of integrated worker health approaches. The scoping review was guided by a framework developed by Arksey and O’Malley and recommendations made by Levac et al.43,44 The following five-step process was followed: (1) identify the research question, (2) identify relevant documents, (3) choose documents based on criteria for inclusion and exclusion (document selection), (4) list data organized by themes and major issues (charting the data), (5) group, summarize, and report the results in order to draft a summary description (data synthesis). The following electronic databases were searched from the past ten years to study inception (January 2008 until February 11, 2019): EMBASE, Ovid Medline, PsycINFO, and ABI Inform. Furthermore, a stakeholder advisory committee was assembled with knowledge and experience of workplace safety and health promotion initiatives (ie, health and safety professionals, wellness consultants, academics) to identify additional documents. A total of 59 documents were reviewed. Details of the methods and review findings are described elsewhere.45 Briefly, the review found facilitators and barriers to implementation at the following levels: extra-organizational factors (relates to macro-level factors outside the workplace, eg, unions, government, and the wider community), the organization (relates to leadership and management perspectives, organizational policies and culture), worker (relates to worker willingness and flexibility to participate in programs), and programs (relates to the specific characteristics and the design of the integrated worker health program).

Workshop Discussions

A full-day workshop with small group breakout discussions was held with organizational participants. Participants were comprised of members of the study's advisory committee and were also suggested by the advisory committee as organizational representatives with relevant perspectives on occupational safety and health promotion. The workshop brought together organizational representatives from consultancy, labour, industry, and government, including workplace health and safety, human resources, employee benefits, employee assistance, workplace health promotion, organized labour, and public health. They were told that the study aimed to identify processes and guiding principles to integrate occupational health and safety and health promotion activities. Fifteen potential participants were invited to attend via an e-mailed invitation, twelve attended the workshop, while three individuals were unable to attend after agreeing to participate. The three organizational representatives who had agreed to participate in the workshop but were unable to attend were emailed a summary of the workshop materials so that they could add their perspectives after the meeting. Informed consent was obtained from all workshop attendants. Participants were offered a small honorarium of $60 to cover travel expenses, although many participants declined the honorarium in accordance with their organizational practices.

The aim of the workshop was to have participants discuss the scoping review findings from the perspective of their own experiences. Breakout sessions asked participants: (i) if they agree with the facilitators and barriers identified from the existing evidence, (ii) their thoughts on what is missing from the evidence, and (iii) what matters most to them when implementing recommendations in the real-world. Specifically, participants were randomly assigned to small discussion groups (three groups, each with four participants) and presented with the scoping review themes and a list of theme or concept definitions to help them understand previous research findings. In a series of group exercises, participants were encouraged to list and discuss within their groups as to what they felt were the three most important facilitators, barriers, and recommendations for implementing integrated worker health and safety practices. A full group discussion followed each of the small group sessions to further clarify and enhance the discussion topics.

Material from the workshop discussions was summarized by the small groups on flip charts. In addition, audio recordings captured full group discussions and were transcribed verbatim, while the research team members took notes on their observations. Data were stored and organized using NVivo (QSR International), a program for the management of qualitative data.46 Since the workshop engaged participants in different ways through open-ended discussions and collected information through multiple avenues (mind maps on flip charts, researcher notes, and discussion transcripts), the data were analysed holistically while following a qualitative thematic analysis structure to identify emerging themes.47 Initially, two researchers independently identified a list of emerging themes from the workshop discussion notes and developed a preliminary coding scheme of recommendations listed under the themes. Both researchers then met to discuss their initial list of themes and any differences in themes/coded recommendations, until they reached consensus. At this point the list of themes and recommendations were shared with the other research team members and discussed. One research team member also retrieved quotes from the workshop discussion transcripts to illustrate the context of each recommendation.

Ranking Exercise of Key Recommendations

To organize the list of themes and recommendations, the research team adopted the Plan-Do-Check-Act (PDCA) framework, an iterative four-step method used in the continuous improvement of management processes.48 The “Plan” step involves establishing objectives and processes required to deliver an integrated approach; “Do” comprises delivering/implementing the plan in the previous phase; “Check” involves actions where the data and results gathered from the “Do” phase are evaluated; and “Adjust” (revised from “Act” in the PDCA cycle) is when records from the “Do” and “Check” steps help identify issues with the process. This step also encompasses making adjustments to components of the integrated approach, where needed. The PDCA framework was found not to capture all implementation processes that emerged from the analysis and the research team extended the framework to include a preliminary “Pre-Plan” step, which involves understanding when to consider planning for an integrated worker health approach. The modified framework is hereinafter referred to as the PPDCA cycle.

The research team developed a web-based ranking exercise using the Qualtrics online survey software (Qualtrics, Provo, UT). The ranking exercise asked participants to rank the list of themes and recommendations identified in the analysis of the workshop discussions and aligned with the PPDCA steps. The ranking exercise was twice piloted by the research team before being finalized. All fifteen of the original organizational representatives were e-mailed a private link to the ranking exercise and provided with a general background of the project and relevance of the exercise. Participants were given 3 weeks to complete the exercise and sent two reminder e-mails. Respondents were also able to view anonymized quotes to better understand the meaning and context associated with each recommendation. The ranking exercise asked participants to rate recommendations within each of the PPDCA steps on a five-point Likert scale (from not important at all, to very important). Participants were also given the opportunity to suggest a better fit for a recommendation or propose additional recommendations that they felt were missing. If respondents suggested additional recommendations, they were asked to rate their importance on the same scale as the other recommendations. Finally, a mean overall score of participants’ ratings were calculated for each recommendation ranging from a lowest score of 0 (not important at all) to a highest score of 5 (very important).

RESULTS

The following section first describes key recommendations identified by participants from the thematic analysis of the workshop discussions. Table 1 provides the full list of recommendations and illustrative quotes for context. Table 2 presents the mean rank given to each recommendation from the ranking exercise. Figure 2 outlines the final PPDCA framework of prioritized recommendations and overarching themes.

TABLE 1 - Recommendations Made by Workshop Attendees and Illustrative Quotes
Recommendations Quotes
Find out if the organization prioritises the safety, health and wellness of employees in their existing practices, mission statement or corporate policies. “Organisations that have worked really hard to foster a safety culture have a much easier time expanding, moving beyond the traditional mindset to incorporate health, wellness, and psychological health and safety because they’ve got that foundation.”“If you have the right overall company culture of everyone working together, then someone may say, I want to champion an eating wellness program at work and everyone is, oh, what a great idea.………The smaller to medium size companies will do that on their own provided that they have a solid culture to begin with. And the leadership buy-in and employee buy-in, again, if the culture is strong”.“Yeah, so just going back to recommendations out of there, and it did talk about building this in, right into the mission statement. So, that's something that my organisation has already done. So, it's there, it's written, but it's now getting to the how's and the whys and whatnot. So, I can definitely see this being one of those things that we start integrating into our health and safety management system. And we’re lucky enough to have occupational health nurses on staff as well, so I can see a lot of these components being something that we share with them, and then they help drive those components of it as well. But yeah, I definitely see a need for it, and we’re starting, at least on our end, starting to chomp at the bit to want to start to do with this, it's just the how and the why, and getting everybody on board, and getting that level of engagement.”
Understand whether the organization is open to reassessing how it supports the health and safety of its employees. “That's what's piquing the interests of many organisations because they know that one of their competitors … or they go to industry conferences and they hear about it. They don’t know what it is, but they hear about it and they think, hey, maybe we should put that on our to-do list.
Examine whether the external economic, funding and political climate is favourable for the implementation of an integrated strategy. “The external economic climate is a barrier that most organisations feel that at one point or another. We know right now in [name of a province] we’re feeling it big time, but the economic climate has a big impact and it can either be a positive or a negative depending on how the climate is at the time. But if we say it's negative then it has an impact on the resources and the people and it's hard to get buy-in.”
Gain leadership buy-in by outlining what employers and employees can gain from an integrated strategy in terms of its value on investment and return on investment. “what are the benefits? This is the pitch. What is the company going to gain? What are the employees going to gain from doing it this way? And it's simply the fact that you have to look at value on investment, not just return on investment which is the money value, and everything else, that might be the benefit for the leaders, the upper management, is the return on investment. But also, what is the value of investment which is something that maybe the employees are more concerned about. Either way, as long as they’re getting paid and they’re doing the work and they’re safe and everything else, they might be happy. But if you don’t take into consideration what the company needs and the company goes under, nobody benefits. So, we go all the way back to this win-win type situation.”
Leverage evidence of the benefits of integrating wellness and safety from data sources (internally or from external studies/implementations). “Leverage your data, the information you’re getting from your employees as well as the leaders, listen to what they have to say. And when you’re developing the plan, then you use that data to reinforce why you’re doing it. Understanding why you’re doing it and how it's going to benefit everyone.”
Listen to what organizations have to say and leverage what you can to get going. “Understanding why you’re doing it, and in this case, what are the situations that are going to give you the win-win, where the employees win and the business, the leaders win.”
Consider how leadership conceptualizes safety and wellness and the integration of both. "In terms of selling that [an integrated strategy], we said that it's really about finding synergies through these normally separate groups so then that flow will happen after breaking down siloes. Then it allows you to leverage resources differently and there's maybe more effectiveness and efficiencies in doing some of the things we already do where we maybe were duplicating, or not leveraging what one group knows and the other one doesn’t. Then in alignment with that or flowing from that, you have to then invest in the development and training programs for leaders and the committees or the various elements of this too so that they really are able to support that shifted thinking.”
Identify change agents and champions within the organization who can help the organization and employees see the value of an integrated strategy. “We also thought as a backbone of this is that you can look at the inclusion of champions with leadership involvement and support, so making sure champions are supported throughout this entire process. ““I do think the champions is really important, identifying someone especially high up who can do things.”
Conduct a needs assessment of employer and employee priorities via meetings, focus groups, surveys etc. “we have to at the same time focus on engaging employees and we thought that would be possible done through needs assessment. It could be a survey, and a survey is something you could possibly look at later to measure your data …We thought, out of that, the common area is where you can have your needs assessment. It might be a committee that includes all employee types including leadership in all different levels of leadership in the organisation and different types of roles, very similar to what this group was talking about with maybe HR, maybe safety, but some people that have those different vested interests. You could do this in a focus group or survey, there's lots of different ways. “
Tailor the integrated strategy towards employer and employee needs and priorities. “we also said that you need to know what employees need and what they want because you have to tailor your approach. There is no one size fits all. We were talking within our three different organisations, they’re very different, and what's going to work is going to be entirely different. So, you have to understand what the employee needs are.”
A planning committee should have representation from organization leadership, employees, department representatives, and possibly members of the community at large that can share their insights on the implementation process (eg, non-profits, health care organizations). “make sure that you have a coordinated team. If the business folks have one plan and the employees have another idea of what they’re going to do and then they try to implement things and it just goes along the wayside. So, you want to make sure that it's a coordinated effort into developing or implementing the solution on there.”“we said one of our recommendations would be to develop an integrated strategy for health and safety which includes wellness, safety, HR, and employees. So, again, depending on the organisation what these are called, or your HR might also … you might have separate employee engagement teams, different people in charge of policy, so those are the high-level branches, but that could look different for different organisations. And then employees need to be part of that too. But it's really bringing those groups together, and what that looks like might look different. It might be that the people working in these different areas, there's a committee that's formed with them, it might actually, depending what size the organisation, be a restructure or you’re bringing those groups together into one office, so how that gets done could look different, but then that they’re creating that shared strategy.”
Consider formal and informal meetings with representation from within the organization and other organizations/researchers/community organizations to learn/share experiences regarding the challenges and successes of implementing an integrated strategy. “So, in my experience, working in different provinces, in [name of a province], the safety associations have regional [designation of personnel]. And especially for small business, what they’re able to do is convene basically informal meetings where people come together, share their challenges, share the successes, learn from each other. And it's a very organic process and it works. The small business in particular says that they’ve really benefited from this. And then in [name of a province] where you have regional [name of a group/organization], the system is organised differently. So, you have local [groups/organizations] and offices funded by the government, and they’ve got, as you know, health promotion experts. So, I think of the example in [City], [name of a province], at the [name of an organization], the [name of a program] program, where they had the local public health professionals involved, they had the union, they had management, and they had a couple of other community-based health promotion organisations involved. So, it actually became quite a community effort because it's a big employer in the community. But it's unique. That isn’t likely to happen, that particular combination in [name of a province] or in [name of a province] because that's not how things are organised. So, basically knowing what the external resources are that you can draw on and then making those connections.”
Consider a change management process to prepare, equip and support leadership and employees on the uptake of the integration strategy. “You have to make sure that at all points in the process that both upper management as well as employees are understanding where they’re going, this is the why, how they’re going to implement it, and then second of all, checking back again, measuring what the results are of it, and making sure that everybody is still on board, that it still matters.”
Train leadership, HR/safety, wellness managers, and employees early on to make sure everyone understands how the strategy will work and its benefits. “what stood out for me in the recommendations that were just on there was the training and manager support in advance of rolling out something such as the healthy and wellness culture in your organisation. Because we missed that mark on a roll out one year and it was pretty huge. And we failed to recognise that employees probably feel more comfortable to the people that they report to and they’re on the front lines with every day. Where we thought all the questions would just funnel to us. But that was a huge lesson learned for us to better equip our leaders, as well as managers and supervisors, to whether it's just a simple FAQ of why [Organization] is making the change, where we expect to go, what are the costs, so they could have those in their hands ready to speak to their employees who are going to, quite frankly, walk in their office and want to talk to them.”
Consider tailoring communication about the strategy to different departments and employees. “We had some organisations we spoke to who said, we need a standard set of rules and processes and that has to be the rule for everybody and roll it out. Otherwise, we don’t look like we’re being transparent and fair and we’re going to get push back. So, transparency and fairness for some organisations was very much about one set of rules and programs. But then we had others, and they were usually the people on the ground doing the work who were saying, you’ve got different jobs, different people, different sectors, different sizes, everything is different. You can only do this well if it's tailored.”
Consider putting in place mechanisms to protect employee privacy, allay any fears of retribution and communicate these clearly to employees. “Privacy is an issue if you’re in a small organisation and you’re trying to do some type of survey or gather information and you know you’re the one smoker in the room, that kind of thing, it could have an impact.”
Ensure budgeting and staffing resource requirements are considered or make clear how existing budgets and staff will be utilised. “Be clear on, we can measure, we can have an evaluation plan, we can talk about budgets and staffing.”“For leaders, the lack of buy-in might be that they maybe don’t have a budget, they don’t have the resources available for employees, there may be external impacts that they’re having which ties us into conflicting priorities so that they can’t meet in the middle because they’re actually not on the same page at this time.”
Find synergies among separate health, safety and wellness groups/programs (if present); then leverage or build upon these existing resources. “Start where you’re at, lever what you can, get going. And we talked about that timely piece. Don’t sit and wait until it's perfect, understand what those levers are and get going with a few of those and the other ones may start to come.”
Carry out an integration strategy with steps and activities required of employees. “The big thing is, is getting the right people involved that understands the process, understands why they’re doing it, has the authority to be able to implement some of these changes, as well as is able to make it a simple solution because anything that's too complicated is going to probably break down.”
Build momentum on early successes from short and simple programs and leverage for larger and more long-term strategies. “it's the baby steps, linking it directly, don’t go big until you’re really ready to go big, pilot test so you maybe have a sense of, we can’t show change at this level. And also, the other thing is then over time, to really … if you want to say, short-term disabilities have decreased, sometime, you don’t have dozens and dozens of short-term disabilities going on all the time. It takes a long time to show that that's made a difference.”“I think in health and wellness, you can have little wins all over the place. I wrote down, [name of a program]. So, I wrote that down, rewording it and putting it into our company language and making that a, let's have an initiative, that would be a pretty easy thing to do. In health and wellness there's easy, little bite wins that you can have that can kind of get the momentum starting while the big stuff is happening. While you’re trying to do program and practice change in the background, you can always do little initiatives, and that's the grassroots stuff that will help drive the bigger change.”“we also thought that this process could be scaled based on the size of the organisation or how big you wanted to take it. So, you could start with a very small subsection of employees and test it and measure it. If you’re working with an area that is as little less ready, you could then measure it and evaluate it and then say, hey, look at this, it worked in 20% of employees but if we rolled it out to a larger scale.”
Ensure that the integration of wellness activities do not compromise safety activities. “it's easier to focus on safety and then you jump right to health promotion programming…………….. But if we jump over that step of really focusing on psychological health and safety as that foundational component, you’ll have lower success…………. it's the safety, it's the psychological components, it's all of those areas around personal healthy behaviours.”
Make sure that all design and implementation steps are conducted in a timely manner. “the barrier that we decided for number two is implementation in organisations with a diverse workforce or complex structure. So, this can mean having a very long design process in rolling something out because of the structure or the approval process at your organisation. I think [stakeholder] and I both agreed that we have very lengthy approval process at our organisations. So, you could be working on something for two years before it gets rolled out like a new wellness program, healthcare spending within the organisation, things like that.”
Ensure leadership presence in program delivery models. “For employees, making sure that leadership presence during the delivery, that it's supported from leadership … And outline the level of involvement and feedback that they’d have. So, it's not going to be a top-down approach, you are going to be included and it's going to be back and forth between the leadership and the employee group.”
Enable change agents to promote the strategy. “If you can equip those people who are ready, willing, and able, with the ideas that they know will resonate in their organisation or in their particular workplace, that can have a powerful effect and actually push the resisters to at least keep them quite for a little while, long enough for some of these ideas to filter out. And that's the organic nature of this change. And so, really, you do research on how people make use of your … how the knowledge transfer process happens. And being able to put it in the hands of those individuals, they might be on committees, they might be team leads, they might be supervisors, union officials, who can actually take it and make use of it in their workplace. That's the key.”
Decide what and how often to communicate the strategy in a way that is meaningful to employees and that will reach the most employees. “I thought the communication comment was great because even you have some people that get 500 emails a day, so they only read the important information. And then others don’t real email, others live by it, and if that's your only form of communication, some people still like paper even though we’re trying to get away from that. But I thought that the meaningful communication, that was really key. …I think we would have to look at, again, with any communication that we deliver, so if we’re talking solution with the platforms. And if we’re going to use that as the methodology, we’re talking a daily communication should go out to keep the end user interested in what we’re reading. If we’re talking emails or newsletters, I don’t know, in my experience I find the value that maybe on a monthly basis would make sense. From executive, again, monthly or every couple of months having an update to say, here's the status of the nation, I find that beneficial. But again, I think you’d have to look at the type of the communication and then look at the marketing strategies behind that and what makes sense based off of the platform that we’re using.”
Have those individuals and departments that employees typically interact with (eg, colleagues, HR, managers) deliver the communication strategy. “what they communicate in language that their colleagues and co-workers totally get because they know the language, a vision of what this organisation can be like. And it's not something that you can … you can’t script it, I can’t script it, but they can because they know what's meaningful”. “the shared understanding of everyone at the table as to what we’re working towards, and the common language. Because I think often, in different departments we speak a slightly different language. And so, if we can invest in that and have a shared … I would call it a shared conceptual framework”.
Ensure a balanced integration of physical and psychological health and safety. “very recently there's more requirements to ensure that there are effective policies and programs dealing with harassment, bullying, violence in the workplace. That's HR's responsibility, but it's opened the door to make connections with psychologically healthy and safe workplaces. So, those discussions are happening, and the connections are being made.”
Develop metrics to measure the progress or successes of the integration strategy. “….the results from employee surveys and being able to simply use, like, even an Excel spreadsheet and break down the data by business unit, or whatever the most meaningful unit in the organisation is, tells a very, very powerful and convincing story about the overall state of play in terms of both performance and health and wellbeing. And it doesn’t take much effort, but it's one thing that … it's a task because it's doing something that draws on your existing resources. It helps you tell a better story or paint a better picture of your organisation. And it's an a-ha moment when organisations see the results, especially when you start breaking it down. It's interesting that those business units that have the lowest engagement scores, well, also have the highest absenteeism, have the highest benefits utilisation for prescription drugs related to depression, anxiety, etcetera. You paint a pretty clear picture, you can do that. And that's something that I think is … it's a tangible task that encourages, actually requires cooperation to pull it off. So, you get these units working together and it's a very quick turnaround. It only takes a couple weeks to do this really, and then they see the picture and then they think, okay, well, how do we work together to address this?”
“think about over the year, over three months, what have you accomplished in three months? What did you develop? Where are you now that you weren’t before, and looking at it more from a positive lens as opposed to where we should be, or we could be, but what have we learned? How have we grown? And that can keep the motivation moving forward.”
Make the organization's leadership and employees aware of any milestones and successes resulting from the integrated strategy. “I think celebrating along the way is really important. So, quite often we talk about a process can take a long time, and specifically for whoever is more leading that project team around this topic, it can feel very deflating when it's taking a long time and nothing's really rolling out. But think about over the year, over three months, what have you accomplished in three months? What did you develop? Where are you now that you weren’t before, and looking at it more from a positive lens as opposed to where we should be, or we could be, but what have we learned? How have we grown? And that can keep the motivation moving forward.”
Consult with the organization's leadership and program participants on their perspectives on how the program was delivered and if any challenges need to be addressed. “So, we go all the way back to this win-win type situation. You have to make sure that at all points in the process that both upper management as well as employees are understanding where they’re going, this is the why, how they’re going to implement it, and then second of all, checking back again, measuring what the results are of it, and making sure that everybody is still on board, that it still matters. Is there something that needs to change? Continuous improvement.”“And it's progress not perfection. You don’t need to … you’re not necessarily, in the first year, have everything perfect. You know it's going to be building on what you have, and everyone has something. You’re not starting from zero.”
If it is difficult to develop or implement progress measures, consider whether there is existing data to inform progress. “In my experience, many large and even medium-size organisations are sitting on a gold mine of data, they simply haven’t connected the data dots. I mean, it's the silos. Different parts of the organisations own different chunks of the data, but putting it together and including in what you’ve just listed off.”
Revisit and adjust the design and implementation of the strategy regularly. “it's progress not perfection. You don’t need to … you’re not necessarily, in the first year, have everything perfect. You know it's going to be building on what you have, and everyone has something. You’re not starting from zero.”“Continuous improvement. I like to think of it as a house that you’re trying to build. You want to make sure first of all that you know the details about how to build the house. Putting down a good solid foundation to work, then you build up from there and you build the rest of the house. And then you have to, as far as the people and everything else, if you’re going to have a houseful, you want to make sure everybody's on board and they’re all getting along in the situation. And then what is the final results of it and whether or not you have to make any tweaks along the way to improve the quality of the house.”
Prepare, support, and help employees in any changes to the refinement of the strategy. “thinking about what are some of the things that might not work so perfectly, and here's how you’re going to manage that I think is important to let them know so that when it happens, they’re not feeling like they’ve failed, they’re feeling like, oh, we just need to make sure that we have this change management process in place to support this shift in how we’re doing things”.

TABLE 2 - Key Recommendations to Implement an Integrated Worker Health Approach Identified via a Web-based Ranking Exercise
Rating Range
Step Recommendation Number of Responses Mean Rating (Max: 5) Min Max
1—Pre-Plan Gain leadership buy-in by outlining what employers and employees can gain from an integrated strategy in terms of its value on investment and return on investment. 10 4.80 3 5
Identify change agents and champions within the organization who can help the organization and employees see the value of an integrated strategy. 10 4.60 4 5
Find out if the organization prioritizes the safety, health and wellness of employees in their existing practices, mission statement or corporate policies. 10 4.10 3 5
Understand whether the organization is open to reassessing how it supports the health and safety of its employees. 10 4.10 2 5
Examine whether the external economic, funding and political climate is favorable for the implementation of an integrated strategy. 10 3.80 3 5
Consider how leadership conceptualizes safety and wellness and the integration of both. 10 3.80 3 5
Leverage evidence of the benefits of integrating wellness and safety from data sources (internally or from external studies/implementations. 10 3.80 2 5
Listen to what organizations have to say and leverage what you can to get going. 10 3.50 2 5
Assess perceptions of enablers and barriers to change among leadership and employees. Understand who believes changes are needed, and why. 4 4.75 4 5
Assess willingness to direct, or redirect, internal resources in support of program development and implementation. 1 5.00 5 5
Understand relevant prior experience--seen as successes or, importantly, failures. 1 5.00 5 5
If unionized, assess support of union leadership and their future role. 1 4.00 4 4
2—Plan Tailor the integrated strategy towards employer and employee needs and priorities. 10 4.80 4 5
Conduct a needs assessment of employer and employee priorities via meetings, focus groups, surveys etc. 10 4.70 4 5
Consider a change management process to prepare, equip and support leadership and employees on the uptake of the integration strategy. 10 4.40 3 5
A planning committee should have representation from organization leadership, employees, department representatives, and possibly members of the community at large that can share their insights on the implementation process (eg, non-profits, health care organizations). 10 4.40 3 5
Train leadership, HR/safety, wellness managers, and employees early on to make sure everyone understands how the strategy will work and its benefits 10 4.20 3 5
Develop metrics to measure the progress or successes of the integration strategy. 10 4.20 3 5
Ensure budgeting and staffing resource requirements are considered or make clear how existing budgets and staff will be utilized. 10 4.10 3 5
Consider putting in place mechanisms to protect employee privacy, allay any fears of retribution and communicate these clearly to employees 10 4.00 3 5
Consider tailoring communication about the strategy to different departments and employees. For small-medium organizations, consider if sending a single message is more appropriate. 10 3.80 3 5
Find synergies among separate health, safety and wellness groups/programs (if present); then leverage or build upon these existing resources. 10 3.80 3 5
Consider formal and informal meetings with representation from within the organization and other organizations/researchers/community organizations to learn/share experiences regarding the challenges and successes of implementing an integrated strategy. 10 3.40 2 5
Consider adding an external stakeholder to the planning group. Consider the addition of an external individual with relevant experience to the planning process 2 4.0 4 4
Include an evaluation framework in plan. 1 4.0 4 4
3—Do Ensure leadership presence in program delivery models. 10 4.50 3 5
Enable change agents to promote the strategy. 10 4.40 4 5
Ensure a balanced integration of physical and psychological health and safety. 10 4.30 3 5
Build momentum on early successes from short and simple programs and leverage for larger and more long-term strategies. 10 4.20 3 5
Decide what and how often to communicate the strategy in a way that is meaningful to employees and that will reach the most employees. 10 4.10 3 5
Ensure that the integration of wellness activities do not compromise safety activities. 10 4.00 3 5
Make sure that all design and implementation steps are conducted in a timely manner. 10 4.00 3 5
Carry out an integration strategy with steps and activities required of employees. 10 3.70 3 5
Have individuals and departments that employees typically interact with (eg, colleagues, HR, managers) deliver the communication strategy. 10 3.50 2 5
Clarify what is voluntary and what is mandatory. 1 5.0 5 5
Communicate how the program goals will be measured. 1 5.0 5 5
Communicate the key motivating factors, particularly how all are expected to benefit from successful implementation. 1 5.0 5 5
Communicate how successes have been achieved, and the consequences of success, in other analogous settings. 1 4.0 4 4
4—Check Consult with the organization's leadership and program participants on their perspectives on how the program was delivered and if any challenges need to be addressed. 10 4.20 3 5
Make the organization's leadership and employees aware of any milestones and successes resulting from the integrated strategy. 10 4.00 3 5
If it is difficult to develop or implement progress measures, consider whether there is existing data to inform progress. 10 3.70 3 5
Communicate barriers to success that were identified and what has been done to attempt to address them. 1 5.00 5 5
Ensure that progress measures reflect goals set out in the original implementation plan. 1 4.00 4 4
5—Adjust Prepare, support, and help employees in any changes to the refinement of the strategy. 10 4.40 4 5
Revisit and adjust the design and implementation of the strategy regularly. 10 4.40 3 5
Share lessons from specific successes/departments/units 1 4.0 4 4
Build idea that this is a continuous improvement process, so the process is never ‘done’. 1 4.0 4 4

FIGURE 2
FIGURE 2:
Final recommendations for implementing integrated worker health approaches as informed by organizational input.

Thematic Analysis of Workshop Discussions

Participants were health promotion researchers from a large health services and research institution (n = 2); the chief benefits officer and the client experience lead of an employee benefits plan provider (n = 2); a health and safety advisor, the lead for employee benefits, and the lead for leave of absence administration for a large private multinational organization (n = 3); a safety engineering specialist at a provincial government labour ministry; an occupational health and safety consultant at an academic institution; and a professional consultant specializing in healthy organizations and work environments. A study co-investigator facilitated the workshop and also participated in large group discussions by sharing her own relevant research experiences with different organizations. Quotes are from the small group breakout sessions and large group discussions.

The workshop participants identified several key themes in response to being asked about the facilitators, barriers and recommendations for implementing an integrated worker health approach. The themes spanned topics related to organizational culture, external constraints and influences, resources, leadership, needs assessments, communication and training, delivering a simple program, evaluation and making improvements and adjustments wherever needed to ensure continual improvement. There was good agreement between participants coming from different organizations in the themes discussed.

Descriptions of the Key Themes

Organizational Readiness and Environmental Constraints [Pre-Plan Step]

Participants discussed the importance of understanding an organization's openness to reassessing how it supports the health and safety of its employees; and examined the external economic and political climate for implementation. They noted ways that some organizations find it easier to implement an integrated approach and the potential counteracting external pressures.

On assessing organizational readiness:

“Organizations that have worked really hard to foster a safety culture have a much easier time expanding, moving beyond the traditional mindset to incorporate health, wellness, and psychological health and safety because they’ve got that foundation” (Consultant in large group discussion.)

On the external economic climate:

“The external economic climate is a barrier that most organizations feel at one point or another. We know right now in [Canadian province] we’re feeling it big time, but the economic climate has a big impact and it can either be a positive or a negative depending on how the climate is at the time. But if we say it's negative then it has an impact on the resources and the people and it's hard to get buy-in.” (Safety specialist while summarising his small group discussion.)

Organizational Resources [Pre-Plan/Plan/Check steps]

Many participants mentioned the importance of organizational resources and a need to recognize the potential value on investment and return on investment:

“What are the benefits? This is the pitch. What is the company going to gain? What are the employees going to gain from doing it this way? And it's simply the fact that you have to look at value on investment, not just return on investment which is the money value, and everything else, that might be the benefit for the leaders, the upper management, is the return on investment. But also, what is the value of investment which is something that maybe the employees are more concerned about. Either way, as long as they’re getting paid and they’re doing the work and they’re safe and everything else, they might be happy. But if you don’t take into consideration what the company needs and the company goes under, nobody benefits.” (Safety specialist while summarising his small group discussion.)

On preparing a plan for resource and staff allocation:

Some stakeholders also identified the importance of assessing an organization's willingness to direct or redirect internal resources in support of new safety and wellness initiatives. They noted that it was essential to ensure budgeting and staffing resource requirements were available, and that planning was needed to ensure existing budgets and staffing could be maintained.

“Be clear on what we can measure, that we can have an evaluation plan, that we can talk about budgets and staffing.” (Employee benefits lead summing up her small group discussion.)

“For leaders, the lack of buy-in might be that they maybe don’t have a budget, they don’t have the resources available for employees, there may be external impacts that they’re having which ties us into conflicting priorities so that they can’t meet in the middle because they’re actually not on the same page at this time.” (Health promotion researcher summing up a small group discussion.)

On using data to reinforce the case for an integrated worker health approach:

It was recommended that implementers consider evidence from internal or external sources and leverage existing resources based on their needs and limitations.

“Leverage your data, the information you’re getting from your employees as well as the leaders, listen to what they have to say. And when you’re developing the plan, then you use that data to reinforce why you’re doing it. Understanding why you’re doing it and how it's going to benefit everyone.” (Health promotion researcher in large group discussion.)

Influencing Leadership [Pre-Plan/Plan/Do/Check steps]

Several participants noted the importance of finding opportunities to shift leadership's conceptualization of safety towards an integration of safety and wellness:

"In terms of selling that [an integrated worker health strategy], we said that it's really about finding synergies through these normally separate groups so then that flow will happen after breaking down siloes. Then it allows you to leverage resources differently and there's maybe more effectiveness and efficiencies in doing some of the things we already do where we maybe were duplicating, or not leveraging what one group knows and the other one doesn’t. Then in alignment with that or flowing from that, you have to then invest in the development and training programs for leaders and the committees or the various elements of this too so that they really are able to support that shifted thinking.” (Chief benefits officer in a large group discussion.)

On the importance of identifying change agents and champions among leadership:

Participants recognized the importance of identifying leaders to be “change agents” and “champions”, especially within the leadership of an organization, who can help show the value of an integrated total worker health strategy. One participant summed this up saying:

“We also thought as a backbone of this is that you can look at the inclusion of champions with leadership involvement and support, so making sure champions are supported throughout this entire process.” (Lead for leave of absence administration for a large private multinational organization summing up a small group discussion.)

“I do think the champions is really important, identifying someone especially high up who can do things.” (Discussion facilitator/study coinvestigator in large group discussion.)

On the importance of having leadership presence in program delivery:

Also raised as important was ensuring leadership presence in program delivery models and consulting with leadership and program participants on how the program was delivered and if any challenges need to be addressed. This was summarised by a participant group as follows:

“For employees, making sure that there is leadership presence during the delivery, that it's supported from leadership … And outline the level of involvement and feedback that they’d have. So, it's not going to be a top-down approach, you are going to be included and it's going to be back and forth between the leadership and the employee group.” (Lead for leave of absence administration for a large private multinational organization summing up a small group discussion.)

“So, we go all the way back to this win-win type situation. You have to make sure that at all points in the process that both upper management as well as employees are understanding where they’re going, this is the why, how they’re going to implement it, and then second of all, checking back again, measuring what the results are of it, and making sure that everybody is still on board, that it still matters. Is there something that needs to change? Continuous improvement.” (Safety specialist while summarising his small group discussion.)

Understand Needs and Priorities [Plan Step]

Understanding employer and employee needs and priorities was mentioned. To understand needs, it was recommended that implementers conduct meetings, focus groups, or surveys among employees. Once needs are identified, it was suggested that implementation planning decisions be undertaken by a planning committee with representation from leadership, employees, department representatives, and possibly members of the community at large (eg, non-profits, health care organizations):

“We have to at the same time focus on engaging employees and we thought that would be possible… through needs assessment. It could be a survey, and a survey is something you could possibly look at later to measure your data… [Our group] thought, out of that, the common area is where you can have your needs assessment. It might be a committee that includes all employee types including leadership at all different levels of leadership of the organization and different types of roles, very similar to what this group was talking about with maybe HR, maybe safety, but some people that have those different vested interests. You could do this in a focus group or survey, there's lots of different ways.” (Lead for leave of absence administration for a large private multinational organization summing up a small group discussion.)

On ensuring that workers’ safety and psychological health needs are prioritized:

Participants stressed that understanding and addressing the occupational safety and psychological health needs of employees should be prioritized first before adding health promotion programming to an implementation strategy:

“It's easier to focus on safety and then you jump right to health promotion programming… But if we jump over that step of really focusing on psychological health and safety as that foundational component, you’ll have lower success…it's the safety, it's the psychological components, it's all of those areas around personal healthy behaviours.” (Health promotion researcher in large group discussion.)

Ongoing Communication and Training [Plan/Do/Check Steps]

Tailoring communication strategies to different departments and employee groups was recommended. For small organizations, a single organizational message was felt to be more appropriate. Participants agreed that communication should be an ongoing process that needed to unfold over time and document successes in order to maintain interest and motivation in integrated health promotion and safety.

“We had some organizations we spoke to who said, we need a standard set of rules and processes and that has to be the rule for everybody and roll it out. Otherwise, we don’t look like we’re being transparent and fair and we’re going to get push back. So, transparency and fairness for some organizations was very much about one set of rules and programs. But then we had others, and they were usually the people on the ground doing the work who were saying, you’ve got different jobs, different people, different sectors, different sizes, everything is different. You can only do this well if it's tailored.” (Discussion facilitator in large group discussion.)

“I thought the communication comment was great because even you have some people that get 500 emails a day, so they only read the important information. And then others don’t real email, others live by it, and if that's your only form of communication, some people still like paper even though we’re trying to get away from that. But I thought that the meaningful communication, that was really key. … I think we would have to look at, again, with any communication that we deliver, so if we’re talking solution with the platforms. And if we’re going to use that as the methodology, we’re talking a daily communication should go out to keep the end user interested in what we’re reading. If we’re talking emails or newsletters, I don’t know, in my experience I find the value that maybe on a monthly basis would make sense. From executive, again, monthly or every couple of months having an update to say, here's the status of the nation, I find that beneficial. But again, I think you’d have to look at the type of the communication and then look at the marketing strategies behind that and what makes sense based off of the platform that we’re using.” (Client experience lead of an employee benefits plan provider in a large group discussion.)

On the importance of training and communicating the strategy across the organization:

In conjunction with communication, there were recommendations for focusing on training others. This included considering a change management process to prepare, equip and support leadership and employees on the uptake of the integrated strategy. It was recommended to train leadership, human resources, safety, and wellness managers and employees early on to make sure everyone understands how the strategy will work and its benefits:

“You have to make sure that at all points in the process that both upper management as well as employees are understanding where they’re going, this is the why, how they’re going to implement it, and then second of all, checking back again, measuring what the results are of it, and making sure that everybody is still on board, that it still matters.” (Safety specialist while summarising his small group discussion.)

“What stood out for me was providing training and manager support in advance of rolling out something such as the health and wellness culture in your organization. Because we missed that mark on a roll out one year and it was pretty huge. And we failed to recognise that employees probably feel more comfortable disclosing to the people that they report to and they’re on the front lines with every day. Where we thought all the questions would just funnel to us. But that was a huge lesson learned for us to better equip our leaders, as well as managers and supervisors, to whether it's just a simple FAQ of why [Organization] is making the change, where we expect to go, what are the costs, so they could have those in their hands ready to speak to their employees who are going to, quite frankly, walk in their office and want to talk to them.” (Health and safety advisor for a large private multinational organization in a large group discussion.)

Develop an Evaluation Strategy; Communicate Successes and Barriers [Plan/Check Steps]

Participants raised the importance of developing an evaluation framework to measure whether an integration strategy was successful. Having existing data already collected by the organization would also inform this step. At the same time, participants often noted that data could be ignored if they felt that they lacked the expertise or knowledge as to what is involved in evaluating the strategy or what should be measured.

“In my experience, many large and even medium-size organizations are sitting on a gold mine of data, they simply haven’t connected the data dots. I mean, it's the silos. Different parts of the organizations own different chunks of the data, but putting it together and including in what you’ve just listed off”

“think about over the year, over three months, what have you accomplished in three months? What did you develop? Where are you now that you weren’t before, and looking at it more from a positive lens as opposed to where we should be, or we could be, but what have we learned? How have we grown? And that can keep the motivation moving forward.” (Consultant in large group discussion.)

On the importance of maintaining employee privacy during program evaluation:

Several participants also recommended putting mechanisms in place to protect employee privacy, allay any fears of retribution and communicate these clearly to employees

“Privacy is an issue if you’re in a small organization and you’re trying to do some type of survey or gather information and you know you’re the one smoker in the room, that kind of thing, it could have an impact.” (Client experience lead of an employee benefits plan provider in a large group discussion.)

Communicate Successes and Barriers [Check Step]

Making an organization's leadership and its employees aware of any milestones and successes was perceived by some workshop participants to be a key step to maintaining engagement and buy-in. It was also important that barriers to success be identified and to communicate any steps needed to address them:

“I think celebrating along the way is really important. So, quite often we talk about a process can take a long time, and specifically for whoever is more leading that project team around this topic, it can feel very deflating when it's taking a long time and nothing's really rolling out. But think about over the year, over three months, what have you accomplished in three months? What did you develop? Where are you now that you weren’t before, and looking at it more from a positive lens as opposed to where we should be, or we could be, but what have we learned? How have we grown? And that can keep the motivation moving forward.” (Health promotion researcher in large group discussion.)

Participants also discussed leveraging the successes of smaller short-term strategies before planning larger long-term strategies.

“It's the baby steps, linking it directly, don’t go big until you’re really ready to go big, pilot test so you maybe have a sense of, we can’t show change at this level. And also, the other thing is then over time, to really … if you want to say, short-term disabilities have decreased, sometime, you don’t have dozens and dozens of short-term disabilities going on all the time. It takes a long time to show that that's made a difference.” (Discussion facilitator in large group discussion.)

“In health and wellness there's easy wins that you can have that can kind of get the momentum starting while the big stuff is happening. While you’re trying to do program and practice change in the background, you can always do little initiatives, and that's the grassroots stuff that will help drive the bigger change.” (Consultant summarising a small group discussion.)

Refine the Program and Continually Improve [Adjust Step]

Some stakeholders brought up the idea that implementation is a process of continual improvement regularly revisiting and adjusting the design or implementation of the integrated strategy; and prepare, support, and help employees in any changes to the adjusted strategy.

“Continuous improvement. I like to think of it as a house that you’re trying to build. You want to make sure first of all that you know the details about how to build the house. Putting down a good solid foundation to work, then you build up from there and you build the rest of the house. And then you have to, as far as the people and everything else, if you’re going to have a houseful, you want to make sure everybody's on board and they’re all getting along in the situation. And then what is the final results of it and whether or not you have to make any tweaks along the way to improve the quality of the house.” (Safety specialist while summarising his small group discussion.)

On recognizing that implementation is an incremental process:

“And it's progress not perfection. You don’t need to … you’re not necessarily, in the first year, have everything perfect. You know it's going to be building on what you have, and everyone has something. You’re not starting from zero.” (Health promotion researcher in large group discussion.)

Stakeholders’ Ranking Exercise

The themes identified in the workshop were categorized according to the PPDCA cycle. Multiple statements drawing on the themes were created, and participants were then asked to rate the importance of each recommendation for integrating worker health approaches in organizations. Ten of the sixteen (63%) invited organizational representatives completed the ranking exercise. Table 2 outlines the ranked recommendations in order of their importance to participants.

For the Pre-Plan step, participants prioritized gaining leadership buy-in by making a case for the value and return on investment (mean rating: 4.80). In addition, identifying organizational change agents and champions was also rated as most important (mean rating: 4.60). At the Plan step, tailoring the integrated strategy to employer and employee needs (mean rating: 4.80), and conducting a needs assessment of priorities (mean rating: 4.70) were prioritized. For the Do step, ensuring leadership presence in program delivery (mean rating: 4.50) and enabling change agents to promote the program (mean rating: 4.40) were most important. For the Check step, evaluating leadership and employee experiences with the integrated program and addressing any challenges (mean rating: 4.20) was important to stakeholders. Lastly, regularly revisiting and adjusting the design and implementation strategy (mean rating: 4.40) and supporting and helping employees to adjust to any program refinements (mean rating: 4.40) were most important.

On average, participants estimated that 14% of an implementer's time and resources would be required for the Pre-Plan step, 26% for the Plan step, 35% for the Do step, 12% for the Check step, and 13% for the Adjust step. It was also acknowledged that time and resource estimates will vary considerably for different organizations, while the allocation of time and resources should in itself, be adjustable and reflect an understanding of the specific workplace needs, culture, available data and resources. The PPDCA framework in Fig. 2 illustrates how the various recommendations and overarching themes fit together as agreed upon by the researchers and organizational representatives.

DISCUSSION

The study findings add to the existing literature by highlighting priorities, facilitators and barriers from an organizational perspective for implementing integrated worker health approaches. Organizational perceptions are important because an integral part of implementing health promoting policies and programs into the workplace is obtaining support from those in managerial or leadership roles. The use of a broad and diverse cohort of organizational representatives to provide input on existing recommendations is a clear strength and should help with the uptake and acceptance of these findings. The data generated provide important information that can assist organizations, researchers, and practitioners to more effectively generate interest and action from employers.

A distinct study finding compared to the majority of guidance for integrating worker health strategies35–38 is the importance placed on identifying the suitable conditions for planning an integrated approach (corresponding to the “Pre-Plan” stage of the PPDCA framework). Readiness is a key factor in many dissemination and implementation frameworks, yet it is not often addressed in integrated worker health strategies. These findings may be a result of the challenges perceived by stakeholders in initiating an integrated worker health strategy, whereas previous recommendations have largely focused on best-practices after organizational buy-in has already taken place. The importance of identifying readiness and important implementation conditions is supported by the theoretical literature, whereby organizational culture, structure, and staff attributes along with supportive governmental policies can facilitate supportive organizational change for new initiatives.32,33 The study findings and existing literature also note that organizations can face several barriers to their readiness for implementation.34,49,50 For example, small workplaces can experience several obstacles to initiating workplace health promotion such as constraints on assigning or having access to resources for health promotion initiatives, and perceiving a lack of employee interest.51 Similar to the work by Hannon et al (2017) for workplace wellness programs in small organizations, the development of reliable and valid theory-based instruments to measure readiness at the outset of an integrated worker health change initiative are required.52

Several of the key recommendations identified by the organizational representatives draw parallels with components of successful integrated worker health interventions. In a hospital-based integrated worker health intervention consisting of regular planning meetings among employees and leadership to identify work problems, discuss possible solutions, and develop evaluation strategies, von Thiele Schwartz found improving trends in employee engagement, workability and productivity.53 Two other studies also found success in the adoption and long-term implementation of integrated worker health strategies when leadership were supportive of the strategy and were committed to attending regular planning meetings with other employees. Furthermore, the studies noted that having satisfactory financial resources and regular training staff also facilitated implementation.54,55 Although undertaking all the recommendations identified in this study may not be feasible for all organizations, targeting some aspects of the listed recommendations that are relevant to specific needs and resources can be a useful starting point when planning for integrated worker health approaches in different organizations.

Participatory action research provides a way forward for sharing and documenting implementation priorities and constraints. Compared to guidance from studies based mostly on case study and expert consensus evidence,35,37,38 some differences in priorities using organizational perspectives were noted. For example, there was little mention of instituting benefits and incentives to promote an integrated worker health approach. As Sorenson et al noted, examples of incentives and benefits can include employees receiving a cash bonus for completion of a health risk appraisal, attendance at health and safety trainings, or quitting smoking; while incentives for managers may acknowledge success in leading workplace health promotion and protection.35 Study respondents also did not specifically acknowledge the potential synergistic or additive effects of exposures to occupational hazards and individual health behaviours when describing the components of integrated worker health approaches. For example, programs aimed at reducing musculoskeletal disorders may incorporate training and messaging that address work-related musculoskeletal risks along with behavioural risk factors such as physical inactivity and inadequate sleep.56 It is possible that workshop participants were not aware of some specific features of an integrated worker health approach (eg, specific incentives, benefits, and integrated programming). Study findings and findings from other studies might also reflect differences in priorities among organizational representatives and researchers.

Study findings highlighted some potential facilitators and barriers to implementing an integrated worker health approach. An organization or practitioner seeking to implement an integrated worker health approach might face difficulty doing so if there are budgetary constraints or if organizations have limited capability to change their existing work conditions and policies.57,58 Failing to convince senior leadership of the benefits of an integrated approach in terms of a return or value on investment can dissuade interest which is especially the case when management and staff are uncooperative on changing existing work plans.59,60 Similarly, organizations with existing policies, programs and practices focused on flexible and supportive working conditions57,61–66 and that had a business and mission statement closely aligned with goals to protect and promote the health of their workers were viewed as more supportive of integrated worker health approaches.64,67 Having sufficient resources and budgets also were reported as helpful to support the case for an integrated approach, although is not always possible.68,69

The workshop discussions highlighted a keen interest from the organizational participants for integrated worker health strategies, in contrast to workplace health promotion-only studies which have reported that employers typically do not feel responsible for influencing their employees’ health behaviours, unless there is a risk of injury.70,71 In general, participants highlighted the importance of a shared employee and employer approach to decision-making, program design and evaluation, which might create more trust among workers that employers hold an interest in their overall wellbeing, while raising awareness among employers that health promotion is a valuable complement to occupational health and safety. Future research could be directed towards testing and quantifying the recommendations identified in this study so as to advance an understanding of the pathway to successful integrated worker health initiatives, programs, and policies. This would help to improve the capacity of workplaces wanting to effectively implement healthy changes and generate information that more clearly explicates the drivers of this type of change in the workplace.

The PPDCA approach represents a process of continual improvement, regularly revisiting and adjusting the design or implementation of an integrated worker health strategy. While an evaluation strategy will be integral for the iterative development of an integrated worker health approach, it will also be important that future work in this area develop tools for organizations to evaluate and monitor each step of the cycle. Furthermore, there is a need to develop metrics from the recommendations identified in this and other studies that can be used across industries and different workplaces.

There are limitations to work of this nature. There will be stakeholders or practitioners whose views were not captured in this study and might conceive of the recommendations and framework in a different way. The study participants were also predominantly from Canada and these findings can be particularly useful for organizations in regions similar to Canada, where knowledge and implementation of integrated worker health approaches are new to many organizations or where there are fewer incentives for employers to invest in wellness activities as most medically necessary services are covered by a public healthcare system.

CONCLUSIONS

Despite the availability of guidance on implementing integrated worker health approaches, it is unclear as to whether existing recommendations are feasible for organizations. Consulting with different organizational representatives, this study had identified a set of key recommendations for integrating worker health approaches that are aligned broadly into the PPDCA process of continual improvement. Implementers and researchers can use the findings as a roadmap to develop practices, policies and interventions to better implement integrated worker health approaches in organizations. Further research is needed to better understand how these recommendations apply to the diverse workforce and organizations with limited resources.

Acknowledgments

We thank Maggie Tiong (research librarian) and Joanna Liu (library technician) for developing the scoping review search strategy and supporting the data collection process. We also thank Albana Çanga for assistance with editing the reference bibliography and preparing the manuscript for journal submission.

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Keywords:

consensus; health promotion; intervention; occupational health and safety; worker safety

Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Occupational and Environmental Medicine.