+1(978)310-4246 credencewriters@gmail.com


Select a peer reviewed journal article related to the wellness program enhancement that you pitched to your supervisor that utilized a qualitative data collection method. Provide a summary of the article focusing on the qualitative data approach. Describe how this article provides justification for the program you proposed in your Future Direction Program Pitch.

HHS Public Access
Author manuscript
Author Manuscript
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Published in final edited form as:
J Occup Environ Med. 2019 October ; 61(10): 829–835. doi:10.1097/JOM.0000000000001671.
Showers, Culture, and Conflict Resolution: A Qualitative Study
of Employees’ Perceptions of Workplace Wellness Opportunities
Michael W. Seward, AB1, Roberta E. Goldman, PhD2,3, Stephanie K. Linakis, MS1,4, Paul
Werth, MS1,5,6, Christina A. Roberto, PhD7, Jason P. Block, MD, MPH1
of Chronic Disease Research Across the Lifecourse, Department of Population
Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA
Author Manuscript
of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health,
Boston, USA
of Family Medicine, Warren Alpert Medical School of Brown University, Providence,
Scholar, Boston, USA
Medical Center, Department of Orthopaedic Surgery, Lebanon, USA
of Psychology, Saint Louis University, St. Louis, USA
of Medical Ethics & Health Policy, Perelman School of Medicine, University of
Pennsylvania, Philadelphia, Pennsylvania.
Author Manuscript
Objective: Research on employee opinions of workplace wellness programs is limited.
Methods: At a large academic medical center in Boston, we conducted 12 focus groups on
employee perceptions of wellness programs. We analyzed data using the immersion-crystallization
approach. Participant mean age (N=109) was 41 years; 89% were female; 54% were White.
Author Manuscript
Results: Employees cited prominent barriers to program participation: limited availability; time
and marketing; disparities in access; and workplace culture. Encouraging supportive, interpersonal
relationships among employees and perceived institutional support for wellness may improve
workplace culture and improve participation. Employees suggested changes to physical space,
including onsite showers and recommended that a centralized wellness program could create and
market initiatives such as competitions and incentives.
Conclusions: Employees sought measures to address serious constraints on time and space,
sometimes toxic interpersonal relationships, and poor communication, aspects of workplaces not
typically addressed by wellness efforts.
Corresponding Author: Jason P. Block, MD, MPH, Division of Chronic Disease Research Across the Lifecourse (CoRAL), Harvard
Pilgrim Health Care Institute, Department of Population Medicine, 401 Park Drive, Suite 401 East, Boston, MA 02215, 617-509-9841
(phone), 617-509-9853 (fax), jblock1@partners.org.
Conflicts of Interest: None declared
Seward et al.
Page 2
Author Manuscript
worksite; workplace; health promotion; qualitative research; wellness; obesity; employer;
employee; nutrition; exercise; benefits
Author Manuscript
Chronic disease in the US accounted for 7 of the top 10 causes of death in 2014. Heart
disease and cancer together were the underlying causes of 46% of deaths.1 People with
chronic medical conditions also accounted for 86% of all health care spending in 2010.2
Because full-time, employed Americans spend most of their waking hours at work – an
average of 47 hours per week3 – the workplace has evolved as a key setting to promote
healthful lifestyles. In 2016, almost half (47%) of American employers, including 46% of
small firms and 83% of large firms with over 200 employees, provided some form of a
workplace wellness program, with stated goals of improving health and decreasing
healthcare costs.4 The breadth of workplace wellness programs varies widely, including (1)
individually-focused workplace programs such as nutrition counseling, gym membership
reimbursements, health screenings, and wellness competitions, (2) environmental-level
changes such as onsite gyms and improvements in the diet quality of offerings at cafeterias,
and (3) factors that contribute to healthy workplace cultures and employee satisfaction, such
as flexible work hours and programs to promote supportive workplace relationships and
decrease interpersonal conflict.
Author Manuscript
Author Manuscript
Despite the growing popularity of workplace wellness programs, multiple reviews and metaanalyses of program effectiveness have shown mixed results. A recent randomized clinical
trial of almost 33,000 employees at one large US retail company found that employees at
worksites with wellness programs reported an 8.3% higher rate of regular exercise and a
13.6% higher rate of actively managing their weight than control participants whose
worksites did not have programs; there were no differences in other health behaviors,
clinical markers of health, or healthcare spending after 18 months.5 Evaluations of wellness
programs at Pepsico and BJC Healthcare found no net savings or positive return on
investment (ROI).6,7 A more recent review by McIntyre et al. found that most wellness
programs, especially those that focused on lifestyle over chronic disease management, have
limited effectiveness.8 In contrast, a meta-analysis by Baicker et al found positive ROIs after
3 years of up to $3.27 for every dollar invested.9 A large RAND study of multiple employers
found that programs were associated with decreases in weight and smoking rates, along with
increases in physical activity, but no meaningful differences in cholesterol measures or
healthcare expenditures.10 Other reviews for wellness programs found high variability in
design and quality but concluded that some comprehensive wellness programs improved
both health and financial outcomes in the long-term (over three years).11-13 A 2008 US
national survey found that less than 7% of employers offer such comprehensive programs,14
defined by the Healthy People 2010 initiative as those that incorporate health education,
have supportive environments, are integrated into the organization and linked to other
assistance programs, and include workplace health risk screenings.15
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 3
Author Manuscript
Previous research has often only considered employer views on programs (e.g. ROIs,
productivity, absenteeism), while research on employee opinions of these programs is
limited.16 The sparse research available has found frequent mismatches between employer
and employee perceptions of access to programs,16 effects,17 and workplace causes of stress.
18 In particular, there has been a recent change in efforts by employers to improve workplace
culture instead of only creating programs that focus on healthy behaviors,18 and qualitative
research is needed to reveal what employees want from such efforts, as well as what they
consider a culture supportive of employee wellness. Workplace culture refers to the shared
social norms, values, and attitudes toward employee health; healthy workplace relationships
that can facilitate resolving interpersonal conflict; and perceived support of employee
wellness from institutional leadership.19 It also is unclear which is more important for
employee wellbeing: optimizing wellness offerings by determining the ideal content,
frequency, and marketing of programming, or instead focusing on workplace policies and
cultures that may promote healthier lifestyles and reduce stress irrespective of wellness
offerings. While the ideal workplace wellness program would encompass all these factors,
there is no research on how employees prioritize these factors or how these factors may be
combined into a comprehensive program.
Author Manuscript
Author Manuscript
This qualitative study was conducted at a large academic medical center in Boston to gauge
employee perceptions of existing and potential future workplace wellness programs.
Hospitals are unique environments because of the emphasis on caregiving and health. They
are also diverse work environments where people work in a range of roles from engineering
and maintenance to professional and management roles, providing opportunities to explore
perceptions across a wide socioeconomic spectrum. A review of the impact of shift work on
health outcomes suggested a higher risk of breast cancer for night shift workers, and
increased risk of cardiovascular disease, metabolic syndrome, and diabetes for shift workers
in general.20 Given the health risks associated with shift work, this qualitative study
specifically included vulnerable work groups such as overnight employees and those
working in positions such as housekeeping and transport.
Study Design
Author Manuscript
Between March and May 2014, we conducted 12 one-hour focus groups with employees of
Brigham and Women’s Hospital, a large academic medical center in Boston, MA. Seven of
the focus groups were open to any employee regardless of team or occupation, two were
held at clinical sites away from the main medical center campus, and three were reserved for
people who met specific criteria because they were underrepresented in other focus groups:
environmental service staff, nurse managers, and overnight shift employees. Each of these
three targeted focus groups were homogenous with regards to occupation to promote open
discussion. At the time of this qualitative study, wellness opportunities available were varied
and not connected under one centralized wellness program. Focus group participants
identified the available activities including exercise groups, yoga classes, discounts on gym
membership, employee organized contests such as a “Biggest Loser” weight loss program,
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 4
Author Manuscript
and general employee assistance programs for mental health services, among others. This
study was approved by the Harvard Pilgrim Health Care Institutional Review Board.
At the beginning of each focus group, participants completed a brief, anonymous
questionnaire that included questions about 1) demographics, height, weight, and
occupation, 2) participation in current workplace wellness activities, and 3) interest in
financial incentive wellness programs.
Author Manuscript
Two of the investigators (JPB, SKL) facilitated the focus group discussions using an
interview guide of open-ended questions designed to capture a wide range of employee
perceptions of existing and potential future workplace wellness programming. We asked
participants questions about opportunities to pursue healthy behaviors at work, barriers to
healthy lifestyles at work, perceptions of their employer’s role in promoting wellness, and
their thoughts about the potential use of financial incentives for achieving health outcomes,
including weight loss (Box 1). We asked spontaneous follow-up questions to probe
participants when necessary. Focus group discussions were audio recorded and
professionally transcribed, verbatim.
We recruited employees using advertisements in emailed employee newsletters and flyers on
bulletin boards throughout the medical center. We conducted focus groups primarily over
lunch breaks or other times that suited employee schedules (i.e., in the evening for overnight
workers). To encourage participation, we provided a light meal and $25 at the end of each
focus group.
Author Manuscript
We analyzed transcript data using principles of immersion-crystallization.21 This qualitative
approach entails carefully reading the transcripts to identify themes and patterns.21 Five of
the investigators (MWS, PW, SKL, REG, JPB) individually read the transcripts and took
notes, followed by analysis team discussions of the data. Next, one investigator (PW)
conducted line-by-line coding of the transcripts based on these identified themes and topical
categories within the data using Provalis Research QDA Miner,22 a qualitative data
management software. Coding facilitated further analysis by topic/theme, and all members
of our study team reviewed the coded data to agree upon final themes and interpretation of
the data.
Author Manuscript
The total number of participants in the 12 focus groups was 109 with a range of 3 to 11
participants per group. Mean age was 41 years; 89% were female; and the mean body mass
index (BMI), calculated from self-reported heights and weights, was 26.1 kg/m2 (Table 1).
The focus groups included more women (89% vs. 70%) and people of minority race/
ethnicity (46% vs. 35%) than the general population of Brigham employees. Just over half
(54%) self-identified as White, 21% Black, 15% Hispanic, and 9% Asian. In pre-focus
group questionnaires, 21% reported current participation in a wellness activity at work, and
87% reported interest in financial incentives for wellness.
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 5
Author Manuscript
In the focus group discussions, several key themes emerged about existing and potential
workplace wellness initiatives: 1) Employees appreciate current wellness activities that are
available; 2) Various stressors and barriers hinder participation in workplace wellness
programming; and 3) Increasing employer support of workplace wellness requires several
levels of change, including workplace cultural and physical infrastructure modifications.
Employees appreciate current wellness activities
Author Manuscript
Employees reported positive experiences with several workplace wellness offerings
including exercise classes, walking clubs, and step competitions. The social component of
these classes frequently drove participation. One participant stated, “Knowing other people
are doing it too and seeing familiar faces and seeing other people participate is just even a
little bit more motivating. And it almost helps you make an excuse to do it.” The existence
of a program was felt to provide some permission to participate. Having an excuse to
participate was important, because generally the fast-paced workplace was not seen as
supportive of taking breaks for exercise or other wellness activities (see “Workplace culture
not conducive for wellness” section).
Outside of physical activity, employees noted improvements to the cafeteria that came with a
food labeling project: “They’re pushing the healthy options more, and instead of fries…ask
for a side of vegetables…given the caloric intake. I’ve definitely noticed that. So it does help
me make better choices.” This comment referred to a traffic light labeling program that
highlighted the dietary quality of menu items (green – highest dietary quality; red – lowest).
Appreciation for this program was notable because generally, the unhealthy nature of
cafeteria offerings and its physical infrastructure were viewed poorly.
Author Manuscript
Wellness programs signal that the hospital cares about employees—Although
employees appreciated current wellness programming, they hoped for more activities,
especially because they viewed these activities as not just providing opportunities for
improving diet and physical activity. They described wellness programs as “something that
would make me feel that, not that I don’t care for myself, but that somebody else also is
invested in my health.” Another employee stated, “We spent so much time taking care of
these patients…Dressing them, getting them undressed, talking to them about their health.
Do you smoke? What did you eat today? You drinking soda? No one has ever done that for
me. Showing same empathy for us as we’re expected to show for our patients.” Employees
felt increased wellness offerings were a caring message of support from leadership.
Barriers to workplace wellness
Author Manuscript
Lack of marketing and availability of wellness programming limits
participation—Although employees were aware of some wellness programs, many of the
focus group participants were unaware of existing activities. Employees sought more
transparency about offerings with centralized information made available to all employees.
Employees thought that marketing and communication of programs was limited: “There’s a
huge disconnect,” and activities were “not very well publicized.” Employees felt they “get
bombarded with so much information,” and that word about wellness activities “doesn’t
always trickle to everybody.” Many participants asked, “Where is the big list [of offerings]?”
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 6
Author Manuscript
and suggested a “calendar of events” that would allow for employees to view all available
Off-site and overnight employees are missing out—Focus groups for offsite and
overnight employees revealed disparities in wellness opportunities compared to those
available to main campus, day-shift employees: “I think that being here offsite is a
disadvantage to us because I used to work on [the main campus], and I never felt the way I
do now.” Many overnight participants expressed similar concern that “The hospital basically
runs for first [day] shift only.” Even food options during the night shift were limited: “You
don’t even want to really mess with that food because it’s sitting in the burners all day.” The
overnight shift was a general barrier to wellness program participation, because of the type
of work done and the limitations on staffing: “On nights there’s just not enough of us that we
feel comfortable about really leaving [duties] for thirty minutes.”
Author Manuscript
Not enough time for wellness—Limited schedule flexibility and lack of time
commonly emerged as key barriers to wellness. One nurse said they were “at the mercy of
the schedule. So we’re lucky we get lunch.” Those who did report breaks during the day
often felt they were insufficient to take advantage of them: “Half an hour? That doesn’t do
anything. That barely gets you to the bathroom and back.” Other employees agreed,
explaining that “You have to get undone, lab coats and gloves and wash and, it takes us
[time]; it’s a project.” Employees identified a challenging paradox of wellness
programming. Even when available, programming was hard to attend, and access was highly
dependent on schedules and availability. As one employee stated, “[I am] really happy the
hospital is offering these. We wish though there was some more variety in the timing.”
Author Manuscript
Author Manuscript
Workplace culture not conducive for wellness—Employees identified the hospital as
a particularly stressful environment. Stress as an underlying concept was consistently
mentioned in the context of specific barriers as well as cultural problems or conflicts.
Although employees raised logistical time-related concerns, employees identified
generalized cultural barriers leading to a perception of lack of support for employee
wellness: “One value we don’t show is the valuing of our own health.” Many participants
said they felt guilty taking a break to eat lunch, let alone using the break for wellness
activities: “It almost seems as a detriment if people do take lunch. Like oh my gosh you’re
taking lunch?” Another employee explained that “working out for a lunch break is kind of
like a pampering thing.” Employees felt that “It’s not part of the culture,” and that “We’re a
hospital. We’re open twenty-four/seven. So we should always be available, always, always,
always.” As a result, employees said they would “stuff your [gym] bag underneath your desk
so no one sees it,” and some felt the need to “sneak off” to do exercise to avoid judgement.
One employee summarized workplace wellness at the hospital: “You’re sending mixed
messages. You’re saying you have these programs here. And they’re available to you. And
you should do it, but…if they do take you up on that offer they’re frowned upon like ‘are
you really going to do that right now?’” Available programming, especially if provided
during the day, was unavailable to many employees because of job requirements and lack of
flexibility. Employees felt that program participation would require direct or at least the
perception of permission from supervisors and recognition by coworkers that wellness
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 7
Author Manuscript
activities are acceptable. One participant said, “there’s no managerial push to be healthy,”
and others said if “management can be more aware or be supportive for these issues I think it
would be better.” Culture barriers were stark for some employees, especially those in
housekeeping. They reported a general lack of empowerment and acceptance from other
employees. This was exacerbated by a lack of areas to take breaks. They felt this poor
treatment was a barrier to rudimentary feelings of inclusion, precluding consideration of
more active wellness.
Improving employee health through workplace initiatives requires several levels of change
Author Manuscript
While workplace wellness programs are typically focused on specific activities around
nutrition and physical activity, these focus group discussions highlighted that wellness is
more than practicing healthy behaviors at work. Employee recommendations for improving
workplace wellness included three levels of change starting with improving workplace
culture (Figure 1, level 1). Culture consisted of interpersonal relationships with peers and
supervisors as well as perceived support of wellness from the institution. Employees
recognized that culture would be difficult to change but felt it would have the greatest effect
on wellness. The second level of recommended change involved infrastructure
improvements such as onsite showers, employee lounges or break areas, onsite gyms, and a
better cafeteria as essential to provide and enable participation in wellness opportunities
(level 2). Finally, employees suggested that these base levels of support for wellness would
set the proper foundation for a centralized wellness program that organized and marketed
wellness initiatives such as health screenings and competitions (level 3).
Author Manuscript
Author Manuscript
Support for wellness must come from the top-down—Employees suggested that
department directors and upper level management needed to make wellness a priority with
their employees and to encourage middle managers to provide support. In a comment that
was echoed by other focus group participants, one person stated: “I think it has to start from
the top. If the institution supports it, then I think your boss/supervisor would have no choice
but to hopefully [support it].” Employees also emphasized how important it is for
management to not only approve of wellness activities but to explicitly encourage employee
participation: “If they were to say, hey, these types of activities are okay. Join a walking
group. Do the [stair] climbing thing. That would probably push more people to do it.”
Participants said that this clear support from management would make them feel less guilty
about engaging in wellness programming: “I can go and feel comfortable that I’m there, that
I’m allowed to be there and that I’m not neglecting my job.” Employees felt that once
higher-level management explicitly approved and supported a healthy workplace culture, it
would enable and encourage participation and engagement in wellness activities.
Employer support for grass roots efforts—Employees felt that top-down support of a
healthy workplace culture could not only increase utilization of centralized wellness
programming but also foster effective grass roots wellness campaigns. Many employees
described successful grass roots efforts including departmental walking and stair climbing
groups as well as weight-loss and step competitions run by nurses on each floor of the
hospital. These informal activities were popular because they were actively organized by
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 8
Author Manuscript
participants: “Because we don’t get the chance to participate in whatever Brigham has to
offer because of our working hours, the people that we work with have…decided to form a
motivation group…that they’re trying to get everybody to join, and…started a Biggest Loser
[weight loss] program.”
Author Manuscript
“Wellness” is more than just improving diet and exercise; it includes
improving interpersonal relationships at work—Many employees described
wellness as starting with improving sometimes strained interpersonal relationships;
employees felt this was a particular need in an intense and stressful hospital workplace:
“When I think of [a] healthy work environment…how…we communicate with one another”
is key “because when we are in this kind of pressure cooker environment, it does cause
people to turn on one another.” One participant described a need for some supervisors to
change their communication style: “The way that the supervisor talks to us. I don’t think I
even talk to my kids the way he talks to me, to us, you know? This is a problem.” Several
employees identified the stressful nature of a healthcare workplace as a reason for notable
problems with relationships and communication.
Author Manuscript
In a targeted focus group of nurse managers, one participant discussed experience
confronting particularly toxic relationships. Her department worked with an outside group
on conflict resolution and improved communication and management of the group,
discussing “principles about when we are in discord with someone, how we look to try and
get to a better place.” Without these strategies to promote better interpersonal relationships,
the manager stated: “It’s like putting on your earrings or your tie before you figure out what
you’re wearing for the day… just so basic to really strategically thinking about ‘how do we
communicate with one another?’” Another employee stated: If “we don’t teach people how
they might be able to engage with one another in a different way, then we may lose an
opportunity to really fully reach our potential.” In a wellness context, this reflects how a
supportive workplace culture could form the framework for the more traditional aspects of
workplace wellness programs: infrastructure improvements and program offerings (Figure
Brick and Mortar (Infrastructure) and Programs to Support Wellness
Author Manuscript
Lack of onsite showers are exercise deal breakers—One of the most commonly
repeated answers that emerged when we asked participants how they would improve
workplace wellness was to provide on-site showers. Many employees said a lack of showers
was a major barrier to exercise: “That would be something that is so attractive to me because
I could use a part of my day to do more for myself, but I’m a sweater.” Although a few
employees had access to showers, they described them as “scary” and in disrepair.
Lack of physical spaces like lounges, gyms, and cafeterias is a major
impediment to “wellness”—Providing a dedicated employee-only lounge for breaks and
lunch was also a popular recommendation across focus groups. Many employees echoed one
participant who wanted a place to “disconnect” from the rest of the hospital during breaks.
This was most important for employees who had no areas to take breaks; some employees
even felt judged if they took breaks in public areas because they lacked access to private
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 9
Author Manuscript
areas to do so. An onsite gym was attractive to employees, though they recognized that
adding a gym would be a significant and expensive undertaking for any institution.
Employees highlighted that an onsite gym would allow them the benefit of being able to
exercise at any time of the day.
Employees said the “whole cafeteria needs to be revamped” including improvements to the
physical space of the cafeteria such as better lighting and aesthetics. Employees consistently
said cafeteria food was mostly unhealthy and that the cafeteria layout was limiting. Many
employees were dissatisfied with the cafeteria food and tried to bring food from home if
their departments offered fridge space: “I mean it’s a hospital, but the meals…put you in the
Author Manuscript
Author Manuscript
Overall support for wellness financial incentives despite some privacy
concerns—Focus group participants generally liked the idea of employers giving financial
incentives for wellness. Participants said that “Money always talks,” and that incentives
“could be the push, the catalyst,” for achieving lifestyle changes. Many employees added
that incentives that were part of wellness competitions would be effective. However, a few
employees raised privacy concerns about how employers might use health data collected
through a financial incentive program, such as one that requires employees to have
laboratory and vital sign screenings, with incentives to meet certain health metrics: “I would
be very nervous disclosing all my health information if I had like high cholesterol or
osteoporosis or any chronic issues. For the hospital to know this is you don’t know how
they’re going to use it. It’s like the big brother watching you.” When asked about financial
rewards (e.g., reduced premiums for meeting health goals or other monetary incentives)
versus financial penalties (e.g. increased premiums for smokers), employees preferred
rewards and felt it was important to establish rewards before implementing penalties.
Author Manuscript
In focus groups of healthcare employees from a range of jobs, shifts, and worksites
associated with Brigham and Women’s Hospital, we found that employees appreciated
current wellness activities, but acknowledged several barriers to participation: 1) limited
availability and marketing of wellness programming, 2) disparities in access to wellness
opportunities for off-site, overnight, and housekeeping employees, 3) not enough time at
work for wellness, and 4) unhealthy workplace culture and relationships with managers.
Three major employee recommendations for improving workplace wellness emerged. First,
employees strongly advocated for improvements in everyday workplace culture, like help in
navigating difficult interpersonal relationships. Employees viewed healthy relationships as
foundational for wellness and needed before employees could take full advantage of
wellness programming. Supportive work relationships and explicit approval from leadership
for employees to prioritize workplace wellness could also increase engagement in
centralized wellness programming and help foster grass roots wellness programs. Hospitals
could provide grass roots programs with structure- and resource-based support, like
marketing and organizational assistance or funding the incentives for participation or
engagement. Second, employees wanted greater access to spaces that would facilitate
healthy behaviors. This included onsite gyms, more attractive cafeterias, and employee-only
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 10
Author Manuscript
lounges where they could unwind. Lack of onsite showers, for example, was viewed as a key
barrier to exercising during the day. Of note, after these focus groups were completed, a fullscale renovation of the cafeteria was completed. Third, employees felt a centralized,
branded, and organized wellness program was needed to properly market the wellness
Author Manuscript
Author Manuscript
Although prior research on employee perceptions of workplace wellness programs in the US
is limited,16 some of the themes that emerged in our analysis are consistent with results from
focus groups of university employees, about half of whom participated in a workplace
wellness program.23 That study also reported that inconvenient locations, lack of time, and
scheduling issues were key barriers, along with insufficient financial incentives to
participate.23 Similarly, a study of nurse assistants who participated in a workplace wellness
program found that patient care workloads and scheduling issues (e.g. not offering early
morning activities before work) were major barriers to participation.24 Our study
additionally identified employees’ desire for all traditional wellness programming, such as
health education and exercise classes, to be rooted in a supportive workplace culture. Recent
surveys on work environment perceptions echoed this sentiment.16 In an analysis of two
independent, nationally representative surveys of US employers (N=705) and employees
(N=1833) working at least part-time for companies with 50 or more employees, McCleary et
al. found that perceptions of a healthful work environment were shaped by both physical
spaces (e.g., gyms, healthy food options) and a healthy work culture, and that managers
should lead by example and openly participate in workplace wellness programming.16 In our
study, employees emphasized how important it is for cultural change to be made from the
top-down, and that explicit encouragement from executives and supervisors could mitigate
judgement from peers and managers when employees take time during the work day for
wellness activities. A process evaluation of a University of California wellness program
made similar recommendations that involving leadership at multiple levels, especially
among middle managers, was critical to successful implementation.25 Employee perceptions
of support from leadership has been shown to be an important determinant of commitment to
programs.26 An online study by Jenkins et al. analyzed 10,000 university employee
questionnaires on favorable workplace cultures of health and found similar results; the most
important factors were leaders and supervisors who demonstrated interest in wellness, as
well as having colleagues participate in wellness activities to set good examples.27
Author Manuscript
Employees in our study also felt that improvements in interpersonal relationships, perhaps
promoted by conflict resolution training, would help set the stage for wellness at work. In
turn, employees felt improved relations might both reduce stress and encourage colleagues
to participate in organized wellness programming. Research at a multinational company
found that employees who engaged in workplace conflict resolution reported significantly
lower rates of stress, poor general health, and sick time compared to employees who did not
report attempting conflict resolution at work.28 Another qualitative study of kitchen and
laundry room employees in an Icelandic hospital concluded that supportive work
relationships developed employees’ sense of self-worth and belonging, promoting open
communication and information exchange.29 Positive interpersonal relationships may reduce
stress irrespective of wellness program participation. In another setting, a process evaluation
of a university wellness program found that workplaces with good social climates (i.e.
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 11
Author Manuscript
abundant social interaction among staff) had more success implementing wellness programs.
25 Conflict resolution training could help foster these healthier social climates. Furthermore,
collaborative work environments with open communication may encourage employees to
not only participate in centralized wellness programming but also provide input and
spearhead new grass roots wellness initiatives.
Author Manuscript
The theory of social capital in health can help explain how workplace culture and
interpersonal relationships may improve workplace wellness. Social capital refers to
resources accessed by people within a social structure that promote cooperation, collective
action, and the maintenance of health behaviors. Growing literature supports the link
between social capital and health outcomes.30 In our study, employees felt the social
component of wellness programs often drove participation, and explicit support from
institutional leaders enabled participation and prevented judgement from peers around taking
time during busy work schedules for wellness activites. A study by Kwon et al. analyzed
workplace culture in a health care organization and medical equipment company. Using a
factor analysis, they found the most beneficial characteristics for culture were also elements
of social capital including coworker support, supervisor support, and senior leadership and
policies rather than wellness program content and incentive design.31
Author Manuscript
We conducted this study at one academic medical center in Boston, MA. Wellness
programming and physical structures of workplaces are typically unique to specific
institutions. While results may not be generalizable to other settings, this study provides a
more in-depth, contextualized understanding of the employee experience of workplace
wellness.32 Because renovations of the cafeteria were completed after focus groups,
comments about the cafeteria may not apply to the current physical environment. Although
we sought to include nurses, managers, overnight staff, and employees from environmental
services, those groups were underrepresented in our focus groups compared to other
occupations; no physicians participated. This study also did not include participants from
upper-level management such as executives or department chairs, which could benefit future
research. Most of the focus groups were open to all occupations. While this maximized the
number of participants who could join each session, it is possible that including employees
from managerial and non-managerial roles in the same group may have influenced what
non-managerial employees were willing to discuss. However, themes regarding a top-down
approach were consistent across focus groups, including the three focus groups limited to
single occupations or managers.
Author Manuscript
Considering the recent focus of employers to improve workplace culture rather than
wellness program design, our results suggest that institutions should encourage company
leaders and middle managers to express explicit support for employees engaging in wellness
activities at work and lead by example by participating in these activities themselves.
Employees are interested in aspects of workplace wellness outside of traditional
programming, such as conflict resolution trainings to improve interpersonal relationships.
Employees recognized that changing the culture could be beneficial to their overall
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 12
Author Manuscript
wellbeing at work even without measurable improvements in biometrics or financial
outcomes. Often employers focus on wellness programming content and incentive design
without attention to potentially more impactful factors such as support from managers and
coworkers that are elements of social capital. While initiatives to improve support and
workplace relationships have not been explicitly tested, the lack of these components in
wellness programming may explain how some prior studies have found limited effects of
these wellness programs on clinical health outcomes. Employees felt that modifying
workplace culture through interpersonal relationships with peers, and perceptions of support
from the institution, could improve employee experiences at work and lead to more
successful wellness programming. Explicit health improvements and perhaps employer
healthcare cost-savings could eventually flow from these initial foundational improvements.
Author Manuscript
J. P. Block was supported by a career development award from the National Heart, Lung, and Blood Institute (grant
number K23HL111211). Funding sources had no role in the study design, data collection and analysis, or writing of
the manuscript.
Author Manuscript
Author Manuscript
1. Centers for Disease Control and Prevention. NCHS FastStats – Deaths and Mortality. https://
www.cdc.gov/nchs/fastats/deaths.htm. Accessed June 17, 2017.
2. Gerteis J, Izrael D, Deitz D, et al. Multiple Chronic Conditions Chartbook. Rockville, MD; 2014
decision/mcc/mccchartbook.pdf. Accessed February 18, 2019.
3. Saad L The “40-Hour” Workweek Is Actually Longer — by Seven Hours. https://news.gallup.com/
poll/175286/hour-workweek-actually-longer-seven-hours.aspx. Published 2014 Accessed June 7,
4. Claxton G, Rae M, Long M, et al. Employer Health Benefits. Menlo Park; 2016 http://files.kff.org/
attachment/Report-Employer-Health-Benefits-2016-Annual-Survey. Accessed February 18, 2019.
5. Song Z, Baicker K. Effect of a Workplace Wellness Program on Employee Health and Economic
Outcomes. JAMA. 2019;321(15):1491. doi:10.1001/jama.2019.3307 [PubMed: 30990549]
6. Caloyeras JP, Liu H, Exum E, Broderick M, Mattke S. Managing manifest diseases, but not health
risks, saved pepsico money over seven years. Health Aff. 2014. doi:10.1377/hlthaff.2013.0625
7. Gowrisankaran G, Norberg K, Kymes S, et al. A hospital system’s wellness program linked to health
plan enrollment cut hospitalizations but not overall costs. Health Aff. 2013. doi:10.1377/hlthaff.
8. McIntyre A, Bagley N, Frakt A, Carroll A. The dubious empirical and legal foundations of
workplace wellness programs. Health Matrix. 2017.
9. Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Aff. 2010.
10. Mattke S, Liu HH, Caloyeras JP, et al. Workplace Wellness Programs Study. RAND Corporation;
2013 https://www.rand.org/pubs/research_reports/RR254.html. Accessed June 7, 2017.
11. Goetzel RZ, Henke RM, Tabrizi M, et al. Do workplace health promotion (wellness) programs
work? J Occup Environ Med. 2014. doi:10.1097/JOM.0000000000000276
12. Lerner D, Rodday AM, Cohen JT, Rogers WH. A systematic review of the evidence concerning the
economic impact of employee-focused health promotion and wellness programs. J Occup Environ
Med. 2013. doi:10.1097/JOM.0b013e3182728d3c
13. Serxner S, Gold D, Parker K. Financial Impact of Worksite Health Management Programs and
Quality of the Evidence In: Rippe JM, ed. Lifestyle Medicine. Boca Raton, FL: CRC Press;
2013:1325–1336. http://web.a.ebscohost.com.ezp-prod1.hul.harvard.edu/ehost/ebookviewer/
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 13
Author Manuscript
Author Manuscript
Author Manuscript
Author Manuscript
af3f-7d9652a21640@sessionmgr4007&vid=0&format=EB&lpid=lp_Cover-2&rid=0. Accessed
February 18, 2019.
14. Linnan L, Bowling M, Childress J, et al. Results of the 2004 National Worksite Health Promotion
Survey. Am J Public Health. 2008. doi:10.2105/AJPH.2006.100313
15. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and
Improving Health. Washington, DC; 2000 http://www.health.gov/healthypeople/. Accessed June 7,
16. McCleary K, Goetzel RZ, Roemer EC, Berko J, Kent K, De La Torre H. Employer and Employee
Opinions about Workplace Health Promotion (Wellness) Programs: Results of the 2015 Harris Poll
Nielsen Survey. J Occup Environ Med. 2017. doi:10.1097/JOM.0000000000000946
17. Hasson H, Gilbert-Ouimet M, Baril-Gingras G, et al. Implementation of an Organizational-Level
Intervention on the Psychosocial Environment of Work. J Occup Environ Med. 2012;54(1):85–91.
doi:10.1097/JOM.0b013e31823ccb2f [PubMed: 22193115]
18. Willis Towers Watson. 2015/2016 Staying@Work — United States Research Findings.; 2016
https://www.willistowerswatson.com/en/insights/2016/04/2015-2016-staying-at-work-unitedstates-research-findings. Accessed June 7, 2017.
19. Pronk N A workplace culture of health. ACSM’s Heal Fit J. 2010;14(3):36–38. doi:10.1249/FIT.
20. Wang X-S, Armstrong MEG, Cairns BJ, Key TJ, Travis RC. Shift work and chronic disease: the
epidemiological evidence. Occup Med (Lond). 2011;61(2):78–89. doi:10.1093/occmed/kqr001
[PubMed: 21355031]
21. Borkan J Crystallization-Immersion In: Crabtree BF, Miller WL, eds. Doing Qualitative Research.
Thousand Oaks, California: Sage Publications; 1999:179–194. http://www.uk.sagepub.com/books/
22. Provalis Research QDA Miner Lite – Free Qualitative Data Analysis Software.
23. Person AL, Colby SE, Bulova JA, Eubanks JW. Barriers to participation in a worksite wellness
program. Nutr Res Pract. 2010. doi:10.4162/nrp.2010.4.2.149
24. Flannery K, Resnick B. Nursing Assistants’ Response to Participation in the Pilot Worksite Heart
Health Improvement Project (WHHIP): A Qualitative Study. J Community Health Nurs. 2014. doi:
25. Hopkins JM, Glenn BA, Cole BL, McCarthy W, Yancey A. Implementing organizational physical
activity and healthy eating strategies on paid time: Process evaluation of the UCLA WORKING
pilot study. Health Educ Res. 2012. doi:10.1093/her/cys010
26. Neubert MJ, Cady SH. Program commitment: A multi-study longitudinal field investigation of its
impact and antecedents. Pers Psychol. 2001;54(2):421–448. doi:10.1111/j.
27. Jenkins KR, Fakhoury N, Marzec ML, Harlow-Rosentraub KS. Perceptions of a Culture of Health:
Implications for Communications and Programming. Health Promot Pract. 2015. doi:
28. Hyde M, Jappinen P, Theorell T, Oxenstierna G. Workplace conflict resolution and the health of
employees in the Swedish and Finnish units of an industrial company. Soc Sci Med. 2006;63(8):
2218–2227. doi:10.1016/J.SOCSCIMED.2006.05.002 [PubMed: 16782255]
29. Gunnarsdóttir S, Björnsdóttir K. Health promotion in the workplace: The perspective of unskilled
workers in a hospital setting. Scand J Caring Sci. 2003. doi:10.1046/j.1471-6712.2003.00122.x
30. Kawachi I, Subramanian IV., Kim D Social Capital and Health.; 2008. doi:
31. Kwon Y, Marzec ML, Edington DW. Development and validity of a scale to measure Workplace
Culture of Health. J Occup Environ Med. 2015. doi:10.1097/JOM.0000000000000409
32. Polit DF, Beck CT. Generalization in quantitative and qualitative research: Myths and strategies. Int
J Nurs Stud. 2010;47(11):1451–1458. doi:10.1016/j.ijnurstu.2010.06.004 [PubMed: 20598692]
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 14
Author Manuscript
Clinical Significance: Employees felt improving workplace culture could be beneficial
to their overall wellbeing at work even without measurable improvements in biometrics
or healthcare cost reductions that employers seek. These basic improvements could
eventually lay a foundation for centralized wellness programs that lead to improved
health and healthcare cost savings.
Author Manuscript
Author Manuscript
Author Manuscript
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 15
Author Manuscript
Box 1:
Focus Group Guide
Author Manuscript
Author Manuscript
Author Manuscript
If a BWH employee wants to try to stay healthy, or to become healthier while
at work, how easy would that be?
If someone wanted to be physically active or get some exercise
during the day, how could he/she do it here at the hospital?
If an employee wanted to eat healthy food, how could he or she do
that during their work shift?
How could your workplace do a better job of promoting a healthy lifestyle?
What would you like to see more of? Opportunities or facilities for
exercise? More healthy foods? Stress reduction programs? Other
What would you like to see less of or changed?
How do you take advantage of opportunities to be physically active at the
Who here makes a point to get some physical activity at some point
throughout the day? Let’s see a show of hands. How do you do that?
What facilities, programs, building features, people, etc make it
easier to be active here?
What factors do you consider when moving throughout the building?
How do you take advantage of healthy food options at the workplace?
How many of you buy lunch in the cafeteria at least some days of
the week? Let’s see a show of hands. OK, what do you like about
buying lunch there? What don’t you like about buying lunch there?
How do you use the hospital’s vending machines?
What factors do you consider when purchasing food on or off site?
Who brings their own food from home at least some days of the
week? Let’s see a show of hands. What do you like about bringing
your own food? What is challenging about bringing your own food?
Do people you work with bring in food to share from home? Are
there communal areas with food? What kind of food? How often do
you eat that? Do you like or dislike when people do this?
Is there anything about BWH policies or environment that makes it difficult
for employees to pursue a healthy lifestyle?
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 16
Author Manuscript
What should be the role of Brigham and Women’s in promoting a healthy
BWH is your employer and, for many of you, provides you with
health insurance. Does their role in promoting a healthy lifestyle
differ as your employer versus the company that provides you with
health insurance?
Do you think BWH cares about your health? Why or why not?
Are there wellness activities that BWH might provide to you (even if
they don’t now) that you might consider inappropriate or offensive?
Are there healthy lifestyle choices that you have adopted here at work that
you then put into practice outside of work? What?
Author Manuscript
Now, let’s talk about a health promotion activity that has occurred at your
workplace over the last several years. What if any changes have you noticed
in the cafeteria?
Author Manuscript
What are your thoughts about the changes that have been made in
the cafeteria?
Labeling of nutritional content of menu items, using a red,
yellow, green labeling system?
Keeping healthy food items priced low?
How do you feel about these changes?
Have any of these changes in the cafeteria made you interested in
changing any of your eating behaviors? At work? At home? How
Have you heard about programs where employers offer financial incentives to
participate in a wellness program or to meet wellness targets, such as a lower
body weight, not smoking, and meeting healthy blood pressure and
cholesterol targets?
Author Manuscript
What would you think about having this kind of program here?
How do you feel about these specific health targets (weight,
smoking, blood pressure, and cholesterol)?
How much should the financial incentive be?
Should the financial incentive be offered as cash, as part of the
paycheck, in some other form? A reduction in your health insurance
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 17
Author Manuscript
premium? Credit to your health savings account? Extra vacation
What would you think if Brigham offered a voluntary program to promote
weight loss or maintenance of weight already lost by allowing you to bet on
your own success? You would contribute money every ten weeks and only
receive the money back if you meet weekly weight targets. The money would
be split in 10 ways. If you meet the weekly weight target, you would receive
1/10 of your money back. If you do not meet the weekly weight target, you
would lose that money. Programs like this have been shown to be successful
in promoting weight loss.
Author Manuscript
How would you feel if BWH offered a program like this to its
Do you think a program like this would work?
What is it about a program like this that would make it
likely to succeed?
Who would be likely to participate in a program like this?
Do you know anyone who might participate in a program
like this?
Would you participate in a program like this? Why or why
Author Manuscript
Author Manuscript
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 18
Author Manuscript
Author Manuscript
Figure 1:
Employees emphasized that wellness improvements follow levels of change, starting from
fundamental relationships with peers and supervisors up to physical spaces and centralized
wellness programming.
Author Manuscript
Author Manuscript
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.
Seward et al.
Page 19
Table 1:
Author Manuscript
Participant characteristics
Mean Age
41 years
26.1 kg/m2
% Female
% White
% Black
% Hispanic
% Asian
Interested in financial incentives for wellness?
Wellness activity participation?
Author Manuscript
Author Manuscript
Author Manuscript
J Occup Environ Med. Author manuscript; available in PMC 2020 October 01.

Purchase answer to see full

error: Content is protected !!