gms | German Medical Science

Protected by law, workplace health promotion in Germany is an integral part of prevention. Ever changing conditions in the working environment such as globalization, the increasing significance of information technology and telemedicine as well as the continuous change with regard to the types of employment like temporary jobs and part-time jobs have an impact on the employability of the working population.

In view of these changing conditions, also the working environment of health care personnel will change dramatically in the upcoming years. Gradually, staff in the field of health care will not only have to deal with the changing conditions mentioned above, but will additionally be faced with an increasingly growing number of elderly people in need of nursing care. Also the number of health care workers is likely to decrease significantly due to the shortage in personnel caused by staff retirement. In particular, health care workers will have to deal with heavy workload in the upcoming years.

Moreover, health care personnel have to bear physical and psychological burden affecting their health negatively. Such burden is frequently caused by overtime and working in shifts – often at odds with the biological rhythm and family life, the absence of regular breaks, as well as lifting and carrying patients causing quite an extraordinary burden on the physical health. Due to this burden, health care personnel are particularly prone to fall ill, leading to working time lost as well as once again an increased workload for the remaining staff. Health care workers also are strongly represented among people diagnosed with early disability retirement.

The demographic change and working conditions of health care workers therefore urgently require rethinking. Interventions in workplace health promotion may improve the physical and psychological situation and thus help maintain working capacity.

• What kind of interventions in workplace health promotion help maintain the working capacity of health care personnel?
• How much do these interventions in workplace health promotion cost?
• What kind of interventions in workplace health promotion to maintain the working capacity of health care personnel has verifiable economic benefits for both employers and society?
• What is the cost-effectiveness of interventions in workplace health promotion as to maintain the working capacity of health care personnel?
• Which ethical, social und juridical issues need to be considered when assessing interventions in workplace health promotion to maintain the working capacity of health care personnel?

A systematic literature search is conducted in 32 databases limited to English and German publications since 1990: MEDLINE, EMBASE, AMED, BIOSIS Previews, MEDIKAT, Cochrane Library – Central, gms, SOMED, CAB Abstracts+CAB, ISTPB+ISTP/ISSHP, ETHMED, GLOBAL Health, Deutsches Ärzteblatt, EMBASE Alert, SciSearch, CCMed, Social SciSearch, Karger-Verlagsdatenbank, Thieme-Verlag database, Derwent Drug File, IPA, gms Meetings, DIQ-Literatur, HECLINET, Hogrefe-Verlag database and fulltexts, Thieme-Verlag database PrePrint, Krause & Pachernegg Verlag database. Especially HTA-reports, systematic reviews and health economic evaluation are searched in databases of the Cochrane-Library (CDSR93), NHS-CRD-DARE (CDAR94), the International Agency for Health Technology Assessment NHS-CRD-HTA (INAHTA), the National Health Service in Great Britain NHSEED and the HTA database of the German Agency of Health Technology Assessment (DAHTA). Moreover, internet-searches are performed and the reference lists of identified articles are scanned.

The selection of the literature identified for this HTA examined according to predefined inclusion and exclusion criteria by two independent reviewers. Full texts focusing on workplace health promotion for health care personnel with respect to the research question are included in the report. Data extraction and tables of evidence and the assessment of risk of bias by means of the Cochrane Collaboration’s tool are verified by a second expert. A review and an assessment of the quality are done according to widely accepted standards of evidence-based medicine.

We have identified eleven intervention studies in 16 publications and two systematic reviews displaying a focus on workplace health promotion interventions.

Interventions for the improvement of physical health were examined in three randomized controlled trials (RCT) and one controlled trial without randomization (CCT); the improvement of psychological health was examined in four RCTs and two CCT. Aspects of psychological and physical health were examined in one RCT for both. The duration of the studies included for examination ranged from four weeks to 24 months. The number of participants included in each publication ranged from 20 to 345 with a median of 56. Interventions and study populations were predominantly heterogeneous.

Studies with interventions for the improvement of physical health recommended practical trainings like coordination, power and stretch exercises, aerobic or other standardized training programmes. Also theoretical training such as body motoric, motion patterns or the use of ergonomic aids were recommended. Regarding psychological health, the studies offered interventions ranging from teaching coping-strategies for better stress and conflict management over communication skills to problem solving strategies, exchange of experiences among colleagues and methods of individualized care.

In three studies interventions for the improvement of physical health were found to result in less complaints and to lead to increased strength and flexibility with statistically significant differences between the study groups. In one study, the consumption of analgesics decreased over a time period of four months, just like the perceived restrictions in terms of household or leisure time activities.

Study personnel actively taking part in psychological health interventions benefited from a significantly decreased intake of analgesics, better stress management and better coping with workload; they also displayed improved communication skills and gained additional vocational training. After three months of intervention the study population of an oncology ward displayed more positive attitudes to cancer illness, patients, colleagues and themselves. Also psycho-social intervention training of forensic health care personnel led to better attitudes to patients, deepened their knowledge about severe mental illness and showed a significant reduction of burnout in the study population. After one year of intervention in clinical supervision health care personnel for patients with dementia illness showed decreased burnout rates as well.

After a nine month study examining interventions for improving physical and psychological health found a significant increase in subjective health perception, physical fitness and work situation for the intervention group in contrast to the control group. At the same time, the intervention group mentioned in comparison to the control group a decrease of muscle pain and highlighted a subjective perception of being able to handle stress.

Due to the specific workload in the different work spaces of the different study populations, a synopsis of all study results is not reasonable.

The authors of one of the two systematic reviews concluded that interventions mainly focusing on technical training are improper for the reduction of musculoskeletal injuries. Instead alternative strategies would need to be considered. The authors of the second systematic review also reported that physical training and advanced training do not suffice to reduce musculoskeletal symptoms in study population. Preferably, multifactorial interventions should be implemented in the work day of health care personnel.

Taking into consideration the small and very small sample sizes as well as the high classified risk of bias in particular with regard to missing data for concealment and with no blinding, the study results are limited in terms of validity. Due to the heterogeneity of the health interventions in each study examined for the HTA, the study populations with differing job specializations in health care as well as the different length of study durations ranging from four to 24 months and follow-up periods, the comparison of results would not be convincing within the scope of this HTA.

Also the poor quality of reporting in various studies has to be considered as a limiting factor for the validity of the results in this HTA. Despite frequent communication with the authors of the studies not all questions with regard to the study populations and methods could be answered to entire satisfaction.

This HTA can only be considered as an overview of verified interventions for the maintenance and improvement of the employability of health care personnel. This overview therefore rather needs to be understood as a synopsis than an evaluation of benefits. Further research is necessary including larger sample sizes, sufficient study duration and follow-ups, a lower risk of bias while taking into consideration relevant quality criteria and thus guaranteeing a better documentation of the results in the publications.