Strategies for Health Organizations

Occupational safety aims to prevent disease or injury that may be physical or psychological and occurs in relationship to work. Health workers are at risk for infectious diseases, physical harm in the course of their work, and situations that evoke stress and/or trauma, any of which can worsen existing physical and mental health conditions. This section provides general resources focused on strengthening and investing in occupational safety, while other sections focus specifically on workplace violence, mental health, and stress/trauma.

‍Evidence

During the earlier parts of the COVID-19 pandemic, health workers were reported concerns about unclear COVID-19 policies, infection of family and friends outside of the hospital setting, and availability of personal protective equipment, which affected occupational safety and mental health.¹ Low organizational support for worker safety has been associated with worse work experiences for health workers during the COVID-19 pandemic.² Organizations with high safety cultures are associated lower emotional exhaustion, higher perceptions of institutional support for “second victims,” higher employee engagement, and lower turnover.^3-5 

‍Resources

The Occupational Safety and Health Administration (OSHA) has a plethora of resources on their website, Worker Safety in Hospitals, for healthcare workers and their organizations. It includes pages on:

• Understanding the Problem: Workers in healthcare settings face unique risks and challenges
• Safety & Health Management Systems: this page offers tools & resources for building a culture of safety.
• Safe Patient Handling: this page offers resources about safe patient handling and an assessment to assess your organization’s safe patient handling program and identify areas of improvement. 
• Preventing Workplace Violence (Discussed more in WPV tab): this page highlights some of the resources linked below and has resources regarding how workplace violence prevention fits with other organizational goals.

The World Health Organization also has some recent resources regarding occupational health of safety of workers in healthcare settings. 

• Occupational hazards in the health sector: this e-tool is for organizational leaders interested in what the WHO recommends for protecting health workers’ physical and mental health. It includes in-depth information about the most common occupational hazards. 
• Caring for those who care: Guide for the development and implementation of occupational health and safety programmes for health workers: This guide provides an overview of the central elements of occupational health and safety programs for health workers and guidance for developing and implementing these programs at your organization. 

National Institute for Occupational Safety and Health (NIOSH) developed the Total Worker Health® (TWH) Program which is defined as “policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness-prevention efforts to advance worker well-being.” Resources include:

• Fundamentals of Total Worker Health Approaches: Essential Elements for Advancing Worker Safety, Health, and Well-Being is a guide to help develop new workplace safety initiative or integrate current interventions with the TWH approach. 
• NIOSH Centers of Excellence for Total Worker Health® are 10 research centers dedicated to building the scientific evidence for effective strategies to address complex occupational safety and health issues. 
• NIOSH Worker Well-Being Questionnaire (WellBQ) is a measurement tool for worker well-being that assess the five domains of worker well-being: Work Evaluation and Experience, Workplace Policies and Culture, Workplace Physical Environment and Safety Climate, Health Status, Home, Community, and Society

‍References

¹ Norful AA, Rosenfeld A, Schroeder K, Travers JL, Aliyu S. Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States. General Hospital Psychiatry. 2021;69:20-26

² Siddique S, Rice S, Bhardwaj M, et al. Health Care Organization Policies for Employee Safety and COVID-19 Pandemic Response: A Mixed-Methods Study. J Occup Environ Med. 2023;65(1):1-9.

³ Sexton JB, Adair KC, Profit J, et al. Perceptions of Institutional Support for "Second Victims" Are Associated with Safety Culture and Workforce Well-Being. Jt Comm J Qual Patient Saf. 2021;47(5):306-312.

⁴ Daugherty Biddison EL, Paine L, Murakami P, Herzke C, Weaver SJ. Associations between safety culture and employee engagement over time: a retrospective analysis. BMJ Qual Saf. 2016;25(1):31-37.

⁵ Temkin-Greener H, Cen X, Li Y. Nursing Home Staff Turnover and Perceived Patient Safety Culture: Results from a National Survey. The Gerontologist. 2020;60(7):1303-1311.

Workplace violence against health workers has been rising. Addressing and preventing violence is key for organizations to create safe and accountable environments for health workers and learners. Strategies include:

• Establishing workplace violence prevention programs that define workplace violence; identify root causes, roles, and departments with higher risks; implement evidence-based programs; and establish structures for escalation
• Creating institution-wide policies and guidelines around workplace violence and bullying that are circulated to patients, visitors, clinicians, and staff and enforced through processes for accountability

‍Evidence

Many healthcare workers and particularly nurses report experiencing violence and bullying in the workplace.^1,2 While workplace prevention training has been shown to increase confidence and ability to manage violent incidence among health workers,^3,4 there is little evidence that it works to decrease workplace violence.⁵ A few studies have found that multi-component interventions that include training in addition to other mechanisms (e.g., organization-level changes, like workplace violence reporting systems and worksite walkthroughs) can have a positive impact.^6,7 

Studies of anti-bullying policies have found that those with a wide range of resolution options (e.g., both formal and informal), setting time frames for resolution processes,⁸ feedback mechanisms (e.g., anonymous surveys, exit interviews),⁹ consistent but thoughtful implementation by managers,¹⁰ and organizational support and governance are more effective than policies without those characteristics and result in increased participation by workers.¹¹ 

‍Resources

The Occupational Safety and Health Administration (OSHA) 2016 Guidelines for Preventing Workplace Violence for Healthcare and Social Services Workers: 1) provides an overview; 2) details violence prevention programs; and 3) provides workplace violence program checklists for hospitals, residential and non-residential treatment settings, community care, and field work.

‍American Hospital Association (AHA)’s resource clearinghouse for workforce and workplace violence prevention includes: 

• The AHA Framework for hospital and health systems leadership to build safe communities and the American Organization for Nursing Leadership and Emergency Nurse Associations’ Guiding Principles for Mitigating Violence in the Workplace
• The Tennessee Hospital Association’s Developing a Workplace Violence and Prevention Program which includes recommendations, self-assessment tools, and case studies to aid in identifying root causes and risk factors and develop programs. 
• AHA’s Advancing Health podcast with episodes that include Protecting Health Care Workers from Being Targets of Violence, Combating Workplace Violence in Health Care by Creating Safer Workplaces, and Codes of Conduct – An Approach to Reducing Workplace Violence 

‍American Society for Health Care Risk Management: Risk assessment toolkit, including a readiness survey and checklist to assist with both proactive and reactive responses to patient-staff violence, visitor/family-staff violence, staff-staff violence/harassment, physician/third-party profession-staff violence/harassment, and nonemployee-staff violence. 

ECRI Institute: Policy and Procedure Builder: Workplace Violence Prevention Program is a template for developing workplace violence prevention programs including sample policy language and definitions.

‍Minnesota Department of Health: Sample forms and policy language for health care systems and facilities to create effective policies, including:

• Reporting mechanisms (an example of developing a data collection instrument and sample Excel workbook for incident tracking)
• Incident response (staff after care checklist and sample incident response form)

Resources for creating effective anti-bulling policies, including: 

• Nurses Service Organization
• American Nurses Association
• National Institute for Occupational Safety and Health (NIOSH) interactive course
• American Association of Critical Care Nurses position statement on bullying

‍Spotlights

‍Grady Memorial Hospital: Through a risk assessment, the hospital identified both operational and staff needs to improve workplace safety. These strategic priorities were created with a group of stakeholders, including clinic and executive leadership. Changes include increased visibility of public safety officers, de-escalation training for officers and staff, access cards, Schwartz Rounds, and peer responders to incidents to support affected staff. 

‍Bristol Health: To decrease workplace violence, Bristol Health replaced contracted security with an in-house team, added panic buttons in the emergency department, and implemented leadership team rounds after incidents to check in with staff (Support Our Staff teams). These changes have resulted in only 24 incidents in 2022 compared to 152 in 2019. 

‍New York-Presbyterian: The health system created the Behavioral Health Emergency Reponses Team (BERT) to intervene in workplace violence incidents when de-escalation tactics have failed. Using new IT infrastructure, the system uses a violence risk assessment tool to flag potential risk for clinicians using electronic medical records of patients.

‍Inova Health: Describes the Safety Always for Everyone (SAFE) Team, debriefing policies after an incident, and crisis prevention training. Since implementing these changes, violence within emergency departments has decreased by 60%.

‍UC Health: Created behavioral health rounders, non-nurse clinicians who intervene with at-risk patients and provide guidance to staff in developing mitigation strategies for violent incidents.

‍References

¹ Pompeii LA, Schoenfisch AL, Lipscomb HJ, et al. Physical assault, physical threat, and verbal abuse perpetrated against hospital workers by patients or visitors in six U.S. hospitals. Am J Ind Med. 2015;58(11):1194-1204.

² Bureau of Labor Statistics, US Department of Labor. Nonfatal Injuries and Illnesses Resulting in Days off Work among Nurses up 291 Percent in 2020. May 6, 2022.

³ Baig LA, Tanzil S, Shaikh S, et al. Effectiveness of training on de-escalation of violence and management of aggressive behavior faced by health care providers in a public sector hospital of Karachi. Pak J Med Sci. 2018;34(2).

⁴ Ming JL, Huang HM, Hung SP, et al. Using Simulation Training to Promote Nurses’ Effective Handling of Workplace Violence: A Quasi-Experimental Study. IJERPH. 2019;16(19):3648.

⁵ Al-Ali NM, Al Faouri I, Al-Niarat TF. The impact of training program on nurses’ attitudes toward workplace violence in Jordan. Applied Nursing Research. 2016;30:83-89.

⁶ Arnetz JE, Hamblin L, Russell J, et al. Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med. 2017;59(1):18-27.

⁷ Hamblin LE, Essenmacher L, Luborsky M, et al. Worksite Walkthrough Intervention: Data-driven Prevention of Workplace Violence on Hospital Units. J Occup Environ Med. 2017;59(9):875-884.

⁸ Duffy M. Preventing workplace mobbing and bullying with effective organizational consultation, policies, and legislation. Consulting Psychology Journal: Practice and Research. 2009;61(3):242-262.

⁹ Richards J, Daley H. Bullying policy: Development, implementation, and monitoring. In: Einarsen S, Hoel H, Cooper C, eds. Bullying and Emotional Abuse in the Workplace: International Perspective in Research and Practice. Taylor & Francis; 2003.

¹⁰ Woodrow C, Guest DE. When good HR gets bad results: exploring the challenge of HR implementation in the case of workplace bullying: Implementation of workplace bullying policy. Human Resource Management Journal. 2014;24(1):38-56.

¹¹ D’Cruz P, Noronha E. Organizational Governance: A Promising Solution for Varieties of Workplace Bullying. In: Ashkanasy NM, Härtel CEJ, Zerbe WJ, eds. Research on Emotion in Organizations. Vol 12. Emerald Group Publishing Limited; 2016:409-444.

Stigma is a barrier for health workers and learners seeking mental health care; and concerns regarding licensure, confidentiality, perceived ability to perform their work, time constraints, and lack of access to services have been identified as further barriers. Recognizing mental health and stress/trauma are on a continuum, we address mental health screening and treatment here and stress/trauma and resilience in another section. Organizations can address mental health by:

• Reducing stigma through open discussion around mental health and well-being
• Establishing a culture of mental health and changing policies to create supportive environments 
• Increasing screening and services for mental health issues, considering the need for confidentiality

‍Evidence

Healthcare organizations are just beginning to build workplace cultures that better support health workers’ mental health. Thus, there is little research about which policy changes are effective in protecting workers’ mental health. Though most healthcare organizations offer access to mental health services through an Employee Assistance Program (EAP), utilization rates for EAPs across industries are quite low due to some of the barriers listed above.¹ When EAP services are utilized, there is evidence that employees experience decreased stress and increased engagement and satisfaction.^2,3 Evidence for the effectiveness of system-wide, anonymous screening tools is limited, though organizations with such programs are reporting positive outcomes.⁴ 

While limited, one study of a single institution "opt out" well-being assessment visit for physician residents found 93% attended appointments and residents reported an increased likelihood of using the faculty and staff assistance program in the future.⁵

‍Resources

Impact Wellbeing provides an overview of NIOSH’s mental health initiative for healthcare workers and describes why health workers may experience mental health problems. A related NIOSH webpage details training and resources on health workers and their mental health. 

‍American Psychiatric Association Foundation’s Center for Workplace Mental Health provides several resources related to employee mental health in the workplace, including:

• Mental Health Works Guide, a comprehensive guide for employers to plan a workplace mental health initiative as well as other resources for employers to support workers’ mental health. 
• Frontline Connect: Mental Health for the Healthcare Workforce, a high-impact video toolkit that highlights effective strategies for healthcare leaders to improve access to mental health care. The toolkit includes information on suicide prevention, licensure & credentialing, physician health programs, and clinician culture competency training, and more.

World Health Organization’s e-tool has a dedicated page for Psycho-social risks and mental health for health workers and included both organizational and individual-level interventions. 

‍Suicide Prevention: Evidence-Informed Interventions for the Health Care Workforce, a report offered by the American Hospital Association, offers evidence-informed interventions that hospitals and health systems can implement for suicide prevention among health workers. 

The Dr. Lorna Breen Heroes’ Foundation recommends three steps that medical boards, hospitals, and health systems can take to reduce stigma and remove intrusive mental health questions from credentialling in its Remove Intrusive  Mental Health Questions from Licensure and Credentialing Applications toolkit. 

‍Health Systems Making Suicide Prevention a Priority, an interview with the American Foundation for Suicide Prevention’s (AFSP’s) Christine Moutier and Maggie Mortali, discusses programs and tools that support health workers.

‍Five Steps to Increasing Utilization of Your Employee Assistance Program: This short article outlines five steps one company took to increase their EAP utilization rate: 1) Make the program easily identifiable with distinct brand and logo; 2) Train managers on how to access EAP services and to start dialogue around EAP use; 3) Ensure Confidentiality; 4) Communicate availability of services; 5) Hold annual meetings with EAP providers and other stakeholders

‍Spotlights

‍In an executive letter that went out to all employees, Dr. Gigrah, Chief Wellness Officer at Ochsner Health, shared reflections about his own mental health and acknowledged that he had sought help. This letter was the “most-opened executive letter” and he received overwhelmingly positive responses from employees and other executive team members.

‍Allina Health recently earned the Platinum Bell Seal for Workplace Mental Health from Mental Health America. The Bell Seal is a national certification program that recognizes employers committed to creating mentally healthy workplaces.

‍Hartford HealthCare Focuses on Employee Well-Being and Mental Health is a short news clip that discusses the interventions and programming that Hartford HealthCare implemented early in the pandemic, including the development of a well-being app for their workers.

‍Carilion Clinic provides on-site counselors who round with the staff can offer just in time support as needed. 

‍References

¹ Attridge M. Profile of Small Employers in the United States and the Importance of Employee Assistance Programs During the COVID-19 Pandemic. Am J Health Promot. 2022;36(7):1229-1236.

² Attridge, Mark;, Sharar, David A., DeLapp, Gregory P, Veder, Barb. EAP Works: Global Results from 24,363 Counseling Cases with Pre-Post Data on the Workplace Outcome Suite (WOS). International Journal of Health & Productivity. 2018;10(2):7-27.

³ Bondar J, Babich Morrow C, Gueorguieva R, et al. Clinical and Financial Outcomes Associated With a Workplace Mental Health Program Before and During the COVID-19 Pandemic. JAMA Netw Open. 2022;5(6):e2216349.

⁴ Kanellopoulos D, Solomonov N, Ritholtz S, et al. The CopeNYP program: A model for brief treatment of psychological distress among healthcare workers and hospital staff. General Hospital Psychiatry. 2021;73:24-29.

⁵ Sofka S, Grey C, Lerfald N, Davisson L, Howsare J. Implementing a Universal Well-Being Assessment to Mitigate Barriers to Resident Utilization of Mental Health Resources. J Grad Med Educ. 2018;10(1):63-66.

Healthcare and public safety work is inherently stressful because the well-being of others is at stake and unpredictable, urgent, and emergent situations often arise. Organizations are: 

• Establishing programs for workers to communicate about and receive support around occupational distress, grief, and mental health challenges in the workplace
• Providing psychoeducational interventions to strengthen individual mindfulness and resilience

‍Evidence

Many current health worker and learner wellness programs are psychoeducational programs that focus on recognize, understanding, and managing stress (e.g., mindfulness and resilience training). A 2020 Cochrane Review found that resilience training may increase resilience and reduce depression and stress symptoms immediately post-intervention, but evidence of their effectiveness remains limited and uncertain, largely because of methodological challenges (e.g., small sample sizes, missing post-intervention follow-up).^1,2 Reviews of resilience training/curriculum for learners have similarly seen mixed results and reported similar study limitations.^3,4

However, there are some single-exposure well-being interventions that have shown success with reducing emotional exhaustion, happiness, and work-life balance.⁵ the randomized-control trial of a web-based implementation for the science of enhancing resilience (WISER) intervention designed to treat burnout showed that a brief intervention can reduce emotional exhaustion and depression and produced a lasting effect through the 6-month post-intervention follow-up.⁶

Studies also suggest there is significant gap between resources workers and learners are asking for and the support offered by organizations,² and workers report their well-being is related to other aspects of the work environment such as team processes, working conditions, communication, and staffing.⁷ Resources are most successful and well-received by health workers and learners when they meet professional and personal needs as well as open channels for communications between workers/learners and leadership.⁸  

‍Resources

The U.S. Department of Veterans Affairs National Center for PTSD features Stress First Aid, a framework to improve recovery from stress in self and others. The American Medical Association (AMA) also provides a STEPS Forward module on Stress First Aid for Health Care Professionals. 

‍The Vicarious Trauma Toolkit (VTT) by the U.S. Department of Justice Office of Victims of Crime includes tools and resources tailored specifically to the fields of victim services, EMS, fire, and law enforcement. It provides the knowledge and skills necessary for organizations to address the vicarious trauma needs of their staff. 

‍The Schwartz Center is “working to support caregivers, healthcare leaders and others and bring compassion to every healthcare experience.” Their organization created Schwartz Rounds, which are sessions in which care team members can discuss the emotional impact of caring for patients and their families. Though most of the research on Schwartz Rounds is focused on participant experience rather than the effectiveness of the interventions, a recently published realist evaluation identified the mechanisms behind Schwartz Rounds and conditions needed for the intervention to work optimally. 

How to Get Employees to (Actually) Participate in Well-Being Programs by Carolina Valencia in the Harvard Business Review provides three recommendations on how organizations can increase utilization and engagement of wellness programming. 

‍Resources from the literature:

• Kim et al. provide A Scoping Review of Vicarious Trauma Interventions for Service Providers Working With People Who Have Experienced Traumatic Events. This review examines the effectiveness of vicarious trauma interventions.
• Parsons et al. review Evidence-Based Interventions that Promote Resident Wellness from the Council of Emergency Residency Directors.
• Dyrbye and Shanafelt provide A narrative review on burnout experienced by medical students and residents, including interventions recommended in the literature.

‍Spotlights

‍Northwell Health Center for Traumatic Stress, Resilience, and Recovery (CTSRR) is a partnership among the department for occupational medicine, behavioral health service department, and human resources that surveys the well-being of their workforce annually, runs the Stress First Aid peer support model for health workers, and regularly assesses psychological services offered to clinical staff after traumatic incidents.  

‍The Care for the Caregiver peer support program at Christiana Care  was designed to support clinicians who have experienced trauma from an adverse event in the workplace.

The UC San Diego Health Education Assessment and Referral (HEAR) Program is an example of an anonymous screening, assessment, and referral program coupled with an educational school-wide campaign on physician burnout, depression, and suicide. 

A case study of Resilience in Stressful Events (RISE) describes this evidence-based peer support program for health workers that began at Johns Hopkins Hospital.

‍References

¹ Kunzler AM, Helmreich I, Chmitorz A, et al. Psychological interventions to foster resilience in healthcare professionals. Cochrane Developmental. Cochrane Database of Systematic Reviews. 2020;2020(7).

² Robins-Browne K, Lewis M, Burchill LJ, et al. Interventions to support the mental health and well-being of front-line healthcare workers in hospitals during pandemics: an evidence review and synthesis. BMJ Open. 2022;12(11):e061317.

³ Van Der Riet P, Levett-Jones T, Aquino-Russell C. The effectiveness of mindfulness meditation for nurses and nursing students: An integrated literature review. Nurse Education Today. 2018;65:201-211.

⁴ Seo C, Corrado M, Fournier K, Bailey T, Haykal KA. Addressing the physician burnout epidemic with resilience curricula in medical education: a systematic review. BMC Med Educ. 2021;21(1):80.

⁵ Adair KC, Rodriguez-Homs LG, Masoud S, Mosca PJ, Sexton JB. Gratitude at Work: Prospective Cohort Study of a Web-Based, Single-Exposure Well-Being Intervention for Health Care Workers. J Med Internet Res 2020;22(5):e15562

⁶ Profit J, Adair KC, Cui X, et al. Randomized controlled trial of the “WISER” intervention to reduce healthcare worker burnout. J Perinatol. 2021;41(9):2225-2234.

⁷ Halms T, Strasser M, Papazova I, et al. What do healthcare workers need? A qualitative study on support strategies to protect mental health of healthcare workers during the SARS-CoV-2 pandemic. BMC Psychiatry. 2023;23(1):195.

⁸ David E, DePierro JM, Marin DB, Sharma V, Charney DS, Katz CL. COVID-19 Pandemic Support Programs for Healthcare Workers and Implications for Occupational Mental Health: A Narrative Review. Psychiatr Q. 2022;93(1):227-247.