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The health care sector is large, employing around 10% of workers in the European Union . The health and social work sector is the sector with the largest rise in employment between 2009 and 2017 with over 2.6 million new jobs. Hospitals are the primary employer of health care workers, while other employers include medical practices, nursing homes and other health care domains such as blood banks or medical laboratories . The evidence indicates that mental health issues are of increasing concern in the health care sector and a number of initiatives have been implemented to address these issues. This article provides an overview of the factors which pose a threat to the mental health of workers in the sector and identifies and evaluates interventions used for promoting the mental health of health care workers.
Many of the settings in which health care workers (HCWs) carry out their jobs and the multiplicity of tasks they perform can present a great variety of hazards which makes it absolutely vital that health and safety is a priority in this sector. Yet results from the EU labour force survey show that the percentage of workers who report exposure to factors that adversely affect mental well-being rose from 25% in 2007 to 28% in 2013 (average for all workers, all sectors). Exposure to time pressure or overload of work was most often selected as the main risk factor (23,3%), followed by harassment or bullying (2.6%), and violence or threat of violence (2.2%). While exposure to factors affecting mental health substantially varies across sectors, exposure occurred most often in the sector ‘health and social work’ with 40.6% of the workers in the sector reporting to risk factors affecting their mental health .
Mental health is described by the World Health Organization  as ‘a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’. In this positive sense, mental health is the foundation for well-being and effective functioning for an individual and for a community. Mental health and mental illnesses are determined by multiple and interacting social and psychological factors , including psychosocial hazards, which are prevalent in all workplaces. Psychosocial risks refer to the likelihood that work-related psychosocial hazards will have a negative impact on employees’ health and safety through their perceptions and experience  .
Psychosocial risk factors
Many work-related psychosocial hazards exist. Those which are typical for the health care sector  include amongst others:
- high demands combined with insufficient time, skills and social support
- time pressure (e.g. in emergency departments)
- dealing with difficult clients/patients, including complaints and possible litigation as well as violence at work
- harassment (also referred to as bullying or mobbing) exposure to traumatic events
- confrontation with pain
- dealing with dying people
Prevalence and incidence of psychosocial risks
The sixth European working conditions survey (EWCS 2015) reveals the prevalence for some of the hazards faced by healthcare workers. The findings from the survey highlighted that 14% of health care workers report that they never/rarely have time enough to do their job. This is the highest score compared to the other sectors (figure 1). Furthermore a fairly large proportion of workers in the health care sector (44%) report having to hide their feelings and hiding or suppressing feelings may result in psychological strain. The data also indicates that the health care sector is amongst those sectors where the largest proportion of workers report having to deal with angry clients and emotionally disturbing situations.
Prevalence of stress
All major European employee and employer surveys as well as several national studies highlight the prevalence and incidence of stress, harassment and violence in the health care sector. The Europe-wide establishment survey on new and emerging risks (ESENER 2019) highlighted that psychosocial risk factors are reported more often in the health sector than in other sectors (table 1). These results are in line with findings from workers’ surveys in Europe  .
Table 1 – Reported psychosocial risk factors (% of establishments) – ESENER 2019
|Human health and social activities||All sectors|
|Pressure due to time constraints||58%||45%|
|Poor communication or cooperation within the organisation||28%||18%|
|Fear of job loss||11%||13%|
|Having to deal with difficult customers, patients, pupils etc.||84%||60%|
|Long or irregular working hours||31%||22%|
An EU-OSHA report  summarises these trends and prevalence of work-related stress and related outcomes in terms of sectors and occupation. It finds that trends are similar for harassment and third-party violence as for stress. The report also highlights that the risk is substantially higher in several occupational sectors, amongst them health care and social work. A study carried out among doctors in Slovenia revealed that 37% of them feel they are exposed to high stress at work, whereas 40% reported moderate stress. The reasons given for high stress levels were related to work duties, high demands and responsibility at work, work with patients who were ‘a nuisance’, high numbers of patients, having to report bad news about patients’ health and dealing with death. Physicians employed in the public sector were at highest risk of experiencing stress at work .
Prevalence of harassment and violence
The health and social sector also has the highest reported exposure to harassment and violence at work in the EU-28. Data from the sixth European working conditions survey (2015) indicates that the health sector reported the highest percentage of workers subjected to all of the adverse social behaviour indicators, with the exception of workplace threats, which was found to be highest in public administration. Respondents of the sixth EWCS were asked if they had been exposed to different forms of adverse social behaviour in the month prior to the study or within 12 months prior to the study. The results show that one out of 5 respondents in the health sector experienced verbal abuse (20%) in the month prior to the study. They were also confronted with other forms of adverse social behaviour:
- unwanted sexual attention (3%), humiliating behaviour (8%), threats (7%) (% of the respondents in the health sector, question on forms of adverse social behaviour in the month prior to the study);
- physical violence (7%), sexual harassment (2%) and bullying/harassment (9%) (% of the respondents in the health sector, question on forms of adverse social behaviour in the month prior to the study).
Studies in Denmark have shown that professions most likely to be exposed to violence are social educators in residential care units, and nursing staff in hospitals and nursing homes . Elsewhere in Europe, research from Finland , Poland , Ireland  and Latvia  show that employees of the health services face higher than average levels of risk for physical violence or threats from clients/patients. A study carried out in 2016 in 5 European countries (Poland, the Czech Republic, the Slovak Republic, Turkey, and Spain) assessed physical and non-physical acts of workplace violence towards nurses working in the health sector. 54% of the respondents stated that they had been exposed to non-physical violence and 20% had been exposed to physical violent acts. The most common perpetrators were patients and patients’ relatives. In about 70% of these cases, no actions were taken after the act of violence to investigate its causes. 1 out of 2 respondents indicated that they did not report workplace violence as they believed it was useless or not important. This shows that workplace violence is often seen by nurses as an occupational hazard and, as such, it remains not reported. Acknowledgement of workplace violence is the first and important step towards prevention.
According to the fourth European working conditions survey, the risk of experiencing harassment is highest in the health care where over 8% of the respondents had experienced harassment at work during the last 12 months as compared to the EU-27 average of 5% . National studies also indicate similar trends. A study carried out by the Confederation of Independent Bulgarian Trade Unions in 2000 indicated that that 38.1% of the nurses questioned had experienced one form of harassment. Other national surveys showed that in Finland 5% of healthcare employees perceived harassment , while in Denmark this was 3% for hospital employees .
Impact of psychosocial hazards on mental and physical health of health care workers
There is strong evidence to indicate an association between work-related health complaints and exposure to psychosocial hazards and to an interaction between physical and psychosocial hazards, to an array of health outcomes at the individual level  and at the organisational level . Specifically, psychosocial risks, including harassment and violence in the workplace have been demonstrated to have a possible detrimental impact on workers’ physical, mental and social health . A number of studies have examined the impact of exposure to psychosocial hazards, including harassment and violence, on mental health of health care workers.
The findings from the fifth European working conditions survey highlighted that health care workers were more likely to report that their work affects their health negatively  and poor mental health can further lead to injuries, decline in productivity, increase in errors etc. For instance, in a study to explore the impact of poor mental health on nurses across eight general hospitals in Tokyo, nurses classified as being in ‘mentally poor health’ reported significantly higher rates of medical errors as compared to those nurses classified as ‘mentally in good health’ in relation to: drug-administration errors, incorrect operation of medical equipment, errors in patient identification, and needlestick injuries .
A review of research on the effects of long working hours on the performance and health of junior hospital doctors found that a significant proportion of newly qualified doctors develop some degree of psychological ill health. It was concluded that this may be related to sleep loss which probably increases doctors’ vulnerability to other work hazards . Another study found a direct link between the number of hours worked and stress levels and indicated that despite having access to higher levels of effective social support, junior hospital doctors faced significantly greater sources of stress and poorer mental health than their senior counterparts . Research examining the relationship between specialist doctors’ mental health and their job stress and satisfaction, as well as their job and demographic characteristics reported that while job satisfaction significantly protected consultants’ mental health against job stress, feeling overloaded, and its effect on home life; feeling poorly managed and resourced; and dealing with patients’ suffering, were associated with both burnout and psychiatric morbidity . Another study found that even after the effects of personal vulnerability to psychiatric disorder and on-going social stress outside of work had been taken into account, stressful situations at work contributed to anxiety and depressive disorders in healthcare professionals .
Several studies show that healthcare workers and especially nurses are more likely to develop stress and burnout. Overall, satisfaction with job demands, control, support and role clarity are lower in the health sector - especially among nurses in comparison with other professional groups and this is strongly linked to stress and burnout. Burnout is a syndrome that can be specifically linked to work-related factors. The World Health Organisation (WHO) describes burnout as follows:
Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:
- feelings of energy depletion or exhaustion;
- increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and
- reduced professional efficacy.
Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.
Impact of harassment and violence
Harassment and violence in the workplace has been shown to be linked to mental and physical health problems , associated with behavioural effects such as for example social withdrawal, substance abuse, increased irritability, and an increased risk of suicide . A Finnish study of more than 5 000 hospital staff found that those who had been bullied had 51 % more certified sickness absence than those who were not bullied, when figures were adjusted for base-line measures one year prior to the survey . In a study on the threats and violence in the Swedish health care sector indicated that feelings of anger, irritation, sadness, frustration and helplessness but also minor physical injuries were frequent reactions to violence in healthcare and welfare sector .
Furthermore, studies have also shown that the targets of bullying use sleep-inducing drugs and sedatives more often than those not bullied . A study from the United States examining past-year substance use amongst registered nurses (balanced stratified sample n = 4438) reported their use of marijuana, cocaine, and prescription-type drugs, as well as cigarette smoking and binge drinking was 32%, the authors also reported that other studies estimate that 2% to 3% of all nurses are addicted to drugs and that 40,000 nurses or 2.5% of all nurses in the United States suffer from alcoholism . A review study further reported that physicians are also at high risk for substance abuse, where at least 8% to 12% of physicians in the US, develop a substance abuse problem during their career and at any given time, as many as 7% of practicing physicians - 1 out of every 14 - are active substance abusers . The impact of substance abuse is severe. In addition to causing negative effect on a worker’s own health, being ‘under influence’ of drugs or alcohol can cause medical malpractice, put patients and other colleagues in danger and finally can also lead to lawsuits.
A pan-European study involving 10 countries on identifying factors leading premature departure from the nursing profession showed that, between 2002 and 2003, exposure to frequent violent events was highest amongst nurses from France (39%), the United Kingdom (29%), and Germany (28%) and one of the key factors leading to staff turnover . During 2007/08 in the United Kingdom, the National Health Service (NHS) estimated that physical violence against NHS employees cost the NHS £60.5 million, of this nearly £30 million (70.9 million and 35 million Euro respectively) was attributed to the costs associated with staff quitting the NHS as a direct response to assault incidents .
The Luxembourg Declaration  on Workplace Health Promotion (WHP) states that WHP “can be achieved through a combination of improving work organisation and the working environment, promoting active participation, and encouraging personal development." The EU-OSHA further emphasises that “there is no point in implementing a WHP programme without also offering a safe and healthy working environment. WHP is based on a healthy culture first of all requiring proper risk management." Mental health promotion is ‘the process of enhancing protective factors that contribute to good mental health’  . The European Pact for Mental Health and Well-being recommends implementation of the mental health and well-being programmes with risk assessment and prevention programmes for situations that can cause adverse effects on the mental health of workers (stressful work environment, abusive behaviour such as violence or harassment at work, substance abuse) and early intervention schemes at workplaces . These interventions need to focus on areas to be improved, both on individual level (person-directed) and on organisational level (work-directed). It is important to build a working culture in which mental health issues are not taboo. In order to reduce psychosocial risk factors and promote mental health in the health care sector, different types of interventions exist. They are outlined in the following sections.
Interventions directed at factors at work, or work-directed interventions typically contain measures to change the working environment and work organisation (work tasks or working methods) . Interventions at organisational level are aimed at changing the structure of the organisation and/or at changing physical and environmental factors. These interventions try to reduce negative elements in the work organisation. These interventions are meant to eliminate the causes of stress at work . Stressors can be monitored through a psychosocial risk analysis. The analysis will show which elements in the organisation (at task, team or organisational level) are critical and need improvement. Examples of organisational level interventions in the health care sector include :
- improved staffing levels during peak hours; this enables a reduction in workloads, improvements in organising shifts, and absence and contingency cover;
- specifying functions and responsibilities; for example, in nursing auxiliaries, for dispensing assistance with medication, and assistance and backup for providing treatment;
- establishing a communication protocol for those situations that, in the opinion of the workers, could pose risks to their health and safety;
- introducing a degree of discretion in carrying out some tasks, under the guidelines set by the corresponding department, to certain groups of workers to improve autonomy and decision-making;
- promoting worker participation through meetings, enabling them to contribute suggestions, ideas and opinions.
Interventions focusing on people, or person-directed interventions, aim at teaching personal skills, techniques or remedies to decrease the effects of stressors at the individual level. For example, interventions aimed at mitigating the effects of stress by relaxation techniques or cognitive-behavioural techniques that increased coping skills, without changing the work environment or work tasks . These interventions try to increase the workers’ resources and their ability to tackle stress. The employer should invest in interventions to increase the coping capacity of his employees, for example via training. However it’s important to mention that interventions at organisational level should always come first and only when there is no solution or no way to totally eliminate certain risks, individual level interventions should be considered. Examples of such interventions include :
- improving relationships between colleagues and managers at work;
- establishing support groups;
- improving person-environment fit;
- clarifying role issues;
- increasing participation and autonomy;
- training to enhance employees’ self-esteem and self-worth, sense of belonging;
- learning coping strategies;
- cognitive-behavioural training;
- a Mindfulness-based stress reduction programme: this programme consists of a training to improve communication skills, learn how to deal with stress reactions, self-compassion;
- training to improve practical skills to reduce stress, to improve relation and functioning with patients, and coping with violent behaviours;
- staff training in coping with situations experienced such as death, pain and the terminally ill.
Effectiveness of interventions
Detailed studies on evaluation of stress interventions are scarce, both the evaluation of the cost-benefits as well as the evaluation of effectiveness of individual stress reduction measures . Some of the key methodological deficiencies and limitations observed in the literature relate to research design, outcome measures, follow-up period and process evaluation and it is not always possible to determine clearly which outcomes are the actual results of an intervention . Taking these limitations into consideration systematic meta-analyses and qualitative analyses of studies on mental health promotion interventions in the healthcare sector conclude that that organisational interventions reduce the levels of stress, burnout, and general ill health symptoms while person-directed interventions among health care workers effectively reduce the levels of burnout, anxiety, and stress  .
Training has been found to be an effective intervention. The results of one study  showed that psychosocial training (e.g., about attitudes and communication skills) reduced stress when compared with no intervention. Another study showed that, when compared with six weeks of cognitive–behavioural training, having refresher sessions at 5, 11, and 17 months led to significantly lower emotional exhaustion and lack of personal accomplishment after two years and reduction in burnout . Other studies  also indicate that person-directed interventions significantly reduced anxiety when compared with no intervention. It has also been found that a combination of training knowledge and skills and individual programme-planning decreased general symptoms of psychological distress .
Organisational interventions such as increased worker participation, and support provided by managers have also reported to be effective in reducing stress and improving general health. According to a study , support and advice given by nurse managers or quality-care coordinators reduced burnout symptoms. An evaluation of a caregiver support programme which was designed to increase participation and social support in work-related decision-making for caregiver teams in (mental) health care facilities indicated that the programme effectively increased the ability of teams of caregivers to mobilise socially supportive team behaviour and problem-solving techniques which strengthened participants’ belief and perception that they were able to cope with disagreements and overload at work, and enhanced the team climate, mental health and job satisfaction .
While traditionally, stress prevention and management initiatives have exclusively focused on one type of intervention, the evidence indicates that to successfully prevent and manage work-related stress, intervention strategies should comprehensively incorporate elements work-directed and person-directed interventions. Specifically, they should address the root causes of work-related stress (primary prevention); provide training to managers and employees on stress management in order to reduce its impact (secondary prevention); and, for those that have suffered ill health as a result of work-related stress, provide them with resources to manage and reduce their respective effects (tertiary prevention) .
In 2002, the International Labour Office, International Council of Nurses, World Health Organization and Public Services International published through a joint programme on workplace violence in the health care sector the framework guidelines for addressing workplace violence in the health sector . The guidelines should be considered a basic reference tool for stimulating the autonomous development of similar instruments specifically targeted at, and adapted to, different cultures, situations and needs. Beyond these guidelines, more specific interventions to tackle violence and harassment in the health care sector are needed.
On an organisational level the following interventions can be taken :
- information and education on harassment (bullying, mobbing) and its consequences;
- guidelines — containing information on the nature and extent of the problem and its effects on health and quality of life;
- code of ethics — charter with indications that the company will not tolerate violence, harassment, unethical acts and discrimination;
- employment contracts — terms should be included in the contracts, regulating the matter and applying sanctions for any breach of the rules.
- developing a human-centred workplace culture and issuing a policy statement in which is clearly stated that violence or aggression against health care staff is not tolerated; all parties involved should be aware of the policy: patients, employees and managers;
- commitment to prevent violence and harassment;
- clear information and communication;
- conduct risk assessments on violence, aggression and harassment at work;
- environmental control: securing safety by using effective technology and procedures (e.g. alarm systems, create distance between client/patient and staff by using a deeper counter, etc.);
- information on necessary precautions, on increased risks with certain patients, etc.
- establishing procedures for reporting and recording of all incidents of violence and aggression.
On an individual level the following steps can be taken :
- pre-incident training of staff on how to recognize actual or possible threats in the workplace; training of staff on how to react in violent situations.
- assistance and support (through designated confidantes, colleagues or managers)
- conflict resolution and mediation assistance
- to recognise the aggression, and, if necessary, to modify their own behaviour
- grievance procedures;
- debriefing (e.g. by establishing consciousness-raising groups that bring together people who have suffered from violence or harassment in different situations. Sharing similar experiences in a group allows the targets to realise that they are not the ones responsible for the event)
- rehabilitation for staff who were victim of a violence incident.
Evidence from the workplace case studies strongly suggests that implementing a mental health programme in the workplace has a great potential to generate economic returns and improve the mental health of the workforce . However, due to the range of programmes and the different methodologies applied, no consistent evidence was found in the literature to support any one particular type of programme or approach. It’s important to find the best fitting approach according to the establishment’s characteristics. Smaller entities, like e.g. a doctor’s surgery need a different approach from large companies like e.g. hospitals.
Comprehensive mental health promotion interventions exist, though often organisations do not pay equal attention to all intervention levels . In order to implement a good mental health promotion policy, any organisation needs to approach this topic from a holistic point of view by implementing actions on all levels with both employers and employees working together . As the causes of mental ill health are multifactorial (e.g. a combination of staffing issues, workloads, work organisation issues and physical working conditions) all of these causes need to be tackled together for an intervention to be effective .
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