Workplace Health Programs In the Long Term Care Setting

Employers and employees in Long Term Care settings face many unique issues and challenges related to workplace health. Demographically, the employee population is aging. A large percentage of employees are female, and many of them face caregiving responsibilities at home as well as at work. Some will have pre-school children, while others are members of the "sandwich generation" who, in addition to their work responsibilities, must provide care and support to aging parents as well as their children.

There are a variety of occupational health and safety hazards in the Long Term Care setting. Included are such things as: heavy lifting, biological hazards, workplace violence, shiftwork, stress, exposure to chemical agents, slips and falls, and repetitive strain injuries.

Statistics indicate that health care settings have an increased incidence of employee absence compared to other industries. In Canada, in 1998 (Akyeampong, Statistics Canada, 1999) an estimated 5.7% (525,000) of full-time employees were absent from work for all or part of any given week for personal reasons. The average full-time employee lost 7.8 days over the year - 6.6 days for illness or disability and 1.2 days for personal or family responsibilities. Absence levels vary by demographic group, industry, occupation and province. By industry grouping, full-time workers in the health care and social assistance industry lost the most days (12.8). Workers in health occupations lost 13.4 days.

In the United States, the average cost of unscheduled absenteeism in 1999 was $602 per employee (CCH, 1999). The US Bureau of Labor Statistics (1994) reports that the incidence of occupational injury and illness cases per 100 full-time workers in nursing homes in the US for 1994 was 16.8 compared to 8.4 in private industry. The incidence rate of lost workdays per 100 full-time nursing home workers in 1994 was 8.4 compared to 3.8 in private industry.

To combat rising costs of workplace absences, many employers recognize the importance of providing an environment that supports and promotes employee and family health through the implementation of workplace health programs. Workplace health programs provide the opportunity to reach individuals as well as the overall workplace population. Programs that are integrated rather than operating in isolation are most effective (Pender, 1996).

Factors Affecting Workplace Health

Employee and organizational health are affected by many factors. Underlying factors that account for the differences in employee absence from the workplace include such things as (Akyeampong, 1999):

• Family circumstances - especially the presence of preschool-aged children;
• The physical health of the worker, which is frequently related to age;
• Work environment (size of organization, nature of work);
• Degree of job stress;
• Employer-employee relations;
• Union coverage (union - 11.4 days lost vs. 6.0 for non-union);
• Work schedules; and Benefit plan design.

Health Canada has identified other factors contributing to employee absenteeism. As part of their workplace health system, a nonrandom needs assessment of 50,000 employees from large companies seeking to improve their workers" health was conducted. The results provided insight into the relationships between health, work and home environments, health practices, and personal resources supporting health. (Health Canada, 1998) The results of this assessment indicated that as many as 86% of employees reported being concerned about the physical environment at their workplace. In looking at the social environment at work, the results indicated that three-quarters of Canadian workers experience stress due to the social environment at work.

Employee concerns were related to:

• Job demands (52%);
• Job related changes (33%);
• Management practices (28%);
• Lack of job control (25%);
• Interpersonal relations (18%); and
• Other aspects of the social environment at work (29%).

Other areas that impact the health of employees include: home life concerns and balancing work and home life; health practices, including such things as activity, smoking, alcohol use and medication use; and personal resources.

A 1999 Canada @Work study, conducted by Aon Consulting in partnership with the Royal Bank, examined 35 potential drivers of employee commitment. The results indicate that the organizational factor that most significantly affects workforce commitment is management's recognition of the importance of personal and family life (Aon, 1999).

Canadians are recognizing the importance of maintaining a healthy work-life balance, and have increased expectations for support from their employers.

Canadian Public Health Association (CPHA, 1992) defines health as "a state of complete physical, mental, social and ecological wellbeing." O'Donnell (1995) defines optimal health as "a balance of physical, emotional, spiritual, intellectual and social health."

Overall determinants of health are defined in Health Canada's Strategies for Population Health (1994) as factors that impact on the health of individuals. These are outlined as:

• Income and Social Status;
• Social Support Networks;
• Education;
• Employment and Working Conditions;
• Physical Environments;
• Biology and Genetic Endowment;
• Personal Health Practices and Coping Skills;
• Healthy Child Development; and
• Health Services.

Several determinants relate to the workplace and can be impacted by workplace health programs.

Benefits of Workplace Health Programs

Effective workplace health programs benefit both the employees and the organization. Some recognized benefits to the employer include:

• Communication to employees that they are a valuable asset;
• Decreased absenteeism equals decreased costs;
• Decreased health care costs;
• Decreased costs for hiring and retraining;
• Increased productivity and less disruption of processes;
• Retention of skilled workers;
• Positive environment and employee relations.

Benefits to the employee include:

• Enhanced well-being;
• Ability to be productive and continue earning a living;
• Decreased stress related to the ability to return to work if ill/injured;
• Maintenance of self-esteem and emotional well-being;
• Supportive environment for healthy behaviours;
• and Positive employee/employer relations.

Who is Involved in Workplace Health Programs?

The success of workplace health programs depends on the participation of all stakeholders from the initial planning stages. Senior management commitment is essential to the success of the program. This must be demonstrated through actions, as well as within written policies and procedures that support the program. Also critical is the participation and involvement of employees and unions (where applicable). Employees are much more likely to support and participate in programs when they have input into the planning and development stages, and feel "ownership" of the program.

Other stakeholders in workplace health programs may include: supervisors and managers, human resources personnel, benefits personnel, labour relations, Employee Assistance professionals, internal and external health care providers, occupational health professionals, safety professionals, and insurance providers.

Workplace Health Programs

The principles of workplace health programs are the same in all settings; however, programs must be developed to meet the needs of the organization and employees of the specific workplace setting. An overview of the most common workplace health programs is provided below.

Wellness/Health Promotion Programs

The key to the success of all workplace health programs is to create a culture that supports healthy activities and behaviours, and a move towards both personal and organizational health. Workplace wellness or health promotion programs may provide many activities and cover areas such as nutrition, exercise, fitness, medication usage, blood pressure and cholesterol screening, cancer prevention.

O'Donnell (1995) outlines three levels of health promotion:

Level I: Awareness

Increases the participant's level of awareness or interest in the topic of the program. Examples of awareness activities include newsletters, posters, flyers, health fairs, educational classes, weekend retreats, and health screening without feedback and follow-up.

Level II: Lifestyle Change

Goes a step beyond awareness by setting lifestyle-related behaviour change as the desired outcome. Changes may include: quitting smoking, exercising on a regular basis, successfully managing stress, eating more nutritious foods, or losing weight. According to O'Donnell, the most successful lifestyle change programs use a combination of health education, behaviour modification, experiential practice, and feedback opportunities.

Level III: Supportive Environment

The goal at this level is to create an environment within the work setting that encourages a healthy lifestyle. This is critical to helping people maintain their lifestyle changes. Creating an environment that supports healthy lifestyle behaviours can include:

• Changes in the physical environment (showers, workout area; healthy food in vending machines and cafeteria; no smoking);
• Corporate policies such as flexible work schedules, medical care coverage, nonsmoking policy;
• Corporate culture which encourages employee's involvement in the workplace health programs;
• and Employee ownership of the program.

The most effective workplace health program combines all three levels.

B. Occupational Health and Safety Programs

A health and safety program is "a definite plan of action designed to prevent accidents and occupational diseases." (CCOHS, October, 1998). In Canada, some form of occupational health and safety program is required in most jurisdictions under Provincial (Occupational Health and Safety Acts) or Federal (Canada Labour Code) legislation.

In the United States, the Occupational Safety and Health Administration (OSHA) sets the standards to protect employees" health and safety. Internationally, the International Labour Organization (ILO) and the World Health Organization (WHO) work hand in hand to protect the workforce and to ensure health and safety at work (WHO, 1999).

Employers are responsible for ensuring the health and safety of their workers. Key components of all occupational health and safety programs are:

• A company health and safety policy and management commitment;
• Hazard identification;
• Hazard control;
• Ongoing work site inspections;
• Worker competency and training;
• Emergency response planning;
• Incident reporting and investigation; and
• Program administration.

Alberta Human Resources and Employment, Partnerships

Several resources exist to assist Long Term Care facilities in establishing health and safety programs specific to their needs. In the United States, OSHA has published a "Framework for a Comprehensive Health and Safety Program in Nursing Homes" which may serve as a useful reference in the development or revision of health and safety programs in Long Term Care. In Canada, other resources exist including the "Long Term Care: Health and Safety Program Guidelines (April, 1997)" developed by the Alberta Long Term Care Association (ALTCA).

C. Disability Management Programs

Disability management can be defined as "an active process of minimizing the impact of an impairment on the individual's ability to compete in the workplace." (Shrey & Lacerte, 1995) The goal of disability management is to return the employee to work in a timely and safe manner - preferably to their pre-injury/ illness job. A comprehensive disability management program will incorporate the components outlined in the model. [Graphic: Umbrella of a Disability Management Program (Dyck, 2000)]

In Canada, Provincial and Federal Human Rights legislation exists that prohibits discrimination against persons with a physical or mental disability in employment practices; employment applications or advertisements; or in trade unions, employers" organizations or occupational associations. There is a "duty to accommodate" ill or injured workers back into the workplace.

D. Employee Assistance Programs

An Employee Assistance Program (EAP) provides confidential professional assistance to employees (and often their families) to help them resolve problems that affect their personal lives, and in some cases their job performance. In 1996, a Conference Board of Canada survey found that 80% of companies surveyed had an EAP in place. Studies indicate that between 14% to 20% of any organization's work force is dealing with personal problems that could affect work performance. A study by the Conference Board of Canada (MacBride- King & Bachmann, 1999) found that almost half of Canadians are experiencing a moderate to high level of stress today as a result of trying to balance their work and home lives. Factors affecting the employee's health and ability to work may include:

• Marital and Family Discord
• Psychological Stress
• Work Related Problems
• Alcohol and Drug Dependencies
• Grief and Bereavement
• Life Style Problems
• Traumatic Distress
• Retirement Issues and Problems
• Elder Care/Child Care
• Certain Financial or Legal Problems
• Career Transition Adjustment

It is estimated that 10-15% of employees experience one of these types of problems.

Providing a confidential EAP allows employees to obtain assistance at an early stage and can prevent workplace absences. EAPs provide support for supervisors and management as well by removing responsibility for the employee's personal problems from the supervisor.

EAPs may be developed in-house, through external providers, or a combination of both. External models are generally more accessible to small and medium sized employers, as they may be less costly. (Gilbert, 1994) As with all workplace health programs, EAPs must be designed to meet the needs of the specific workplace and both employers and employees.

E. Benefits Programs

Effective workplace health programs must be integrated with, and supported by, the employee benefits design and funding. Effective health benefits programs should provide:

• Funding and administration of the workplace health priorities;
• Cost-effective service providers and underwriters;
• Benefits which are flexible and adaptable to the organization's changing and future needs;
• Management of the costs of employee absenteeism and disability;
• Tax effective coverage and compliance with regulatory and legislative requirements; and
• Minimum administrative and financial burdens associated with implementing and maintaining the benefit plans.

How to Develop and Implement Workplace Health Programs

To develop workplace health programs, one recommended approach for companies is to adopt a preparation strategy. This strategy assists the organization in determining the current and desired states of workplace health and identifies any existing gaps.

The steps of the preparation strategy are outlined as follows:

1. Conduct a Review

A review of programs, policies and procedures, and organizational structure is completed.

2. Identify the Current State

Areas to consider in assessing your current state include: determining the corporate mission, values and goals; the level of support for the program from senior management, unions, supervisors, employees and other related departments; what programs are currently in place; what providers are currently in place; the effectiveness of current programs and relationships; the organization's perceived needs; the prevalence of risk; current habits within the organization; socio-demographic characteristics; current costs of services; and utilization rates for existing programs.

3. Identify the Desired State

Once the current state has been determined, it is important to define what you want. Areas to consider include: the level of support for the program; the level or type of program that you want; what resources are available (realistically); what are the identified priorities; what initiatives will have the most impact; whether internal or external providers will be used; and how you will measure success. Questions to ask when identifying the "Desired State":

• What are others in our situation doing? (Benchmarking, Best Practices)
• How do we assess our internal capabilities?
• What should we provide for our employees?
• How can we reduce costs?
• How can we control the rate of future cost growth?
• What is the corporate culture?

4. Identify Gaps

Once you have identified your current and desired state, you can identify the gaps between the two. Gaps may include such things as: lack of or inadequate programs, policies and processes; the inability to identify issues and act upon them; training requirements; relationship issues (are stakeholders working together? Are there conflicts?); communication gaps; or lack of performance measures.

5. Develop Strategies to Reduce the Gaps: How Will You Achieve Your Goals?

When working in partnership with all stakeholders, it is important to develop clear goals, objectives and processes for your program. This includes clearly defining the roles and responsibilities of participants in the programs. Expectations must be communicated to all stakeholders.

6. Implement and Monitor the Program

Critical to the success of the implementation phase is communication of the program to all stakeholders. Once the program is implemented, it must be monitored on an ongoing basis.

7. Evaluate the Effectiveness of the Program

Program evaluation should be outlined in the planning stages of the program. It is important to benchmark the performance measures at the beginning and the end of the program to determine its success. Areas to consider include the determination of the degree to which the program outcome measurements meet the program goals, objectives, and targets; the effectiveness of the program; employee and supervisor satisfaction with the program; and the return on investment.

Success REQUIRES...

The success of workplace health programs requires the cooperation and commitment of all stakeholders including senior management, front line supervisors, employees, Unions (if applicable), Human Resources, Occupational Health and Safety professionals, Employee Assistance professionals, benefits, external health care professionals, and insurance providers. For programs to be successful, health must become a "value" of the organization. (Nagel, Schmitz & Cutt, 1998)

Employers and employees in the Long Term Care setting face many challenges in maintaining a safe and healthy workplace. An integrated health strategy in the workplace can meet both individual and corporate agendas, resulting in decreased absenteeism, increased productivity and increased profitability as well as increased employee morale and a positive and healthy working environment. Creating a culture that promotes and supports employees in maintaining their personal health, benefits both the individuals and the organization.