What is the concept of a more “healthy healthcare”?

By: Annet de Lange (HAN University of Applied Sciences), Lise Løvseth (Department of Mental Health, NTNU), Kevin Teoh (University of London), Marit Christensen (Department of Psykology, NTNU)

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).