ORIGINAL PAPER

International Journal of Occupational Medicine and Environmental Health 2015;28(5):891900

http://dx.doi.org/10.13075/ijomeh.1896.00465

PROTECTING AND PROMOTING MENTAL

HEALTHOF NURSES IN THEHOSPITAL SETTING:
IS IT COST-EFFECTIVE FROM AN EMPLOYERS
PERSPECTIVE?
CINDY NOBEN1,2, SILVIA EVERS1,2, KAREN NIEUWENHUIJSEN3, SARAH KETELAAR3, FANIA GRTNER3,
JUDITH SLUITER3, and FILIP SMIT1,4,5
Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, theNetherlands
Department of Public Mental Health
2
Maastricht University, Maastricht, theNetherlands
Department of Health Services Research, CAPHRI School of Public Health and Primary Care
3
Academic Medical Center, Amsterdam, theNetherlands
Coronel Institute of Occupational Health
4
VU University Medical Centre, Amsterdam, theNetherlands
Department of Epidemiology and Biostatistics, EMGO+ Institute for Health and Care Research
5
VU University Medical Centre, Amsterdam, theNetherlands
Department of Clinical Psychology, EMGO+ Institute for Health and Care Research
1

Abstract
Objectives: Nurses are at elevated risk of burnout, anxiety and depressive disorders, and may then become less productive.
This begs thequestion if apreventive intervention in thework setting might be cost-saving from abusiness perspective.
Material and Methods: Acost-benefit analysis was conducted to evaluate thebalance between thecosts of apreventive
intervention among nurses at elevated risk of mental health complaints and thecost offsets stemming from improved productivity. This evaluation was conducted alongside acluster-randomized trial in aDutch academic hospital. Thecontrol
condition consisted of screening without feedback and unrestricted access to usual care(N=206). In theexperimental condition screen-positive nurses received personalized feedback and referral to theoccupational physician(N=207). Results:
Subtracting intervention costs from thecost offsets due to reduced absenteeism and presenteeism resulted in net-savings
of244euros per nurse when only absenteeism is regarded, and651euros when presenteeism is also taken into account. This
corresponds to areturn-on-investment of5euros up to11euros for every euro invested. Conclusions: Within half ayear,
thecost of offering thepreventive intervention was more than recouped. Offering thepreventive intervention represents
afavorable business case as seen from theemployers perspective.
Key words:
Cost benefit, Mental disorders, Nurses, Occupational health, Prevention, Work functioning
The economic evaluation alongside theMental Vitality@Work trial was funded by the grantNo.208010001 from theNetherlands Organization for Health Research
and Development(ZonMw) and co-financed by a grant from the Dutch FoundationInstitute Gak. Netherlands Trial RegisterNTR2786.
Received: September 19, 2014. Accepted: December 18, 2014.
Corresponding author: C. Noben, Maastricht University, Department of Health Services Research,P.O.Box616,6200MDMaastricht, theNetherlands
(e-mail:c.noben@maastrichtuniversity.nl).

Nofer Institute of Occupational Medicine, d, Poland

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C. NOBEN ETAL.

INTRODUCTION
Some nurses are at elevated risk for stress and mental
health problems due to high job demands and alack of
autonomy[1,2]. Poor mental health is undesirable in its
own right, but it may also have financial implications for
theemployer[3,4] via absenteeism, presenteeism (reduced at-work job performance) and staff turnover[5,6].
From a business point of view, it might therefore be of
value to protect and promote mental health of nurses and
maintain thequality of their work.
Periodic screening could be useful to detect early signs
of mental health complaints and personalized feedback
could encourage help-seeking among nurses. AWorkers
Health Surveillance(WHS) instrument was developed for
this purpose. TheWHS is apreventive strategy that aims
at theearly detection of negative health effects and work
functioning problems and includes personalized feedback.
TheWHS is followed up by referral to theoccupational
physician(OP) for screen-positive nurses in need of intervention. This3-tiered intervention aims to detect mental
health problems in theearliest stages and prevent further
deterioration of these problems. In so doing, theintervention may also enhance job performance[7,8].
Elsewhere, we published acost-effectiveness analysis of
theintervention from thesocietal perspective[9]. That
study took account of thecosts of health care uptake, pharmacy use and nurses out-of-pocket expenses for travelling to health care services. Theoutcome of interest was
the treatment response. It was concluded that screening,
feedback andOP care led to improved work functioning
and these were associated with a75%likelihood of lower
costs than ado nothing scenario, as seen from asocietal
perspective. However, anemployer is likely to look at adifferent set of financial parameters to inform decisions about
implementing anintervention in thework setting. This paper adopts theemployers perspective and assesses whether providing screening followed by personalized feedback
and referral to theOP represents aviable business case.
892

IJOMEH 2015;28(5)

In contrast to theaforementioned cost-effectiveness

analysis, we now look at thecosts that are incurred by
theemployer of offering thepreventive intervention.
These costs are then compared with the benefits (expressed ineuro()) that are, again, relevant from theemployers perspective, such as thecost differences stemming
from reduced absenteeism and improved productivity
while at work. In short, this paper is conducted as acostbenefit analysis to address thequestion if thebenefits outweigh thecosts. If this were thecase, then thenet-benefits
would be suggestive of afavorable business case that may
persuade employers to implement thepreventiveWHS intervention in thework setting.
MATERIAL AND METHODS
Study design
The study was conducted in anacademic medical centre
in theNetherlands as apragmatic cluster randomized
controlled trial with randomization at thelevel of hospital
wards. Acost-benefit analysis was conducted from theemployers perspective to see if there is abusiness case for
investing in theemployees mental health and work functioning. All costs were calculated in Euro for thereference
year2011 using theconsumer price index from Statistics
Netherlands[10]. For thecurrent cost-benefit analysis, we
compared2conditions: 1) theOP condition (screening,
feedback followed by referral to theOP for thescreen
positives),vs.2) thecontrol(CTR) condition (screening
without feedback and without referral to theOP).
Within thehospital,29wards (with207consenting nurses) were randomized to theOP condition and28wards
(with206consenting nurses) to theCTR condition. The
data was collected at baseline and after3 and6months
(hencefortht0,t1 and t2). Both costs and benefits were
computed over a6-month time horizon, corresponding to
thefollow-up period of thestudy. We excluded healthcare
costs (other than those attributable to theintervention)
and nurses out-of-pocket costs for obtaining health care

PROTECTING AND PROMOTING MENTAL HEALTH

Randomization of 57 wards to study arm 1 and 2

Nurses (N = 1 152)
Study arm 1 CTR (28 wards)
Nurses (N = 561)

Study arm 2 OP (29 wards)

Nurses (N = 591)

211 started
baseline questionnaire

210 started
baseline questionnaire

Exclusion (N = 5)

Exclusion (N =3)

206 included
for economic analysis

207 included
for economic analysis

195 completed baseline questionnaire

(206 analyzed)

197 completed baseline questionnaire

(207 analyzed)

145 completed 3 month follow-up

questionnaire (206 analyzed)

130 completed 3 month follow-up

questionnaire (207 analyzed)

138 completed 6 month follow-up

questionnaire (206 analyzed)

113 completed 6 month follow-up

questionnaire (207 analyzed)

CTR control; OP occupational physician.

Fig.1. Flow-chart of participants throughout thestudy

because they were deemed not to be relevant from theemployers perspective. Costs and benefits were not discounted because thefollow-up time did not exceed1year.
Amedical ethics committee approved thestudy. TheFigure1 presents theflow of participants through thetrial.
More information regarding thedesign of theMental Vitality@Work study may be obtained elsewhere[11].
Intervention and control conditions
All participants were screened for work functioning impairments and6types of mental health complaints: distress, work-related fatigue, risky drinking, depression,
anxiety, and post-traumatic stress disorder. Nurses in
theCTR condition filled out thescreening questionnaire
and no further steps were taken. In theOP condition,
screening was followed by personalized feedback and

ORIGINAL PAPER

screen-positive nurses received aninvitation to visit theoccupational physician. ThesubsequentOPconsultation

was structured according to a7-step protocol, with thefocus on identifying impairments in work functioning and
providing advice on how to improve wellbeing and work
functioning. The7-step protocol included thefollowing:
discussing expectations;
discussing screening results and characteristics of work
functioning and mental health complaints;
discussing possible causes in theprivate, work,
and health condition and consequences for work
functioning;
identifying theproblem and offering rationale;
giving advice on how to tackle thehealth complaints,
how to improve work functioning, how to prevent consequences of impaired work functioning, and how to
communicate with thesupervisor about work functioning and mental health;
discussing possible follow-up or referral to other care
providers;
summarizing theconsultation.
All participatingOPs received3-hour training in using
theprotocol[12].
Computation of intervention costs
The costs of offering theintervention included:
the costs of operating theweb-based screening and
feedback module,
the costs for periodically upgrading themodule,
the costs of hosting themodule on aserver (including
maintenance costs).
These costs amounted to4euros per user (calculations
may be obtained from the 1st author). Furthermore,
theper-participant costs for consulting theOP(73euros)
and thecosts for theOP-assistant for scheduling thenurses visits to theOP(3euros) are also included. To these we
added thecosts of training theOPs in using thepreventive consultation protocol(50euros perOPvisit). Thus,
IJOMEH 2015;28(5)

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C. NOBEN ETAL.

anurse who engaged in screening, received feedback

and made asingle visit to theOP would generate costs in
the amount of130euros. However, it needs to be borne
in mind that some screen-positive nurses did not visit
theirOP, while others made asingle visit or multiple visits.
Computation of thebenefits
As seen from theemployers perspective, thebenefits from
theintervention are related to the increased productivity
levels due to the reduced absenteeism and presenteeism.
Changes in productivity were valued in monetary terms,
using thehuman capital method. This method assesses
theloss of productivity by multiplying theself-reported
number of working days lost due to absenteeism multiplied by theaverage gross gender and age specific wages
per paid employee. Thewage was estimated according to
theDutch guideline for health economic evaluation and
itmay be found in theTable1[1315].
The work days lost due to diminished productivity were
basedon theself-reported number of work days when the
nurse did not feel well while at work over the past 6months,
weighted by aninefficiency score derived from theProductivity and Disease Questionnaire(PRODISQ)[16]. This
Table1. Productivity in study groups
Age
[years]

894

Productivity
[euro]
men

women

1519

9.88

8.97

2024

18.18

17.59

2529

24.77

24.19

3034

30.37

28.20

3539

34.85

29.96

4044

37.25

29.76

4549

39.25

29.61

5054

40.00

29.96

5559

40.33

30.21

6065

40.07

29.36

IJOMEH 2015;28(5)

was done on a10-point rating scale, ranging from0 to1,

with0meaning not inefficient and1completely inefficient.
Thenumber of work days lost due to inefficiency was then
multiplied with gender and age-specific wages indexed for
theyear2011[10,15]. Finally, thebenefits were computed
by comparing thepre-intervention costs (att0) with those
post intervention (att2). This yielded apre-post cost difference in each condition and these could then be compared
across theconditions.
Cost-benefit analysis
All analyses were performed in agreement with theintention-to-treat principle, thus including all participants
as randomized. In themain analysis, the missing data was
replaced by their most likely value under theexpectation
maximization(EM) algorithm in theStatistical Package for
theSocial Sciences(SPSS)19.
The incremental costs,C, were theintervention costs
of theOPcondition minus theintervention costs of
theCTRcondition. Theincremental benefits,B, were computed as thecost savings due to the reduced productivity
losses (owing to pre-post changes in both absenteeism and
presenteeism) in theOPcondition minus thecost savings in
theCTRcondition. Net-benefits were computed asBC,
the cost-to-benefit ratio as C/B and the return on investment(ROI) asB/C.
The net benefits, cost-to-benefit ratio and return on investment were analyzed in Stata (version12.1) using non-parametric bootstrap techniques. Theanalyses took into account
that observations were clustered, as nurses were nested in
different wards at thehospital. Therefore, the robust sample
errors were obtained using the1st-order Taylor series linearization within each of the1000bootstrap steps. This procedure
was conducted on thedataset that was imputed usingEM.
Sensitivity analysis
Sensitivity analyses were conducted to assess therobustness of our findings by making less optimistic assumptions

PROTECTING AND PROMOTING MENTAL HEALTH

about thebenefits. In this context it is of note that thebenefits

due to reduced presenteeism were computed by multiplying
theinefficiency score by thenumber of days at work with diminished work productivity. However, it may be assumed that
presenteeism may not have any impact on productivity levels
when thediminished productivity is compensated for during
normal working hours by thenurse or by colleagues[17]. If
that is true, then we may have produced anoverly optimistic
estimate of thebenefits. Thus, to test therobustness of our
findings, we recomputed thecost benefit ratio by reducing
thebenefits by10%,20% and30%, and by omitting thecost
offsets of reduced presenteeism altogether.
RESULTS
Sample characteristics
Baseline characteristics of thegroups are shown in theTable2. Both groups were quite similar, regarding demographic and occupational characteristics. Themajority

ORIGINAL PAPER

of theparticipants were female nurses born in theNetherlands, who lived together with apartner. On average theparticipants were aged42years and had more
than10years of work experience. We concluded that
randomization resulted in abalanced trial.
Cost-benefit analysis
The Table3 presents theper-nurse intervention costs and
benefits in the OP and the control condition as well as
thenet-benefits.
The mean per-nurse intervention costs amounted to89euros in theOPcondition and25euros in theCTRcondition. Thecost difference between theconditions was
therefore64euros(95%CI:5276), which was statistically significant (robust bootstrapped SE = 6.03,
Z=10.5,p<0.001).
Cost reductions due to greater productivity were715euros(95%CI:2261203) in theOPcondition relative to

Table2. Baseline characteristics of thestudy groups

Respondents
Characteristic

CTRgroup
(N=206)

OPgroup
(N=207)

41.8311.3

42.5611.4

159(77.2)

170(82.1)

146(70.9)

124(59.9)

9(4.4)

14(6.8)

nurse practitioner

23(11.2)

14(6.8)

allied health professional

21(10.2)

31(15.0)

anesthetic nurse

0(0.0)

13(6.3)

other

7(3.4)

11(5.3)

Age [years](MSD)
Females[n(%)]
Function[n(%)]
nurse
surgical nurse

Working hours(MSD)

30.986

28.738.1

Living with apartner[n(%)]

154(74.8)

Born in theNetherlands[n(%)]

176(85.4)

167(80.7)

Work experience [years](MSD)

11.310.1

12.5310.4

22(10.7)

27(13.0)

Turnover intention[n(%)]

153(73.9)

M mean; SD standard deviation. Other abbreviations as in Figure1.

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Table3. Intervention costs, benefits and net-benefits in study groups

Variable
Intervention costs
screening
added costsOPtraining
OPcaret0
OPcaret1
OPcaret2
total
Benefits
absenteeismt0
absenteeismt2
averted absenteeism cost
presenteeismt0
presenteeismt2
averted presenteeism cost
total
Net benefits
presenteeism included
presenteeism excluded

OPgroup
[euro/nurse]

CTRgroup
[euro/nurse]

DIFF(OPCTR)
[euro/nurse]

4
50
13
17
5
89

4
0
6
7
7
25

0
50
7
10
3
64

660
234
426
1 125
916
209
635

492
374
118
1 069
1 267
198
80

546
337

105
93

308

407
715
651
244

DIFF(OPCTR) difference (occupational physician group minus control group).

Other abbreviations as in Figure1.

those in theCTRcondition. These cost savings were

statistically significant (robust bootstrapped SE = 249,
Z=2.87,p=0.004) and in favor of theOPcondition.
Subtracting per-participant intervention costs from
theper-participant cost offsets due to reduced absenteeism and presenteeism resulted in net-savings of651euros
per nurse. The net-benefits were statistically significant
(95%CI:1671135,SE=247.13, Z=2.63,p=0.008)
and in favor of theOPcondition. The benefits stemming
from the reduced presenteeism are hard-to-quantify,
by excluding these benefits and focusing on net-benefits
when only absenteeism is regarded, resulted in net-be
nefits of244euros per nurse in favor of theOP condition,
still representing afavorable business case as seen from
the employers perspective.
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IJOMEH 2015;28(5)

Base-case and sensitivity analyses

In thebase-case analysis thereturn on investment
for theOP condition was7euros per1invested euro
and 3euro per1invested euro for theCTRcondition(i.e.,negative benefits, thus higher costs). Thereturn
on investment was(715/64euro=)11euros per1invested
euro (Table4).
Various sensitivity analyses were performed to attest
therobustness of thefindings and theresults are summarized in theTable4. Theresults of thesensitivity analyses
attest to therobustness of themain analysis. Theincremental costs of offering theintervention are more than
compensated for by productivity gains. Even when productivity gains in theOP-condition are lowered by30% thenet
benefit per employee is still461euros after6months and

PROTECTING AND PROMOTING MENTAL HEALTH

ORIGINAL PAPER

Table4. Base-case and sensitivity analyses

Net-benefits
(BC)
[euro]

Cost-benefit
ratio
(C/B)
[euro]

Return on
investment
(B/C)
[euro]

715

651

0.09

11

80

651

587

0.11

10

508

80

588

524

0.11

30%OPbenefit

444

80

525

461

0.12

presenteeism

426

118

308

244

0.21

OP group
[euro]

CTR group
[euro]

DIFF
(OPCTR)
[euro]

89

25

64

635

80

10%OPbenefit

571

20%OPbenefit

Variable
Base-case
costs(C)
benefits(B)
Sensitivity analysis

Abbreviations as in Figure 1.

thereturn-on-investment is still asubstantial8euros

per1invested euro. When ignoring thehard-to-quantify
benefits stemming from reduced presenteeism, there still
is areturn on investment of almost5euros.
DISCUSSION
Main findings
The primary aim of thestudy was to conduct acost-benefit analysis from theemployers perspective by considering thebalance of thecosts of apreventive intervention
and thecost offsets stemming from improved producti
vity. Net-benefits were651euros per nurse and were statistically significant atp=0.008. In other words, thepayout is11euros per one euro invested. It is worth noting
that thecost offsets occur within6months post intervention, thus representing afavorable business case from
anemployers perspective where theinitial investments
are more than recouped within ashort period of time.
Themain conclusion that offering theintervention offers
good value for money from theemployers perspective
remains intact when confining theanalysis to thechanges
in absenteeism and ignoring any benefits due to reduced
presenteeism.

Placing theresults in thewider context of theliterature

There are only afew studies evaluating thecosts and
benefits of mental health promotion and prevention in
theworkplace. Knapp et al. have assessed theeconomic
impact of mental health and well-being improvements
associated with various programmes based on alimited range of studies using economic modeling[18]. Arendsetal. evaluated areturn-to-work intervention and
focused on theprevention of recurrent sickness absence
and helping workers to stay at work. Theauthors demonstrated the12-months effectiveness of aproblem-solving
intervention for reducing recurrent sickness absence in
workers with common mental disorders[19]. Iijimaetal.
conducted acost benefit analysis of mental health prevention programmes within Japanese workplaces. They concluded that themajority of companies gained anet benefit
from themental health prevention programmes[20]. Another Japanese study concluded that aparticipatory work
environment improvement programme and individualoriented stress management programmes showed better
cost-benefits, suggesting primary prevention programmes
for mental health at theworkplace economically advantage employers[21].
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C. NOBEN ETAL.

Although theresults of our study unite with theresults of

the previously conducted studies which took place during
and after thesickness absence period, or within another
cultural, ethical and geographical setting, our study might
be seen as awelcome addition to alimited evidence-base.
Strengths and limitations
Several strengths of this study need to be mentioned.
Firstly, this study was a trial-based economic evaluation
and is therefore firmly rooted in empirical data. Secondly,
thestudy was conducted as apragmatic trial, thus enhancing theecological validity of theresults[22]. Thirdly, we
reviewed both thecost reductions due to less absenteeism and reduced presenteeism. Although including presenteeism is astandard practice in economic evaluations,
it is worth mentioning that owing to their lower visibility,
these costs are not so evident to anemployer and are often
overlooked[13,23].
The results need to be placed in thecontext of thestudys
limitations. Firstly, thetrial data was affected by drop-out
and this may have distorted theoutcomes. That said, we
conducted anintention-to-treat analysis by imputing missing observations under theEMalgorithm. In our health
economic evaluation of thesame data we demonstrated
that theresults after theEMimputation are very similar
to those obtained under alternative imputation strategies such as regression imputation and last-observationcarried-forward imputation. Nonetheless, drop-out rates
were substantial and may have biased our outcomes.
Secondly, all outcomes were based on self-report. However, it is hard to see how the presenteeism may be measured without resorting to self-assessments of diminished
productivity. Unfortunately, thevalidity of the self-reported presenteeism has not often been researched[2428]. It
is precisely for this reason that we conducted sensitivity
analyses to gauge therobustness of thestudys outcomes
when less optimistic assumptions are being made about
thebenefits in theOPcondition.
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IJOMEH 2015;28(5)

Thirdly, some potential impacts of theintervention were

not assessed, such as thecosts of staff turnover and thespillover effects of absenteeism by1nurse on theworkload of
her colleagues. As to staff turnover, thedata indicate that
turnover intention was reduced from27nurses att0 down
to10nurses att2 in theOPcondition. In theCTRcondition
these were22 and14, respectively. This data suggests that
theOPintervention may have additional favorable effects
on staff turnover, but these were not quantifiable in terms
of actual changes in staff turnover. As aconsequence, we
may now only speculate that thecost benefits that we reported represent lower bounds of thetrue cost benefits.
Fourthly, it should be noted that all intervention costs are
computed for. Thus theinitial investments required for
developing and implementing theinterventions were part
of our study. Although this might contradict with guidelines for economic evaluations[29], where one would solely account for intervention costs when fully implementing
theintervention, we recognized that thecosts required
for developing and implementing theinterventions were
interesting in their own right and therefore included in
thetotal intervention costs.
Fifthly, there are 2 main approaches to cost-productivity
losses; thehuman capital approach and thefriction cost approach. However, both approaches produce similar results in
theshort term, as is thecase in our study with afollow-up
after6months. We therefore expect that choosing one approach or theother is unlikely to have amajor impact on our
conclusions. From abusiness case point of view, therelatively
short follow-up time is not alimitation, because it is easy to
see that thecosts of offering theintervention are recouped
within such ashort time span. Nevertheless, as yet we do not
have data concerning thelonger-term outcomes.
CONCLUSIONS
Areturn-on-investment of11euros within6months represents avery appealing business case, and wider implementation of theintervention may be recommended.

PROTECTING AND PROMOTING MENTAL HEALTH

However, and as noted above, thetime horizon of this

study is limited, so that we only look at costs and cost
reductions over a6-month period. Therefore, we do not
know if effects are maintained over time. In all likelihood,
theinterventions impact will need to be sustained by periodic repetition of theintervention,e.g., ascreening plus
personalized feedback plus referral to theOP for screenpositives every12 or24months.

ORIGINAL PAPER

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