Project report

Advancing employee engagement through a

healthy workplace strategy

Andrea Seymour, Kathryne Dupré1

Health Information, River Valley Health, Fredericton, New Brunswick; 1Organizational Behaviour and Human Resource Management, Faculty
of Business Administration, Memorial University of Newfoundland, St John’s, Newfoundland, Canada

Background: In recent years, there has been increased focus on improving the quality of the working lives of
staff in health care organizations. Research shows that improvements can be achieved through a
comprehensive organizational approach to workplace health. Improved worker engagement is a realizable
outcome of such an approach, provided that it is based on reliable and relevant data and is tailored to the
specific environment in which it is being implemented.
Assessment of problem: An intervention project was designed to develop an organization-wide approach to
employee workplace health. A comprehensive health risk assessment was undertaken, along with a staff
survey on workplace culture, individual health practice and environmental effects on physical health.
Results: In general, the findings present a positive picture of the culture and factors that influence
psychological wellbeing. However, improvement is needed in some areas: satisfaction is only marginally
outweighing stress, and musculoskeletal disorders account for much absenteeism. Employee health needs
include weight management, improving fitness and nutrition, and decreasing coronary risk.
Strategies for change: Results have prompted this organization to pursue the development of a Healthy
Workplace Policy that will be used as a filter for all other policies relating to workplace culture, environment
and practice, and have provided the impetus and focus to review the organization of employee health services.
Lessons learned: Three major administrative activities are necessary to move from planning to sustained action:
ensure adherence of all staff to any policy derived from a health risk assessment; ensure staff feel proposed
changes are relevant and important; and create a road map to guide the development of a strategic and an
implementation plan. The findings outlined in this report can be addressed by organizations that are willing
to commit to a comprehensive approach to workplace health.
Journal of Health Services Research & Policy Vol 13 Suppl 1, 2008: 35 –40 # The Royal Society of Medicine Press Ltd 2008

Background healthy workers and workplaces.2 In its 2002 report,

In recent years there has been growing recognition that
the supply of health care providers is just one part of the
equation in ensuring an adequate and qualified body of
health care practitioners. The Canadian Council on
Health Services Accreditation recognizes that support
of existing workers is an integral factor in employee
retention.1 The Council suggests that organizations
must create a work environment that supports high
quality performance, as well as individual and organiz-
ational health, development and growth. Few
Canadian health service organizations have, however,
developed comprehensive strategies to address improv-
ing the work environment even though evidence
suggests that such an approach is effective in creating
Andrea Seymour, Vice President Health Information and Chief
Information Officer, River Valley Health, PO Box 9000, Fredericton,
NB E3B 5N5, Canada; Kathryne E Dupré PhD, Associate Professor,
Organizational Behaviour & Human Resource Management, Faculty
of Business Administration, Memorial University of Newfoundland,
St. John’s, Newfoundland, Canada.
Correspondence to: Andrea.Seymour@rvh.nb.ca
Building on Values, the Commission on the Future of
Health Care in Canada reported that a lack of human
resource planning has contributed to the decline in
the quality of work life for health professionals.3
Further, the Commission cited low morale, concerns
regarding scope of practice, shortages among several
professional groups and the trend toward poaching of
scarce health professionals across regions or jurisdic-
tions as key issues that must be resolved. The conclusion
of the report, that a concerted focus on the wellbeing of
employees in the health care system is necessary, is sup-
ported in research.3 – 8
In 2006, the Canadian Institute for Health
Information estimated that national health care expen-
diture would exceed $148 billion, representing approxi-
mately 10.3% of GDP.9 The largest category of
spending, hospitals, was projected to be $39.9 billion,
representing 30.3% of the total.9 It is estimated that
approximately 70% of the total expenditure is remu-
neration for health care professionals in the hospital
setting.9,10 Given that, health care organizations are

DOI: 10.1258/jhsrp.2007.007031 J Health Serv Res Policy Vol 13 Suppl 1 January 2008 35
Project report
publicly accountable to ensure efficient and optimal util-
ization of human resources.
There is evidence that this is not occurring. The
Statistics Canada Labour Force Survey indicates that for
each of the last six years, nurses, technical and support
staff missed more time from work due to personal illness
or injury than all other occupations in Canada.11
Moreover, this same survey found that for health care
staff, days lost were double the national average.11 Other
research at the national level demonstrates that, when
compared to other occupations in Canada, health care
professionals take the most sick time and have the lowest
commitment to their employer.12,13
Overall, there is evidence that engagement among
health care employees is low.12 An engaged employee11
is aware of the business context, and works with colleagues
to improve performance within the job for the benefit
of the organization. The organization must work to
nurture, maintain and grow engagement, which requires
a two-way relationship between employer and employee.14
This paper describes an intervention project that was
designed to develop an organization-wide approach to
improving the quality of the working lives of employees.
It was guided by research demonstrating that this can be
achieved by a comprehensive organizational approach.
When employees are healthy, and when their quality
of work life is high, worker engagement is more likely
to occur.14 Research suggests that there are three
elements that successful healthy workplace strategies
contain: a comprehensive committed approach to work-
place wellness; a partnership between employer and
employee; and a focus on employees needs.8,15,16
First, there is growing recognition that individual
health is related to a comprehensive committed
approach to workplace wellness. 8,13,17 – 20 The national
Quality Worklife – Quality Healthcare Collaborative
highlights the relevance of commitment in their defi-
nition of a healthy workplace: ‘a work setting that
takes a strategic and comprehensive approach to pro-
viding the physical, cultural, psychosocial and work/
job design conditions that maximizes the health and
wellbeing of health care providers, quality of patient
outcomes and organizational and system perform-
ance’.17 It summarizes the major issues relevant to
wellbeing and encourages partnership between
employer and employee as a critical element of a suc-
cessful healthy workplace. This is supported by the
Canadian Policy Research Network’s Changing
Employment Relationships Project, which identifies
employment relationship factors as strongly predictive
of important workplace outcomes. Finally, it is also
important to focus specifically on employees them-
selves in creating healthy workplaces. This not only
informs the organization of what employees need but
creates an environment in which employees feel
valued, have input, have some measure of job control
and have the opportunity to improve their own
health.17 These three core elements guided the devel-
opment of this organization’s strategy for a healthy
workplace described in this paper.
36 J Health Serv Res Policy Vol 13 Suppl 1 January 2008
Employee engagement through a healthy workplace
Evidence supports the notion that focusing on the
health of employees will result in employee engage-
ment. Employee engagement is important because it is
related to improved organizational performance and
better retention of staff.21,22 The goal of this interven-
tion project was to identify and evaluate the health
risks, perceptions and practices faced by employees in
one health care organization. This information could
then be used to determine what conditions or strategies
must be implemented to promote the adoption of a
healthy workplace culture, and to encourage modifi-
cation of unhealthy practices of staff. The ultimate
goal is to use the evidence to develop processes and
structures to prioritize activities and develop a compre-
hensive approach to workplace wellness that will
improve employee health, engagement and ultimately
retention over the long term.
Assessment of problem
The organizational intervention applied to a large
regional health authority (RHA) that employs approxi-
mately 4000 people in eastern Canada. The RHA, span-
ning a geographic area of 23,000 square km, comprises
an integrated network of hospitals, health centres and
specialty care programs that provide a broad range of
health services to just over 20% of the province’s popu-
lation. For more than a decade, this RHA has also been
immersed in system re-design, including regionalization
and centralization of services across jurisdictions.
Evidence indicates that system re-structuring and
rationalization increases employee turnover and
decreases employee productivity and engagement.22
Research further demonstrates that job insecurity, a
lack of job control, role stressors, interpersonal pro-
blems, job content, and individual preferences and
needs adversely affect employee performance and
retention.6,13,22,23 Thus, this continuous re-design of
the health care system has likely had a destabilizing
effect on people in this organization.
The organization made a concerted effort to reduce
sick time and increase performance between 2000 – 04.
Although this produced benefits, recently the organiz-
ation recognized that sustainability of these results,
without a longer term ‘assets view’ of the workforce,
was unlikely. Moreover, although new initiatives had
been developed to address the quality of work life,
these disparate activities evolved over time without an
integrated framework or structure, and without clearly
aligned goals. As a result, in the fall of 2004 following
an intensive consultative process, the Board of
Directors of this RHA released a four-year strategic
plan. The third of four strategic directions, Strong
People – Strong Partnerships, committed the organization
to ‘the cultivation of a rewarding work environment and
to becoming an employer and partner of choice’. From
this emerged a model that identified physical health,
organizational culture and environmental safety as the
three cornerstones of a healthy workplace.
Employee engagement through a healthy workplace
It was necessary for the organization to begin the
process of creating a healthy workplace by developing
an understanding of the unique characteristics of its
workforce and environment. It was determined that a
health risk assessment be undertaken to measure scien-
tifically: the health and lifestyles of staff; workplace
culture and the extent to which this organization was a
supportive environment; and effect of the physical
environment, from a safety and policy perspective, as
it related to musculoskeletal injuries to staff. The assess-
ment consisted of physical testing of staff and the com-
pletion of an online questionnaire.
This approach engaged the entire organization in dis-
cussion about health and in taking action to promote
personal health and prevent illness. It also provided
individualized information to employees, resulting in
initiatives to target high-risk or high volume health
needs, and allowed the organization to develop a base-
line measure against which the effect of subsequent
initiatives and activities could be measured.
Although there are many questionnaires available to
measure both personal health practice and the effect
of the environment on musculoskeletal health, there is
no obvious instrument with which to measure organiz-
ational culture. An existing systematic review24 was con-
sulted to understand the key instruments that measure
organizational culture and to determine if there were
validated tools available that could be used in this
RHA. The conclusion was that the choice of instrument
should be determined by how organizational culture is
conceptualized by the research team, the purpose of
the investigation and the intended use of the
results. Given this, the RHA decided to implement
the Healthy Workplace Questionnaire.25 This
measured the three components identified in the
RHA’s healthy workplace model: practice, environment
and culture.
The questionnaire consisted of 70 questions, 40
related to personal health and lifestyle as measured
with the Personal Wellness ProfileTM.26 This proprie-
tary tool is a health and lifestyle assessment tool that is
based on national guidelines and rated by the Centre
of Health Promotion, University of Toronto and vali-
dated by the University of Southern Florida.
A further 19 questions related to organizational
health and workplace culture,26 of which 15 were a com-
posite of items based on Gallop’s top 12 drivers of
business outcomes, and the Sears Employee Index.26
These mapped onto the psychologically healthy work-
place model (safety of work environment, employee
development and involvement, work content and
characteristics, a culture of support, respect and fair-
ness, work – life balance, and interpersonal relationships
at work) developed by Kelloway and Day.19 The remain-
ing four organizational health and culture questions
were the validated questions of the Business Health
Culture Index:27 assessing demand, control, effort
and reward.
The last 11 questions related to musculoskeletal
health. This component of the Healthy Workplace
J Health Serv Res Policy Vol 13 Suppl 1 January 2008 37
Project report
Questionnaire measures the impact of the environment
on employees as it relates to musculoskeletal disorders.
In addition, physical testing for height, weight, waist
circumference, blood pressure, blood sugar and choles-
terol was undertaken.
All participants received their own personal wellness
profile based on results relating to their personal
health and current lifestyle. The profile is an eight-
page health and lifestyle assessment tool that provides
an individual with his or her wellness score, health
age, current fitness and nutrition habits, and rec-
ommendations for preventative exams and actions
based on specific personal needs. It is not a medical or
diagnostic tool but rather identifies current health beha-
viour and risks that require primary prevention strat-
egies or actions, and chronic disease risk factors for
secondary follow-up. The organization received the
aggregate of these data to drive the development of
key directions and initiatives.
Results
A total of 1641 employees (43% of all employees) comp-
leted the online Healthy Workplace Questionnaire and
physical testing. The sample consisted of 196 men and
1445 women, which is representative of the gender com-
position of the organization.
The first section of the Healthy Workplace
Questionnaire provided the organization with infor-
mation on the top four Personal Health needs of
employees. These included weight management (60%
were overweight, with a BMI .25); improving fitness
(51% need to improve their level of physical activity);
improving nutrition (41% need to improve eating
habits; 43% do not eat breakfast); and decreasing coron-
ary risk (50% had two or more modifiable risk factors).
The second section on Organizational Health pre-
sented a positive picture of organizational culture and
the factors that influence psychological wellbeing
(Table 1). Over 80% of participants responded positively
(agree or strongly agree) to eight of the 19 items and
most participants were positive about their contribution
to the organization’s success (88%) and their pride
(80%) in working it. The majority of staff believed
there was a culture of support, respect and fairness, a
positive environment of development and involvement,
satisfying work content and characteristics, a good
work – life balance and positive communication with col-
leagues. Areas for improvement included: encouraging
professional development (61% were encouraged in
professional development); increasing buy-in to the
strategic plan (62% understood the plan); investigating
why only 53% believe that everyone strives to deliver
quality work; improving the physical work environment
(66% were happy with the current environment); and
managing relationships (69% believe that their man-
agers cared about them as a person). The organizational
health results must be weighed against the results from
the Business Health Culture Index which shows that sat-
isfaction is only marginally outweighing stress (Box 1).
Project report Employee engagement through a healthy workplace

Table 1 Employee views of organizational culture and factors that influence psychological wellbeing (n ¼ 1641)

Mean Disagree Neutral Agree

Statements Responses score (%) (%) (%)

Development and involvement

I am trained and equipped to do my job well 1454 4.3 2 4 94
I know what is expected of me in my job 1464 4.3 2 3 95
I am empowered to make decisions that affect how my work is 1519 3.9 1 14 80
performed
I feel good about the opportunities I have to learn and grow 1530 3.7 9 19 72
There is someone at work who encourages my professional 1539 3.6 13 26 61
development
Work content and characteristics
I understand how my work contributes to our organization’s success 1493 4.2 2 6 92
I understand the strategic directions of River Valley Health 1551 3.7 7 31 62
In my opinion, everyone at River Valley Health strives to deliver quality 1567 3.4 14 33 53
work
I am proud to say I work for River Valley Health 1586 4.0 2 18 80
I am happy with our work environment 1591 3.7 12 22 66
I like my job 1592 4.2 2 10 88
Culture of support, respect and fairness
My manager/boss seems to care about me as a person 1501 3.8 9 22 69
My co-workers treat me with consideration and respect 1513 4.1 3 10 87
Work –life balance
I am able to complete all important tasks within my scheduled work 1526 3.8 13 10 77
hours
Interpersonal relationships
My co-workers and I communicate effectively 1515 4.1 3 8 89

The findings of the musculoskeletal health com-
ponent of the survey were reviewed and showed that
musculoskeletal disorders accounted for many cases of
employee absence from work. Lower back pain was
the most common condition reported by employees
(57%) followed by neck pain (49%). Many employees
have had one or more condition during the last 12
months (89%) although a much smaller percentage
reported that a musculoskeletal disorder interfered
with their normal work (15%). Approximately 22% of
employees had missed work at some point in their
careers. This is consistent with the estimate by Health
Canada that musculoskeletal disorders account for
16 – 20% of absenteeism costs.28
Strategies for change
The health risk assessment has created a baseline of
information and knowledge about the organization
and the people who work in it. Activity will now be
concentrated on identifying key priorities and a five-
year action plan to address issues and support change.
To promote healthier lifestyle choices, action-oriented
programming relating to the priorities identified in
the assessment have been offered including: Ulcer and
Heartburn Care Pathway to Heart Healthy Lifestyle,
Living Well with Shift Work, Creating a Great Family
Life, Respectful Workplace and Change Management
workshops. Other health promotion activities included
the Cross Country Challenge, Portion Distortion nutri-
tional counselling, the Integrated Leadership Program
and a walking club.
Organizational health results prompted the organiz-
ation to pursue the development of a Healthy
Workplace Policy that will be used as a filter for all
other policies relating to workplace culture, environ-
ment and practice. Results from the health risk
assessment have provided impetus and focus to
review the organization of the Employee Health
Services. Targeted measures on areas of workplace

Box 1 Business Health Culture Index

Control Effort Results

Statement: I am satisfied with the
amount of involvement I have in
decisions that affect my work.
Overall result: 0.63
Interpretation: Caution
Reward
Statement: I feel I am rewarded
(recognition and praise) for the level
of effort I put out for my job.
Overall result: 0.52
Interpretation: Caution
In the last six months, I have
experienced worry or stress from
mental fatigue at work.
Overall result: 0.40
Interpretation: Caution
Demand
Statement: In the last six months, too
much time pressure at work has
caused me worry or stress.
Overall result: 0.37
Interpretation: Full speed ahead
Using the Stress & Satisfaction formula, marks were
assigned to each of the four domains and tabulated
to yield an overall score.
Stress & Satisfaction Business Health Culture
Index Score: 0.39
When Control exceeds Effort and Reward exceeds
Demand it means that satisfaction outweighs stress.
Interpretation: Caution
In this organization, there is a narrow positive margin.
This indicates that close attention must be paid to
control and involvement in decision-making.

38 J Health Serv Res Policy Vol 13 Suppl 1 January 2008

Employee engagement through a healthy workplace
safety that affect employee health and performance will
be pursued.
Research evidence indicated that sustainability of
healthy workplace strategies requires the commitment
of management and staff over a long period of time,
and the embedding of the philosophy of good health
and wellness in the mission and culture of the organiz-
ation. Given this, it was decided that National Quality
Institute certification would ensure that the structure
required to support a healthy workplace was in place
and that this, in turn, would demonstrate tangible com-
mitment to staff.
Engaging employees to take active and decisive per-
sonal steps towards health promotion and prevention
is difficult. Traditional change management strategies
could be supplemented by an understanding of the
theory of planned behaviour and incorporated into
the development of programs that are targeted at staff
that have different levels of understanding, intention
and perceived behavioural control. Activities must be
targeted at behaviour and activities that employees
have a desire to change; initiatives must be transparent,
aligned and well communicated. It was important to
create site specific champions who are both front line
and management staff.
There is little practical material available to health
care employers that would help to expedite the
implementation of a healthy workplace philosophy
and approach. For example, less than half of the ten
best practice organizations surveyed had developed
healthy workplace policies, and only one had a compre-
hensive policy in place. The findings from the work
reported here may be of help in the development of a
national approach to Healthy Workplaces through the
sharing of knowledge, process and tools. This may
include sharing of policy and structure, publication of
research and evaluation results, presentations at confer-
ences and symposiums, participation in national
working groups or committees, or acting in an advisory
capacity to organizations undertaking new initiatives.
Given the complexity and resource intensity of this
process, validation of the results reported here did not
occur. It is recommended that future work in this area
allows non-respondents the opportunity to confirm,
refute or adapt the findings.
Lessons learned
There are three major administrative activities that must
be completed to move from planning to sustained
action. Firstly, this organization must ensure adherence
of all staff to the policy that has been developed based on
the results of a health risk assessment and review of the
research literature. Secondly, there must be focus
groups to determine initiatives so that employees feel
change strategies are relevant and important. And
finally, the results of the focus groups, combined with
the data collected, must be used to create a road map
that will guide the development of a strategic plan and
a five-year action plan.
J Health Serv Res Policy Vol 13 Suppl 1 January 2008 39
Project report
Research suggests that the findings outlined in this
paper can be addressed by organizations that commit
to a comprehensive approach to workplace health.8
Improved worker health, job satisfaction, productivity,
engagement and retention are attainable outcomes of
a healthy workplace strategy.13 Opportunity for
success is greater if the strategy is based on reliable
and organizationally relevant data and an approach
that is tailored to the specific environment in which it
is being implemented.29,30
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