Mental health in organizations: Some reflections from an occupational health nursing perspective

Mental health and work are closely linked in a significant proportion of the world's working population. ¹ The recent health crisis caused by COVID-19 has resulted in mental health problems in society as a whole. It is estimated that globally one in two people will develop some episode of mental disorder in their lifetime ² with prevalence in the working population being around 15%. ³ Consequently, these estimates pose a challenge for society, health systems, businesses and occupational health professionals. Accordingly, the nature and impact of this reality implies the need to incorporate this health response in the training itinerary of the future occupational health specialist, as well as its inclusion both in research lines and in company health and safety policies. The aim of this article is to reflect on this post-pandemic situation and its influence on people and organisations, to find out the priorities of the institutions involved and to highlight the role of OHN.

The professional environment is one of the main determinants of mental health among workers. In this context, the work environment has a positive or negative effect on this type of illness and can be the origin of some of these pathologies or contribute to their development. ⁴ It also influences their performance regardless of the cause and favours the readaptation and recovery of the person with mental health problems.^5,6 The upward trend of this reality in the last decade reached its peak during the pandemic, a circumstance that highlighted the relationship between the health crisis and the worsening of mental health with a direct influence on personal well-being. The most vulnerable groups include people with previous health problems, health professionals, women, low-skilled workers and those on low wages.^7–9 It also highlighted the weakness of public health structures and occupational health services, limited communication between health systems and occupational risk prevention units, the scarcity of material, financial and human resources, the lack of training and the need to update protocols for future pandemics, among others. ¹⁰

At a time of social, occupational, environmental, digital and economic change, we face a challenge with profound implications for people's mental health and well-being. From this premise, the World Health Organization (WHO) assumes that the global burden of mental health problems in the workplace represents a pressing and pervasive situation, an issue compounded by stigma and associated discrimination that limits the demand for care.^11–13 In parallel, the European Commission shows a similar concern, in its proposal inviting member states to recognise the magnitude of work-related mental disorders and to plan interventions. ⁵ The International Labour Organisation (ILO) proposes to revise the list of occupational diseases on the basis of psychosocial risks and mental health. ¹⁴ Finally, The National Institute for Occupational Safety and Health (NIOSH) advocates raising awareness among workers, involving managers in the problem and highlighting the influence of working conditions on occupational health,^15,16 as well as promoting a global intervention based on the Total Worker Health^® programme. ¹⁷ Moreover, the strategy of the International Council of Nurses (ICN) aims to unify nursing care in this type of situation and to ensure homogeneous training of the professional. ¹⁸ Among professional societies, the American Association of Occupational Health Nurses (AAOHN) identifies mental health and stress management as a priority area for risk assessment among OHN. ¹⁹ Similarly, the Federation of Occupational Health Nurses within the European Union (FOHNEU) delves into the impact of post-pandemic stress and its incidence on nurses themselves. ²⁰ Finally, the Australian College of Mental Health Nurses (ACMHN) and the American Nurses Association (ANA) approach mental health in the workplace from a holistic, multidisciplinary, collaborative, personalised, evidence-based approach that provides person-centred care tailored to individual needs and goals. This model promotes prevention and early intervention strategies, in particular risk reduction. Furthermore, based on the code of ethics, it incorporates shared decision-making, promotes individual autonomy, minimises stigma and provides counselling according to individual capacity.^21–25

Based on these approaches and despite the unequal distribution of mental health problems according to social, occupational, gender and age status, the approach of the parties involved should contribute to a health response to this social demand. Thus, the European Agency for Safety and Health at Work (EU-OSHA) points out that in the last twelve months, 27% of European workers say they have suffered from stress, depression or anxiety and 37% from general fatigue. It also highlights that 38% of employees have been offered psychological support in their company, 42% access information and training on wellbeing and stress management and 43% are consulted on stressful aspects of work. In addition, 50% say that having a mental health problem has a negative impact at work, 51% say that the pandemic has made it easier to talk about stress and mental health in the workplace and 44% assume that the health crisis has increased their work-related stress.^26,27 In Europe, it affects 84 million people, costs the equivalent of 4% of Gross Domestic Product, accounts for almost 50% of lost working days and is the second leading cause of temporary and permanent disability. ⁵ In the United States, it affects 57.8 million people, representing 22.8% of the adult population, ²⁸ of whom 20 million are health care workers. Among these, 93% reported stress due to work overload, 82% felt emotionally and physically exhausted and 45% of nurses have not received sufficient emotional support. This reality implies an associated cost, in the specific case of depression between 30 and 44 billion dollars per year.^15,29

The work environment is a determinant of health that is particularly related to the structure and organisation of the company, working conditions and the social context. Indeed, exposure to certain working conditions is associated with an increased occurrence of depression and other more frequent mental disorders. Although the causes are openly debated, there is a growing consensus that preventive interventions are effective. ⁴ Along these lines, the WHO proposes a three-tiered approach: universal prevention (targeting the company and its employees), selective prevention (targeting individuals at higher risk) and indicated prevention (targeting individuals at high risk). Complementarily, it also contemplates other actions related to the return and reincorporation of the worker after a period of absence.^30,31 The most common practices are individual interventions targeting individuals and their illnesses. In contrast, initiatives targeting working conditions that improve mental health are less common.^1,6 Even so, many of the actions to address problems related to workers’ mental disorders require a cross-cutting and multidisciplinary approach. From this perspective, a systematic review reports that multiple or hybrid interventions significantly reduced stress, anxiety, fatigue, burnout and depression.^6,32 These supportive mental health care interventions have an estimated return on investment of $4 for every $1 invested. ³³

Within the scope of OHN competencies, it is a matter of planning or selecting interventions based on a care plan that addresses several aspects: counselling people with mental health-related symptoms, responding to stressors or stressful situations, developing coping skills, resilience and risk reduction strategies, help-seeking, peer support, mindfulness or meditation practices; as well as reducing myths and prejudices, analysing working conditions, adapting the working environment to needs, providing digital self-help tools, promoting autonomy and consensual decision-making, monitoring during the process, evaluating the impact of measures or referring to a specialist.^6,13,18,30 In this way, nursing practice is conditioned by the design and evolution of healthcare systems, the type of occupational health service, developments and resources related to research and evidence-based practice, as well as the needs and demands of workers, cultural diversity and the professional work context. ²⁵

In this post-pandemic scenario that places people at the centre of occupational safety and health actions, ¹⁴ the recent health crisis has been a turning point at the beginning of this century. Adapting to the new reality implies providing a response conditioned by the effects of the pandemic and the socio-occupational situation. In particular, mental health-related problems in the working population, their impact and the approach in companies stand out.^34,35 Approximately one in eight people in the world lives with a mental disorder. ¹⁸ This accounts for 10% of the global burden of disease, poses an economic challenge to society and influences the quality of life of the worker.^12,13 In fact, 76–85% of people with severe mental illness do not receive treatment in low- and middle-income labour market countries, compared to 35–50% in high-income countries.^12,30 In parallel, exposure to work-related psychosocial risks is so widespread that they almost surpass other occupational risks in their influence on health, occupational accidents, direct costs and impact on business productivity. ³⁶ In Europe, the proportion of people with a temporary disability increased by 44% between 2006 and 2020, from 3.6 to 5.2 million, ³⁷ which implies a decline in the quality of working life. ³⁸

In these situations, the biomedical model of mental health often focuses on diagnosis, pharmacological treatment and symptom reduction, without considering social, occupational and environmental factors to the fullest extent. This can sometimes result in a failure to address root causes and a limited focus on the value of care. ³⁹ In this context, OHN promotes physical and psychosocial well-being, addresses the influence of working conditions and provides care with a holistic perspective. It also deepens the interpersonal relationship as a therapeutic tool based on communication, informs and assists in health decision-making, promotes job retraining and considers the environmental and gender perspective.^22,40,41 It also develops actions for health promotion and education and early detection of risks. In addition to training, research, management and interdisciplinary collaboration activities to improve access and quality of health care. In a complementary way, the following interventions contribute to preventing and controlling these risks: increasing awareness of the issue through information and publicity initiatives; allocating more resources to research on causes, intervention and programme implementation; increasing early detection and surveillance and follow-up of cases; transferring research results to social actors; increasing the number and diversity of professionals to deal with psychosocial risks; and making the necessary legislative changes. ³⁶

In parallel, a systematic review points to organisational interventions that improve mental well-being, burnout, stress, depression and anxiety symptoms. In fact, they are the second most common work-related health problem. ⁴² The intervention jobs and tasks modifications shows a high level of evidence, and in the case of flexible work and scheluding and changes in the physical work environments the evidence is moderate. ⁴³ These circumstances allow for the creation of a safe environment that promotes positive change.^18,44,45 This aspect is in line with the epistemological approach presented by some of the references that underpin nursing care. These include the model of Virginia Henderson, ⁴⁶ Callista Roy, ⁴⁷ Joyce Travelbee ⁴⁸ and Phil Barker. ⁴⁹ As well as, the theories of Hildegard Peplau, ⁵⁰ Paterson and Zderad, ⁵¹ Ludwig von Bertalanffy, ⁵² Madeleine Leininger ⁵³ and Imogene King. ⁵⁴ These models and theories of nursing care constitute a conceptual representation of reality that supports professional practice. In this way, they favour a common thinking and language, reinforce the identity as a collective, describe the necessary competences, allow quality indicators to be established, place the worker as the central axis of care, constitute a tool for defining a care plan, invite professional reflection and denote the nursing contribution both in the multidisciplinary team and to the health system.^47,55 In summary, in a complex, diverse, fluid and changing work environment, systemic and long-term interventions with individual, collective and organisational focus are needed to protect the worker from mental wellbeing challenges. More investment in improved working conditions, preventive training that addresses task-related psychosocial risks and support for the destigmatisation of mental health is therefore needed.^26,56–58

The nature of these proposals and the improvement of mental health nursing care will be part of a strategy for safety, health and well-being in the company. This strategy encompasses prevention, early detection, follow-up, return to work and evaluation. The approach is based on the commitment of all levels of the organisation and on research into the determinants of work-related mental health, intervention strategies and how to implement specific actions. Among other lines, it is necessary to broaden the evidence base by delving deeper into risk factors, protective factors, mechanisms of action, evaluation of mixed intervention strategies and their effectiveness.^4,59,60 A multifaceted reality where joint efforts and social awareness are essential in the development of mentally healthy work.