Europe is facing urgent and significant challenges in maintaining sufficient standards of quality in healthcare. We discussed the increasing shortage of healthcare staff throughout Europe, as well as the high turnover of healthcare staff leaving the sector to continue their careers in different types of jobs and the growing percentage of occupational health-related disorders reported among healthcare staff (e.g. burnout, depression etc.) during an EAOHP “Healthy Healtcare” Small Group Meeting in March. Moreover, due to an aging workforce, more and more healthcare staff are expected to go to retirement. All of this has led to more and more healthcare employers searching for creative solutions to maintain and retain enough staff at work.

Healthy healthcare implies that healthcare systems are designed, managed and financed in balance with the available resources to improve workers’ health and performance as well as providing high quality of care (Illustration: iStock)

In our small group meeting, 26 participants came together to examine new, creative and more preventive solutions that can be found within the network of the European Academy of Occupational Health Psychology, and more specifically reflect, discuss and define the concept of a more Healthy Healthcare.

Healthy healthcare implies that healthcare systems are designed, managed and financed in balance with the available resources to improve workers’ health and performance as well as providing high quality of care. It emphasizes the importance of three distinct, but related, pillars that represent: (i) the healthcare system and working environment; (ii) staff wellbeing; and (iii) patient care. Ultimately, a balanced-based perspective taking into account the patient, staff and the complex healthcare system will lead to a more resource-efficient delivery of high quality healthcare services.

Ultimately, a balanced-based perspective taking into account the patient, staff and the complex healthcare system will lead to a more resource-efficient delivery of high quality healthcare services.

During the small group meeting, researchers shared evidence-based practice and research on one or more links between healthcare services and the work environment, staff wellbeing and the quality of patient care. Moreover, we discussed how to conduct interventions and research on healthy healthcare with different populations and settings. We ended the meeting summarizing important lessons-learned from the different presentations and discussions during the meeting and formulated a new research agenda for the future. More specifically the following take-home messages were formulated around the two points below:

What we know:

1. Most presentations include results of two out of the three pillars from the aforementioned Healthy Healthcare concept (patient, staff, and/or organizational practice). The most common pillar was the third one, which could include indicators of patient safety, satisfaction or other relevant patient-based outcomes.
2. Most results focused on negative predictors from the work environment or occupational health or well-being of healthcare staff (e.g. stressors at work, burnout etc.). Few studies address more positive outcomes like work engagement or meaning of work, and the simultaneously interplay between positive and negative factors and outcomes. Moreover, most studies focus on individual-level data, and do not report results on team-based or organisational level outcomes. Finally, unpaid work is a significant contributor to Quality of Care worldwide. The emotional demands of healthcare work equally affects professionals as voluntary workers in health care.
3. There was a heavy emphasis on the importance of a contingent perspective where one size does not fit all contexts and professions in healthcare. This means that a stressful demand in one context can be experienced as a job resource in another context.
4. In intervention design and implementation, the most effective programs are based on bottom-up (and team-based) methods where stakeholders help design the interventions. To sustain the effective bottom-up approaches, top-down management support is needed. Furthermore, process intervention research highlights the importance of a continuous learning cycle to create more healthy work environments that include learning goals for multiple stakeholders at different levels of healthcare institutions.
5. The importance of leadership in creating healthy workplaces was highlighted during the small group meeting, and has already received research attention in occupational health research. Nonetheless, a concept like health-promoting leadership has not yet been well established in occupational health research and models, and therefore warrants further exploration.
6. More and more technology is used in occupational health research to measure relevant predictors and outcomes as well as to implement intervention programs that facilitate Healthy Healthcare. However, the impact of this technology use on end-users has not yet been examined in detail. For example, one of the studies presented at this meeting highlighted the high drop-out of technology use across time. Few participants adhere to the whole intervention program cycle based on technology use and solutions may require a combination of online and offline (human based) intervention elements.
7. There is a need to develop a learning community to facilitate knowledge-sharing and best practice. Researchers are often connected to different employer associations with a network of >100 healthcare institutions that have relevant evidence-based practices to share. Moreover, large-scale datasets are available on a regional as well as a national level on healthcare data that are currently not yet used for further analyses by OHP researchers in Europe. Nonetheless, more data and practices exchange across Europe can help in synthesizing important findings and conclusions in relation to facilitating Healthy Healthcare.

What are the gaps in current research to develop more Healthy Healthcare projects?

1. One of the most important conclusions of our small group meeting is that all researchers recognize the importance of sharing the Healthy Healthcare concept in Europe. However, it will help to formulate a conceptual model to further facilitate integrated research in Europe on Healthy Healthcare.
2. The urgent need to retain enough healthcare staff was mentioned several times. Surprisingly, there is little exit research on the reasons as to why staff leave the healthcare sector and where they go?. We therefore call for more new research into this, and how these relate to indicators of occupational health-related topics (e.g. work stress, team climate, leadership, occupational health). Furthermore, we would like to raise more awareness and research on the impact of unpaid work in healthcare in relation to paid staff, patient outcomes and organisational practices in healthcare.
3. The added value of our joint occupational health network is currently unknown among EU-grant awarding institutions. The European Academy of Occupational Health Psychology could help with highlighting the joint impact of healthy healthcare research teams.
4. Occupational health researchers typically focus on the relationship between occupational health and organisational practices, but we also need to integrate results based on patient outcomes (e.g. patient outcomes, satisfaction or safety).
5. Based on our discussions we noticed substantial differences in (cross-cultural) context and therefore stress the importance of developing more cross-national case-comparative studies to further understand the role of cross-cultural differences. This was evident in the presentation by Dr. Safiye Sahin showing the extent of staff shortages in Turkey as well how the interpretation of work stress in Turkey differs in comparison to for example Norway.
6. More theoretical attention can be given to the gendered nature of healthcare work (e.g. gender roles) and to integrate life course perspectives on successful aging of staff members in healthcare work.
7. We need to write a joint position paper based on the aforementioned findings and present a clear research agenda. This will be done at the next EAOHP conference in Cyprus and in a special issue of Frontiers of Psychology: https://www.frontiersin.org/research-topics/9811/healthy-healthcare-empirical-occupational-health-research-and-evidence-based-practice.
8. The importance of creating a learning community moving forward. We hope that the EAOHP Executive recognizes this new consortium of researchers and the importance of providing more knowledge across contexts on Healthy Healthcare, and to support future meetings across Europe in the coming years on topics like:
   1. Positive interventions: process and implementation research;
   2. Develop theory model of Healthy Healthcare;
   3. Exchange knowledge on multi-level approaches and business cases;
   4. Exchange results on different research methodology: like realist evaluation (such as the Context-Mechanism-Outcome framework), process evaluation and learning from implementation sciences;
   5. Looking for national and European funding to start case-comparative studies on Healthy Healthcare across Europe;
   6. How to further communicate the idea of Healthy Healthcare to patients, managers, policymakers, practitioners and other stakeholders in this community;
   7. Health-promoting leadership/management in context.

The following months the consortium will investigate possible funds for further collaboration (on EU-level and national level). For more information or to join the Healthy Healthcare consortium please email Annet de Lange (annet.delange@han.nl).

Research from several different countries has shown that spending time in child daycare institutions may cause increased levels of stress in small children. In Norway 80 percent of 1-year-olds attend daycare. We know nothing about their stress levels.

In the international studies the children’s stress levels have been measured through analysing the levels of cortisol, also called “the stress hormone”, in spit samples taken at different times in the cause of a day. Our levels of the hormone cortisol increase in situations involving danger and make our bodies prepared for situations perceived as difficult or threatening.

Illustration: Photos.com

Normally, our levels of cortisol are highest in the morning, decrease during the day and are at their lowest in the evening. Research in other countries has shown that many of the smallest children attending daycare institutions have cortisol levels that remain high throughout the day. When the children spend a day at home their cortisol levels act normally again, falling during the day. This finding indicates that some small children are constantly alert in order to tackle challenges and difficulties when they are in daycare. Perhaps they are spending too much time on their own without support from grown-ups they feel secure with.

Small children need attentive and available adults around them that can help them when they need it. This is not always the practice during busy days in a daycare institution, not in Norway either. Some small children are assumed to be more exposed for experiencing daycare as stressful, because they for instance have a more vulnerable temperament. It is also assumed that a large number of activities controlled by grown-ups and plenty of time spent in a big group can cause higher stress levels in small children.

Negative stress over time can cause a weakened immune system and reduced memory, capability to regulate own behaviour and handle future stress situations. At present, there is not enough knowledge to say if stress caused in child care institutions has these effects.

This autumn we start collecting data for the study “Small in daycare” (“Liten i barnehagen”), where around 400 parents from Trondheim and Oslo will be invited to participate with their children. We will be measuring the children’s levels of cortisol both in daycare and at home as part of the research. Further, we will observe the interaction between the children and the personnel to see if there is a connection between positive interplay and reduced stress levels in the children. We will also investigate factors such as physical buildings, the size of the group of children and number of children per grown-up.

The research project is collaboration between the Regional Centre for Child and Youth Mental health and Child Welfare at NTNU and the Regional Center for Child and Adolescent Mental Health – Region East and South. In addition international researchers on child care will take part in the research.

Data about the participants has been collected already from pregnancy, a fact that makes the project unique, also on an international level. By controlling other factors that also may cause stress we can be sure that it actually is stress related to the child care institution we are examining. We can also investigate if some children are more vulnerable than others when it comes to kindergarten-related stress. So far, little research has been conducted on this topic internationally.

Our research project will show if the youngest children in daycare in Norway are less stressed than small children in other countries. Perhaps Norwegian daycare institutions are of such a quality that this is the case, but so far we do not know.

References:

Badanes, L.S., Dmitrieva, J. & Watamura, S.E. (2012). Understanding cortisol reactivity across the day at child care: The potential buffering role of secure attachment to caregivers. Early Childhood Research Quarterly, 27, 156-165.

Bratterud, Å., Sandseter, E.B. & Seland, M. (2012). Barns trivsel og medvirkning i barnehagen. Trondheim: Barnevernets Utviklingssenter, Rapport 21/12.

Gunnar, M.R., Kryzer, E., van Ryzin, M.J. & Phillips, D.A. (2010). The rise in cortisol in family day care: Associations with aspects of care quality, child behavior, and child sex. Child Development, 81, 853-870.

Phillips, D.A., Fox, N.A. & Gunnar, M.R. (2011). Same place, different experiences: Bringing individual differences to reserach in child care. Child Development Perspectives, 5, 44-49.

Sajaniemi, N., Suhonon, E., Kontu, E., Rantanen, P., Lindholm, H., Hyttinen, S. & Hirvonen, A. (2011). Children’s cortisolpatterns and the quality of early learning environment. European Early Childhood Education Research Journal, 19, 45-62.

Vermeer, H.J. & IJzendoorn, M.H. (2006). Children’s elevated cortisol levels at daycare: A review and meta-analysis. Early Childhood Research Quarterly, 21, 390-401.

Parental involvement in their children’s education is one of the strongest predictors of children’s school success and has a powerful influence on the children’s achievement and adjustment.

As part of my PhD project at the Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU) I have examined parent involvement in relation to children’s behavioural problems and social competence in school. For children with behavioural problems, parent involvement is especially important for how the children cope in school.

Illustration: Photos.com

Parental involvement in school involves behaviour by parents in school settings and at home that is intended to support their children’s educational development. These are behaviour like getting involved with school/ teacher, attending parent-teacher conferences and school meetings and encourage the child’s positive attitude towards education, e.g.; helping the child with its homework, playing games to teach the child new things, taking the child to the library, reading to child and so on.

Positive involvement between parents and school/teachers has been shown to improve the children’s academic accomplishment on all levels as well as their social functioning in school. For children in general, parental involvement in school is reported to lead to improved behaviour, attitudes and attendance at school, as well as better emotional adjustment and greater well-being.

For the youngest children in school, parental involvement is associated with early school success, this including academic and language skills and social competence. Further; parent’s expectations and involvement in school seem to have a stronger influence on the youngest children’s achievement compared to children in the later years of elementary school.

For children with behavioural problems, parent involvement is especially important for how the children cope in school.

In general, children with behaviour problems often have learning difficulties and lack social competence and therefore tend to be rejected by prosocial children. For these children parent involvement in school and co-operation between parents and school/ teacher is in particular important.Young children with high levels of behaviour problems are considered less academically competent, they have poorer reading and verbal skills, they perform worse in school and they receive more negative feedback from teachers than their more behaviourally competent peers.

Positive parent–school involvement for children with behaviour problems is a predictor of later social and academic success and the lack of parental involvement may contribute to extend the child’s behavioural problems.

Maintaining a good working relationship between parents and school is a mutual responsibility. Good communication between home and school, as well as mutual respect is decisive for good cooperation.

Reference:

Kirkhaug, B., Drugli, M.B., Klöckner, C.A., & Mørch, W-T. (2013). Association between parental involvement in school and child conduct, social, and internalizing problems: teacher report. Educational Research and Evaluation, 1-16.