Total Worker Health

Abstract

Total Worker Health™ is defined as a “strategy integrating occupational safety and health protection with health promotion to prevent worker injury and illness and to advance worker health and well-being.” This strategy aligns workplace safety with individual behaviors that support healthy lifestyles. The Patient Protection and Affordable Care Act of 2010 presumes that incentive-oriented worksite health promotion provides a critical pathway to reduce group health costs. Because of their scientific and clinical backgrounds, professional nurses are well qualified to educate and assist individuals with healthy lifestyle choices. Occupational health nurses and patient advocates can shape wellness initiatives that best serve both employees and their employers.

Introduction to Total Worker Health™ (TWH)

Evidence supporting the integration of employee wellness and health promotion with safety in the workplace has grown over the past 30 years (Merchant, Lind, Kelly, & Hall, 2013). The 2004 National Institute for Occupational Safety and Health (NIOSH) Steps to a Healthier U.S. Workforce Conference influenced the foundation of the WorkLife Initiative, which became the TWH Program in 2011 (Merchant et al., 2013). TWH is defined as a “strategy integrating occupational safety and health protection with health promotion to prevent worker injury and illness and to advance worker health and well-being” (NIOSH, 2013). This strategy supports the development of programs that align workplace safety with individual behaviors that encourage healthy lifestyles. The American College of Occupational and Environmental Medicine (ACOEM) explains that components of workplace health and promotion programs include efforts that are strategic, integrated, and systematic, bringing together environmental and safety policies that prevent work-related injuries with activities that enhance the overall health and well-being of workers (Prank, 2013).

The NIOSH website is replete with information on interventions consistent with TWH. One example is the provision of mandated respiratory protection programs that simultaneously and comprehensively address and provide support for tobacco cessation. Another intervention is the development of stress management efforts that first seek to diminish workplace stressors, and only then work on building worker resilience. Another is the implementation of training and prevention programs that counter both occupational and non-occupational hazards and risks potentially faced by workers. NIOSH also encourages development of models that combine occupational health services with workplace primary care (NIOSH, 2013).

Hypertension, obesity, and smoking are major contributing factors to serious chronic diseases such as heart disease, stroke, diabetes, pulmonary disease, and cancer. The TWH concept recognizes the platform available for disease and injury prevention through the workplace. Occupational health providers can educate and motivate working adults to take responsibility for reducing health and safety risks by modifying their behaviors. Most working adults spend more waking hours at work than anywhere else, which offers a logical venue to encourage healthy lifestyle choices. Successful implementation of TWH is mutually beneficial to the employer and the employee.

How Does TWH Benefit Employers and Employees?

Rising health care costs affect individuals and society as a whole, including employers. Many employers report a competitive disadvantage in global markets due to the high cost of insurance premiums, workers’ compensation claims, absenteeism, and reduced worker productivity (Centers for Disease Control [CDC], 2013a). By implementing evidence-based strategies demonstrated to effectively change unhealthy behaviors and improve health outcomes, workplace wellness programs not only improve worker health but also control health care expenses. A 1% reduction in excess weight and elevated blood pressure, glucose, and cholesterol has been shown to save US$83 to US$103 per person annually in health care costs (CDC, 2013a).

Employers also have a role in curbing employee obesity by offering workplace wellness programs, facilitating opportunities for physical activity at work and access to healthy food and beverage choices as well as incentivizing weight loss and healthy behaviors (CDC, 2013a). Individuals rarely change behaviors without substantial reasons that outweigh the challenges of change. Incentives can provide that motivation (Hall, 2008).

Investment in workplace wellness programs demonstrates to employees that companies value them as assets, stimulating employee efforts to maintain physical and mental health. Wellness programs have been shown to improve morale and increase employee appreciation of their companies (MacDonald & Westover, 2011). Committed employees are more likely to perform at their best and enhance the growth of their companies, and less likely to move on to other opportunities.

Programs with the highest return on investment (ROI) have in common a low per person annualized cost. Cost-effectiveness ratios may be relevant for evaluating interventions in terms of health benefits, but ROI is essential for decision makers (Cherniak, 2013). After a review of experimental studies, literature review articles, and committee reports, Prank (2013) concluded that sufficient evidence exists to support the theory that integrated workplace health promotion generates improvement in worker health. Although emerging evidence indicates that health promotion may generate positive productivity outcomes, the evidence base for health care cost reduction is considered insufficient (Prank, 2013). Furthermore, research over longer periods of time is needed to fill this gap. It is worth noting that even though workers improve their health and lower their risks of chronic diseases, the full benefit of health-related changes is often bestowed upon future employers or during retirement. For instance, employees may engage in employer-sponsored health promotion programs and successfully lose weight or lower blood pressure and blood sugar. If employees subsequently change employers or retire, the lower cost of their subsequent health care would be appreciated by a new insurance carrier or Medicare. Each worker, of course, is the greatest beneficiary of lifestyle changes. By lowering their risks for diabetes, hypertension, and heart disease, workers enjoy a more active and healthy life following retirement.

What Are the Essential Elements?

The NIOSH TWH website lists several components to a successful TWH program, including management commitment, safety culture/climate, culture of health, hazard recognition training, and worker empowerment. These components have long been recognized as essential occupational health and safety program components; however, improving overall health and well-being of workers adds another dimension.

As with any business improvement plan, adopting wellness initiatives requires the employer to invest the cost of time and dollars to TWH. Besides stimulating company leadership to take control of their own health, when they invest in improving worker health, they may also increase company profits. CDC (2013a) has reported a financial ROI when embracing TWH, with a decrease in health care costs and an increase in worker productivity.

Developing a culture of safety is a challenging undertaking. Involving all levels of the workforce in TWH is crucial to gaining organizational support. If the majority of employees are focused on safely executing their responsibilities, occupational injuries and illnesses can be substantially reduced (CDC, 2013a). The message from leadership must be clear: Safety shortcuts or workarounds are not acceptable. Training all employees to recognize and mitigate hazards is essential to creating a safe workplace.

Promoting a culture of health is a step beyond a culture of safety. Personal health has previously been off limits to employers, remaining confidential. However, health challenges can be addressed professionally, without threatening individual workers’ employment. Occupational health nurses can address personal health issues confidentially, without disclosing personal health information to employers. While focusing on improving overall health and well-being of employees for their own benefits, occupational health nurses can also recognize the benefit of improving worker health to the organization, reducing overall health care costs by lowering insurance premiums, decreasing worker absenteeism, and improving worker productivity.

When management commits to a workplace culture centered on safety and health, workers are empowered to improve their own well-being (CDC, 2013a). When employees realize that workplace health and safety are company expectations, these expectations overshadow the notion of completing the job, regardless of cost. Recognizing employees for their health and safety ideas and accomplishments further empowers employees to work safely.

The University of Pittsburgh Medical Center Health Plan and WorkPartners developed an integrated strategy called the Employer Health and Productivity Roadmap™. They recognized the core drivers of excessive health care costs and lost productivity related to obesity, physical inactivity, and tobacco use. The goal was to achieve maximum efficiency, effectiveness, and employee focus for their workforce and dependents. The elements of the “roadmap” included optimizing the environment (i.e., building a culture of safety and health), increasing healthy behaviors, minimizing avoidable or inefficient acute care, optimizing chronic disease care, reducing excessive surgery, and speeding transitions from care to home and work (Parkinson, 2013). The roadmap is energized by providing incentives for participation in comprehensive health management programs and choosing healthy behaviors. Alignment of healthy behaviors and care engagement with health care cost transparency and financial incentives can accelerate improvements in worker health, appropriate health care use, and economic savings (Parkinson, 2013).

What Has Worked

The TWH website includes a section called “Promising Practices for Total Worker Health™.” The website features organizations that have taken steps to effectively integrate worker health protection and health promotion (CDC, 2013b). New information is added to the site quarterly, and CDC welcomes organizations to report their success stories for publication.

Statistical Analysis Systems (SAS) is a software company in North Carolina. The owner of the company, Jim Goodnight, has been a front-runner in creating a balanced work–life for SAS employees. His philosophy is that “an environment that encourages creativity and innovation while allowing employees to balance work and life” creates the optimally productive environment (MacDonald & Westover, 2011). The campus of SAS includes a 66,000 square foot fitness center, a health care facility, and a daycare center. Healthy food choices are subsidized in the onsite cafe. With this environment, SAS has a turnover rate of less than 3% in an industry, which averages a 26% turnover rate nationally (MacDonald & Westover, 2011).

Dartmouth-Hitchcock is an academic medical center in New Hampshire with more than 8,000 employees working at several sites. When leadership recognized that their healthcare costs for employees and their dependents were taking nearly 10% of the medical center’s budget, it was time to take action. The medical center adopted, as part of their corporate vision, a commitment to having the healthiest workforce possible. The strategic priority, Live Well/Work Well (LWWW), was created with its mission to create a culture of worker health, safety, and well-being (CDC, 2013b).

Domtar and 3M were recognized for their hearing protection programs. Their programs went beyond the usual comprehensive occupational hearing loss prevention program, including hearing conservation during family and community recreational activities (CDC, 2013b). Erickson Living and BJC HealthCare are organizations that serve senior health care. They recognized that they could offer similar preventive health care strategies for their employees as the ones they offer their patients. Ohio’s Bureau of Workers’ Compensation created a fund to award grants to companies who were developing health promotion programs. They recognized that 25% to 39% of the adult population in Ohio were considered obese. To reduce workers’ compensation claims as well as improve the health of Ohio citizens, the Bureau committed to this venture.

At a conference titled “The Weight of the Nation” in 2012, speakers identified several strategies employers could implement to address worker obesity and physical inactivity. One strategy was to encourage physical activity as part of the workday. For some companies, encouraging physical activity might mean providing walking paths on campus, motivational signage for taking the stairs or moving during the workday or adjustable desks for standing to complete some work tasks, or scheduling walking meetings. Another initiative was to offer healthy vending choices. Making a healthy choice the easy and affordable choice is a winning strategy. Partnering with vendors to offer wellness promotions or using services available from insurance carriers can both be effective strategies to improve worker health. Some employers have partnered with community-based organizations (e.g., Boys and Girls Clubs and United Way) to reach the community (Lankford, Lang, Bowden, & Baun, 2013).

Implications for Occupational Health Nurses

The TWH concept is a change in dynamic for occupational health nurses. The focus changes from being worker- and workplace-centered to citizen- and community-centered (Sepulveda, 2013). This strategy requires occupational health nurses to apply a systems approach that has been used successfully in the workplace and extending the strategy to families and communities. The Patient Protection and Affordable Care Act of 2010 encourages incentive-based worksite health promotion programs to reduce group health costs (Cherniak, 2013). Evidence exists to support the health outcomes of this integrated model, but more research is needed to build the business case for employers of all sizes and industry types to adopt TWH (Prank, 2013).

Because of their scientific and clinical backgrounds, occupational health nurses are well qualified to educate workers and coach them through lifestyle changes. A financial institution in Chicago in 2009 engaged the services of two nurses to provide counseling for their employees after they completed health risk assessments. To achieve successful outcomes, the nurses used familiar elements of the nursing process: assessment, planning, intervention, and evaluation. The employees completed online heath risk assessments. The nurses analyzed the aggregate data, identifying the most frequent health risks and preparing written materials to distribute in addition to private, in-person counseling sessions. The subsequent surveys completed by participants indicated that 68% of those workers who returned their surveys found the service very useful or extremely useful. The remainder of the workers were equally divided between neutral and somewhat useful. Only 21% reported that they had not made any changes in their health-related behaviors after counseling (Carlson & Murphy, 2010).

Occupational health nurses have the opportunity to influence employers to launch health and wellness programs. The TWH program has outlined elements to increase the success of these initiatives. The elements include securing leadership support, developing a culture of safety and health, and empowering workers. Workers can use these tools to make healthy choices, the affordable, easy, and attractive choices. Employers can identify high-risk groups among their employees and tailor programs to address those particular issues. By generating interest and enthusiasm in health-related topics and challenges, occupational health nurses can motivate employees to take their personal health seriously and make needed improvements in their lifestyles. By affecting employees, occupational health nurses can extend information and motivation to workers, their families, and their communities.