Creating Healthy Workplaces - November 7, 2014

Creating Healthy Workplaces

October, 2014

The Problem

America is in the midst of a health crisis.[i]  Physical and mental health issues ranging from obesity levels, lack of physical activity, stress, anxiety and depression are growing at an alarming rate but individuals have difficulty doing it alone, and “quick fix” diets, exercise regimens, job and organization redesign have not improved Americans’ health and well-being appreciably.  A review of the literature on the efficacy of different approaches to improving working Americans’ health and well-being, whether it is through preventive programs, health promotion programs, or ill-health mitigation programs, revealed why so little progress has been made:

• Optional programs that employees have to elect to participate in show low participation rates overall, and participation in optional programs differ by organization level and by socio-economic status; those with the greatest needs are the least likely to benefit from them.
• Most programs involve a single factor, and without controlling other factors that may also affect employee health and well-being, any progress made may be mediated by the effects of these other factors, thus limiting the impact of any single factor.
• Most approaches involve programs that are external to the work itself, requiring employees to choose between involvement in the program and involvement in other activities such as leisure, other jobs, or family responsibilities, and the choice tips in favor of the activity that is perceived to have greater value.
• Interventions are rarely evidence-based and therefore, there is little accumulated knowledge to direct the creation of programs or the selection of programs offered by vendors to organizations for implementation.
• Leadership and management are not sold on health and well-being programs, possibly because they are external to the work itself and thus, take employees away from their jobs, creating a conflict between management’s business needs and future organizational benefits associated with employees’ short- and long-term health and well-being.

If we aggregated all of this knowledge into an integrated view of the factors that promote employee health and well-being, could we “build” the first comprehensive, systematic, and evidence-driven template of the healthy workplace?  We believe a healthier workforce will be more productive and decrease costs, and more important, will enable competitive advantage.

We need to address the way Americans live and what they experience day to day at work.  We also need to anticipate and be ready for dramatic changes in the experience of work resulting from the digital revolution. The change must be multi-pronged and experienced as a new way to work and be at work.  By doing so, Americans are likely to adopt healthier living and working habits because it will be “baked” into their work and workplace experience.

What Would A Healthy Workplace Look Like Now and in the Future?

In order to answer this question, we need to establish the connection between attributes of the organization and states of employee health and well-being that lead to increased productivity, job satisfaction and/or reduced costs.  In other words, we are determining what aspects of the organization and workplace need to be present in order to provide employees work and a work environment that create or stimulate positive psychological and physical states and by doing so, collectively improve employee health and well-being?  If we understand this connection, we will be able to answer questions often asked by management such as:

• “What actions should I take which will increase my employees’ health, well-being and productivity while lowering my total healthcare cost?”
• “Which actions generate the greatest payoff to the organization overall?”

Today, we don’t have answers to those questions because we don’t know enough about the efficacy and impact of various approaches to improving employee health and well-being.  The evidence is scattered, incomplete, unreliable, and often narrow in focus.  We need to do more interdisciplinary research and exercise our imagination to explore new approaches, and we need to make sense out of what we currently have.  We need a way of piecing together disparate bits of knowledge extracted from the scientific evidence in a manner that generates insight into the determinants of health and well-being in the workplace.

This paper lays out an approach to accomplishing the task of knowing not only what factors are essential for creating healthy workplaces but also how these factors need to be knitted together to create a robust, sustainable, multi-pronged and effective solution to stem the health crisis starting with people at work and then building a positive framework for the future.

A Model for Creating Healthy Workplaces

We have developed a conceptual model for articulating how to create healthy workplaces, and this model is graphically depicted below.

The model depicts nested relationships among organizational context, organizational support, individual behavior change and physical and psychological states as concentric circles.  Organizational context broadly determines how organizational support, individual behavior change and physical and psychological states will be expressed in a particular organization.  For example, new organizations (e.g., start-ups) will approach employee health and well-being differently from more mature organizations (e.g., multi-nationals), and different occupations (e.g., blue collar vs. white collar) within an organization will have different needs and therefore, will also require different approaches.  Thus, organizational context dictates the parameters management has to work with (e.g., maturity, resources, workforce diversity, and financial status) in order to address the health and well-being needs of its workforce.

Given the organizational context, two separate approaches to improving employee health and well-being emerge.  One set of approaches come from the structural components of an organization whereby “healthy” behaviors and work styles can be encouraged and/or determined as a function of the systems, processes, procedures and rules implemented in the workplace.  These are what we call “baked-in” solutions because the structural elements of the organization constrain employee behavior and shape work practices in ways that promote health and well-being.  Organizational policies such as child care and elder care leaves, living wages, limitations on work hours, organized social groups, among others can have the effect of driving behaviors that will have the effect of better health.   This set of approaches can be further distinguished as those that prevent illness and injury, and those that promote health and well-being.

The second set of approaches comes from behavior changes employees make themselves in order to promote their health and well-being.  These consist of elective behaviors exhibited by individual employees based on decisions they make to improve their health.  “Elective” as opposed to “baked-in” approaches have the quality of discretion exercised by the employee, and examples are an employee’s choice to use a treadmill desk, take fitness classes after work, eat healthy food in the cafeteria, stop smoking, engage in walking meetings, and limit his/her time returning emails and doing work past 7pm in the evening.  Both of these sets of approaches reflect the different types of interventions organizations may employ to affect employees’ responses to their work and work environments.

Both organizational supports and behavior changes are believed to have an impact on employees’ physical and psychological internal states.  This is the critical innovation of the model.  It is argued that what a person feels directly affects their health status and their work outcomes.  In order for employees to thrive in the workplace, employees must experience these positive internal states–by doing so, they create the basis from which good physical, emotional and psychological health is established and the drive for positive organizational outcomes is realized.  The model articulates a subset of important internal states.  These are the “engines” of health and well-being, and they are the targets that we as architects of healthy workplaces strive to create with any and all interventions.

From these physical and psychological states come physiological indicators of health like BMI, cholesterol, blood pressure, blood sugar, and cortisol levels and psychological and social indicators of well-being like job and work satisfaction, productivity, engagement, lower absenteeism and presenteeism, lower turnover, and fewer instances of illness, injury and chronic pain.  For employers, these latter outcomes are desired as they translate into lower operating costs, fewer workers compensation claims, lower healthcare costs, fewer job vacancies and sick leaves, fewer complaints and lawsuits, and potentially sustainable return on capital.  Theoretically, both sets of outcomes can be achieved if we understand at a deeper level how employees respond physically and psychologically to a variety of organizational attributes in the workplace and how employee responses to these attributes result in changed behavior and their desire to come to work and do their best work.

The Interdisciplinary Approach to Creating Healthy Workplaces: Three Key Steps

1. Defining Health and Well-Being
2. Aggregating Scientific Findings Across Disciplines
3. Establishing The Value Proposition For Organizations

Defining Health and Well-Being

We need to define “employee health and well-being” and establish the desired outcomes we ultimately want to achieve.  We define health and well-being holistically as do others (e.g., NIOSH, WHO) by including psychological, social, economic, and physical indicators of the absence of suffering, illness and injury and the presence of a positive mental outlook and personal state of psychological security, enjoyment and satisfaction at work.  As explained above, the specific psychological and physical states comprising employee health and well-being form the centerpiece around which all components of the solution are linked.  These psychological and physical states are the point—our destination—our proof that what we have done has truly made a difference.

Aggregating Scientific Findings Across Disciplines 

The second step in finding workable solutions is aggregating everything we know currently about employee health and well-being across disciplines.  Multiple disciplines have taken up the topic of “wellness” and some of these have dedicated research efforts to employee wellness.  Typical disciplines in which we would find research literature on employee wellness are public health, public policy, medicine, psychology, sociology, social welfare, ergonomics, nutrition and economics.  Today, for various reasons other less traditional disciplines have directed their attention to employee wellness such as business, architecture and environmental design, interior design, engineering, computer science, materials science and law.  Customer need and competitive advantage probably fueled the latter disciplines’ entrance into the health and wellness space, signaling that companies may be ready for innovative solutions to address cost and productivity issues tied to employee health and well-being problems.

The health and wellness-related literature in each of these disciplines is largely highly specialized, single-variable, and specifically-directed to members of its own field—not conducive to public dissemination and cross-fertilization with other disciplines.  Different methodologies, unfamiliar analyses, variously defined variables and different levels of analysis serve to create silos of knowledge which have undoubtedly hampered our efforts to make significant progress in this area. However, these silos can be broken down, and the knowledge can be generalized for sharing across disciplines through guided communications with subject matter experts (SMEs) in each discipline, enabling this knowledge to be translated into general findings and evidence-based guidance which can be easily understood by parties outside each discipline.  The ICHW has hosted several mini-conferences with discipline-specific SMEs for this purpose and has proven that cross-discipline knowledge sharing is possible and in fact, very helpful to forming a broader understanding of the determinants of employee health and well-being based on scientific evidence.

Access to a broad base of research literature enables us to piece these various literatures together to see the emerging picture of the factors that need to be taken into account in the creation of a healthy workplace.   Each discipline contributes unique factors from their research that have been shown to affect employee health and well-being.  The question is, does combining these factors into a coherent whole significantly add to our ability to affect employee health and well-being?  The answer to this question lies in how employers can and do utilize this information to make decisions that will affect where and how employees work, working conditions, compensation and benefits, organizational policies and procedures, and cultural values.

Establishing The Value Proposition For Organizations

Knowledge sharing across researchers and academics is important for the literature to become accessible beyond members within each discipline and to be generalized to a point where it can be integrated with literature outside its domain.  The mere act of sharing across disciplines enables insights to be gained about the underlying mechanisms of employee health and well-being, as we have seen through our own interdisciplinary and cross-stakeholder meetings and discussions.  Once this literature is integrated and understood, then it can be transformed to better suit the needs of organizations.

What have we heard from corporate entities about their needs regarding health and wellness?  In a nutshell, they say they want us to tell them what to do–where’s the checklist of things to do to increase employee health and well-being, and where’s the manual for how to implement one or more of these things?  And which ones would be the best ones to invest in?  Employers’ needs are very practical.  How can we help them make important decisions that will get them closer to their goals of having happier, more satisfied, healthier, and more productive employees?  Fortunately, the scientific literature is helpful here.

Multiple functions and departments in organizations engage in decision-making that impact employee health and well-being, among other things.  These include HR, Risk Management, EAP, Comp & Benefits, Facilities, Real Estate, Occupational Health, EH&S, OD, and IT.  Operational decisions are made in each of these functions and departments, some of which are intended to prevent illness/injury/harm whereas others promote employee health and well-being.  The scientific literature can inform decisions in each of these functions and departments, thus increasing the quality of the decision-making and potentially improving the intended outcomes of illness/injury prevention and health promotion.

An example can illustrate this point.  HR makes decisions in concert with operations on such things as job design and job descriptions, organizational policies, performance management and other HR systems, employee relations, employee reward and recognition programs, and anti-harassment practices.  If HR were to contribute to employee health and well-being, what organizational attributes would be important to have in place that would have the effect of supporting employees’ desired psychological and physical states?  What would give employees the feeling of being respected, having personal control over their work, experiencing a sense of accomplishment, and being treated fairly and equitably?  HR could design into their programs, practices and systems organizational attributes such as fair process policies, reasonable work expectations, limited work hours, employee ombudsmen, public recognitions of all high performers and contributors, among others that employees would perceive as having these psychological and physical effects.  In fact, employees could indicate which scientifically-supported organizational attributes would significantly impact their psychological and physical states, and subsequently, HR and other functions and departments could use that information to introduce elements into the workplace that have the desired effects.

Another example is Real Estate.  Real Estate has responsibility for building company structures and designing interior spaces for use by company employees. Decisions regarding location, architectural design, materials, furniture/equipment, interior design, layout, air/heat/light/temperature, and traffic flow, among others impact employees’ experience of the physical space they work in.  Researchers could identify the organizational attributes that result in desired psychological and physical states, and Real Estate could make decisions to introduce these elements into the workplace.

The same process can ensue in all the other functions and departments.  Organizational attributes that are perceived by employees to have these desired physical and psychological effects could be identified, and then changes can be made or new elements introduced into the workplace to create the desired effects.

When all the functions and departments share knowledge across domains, capitalizing on all known science across disciplines, two things could result: 

• Organizational functions and departments achieve a common understanding of the factors that affect employee health and well-being and as a result, can establish common goals, interests and focus based on that understanding; and
• Having common goals, interests and focus, organizational functions and departments can engage in cooperative and coordinated action, increasing efficiency and eliminating internal conflicts and barriers to success.

By sharing their knowledge and acting upon the same knowledge base, functions and departments have the potential to make internally consistent, mutually reinforcing decisions to actively support those activities and organizational changes that prevent illness/injury and promote health and well-being.

In summary, the greatest value of an interdisciplinary approach to employee health and well-being for organizations is improved decision-making both within and across functions and departments, resulting in a coordinated set of decisions that have a mutually reinforcing positive effect on employees and productivity. Coordinated and focused decision-making would also lessen the opportunity for internal inconsistencies and conflicts, making achievement of health and wellness goals more likely.  Costs associated with suboptimal decision-making, ineffectual changes and programming, and continued declines in employee health and well-being could be minimized by taking an interdisciplinary and integrated approach to creating healthy workplaces.

Linking Desired Physical and Psychological States to Organizational Attributes

To create a template of the healthy workplace, we need to identify the most relevant psychological and physical states that comprise employees’ health and well-being, and then link those to organizational attributes that cut across different organizational functions and departments.  Psychological and physical states are rarely studied independently for the purpose of understanding the dynamics underlying program interventions and health and organizational outcomes.  We know from experience and descriptive studies that poor psychological and physical states result in poor health and organizational outcomes, but we know a little about the relationship between good psychological and physical states and positive health and organizational outcomes.  Which states have the greatest impact on overall health status and organizational outcomes?  A preliminary list could include the following:

• Need for physical activity
• Personal control over work and workspace
• Physical comfort
• Sense of safety and security
• Being respected
• Sense of accomplishment and time well-spent
• Sense of equity and fair treatment
• Positive social relationships
• Compatibility with organizational values
• Sense of personal support from others
• Relaxed, rested
• Being present
• Happiness

Exploring the research literature for support for these and/or additional states would solidify the foundation of employee health and well-being we are striving to improve through our design and intervention efforts.  New studies can be constructed to test the external validity of the final set of states.  Once this foundation is established, we can turn to exploring the linkages between psychological and physical states and organizational attributes.  We can do so by conducting studies of the impact of a variety of organizational attributes on employee states through observation and self-report questionnaires.  A preliminary list of organizational attributes could include:

• Pay and leave policies
• Medical clinics
• Attractive office design
• Process for setting realistic job expectations
• Process for customizing the air/temp/lighting of personal workspace
• Established work hours
• Fair process for appealing employment decisions
• Access to ergonomically-appropriate furniture/equipment
• Attractive options for physical activity within the workplace
• Access to affordable nutritional food at the workplace
• Ways to minimize long periods of sitting
• Ways to take care of unexpected elder care responsibilities
• Ways to take care of unexpected child care responsibilities
• Ways to accommodate urgent personal needs
• Access to mental health support
• Access to private space when needed
• Programs to engage employees in important aspects of the enterprise
• Ways to form and reinforce social relationships at work
• Ways to improve the quality of and skill in supervision
• Protections from health and safety hazards
• Protections from physical violence
• Programs for balancing the effort/reward equation
• Demonstrations of leadership support for employee health and well-being
• Leadership engagement in health and well-being activities
• Technology-based opportunities for health and well-being monitoring/feedback
• Ways to ensure compliance with labor and employment laws

We could engage corporate representatives to work with researchers to develop a list of attributes within each function or department that may be relevant for improving employee health and well-being.  Given a list of psychological and physical states and a list of organizational attributes for each relevant function or department, we could then apply research techniques to link the two lists.  If so, we could begin to answer the question, “What kinds of changes should I make that will result in improved employee health and well-being?”

Customizing Organizational Decisions by Occupation, Demographics and Location

The last step in the approach to creating healthy workplaces is establishing a decision map that adjusts organizational attributes for different organizational contexts such as by occupation, demographics and location.  Blue collar options, for example, will be quite different from those of pink or white collar options.  Similarly, options may also different by age, ethnic group, culture, geographic location, position, and hierarchical level.  Whether employees work in an office, an agricultural field, in the community, home or Starbucks may also be relevant in determining relevant organizational attributes that are linked to psychological and physical states and their relative importance in that context.  Additional research is needed to refine these distinctions and capture the unique relationships between organizational attributes and psychological and physical states by context.

Putting the Interdisciplinary Approach and Healthy Workplace Model Together

It is clear that we need to have a new way of thinking about how to improve employee health and well-being beyond wellness programs, health-improvement incentives, and workplace design.  The model helps us think about employee health and well-being as being multi-dimensional, multi-pronged, and under the control of both the individual employee and the organization.  The model makes clear what we are trying to achieve (“Desired Outcomes”) and how we are going to achieve them by isolating factors identified in the broad-based literature as having an impact on employee health and well-being.  These factors have been divided into those for which the organization must address (“Organizational Support”), and those for which the individuals and groups need to change (“Behavior Change”).  The model also makes clear that the factors that are likely to impact employee health and well-being could different depending on the organizational context (“Organizational Context”).  The model is useful for building out the factors in each of the three components (Context, Support, and Behavior Change).

These identified factors form the foundation for exploring which organizational attributes might be important to change or design into the workplace to have a positive effect on employees’ psychological and physical states.  By isolating factors proven to affect employee health and well-being and then determining whether they are under the organization’s or employee’s control, we can begin building out the organizational attributes associated with these factors and assist decision-makers in making changes that serve to prevent illness/injury and promote employee health and well-being.

It will take the coordinated effort of multiple parties within organizations to work together and make decisions that efficiently and effectively change the work and workplace that employees experience day to day.   To the extent employees experience those positive psychological and physical states as a function of the work they perform and the environment in which it is performed, they will be encouraged to work in a healthier manner and adopt healthier personal habits, resulting in a healthier employee.  If so, then the organization will reap the benefits of a thriving workforce.

[i] America leads most countries in the rate of obesity–two out of every three Americans are considered overweight or obese.  By 2030, the rate will increase to one out of every two Americans.  Diabetes is now the number one burden of disease globally for the next decade, and in 2012 alone, the disease caused 4.8 million diabetes-related deaths.  Diabetes affects over 21 million Americans, and 33% of the US population is expected to have the disease by 2050.    Mental disorders are also increasing within the American population.  One in four adults suffers from a diagnosable mental disorder; depression alone affects 8% of the population.  Depression, hypertension, diabetes, allergies and other medical conditions account for a significant portion of productivity losses in organizations.  Presenteeism, a condition where employees who are physically present at work but exhibit lower levels of productivity because of illness or other barriers to performance such as financial problems, addiction, divorce or family difficulties, and childcare issues, accounts for 75% of these productivity losses, amounting to $12,000 per employee per year.  Americans also suffer from insufficient physical activity.  Up to half of all Americans 15 years and older exercise less than five times a week for 30 minutes of moderate activity or less than three times a week of 20 minutes of vigorous activity or the equivalent.  Most of the world population is more physically active than Americans.  We are getting sicker as a nation, and we are facing a tsunami of health care costs that may equal or surpass our most recent financial crisis as Baby Boomers age and live longer and all Americans eat poorer food and live more stressful lives.  It appears that the public is actually interested in becoming healthier, and we can capitalize on this trend.