Healthcare workers are at a high risk of mental health issues, including stress, burnout, and symptoms of anxiety and depression. These challenges, exacerbated by high workloads, critical incidents, and verbal abuse, can lead to absenteeism, reduced patient care quality, and increased staff turnover (Montgomery & Lainidi, 2024).
Addressing these issues is critical, not only to protect workers’ mental health but also to ensure the sustainability of healthcare systems globally and protect quality of patient care and safety. For example, in the United Kingdom a report from the International Public Policy Observatory (IPPO) estimates that the financial cost to the NHS of poor wellbeing is £12.1 billion a year (Daniels et al., 2020).
We have sufficient evidence in healthcare, to understand that the consistent and widespread poor well-being and mental health among healthcare workers (HCWs) should be considered symptoms of a dysfunctional organisational system or unhealthy workplaces (Montgomery & Lainidi, 2023). Thus, organisational interventions—workplace-level changes targeting psychosocial work environments—are increasingly recognised as a potentially effective approach to promoting improved and sustained mental health and wellbeing (Christensen et al., 2020).
However, compared to individual-level interventions (e.g., resilience training for frontline staff), organisational approaches have received less research attention and have been criticised with regards to feasibility and scalability. This systematic review by Aust et al. (2024) examined whether organisational approaches are effective in improving mental health outcomes for healthcare workers, in a variety of clinical settings.
Poor mental health and burnout among healthcare workers is a systemic issue requiring organisational-level interventions to protect both staff well-being and patient care.
Methods
The authors conducted a systematic review to evaluate organisational interventions targeting healthcare workers’ mental health in any type of healthcare organisation and more specifically in Small to Medium Enterprises (SMEs) in healthcare. The search spanned six databases—Academic Search Complete, CINAHL, PsycINFO, PubMed, Scopus, and Web of Science—and covered publications from January 2010 to July 2021, prior to the onset of the COVID-19 pandemic.
Studies were included if they:
- Focused on organisational-level interventions, such as changes to job roles, workplace culture, or psychosocial working conditions).
- Targeted healthcare workers, including nurses, physicians, and allied health professionals and/or managers within the healthcare sector.
- Used controlled designs (e.g., RCTs).
- Measured non-clinical mental health outcomes, including stress, burnout, anxiety, depression and mental wellbeing.
Interventions were categorised into six types (following Fox et al., 2022):
- Job and task modifications
- Flexible work and scheduling
- Changes to the physical work environment
- Leadership and supervisor training
- Organisational policy changes
- Multifaceted approaches
The methodological quality of studies was assessed using the Quality Assessment Tool for Quantitative Studies (QATQS). Studies were rated as strong, moderate, or weak based on factors like selection bias, blinding, and confounder control.
This systematic review evaluated controlled studies of organisational interventions targeting healthcare workers’ mental health across various settings.
Results
In total, 22 studies met the inclusion criteria, encompassing 6,303 healthcare workers across 11 countries. Most studies were conducted in large hospital settings, with limited representation from SMEs.
The review found that different organisational interventions can improve mental health outcomes, to different extents.
Different interventions varied in impact, on the available evidence:
- Stronger evidence was identified for interventions falling under the job and task modifications (e.g., workload adjustments), with consistent improvements in burnout across studies.
- Moderate evidence was identified for interventions under the flexible work and scheduling category and the changes to the physical work environment category with some positive results, though findings were less consistent.
- Insufficient evidence was found for intervention in the categories of leadership training, policy changes, and multifaceted approaches, as these intervention types lacked enough robust studies to draw firm conclusions.
Studies showed differences in achieved and sustained end-outcome improvement:
- Burnout was the most consistently improved outcome, with 11 of 13 studies reporting significant reductions.
- Stress and wellbeing showed less consistent results, with some studies showing improvements and others finding no significant effects.
- Depression and anxiety symptoms showed less frequently reported improvements than for burnout, which was a more general outcome.
The review highlighted the absence of studies conducted in independent SMEs, despite their significant presence in healthcare. Of the 22 studies, only five involved SMEs attached to larger organisations, and their results were mixed.
This review found that organisational interventions can improve burnout and mental health outcomes, with job and task modifications showing the strongest evidence.
Conclusions
The authors concluded that organisational interventions have the potential to improve healthcare workers’ mental health, particularly by reducing burnout. However, they emphasised that the effectiveness varies by type of intervention, with job and task modifications showing the most consistent benefits.
Additionally, they highlighted that broader systemic factors can influence the success of these interventions, such as the specific healthcare setting and resource availability and disparities.
Strengths and limitations
The strengths of this review included the inclusion of controlled designs which allowed the authors to draw conclusions from the most robust evidence available. Moreover, grouping interventions into six distinct types clarifies which approaches have been researched more as well as which seem to work best.
While the variability in outcome measures and intervention designs prevented a meta-analysis, reducing the precision of findings, organisational interventions are inherently heterogeneous with the literature supporting that “one size does not fit all” (Nielsen & Noblet, 2018b). This means that a meta-analysis is probably not the most appropriate method to evaluate the effectiveness of organisational interventions and a nuanced analysis such as the one presented by the authors might be preferable as it highlights the complexities in the field.
In terms of limitations, the authors acknowledge that the scarcity of research in SMEs in general and in independent SMEs more specifically means there is an evidential skew. Information about larger hospitals may be over-represented, while little is known on which interventions might work in SMEs.
The decision to exclude studies conducted during the pandemic – while partially justified – limits the review’s relevance to current challenges faced by healthcare workers, especially given that healthcare systems have not yet fully recovered from the problems revealed during the pandemic.
Moreover, there is substantial debate on what constitutes an organisational level intervention (Cox et al., 2010; Nielsen & Noblet, 2018a). For example, it is not clear whether a flexible work/scheduling intervention that only targets HCWs involved in clinical patient care should be considered an organisation-level intervention, as it only targets a specific group of HCWs. One such case from this review is the study by Garland et al. (2012), who assessed the effects of around-the-clock intensivist presence on intensivists’ burnout in the intensive care setting. However it must be noted that while this study only applied to pre-pandemic evidence, its application will be in a world of post-pandemic working, where organisations are more alive to making responsive and flexible workplace accommodations as reasonable and needed.
The study’s methodological rigor and nuanced analysis are strengths but gaps remain, particularly regarding SMEs and applicability in the post-pandemic context.
Implications for practice
This review underscores the importance of addressing organisational factors to improve healthcare workers’ mental health.
Key implications include:
- Prioritise job modifications: adjusting workloads and tasks shows strong evidence of reducing burnout. Healthcare managers should explore these changes as a first step.
- Flexibility matters: flexible work arrangements can help, but further research is needed to optimise their implementation in diverse settings.
- Invest in SMEs (small to medium enterprises): independent SMEs require targeted support to implement effective interventions. Policymakers should prioritise funding and resources for these organisations.
- Adopt a systems perspective: combining organisational and individual-level approaches may maximize benefits for healthcare workers.
- Invest in interdisciplinary collaborations: organisation-level approaches require the collaboration of multiple scientific and applied stakeholders to be successful. Policymakers should prioritise real interdisciplinary research and applications leveraging on expertise in psychological wellbeing, infrastructure and engineering (e.g., ergonomics), implementation and scalability, etc.
Organisational changes, especially tailored job modifications and interdisciplinary collaboration, can play a pivotal role in supporting healthcare worker well-being.
Statement of interests
I have no competing interests to declare.
Links
Primary paper
Aust, B., Leduc, C., Cresswell-Smith, J., et al. (2024). The effects of different types of organisational workplace mental health interventions on mental health and wellbeing in healthcare workers: A systematic review. International Archives of Occupational and Environmental Health, 97(4), 485–522.
Other references
Christensen, M., Innstrand, S. T., & Saksvik, P. Ø. (2020). Healthy workplaces: Designing and implementing health-promoting organizational interventions in healthcare. Integrating the Organization of Health Services, Worker Wellbeing and Quality of Care: Towards Healthy Healthcare, 301-315.
Cox, T., Taris, T. W., & Nielsen, K. (2010). Organizational interventions: Issues and challenges. Work & stress, 24(3), 217-218.
Daniels, K., Connolly, S., Woodard, R., van Stolk, C., Patey, J., Fong, K., et al. (2020). NHS staff wellbeing: Why investing in organisational and management practices makes business sense—A rapid evidence review and economic analysis. London: EPPI Centre, UCL Social Research Institute, University College London.
Fox, K. E., Johnson, S. T., Berkman, L. F., et al. (2022). Organisational- and group-level workplace interventions and their effect on multiple domains of worker well-being: A systematic review. Work & Stress, 36(1), 30–59.
Garland, A., Roberts, D., & Graff, L. (2012). Twenty-four-hour intensivist presence: A pilot study of effects on intensive care unit patients, families, doctors, and nurses. American Journal of Respiratory and Critical Care Medicine, 185(7), 738–743.
Montgomery, A., & Lainidi, O. (2023). Creating healthy workplaces in healthcare: Are we delaying progress by focusing on what we can do rather than what we should do?. Frontiers in public health, 11, 1105009.
Montgomery, A., & Lainidi, O. (2024). Creating a healthy work environment and worker well-being. In Research Handbook on Contemporary Human Resource Management for Health Care (pp. 300-317). Edward Elgar Publishing.
Nielsen, K., & Noblet, A. (2018a). Introduction: Organizational interventions: Where we are, where we go from here?. In Organizational Interventions for Health and Well-being (pp. 1-21). Routledge.
Nielsen, K., & Noblet, A. (2018b). Epilogue: Future directions for organizational interventions. In K. Nielsen & A. Noblet (Eds.), Organizational interventions for health and well-being: A handbook for evidence-based practice (pp. 265–271). Springer.
