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In 2019, Cypress Creek EMS was presented with the Gold Plus Award from the American Heart Association for cardiac care. It's the second year in a row CCEMS has received this honor, which is fitting since CCEMS was formed due to a tragic lack of prehopsital cardiac care as you will read below.
When Cypress Creek EMS (CCEMS) was first established in 1975, the region's main thoroughfare, FM 1960, was a poorly maintained, two-lane asphalt road, offering mostly four-way stop signs at its few major intersections. The nearest strip shopping center was miles away and there were no malls nearby. To dine in a fine restaurant, residents drove twenty miles or so into Houston. However, the area was blessed with a promising new medical facility, the Houston Northwest Medical Center, which had opened its doors in 1973. The founding physicians were convinced that the area, which at the time had no local health facilities, offered tremendous growth potential. They were correct. Their foresight offered a growing population what soon became a wide range of inpatient, outpatient, and diagnostic imaging services close to home...and set the stage for CCEMS.

As is frequently the case, a personal tragedy provided the impetus for action. A dedicated husband and community leader lost his life to heart failure because there was no emergency medical team to come to his aid. After anxious neighbors called for help, they waited in vain while their loved one died in the arms of his wife...a needless death that instigated support, first by his neighbors, then in his subdivision, and finally, throughout the community.

Convinced that such misfortune could be avoided by prompt treatment, a group of concerned friends and neighbors banded together and took action. In July 1975, their incalculable hours of planning finally culminated in the founding of CCEMS, an organization which became dedicated to providing 24-hour skilled emergency medical care to the FM 1960 community. The organizers staffed its single ambulance with volunteers...in the beginning, mostly themselves. Notably - to this day - volunteers are an important and essential portion of the organization.

Since its founding, CCEMS has saved countless lives and promoted more rapid recoveries with quality emergency care, making our area a safer place to live. Not surprisingly, the delivery of emergency medical services has become much more complex than the original organizers could have imagined. Still, these pioneer forward-thinkers and their surrogates have been quick to revamp and broaden CCEMS's mission, upgrading its role when needed to meet the challenges of a burgeoning population on the northern periphery of Houston, the nation's fourth-largest city.

As predicted by the Northwest Medical Center founders, Northwest Harris County, the sprawling, unincorporated area served by CCEMS, has experienced explosive growth.

"Our service area has a sprawling population comparable (in size) to cities like Baltimore or Philadelphia," CCEMS Executive Director, Brad England notes.

Without the existence of a municipal government to plan, fund and deliver critical emergency services to a large and growing population, local residents had to depend on their own organizational designs to provide fire protection, emergency medical services, and law enforcement; thus, early corporate leaders who commuted into Houston by day found themselves donating precious "family-time" evenings to the intricacies of governing subdivisions and solving neighborhood problems.

The read more about the history of Cypress Creek EMS click here.

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In 2019, Cypress Creek EMS was presented with the Gold Plus Award from the American Heart Association for cardiac care. It's the second year in a row CCEMS has received this honor, which is fitting since CCEMS was formed due to a tragic lack of prehopsital cardiac care as you will read below.

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Lori L. Boland, MPH, *† Tyler G. Kinzy, MS,* Russell N. Myers, BCC,* Karl M. Fernstrom, MPH, † Jonathan W. Kamrud, NREMT-P,* Pamela J. Mink, PhD, MPH, † and Andrew C. Stevens, MD*

Abstract

Introduction

Very little quantitative data on occupational burnout and exposure to critical incidents are available from contemporary United States emergency medical services (EMS) cohorts. Given that burnout has been associated positively with turnover intentions and absenteeism in EMS workers, studies that uncover correlates of burnout may be integral to combating growing concerns around retention in the profession.

Methods

We administered a 167-item electronic survey that included the Maslach Burnout Inventory (MBI) and a modified version of the Critical Incident History Questionnaire (n=29 incident types) to paramedics, emergency medical technicians (EMTs), and dispatchers of a single ambulance service. We defined the presence of burnout as a high score on either the emotional exhaustion or depersonalization subscales of the MBI.

Results

Survey respondents who provided regular 911 response at the time of the survey and completed the MBI portion of the survey were included in our analysis (190 paramedics/EMTs, 19 dispatchers; 54% response). The overall prevalence of burnout was 18%, with prevalence reaching 32% among dispatchers. The seven pediatric critical incident types presented in the survey accounted for seven of the top eight rated most difficult to cope with, and severity ratings for pediatric critical incidents did not differ by parental status (all p>0.30). A significant number of respondents reported that they had been threatened with a gun/weapon (43%) or assaulted by a patient (68%) at least once while on duty. Being over the age of 50, a parent, or in a committed relationship was associated with reduced odds of burnout in unadjusted models; however, these associations did not remain statistically significant in multivariate analysis. Increasing tertile of career exposure to critical incidents was not associated with burnout.

Conclusion

Medical dispatchers may be an EMS subgroup particularly susceptible to burnout. These data also demonstrate quantitatively that in this EMS agency, responders find pediatric critical incidents especially distressing and that violence against responders is commonplace. In this study, a simple measure of career exposure to potentially critical incidents was not associated with burnout; however, individual reactions to incidents are heterogeneous, and assessment tools that more accurately enumerate encounters that result in distress are needed.

INTRODUCTION

The physical and emotional toll of emergency medical services (EMS) work has been acknowledged for several decades, ⁻ and likely contributes to turnover in the profession., Occupational stress in EMS is attributed to a number of factors including performance in potentially hostile or hazardous environments, repeated exposure to traumatic situations, the physical demands of the occupation, the strains of shift work, and the organizational and leadership stressors spawned by the hierarchical cultures prevalent in EMS.,

Occupational burnout has been documented extensively in emergency physicians, and nurses and has been linked to lower quality of care, but less is known about the prevalence and determinants of burnout in EMS clinicians, particularly those currently practicing in the United States (U.S.). With the exception of two recent reports,, existing studies on burnout in U.S. EMS providers are more than two decades old.,,, More recent studies from other parts of the world have examined burnout in EMS workers, ⁻ using the Maslach Burnout Inventory (MBI), the current gold standard for measurement of occupational burnout. Burnout has been associated positively with turnover intentions and absenteeism in cohorts of U.S. EMS workers;, thus, empirical studies to uncover correlates of burnout may be integral to combating growing concerns around retention in the profession and optimizing quality and workforce engagement among EMS workers.

The potential for the development of post-traumatic stress symptoms in EMS personnel after exposure to critical incidents (CI) is well established,, ⁻ and such exposures therefore likely influence provider wellbeing. However, research on the effects of CI exposure on emergency responders has largely focused on post-traumatic stress disorder (PTSD) or other clinically manifest symptoms (e.g., sleep disturbance), and have been conducted in relation to singular sentinel events such as mass casualty incidents or large-scale disasters. The scope and impact of cumulative exposure over the span of an EMS career to smaller scale events that are experienced more frequently but are still potentially disturbing has not been well described.

As part of a provider wellbeing initiative, we conducted a survey among the paramedics, emergency medical technicians (EMTs) and dispatchers in our ambulance service for the purposes of evaluating aspects of general mental wellbeing, informing refinement of support resources, and contributing to generalizable knowledge about mental wellbeing among EMS professionals. In addition to demographics, the survey included the MBI and a comprehensive inventory of exposure to CIs, which provided data about the career frequency and severity rankings for 29 CI types. The objectives of this study were to (1) determine the prevalence of burnout, (2) describe the relative career frequency and perceived severity of specific critical incident types, and (3) examine the association between burnout and a variety of provider factors, including demographics and cumulative exposure to CIs. We hypothesized that increasing cumulative exposure to CIs would be associated with increased levels of burnout.

What do we already know about this issue?

Occupational burnout is common in emergency physicians and nurses, but little is known about the prevalence in emergency medical services (EMS) workers.

What was the research question?

What is the prevalence of burnout in our agency, what clinician factors are associated with burnout, and what critical incident types are perceived as most difficult?

What was the major finding of the study?

The overall prevalence of burnout in our agency was 18%, and reached 32% among dispatchers. Calls involving pediatric patients were rated most difficult.

How does this improve population health?

Reducing burnout in EMS workers may improve quality of care for patients and improve retention in the profession.

METHODS

Setting and Study Design

This cross-sectional survey was conducted at Allina Health EMS, a large ambulance service that provides 911 dispatch, advanced life support, basic life support and scheduled medical transport in approximately 100 communities in and around Minneapolis-St. Paul, Minnesota. The agency employs paramedics, emergency medical technicians (EMT), dispatchers, and support staff, and responds to just over 110,000 calls annually across a service area that covers 1,800 square miles. Crew configuration for all 911 responses in this system is indiscriminately paramedic-paramedic or paramedic-EMT; therefore, exposures and work environment are considered identical for the two certification classes and they have been analyzed in aggregate (hereafter paramedics).

In 2012, we emailed a 167-item electronic survey to all agency employees (n=479) regardless of role. The survey included assessments of occupational burnout and a variety of potential risk factors including demographics, social support, coping style and exposure to CIs. A penultimate draft was field-tested in a small number of paramedics employed by other ambulance agencies in the area who reported that the length and content was acceptable. Employees were told that the survey was voluntary and that there would be no individual follow-up. As an indirect incentive, each respondent was given the opportunity to designate one of three charities to receive a $10 donation on behalf of the ambulance service for their participation. The specific instruments used to assess burnout and exposure to CIs are described below. Additional details about the survey design and methods are available in " Supplemental Material." The study protocol was approved by the Allina Health Institutional Review Board with voluntary completion of the survey constituting informed consent.

Measures

We assessed occupational burnout using the 22-item MBI-Human Services Survey. The MBI quantifies three dimensions of the burnout syndrome: emotional exhaustion (EE; 9 questions), depersonalization (DP; 5 questions) and reduced personal accomplishment (PA; 8 questions). Survey questions are stated as job-related feelings such as " I feel emotionally drained from my work." Respondents indicate how often they feel this way with responses given on a scale from 0 (never) to 6 (every day), yielding the following ranges for the subscales: EE=0-54, DP=0-30, and PA=0-48. In addition to continuous subscale measures, we used previously described cutpoints based on normative U.S. data to define low, moderate, and high values on each scale (i.e., for EE, ≤16=low, 17-26=moderate, ≥27=high; for DP, ≤6=low, 7-12=moderate, ≥13=high; for PA, ≤31=low, 32-38=moderate, ≥39=high)., Finally, a dichotomous construct was created, with burnout deemed present in those with a high score on the EE or DP subscale. This definition has been used by others, ⁻ but approaches to using MBI subscales to determine the presence or absence of burnout are not consistent.

We assessed exposure to CIs during EMS work using a modified version of the Critical Incident History Questionnaire (CIHQ). The CIHQ was initially developed for use with law enforcement officers, but similar to a previously described approach, it was modified in this application by altering or removing items not relevant in EMS work. For example, " Made a mistake in the line of duty that led to the serious injury or death of a fellow officer" was replaced with " Made a mistake that led to the injury/death of a patient." In addition, we added four pediatric incident types and items about mass casualty incidents, severe burn victims, and responding to incidents involving family/friends. The instrument also included two items related to violence against providers. The final instrument consisted of 29 CI types and indexed two dimensions of exposure - frequency and severity. For each incident type, the respondent was asked to estimate how many times during their career as a paramedic/dispatcher they had encountered that situation, using response categories of Never, 1, 2, 3,...9, 10-20, 21-50, or 50+. They were also asked to rate the severity of the incident type by answering the question " In your opinion, how difficult would it be for paramedics/EMTs/dispatchers to cope with this type of incident?" with ordinal responses ranging from 0 ( Not at all) to 4 ( Extremely).

The survey also contained basic demographic items including age, gender, current relationship status (single/not in a committed relationship, married/partnered), and parental status (yes, no). Respondents indicated their current position as Paramedic - Field staff, Paramedic - Supervisor/Manager, Dispatcher, Paramedic - Support staff (administration, education, clinical services etc.), interfacility transfer personnel, or other, with the first three categories used to identify the subset of respondents that provide regular 911 response. EMS tenure reflects the total number of years providing 911 response and/or direct patient care as a paramedic or dispatcher.

Data Analysis

We summarized characteristics of the study participants and burnout measures using proportions (categorical variables) or means and standard deviations (continuous variables). Mean frequency and severity ratings for each of the 29 CI event types were computed and rank ordered to examine which event types were encountered most frequently and which were perceived as most difficult for providers. We examined crude prevalence of burnout across categories of a variety of provider characteristics, including age, gender, and EMS tenure. To examine cumulative career exposure to CIs as a risk factor for burnout, we summed the reported number of experienced incidents across all 29 event types for each respondent, with the response categories "10-20," "21-50," and "50+" assigned midpoint values of 15, 35.5, and 51, respectively. Tertiles of this measure of cumulative career frequency of CIs representing low, moderate, and high levels of exposure were then used in analysis. We used logistic regression to generate crude odds ratios of burnout in categories of provider characteristics and tertiles of cumulative CI exposure. Adjusted odds ratios were computed using multivariate logistic regression models that included all variables that had statistically significant univariate associations with burnout, i.e., age category, parental status, relationship status, provider role, and response setting. We performed all statistical analyses using Stata version 14.1 (StataCorp LP, College Station TX, USA).

RESULTS

The overall survey response rate across all agency roles was 56% (266/479). We used human resources data to compare demographic characteristics of respondents with those of the target population where available, and the distributions of age, gender, years in current position and primary work setting among respondents closely reflected those of the agency as a whole.

At the time of the survey, 399 employees regularly provided 911 response, 217 of whom returned the survey (54% response). Among those 217, n=209 had complete data for the MBI and were used in this analysis. The average age in the analysis sample was 40, 60% were male, approximately two-thirds were parents, and 75% reported being married/partnered (). Slightly more than half reported they had been working in EMS for > 10 years, with nearly one third having an EMS tenure of 20+ years.

Table 1

The overall prevalence of professional burnout in this cohort was 18% (). Using cutpoints derived from a normative U.S. sample, 6% and 15% of respondents scored high on the emotional exhaustion and depersonalization subscales, respectively, while 56% scored low on the dimension of personal accomplishment.

Table 2

Survey respondents indicated that they perceived CIs involving children to be among the most difficult to experience and cope with. All seven of the pediatric incident types presented in the survey had very high average severity ratings, and accounted for seven of the top eight event types rated most difficult to cope with (). There was no difference in the mean severity ratings assigned by parents vs. non-parents for any of the seven pediatric incident types (all p>0.30). A strong inverse correlation of r = −0.72 (p<0.001) was observed between average severity rating and average reported career frequency across the 29 incident types. Using the median average severity rating (2.52) and the median average career frequency (3.92) to dichotomize incident types into high vs. low severity, and high vs. low frequency, four incident types emerged as being "high-frequency, high-severity" events: encountering a child that has been accidentally killed; encountering a child that has been severely injured; encountering a sudden infant death; and responding to a scene involving family/friends known to the crew. A significant number of respondents reported that they had been threatened with a gun/weapon (43%) or assaulted by a patient (68%) at least once while on duty during their EMS career.

Table 3

Severity Rating Mean (SD)

Career Frequency Mean (SD)

The prevalence and odds ratios of burnout by provider characteristics and exposure to CIs are presented in . In univariate models, being over the age of 50, a parent, or in a committed relationship was associated with reduced odds of burnout. Dispatchers were at increased risk of burnout as compared to paramedics. This difference was not statistically significant, likely due to the small number of dispatchers in the analysis; however, the survey response rate among dispatchers was very high (76%; 19/25). There was no significant association between increasing tertile of cumulative career exposure to CIs, and burnout. Associations remained directionally consistent in a multivariate model, but none of the examined factors could be characterized as independently associated with burnout as all 95% confidence intervals included 1.0.

Table 4

DISCUSSION

Burnout

Burnout has been linked to lower quality of care in other healthcare occupations;, therefore, understanding burnout and its correlates in EMS professionals may have implications for optimizing experience and outcomes for persons treated in the prehospital setting. The overall prevalence of burnout in this cohort was 18%, with particularly high levels of burnout occurring in dispatchers (32%), and in clinicians who did not have children (26%), or were not in a committed relationship (28%). Only 5% of providers over the age of 50 in our sample appeared to be experiencing burnout.

Two early studies that used the Burnout Scale for Health Professionals found burnout among EMS providers was more prevalent than in other healthcare professionals in the U.S., Two recent surveys conducted in U.S. paramedics and EMTs captured burnout measures using the Oldenburg Burnout Inventory and the Copenhagen Burnout Inventory., One reported a work-related burnout prevalence of 30% in paramedics and 19% in EMTs, and both found burnout was associated positively with turnover intentions and absenteeism., In the only prior report of MBI data from a cohort of U.S. paramedics, mean scores for EE, DP, and PA were 19.2, 9.3, and 28.1, respectively. MBI data from ambulance personnel outside the U.S. have been reported,,⁻, but variability in defining burnout as a dichotomous construct makes inter-study comparisons difficult. Among Scottish ambulance personnel, the prevalence of high DP and high EE were 26% and 20%, respectively. Burnout among Dutch paramedics has been estimated at only 8.6%, but this prevalence is still higher than the 5.3% observed in a sample of the general working population in the Netherlands.

Occupational burnout in large samples of employed physicians and the general working population of the U.S. has been estimated at 38% and 28%, respectively, both considerably higher than our observed overall prevalence of 18%. Recent MBI data from primary care physicians in our own health system revealed a burnout prevalence of 38%. While our paramedics appear to experience burnout at a comparatively low rate, the level of burnout among our dispatchers approaches the alarming level documented in physicians and exceeds that of the general working population of the U.S. Hypotheses about why burnout may be more prevalent among dispatchers in our agency include the high call volume and lack of "downtime" during shifts, stresses associated with operational accountability for a large number of crews and vehicles across an expansive coverage area, and the relatively sedentary environment. Dispatchers rarely have intervals void of incoming calls, whereas paramedics will often have some respite between patient encounters. To our knowledge, these are the first published data on dispatcher burnout, and studies in larger samples of this occupational subgroup are needed to elucidate whether this finding is unique to our agency.

Critical Incidents

Symptoms of PTSD (e.g., intrusive memories, nightmares) occur in 10% of rescue workers worldwide, and estimates in EMS responders are consistently higher than those in firefighters and police officers. Logically, exposure to CIs has received a great deal of scrutiny as a primary contributor to the development of PTSD in rescue workers, with studies primarily focused on examining stress reactions after specific large-scale or widely-publicized events. But cumulative exposure to smaller-scale traumatic incidents outside the realm of extraordinary events may be equally deleterious, and examination of the full continuum of CI exposure in EMS workers is needed. The development of a comprehensive inventory to assess CI exposure in EMS professionals has been led by Donnelly and Bennett, who administered a modified version of the CIHQ in a sample of U.S. paramedics and EMTs. Their findings and suggested modifications served as the basis for the instrument used in our study.

Not unexpectedly, our data indicate that the most difficult CIs to cope with involve children, persons known to the crew, or a clinical error that results in an adverse outcome for a patient. A number of studies from around the world have presented paramedics and dispatchers with ad hoc lists of event types for severity ranking and comment.,,,,,, Consistent with our findings and irrespective of methods or geography, studies universally report that calls involving children or persons personally or professionally known to the crew are among the most disturbing. Unique to the current study, however, was an examination of incident severity rating by parental status. We hypothesized that emergency responders with children might find pediatric CIs more distressing because of mental and emotional transference of the situation to children in their own lives, but our findings did not support any difference in perceived severity by parental status.

Interpretation of frequency data from the modified CIHQ is less clear. We did not verify reported estimates of career frequencies as this was not feasible, so statements about absolute numbers of reported experiences would be speculative. However, similar to what has been observed in law enforcement officers, the total number of CIs experienced by each respondent was positively correlated with years in EMS ( r=0.52; p<0.001), which offers some support for validity. The inverse correlation we observed between career frequency and severity rating ( r= −0.72) is also comparable to that observed by Weiss et. al. in law enforcement officers ( r= −0.61), and supports the hypothesis that frequent exposure to certain incident types may foster resilience.

Contrary to our hypothesis, we found no evidence that cumulative exposure to CIs in our responders is associated independently with professional burnout. This finding may be interpreted as being consistent with the viewpoint that an individual's reactions after distressing incidents are of greater importance than the absolute number of potential CIs to which they are exposed. As noted by others, there is heterogeneity across individual emergency responders as to what constitutes a "critical incident,", and we readily acknowledge that the inventory used in this study only quantifies exposure to incident types with a high likelihood of heightened stress reactions and does not quantify the number of heightened reactions and resultant stress that is experienced. In the only other study that has attempted to quantify career exposure to CIs in EMS responders, the investigators observed that the correlation between lifetime CI exposure and a continuous measure of post-traumatic stress symptoms was relatively weak ( r=0.25; p<0.01), and that more strongly correlated with post-traumatic stress symptoms was the level of stress that responders reported experiencing after such events ( r=0.39; p<0.01). These findings suggest that a more ideal instrument for assessing cumulative CI exposure in EMS professionals would more strictly capture incidents that resulted in distress for the responder personally.

LIMITATIONS

This study was conducted at a single, Midwestern EMS agency, and significant variation in EMS system models in terms of structure, volume, personnel attributes and geography likely compromise the generalizability of these results. Burnout may have been underestimated if employees who are disengaged were less likely to participate, or if those with extreme burnout have already exited the profession. However, providers who have strong concerns about work stress may have been more likely to embrace the opportunity to contribute to a wellbeing survey. Our response rate, while seemingly modest, is comparable with previous studies on the topic (40%-72%).,,,,, We attempted to address the multifactorial nature of burnout by conducting multivariable analysis; however, our limited sample size resulted in wide confidence intervals and compromised our ability to make definitive statements about the predictive value of the factors examined.

Implications

As a result of these findings, our agency instituted a process that offers timely chaplaincy support to providers after all potentially traumatic CIs, with particular attention to pediatric calls. Using real-time data mining, calls with specific trigger characteristics (e.g., pediatric death, more than four units on scene) generate an alert text message to the EMS chaplain who contacts the crew to offer support. A full-time EMS chaplain makes this protocol feasible, and the systematic approach acknowledges evidence that EMS providers are unlikely to seek assistance of their own volition after CIs., However, individualized response makes it difficult to accurately identify which calls will be troublesome and peer support models may be a more effective approach within existing EMS culture., We have also recently conducted paramedic focus groups to improve understanding of difficulties with pediatric calls. These initiatives represent an important starting point for both normalizing expression around stressors and altering the common perception among EMS providers that management is not concerned about their mental wellbeing and that agency support is inadequate. ⁻,,

CONCLUSION

Medical dispatchers in this sample exhibited a level of professional burnout commensurate with that of physicians and significantly higher than that experienced by the paramedics and EMTs who responded to the survey. These data also provide quantitative evidence that our EMS responders find pediatric CIs especially distressing, and that being threatened with a gun/weapon is commonplace in this population. In this study, a simple measure of career exposure to potentially critical incidents was not associated with burnout, but tools for more accurately capturing the number of incidents that resulted in distress are needed. EMS agencies should consider conducting assessments of burnout and other measures of wellbeing as a tool for mitigating systemic decline of wellbeing across the profession and averting personal tragedies in providers who are struggling.

Supplementary Information

ACKNOWLEDGMENT

We wish to thank the employees of Allina Health EMS for their participation in the survey.

Footnotes

Section Editor: Joshua Gaither, MD

Full text available through open access at http://escholarship.org/uc/uciem_westjem

Conflicts of Interest: By the West JEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

REFERENCES

19. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd Ed. Palo Alo, CA: Consulting Psychologists Press; 1996. [ Google Scholar]

31. Donnelly EAB, Bennett M. Development of a critical incident stress inventory for the emergency medical services. Traumatology. 2014;20(1):1-8. [ Google Scholar]

44. Lateef F. Job-related evaluation of post-traumatic stress (JETS) [ Google Scholar]

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Burnout and Exposure to Critical Incidents in a Cohort of Emergency Medical Services Workers from Minnesota

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Lori L. Boland, MPH, * † Tyler G. Kinzy, MS,* Russell N. Myers, BCC,* Karl M. Fernstrom, MPH, † Jonathan W. Kamrud, NREMT-P,* Pamela J. Mink, PhD, MPH, † and Andrew C. Stevens, MD* Very little quantitative data on occupational burnout and exposure to critical incidents are available from contemporary United States emergency medical services (EMS) cohorts.

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Emergency medical services (EMS) workers provide pre-hospital emergency medical care. Their duties create an inherent risk for on-the-job injuries and illnesses. Research shows that EMS workers have high rates of fatal injuries and nonfatal injuries and illnesses.

Learn about results from a 4-year study capturing data from EMS workers treated in emergency departments, and get recommendations to prevent injuries and exposures. Download the fact sheet

NIOSH and the Department of Homeland Security partnered with other federal agencies and ambulance manufacturers to crash-test ambulances. Download the infographicpdf icon

Get updated recommendations from NIOSH on preventing fentanyl exposure among emergency responders.

Who are EMS workers?

Vital to disaster response, EMS workers include: first responders, emergency medical technicians (EMT), paramedics, and others whose titles may not always suggest their EMS duties. For example, firefighters and nurses may provide pre-hospital emergency care as part of their routine job duties.

The 2011 National EMS Assessment reported a total of 826,000 licensed and credentialed EMS professionals in the United States. This estimate includes paid and volunteer EMS workers. The 2016 Current Population Survey estimate for full-time employed EMTs and paramedics was 211,200.

What job hazards do EMS workers face?

EMS workers face many potential job hazards, including:

Lifting patients and equipment

Treating patients with infectious illnesses

Handling hazardous chemical and body substances

Participating in the emergency transport of patients in ground and air vehicles

How is NIOSH working to prevent EMS injuries and illnesses?

Collaborating with the National Highway Traffic Safety Administration, Office of Emergency Medical Services,external icon NIOSH uses the occupational supplement to the National Electronic Injury Surveillance System ( NEISS-Work ) to collect data on nonfatal injuries and illnesses among EMS workers.

In 2016, there were an estimated 21,900 injuries and illnesses among EMS workers that were treated in U.S. hospital emergency departments. The most recent injury and illness data are described in the data section of this topic page.

There are a number of other coordinated efforts by various Federal agencies to improve occupational safety and health for EMS workers. Information on some of these efforts is available at www.ems.gov.external icon

Page last reviewed:

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national institute for occupational safety and health

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CDC - Emergency Medical Services Workers - NIOSH Workplace Safety and Health Topic

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Emergency medical services (EMS) workers are primary providers of pre-hospital emergency medical care and integral components of disaster response. The potentially hazardous job duties of EMS workers include lifting patients and equipment, treating patients with infectious illnesses, handling hazardous chemical and body substances, and participating in the emergency transport of patients in ground and air vehicles.

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Stress is detrimental to any person's health, but general stress and the stress of an emergency responder are obviously very different. There is stress from having an unpaid bill or too much homework due in too little time; then there's the stress of working a cardiac arrest where the patient can't be resuscitated.

When extremely emotional situations are mixed with common everyday emotions, it can be hard to juggle solutions and cope. On a daily basis firefighters, police, and emergency medical workers are all exposed to the risks of seeing death and destruction.

Suicide rates are high in the public safety professions. Divorce rates are growing. Burnout must be addressed, as well as long hours. New solutions must be proposed and evaluated.
Young Personnel
Paramedics as young as 19 years old work on advanced life support ambulances. Studies have shown the human brain does not fully mature until age 25. ¹ A crew on an EMS shift may run multiple calls during a single shift, where they may be responsible for pronouncing patients deceased.

A 19-year-old provider could respond to a decapitated body on a roadway or enter a home in which an infant is dead in its crib. After making the pronouncement and breaking the news to the family, their next call may be for someone who claims to have back pain but just wants to be medicated. This is where the stress begins.

After a young provider earns his or her license, those initial calls are fueled with adrenaline, making the new provider proud to be who they are. But after three years of those calls, the stress and pressure that accompany the job can begin to weigh on them. That bright 19-year-old is now 22 and still three years away from reaching average brain maturity level.
Shift Hours
A 2009 survey indicated more than 54% of EMS services still use 24-hour shifts, around 29% use 12-hour shifts, and only 7% report using either 8- or 10-hour shifts. ² Coupled with stress, shift hours can be very detrimental to workers' mental and emotional well-being.

According to Lt. Keith Ellis, Tennessee's Washington County-Johnson City EMS uses both 12- and 24-hour shifts. It's recently begun working some crews on 12-hour shifts due to the danger of employee fatigue. The service's average call volume is 32,000 annually, or 10-20 calls per day per ambulance. Each call can take anywhere from 1-3 hours to clear, depending on its nature.

Do this math, and you'll find some crews may not stop during their entire 24-hour shift. Half of EMS personnel sleep only six hours every 24, with more than half reporting poor sleep quality and 70% reporting some problems with sleep. ³ Loss of sleep, stressful situations, and not eating on a regular schedule could push an already-stressed employee close to the edge.

Insufficient sleep has been linked to cardiovascular disease, obesity, metabolic disorders, gastrointestinal conditions, hunger/appetite, and changes in emotion. ³ Research has found higher levels of negative behavior correlating to sleep deprivation and that a person going without sleep for 24 hours experiences impairment equivalent to a blood alcohol level of 0.10%. ²
The Dangers of the Job
The high potential for serious injury in EMS is also a stressor. In 2014 the Bureau of Labor Statistics reported the overall injury rate for EMTs and paramedics was 333 injuries per 10,000 workers-more than three times higher than the average rate of 107 for all occupational groups in the U.S. ⁴

Occupational hazards for EMS professionals include emergency vehicle accidents or being struck by an oncoming vehicle while working a motor vehicle accident; issues of exposure to communicable diseases due to working with needles and blood in the back of a moving vehicle; and patients who become combative due to drug use, seizures, or even blood sugar issues. Furthermore, obesity continues to skyrocket, increasing our risk of neck and back injuries.
AIDS: Ambulance-Induced Divorce Syndrome
After working a long, dangerous shift, taking your work home is problematic. Employees may need a way to vent their emotions, and often they turn to family. Some spouses may be able to withstand the pressure, but others prefer not to hear about a dead child or someone being decapitated. The provider is unable to share their emotions with the person they rely on most for support.

A 2015 look at firefighters' divorce rates found 77% of male firefighters married and 11.8% divorced. ⁵ The U.S. population averages are 57.5% married and 9.4% divorced. Among female firefighters, 42.6% were married and 32.1% divorced. The U.S. averages for women are 55.4% and 10.4% respectively.

For an already-stressed emergency responder, divorce could be the turning point for a potential emotional breakdown.
What Is EMS Burnout?
Currently the average career span of an EMT or paramedic is only five years. ⁶ This is due in part to burnout and stress and in part to the job's physical toll.

Burnout is typically described as a pattern of negative affective responses that further reduce job satisfaction, productivity, and performance, and that is known to increase absenteeism and turnover. ⁷ Along with this come decreased social engagement, poor bedside manner, trouble at home due to negative emotions after shifts, and possibly suicidal ideations.

At this point it's time for solutions and for supervisory staff to see the importance of stress management before devastating life-changing decisions are made.

Burnout, no sleep, low nutrition, and fatigue comprise a recipe for post-traumatic stress disorder, prevalent in the emergency services. PTSD is characterized by an initial state of numbness while the individual attempts to assimilate the traumatic experience. ⁸ When an emergency responder runs a bad call, they must clear the call, clean the ambulance, and prepare for whatever's next. Getting another bad call right away is a strong possibility and departments should weigh preventive and proactive policies.

The national average for suicide contemplation, per the CDC, is about 3.7%. A 2015 survey of emergency personnel found their rate to be 37%. The national average for suicide attempts is 0.5%; among emergency personnel it's 6.6%. ⁹
Solutions to Stress
Unfortunately it's impossible to unsee what's seen or undo what's done. Emergency services must find better ways to help their employees cope.

Call-in crews- One solution could be "call-in crews." These crews could be stocked with part-time employees who can replace full-time employees in the event they run a defined "bad call." If a crew works a call with a dead or seriously injured child or other troubling stressor, they should be able to come off shift immediately if they feel the need. Some employees have their "outlet person" at work; being off duty will provide time to express feelings to this person without the interruption of the radio.

Critical incident stress debriefings-Many services implement critical incident stress debriefings. These are aimed at helping individuals contextualize their experience of trauma at an early stage, thus preventing the development of PTSD. ⁸ CISD is for all services and is recommended to be held no longer than 72 hours after the incident. ¹⁰ This meeting will allow each person on scene to discuss their feelings openly with no judgment. There is a professional present for reassurance of skills performed on scene and general handling of the situation.

CISD attendance should be not mandatory. Some crew members may not feel comfortable discussing their feelings with others. Some may have attended stress debriefings they felt were unorganized or unprofessional.

The organization and effectiveness of meetings should be given a closer look. There have been reports of spouses and boyfriends or girlfriends being involved, or others in the department who weren't on the call. Only those involved with the tragic event should attend.

A CISD should not be a show; it should be a neutral setting where those who have difficulty expelling their feelings have a common, comfortable outlet. In one study of duty-related stress among police officers, 63% of respondents found CISDs beneficial. ⁸

Psychological first aid (PFA)-PFA is similar to CISD in offering immediate mental care for those who've just experienced a traumatic event, but it uses more of a "laid-back" approach. While CISD is more protocol-driven, PFA is built more for enhancing one's natural resilience to the traumatic events. ¹¹ PFA is also focused more toward individual needs than being a group practice.

Emergency services have come a long way in a short time in this country. However, many issues still need to be worked out, particularly concerning the well-being of our caregivers. Sometimes it's the heroes who need to be saved.
References
1. University of Rochester Medical Center. Understanding the Teen Brain, www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=1&ContentID=3051.

2. Cotter S. Seeking Shift Work Solutions. EMS World, www.emsworld.com/article/10231867/seeking-shift-work-solutions.

3. Patterson D. Evidence-based guidelines for combatting fatigue in EMS. J Emerg Med Serv, 2018 Feb; 43(2).

4. Maguire BJ, O'Neill BJ. Emergency medical service personnel's risk from violence while serving the community. Am J Public Health, 2017 Nov; 107(11): 1,770-5.

5. Jahnke S. Firefighter divorce: 3 important facts. FireRescue1, www.firerescue1.com/fire-rehab/articles/2181154-Firefighter-divorce-3-important-facts/.

6. Grayson K. Joining EMS? Here's what you're really getting into... EMS1, www.ems1.com/ems-education/articles/894089-Joining-EMS-Heres-what-youre-really-getting-into/.

7. Collopy KT, Kivlehan SM, Snyder SR. Are You Under Stress in EMS? EMS World, www.emsworld.com/article/10776875/are-you-under-stress-ems.

8. Irving P, Long A. Critical incident stress debriefing following traumatic life experiences. J Psychiatr Ment Health Nurs, 2001 Aug; 8(4): 307-14.

9. Newland C, Barber E, Rose M, Young A. Survey reveals alarming rates of EMS provider stress and thoughts of suicide. J Emerg Med Serv, 2015; 40(10).

10. Schottke D. Workforce Safety and Wellness. In: Pollak A (ed.), Emergency Medical Responder: Your First Response in Emergency Care. Burlington, MA: Jones and Bartlett, 2018.

11. Siarnicki RJ. Understanding Psychological First Aid for First Responders. My Firefighter Nation, https://my.firefighternation.com/profiles/blogs/understanding-psychological.
Hollie Backberg, NRP, AAS, is a health science/EMR instructor at David Crockett High School in Jonesborough, Tenn.

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Stress: The Silent Killer of the EMS Career

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Stress is detrimental to any person's health, but general stress and the stress of an emergency responder are obviously very different. There is stress from having an unpaid bill or too much homework due in too little time; then there's the stress of working a cardiac arrest where the patient can't be resuscitated.

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There's no denying a career in EMS can be stressful. We are witnesses to gunshot victims, steel-bending motor vehicle collisions, unresponsive babies, and disturbing suicides and murders.

As practitioners, what often affects us more even than what we see is our own personal associations-that suicide may remind us of our own child who struggles with mental health issues, or an elderly cancer patient may recall our grandmother battling the same diagnosis.

As the years go by, calls have a way of accumulating in the mind-space and can affect us in insidious ways. To top it off, EMS workers have to walk a tightrope of work-life balance and attempt to keep work stress at bay in their personal lives. Left unchecked, stress can manifest into more severe conditions such as anxiety and depression or lead to stress disorders such as obsessive-compulsive disorder and post-traumatic stress disorder (PTSD).

There has recently been widespread attention to mental health in first responders, and it's about time: In Canada 46 first responders and 10 military members died by suicide in 2017 (and these are only the reported cases). ¹ In Australia a study concluded that 37% of paramedics suffered from some form of depression. ² In the wake of these alarming statistics, how do we protect ourselves and help ensure career longevity?
Stress: What It Is
Stress can be an ambiguous term applied to many situations. Saying "I'm feeling stressed out these days" is different than the immediate physical response of a pounding heart and sweating when someone waves a knife at you; yet both mental perception of stress and its physical effects are interconnected.

Stress is a necessary and fundamental part of being human. In a nutshell, acute stress kick-starts hormonal and behavioral responses that allow an organism to make adaptations to environmental pressures. Chronic stress, or dysregulation of the stress system, can greatly disrupt homeostasis and lead not only to debilitating mental health disorders but also to reproductive dysfunction, growth disruption, suppressed immune function, decreased muscle and bone mass, atherosclerosis, visceral obesity, gastrointestinal disorders, and insulin resistance. ³
Stress and EMS
In EMS, we have many stressors. They include workplace conflicts (colleagues, management), high call volumes, overtime, shift work, abuse of the 9-1-1 system, unstable and dynamic working conditions, skills proficiency and protocol changes. EMS workers also carry a high level of responsibility; a 2012 study of Ottawa emergency service workers found that paramedics carry the highest rate of PTSD, even more than firefighters and police. ⁴ With responsibility, guilt can arise-and stress as a result-especially if clinical mistakes are made or patients die despite our efforts.

Apart from workplace stress, our personal lives also have a monumental impact on our overall resilience. If we're experiencing relationship issues, going through life transitions or the loss of a family member, or have had other traumas, we are more likely to carry that stress over on our shifts at work. We can attempt to keep our personal and work lives separate, but that can only be protective to a degree; sooner or later our personal life can begin to affect our work life, and vice versa.

How could chronic stress affect EMS personnel? One may begin to notice an impaired memory-for example, it may take longer to recall drug calculation dosages-or impaired concentration while initiating a difficult IV or intubation. Mental focus may be fuzzy. One may become irritable and short-tempered with difficult patients or overtime calls. Coordination could even be off, and one may find themselves slipping more on icy surfaces or bumping into corners. These impairments are due to a complex interaction of many factors, including increased cortisol levels that can remain in our system for some time.

There is no denying that changes in the ability to respond to stressors, such as in chronic states, can lead to disease. What can we do about it? Can we prevent acute stress from manifesting into chronic issues?
HPA Axis and the Amygdala
Bill is a paramedic new to the industry. One day he responds to his first pediatric anaphylaxis call. As soon as he receives the dispatch, Bill begins to perspire. His heart rate increases, his hands begin to tremble, and his stomach feels queasy. While responding with lights and siren, Bill struggles to compose himself and has difficulty remembering weight-based dosage calculations and advanced airway adjunct sizes.

When he and his partner arrive on scene, they find a 2-year-old girl in her mother's arms. She is centrally cyanotic and struggling to breathe. Bill freezes and feels a lump rise in his throat. His partner hands him an epinephrine vial; Bill looks at the concentration and dosage on the packaging but cannot comprehend what his brain is trying to read.

Does any of this sound familiar? Most practitioners experience "tunnel vision" to some extent at least once in their careers. This is when the sympathetic nervous system-our "fight, flight, or freeze" (FFF) response-initiates and autonomic processes begin. Responses include increased heart and respiration rates, dilated pupils, blood shunting from the core to extremities, and a cessation of digestion. All of this happens instinctively as a survival mechanism in the face of threats or the unknown. The problem with this stress response when it is all-consuming (as happened with Bill) is that it interferes with our prefrontal cortex, or our ability to think rationally.

Human biology is powerful. The human brain is the continuous conductor of physical functions. Inside our skulls we have a brain stem (the "reptilian" brain responsible for autonomic responses such as heart rate, respiration, and digestion), limbic system (emotional center), and prefrontal cortex (capable of conscious, rational thought). When a stressor is present, or even the thought of one, information is relayed up through the brain stem and limbic system twice as fast as the time it takes to reach the prefrontal cortex. Before we even have time to consciously respond to the stressor, problem-solve, or decide there is no real threat, our autonomic nervous system and stress response have already kicked in. After that it can become difficult to access the prefrontal cortex until our stress-response symptoms begin to abate. ⁵

Key components of the stress system are the hypothalamic-pituitary-adrenal (HPA) axis and the autonomic nervous system (ANS). These systems interact with other vital centers in the central nervous system (CNS) and tissues/organs in the periphery to mobilize a successful adaptive response against the imposed stressor(s). ³ When there is a sustained or frequent stress response, or even a perception of stress, the HPA axis is stimulated, which initiates physical responses and the release of chemicals that work together to create and condition the pathway. Over time this creates detrimental psychological effects and disease processes in the body.

The amygdala connects to the limbic system and is one of two almond-shaped clusters of nerve cells located in the temporal lobe of the brain. It responds to information from the body's senses and is involved with the development of the fear emotion-it presses the "panic button."

The amygdala is connected to all parts of the brain and will send signals to the brain stem to activate the FFF response. As with the HPA axis, the amygdala will respond and even increase in physical size with persistent stressors; its neuropathways can be reinforced with its activation of the fear emotion. This can cause paranoia, an increased startle response, inability to cope, and a generally overtaxed sympathetic nervous system-symptoms that can lead to PTSD. ⁶
Perception and Brain Training
As mentioned earlier, perceived stressors can be as important as real ones. One study enrolled 26 participants in an eight-week mindfulness course. ⁷ (The definition of mindfulness is the nonjudgmental awareness of present-moment experiences. Participants practiced meditation techniques designed to increase awareness of present-moment experiences such as thoughts, emotions, and physical sensations. They also learned to use this awareness in responding more skillfully to stress in their everyday lives).

Participants in the study were "stressed" but otherwise healthy. Researchers took precourse and postcourse MRI scans of subjects and correlated the scans to participants' current perceived levels of stress. At the conclusion of the study, researchers discovered a confirmed correlation between stress level scores and a decrease in gray matter density within the right amygdala, without anything significantly changing in the participants' lives in terms of stressors.

This demonstrated that neuroplastic changes in the brain are associated with improvements in a psychological mind-set. In other words, if one changes their perception of and reaction to stress, they can change the physical structure of their brain and will be able to respond more effectively with higher-level thinking in the face of stressors.

One can train their brain, with both real and perceived stressors, to harness autonomic responses and allow the prefrontal cortex to problem-solve. ⁸ One can practice engaging the cortex and working "from the top down" to condition instincts to react better in the face of fear. Without conscious practice, we can be susceptible to allowing our instincts to control fear and stress.

The next part of this series will dive into resilience, with specific techniques to practice harnessing stress and even using it to our advantage.
Summary
With a clinical understanding of the physiology of stress and its impacts on both the body and psychological state, we can begin to reduce the stigma of stress and its effects. With this awareness we recognize that our biology is susceptible to stress-and with awareness can come change. We can learn to use biology to our advantage and practice resilience in our workplace and our lives.
References
1. Tema Conter Memorial Trust. https://www.tema.ca/inthenews.

2. Sofianopoulos S, Williams B, Archer F, Thompson B. The exploration of physical fatigue, sleep and depression in paramedics: A pilot study. Australasian J Paramed, 2011; 9(1).

3. Tsigos C, Kyrou I, Kassi E, Chrousos GP. Stress, Endocrine Physiology and Pathophysiology. In: De Groot LJ, Chrousos G, Dungan K, et al., eds. Endotext. South Dartmouth, MA: MDText.com, 2016.

4. Drewitz-Chesney C. Posttraumatic stress disorder among paramedics: Exploring a new solution with occupational health nurses using the Ottawa Charter as a framework. Workplace Health Saf, 2012 Jun; 60(6): 257-63.

5. Arnsten A. Stress signaling pathways that impair prefrontal cortex structure and function. Nat Rev Neurosci, 2009.

6. PTSD UK. The science and biology of PTSD, http://www.ptsduk.org/what-is-ptsd/the-science-and-biology-of-ptsd/.

7. Holzel BK, Carmody J, Evans KC, et al. Stress reduction correlates with structural changes in the amygdala. Soc Cogn Affect Neurosci, 2010 Mar; 5(1): 11-7.

8. Amen D. Change Your Brain, Change Your Life: The Breakthrough Program for Conquering Anxiety, Depression, Obsessiveness, Anger and Impulsiveness. Harmony Books, 1999.
Veronica Ryl, EMT-P, CP-C, is a Canadian paramedic who has been in the industry for 11 years. She works for a busy metropolitan 9-1-1 service as a community paramedic and on a specialized mental health team. She is also an instructor on mental health readiness.

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There's no denying a career in EMS can be stressful. We are witnesses to gunshot victims, steel-bending motor vehicle collisions, unresponsive babies, and disturbing suicides and murders. As practitioners, what often affects us more even than what we see is our own personal associations-that suicide may remind us of our own child who struggles with mental health issues, or an elderly cancer patient may recall our grandmother battling the same diagnosis.

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A key organizational strategy to improving clinician well-being is to measure it, develop and implement interventions, and then re-measure it. A variety of dimensions of clinician well-being can be measured including burnout, engagement, and professional satisfaction. Below is a summary of established tools to measure work-related dimensions of well-being. Each tool has advantages and disadvantages and some are more appropriate for specific populations or settings. This information is being provided by the Research, Data, and Metrics Working Group of the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience.

Click or scroll below for an overview of each validated instrument to assess work-related dimensions of well-being.
Pragmatic approaches for organizations to measure health care professional well-being >>
Burnout

Provide feedback on these instruments

To measure burnout in individuals who work with people (human services professions).

Maslach Burnout Inventory - Human Services Survey (MBI-HSS) is a 22-item survey that covers 3 areas: Emotional exhaustion (EE), Depersonalization (DP), and Low sense of personal accomplishment (PA). There are multiple questions for each of these subscales and responses are in the form of a frequency rating scale (never, a few times a year or less, once a month or less, a few times a month, once a week, a few times a week, every day).

Measure released in 1981.

Emotional Exhaustion: 1, 2, 3, 6, 8*, 13, 14, 16, 20

Depersonalization: 5, 10*, 11, 15, 22

Personal Accomplishment: 4, 7, 9, 12, 17, 18, 19, 21

*items with highest factor loading on the subscale in samples of physicians and trainees (see below development and testing). 2,3

It is preferred to examine relationships with subscale scores as continuous variables and outcomes. An alternative approach is to categorize results separately using established definitions of low, average, and high cut-off scores for each subscale (see MBI manual). ¹ Investigators often dichotomize into burnout/no burnout but there is no accepted standard definition. ⁴ A common approach is to consider individuals as having at least one symptom of burnout if they have high scores in either the EE (score of 27 or higher) or DP (score of 10 or higher) subscales. Evidence indicates that high scores on these subscales can distinguish the clinically burned out from the non-burned out. ⁵ because this approach identifies individuals whose degree of burnout places them at increased risk of potentially serious personal and professional consequences. ⁶⁻¹¹ An alternative option is to consider individuals to have burnout if they have a high EE score along with either a high DP score or a low PA score (score less than 33). ⁴

Development and Testing

The instrument was developed following exploratory research with interview and questionnaire data, testing in a variety of health and service occupations, and factor and confirmatory data analysis. Reliability coefficients, test re-test reliability, convergent validity, and discriminant validity among human service professionals are summarized in the manual. 1,12

As the 22-item version is not always practical, such as in long surveys assessing multiple different dimensions, investigators have identified 2 single questions with the highest factor loading on the EE and DP subscales in samples of 2248 medical students, 333 internal medicine residents, 465 internal medicine faculty, and 7905 practicing surgeons: item 8 ("I feel burned out from my work") and item 10 ("I have become more callous toward people since I took this job"). 2,3 These two items correlated strongly with the EE and DP domains as measured by the full MBI in a sample of more than 10,000 trainees and physicians with an area under the receiver operator characteristic curve of 0.94 and 0.93 for EE and DP, respectively, for these single items relative to the full MBI. Concurrent validity for the 2-item instrument has been established by showing, relative to the full MBI, that the single item measures have strong and consistent correlations with key outcomes in medical students, residents, and practicing surgeons (e.g., suicidal ideation, serious thoughts of dropping out of medical school, poor professionalism, major medical errors). 2,3 A response of "a few times a week" or more on single items indicates a high degree of burnout in each domain. In a separate study of 308 rural physicians and advance practice providers, the 2 items (item 8 and item 10) correlated well with their parent subscales of the full MBI (Spearman's r = .89 and .81, p <.0001). In multivariable models, the EE item predicted high/low EE, whereas the DP item predicted only low DP. ¹³

Links to Outcomes or Health System Characteristics Related to Health Care Professionals

Substantial data 14,15 supports associations between burnout as measured using the MBI and health care related outcomes (e.g., medical error, 8,10,11 malpractice, ¹⁶ suboptimal patient care practices, ¹⁷ physician turnover and early retirement, 18,19 and lower medical knowledge ²⁰), suboptimal professionalism, 7,21 and personal outcomes (e.g., alcohol abuse ²²⁻²⁴, suicidal ideation, 6,9 and motor vehicle incidents ²⁵) From a health system characteristics perspective, associations have been found between burnout and practice setting, work hours, clerical burden, and specialty. 14,26-29

United States of America

Past or Validated Applications

Population: human service/helping professionals (e.g., teachers, social workers, police officers), including physicians, residents/fellows, medical students, and nurses

Individual Report - $15; Group Report - $200. Instrument is proprietary. Permission can be obtained through www.mindgarden.com.

Multiple language translations are available

MBI-General Survey (MBI-GS) is applicable to more general, non-social jobs.

Access the Maslach Burnout Inventory

Access the Oldenburg Burnout Inventory
To measure burnout in any occupational group.

Oldenburg Burnout Inventory is a 16-item survey with positively and negatively framed items that covers 2 areas: exhaustion (physical, cognitive, and affective aspects) and disengagement from work (negative attitudes toward work objects, work content, or work in general). ¹ There are multiple questions for each of these subscales and responses are in the form of a 4 point Likert scale from strongly agree (1) to strongly disagree (4).

Measure released in 2002.

Each burnout dimension is treated separately as a continuous variable.

Development and Testing

Developed in response to the MBI not having negatively worded items, and based on job demands-resources model where job demands are primarily related to exhaustion and job resources are primarily related to disengagement. 2,3 Two factor structure has been confirmed in a sample of Dutch workers, ³ Dutch physicians ¹ and US workers ⁴ whereas a four factor model (exhaustion, energy, disengagement, and engagement) was supported in study of Chinese nurses. ⁵ There is some evidence of convergent validity of OLBI with a shortened (16-item) version of the MBI-GS in a sample of 2431 US workers ⁴ and in a sample of Chinese nurses though convergent validity data suggests positively worded items should be dropped. ⁵ In a study of 232 Greek employees bivariate correlation between OLBI-exhaustion and MBI-GS-emotional exhaustion was 0.6, and the bivariate correlation between OBLI-disengagement and MBI-GS depersonalization was 0.6. ³ In a study of 528 South African employees working in construction, bivariate correlation between OLBI-exhaustion and MBI-GS-emotional exhaustion was 0.6, and the bivariate correlation between OBLI-disengagement and MBI-GS depersonalization was 0.37. ⁶

Links to Outcomes or Health System Characteristics Related to Health Care Professionals

Existing data is limited as a majority of studies have included small samples of physicians and other health care providers, and have mostly been conducted outside of the United States. Studies in Swedish nurses and other Swedish public health professionals suggest that OLBI scores predict intent of turnover and lower self-reported mastery of occupational skills. ⁷⁻⁹ Correlations have also been reported between OLBI scores and self-rated health (n=342 Swedish medical students ¹⁰ and n=290 medical residents ¹¹). In a longitudinal sample of 186 Swedish medical students, end of medical school OLBI-exhaustion and worries about their future endurance/competence predicted 6-10 month postgraduate OLBI-exhaustion. ¹²

Past or Validated Applications

$0. Instrument publicly available in appendix of article. ⁶

Multiple language translations are available
Access the Oldenburg Burnout Inventory

Access the Physician Work-Life Study's Single Item
To measure burnout in any occupational group.

Single-item. Stem and response items vary in publications. The following item was utilized in Dolan et al. ⁴: "Overall, based on your definition of burnout, how would you rate your level of burnout?" Responses, options are (1) "I enjoy my work, I have no symptoms of burnout," (2) "Occasionally I am under stress and I don't always have as much energy as I once did, but I don't feel burned out," (3) "I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion," (4) "The symptoms of burnout that I am experiencing won't go away. I think about frustration at work a lot," and (5) "I feel completely burned out and often wonder if I can go on. I am at a point where I may need some changes or may need to seek some sort of help."

Measure released in 2000.

Often dichotomized as no symptoms of burnout (score of 2 or less) vs. 1 or more symptoms (score of 3 or more). These cut-off scores were not established based on validity evidence.

Development and Testing

In a sample of 5400, VA employees correlation between responses to the PWLS single-item with single-item for MBI-EE (item 8:"I feel burned out from my work") score was r = 0.79. Compared to single MBI-EE item, the PWLS single-item had a sensitivity of 83.2%, specificity of 87.4%, and AUC was 0.93. ⁴ In a separate sample of 307 physicians PWLS single-item correlated modestly with MBI-EE score r = 0.64. ⁵ In a third study, PWLS single-item responses in sample of 308 rural physicians and advance practice providers correlated with full MBI EE and DP domain scores (Spearman's r =.72 and .41, p<.0001). In multivariable models, PWLS single item predicted high EE (but neither low EE nor low/high DP) as measured by the MBI. In this sample, the original MBI 2 items (item 8: "I feel burned out from my work" and item 10: "I have become more callous toward people since I took this job") correlated better with their respective parent subscale (Spearman's r = .89 and .81, p <.0001). The summary from that study was that the PWLS single item predicts high levels of EE but not low EE or DP, and that it is not effective at capturing individuals who have evidence of burnout in the depersonalization or personal accomplishment domains. ⁶

Links to Outcomes or Health System Characteristics Related to Health Care Professionals

In a study of 422 primary care physicians, PWLS single item burnout characterization was associated with lower satisfaction, greater time pressure, poor work control, and intent to leave the medical practice on univariate analysis. ⁷ No relationship was found between burnout and quality of care, as measured by chart review of 1419 patients. In a related study involving 426 primary care physicians structural equation modeling found significant and small to modest path coefficients between stress, satisfaction, and PWLS single item burnout and between PWLS single item burnout and self-reported medical error and suboptimal patient care practices. ⁸

United States of America

Past or Validated Applications

Population: Physicians
National benchmark data not available for US physicians, medical students, or general population. Some data in VA primary care, including 1769 providers⁴

Access the Physician Work-Life Study's Single Item Access the Copenhagen Burnout Inventory
To measure burnout in any occupational group.

Copenhagen Burnout Inventory is a 19-item survey with positively and negatively framed items that covers 3 areas: personal (degree of physical and psychological fatigue and exhaustion), work (degree of physical and psychological fatigue and exhaustion related to work), and client-related (or a similar term such as patient, student, etc.) burnout. There are multiple questions for each of these subscales and responses are in the form of either always, often, sometimes, seldom, and never/almost never or to a very high degree, to a high degree, somewhat, to a low degree, and to a very low degree.

Measure released in 2005.

Overall physical and psychological fatigue: 6 items

Physical and psychological fatigue related to work: 7 items

Client-related burnout: 6 items

(Questions are to be mixed with questions on other topics to avoid stereotyped response patterns)
Each dimension is separately treated as a continuous variable. The response options are recoded into scores of 100, 75, 50, 25, and 0. Next, items within the subscale are averaged, with one item reverse scored. Higher scores indicate a higher degree of burnout. Possible score ranges for all scales is 0-100. In one study investigators chose a score of 50 or higher to indicate burnout as a dichotomous variable. ¹ In a separate study investigators chose scores of 25 or lower, 25 to 50, and higher than 50 to categorize low, intermediate, and high burnout. ² These cut-off scores were not established based on validity evidence.

Development and Testing

Developed with a framework that characterizes the core of burnout as fatigue and exhaustion, which are attributed to specific domains in a person's life (personal, work-related, and client-related). In a sample of 1914 individuals from seven different workplaces CBI scales had high internal reliability, scores correlated with SF-36 scales, and scores predicted future sickness absence, intention to quit, and sleep problems. ³

Links to Outcomes or Health System Characteristics Related to Health Care Professionals

Existing data is limited as a majority of studies have included small samples of physicians and other health care providers, and have mostly been conducted abroad. In terms of potential health care related outcomes, CBI scores have been associated with lower perceptions of quality of care (psychosocial care, diagnosis/therapy, quality assurance, diagnostic and therapeutic errors in a study of 1311 German surgeons), ⁴ nurse turnover intention (in a study of 159 ICU nurses in Iran), ⁵ self-reported sick absences (prospective study of 824 Danish workers in human service sectors), ⁶ and sickness days, sleep problems, use of pain killers, and intention to quit work (prospective study of 1914 Danish employees in human sector). ⁷ In terms of personal outcomes, CBI scores predicted the WHO-Five Well-Being Index score among 317 Canadian residents, ⁸ and antidepressant treatment, especially among men (prospective study of 2936 Danish employees). From a health system characteristics perspective, associations have been found between CBI score and job strain, over-commitment, and low social support (Taiwanese health care professionals) ⁹ and between practice setting and recent reorganization at work (598 Norwegian midwives). ¹

Past or Validated Applications

$0. Publicly available in Table S1 ¹ and http://www.arbejdsmiljoforskning.dk/upload/cbi-scales.pdf

Multiple language translations are available
Access the Copenhagen Burnout Inventory Access the Stanford Professional Fulfillment Index
To measure burnout and professional fulfillment in physicians.

The Stanford Professional Fulfillment Index (PFI) is a 16-item survey that covers burnout (work exhaustion and interpersonal disengagement) and professional fulfillment. Response options are on a five-point Likert scale ("not at all true" to "completely true" for professional fulfillment items and "not at all" to "extremely" for work exhaustion and interpersonal disengagement items.)

Measure published in 2018.

Professional fulfillment: items 1-6

Work exhaustion: 7-10

Interpersonal disengagement items: 11-16

Items are scored 0 to 4. Each dimension is treated as a continuous variable. Scale scores are calculated by averaging the item scores of all the items within the corresponding scale. Scale scores can then be multiplied by 25 to create a scale range from 0 to 100. Higher score on the professional fulfillment scale is more favorable. In contrast, higher scores on the work exhaustion or interpersonal disengagement scales are less favorable. Dichotomous burnout categories are determined from the average item score (range 0 to 4) of all 10 burnout items (work exhaustion and interpersonal disengagement), using a cut-point of 1.33. Dichotomous professional flfillment is recommended at an average item score cut-point of >3.0.

Development and Testing

The PFI was developed for use in physicians. ¹ Development involved input from members of a physician wellness committee (n>30) and two national physician wellness experts. The efficacy of the PFI has been evaluated in a sample of 185 residents and 65 practicing physicians. Principal components analysis of data from this sample justified the three PFI subscales of professional fulfillment, work exhaustion, and interpersonal disengagement. In a subsample of 100 responders who had stable sleep-related impairment scores over a 2-3 week period, test-retest reliability estimates were 0.82 for professional fulfillment (α = 0.91), 0.80 for work exhaustion (α = 0.86), 0.71 for interpersonal disengagement (α = 0.92), and 0.80 for overall burnout (α = 0.92). The correlation between the PFI work exhaustion subscale score and Maslach Burnout Inventory emotional exhaustion subscale score was 0.72. The correlation between PFI interpersonal disengaement score and Maslach Burnout Inventory depersonalization subscale score was 0.59. The correlation between the PFI professional fulfillment score and Maslach Burnout Inventory personal accomplishment subscale score was 0.46. Compared to the Maslach Burnout Inventory, the PFI burnout scale sensitivity and specificity in identifying those with burnout was 72% and 84%, respectively, and AUC was 0.85. PFI scales also correlated in the expected directions with Patient-Reported Outcomes Measurement Information System (PROMIS) sleep-related impairment, depression, and anxiety scores, and with World Health Organization Quality of Life-BREF scores, PFI scales demonstrated sufficient sensitivity to detect expected effects of a two-point (range 8-40) change in PROMIS sleep-related impairment. ¹

Links to Outcomes or Health System Characteristics Related to Health Care Professionals

In the study of 250 resident and practicing physicians PFI work exhaustion and interpersonal disengagement had small (r=.15 and .33, respectively) but statistically significant correlations with scores on a 4-item medical error scale (internal consistency reliability estimate α =.62). Mean medical error scale scores were higher among those physicians with burnout (as classified using the PFI) in comparison to those without burnout. The Cohen's d effect size difference in self-reported medical errors for high versus low burnout classified using the PFI was 0.55.

Past or Validated Applications

Publicly available in article. No cost for non-profit organizations using the PFI for research or program evaluation. Cost for commercial use or use by for-profit organizations depends on application; contact the Stanford Risk Authority at wellness.surveyteam@TheRiskAuthority.com.
Access the Stanford Professional Fulfillment Index

References for Stanford Professional Fulfillment Index

Trockel M, Bohman B, Lesure E, et al. A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians. Acad Psychiatry. 2018;42(1):11-24.

Access the Well-Being Index
To identify distress in a variety of dimensions (burnout, fatigue, low mental/physical quality of life, depression, anxiety/stress). ¹⁻⁵

7 or 9-item instrument with yes/no response categories.

Measure released in 2010.

A total score is calculated by adding the number of 'yes' responses. In a sample of physicians, medical students, and US workers, every one point increase in score resulted in a step-wise increased probability of distress and risk for adverse personal and professional consequence. For the 7-item version, score range is 0 to 7, and threshold score to identify individuals in distress is 4 or higher for medical students, 5 or higher for residents, 4 or higher for practicing physicians, and 2 or higher for other US workers. In the expanded 9-item version, the original 7-items are scored in a traditional manner, with responses to meaning in work and satisfaction with work-life balance items resulting in 1 point being added or subtracted, ¹ resulting in a score range of -2 to 9.

Development and Testing

The 7-item Well-Being Index (WBI) was originally designed to be used in medical students. 4,5 Development involved input from experts, correlation analysis from previously administered assessments, and a multi-step validation process. After initial development in a sample of 2230 medical students, the efficacy of the WBI was confirmed in a separate sample of 2682 medical students. At a threshold score of 4 or higher, the WBI's specificity for identifying medical students with severe distress ranged from 88-91% with sensitivity of 59-93%. ⁴ The WBI was validated in a national sample of 7560 US residents in 2012. ³ At a threshold score of 5 or higher the index's specificity for identifying residents with low mental QOL, high fatigue, or recent suicidal ideation was 84%. The score also stratified residents' self-reported medical errors. The WBI was also validated in a national sample of 6994 US physicians. At a threshold score of 4 or higher, the index's specificity for identifying physicians with low mental QOL, high fatigue, or recent suicidal ideation was 86%. ² The score also stratified career satisfaction, reported intent to leave the current practice, and self-reported medical errors. In 2014, the 7-item WBI was tested in a sample of 5392 US workers and 6880 US physicians, and the 9-item WBI was developed and tested. ¹ The 9-item was created in an effort to identify individuals who were thriving, and included items exploring satisfaction with work life integration and meaning in work, both of which may mitigate the relationship between job-related stress and psychological distress. ¹ The 9-item WBI predicted low and high QOL, high fatigue, recent thoughts of suicidal ideation, and burnout in both samples. The area under the curve of the 7-item and the 9-item for identifying burnout was 0.84 and 0.85 in the physician sample, respectively.

Links to Outcomes or Health System Characteristics Related to Health Care Professionals

National studies have found associations between WBI scores and health care related outcomes (e.g., medical error, physician turnover) and personal outcomes (e.g., fatigue, recent suicidal ideation). ¹⁻⁵

Past or Validated Applications

The WBI is free for research use and for use in quality improvement efforts by nonprofit organizations. An interactive version of the index that provides personalized feedback to individuals and links to national resources is also free for individual use. The organizational version of the interactive WBI that provides individualized feedback, links to local and national resources, and organization level reports is also available but requires a fee for use. Access to the tool and information regarding cost and permission to use the tool is available at https://www.mededwebs.com/well-being-index.
Access the Well-Being Index

References for Well-Being Index

1. Dyrbye LN, Satele D, Shanafelt T. Ability of a 9-Item Well-Being Index to Identify Distress and Stratify Quality of Life in US Workers. J Occup Environ Med 2016;58:810-7.

2. Dyrbye LN, Satele D, Sloan J, Shanafelt TD. Utility of a brief screening tool to identify physicians in distress. J Gen Intern Med 2013;28:421-7.

3. Dyrbye LN, Satele D, Sloan J, Shanafelt TD. Ability of the Physician Well-Being Index to identify residents in distress. J Grad Med Educ 2014;6:78-84.

4. Dyrbye LN, Schwartz A, Downing SM, Szydlo DW, Sloan JA, Shanafelt TD. Efficacy of a brief screening tool to identify medical students in distress. Acad Med 2011;86:907-14.

5. Dyrbye LN, Szydlo DW, Downing SM, Sloan JA, Shanafelt TD. Development and preliminary psychometric properties of a well-being index for medical students. BMC Medical Education 2010;10:8.

Access the Patient Health Questionnaire-9
To measure major depression and suicidal ideation.

The Patient Health Questionnaire-9 (PHQ-9) is the self-report component of the PRIME-MD (Primary Care Evaluation of Mental Disorders) inventory. For each of the 9 DSM-5 (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) depressive symptoms, participants indicate whether, during the previous 2 weeks, the symptom has bothered them "not at all," for "several days," for "more than half the days," or "nearly every day."

Suicidal ideation is screened for with item 9 of the Patient Health Questionnaire-9 (PHQ-9) (i.e., "Thoughts that you would be better off dead, or hurting yourself in some way" over the past 2 weeks). Positive response to this item increases the cumulative risk for a suicide attempt and suicide completion over the next year by 10- and 100-fold, respectively.

Measure released in 1999.

The PHQ-9 is most often used as a continuous measure, with scores for individual items summed to produce a composite depressive symptom score between 0-27. Cut points of 5, 10, 15 and 20 representing mild, moderate, moderately severe and severe levels of depressive symptoms. The PHQ-9 can also be used as a diagnostic algorithm to make a probable diagnosis of major depressive disorder (MDD).

Development and Testing

PHQ-9 scores ≥10 have a sensitivity and specificity of 88% for major depressive disorder,. The PHQ-9 performs similarly across sex,, age and racial/ethnic groups. Importantly for longitudinal assessments, the PHQ-9 shows high sensitivity to change over time,.

Compared to other available depression measures, the PHQ-9 is relatively short and demonstrates good validity, sensitivity and specificity in both clinical and non-clinical populations,. Further, the PHQ-9 is the primary depression instrument utilized by large health care providers such as the U.S. Department of Veterans Affairs and the National Health Services, and is the instrument that web users are taken to after a Google search for "clinical depression.", ( https://www.blog.google/products/search/learning-more-about-clinical-depression-phq-9-questionnaire/). The widespread use of the PHQ-9 ensures a range of normative data for comparison.

Links to Outcomes or Health System Characteristics Related to Health Care Professionals

United States of America

Past or Validated Applications

Patient age: Adolescents, adults, and older adults

Population: any occupational group
From meta-analyses, comparison data are available for the general population, medical students (N=10,386), and resident physicians (N=3,756)

$0. Available at: http://www.phqscreeners.com/sites/g/files/g10016261/f/201412/PHQ-9_English.pdf.

Multiple language translations are available.

Alternate Depression Measure

The abbreviated 2-item PHQ-2 instrument has been developed for situations where administration of the full PHQ-9 is not feasible. The PHQ-2 is composed of the first two items of the PHQ-9 (assessing low mood and loss of interest) and subjects receive a score between 0 and 3 on each item. With a composite score range between 0-6, scores of ≤2 or ≤3 have been considered a positive screen for depression depending on the study. A positive PHQ-2 screen for depression correlates well with positive screens on the PHQ-9 and other longer depression instruments. Further, the PHQ-2 has generally shown moderate to good sensitivity to detect clinical depression. However, the specificity of PHQ-2 has been variable across studies and low in many studies,. Thus, the PHQ-2 is most accurately viewed as a screening tool for depression rather than a diagnostic instrument.
Access the Patient Health Questionnaire-9 Provide feedback on these instruments

Are there clear advantages for using one instrument versus another? For example, does use of MBI better enable comparisons with results from previous studies of U.S. physicians or in other specialties?

The Maslach Burnout Inventory is the gold standard for research purposes. Use of the full MBI allows for scores to be compared to results from previous studies of U.S. physicians (Mayo Clinic Proc, December 2015;90(12):1600-1613). The full MBI is 22 items long and therefore may not be practical in all settings. The use of 2 single items from the Maslach Burnout Inventory is the second best option: item 8 ("I feel burned out from my work",) and item 10 ("I have become more callous toward people since I took this job") correlate strongly with the emotional exhaustion and depersonalization subscale scores and concurrent validity has also been demonstrated (J Gen Intern Med 2012;27:1445-52. J Gen Inter Med 2009;24:1318-21.)

Are there some advantages to combining survey questions on burnout with those to assess some aspects of well-being, such as meaning of work?

Organizations interested in measuring physician well-being could consider a variety of dimensions including burnout, stress, fatigue, satisfaction, and quality of life. Various instruments are available to measure these domains. Instruments with national benchmark data and shown to correlate with patient satisfaction, safety, quality measures, productivity, turnover, and other outcomes of interest are preferred. A review of self-reported measures for assessing well-being has been published in BMJ (Linton M, Dieppe P, Medina-Lara A. Review of 99 self-report measures for assessing well-being in adults: exploring dimensions of well-being and developments over time. BMJ Open 2016;6:e010641. doi: 10.1136/bmjopen-2015-010641.) Commonly used instruments, number of items, whether or not there are national benchmarks for US physicians and scores have been shown to correlate with relevant outcomes can also be found in the Table on page 6 of the article "Executive Leadership and Physician Well-Being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout" By Drs. Shanafelt and Noseworthy (Mayo Clin Proc. 2017 Jan;92(1):129-146. doi: 10.1016/j.mayocp.2016.10.004).

Conducting a survey to measure burnout or other dimensions of distress is the first step to managing the problem. Including questions on such surveys that explore key drivers of burnout, such as meaning in work, workload, work efficiency, social support at work, control/flexibility, work-life balance, and organizational culture and values, can provide a starting point for conversation and action.

Are there best practices for combining different instruments?

Surveys are an important research methodology. The most important piece is to use instruments with acceptable reliability and validity that have national benchmark data to help with interpreting results, and are preferably associated with outcomes of interests. Using the entire instrument with exactly the same instructions and response categories is critical. If there are plans to repeat the survey over time the instruments should follow one another in the same order. It is acceptable to include more than one instrument in a survey. Just be sure to keep the instructions that precede the items and the response categories the same as the original instrument.

Survey-related books:

Neumann, W. L. (2003). Social Research Methods: Qualitative and Quantitative Approaches. Boston, MA: Allyn & Bacon.

Salant, P. & Dillman, D. A. (1994). How to Conduct Your Own Survey. New York, NY: John Wiley & Sons.

Cohen, L. Manion, L. and Morrison, L. Research Methods in Education (Fifth Edition), London, Routledge Falmer, 2000.

Dillman, D. A. Mail and Internet Surveys, The Tailored Design Method. 2nd Edition. Wiley, 2000.

Fink, A. and Kosecoff, J. How to Conduct Surveys: A Step-by-Step Guide. Sage, 1985.

Is there an optimal number or upper limit on the number of questions to maximize response rates?

There are many factors that influence response rate, including interest of your sample population in the topic and survey length. Short, simple questionnaires typically have better response rates than long, complex surveys. There are a number of factors beyond how many questions there are on a survey that influence how long it takes to complete a survey. Surveys that take less than 10 minutes for an individual to complete tend to have better response rates. Prior to administering a survey to a large group of individuals it is advised to pilot test the instrument with a smaller cohor. Doing so can help identify error and ensure the success of the project.

For more details see:

"Increasing response rates to postal questionnaires: systematic review" by Edwards P, Roberts I, Clark M, DiGuiseppi C, Pratap S, Wentz R, and Kwan I published in BMJ.com 2002;324:1183.

"Physician response to surveys. A review of the literature". Kellerman SE, Herold J. Am J Prev Med, 20(1), 61-67, 2001.

"How to Conduct Surveys. A Step by Step Guide." Fink A. 4th Edition, Sage Publications.

Are there unique considerations for inclusion of depression-related questions in surveys?

When assessing sensitive topics such as depression, suicide, and substance abuse there is potential tension between the desire to directly help respondents exhibiting signs of pathology and maintaining respondent confidentiality. Especially, with the unfortunate continued stigma around mental health among clinicians, ensuring confidentiality is critical to respondents and to collecting accurate results. One compromise solution is to take all participants to a new screen at the end of the survey that provides a) general information about depression b) encouragement to seek help if experiencing depressive symptoms and STB c) and information on resources for mental health services by state, including a suicide hotline.

Provide feedback on these instruments

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Valid and Reliable Survey Instruments to Measure Burnout, Well-Being, and Other Work-Related Dimensions - National Academy of Medicine

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Validated Instruments to Assess Work-Related Dimensions of Well-Being A key organizational strategy to improving clinician well-being is to measure it, develop and implement interventions, and then re-measure it. A variety of dimensions of clinician well-being can be measured including burnout, engagement, and professional satisfaction.

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Gallup's research shows a clear link between employee engagement and well-being, with managers serving as a conduit between the two.

These days, doctors aren't the only ones interested in well-being. Banks, pharmacies, grocers, and other businesses are introducing programs designed to enhance their customers' wellness. But of all the places you go each day, your workplace may have the greatest influence on your well-being. And the person who can best help you achieve results is someone you probably least expect: your manager.

Many employers have hopped aboard the wellness bandwagon in recent years, recognizing that they can play an influential role in helping employees curtail unhealthy behaviors that can lead to costly chronic conditions. A recent RAND Corporation study found that more than 85% of U.S. companies employing 1,000 people or more offer some sort of workplace wellness program. It's safe to assume that these companies genuinely want to help their employees lead healthier lives while seeing a healthier bottom line too. Not only do employers spend a fortune subsidizing employees' healthcare costs, but they also see greater productivity and fewer missed workdays from employees with higher well-being.

The Gallup-Healthways Well-Being 5

Gallup and Healthways have developed a comprehensive, definitive source of well-being measurement, the Gallup-Healthways Well-Being 5. This scientific survey instrument and reporting experience measures, tracks, and reports on the well-being of individuals and organizations. The five essential elements of well-being are:

Purpose: liking what you do each day and being motivated to achieve your goals

Social: having supportive relationships and love in your life

Financial: managing your economic life to reduce stress and increase security

Community: liking where you live, feeling safe, and having pride in your community

Physical: having good health and enough energy to get things done daily

Yet simply offering a wellness program -- no matter how well-intentioned -- provides no guarantee of improving employees' well-being. Workers must be aware the program exists and be persuaded to use it -- and that's where things get tricky. Though more than 85% of large employers offer a wellness program, Gallup research shows that only 60% of U.S. employees are aware that their company offers a wellness program -- and only 40% of those who are aware of the program say they actually participate in it. The upshot is that at companies that offer wellness programs, only 24% of employees are participating. For companies that provide these programs, it might be time for a checkup.
The manager's role in improving employees' well-being
Clearly, companies must do more work to close the awareness and participation gaps that plague workplace wellness programs, and this is where managers play a vital role. Managers are uniquely positioned to ensure that each of their employees knows about the company's wellness program, to encourage team members to take part, and to create accountability for results.

Gallup's research shows a clear link between employee engagement and well-being, with managers serving as a conduit between the two. Managers account for at least 70% of team variation on employee engagement. And engaging employees is vital to getting them involved in company-sponsored initiatives, because engaged workers are 28% more likely to participate in a wellness program offered by their company than are average employees. And research findings suggest a contagion effect; direct reports of managers with high overall well-being are 15% more likely to have high overall well-being six months later.

It takes great managers to engage employees. Over the past decade, Gallup has worked with hundreds of organizations to help their managers create engagement and boost employees' well-being. To measure engagement, we ask employees to respond to 12 statements, including whether their supervisor (or someone at work) seems to care about them as a person. This statement in particular reveals whether workers feel that their manager truly cares about their well-being. Those who agree with it are more likely to be top performers and to produce higher quality work, and they are less likely to get sick, change jobs, or be injured at work.

But before managers can talk to employees one-on-one about their well-being, they must first build trusting relationships with their direct reports so team members feel comfortable discussing sensitive topics and setting health-related goals with them. This can be a challenge. A 2008 Gallup study revealed that, on average, employees find spending time with their boss about two to four times as unpleasant as spending time with friends. Men in particular report high levels of stress and low levels of happiness when spending time with their managers.

Too many company wellness programs focus solely on Physical Well-Being.

Managers who engage their employees have an edge when it comes to boosting workplace well-being, though. Engaged employees are more than two times as likely as actively disengaged employees to say they are very or somewhat comfortable discussing their well-being with their manager.
Engagement isn't enough to guarantee well-being
Though engagement is essential to creating a culture of workplace well-being, it's not enough on its own to create high well-being in all five elements. When employees are engaged, they're twice as likely as average employees to have thriving well-being in four or five elements, but two-thirds of engaged employees still struggle or suffer in two or more of the five elements.

What's more, the five well-being elements are interdependent and reinforce one another. When employees are thriving in multiple elements, it becomes easier for them to accomplish things that are in their own best interest, such as maintaining good physical health. If you have thriving Social Well-Being, for example, it's more likely that people you care about will be interested in your health. People with more daily stress make worse decisions in the moment. But if you have thriving Financial Well-Being, you will have less daily stress, which makes it more likely you will not fall back on instant gratification that may work against your long-term health interests.
Well-being is more than physical health
Companies are most successful at creating a culture of well-being when they provide managers with the right tools for a holistic, multifaceted approach. Workers are more likely to thrive when their companies and managers address their needs in each of the five elements, rather than simply focusing on Physical Well-Being interventions, such as programs that encourage employees to exercise or quit smoking.

Yet too many company wellness programs focus solely on Physical Well-Being, leaving employees to languish in the other four elements. Maximizing workplace initiatives to encompass all five well-being elements will pay dividends by helping companies improve their bottom line and outperform competitors. When comparing adults who are thriving in just Physical Well-Being with those thriving in all five elements, those in the latter group:

report 41% fewer unhealthy days

are more than twice as likely to say they always adapt well to change

are 36% more likely to say they always fully bounce back after an illness

are 23% more likely to donate money

are 43% more likely to have volunteered

are 65% less likely to be involved in a workplace accident

are 81% less likely to look for a new job when the job market improves

Workplace wellness plans aren't cheap. RAND estimates that these programs cost U.S. companies a combined $6 billion a year. But if they're done right, they have the potential to offset rising healthcare costs and build a more productive workforce. To ensure that wellness programs achieve this potential, companies must regularly audit their wellness initiatives to determine whether employees are participating in and benefiting from them. If they aren't, it's vital to find out why. An ineffective program drains financial resources, erodes credibility, and yields no return on investment.
What businesses can do
To determine whether their company's wellness program is making a difference at key organizational levels, leaders must be able to answer yes to these questions:

Culture: Do my company's programs encompass all five well-being elements? Does our organizational culture support our wellness initiatives? For example, is it socially acceptable in our organization for employees to exercise in the middle of the day or to leave early to participate in a charitable function?

Leaders: Do all my company's leaders support the well-being initiative? Do they regularly communicate the value of the program and reinforce how it fits with the organization's purpose and brand identity? Do they consistently model the behaviors that the program seeks to impart?

Managers: Are all managers successful at engaging their teams? Do they create the time and focus for employees to participate in the right company-sponsored programs to develop their well-being? Do they help their team members set goals to improve their well-being?

As long as healthcare costs continue to skyrocket -- and diabetes, heart disease, and other preventable conditions remain a threat to public health -- wellness programs will continue to proliferate. U.S. companies that promote wellness are on the right track to help workers control their healthcare costs and lead more productive lives, but their wellness programs are probably not as effective as leaders want them to be.

Companies can improve the prognosis for better results if they enlist managers to promote well-being initiatives with their teams and in one-on-one conversations with their employees. Expanding wellness programs to track, manage, and enhance employees' well-being in all of the five elements can help companies reduce healthcare costs while improving employee performance and customer engagement.

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Why Your Workplace Wellness Program Isn't Working

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Gallup's research shows a clear link between employee engagement and well-being, with managers serving as a conduit between the two. These days, doctors aren't the only ones interested in well-being. Banks, pharmacies, grocers, and other businesses are introducing programs designed to enhance their customers' wellness.

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Work Engagement and occupational stress article

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Work Engagement and occupational stress article

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Workplace Mental Health - Workplace Stress

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Workplace Mental Health - Workplace Stress

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The nature of work is changing at whirlwind speed. Perhaps now more than ever before, job stress poses a threat to the health of workers and, in turn, to the health organizations. Through its research program in job stress and through educational materials such as this booklet, NIOSH is committed to providing organizations with knowledge to reduce this threat.

This publication highlights knowledge about the causes of stress at work and outlines steps that can be taken to prevent job stress.

Publication No. 99-101 was prepared by a NIOSH working group:
Steven Sauter - Lawrence Murphy - Michael Colligan - Naomi Swanson - Joseph Hurrell, Jr. - Frederick Scharf, Jr. - Raymond Sinclair Paula Grubb - Linda Goldenhar - Toni Alterman - Janet Johnston - Anne Hamilton - Julie Tisdale

Stress in Today's Workplace

The longer he waited, the more David worried. For weeks he had been plagued by aching muscles, loss of appetite, restless sleep, and a complete sense of exhaustion. At first he tried to ignore these problems, but eventually he became so short-tempered and irritable that his wife insisted he get a checkup. Now, sitting in the doctor's office and wondering what the verdict would be, he didn't even notice when Theresa took the seat beside him. They had been good friends when she worked in the front office at the plant, but he hadn't seen her since she left three years ago to take a job as a customer service representative. Her gentle poke in the ribs brought him around, and within minutes they were talking and gossiping as if she had never left.

"You got out just in time," he told her. "Since the reorganization, nobody feels safe. It used to be that as long as you did your work, you had a job. That's not for sure anymore. They expect the same production rates even though two guys are now doing the work of three. We're so backed up I'm working twelve-hour shifts six days a week. I swear I hear those machines humming in my sleep. Guys are calling in sick just to get a break. Morale is so bad they're talking about bringing in some consultants to figure out a better way to get the job done."

"Well, I really miss you guys," she said. "I'm afraid I jumped from the frying pan into the fire. In my new job, the computer routes the calls and they never stop. I even have to schedule my bathroom breaks. All I hear the whole day are complaints from unhappy customers. I try to be helpful and sympathetic, but I can't promise anything without getting my boss's approval. Most of the time I'm caught between what the customer wants and company policy. I'm not sure who I'm supposed to keep happy. The other reps are so uptight and tense they don't even talk to one another. We all go to our own little cubicles and stay there until quitting time. To make matters worse, my mother's health is deteriorating. If only I could use some of my sick time to look after her. No wonder I'm in here with migraine headaches and high blood pressure. A lot of the reps are seeing the employee assistance counselor and taking stress management classes, which seems to help. But sooner or later, someone will have to make some changes in the way the place is run."

What Workers Say About Stress on the Job

Scope of Stress in the American Workplace

David's and Theresa's stories are unfortunate but not unusual. Job stress has become a common and costly problem in the American workplace, leaving few workers untouched. For example, studies report the following:

One-fourth of employees view their jobs as the number one stressor in their lives. -Northwestern National Life

Three-fourths of employees believe the worker has more on-the-job stress than a generation ago. -Princeton Survey Research Associates

Problems at work are more strongly associated with health complaints than are any other life stressor-more so than even financial problems or family problems. -St. Paul Fire and Marine Innsuance Co.

Fortunately, research on job stress has greatly expanded in recent years. But in spite of this attention, confusion remains about the causes, effects, and prevention of job stress. This booklet summarizes what is known about job stress and what can be done about it.

What Is Job Stress?

Job stress can be defined as the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker. Job stress can lead to poor health and even injury.

The concept of job stress is often confused with challenge, but these concepts are not the same. Challenge energizes us psychologically and physically, and it motivates us to learn new skills and master our jobs. When a challenge is met, we feel relaxed and satisfied. Thus, challenge is an important ingredient for healthy and productive work. The importance of challenge in our work lives is probably what people are referring to when they say "a little bit of stress is good for you.

But for David and Theresa, the situation is different-the challenge has turned into job demands that cannot be met, relaxation has turned to exhaustion, and a sense of satisfaction has turned into feelings of stress. In short, the stage is set for illness, injury, and job failure.

What are the Causes of Job Stress?

Nearly everyone agrees that job stress results from the interaction of the worker and the conditions of work. Views differ, however, on the importance of worker characteristics versus working conditions as the primary cause of job stress. These differing viewpoints are important because they suggest different ways to prevent stress at work.

According to one school of thought, differences in individual characteristics such as personality and coping style are most important in predicting whether certain job conditions will result in stress-in other words, what is stressful for one person may not be a problem for someone else. This viewpoint leads to prevention strategies that focus on workers and ways to help them cope with demanding job conditions.

Although the importance of individual differences cannot be ignored, scientific evidence suggests that certain working conditions are stressful to most people. The excessive workload demands and conflicting expectations described in David's and Theresa's stories are good examples. Such evidence argues for a greater emphasis on working conditions as the key source of job stress, and for job redesign as a primary prevention strategy.

In 1960, a Michigan court upheld a compensation claim by an automotive assemblyline worker who had difficulty keeping up with the pressures of the production line. To avoid falling behind, he tried to work on several assemblies at the same time and often got parts mixed up. As a result, he was subjected to repeated criticism from the foreman. Eventually he suffered a psychological breakdown.

By 1995, nearly one-half of the States allowed worker compensation claims for emotional disorders and disability due to stress on the job [note, however, that courts are reluctant to uphold claims for what can be considered ordinary working conditions or just hard work].
-1995 Workers Compensation Yearbook
NIOSH Approach to Job Stress

On the basis of experience and research, NIOSH favors the view that working conditions play a primary role in causing job stress. However, the role of individual factors is not ignored. According to the NIOSH view, exposure to stressful working conditions (called job stressors) can have a direct influence on worker safety and health. But as shown below, individual and other situational factors can intervene to strengthen or weaken this influence. Theresa's need to care for her ill mother is an increasingly common example of an individual or situational factor that may intensify the effects of stressful working conditions. Examples of individual and situational factors that can help to reduce the effects of stressful working conditions include the following:

Balance between work and family or personal life

A support network of friends and coworkers

A relaxed and positive outlook

NIOSH Model of Job Stress

Job Conditions That May Lead to Stress

The Design of Tasks. Heavy workload, infrequent rest breaks, long work hours and shiftwork; hectic and routine tasks that have little inherent meaning, do not utilize workers' skills, and provide little sense of control.

Example: David works to the point of exhaustion. Theresa is tied to the computer, allowing little room for flexibility, self-initiative, or rest.

Management Style. Lack of participation by workers in decision- making, poor communication in the organization, lack of family-friendly policies.

Example: Theresa needs to get the boss's approval for everything, and the company is insensitive to her family needs.

Interpersonal Relationships. Poor social environment and lack of support or help from coworkers and supervisors.

Example: Theresa's physical isolation reduces her opportunities to interact with other workers or receive help from them.

Work Roles. Conflicting or uncertain job expectations, too much responsibility, too many "hats to wear."

Example: Theresa is often caught in a difficult situation trying to satisfy both the customer's needs and the company's expectations.

Career Concerns. Job insecurity and lack of opportunity for growth, advancement, or promotion; rapid changes for which workers are unprepared.

Example: Since the reorganization at David's plant, everyone is worried about their future with the company and what will happen next.

Environmental Conditions. Unpleasant or dangerous physical conditions such as crowding, noise, air pollution, or ergonomic problems.

Example: David is exposed to constant noise at work.

Job Stress and Health

Stress sets off an alarm in the brain, which responds by preparing the body for defensive action. The nervous system is aroused and hormones are released to sharpen the senses, quicken the pulse, deepen respiration, and tense the muscles. This response (sometimes called the fight or flight response) is important because it helps us defend against threatening situations. The response is preprogrammed biologically. Everyone responds in much the same way, regardless of whether the stressful situation is at work or home.

Short-lived or infrequent episodes of stress pose little risk. But when stressful situations go unresolved, the body is kept in a constant state of activation, which increases the rate of wear and tear to biological systems. Ultimately, fatigue or damage results, and the ability of the body to repair and defend itself can become seriously compromised. As a result, the risk of injury or disease escalates.

In the past 20 years, many studies have looked at the relationship between job stress and a variety of ailments. Mood and sleep disturbances, upset stomach and headache, and disturbed relationships with family and friends are examples of stress-related problems that are quick to develop and are commonly seen in these studies. These early signs of job stress are usually easy to recognize. But the effects of job stress on chronic diseases are more difficult to see because chronic diseases take a long time to develop and can be influenced by many factors other than stress. Nonetheless, evidence is rapidly accumulating to suggest that stress plays an important role in several types of chronic health problems-especially cardiovascular disease, musculoskeletal disorders, and psychological disorders.

Health care expenditures are nearly 50% greater for workers who report high levels of stress.
- Journal of Occupational and Environmental Medicine

Early Warning Signs of Job Stress
Job Stress and Health:
What the Research Tells Us
Cardiovascular Disease
Many studies suggest that psychologically demanding jobs that allow employees little control over the work process increase the risk of cardiovascular disease.

Musculoskeletal Disorders
On the basis of research by NIOSH and many other organizations, it is widely believed that job stress increases the risk for development of back and upper- extremity musculoskeletal disorders.

Psychological Disorders
Several studies suggest that differences in rates of mental health problems (such as depression and burnout) for various occupations are due partly to differences in job stress levels. (Economic and lifestyle differences between occupations may also contribute to some of these problems.)

Workplace Injury
Although more study is needed, there is a growing concern that stressful working conditions interfere with safe work practices and set the stage for injuries at work.

Suicide, Cancer, Ulcers, and Impaired Immune Function
Some studies suggest a relationship between stressful working conditions and these health problems. However, more research is needed before firm conclusions can be drawn.
-Encyclopaedia of Occupational Safety and Health
Stress, Health, and Productivity

Some employers assume that stressful working conditions are a necessary evil-that companies must turn up the pressure on workers and set aside health concerns to remain productive and profitable in today's economy. But research findings challenge this belief. Studies show that stressful working conditions are actually associated with increased absenteeism, tardiness, and intentions by workers to quit their jobs-all of which have a negative effect on the bottom line.

Recent studies of so-called healthy organizations suggest that policies benefiting worker health also benefit the bottom line. A healthy organization is defined as one that has low rates of illness, injury, and disability in its workforce and is also competitive in the marketplace. NIOSH research has identified organizational characteristics associated with both healthy, low-stress work and high levels of productivity. Examples of these characteristics include the following:

Recognition of employees for good work performance

Opportunities for career development

An organizational culture that values the individual worker

Management actions that are consistent with organizational values

Stress Prevention and Job Performance
St. Paul Fire and Marine Insurance Company conducted several studies on the effects of stress prevention programs in hospital settings. Program activities included (1) employee and management education on job stress, (2) changes in hospital policies and procedures to reduce organizational sources of stress, and (3) establishment of employee assistance programs.

In one study, the frequency of medication errors declined by 50% after prevention activities were implemented in a 700-bed hospital. In a second study, there was a 70% reduction in malpractice claims in 22 hospitals that implemented stress prevention activities. In contrast, there was no reduction in claims in a matched group of 22 hospitals that did not implement stress prevention activities.
-Journal of Applied Psychology

According to data from the Bureau of Labor Statistics, workers who must take time off work because of stress, anxiety, or a related disorder will be off the job for about 20 days.
-Bureau of Labor Statistics

What Can Be Done About Job Stress?

The examples of Theresa and David illustrate two different approaches for dealing with stress at work.

Stress Management. Theresa's company is providing stress management training and an employee assistance program (EAP) to improve the ability of workers to cope with difficult work situations. Nearly one-half of large companies in the United States provide some type of stress management training for their workforces. Stress management programs teach workers about the nature and sources of stress, the effects of stress on health, and personal skills to reduce stress-for example, time management or relaxation exercises. (EAPs provide individual counseling for employees with both work and personal problems.) Stress management training may rapidly reduce stress symptoms such as anxiety and sleep disturbances; it also has the advantage of being inexpensive and easy to implement. However, stress management programs have two major disadvantages:

The beneficial effects on stress symptoms are often short-lived.

They often ignore important root causes of stress because they focus on the worker and not the environment.

Organizational Change. In contrast to stress management training and EAP programs, David's company is trying to reduce job stress by bringing in a consultant to recommend ways to improve working conditions. This approach is the most direct way to reduce stress at work. It involves the identification of stressful aspects of work (e.g., excessive workload, conflicting expectations) and the design of strategies to reduce or eliminate the identified stressors. The advantage of this approach is that it deals directly with the root causes of stress at work. However, managers are sometimes uncomfortable with this approach because it can involve changes in work routines or production schedules, or changes in the organizational structure.

As a general rule, actions to reduce job stress should give top priority to organizational change to improve working conditions. But even the most conscientious efforts to improve working conditions are unlikely to eliminate stress completely for all workers. For this reason, a combination of organizational change and stress management is often the most useful approach for preventing stress at work.

Preventing Stress at Work: A Comprehensive Approach

How to Change the Organization to Prevent Job Stress

Ensure that the workload is in line with workers' capabilities and resources.

Design jobs to provide meaning, stimulation, and opportunities for workers to use their skills.

Clearly define workers' roles and responsibilities.

Give workers opportunities to participate in decisions and actions affecting their jobs.

Improve communications-reduce uncertainty about career development and future employment prospects.

Provide opportunities for social interaction among workers.

Establish work schedules that are compatible with demands and responsibilities outside the job.

-American Psychologist
Preventing Job Stress - Getting Started

No standardized approaches or simple "how to" manuals exist for developing a stress prevention program. Program design and appropriate solutions will be influenced by several factors-the size and complexity of the organization, available resources, and especially the unique types of stress problems faced by the organization. In David's company, for example, the main problem is work overload. Theresa, on the other hand, is bothered by difficult interactions with the public and an inflexible work schedule.

Although it is not possible to give a universal prescription for preventing stress at work, it is possible to offer guidelines on the process of stress prevention in organizations. In all situations, the process for stress prevention programs involves three distinct steps: problem identification, intervention, and evaluation. These steps are outlined beginning on page 17. For this process to succeed, organizations need to be adequately prepared. At a minimum, preparation for a stress prevention program should include the following:

Building general awareness about job stress (causes, costs, and control)

Securing top management commitment and support for the program

Incorporating employee input and involvement in all phases of the program

Establishing the technical capacity to conduct the program (e.g., specialized training for in-house staff or use of job stress consultants)

Bringing workers or workers and managers together in a committee or problem-solving group may be an especially useful approach for developing a stress prevention program. Research has shown these participatory efforts to be effective in dealing with ergonomic problems in the workplace, partly because they capitalize on workers' firsthand knowledge of hazards encountered in their jobs. However, when forming such working groups, care must be taken to be sure that they are in compliance with current labor laws.*

*The National Labor Relations Act may limit the form and structure of employee involvement in worker-management teams or groups. Employers should seek legal assistance if they are unsure of their responsibilities or obligations under the National Labor Relations Act.

Steps Toward Prevention

Low morale, health and job complaints, and employee turnover often provide the first signs of job stress. But sometimes there are no clues, especially if employees are fearful of losing their jobs. Lack of obvious or widespread signs is not a good reason to dismiss concerns about job stress or minimize the importance of a prevention program.

Step 1 - Identify the Problem. The best method to explore the scope and source of a suspected stress problem in an organization depends partly on the size of the organization and the available resources. Group discussions among managers, labor representatives, and employees can provide rich sources of information. Such discussions may be all that is needed to track down and remedy stress problems in a small company. In a larger organization, such discussions can be used to help design formal surveys for gathering input about stressful job conditions from large numbers of employees.

Regardless of the method used to collect data, information should be obtained about employee perceptions of their job conditions and perceived levels of

Hold group discussions with employees.

Design an employee survey.

Measure employee perceptions of job conditions, stress, health, and satisfaction.

Collect objective data.

Analyze data to identify problem locations and stressful job conditions.

stress, health, and satisfaction. The list of job conditions that may lead to stress (page 9) and the warning signs and effects of stress (page 11) provide good starting points for deciding what information to collect.

Regardless of the method used to collect data, information should be obtained about employee perceptions of their job conditions and perceived levels of stress, health, and satisfaction. The list of job conditions that may lead to stress (page 9) and the warning signs and effects of stress (page 11) provide good starting points for deciding what information to collect.

Objective measures such as absenteeism, illness and turnover rates, or performance problems can also be examined to gauge the presence and scope of job stress. However, these measures are only rough indicators of job stress-at best.

Data from discussions, surveys, and other sources should be summarized and analyzed to answer questions about the location of a stress problem and job conditions that may be responsible-for example, are problems present throughout the organization or confined to single departments or specific jobs?

Survey design, data analysis, and other aspects of a stress prevention program may require the help of experts from a local university or consulting firm. However, overall authority for the prevention program should remain in the organization.

Step 2 - Design and Implement Interventions. Once the sources of stress at work have been identified and the scope of the problem is understood, the stage is set for design and implementation of an intervention strategy.

In small organizations, the informal discussions that helped identify stress problems may also produce fruitful ideas for prevention. In large organizations, a more formal process may be needed. Frequently, a team is asked to develop recommendations based on analysis of data from Step 1 and consultation with outside experts.

Target source of stress for change.

Propose and prioritize intervention stategies.

Communicate planned interventions to employees.

Implement Interventions.

Certain problems, such as a hostile work environment, may be pervasive in the organization and require company-wide interventions. Other problems such as excessive workload may exist only in some departments and thus require more narrow solutions such as redesign of the way a job is performed. Still other problems may be specific to certain employees and resistant to any kind of organizational change, calling instead for stress management or employee assistance interventions. Some interventions might be implemented rapidly (e.g., improved communication, stress management training), but others may require additional time to put into place (e.g., redesign of a manufacturing process).

Step 3 - Evaluate the Interventions. Evaluation is an essential step in the intervention process. Evaluation is necessary to determine whether the intervention is producing desired effects and whether changes in direction are needed.

Time frames for evaluating interventions should be established. Interventions

Conduct both short- and long-term evaluations.

Measure employee perceptions of job conditions, stress, health, and satisfaction.

Measure employee perceptions of job conditions, stress, health, and satisfaction.

Include objective measures.

Refine the intervention strategy and return to Step 1.

involving organizational change should receive both short- and long-term scrutiny. Short-term evaluations might be done quarterly to provide an early indication of program effectiveness or possible need for redirection. Many interventions produce initial effects that do not persist. Long-term evaluations are often conducted annually and are necessary to determine whether interventions produce lasting effects.

Evaluations should focus on the same types of information collected during the problem identification phase of the intervention, including information from employees about working conditions, levels of perceived stress, health problems, and satisfaction. Employee perceptions are usually the most sensitive measure of stressful working conditions and often provide the first indication of intervention effectiveness. Adding objective measures such as absenteeism and health care costs may also be useful. However, the effects of job stress interventions on such measures tend to be less clear-cut and can take a long time to appear.

The job stress prevention process does not end with evaluation. Rather, job stress prevention should be seen as a continuous process that uses evaluation data to refine or redirect the intervention strategy.

The following pages provide examples of actions some organizations have taken to help prevent stress in their workplaces.
Stress Prevention Programs:
What Some Organizations Have Done

Example 1 - A Small Service Organization. A department head in a small public service organization sensed an escalating level of tension and deteriorating morale among her staff. Job dissatisfaction and health symptoms such as headaches also seemed to be on the rise. Suspecting that stress was a developing problem in the department, she decided to hold a series of all-hands meetings with employees in the different work units of the department to explore this concern further. These meetings could be best described as brainstorming sessions where individual employees freely expressed their views about the scope and sources of stress in their units and the measures that might be implemented to bring the problem under control.

Using the information collected in these meetings and in meetings with middle managers, she concluded that a serious problem probably existed and that quick action was needed. Because she was relatively unfamiliar with the job stress field, she decided to seek help from a faculty member at a local university who taught courses on job stress and organizational behavior.

After reviewing the information collected at the brainstorming sessions, they decided it would be useful for the faculty member to conduct informal classes to raise awareness about job stress-its causes, effects, and prevention-for all workers and managers in the department. It was also decided that a survey would be useful to obtain a more reliable picture of problematic job conditions and stress-related health complaints in the department. The faculty member used information from the meetings with workers and managers to design the survey. The faculty member was also involved in the distribution and collection of the anonymous survey to ensure that workers felt free to respond honestly and openly about what was bothering them. He then helped the department head analyze and interpret the data.

Analysis of the survey data suggested that three types of job conditions were linked to stress complaints among workers:

Unrealistic deadlines

Low levels of support from supervisors

Lack of worker involvement in decision-making.

Having pinpointed these problems, the department head developed and prioritized a list of corrective measures for implementation. Examples of these actions included (1) greater participation of employees in work scheduling to reduce unrealistic deadlines and (2) more frequent meetings between workers and managers to keep supervisors and workers updated on developing problems.

Example 2 - A Large Manufacturing Company. Although no widespread signs of stress were evident at work, the corporate medical director of a large manufacturing company thought it would be useful to establish a stress prevention program as a proactive measure. As a first step he discussed this concept with senior management and with union leaders. Together, they decided to organize a labor-management team to develop the program. The team comprised representatives from labor, the medical/employee assistance department, the human resources department, and an outside human resources consulting firm. The consulting firm provided technical advice about program design, implementation, and evaluation. Financial resources for the team and program came from senior management, who made it clear that they supported this activity. The team designed a two-part program. One part focused on management practices and working conditions that could lead to stress. The second part focused on individual health and well-being.

To begin the part of the program dealing with management practices and job conditions, the team worked with the consulting firm to add new questions about job stress to the company's existing employee opinion survey. The survey data were used by the team to identify stressful working conditions and to suggest changes at the work group and/or organizational level. The employee health and well-being part of the program consisted of 12 weekly training sessions. During these sessions, workers and managers learned about common sources and effects of stress at work, and about self-protection strategies such as relaxation methods and improved health behaviors. The training sessions were offered during both work and nonwork hours.

The team followed up with quarterly surveys of working conditions and stress symptoms to closely monitor the effectiveness of this two-part program.

These examples are based on adaptations of actual situations. For other examples of job stress interventions, see the Conditions of Work Digest, Vol. 11/2, pp. 139-275. This publication may be obtained by contacting the ILO Publications Center at P.O. Box 753, Waldorf, MD 20604 (Telephone: 301-638-3152). Or call NIOSH at 1-800-35-NIOSH.

Need Additional Information?
More about NIOSH

National Institute for Occupational Safety and Health
4676 Columbia Parkway
Cincinnati, Ohio 45226-1998

NIOSH provides information and publications about a wide range of occupational hazards, including job stress at Job Stress, call 1-800-CDC-INFO, or order online at http://wwwn.cdc.gov/pubs/niosh.aspx

More Information about Job Stress:

The Encyclopaedia of Occupational Health and Safety, 4th Edition
(ISBN 92-2-109203-8) contains a comprehensive summary of the latest scientific information about the causes and effects of job stress (see Vol. 1, Chapter 5, Mental Health; Vol. 2, Chapter 34, Psychosocial and Organizational Factors).

International Labour Office (ILO) Publications Center) 301-638-3152
P.O. Box 753
Waldorf, MD 20604

Other Publications about Job Stress Go to the NIOSH job stress internet site, or call the NIOSH 800 number (1-800-35-NIOSH).

Location of a Psychologist or Consultant in Your Area
American Psychological Association (APA) 1-800-964-2000
750 First St., N.E. fax: 202-336-5723
Washington, DC 20002-4242

State psychological associations maintain a listing of licensed psychologists who may be able to help with stress-related issues. Call the APA or your State psychological association for more information, or refer to the APA internet siteExternal with this information .

Sources Used in Preparing This Document

1995 Workers' Compensation Year Book
Elisburg D [1995]. Workplace stress: legal developments, economic pressures, and violence. In: Burton JF, ed. 1995 Workers' Compensation Year Book.
Horsham, PA: LRP Publications, pp. I-217-I-222.

American Psychologist
Sauter SL, Murphy LR, Hurrell JJ, Jr. [1990]. Prevention of work-related psychological disorders. American Psychologist 45(10):1146-1158.

Bureau of Labor StatisticsExternal
Tabular data, 1992-96: Number and percentage distribution of nonfatal occupational injuries and illnesses involving days away from work, by nature of injury or illness and number of days away from work. Date accessed: 1998.

Encyclopaedia of Occupational Health and Safety
Sauter S, Hurrell J, Murphy L, Levi L [1997]. Psychosocial and organizational factors. In: Stellman J, ed. Encyclopaedia of Occupational Health and Safety. Vol. 1. Geneva, Switzerland: International Labour Office, pp. 34.1-34.77.

Families and Work Institute
Bond JT, Galinsky E, Swanberg JE [1998]. The 1997 national study of the changing workforce. New York, NY: Families and Work Institute.

Journal of Applied Psychology
Jones JW, Barge BN, Steffy BD, Fay LM, Kuntz LK, Wuebker LJ [1988]. Stress and medical malpractice: organizational risk assessment and intervention. Journal of Applied Psychology 73(4):727-735.

Journal of Occupational and Environmental Medicine
Goetzel RZ, Anderson DR, Whitmer RW, Ozminkowski RJ, Dunn RL, Wasserman J, Health Enhancement Research Organization (HERO) Research Committee [1998]. The relationship between modifiable health risks and health care expenditures: an analysis of the multi-employer HERO health risk and cost database. Journal of Occupational and Environmental Medicine 40(10).

Northwestern National Life (now ReliaStar Financial Corporation)
Northwestern National Life Insurance Company [1991]. Employee burnout: America's newest epidemic. Minneapolis, MN: Northwestern National Life Insurance Company. (Note: This reference is the source for the statistics cited on page 5.)

Northwestern National Life Insurance Company [1992]. Employee burnout: causes and cures. Minneapolis, MN: Northwestern National Life Insurance Company. (Note: This reference is the source for the information presented in the graph on page 4.)

Princeton Survey Research Associates
Princeton Survey Research Associates [1997]. Labor day survey: state of workers. Princeton, NJ: Princeton Survey Research Associates.
St. Paul Fire and Marine Insurance Company
St. Paul Fire and Marine Insurance Company [1992]. American workers under pressure technical report. St. Paul, MN: St. Paul Fire and Marine Insurance Company.

Yale University
Barsade S, Wiesenfeld B, The Marlin Company [1997]. Attitudes in the American workplace III. New Haven, CT: Yale University School of Management.

Disclaimer

Mention of any company name or product does not constitute endorsement by the National Institute for Occupational Safety and Health.
This document is in the public domain and may be freely copied or reprinted.

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The nature of work is changing at whirlwind speed. Perhaps now more than ever before, job stress poses a threat to the health of workers and, in turn, to the health organizations. Through its research program in job stress and through educational materials such as this booklet, NIOSH is committed to providing organizations with knowledge to reduce this threat.

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Fact Sheets, Books, and Tools

Healthy Work Campaign Tools for employers, union organizers and working individuals to create and sustain a healthy workplace

CPH-News & Views
Written by CPH-NEW investigators, CPH-News & Views is a semi-monthly column on emerging topics related to healthy workplaces.

Fact Sheet- Introduction to Job Stress (pdf)
Developed by CPH-NEW, this fact sheet gives an overview of job stress including: Prevalence of job stress, signs and symptoms of job stress, health effects of job stress, suggestions for designing healthier jobs, examples of workplace stressors, and more.

Fact Sheet- Business Case for Addressing Job Stress (pdf)
Developed by CPH-NEW, this fact sheet outlines the financial costs of job stress resulting from various aspects of workplace stress including:Turnover, health insurance, absenteeism, depressive illness, and more.

Job Stress Intervention Guide (pdf) Developed by CPH-NEW, the purpose of this intervention guide is to assist workplace health and safety practitioners use a participatory approach to design, implement, and evaluate comprehensive stress prevention and control strategies for the workplace. The information contained in this guide coordinates with CPH-NEW Intervention, Analysis and Design Scorecard (IDEAS) tool, available as part of the Healthy Workplace Participatory Program toolkit.

NIOSH- Stress At Work Booklet (pdf)
This booklet provides information pertaining to what job stress is, causes of job stress, job conditions that may lead to stress, job stress and health, warning signs, stress and productivity, prevention, and examples of what some organizations have done to reduce job stress.

This informational blog post provides insights into compassion fatigue, secondary trauma, moral distress, and burnout in the healthcare workers. The blog also discusses how to recognize determinants of workplace stress and how to form healthy habits for self-care and improvement. Additionally, the resource provides strategies to overcome barriers raised by workplace stress.

APA: Mind/Body Health
This interactive tool shows how stress affects your body's physical health.

HelpGuide: Stress at Work: How to Reduce and Manage Job and Workplace Stress
Informational webpage that describes coping with work stress in today's uncertain climate, warning signs of excessive stress at work, ways to reduce job stress, and what managers or employers can do to reduce stress at work.

HelpGuide: Stress Management: How to Reduce, Prevent and Cope with Stress
This informational webpage describes ways that individuals can reduce, prevents, and cope with stress. Topics include: Identify the sources of stress in your life and look at how you currently cope with stress. Additionally, the site provides various stress management strategies.

Sloan Work and Family Research Network
This website provides various fact sheets that address topics such as: flexible work schedules, low wage workers, health and workplace flexibility, older workers, overwork, part-time work, shift work, and more.

Unhealthy Work: Causes, Consequences, and Cures
Schnall, P.L., Dobson, M., Rosskam, E.(2009). Baywood Publishing Inc., Amityville, NY.
This is an interdisciplinary book that examines the changing nature of work, new evidence linking work conditions with ill-health, and unhealthy work as a public health problem.

Wellness Council of America
This website provides resources for improving worksite wellness and is dedicated to helping organizations build and sustain results-oriented wellness programs. Some of their resources include: reports, interviews, case studies, presentations, surveys, and more.

Healthy Work: Stress, productivity and the reconstruction of working life. (1992). Karasek, R., Theorell, T.Basic Books, Inc. New York, NY.
This book analyzes various stress/work studies done in America and Europe.The authors discuss various ways to deal with the lack of worker participation in decision-making on the job. The authors conclude that the well-being of employees can and must be enhanced through meaningful involvement in formulating the manner and mode of their tasks.

Working on Empty is a transmedia and film project intended to address the "silent epidemic" of work-related illness and death in America. This website highlights facts about work stress and death and emphasizes the need to change the work culture in America to prevent unhealthy work stressors.

Surveys

Copenhagen Psychosocial Questionnaire (COPSOQ) - A psychosocial risk assessment tool designed for use in businesses to assess the need for action and to help the decision making process on preventive measures at the workplace level. The questionnaire was developed in 2000, and is available in 25 languages.

Stress Assess survey questionnaire (Occupational Health Clinics for Ontario Workers) - This survey is based on COPSOQ and is customized to address concerns within the Canadian workplace. This survey is available in "personal edition" for individual workers and "workplace edition" for people who want to administer the survey with employees in their organization.

The Job Content Questionnaire - The JCQ is an instrument created by Karasek, R., et al. for internationally comparative assessments of psychosocial job characteristics.

Karasek, R., Brisson, C., Kawakami, N., Houtman I., Bongers, P., Amick, B. (1998). The job content questionnaire (JCQ): An instrument for internationally comparative assessments of psychosocial job characteristics. Journal of Occupational Health Psychology, 3(4), 322-355 (PubMed).

NIOSH Quality of Worklife Questionnaire
This 76-item questionnaire is available in the public domain; questions deal with a wide assortment of work organization issues, such as hours of work, workload, worker autonomy, layoffs and job security, job satisfaction/stress, and worker well-being. Normative data are available by industry using personal interview data collected in the Fall/Winter of 2002; the final dataset contains responses from 2,765 persons. Download the PDF version of the survey from theNIOSH website.

Landsbergis, P.A., Schnall, P.L., Pickering, T.G., &Schwartz, J.E.(2002). Validity and reliability of a work history of a work history questionnaire derived from the Job Content Questionnaire. Journal of Occupational and Environmental Medicine, 44(11), 1037-1047 (PubMed).

Siegrist, J., Starke, D., Chandola, T., Godin, I., Marmot, M., Niedhammer, I., et al. (2004).The measurement of effort-reward imbalance at work: European comparisons.Social Science & Medicine, 58(8), 1483-1499. (PubMed)

NIOSH Quality of Worklife Questionnaire. This 76-item questionnaire targets a variety of work-life topics such as hours of work, workload, worker autonomy, layoffs/job security, job satisfaction, stress, and worker well being.

Working on Wellness Toolkit (pdf).Massachusetts Department of Public Health. This toolkit provides employers with ways to promote and protect the health and well-being of the organization. It contains a sample work site health improvement survey that focuses on company policies and programs, including those addressing stress.

Belkic, K. (2003).The occupational stress index: An approach derived from cognitive ergonomics and brain research for clinical practice. Cambridge International Science Publishing.

American Institute of Job Stress: Job Stress Questionnaire
How much job stress do you have? Use this Likert scale questionnaire to assess how much stress you have.

APA: Stress Smarts Quiz
Quick, six question quiz about health and stress. After each answer is revealed, there is short synopsis of how the body is affected by stress.

Presentation Materials

Beyond Breathing: Organizational Approaches to Reduce Job Stress (pdf)
Nicole Champagne, Suzanne Nobrega, University of Massachusetts Lowell. Workshop given to the Ounce of Prevention Conference, October 21, 2008.

Work Organization, Stress, the Changing Nature of Work, and Cardiovascular Disease: Part I; Part II
Paul Landsbergis, PhD, MPH, Department of Community and Preventive Medicine, Mt Sinai School of Medicine, New York, NY. Presentation given to the Partnership for a Heart Healthy, Stroke-Free MA annual meeting, June 2, 2006.

Work Stressors: Causes, Consequences, and Cures (pdf)
Peter L. Schnall, MD, MPH, Professor of Medicine, University of CA Irvine and Director of the Center for Social Epidemiology. Presentation given to the Partnership for a Heart Healthy, Stroke-Free MA annual education conference, January 30, 2009.

Videos

Working With Stress
This is a NIOSH training and educational video program on the topic of workplace stress. It, "describes workplace factors that can create or exacerbate worker stress, and suggests practical measures for reducing job-related stress through changes in work organization" (17 minutes).

Stress: Portrait of a Killer
In this video, Stanford neurobiologist and author Robert Sapolsky compares the stress response of humans to animals of Africa. It reveals how dangerous prolonged exposure to stress can be, while explaining that "today, we turn on the same life-saving physical reaction to cope with intense, ongoing stressors - and we can't seem to turn it off" (5 minutes).

Organizations Focused on Job Stress

These websites are excellent sources for tools and guidelines that help employers implement workplace changes to reduce stress:

Reports

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Healthy Work Campaign Tools for employers, union organizers and working individuals to create and sustain a healthy workplace CPH-News & Views Written by CPH-NEW investigators, CPH-News & Views is a semi-monthly column on emerging topics related to healthy workplaces.

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The duty of an employer to carry out risk assessments - defined by the Health and Safety Executive (HSE) as 'identifying sensible measures to control the risks in your workplace' - is one that all employers will be aware of. Ensuring that a workplace is safe for staff members, taking note of hazards such as working with chemicals, electricity, or heavy machinery is required by law under the Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulations 1999.

However, including work-related stress as part of these risk assessments may not be something employers regularly do. Identifying factors that may be causing work-related stress and then taking action to reduce these hazards is often harder to define than, for example, ensuring all staff members are wearing the correct safety equipment when working with hazardous chemicals.

However, effectively managing stress in the workplace can have huge benefits for organisations. HSE estimates that stress, depression or anxiety and musculoskeletal disorders account for the majority of days lost due to work-related ill health: 9.9 million days a year. Each new case of stress leads to an average of 23 days off work, leaving employers without valued members of staff for significant periods of time.

Carrying out a stress risk assessment is a good way of tackling workplace stress before it becomes a more substantial issue. HSE's Management Standards for work-related stress gives a good overview of things to consider, and on the Fit for Work advice hub, there is a detailed questionnaire and form that employers can use to carry out a thorough assessment of what may be causing stress in the workplace. This questionnaire identifies risks for employers - such as:

Are staff comfortable with the amount of work they have?

Have employees received appropriate training to ensure they can do their job properly?

Do employees feel comfortable in raising concerns with managers?

Do staff feel they are being offered adequate managerial support?

The questionnaire then suggests ways to mitigate said risks, by:

Adjusting work patterns to cope with busy periods

Reviewing training needs

Taking time to understand the challenges your team members are facing

Encourage staff to share any concerns with you

The benefits of tackling stress in the workplace are clear. The quality of working life for your employees will be better; their productivity and morale will increase; their attendance levels will go up and sickness absence will go down - all benefits which will have a direct impact on how smoothly your company runs. Visit the Fit for Work advice hub to download the stress risk assessment form or get more information on managing stress, or call the Fit for Work advice line on 0800 032 6235 to speak to a trained advisor.

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The duty of an employer to carry out risk assessments - defined by the Health and Safety Executive (HSE) as 'identifying sensible measures to control the risks in your workplace' - is one that all employers will be aware of.

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Workplace Stress - The American Institute of Stress

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Workplace Stress Are you experiencing workplace stress?
The Free AIS Workplace Stress Scale (WSS) was developed in 1978 and modified in 2022
to serve as a preliminary screening measure

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Many organizations think that employee well-being is, well, none of their business. And there's some sense to that -- well-being does seem ill-defined, private, and ultimately unmanageable. According to Tom Rath, leader of Gallup's workplace research and leadership consulting practice, and Jim Harter, Gallup's chief scientist for workplace management and well-being, it's not. But well-being is gravely misunderstood.

Rath, Harter, and teams of Gallup researchers spent years studying well-being to find out what it is and how to increase it. They surveyed people in more than 150 countries; partnered with leading economists, psychologists, sociologists, and physicians; and conducted and studied in-depth well-being research. Ultimately, as Rath and Harter wrote in their New York Times and Wall Street Journal bestseller Wellbeing: The Five Essential Elements -- well-being is the fulfillment of five distinct factors. (See sidebar "The Five Essential Elements of Well-Being.")

The Five Essential Elements of Well-Being

For more than 50 years, Gallup scientists have been exploring the demands of a life well-lived. More recently, in partnership with leading economists, psychologists, and other acclaimed scientists, Gallup has uncovered the common elements of well-being that transcend countries and cultures. This research revealed the universal elements of well-being that differentiate a thriving life from one spent suffering. They represent five broad categories that are essential to most people:

Rath and Harter discovered these core dimensions to be "universal and interconnected elements of well-being, or how we think about and experience our lives." When those factors are fully realized, people thrive -- and so do businesses.

In the U.S., the average sick day costs a business about $348 in lost productivity, according to the Bureau of Labor Statistics and a study published in 2003 in the Journal of Occupational and Environmental Medicine. When we adjust this number because people are sick on weekends and non-working days and because some work does get done on sick days, the cost is still approximately $200 per sick day. But people with high levels of well-being get sick less often; as a result, they cost their organizations less.

Among the most "suffering" employees -- those with the lowest well-being scores -- the annual per-person cost of lost productivity due to sick days is $28,800. For workers who are at the midpoint of the "struggling" zone, the cost is $6,168. But for employees with the highest levels of well-being -- those with the highest scores in the "thriving" category -- the cost of lost productivity is only $840 a year.

Another recent study compared the disease burden -- or the incidence of high blood pressure, high cholesterol, heart disease, back pain, diabetes, depression/anxiety, and sleep apnea/insomnia -- of 662 people with varying levels of well-being. For each disease, Gallup entered the average annual cost into its database -- and after adjusting for demographic differences -- found that respondents in the thriving category averaged $4,929 per person annually in disease burden cost versus $6,763 a year for respondents in the struggling and suffering categories. That's a 37% per-person cost differential. In other words, for an organization with 1,000 workers, thriving employees cost their employers $1.8 million less every year.

And if that weren't startling enough, Gallup tracked changes in disease burden from 2008 to 2009 for the same group of 662 people. Gallup studied the relationship between well-being and recent changes in disease burden and found that the average annual new disease burden cost for people who are thriving is $723, compared with $1,488 for those who are struggling or suffering.

Clearly, it's in an organization's best interest to keep its employees healthy. But well-being is comprised of five interrelated elements. Pushing one dimension of well-being at the expense of the other elements won't improve well-being very much. To reap the most benefits from thriving employees, organizations should pay attention to all five elements.
Career and engagement
Career Well-Being is a natural place to begin -- and it might be the best place to start too. "Most people don't realize how closely intertwined their Career Well-Being is with their overall evaluation of their life and daily experiences," says Harter. "Our research suggests that this may be the single most important element of one's well-being."

Simple motivational techniques, such as recognition for goal achievement, go a long way toward enhancing Career Well-Being.

Career Well-Being doesn't necessarily refer to paid work. Rath and Harter note that stay-at-home parents and devoted volunteers can have high levels of Career Well-Being. But to be engaging, work does have to provide "interest and purpose and the chance to use your strengths regularly," as Harter says. "We spend more of our waking hours at work than anywhere else, so work really needs to provide that outlet." That's why, Rath and Harter suggest, it's a seminal element of well-being. And that might also be why they found a strong connection between employee engagement and well-being. Engaged employees have a sense of purpose and get to do what they do best every day. (See "Feedback for Real" in the "See Also" area on this page.)

Whether or not engaged employees have high levels of well-being -- though it's realistic to expect that engagement naturally promotes well-being -- these workers are an organization's best asset. Workgroups with many engaged employees realize substantially higher levels of customer engagement, productivity, and profitability compared to teams with less engaged employees. And engaged teams have less absenteeism, lower turnover, fewer accidents on the job, less theft or unaccounted for merchandise, and fewer quality defects.

Engaged employees who are thriving in Career Well-Being are twice as likely as actively disengaged employees to be thriving in their lives overall. In contrast, people in disengaged workgroups are nearly twice as likely to be diagnosed with depression, have higher stress levels, and are at greater risk for heart disease. And perhaps not coincidentally, engaged employees are 21% more likely than actively disengaged employees to get involved in a wellness program offered by their employers. This relationship between engagement at work and involvement in wellness programs is consistent across body mass index (BMI) groups (normal, overweight, and obese) and people with and without disease burden. In other words, even among people who are classified as obese and those who have pre-existing disease burden, those with higher Career Well-Being are more likely to become involved in wellness programs that are offered.

There are many ways organizations can improve Career Well-Being. Leaders and managers can help employees connect their work to a higher purpose and focus on employee strengths, which can reduce active disengagement. Even simple but powerful motivational techniques, such as recognition for goal achievement, go a long way toward enhancing Career Well-Being.
Socializing is good for business
While considering the performance boost inherent in higher Career Well-Being, employers should also think about employees' Social Well-Being. Even though socializing may sound antithetical to workplace productivity, Gallup found that socializing at work is actually good for business. "Among those with thriving Social Well-Being," says Rath, "49% were thriving in their careers." Moreover, Gallup has found that employees who say they have a best friend at work are seven times more likely to be engaged in their work. Those who don't feel that way have a mere 1 in 12 chance of being engaged. Yet only 5% of workers strongly agree that their organization helps them build stronger personal relationships. (See graphic "The Benefits of the Water Cooler.")

Nevertheless, it can still be galling for managers to watch employees chatting around the coffee pot when they should be working. The research, however, indicates that office chit-chat serves a productive purpose. "We cite an interesting finding in the book that came from a team at MIT," says Harter. "They studied people who were just walking around different office settings and found that the social cohesiveness created by conversations that weren't at all work-related actually helped boost workplace productivity." (See "News Flash: Workplace Socializing Is Productive" in the "See Also" area on this page.)

Furthermore, Gallup's research shows that to have a thriving day, people need six hours of social time. Few organizations would condone six hours of surfing Facebook on the company dime, but employers can promote Social Well-Being and organizational goals through social activities -- such as mentoring programs and development opportunities -- that can produce important business results.
The money issue
It's logical to assume that organizations are central to employees' Financial Well-Being -- employers issue paychecks, after all, and people rely on those paychecks to meet their needs. But Financial Well-Being is more about financial security than monetary compensation. In fact, Gallup's studies show that financial security has nearly three times the impact of income alone on employees' overall well-being.

That's why pay itself doesn't necessarily correlate to engagement or well-being -- and neither do pay raises. However, if employees don't "perceive their pay to be fair and equitable," says Rath, "it can lead to disengagement and cause them to leave when a better job comes along." There's also the impact of financial worries on employees' mental and physical health. Low Financial Well-Being can lead to stress, anxiety, insomnia, headaches, and depression. And those are costly problems.

Ironically, most organizations don't seem to promote their employees' Financial Well-Being.

Ironically, most organizations don't seem to promote their employees' Financial Well-Being very well. Only 6% of employees strongly agree that their organization does things to help them manage their finances more effectively. But business might be uniquely -- perhaps perfectly -- situated to improve employees' Financial Well-Being. Financial security is integral to well-being, and most organizations offer investment, profit sharing, or savings opportunities.

One way organizations can improve their employees' Financial Well-Being is to make the default setting of savings programs opt-out rather than opt-in. For example, most employees won't participate in a retirement plan if they have to consciously opt in. But when the default is for employees to be automatically enrolled, more than 80% participate in the retirement plan.

Furthermore, according to Rath and Harter, spending money on experiences or on others does more to increase people's Financial Well-Being than spending on things or on themselves. "With experiences, you get a lot of value. There's the anticipation of the experience beforehand, for months beforehand sometimes," says Rath. "Then you get the actual experience itself. And then you usually have fond memories of the experience afterward." For that reason, it might be wise to encourage workers to use their vacation time for actual vacations.
Physical effects
Clearly, doing things like encouraging vacations offers psychic benefits. But Physical Well-Being matters too. As insurance costs have increased, many organizations have made efforts toward improving health in the workplace, and that's wise. Those efforts will be even more effective, however, if the organization reinforces healthy behaviors by making healthy choices easy and unhealthy choices hard. Gallup found that only 9% of U.S. employees say it is very easy to find healthy food at their workplace, and fewer than 5% say their organizations offer financial incentives for leading a healthier lifestyle.

While many leaders focus on the direct costs associated with paying for their employees' medical care -- such as prescription drugs, doctor visits, hospital stays, and insurance premiums -- employees with low Physical Well-Being could be taking an even larger economic toll. When someone with struggling Physical Well-Being shows up for work, it is highly unlikely that he or she has the energy to achieve as much as an employee with thriving Physical Well-Being can. And employees with high Physical Well-Being simply have more energy and get more done in less time. They are also more likely to be in a good mood, thus boosting the engagement of their colleagues and customers.

Offering incentives for lowered cholesterol and providing more vegetables in the cafeteria is a good place to start. But subtler changes can help too -- and can be as simple as designing workspace layouts so people have to walk a little farther every day, sponsoring workgroup athletic events, or hiring a chef for a monthly demonstration of healthy cooking. Organizations can't mandate health, but they can direct employees to changes that outlast the workday.
Community outreach
Organizations can also direct employees to look outward into the larger community. That's because having employees who are thriving in Community Well-Being improves an organization's image and increases its positive impact on the community. On the other hand, when organizations run their business in isolation, they miss out on potential gains in Community Well-Being for their employees and organization.

This aspect of well-being may be the most familiar to business: Organizational leaders have a long history of service in their communities, and many organizations actively support local philanthropic projects -- and sometimes their employees' chosen charities as well. When organizations invest in employees, employees contribute more to their communities. In one study, Gallup found that people in the most engaged workgroups (those in the top quartile of Gallup's employee engagement database) were 56% more likely to give money to the community, and they gave 2.6 times more money than people on less engaged teams (those in the bottom quartile).

Corporate support for community initiatives can result in positive customer relations and recruiting outcomes. Such behaviors can also improve employee well-being by creating the opportunity for social connections and local involvement.
Improving well-being
Some organizations offer health promotion programs. Others actively encourage giving back to the community through donating time or money. And a few take a hand in encouraging employee Financial Well-Being. But for the most part, the crucial activities that promote well-being are left to employees.

Because employee well-being has such a large impact on organizational well-being, businesses would be wise to measure and manage it. Fortunately, many organizations do have programs in place that affect well-being. But the well-being factor -- if it's recognized at all -- isn't leveraged as well as it could be. Businesses that manage well-being consciously, consistently, and with an eye toward improving key outcomes are more likely to have a profound influence on organizational and employee well-being.

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Many organizations think employee well-being is none of their business. That's understandable: Well-being does seem ill-defined, private, and ultimately unmanageable. But according to the authors of a new national bestseller, executives should care about employee well-being because it's good for people and for productivity.

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The TED talks and the ecological model are useful to help with implementation and planning of a worksite health promotion programs. The social contagion theory described by James Fowler (2010) and Nicholas Christakis (2010) can be used to show the importance of having a wellness committee in place. Social contagion theory describes that people are influenced by their friends and family. These networks have the ability to impact and change a persons behaviors. Knowing this, the people who represent the wellness committee can influence and help change the behaviors of employees. When the wellness committee start to exhibit new, healthy behaviors, they are not only making their lives better but also the lives of their friends and families. Social networks have the potential to change people’s lives which can be very helpful when trying to increase engagement and change behaviors through a wellness program. The ecological model is helpful because it shows that the company needs to examine the larger context in which the health issues were created and not just on the individual level (WCHPC, 2014). This can be very helpful during the planning process as it helps program developers look at all the factors that can contribute to unhealthy lifestyles. Once these factors have been examined, the developers are able to have a better understanding of which areas to focus on.

The Total Worker Health (TWH) program does prove to be beneficial in addressing worksite health and wellness. TWH focuses on a holistic approach to determine risk factors related to the work environment that are not benefiting the employee, employer, or nation (CDC, 2017). This program helps protect the well-being of employees through work-related safety that prevents injury's and illness (CDC, 2017). It also focuses on the social determinants of health that can affect an employees well-being (CDC, 2017). This is important because well-being at work is not just about having a safe environment to work. It’s also involves employee’s workload and stress levels, pay rates, paid time off, and health promotion in the workplace. TWH shows employers that health and wellness goes beyond the physical aspects and programs need to focus on the overall well-being of employees.

The theories and models discussed in this weeks lesson can be useful in developing an assessment tool to help plan for a worksite wellness program. The theories and models discuss the importance of social connections and assessing the environment as a whole. Surveys can be developed to help assess the workplace environment and the social relationships at work. This type of tool would be useful for my Briefcase project because it can help with determining the initial areas to focus on for the program. This tool can give a good overview of how the employees perceive their work environment and gives areas to improve. Since my topic is focusing on stress, I think learning about any stressful factors in the work environment would be beneficial. It would be a good starting point for my research.

Centers for Disease Control and Prevention. (2017). What is total worker health? Retrieved from: https://www.cdc.gov/niosh/twh/default.html

Christakis, N. (2010, February). The hidden influence of social networks [Video file]. Retrieved from: https://www.ted.com/talks/nicholas_christakis_the_hidden_influence_of_social_networks

Fowler, J. (2010, March 17). James Fowler: Power of networks [Video file]. Retrieved from: https://www.youtube.com/watch?v=zkmsjFisW_A

Women and Children Health Policy Center (WCHPC). (2014, September 11). An introduction to the ecological model in public health [Video file]. Retrieved from: https://www.youtube.com/watch?time_continue=3&v=Rm00AzC-gEU

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CDC - Essential Elements of Effective Workplace Programs - NIOSH Total Worker Health

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This document, a key part of Total Worker Health ®, is intended as a guide for employers and employer-employee partnerships wishing to establish effective workplace programs that sustain and improve worker health.

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giving guidance on how to create surveys/assessments

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As companies increasingly face rising health costs and competition, comprehensive workplace health programs are becoming more widely used as a strategy for impacting employee health and productivity and, in turn, corporate bottom lines.

Comprehensive workplace health programs aim to reach employees through a variety of ways, including workplace policies, benefits, environmental changes, and programs and services available for employees, spouses, and dependents.

However, each company and its employees is unique and the strategies used to address employee health will vary from company to company based on the resources available, needs and interests of management and employees, and health issues that are priorities.

A key question for wellness coordinators to ask is: How do you know which workplace health strategies will be most valuable for your particular company to implement?

Developing a comprehensive employee workplace health program, or making improvements to an existing one, requires an understanding of what impacts the health of employees at the worksite.

What is workplace health assessment

A workplace health assessment is a process of gathering information about the factors that support and/or hinder the health of employees at a particular workplace and identifying potential opportunities to improve or address them

A workplace health assessment helps to identify the current picture of health at a company as well as ways to improve it that can potentially increase productivity, decrease absenteeism, and control health care costs for both employees and the organization as a whole

It is a necessary first step before goals are developed, resources allocated, strategies adopted and interventions implemented, employees participate, and outcomes are measured

Factors influencing workplace health1, 2

Many factors influence health in the workplace and can be impacted by supportive changes within the following levels of influence:

Individual - elements of an employee's health, such as their health behaviors, health risk factors such as high blood pressure, and current health status

Interpersonal - elements of an employee's social network including relationships with managers, coworkers, and family that provide support; mentoring or role models

Organizational - elements of the workplace structure, culture, practices and policies such as benefits, health promotion programs, work organization, and leadership and management support for workplace health and safety initiatives

Environmental - elements of the physical workplace such as facilities and settings where employees work as well as access and opportunities for health promotion provided by the surrounding community where employees live

How to conduct workplace health assessment

A workplace health assessment involves learning about a workplace and the health of its employees. Employee health is determined by a complex set of interactions between the individual and their social, cultural, and physical environments and can be influenced in many ways. It is important to assess employee health from a number of perspectives using multiple sources of data to gain a more complete picture of the determinants of health. For example, reviewing health care costs will provide information on which health conditions are the biggest contributors to the total, but do not provide insight into what factors contribute to those conditions.

The types of data sources that will be available will depend on the workplace. Some data is readily available, other data may need to be requested from a third party, and some may not be currently available requiring a decision whether to collect it or not. The types of data sources used to gather information in a workplace health assessment may include:

Site visits
Site visits are in person observations of the workplace setting and includes interviews with managers and employees to discuss health attitudes and beliefs; and review health promotion programs and policies; and evaluate the worksite environment for health risks

Employee surveys
Examples ofemployee surveys include Health Risk Appraisals; employee satisfaction and interest surveys; safety surveys and routine inspections

Health benefits
The type ofcoverage and covered services employee receive under the health plan; vacation and sick time; access to health promotion programs

Health care and pharmaceutical claims
A source for identifying the common health conditions and procedures for which employees are seekinghealth care and their costs

Other data sources
Examples includetime and attendance; injury; and participation in, satisfaction with, or outcomes from other employee health programs

Other data sources may also provide information that will be useful for designing and evaluating a workplace health program. Such data sources include data on injury prevalence, causes and workers compensation; absenteeism; use of existing health programs such as EAP or fitness facilities. A possible list of data sources is provided in table below.

Other Additional Sources of Data Relevant to Worksite Health

Number of injuries, percentage of employees with injuries, cost of injuries, days lost by types of injuries, time to return to work

By worksite
By unit

Site Database
OHSA template

Use of EAP

Number of employees and number of sessions and cost by presenting problem

By worksite By unit

EAP Vendor Activity Summary

Job Satisfaction

Ratings of Job Satisfaction, Communication, and Support

By worksite By unit

Employee Engagement Survey

Tools and Resources

Key questions

Overall, a workplace health assessment can help make connections between the various types of risk factors affecting employee health at the individual, intrapersonal, organizational, and environmental levels that are supported through multiple pieces of data. It will help develop a deeper profile of what is going on at a workplace to help inform a workplace health improvement plan for initiating a workplace health program or making enhancements to an existing program. The key questions a workplace health assessment can help answer are:

What are the key health issues affecting employees?

What factors at the worksite influence employee health?

What are the employees' health and safety concerns?

What strategies are most appropriate to address these health issues?

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Work@Health® is an employer-based training program. The ultimate aim of the program is to improve the organizational health of participating employers and certified trainers, with an emphasis on strategies to reduce chronic disease and injury risk to employees and an eye to improving overall worker productivity.

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Links to planning steps

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Stats on how much money can be saved and examples of companies with successful programs

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Stats on how much money can be saved and examples of companies with successful programs

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The Idea in Brief

Employee wellness programs have often been viewed as a nice extra, not a strategic imperative. But the data show otherwise. The ROI on comprehensive, well-run employee wellness programs can be as high as 6 to 1.

The most successful programs have six essential pillars: engaged leadership at multiple levels; strategic alignment with the company's identity and aspirations; a design that is broad in scope and high in relevance and quality; broad accessibility; internal and external partnerships; and effective communications.

Companies in a variety of industries have included all six pillars in their employee wellness programs and have reaped big rewards in the form of lower health care costs, greater productivity, and higher morale.

Since 1995, the percentage of Johnson & Johnson employees who smoke has dropped by more than two-thirds. The number who have high blood pressure or who are physically inactive also has declined-by more than half. That's great, obviously, but should it matter to managers? Well, it turns out that a comprehensive, strategically designed investment in employees' social, mental, and physical health pays off. J&J's leaders estimate that wellness programs have cumulatively saved the company $250 million on health care costs over the past decade; from 2002 to 2008, the return was $2.71 for every dollar spent.

Wellness programs have often been viewed as a nice extra, not a strategic imperative. Newer evidence tells a different story. With tax incentives and grants available under recent federal health care legislation, U.S. companies can use wellness programs to chip away at their enormous health care costs, which are only rising with an aging workforce.

Our extensive research on workplace wellness has led us to arrive at this definition of it: an organized, employer-sponsored program that is designed to support employees (and, sometimes, their families) as they adopt and sustain behaviors that reduce health risks, improve quality of life, enhance personal effectiveness, and benefit the organization's bottom line.

Government incentives or not, healthy employees cost you less. Doctors Richard Milani and Carl Lavie demonstrated that point by studying, at a single employer, a random sample of 185 workers and their spouses. The participants were not heart patients, but they received cardiac rehabilitation and exercise training from an expert team. Of those classified as high risk when the study started (according to body fat, blood pressure, anxiety, and other measures), 57% were converted to low-risk status by the end of the six-month program. Furthermore, medical claim costs had declined by $1,421 per participant, compared with those from the previous year. A control group showed no such improvements. The bottom line: Every dollar invested in the intervention yielded $6 in health care savings.

We've found similar results in our own experience. In 2001 MD Anderson Cancer Center created a workers' compensation and injury care unit within its employee health and well-being department, staffed by a physician and a nurse case manager. Within six years, lost work days declined by 80% and modified-duty days by 64%. Cost savings, calculated by multiplying the reduction in lost work days by average pay rates, totaled $1.5 million; workers' comp insurance premiums declined by 50%.

What's more, healthy employees stay with your company. A study by Towers Watson and the National Business Group on Health shows that organizations with highly effective wellness programs report significantly lower voluntary attrition than do those whose programs have low effectiveness (9% vs. 15%). At the software firm SAS Institute, voluntary turnover is just 4%, thanks in part to such a program; at the Biltmore tourism enterprise, the rate was 9% in 2009, down from 19% in 2005. According to Vicki Banks, Biltmore's director of benefits and compensation, "Employees who participate in our wellness programs do not leave." Nelnet, an education finance firm, asks departing employees in exit interviews what they will miss most. The number one answer: the wellness program.

To understand the business case for investing in employee health, we examined existing research and then studied 10 organizations, across a variety of industries, whose wellness programs have systematically achieved measurable results. In group and individual interviews, we met with about 300 people, including many CEOs and CFOs. We asked about what works, what doesn't, and what overall impact the program had on the organization. Using our findings, we've identified six essential pillars of a successful, strategically integrated wellness program, regardless of an organization's size. Passes to fitness clubs and nutrition information in the cafeteria are not enough, as you'll see.

Strategically integrated wellness programs have six strong pillars that simultaneously support their success, regardless of the size of the organization. Construct them well, and your institution could see the kinds of big returns that the 10 companies in our sample have garnered.

1. Multilevel Leadership

Creating a culture of health takes passionate, persistent, and persuasive leadership at all levels-from the C-suite to middle managers to the people who have "wellness" in their job descriptions.

2. Alignment

A wellness program should be a natural extension of a firm's identity and aspirations. Don't forget that a cultural shift takes time.

3. Scope, Relevance, and Quality

Wellness programs must be comprehensive, engaging, and just plain excellent. Otherwise, employees won't participate.

4. Accessibility

Aim to make low- or no-cost services a priority. True on-site integration is essential because convenience matters.

5. Partnerships

Active, ongoing collaboration with internal and external partners, including vendors, can provide a program with some of its essential components and many of its desirable enhancements.

6. Communications

Wellness is not just a mission-it's a message. How you deliver it can make all the difference. Sensitivity, creativity, and media diversity are the cornerstones.

Outcomes

Lower costs

The savings on health care costs alone make for an impressive ROI.

Greater productivity

Participants in wellness programs are absent less often and perform better at work than their nonparticipant counterparts.

Higher morale

Employee pride, trust, and commitment increase, contributing to a vigorous organization.

To learn how companies can support their employees' well-being in a way that makes good business sense, we conducted field visits with 10 organizations that have financially sound workplace wellness programs.

Biltmore -hospitality and tourism

Chevron -energy

Comporium -communications

Healthwise -health information publishing

H-E-B -grocery retail

Johnson & Johnson -health care products manufacturing

Lowe's -home-improvement retail

MD Anderson Cancer Center -health care

Nelnet -education planning and finance

SAS Institute -software

During our visits to this diverse array of companies, we conducted interviews, lasting 30 to 60 minutes, with senior executives (including the CEO and CFO in most cases); wellness managers and staff; and managers of related functions such as HR, occupational health, employee assistance services, on-site medical clinics, fitness centers, safety, and food service. We also conducted focus group conversations, lasting 60 to 90 minutes, with middle managers, employees who actively used the programs, and employees who chose not to participate in the programs. In all, about 300 people shared their perspectives.

We tailored our questions to the respondents. Senior executives, for example, discussed lessons they had learned, what they would do differently, the business case for wellness, and their vision for the future. We asked middle managers about the on-the-ground management advantages and challenges of the program. Employee participants spoke about what they considered to be the most successful parts of the program, how it could be improved, and why they thought nonparticipants had opted out. We directly asked nonparticipants why they didn't use the program, whether they were considering using it in the future, and what might change their minds.

Pillar 1: Multilevel Leadership

It's easy to find employees who don't participate in wellness programs. Some cite lack of time, little perceived benefit, or just a distaste for exercise. Others don't know about available services or blame unsupportive managers. A few think their health is none of the company's business or mistrust management's motives. As with any worthwhile initiative, creating a culture of health takes passionate, persistent, and persuasive leadership.

The C-suite.

Although employee health correlates with financial health, workers won't buy into a program that's just about money. If the CEO makes time for exercise, for instance, employees will feel less self-conscious about taking a fitness break. When MD Anderson initiated its wellness program, president John Mendelsohn took walks throughout the building with wellness coach Bill Baun. For many, it was the first time the president had been in their work space or had shaken their hand, and he tended to start conversations with "How's your wellness?"

Then there's Johnson & Johnson, which has about 250 distinct businesses around the world. J&J has only a few companywide mandates. Two concern health: Any employee with HIV/AIDS will have access to antiretroviral treatment, and all J&J facilities will be tobacco free. The latter mandate was implemented in 2007 after several years of intense internal discussion. Both decisions demonstrated serious commitment from the top.

Middle managers.

Except in tiny companies, most employees report to a middle manager. By shaping minicultures in the workplace, middle managers can support employees' wellness efforts. Some companies even ask managers to adopt a personal health goal as one of their unit's business goals.

Wellness program managers.

Every organization in our study has an expert who develops and coordinates a clear, comprehensive wellness program, continuously sells it throughout the organization, and measures its effectiveness. The best wellness managers connect their expertise to the culture and strategy of the organization. These people are collaborative by nature, and analytical and credible by background and performance. It's no ordinary management job.

Wellness champions.

Volunteer health ambassadors offer local, on-the-ground encouragement, education, and mentoring-in addition to organizing and promoting local health events. No company in our study embodies this concept better than supermarket chain H-E-B, which has more than 70,000 employees at about 350 stores and other facilities. With more than 500 site-specific and nine regional wellness champions, the company hosts monthly conference calls for the wellness leaders, sponsors training webinars, and maintains an online wellness-resource center.

Pillar 2: Alignment

It's not unusual for firms to enter the wellness space with a big splash that subsides to a ripple. As management priorities shift, the opportunity to integrate a culture of health can pass. Ideally, a wellness program should be a natural extension of a firm's identity and aspirations. But many executives forget that the cultural shift takes time.

Planning and patience.

At Healthwise, CEO Don Kemper's personal commitment has allowed wellness to permeate the culture from day one. The company holds monthly all-staff meetings that always include a wellness team report on current wellness activities and resources. It sponsors an annual Wellness Day, featuring speakers and health-related activities, when employees are encouraged to reflect on the question "How can I be well?" In addition, every other Wednesday afternoon, workers are invited to share a healthy snack and connect with others. One executive calls it "adult recess," an investment that "pays back in spades" by creating opportunities for cross-team connections.

In contrast, Nelnet's early investment in wellness rankled employees. Senior management unexpectedly required health screenings to educate workers about their health risk factors. Not ready to address such personal topics and confused about the company's motives, employees pushed back. The company then hired professional wellness staff and developed a comprehensive, long-term wellness strategy. It now emphasizes early communication and clear explanations to give employees time to ask questions and prepare for change. Today employees embrace Nelnet's wellness culture: 90% participate in health risk assessments (HRAs); about three quarters of those engage in wellness activities.

Carrots, not sticks.

The organizations in our sample favor positive incentives because employees lose trust when they feel they're being forced to act against their wishes. There are, for example, many horror stories about managers who suddenly mandated smoke-free work sites, with violators risking termination. That just sends the behavior underground instead of providing support in beating an addiction.

Lowe's takes a measured approach by initially introducing a concept then eventually making it mandatory, if necessary. Before instituting its tobacco-free policy in 2005, the company gave advance notice and offered assistance to employees who were trying to quit smoking. Starting in January 2011, Lowe's will offer employees a monthly $50 discount on medical insurance if they pledge that they and covered dependents will not use any tobacco products.

A complement to business priorities.

If a program doesn't make business sense, it's automatically vulnerable. Take Chevron, where 60% to 70% of all jobs are considered safety-sensitive, in that employees put themselves or others at risk. Fitness for duty is a central concern on oil platforms and rigs, in refineries, and during the transport of fuel. To reinforce the mantra that healthy workers are safer workers, Chevron has developed a strong wellness program that includes a comprehensive cardiovascular health component, a 10K-a-day walking activity, fitness centers, a repetitive-stress-injury prevention program, and work/life services.

Where Chevron does business in countries that lack basic health care resources, it plays a leadership role by partnering with local health ministries, NGOs, and other private sector firms to build infrastructure that helps to combat diseases such as HIV, malaria, and tuberculosis. It's a matter of both corporate responsibility and business necessity for a company that wants to sustain a healthy, talented, satisfied labor pool. For example, Chevron employees staff two hospitals and four clinics in Nigeria, including a riverboat clinic that sends health care providers to riverside communities.

Pillar 3: Scope, Relevance, and Quality

It's not unusual for a company to think about employee health narrowly. Exercise is exercise, right? But employees' wellness needs vary tremendously.

More than cholesterol.

Wellness isn't just about physical fitness. Depression and stress, in particular, have proved to be major sources of lost productivity. Wellness program administrators need to think beyond diet and exercise. Biltmore, for example, offers a nondenominational chaplain service-on call 24 hours-to assist employees and immediate family members with divorce, serious illness, death and grief recovery, child rearing, and the care of aging parents. The services are confidential, free, and voluntary. The chaplains meet their clients at sites ranging from the family residence to a funeral home to Starbucks.

Individualization.

Many organizations use online employee HRAs to guide investment in wellness. An HRA combines a lifestyle survey and biometric tests such as blood pressure, cholesterol, glucose, and body mass index. The lifestyle responses (stress levels, physical activity, eating patterns, tobacco and alcohol use, and other health behavior information) are often combined with the biometric data to calculate a health-risk status, or "real age." This information is shared confidentially with each participant to help him or her track wellness progress and, when appropriate, receive company-provided assistance in an area such as nutrition counseling. Employees can often complete their biometric tests at company health fairs or on-site medical clinics.

Companies are required by law to protect individual health information, but managers can receive aggregated data that identify categories of greatest need and document changes in workforce health status. H-E-B, for example, tracks the percentage of employees in each retail territory and business unit who are at risk in areas such as high blood pressure, physical inactivity, and smoking against benchmark goals. The information helps management decide where to allocate resources.

Persuading employees to complete HRAs is a challenge, of course, for reasons ranging from privacy, to limited self-awareness about biometric numbers such as blood pressure, to lack of computer access. J&J, however, has managed to achieve an HRA participation rate above 80%. That's in part because employees who complete an HRA and receive the recommended health counseling have their personal health insurance contributions reduced by $500 annually. High participation plus a comprehensive HRA instrument enables J&J to tailor its wellness programs from business to business: One may focus more on cancer prevention, another on diabetes, and so on.

A signature program.

A high-profile, high-quality initiative within a broader wellness program can foster employee pride and involvement. Consider, for instance, when MD Anderson became the first health care organization to earn gold-standard accreditation from the CEO Roundtable on Cancer. Earning the accreditation is no small task: It requires tobacco-free work sites, benefit plans that cover recommended cancer screenings, assistance to employees with cancer in entering appropriate clinical trials, and investment in workers' physical activity and nutrition. Many people throughout the organization view this commitment as a badge of honor.

Fun.

Never forget the pleasure principle in wellness initiatives. For example, Healthwise's 2009 Wellness Day-with the theme Joy, Play, Spirit-featured square dancing. Lowe's sponsors Step It Up, a 10-week walking challenge in which employees are given a pedometer and a step log. The first year's campaign pitted employees against senior management. And SAS's recreation center features a large swimming pool, where director Jack Poll says people can do anything that they do on land, including play basketball, lacrosse, and Ultimate Frisbee. It's a gymnasium on water.

High standards.

Health-related services are, by nature, personal. Employees who perceive them as substandard won't use them. Communication services provider Comporium, for example, has an on-site health and wellness center staffed by an independent medical practice including nurse-practitioners (NPs), with a physician available as needed. It offers useful services such as hypertension management and treatment for strep throat and sinus infections. Initially, the program faltered because quality was not perceived as high. But the company turned that around, and now the experienced NPs enjoy a loyal following of employees, spouses, and eligible retirees. Program participation exceeds Comporium's 2010 goal.

At SAS's Cary, North Carolina, campus, 90% of employees used the on-site health services in 2009, and 73% currently choose the center for their primary care. In the words of Gale Adcock, the director of corporate health services, "Everyone will come for free and good; no one will come for free and lousy."

Pillar 4: Accessibility

Our sample companies make low- or no-cost services a priority, and they know that convenience matters. On the SAS main campus, 70% of employees use the recreation center at least twice a week. Director Jack Poll's explanation: "Our high participation rates are because, when we opened, we thought of all the reasons people wouldn't use the facility and we worked to eliminate every one of them." The center is open before and after work and on weekends, and the staff develops a variety of fresh, engaging programs.

True on-site integration.

On-site fitness centers are sometimes criticized for attracting people who would exercise anyway. But employees at companies who have them love them, and employees at other companies want them. As one Healthwise employee put it, "You see coworkers working out every day. That makes me realize I can do it, too." And Chevron conducts daily "stretch breaks" within certain units at set times. In Houston, for example, professional trainers go to the trading floor each day at 2:30 for a 10-minute stretch series.

Biltmore's two-day health fairs twice a year focus on physical, financial, and spiritual wellness. A wide variety of screenings are offered, including bone scans, cholesterol, blood sugar, lung capacity, and hearing. Women can make appointments for mammograms. Chiropractors are available. The local fire department demonstrates how to install a smoke detector, and the police conduct sessions on home safety and give children a chance to be fingerprinted for safety. Yoga instructors, chaplains, and many others lead seminars. Local bank representatives provide private consultations. Vendors for health and dental insurance and 401K plans are available.

Employees typically consume one or several meals plus snacks during work hours. Healthful food at work has to be tasty, convenient, and affordable. Chevron's food service vendor has a "stealth health" philosophy: It uses quality ingredients and few highly processed foods to offer menu items that delight rather than require sacrifice. Instead of seeing a daily "healthy entrée," employees choose from an array of appetizing healthful options, such as meatloaf made with whole grains and low-sodium soups made from scratch.

Going mobile.

Organizations increasingly use online resources to deliver wellness messages and to let individuals input information such as HRA data and activity reports. Companies can also make wellness websites available on smartphones to increase portability. For decentralized companies such as Lowe's and J&J, online access is critical, although high-tech tools must be complemented by high-touch programs that unite individuals in a culture of health.

Pillar 5: Partnerships

Internal partnerships help wellness programs gain credibility. At Biltmore, for example, wellness professionals partner with the company's finance division to vet the cost-effectiveness of various programs. External partnerships with specialized vendors enable wellness staffs to benefit from vendor competencies and infrastructure without extra internal investment. Lowe's has contracted with a partner to drive custom-built laboratory buses to stores, distribution centers, and corporate offices so that employees can conveniently receive biometric health screenings and complete their HRAs in private kiosks.

The smallest companies in our study have developed comprehensive wellness programs in part by leveraging the resources of vendor partners. Comporium worked with the YMCA and a local medical practice to design a "metabolic makeover" program for willing at-risk employees. Described by one participant as "pure torture" but "a great thing," it is a low-investment way for the company, which has just over 1,000 employees, to enhance its wellness program.

Pillar 6: Communications

Wellness communications must overcome individual apathy, the sensitivity of personal health issues, and the geographic, demographic, and cultural heterogeneity of employees. The range and complexity of wellness services also can pose challenges.

Our sample companies have honed effective practices over time. For one, they tailor their messages to fit the intended audience. H-E-B's culture, for example, is highly competitive, so the company created internally public wellness scorecards for geographic and other company units. Intranet videos featuring employees' health-success stories are especially popular at H-E-B, which recognizes that not all employees read a lot.

Media diversity also helps. Nelnet, for example, includes information about wellness in its regular corporate e-mail on Wednesdays, features health-related messages on its intranet portal, advertises specific wellness benefits, posts flyers about health in elevators and stairwells, and distributes wellness stickers and magnets. At health screening time, employees are greeted with an attention-getting "desk drop" such as a piece of fruit.

Wellness "clues" can be embedded throughout the workplace. According to Dr. Martin Gabica, the chief medical officer at Healthwise, "Wellness is a viral thing. When I meet with a new employee, I say, 'Let's go for a walking meeting.'" MD Anderson provides bicycle racks in parking garages with showers nearby, and it places elliptical trainers in work areas throughout its campus to encourage five-minute stress breaks. At Lowe's headquarters, an arresting spiral staircase in the lobby makes climbing the stairs more appealing than riding the elevator.

The Fruits of Workplace Wellness

Although some health risk factors, such as heredity, cannot be modified, focused education and personal discipline can change others such as smoking, physical inactivity, weight gain, and alcohol use-and, by extension, hypertension, high cholesterol, and even depression. The results are worth the effort.

Companies in our sample of 10 adopted wellness programs because, as Biltmore executive VP Steve Miller said, "It's the right thing to do for our people." Managers also have a responsibility to invest resources wisely, and all the companies in our study emphasized the importance of measuring a wellness program's success.

By capturing key metrics, a wellness dashboard helps to connect investments in a program with short- and long-term results. Sophisticated companies set metrics-related goals and examine trends closely, just as they do for other facets of the business.

Our example dashboard (below) is based on our work in the wellness field. This rubric of the most useful metrics incorporates (1) employee measures of participation, satisfaction, and well-being; and (2) organizational measures of financial, productivity, and cultural outcomes. Items are typically measured monthly, quarterly, or yearly, depending on the metric, and are tracked over time.

Employee Metrics

Employee participation

Utilization -the total number of employees involved in specific program activities

Penetration -the percentage of employees who have participated in at least one wellness activity

Depth -the percentage breakdown of employees who are light or heavy users of wellness activities

Sustainability -the number of employees who continue to engage in a specific risk-reducing behavior

Satisfaction with the program's scope, relevance, quality, and accessibility (from survey data)

Health-risk status identifying the percentages of employees at high, moderate, or low health risk (from HRAs)

Organizational Metrics

Health care

Medical care and pharmaceutical costs and utilization (from claims analysis)

Disability costs

Workers' compensation costs

Safety

Safety incident rates by category or type

Lost and modified work days related to safety incidents

Productivity

Absenteeism

Presenteeism

Organizational culture

Trust in management (from anonymous survey data)

Voluntary turnover

Willingness to recommend the firm as an employer

Lower costs.

H-E-B's internal analyses show that annual health care claims are about $1,500 higher among nonparticipants in its workplace wellness program than among participants with a high-risk health status. The company estimates that moving 10% of its employees from high- and medium-risk to low-risk status yields an ROI of 6 to 1.

For every dollar SAS spent to operate its on-site health care center in 2009, it generated $1.41 in health plan savings, for a total of $6.6 million in 2009 alone. SAS's team-based delivery of health care is less expensive than external care. Not included in the $6.6 million figure is the benefit of employees missing an estimated average of two fewer hours per visit by receiving on-campus care. As one manager noted, "I used to have to take a half-day leave for an appointment. Now I'm in and out without missing a beat."

Greater productivity.

Illness-related absenteeism is an obvious factor in productivity. Less obvious but probably more significant is presenteeism -when people come to work but underperform because of illness or stress. Research consistently shows that the costs to employers from health-related lost productivity dwarf those of health insurance.

A 2009 study by Dr. Ronald Loeppke and colleagues of absenteeism and presenteeism among 50,000 workers at 10 employers showed that lost productivity costs are 2.3 times higher than medical and pharmacy costs. In a seminal Dow Chemical study from 2002, of the average annual health costs for a Dow employee an estimated $6,721 were attributable to presenteeism, $2,278 to direct health care, and $661 to absenteeism. A variety of studies confirm the health conditions that contribute most to lost productivity: depression, anxiety, migraines, respiratory illnesses, arthritis, diabetes, and back and neck pain. Employees with multiple chronic health conditions are especially vulnerable to productivity loss.

Higher morale.

Most analyses of workplace wellness programs focus on hard-dollar returns: money invested versus money saved. Often overlooked is the potential to strengthen an organization's culture and to build employee pride, trust, and commitment. The inherent nature of workplace wellness-a partnership between employee and employer-requires trust. Because personal health is such an intimate issue, investment in wellness can, when executed appropriately, create deep bonds.

Health care is a monumental issue for employers, and too much is at stake to be reactive. It's time for companies to play offense rather than defense. A verifiable payback isn't certain, and the journey can be arduous. But what is the alternative?

A version of this article appeared in the December 2010 issue of Harvard Business Review.

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What's the Hard Return on Employee Wellness Programs?

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The Idea in Brief Employee wellness programs have often been viewed as a nice extra, not a strategic imperative. But the data show otherwise. The ROI on comprehensive, well-run employee wellness programs can be as high as 6 to 1.

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Improve workforce health and productivity

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Improve workforce health and productivity

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Statics on benefits of wellness programs

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willis towers watson health and productivity

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willis towers watson health and well-being

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willis towers watson health and wellness

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2015/2016 Staying@Work - United States research findings

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U.S. findings of Willis Towers Watson's 2015/2016 Staying@Work Survey, a global study of employers' health and productivity strategies

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The resources that were added this week was a bit overwhelming at first. There are so many different sites/resources to be used for workplace wellness programs that it is hard to decide which one would be the right one to use for my project. After reading and looking through, I found that most of the resources follow the same guidelines and steps. It proves that there is not one basic definition of wellness or best practices. All the resources have the same basic theme but have created toolkits and programs that best fit the population. Using these resources helps show that there are a list of general best practices but a company/organization is able to tailor these practices to fit their company. The resources help add to my definition of best practices and wellness by giving steps on how to create and implement programs at a given company.

The information from the toolkits and scorecards are great resources to help background information and steps to great a successful wellness program. The scorecards are a great tool to use when collecting initial data at a company. The information obtained from these scorecards show the strengths and weakness, show any gaps if a program is already implemented, and give guidance on the area that should be focused on for the program. The different toolkits help provide basic steps to help with successful planning and implementation of a program. Each toolkit while different, all present very similar steps to follow when creating a wellness program. The toolkits are very detailed which makes them easy to follow and can be used at any worksite.

I think that all of the resources presented this week are very helpful but after taking a closer look at each one, there are a few that stand out for my project. I think the HERO scorecard would help as an initial survey of the company to show where the opportunities and what the current statues of well-being is at the company I will be working at. This can help guide what the program should focus on as well. I also think the Minnesota Department of Health Work Well Toolkit will be very helpful. This toolkit provide 4 simple steps to follow on planning and implementation. It covers all of the details needed from building a case for a wellness program to how to build, implement, and evaluate. One thing I really liked about this toolkit is the extra resource links that are provided at end of each section. This is very helpful as give gives more resources to use to gain knowledge and different ideas from to help make my project successful. I also really liked the WELCOA checklist. I think it would be beneficial to have a membership as this site helps give valuable information. The data provided from the checklist can help persuade senior leadership, the recommendations given can help guide the focus of the program, and the strengths and weakness can help show what needs to be improved.

References

Health Enhancement Resource Organization. (2017). HERO health and well-being best practices scorecard in collaboration with Mercer (HERO scorecard). Retrieved from http://hero-health.org/hero-scorecard/

Minnesota Department of Health. (n.d.). Work well healthy Minnesota toolkit. A collection of strategies, suggestions and resources to help build your worksite health promotion program. Retrieved from https://mn.gov/mmb/assets/Minnesota-Department-of-Health-Work-Well-Healthy-Minnesota- Toolkit_tcm1059-128447.pdf

Wellness Council of America. (n.d.). The well workplace checklist. Retrieved from: https://checklist.welcoa.org/

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National Wellness Institute 6 dimension general explanation

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National Wellness Institute 6 dimension general explanation

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Gives details about each dimension and examples of how to improve them at work

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Leading employers are changing their focus from offering benefits and programs centered on improving employees' physical health to deploying holistic well-being strategies that enhance various facets of employees' lives.

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Worksite wellness is aimed at motivating employees to continuously develop their mental, physical, and spiritual well being in a healthy work environment. The programs align employee needs and the organizations values to create a culture of wellness in order to encourage people to change their behaviors. Worksite wellness programs will not only help the individual but will also improve the overall performance of the company. These programs are successful when senior and middle management show ownership and commitment, employees are involved in the program development, and when evidence based practices are implemented.

Global Wellness Institute. (2016). The history of wellness. Retreived from https://www.globalwellnessinstitute.org/history-of-wellness/

Khoury, A. (n.d). The evolution of worksite wellness. Corporate Wellness Magazine.com. Retreived from http://www.corporatewellnessmagazine.com/worksite-wellness/the-evolution-of/

Robinson, J. (2013, March 19). How to create a culture of organizational wellbeing. Business Journal. Retreived from http://news.gallup.com/businessjournal/159080/create-culture-organizational- wellbeing.aspx

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Brainstorm Topic

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Workplace Wellness Infograph