Background
To a greater or a lesser extent, everyone has to deal with mental health issues in life. At any point in time, one-sixth of the working age population is suffering from common mental disorders [
1,
2]. Despite all efforts regarding preventative mental health interventions, the OECD and occupational health researchers call for more attention to employees with common mental health problems (CMHP) in the work context [
1,
3,
4]. Work is often considered as an important cause of CMHP, and at the same time an essential solution to enhance mental health, societal participation and general wellbeing of individuals. Staying at work (SAW) while facing mental health issues can be used as a means to decrease the severity of CMHP, resulting in prevention of negative work outcomes such as absenteeism or reduced work performance for employees with CMHP [
5]. Workplace stakeholders, especially supervisors, play a key role in prevention by supporting employees with CMHP, that may avoid employees with CMHP getting absent in the long term [
6,
7]. We define SAW as to continue working while maintaining work performance [
5]. Common mental disorders refer to depression, anxiety disorder, or stress-related disorder [
8,
9]. However, a large number of employees who suffer from common mental health problems are undiagnosed and do not receive treatment, or do not disclose their diagnosis at the workplace [
3,
10]. Therefore, we target a relatively broad group of employees with diagnosed mood, anxiety or stress-related problems as well as self-reported psychological complaints.
The literature in occupational health shows that high quality leadership predicted a reduced risk of long-term sickness absence [
11] and contributes to return to work [
12]. Various studies show how low supervisor support is a risk factor for absenteeism [
13‐
15] and how investing in supervisor support, e.g. to facilitate the dialogue between employee and the nearest supervisor by following a protocol, contributes to better return to work planning [
16]. Only a few studies show promising results that supervisor support enhances employees to stay at work because it is harder to know what worked in prevention of negative working outcomes, such as we aim in this study [
5]. However, a trustful relationship with the supervisor, with whom the employee can discuss needed support or job accommodations, is found to promote SAW [
5]. The increasing number of absenteeism and incapacity for work because of mental health problems over the last decades shows that it is challenging to intervene effectively in the phase of being at work, where practical guidelines for workplace stakeholders such as supervisors are scarce [
17,
18]. This is urgent, because it is often the supervisor, their line manager, who is the first person who needs to act when the employee struggles at work. This workplace stakeholder is often not trained on how to do so accordingly [
19]. In sum, research shows the important role that supervisors have in supporting these employees to SAW, however in case of CMHP they lack strategies or guidelines on how to support [
19‐
21]. To illustrate, 40% of a representative panel of Dutch employers reported not to know how to help employees with CMHP in the workplace [
22]. Therefore, there is a need to provide supervisors with clear directions on ways to promote SAW among employees with CMHP.
There are various reasons why the role of the supervisor in the phase of staying at work with CMHP is under addressed. First, although policies are into place on sustainable employment and promotion of health and wellbeing of employees, in practice, supervisors often act when the employee is yet facing reduced performance or sickness absence [
23]. Second, signalling is hard because employees find it difficult to disclose mental health issues at the workplace, making it harder for supervisors to address mental health [
24]. Third, CMHP usually develop slowly and saliently. Altogether, talking about mental health at the workplace is frequently avoided by both employees and supervisors due to the stigma and fear for losing the job [
25]. In the Netherlands, due to privacy laws, supervisors are not allowed to ask or even know about the employee’s medical condition. Altogether, it is complex for supervisors to effectively support and facilitate employees due to the lack of guidance on their role and ways to deal with mental health in the workplace. This study aims to develop such an intervention, to strengthen supervisor support for employees with CMHP, derived from research and practice.
Well-designed work and workplaces that promote SAW seem essential to prevent negative work outcomes [
2]. For this, effective, preventive workplace interventions are needed. Although organizational interventions have been shown promising in preventing mental health problems of employees [
26,
27], it is yet unknown what the elements and effects of such interventions are on actual supervisors’ supportive behaviour [
7,
28]. So far, preventive interventions that target supervisors’ behaviour as a mechanism of change in employee health, well-being and work outcomes consist of elements such as a behaviour oriented approach [
28,
29] and a participative problem solving approach [
30]. A supportive supervisor can open the door for employees with CMHP regarding their needs for organizational support, e.g. by offering job accommodations or time for treatment. Therefore, it would be valuable to investigate what in the behaviour of supervisors works or does not work to promote SAW for employees with CMHP. Because it is harder to investigate effects of what has not yet occurred, such as in prevention, [
23], it is challenging to know for both employees and their supervisors what can be done in the workplace through a preventative approach [
3]. Relatively few studies are specifically investigating the role of supervisors in prevention, in order to support employees with CMHP to SAW. Therefore, we need to explore what happens in practice and use those learned lessons to develop interventions [
21].
Previous studies targeted supervisor support to reduce negative work outcomes for various employee populations. One promising intervention was presented in a study targeting self-efficacy of supervisors based on the ASE model [
31], aiming to reduce negative work outcomes. This study used strategies such as inter-collegial consultation [
32]. Other studies used different theoretical frameworks, two using the Self-determination theory [
33,
34] and one using the trans-theoretical framework [
35], offering more insights into the behavioural elements of workplace stakeholders. To create mentally healthy workplaces, we assume, as those studies, that it is necessary to target individual behaviour of various workplace stakeholders [
2,
6,
36]. In addition, we emphasize the importance of workplace factors on organisational level. In the previous intervention studies, it remained unclear how environmental factors, such as the learning climate or social safety were targeted or evaluated. Therefore, in the present study, we used the Integrated model of behaviour prediction to frame employer’s behaviour that also incorporates environmental factors [
37].
Besides, the use of a practical, participative approach to intervene is needed. A protocol providing insights and transparency based on theory and evidence may provide support on the development of such an intervention. We searched a systematic approach, in which Intervention mapping (IM) [
38] has been applied previously in workplace interventions. However, it was most often used to target behaviour on the individual level for specific working populations [
33,
39,
40]. Two studies applied IM on behaviour of workplace stakeholders such as supervisors [
35] or occupational health physicians [
34], however not on the promotion of Stay at work for employees with CMHP. This study aims to present the development of such an evidence-based workplace intervention. To meet the recommendations of recent reviews on the use of IM in workplace interventions [
41,
42], we present how active stakeholder involvement, and the use of a theoretical framework were applied to bridge the gap between theory and practice.
Discussion
This study presents the development of the Stay at work-Supervisor Guideline (SAW-SG) intervention to strengthen supervisor support, promoting employees with CMHP to stay at work. Development of the intervention was guided by the IM approach, which resulted in an online guideline and a training protocol for interactive coaching sessions to support supervisors. The online guideline contains five themes to signal and address problems in the workplace and find solutions by stimulating the employee’s autonomy, explore job accommodations and ask for occupational health support. Labour experts as OHPs delivered the intervention as they are independent, and experts in matching employee’s capabilities with work and work environment.
The SAW-SG intervention adds to the literature on workplace interventions in mental health, through an innovative, evidence-based intervention with a preventive approach by strengthening the supervisor's supportive behaviour regarding mental health at work. In line with these previous IM studies, we endorse that (individual) behavioural models on employee-level can be transferred to the behaviour of other workplace stakeholders as individuals who act as change agents in an organization. The additional value of the Integrated model of behaviour prediction was the integrative approach towards behaviour, in which environmental and general motivational factors also were included in the intervention, both content wise by the included basic conditions in the guideline and for delivery through the implementation strategies. In this, the intervention targets the complexity between individual behaviour and actions, and the interaction, often on a interpersonal level, with the work context. Although it is challenging to realize changes in organizational culture or support systems, this study made a first step by facilitating change on the interpersonal level by improving the interaction between OHP, supervisor and employee [
34]. Nevertheless, we did not specifically target psychosocial work exposures that significantly associated with mental health outcomes, as revealed in a recent meta-analysis [
56]. Reflecting on our intervention, these were indirectly addressed in the basic conditions (job strain, psychological demands) and in theme 3 and 4 respectively (stimulating autonomy of employees to avoid decision latitude and explore job accommodations to adjust long working hours).
Staying at work, for employees with CMHP, is a relatively new concept, that is not clearly defined in the literature [
5]. This implies also that ways to promote stay at work are not yet profoundly developed and evaluated in the literature. Therefore, a considerable amount of time was needed to identify promoting factors to SAW for which we used both theory and practice during the needs assessment. Theory of working mechanisms to stay at work on both employee-level and organization-level were retrieved by a systematic realist literature review [
5]. In addition, these promoting factors to stay at work for employees and the role of the supervisor were verified in practice with various workplace stakeholders through a concept mapping study [
57] and focus group discussions. Altogether, this provided content to the intervention, including practical ways to support employees with CMHP who struggle at work. As a result, this study adds to the conceptualization of staying at work.
This intervention turned out to target three key areas, namely general awareness on mental health, basic conditions for a mentally healthy workplace and five stepwise themes with actions to support employees with CMHP. In its essence, these all reflect the way supervisors do position and treat employees with CMHP. Promoting a trustful relationship between supervisor and employee, both before and whilst struggling at work due to mental health problems, was highlighted by all participants as a main challenge for supervisors. In this, the dialogue between employee and supervisor is an important element to signal and talk about symptoms in an early stage. Supervisors addressed the necessity of such an intervention to train all supervisors addressing ‘soft skills’, possibly mandatory, contributing to the quality of this dialogue [
39]. As found in other studies, they need to be facilitated by their organisation, through individual coaching and peer learning through consultation among colleague-supervisors [
22,
32]. It underscores the growing realization by employers that they should and can act pro-actively in prevention to promote mental health at the workplace, by being given the appropriate guidance [
58].
Non-surprisingly, many of the actions and themes addressed in the guideline seemed relevant to all employees: those with and without CMHP. All participants in our study stressed the early signalling and addressing of work-related issues, in a phase that mental health problems are present but not (yet) lead to sick leave. There is a thin line, especially in prevention, between addressing mental health
in general and addressing mental health
problems that affect one’s work. Thus, it can be argued that our intervention does not only benefit employees with CMHP but all employees, possibly resulting into more trustful and sustainable working relationships. We observed during our study that investing in awareness and skills among supervisors leads to more attention and empathy for mental wellbeing of employees in general. Also, basic conditions to create mentally healthy workplaces were addressed, that may reduce psychosocial work exposures that associate with negative health outcomes [
56]. Another study found that this may eventually create more disclosure about mental health issues at the workplace leading to adequate supervisor support [
24].
The SAW-SG intervention was tailored to the rather new role of labour experts as OHPs in the Dutch context, shifting their services in return to work trajectories towards prevention. Various workplace stakeholders in our study appreciated the role of these implementers. Reasons were that they are being trained to match employee’s needs with the work functioning and work environment, being independent, pragmatic and familiar with the work environment, as suggested by the literature in the needs assessment [
5]. However, selecting labour experts as OHPs to deliver this intervention has its limitations. Firstly, the recruitment of labour experts in this study showed that especially those who feel competent to offer psycho-education and coaching are interested to deliver such an intervention. This is a relatively small group having these skills due to various educational backgrounds before these professionals join their training for labour expert. Secondly, many organizations do not have access to a labour expert as OHP. This may limit the broader, nationwide dissemination of the intervention and its sustainability. Thirdly, in various other countries, the role of labour experts and other OHPs differs from the Dutch setting. Therefore, we believe that other OHPs such as organizational psychologists, HR managers who are trained in prevention and mental health or occupational health nurses could also deliver the intervention.
Methodological considerations
Intervention mapping was considered as a valuable tool as it provided a systematic process to identify, structure and prioritize factors and select practical strategies to induce the targeted behaviour. Our initial idea was to develop a guideline, offering information to employers on how to promote SAW for employees with CMHP. However, the evidence gathered in the IM steps and a rigor, theory-based approach, led to the insight that such a guideline can only be effective when delivered through interactive sessions. Therefore, we elaborated the intervention. Although we followed the IM procedure stepwise, we reflected on previous steps also, which led to more optimal use of the input from participants. For example, when reducing the content of the online guideline after the pre-test (step 4), we moved back to the needs assessment to reprioritize the changeable factors.
Especially employers indicated that they need an intervention that can be tailored and easily accessed. IM has been helpful to ensure that despite the plethora of factors to promote SAW, the intervention resulted into a manageable and accessible amount of information. Also, the IM approach helped the researchers to actively and early involve a broad range of stakeholders, that is often aimed by researchers but hard to realize in practice. Paying particularly attention to the participative planning group and workplace stakeholders in each step led to strong adherence and commitment throughout the process [
41]. OHP and employers were actively involved throughout the IM-process, resulting in an intervention that is well-received. Representatives of employees with CMHP were actively involved, however, we could not collect data on employee-level during the pre-test, due to privacy regulations and sensitivity to disclose CMHP. It would have been better to investigate the perception of employees with CMHP, as done in a previous study by Bjork Brämberg et al. [
58]. This also applies to the implementation and evaluation phase, as we target the behaviour and behavioural determinants of supervisors as a direct, proximal outcome of the intervention. Due to the given reasons above and due to various external factors resulting in employee’s well-being or perception of supervisor support, we choose not to evaluate on those outcomes.
Among both supervisors and OHPs, there was some ambivalence regarding the delivery and adherence of the guideline and training protocol, in which on one hand participants appreciated the specific tools and actions on how to support employees with CMHP. On the other hand, they emphasized on their professional flexibility, especially to consider and weigh actively the suggested actions versus the specific case, stimulating a critical attitude towards their own behaviour. Therefore, we decided to present actions in the guideline as options and facilitate feedback and discussion through the interactive coaching sessions. Likewise, we provided suggestions for training material and practical strategies for OHPs, but left room for adjustments. Permitting this level of flexibility in intervention delivery and adherence is somehow contrary to the IM approach, that provides a structured way to monitor and ensure the delivery of the intervention as intended [
59]. As a result, there may be a difference between the suggested tools and actions and the actual supportive behaviour. Thereby, the pilot implementation and evaluation study can provide more insights on the use of the guideline, and what worked, under what circumstances, how and why.
Future research and practical implications
Although the IM process was valuable, it does not guarantee for success [
41,
59]. The forthcoming implementation study will lead to information about the process and impact of the SAW-SG intervention, including the feasibility of selected outcome measures. This will inform researchers and professionals how the intervention can be imbedded in organizations and in educational programs for labour experts and other OHPs. Resulting from this study, we suggest that, through the IM approach or other approaches, researchers and program developers should actively involve multiple stakeholders throughout the process, on a basis of partnership. Ideally, both implementers, users (e.g. supervisors) and ultimate beneficiaries should be involved from as early as possible until evaluation and dissemination.
In such intervention development it is hard to grasp what actually happens during delivery, in line with our choice to allow professional flexibility in intervention delivery for both OHPs and supervisors to tailor information according to their needs [
59]. In future research, we suggest to investigate in practice which strategies have been used during the implementation phase and what the effect was of each. Namely, each strategy can be considered a micro intervention, in which different working mechanisms may be triggered in specific circumstances, leading to intended or unintended outcomes. To better understand those, we recommend to use alternative paradigms to the use of RCTs to bring novel insights into the conditions of their implementation, impact and generalization of the intervention, such as realist evaluation [
41,
55,
60].
The presented intervention targets mainly organizations in which there is a rather traditional ‘supervisor-employee’ relationship based on a rather traditional type of employment in which the line manager is the representative of the formal employer of the employee who has an employment contract. Participants in this study mentioned that the intervention may not (yet) be suitable for more modern, upcoming, types of employment, such as temporary employment agencies, secondment agencies and self-managing teams. Also, we reached mainly large-sized companies and struggled to include medium-small sized companies. Those diversities in employment types may require different implementation strategies or further development of the current guideline.
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