Sustaining health and workability in a 'new normal'

Before the coronavirus pandemic, mental health and musculoskeletal disorders represented the leading, and most long-standing causes of sickness absence and avoidable work disability.[1,2] This was despite increased workplace regulation, clinical guidance[3] and the heightened profile of mental health within national discourse.[4] Presenteeism, or 'showing up for work when one is ill'[5] was also deemed an undesirable accelerating trend with an adverse impact on national productivity.[6] Similarly, beliefs prevailed that work should be avoided until an employee is 100% fit, and that working with a health condition inevitably leads to health deterioration.[3,7]

A more positive perspective regarding work's health benefits had also become a core premise of UK Government consultations and policy in this area;[8,9] namely that 'good work', where there is a person-job fit, is 'good for wellbeing'.[10] Sickness absence beyond four weeks was held to substantially increase the risks of spiralling work disability, long-term absence, and worklessness.[9,11] Moreover, less than half of the UK workforce had access to occupational health services[12].

Since then, the challenges created by the Covid-19 pandemic has added layers of complexity to the health and work relationship. These not only concern preventing exposure to the virus. Unavoidable health challenges exacerbated by the pandemic must also be addressed. This article unpacks these hard-to-prevent challenges and potential work-focused accommodations that could enable more successful adaptation.

Challenges

Foremost, increased numbers of employees will be resuming work having had Covid-19 on a severity continuum ranging from asymptomatic to life-threatening. Some may have spent time in Intensive Care Units, and we have been provided regular reminders within the news of the profound, multi-system impact that this can have on health.[13] The apparent protracted nature of Covid-19 recovery[13] and resemblance to post-viral fatigue attributes[14,15] implies highly managed vocational rehabilitation as potentially necessary.

Secondly, there will be more employees returning to work who have had to self-isolate as part of the test and trace programme, possibly on a recurrent basis.

Thirdly, given the high prevalence of long term conditions within the working-age population,[16] many employees recovering from Covid-19 will inevitably have pre-existing conditions. Understanding of how Covid-19 recovery might interact with either the symptoms or management of pre-existing conditions is clearly at an early stage.[14]

Fourth, workers classified as vulnerable because of existing health conditions will sooner or later need to reengage with work where they have been unable to do so under shielded conditions.

Finally, many essential workers have continued working with their existing health conditions. Until it is established whether Covid-19 infection affords full immunity, all such workers with 'compromised' health must contend with the continued risk of (re)infection while they are at work.

Further complexity will be created by where the work occurs. Non-essential workers may not have to return to their actual place of work. For them, the challenge concerns a return to 'working' rather than a return to work. Absence of a commute, increased flexibility over when and how to work, and greater isolation from Covid-19 (re)infection risks could arguably make their resumption of work easier. Some may need to go back to an actual workplace (e.g. people-facing occupations, manufacturing, essential workers). Others may need to do a combination of both. Consequently, the increased remote working arrangements required of lock-down will need to remain. Workforce composition and capacity is also likely to be in a state of flux. Different workers may be absent at any one point in time to either to self-isolate or to care for family. Thus, the pandemic and its aftermath look set to substantially increase the heterogeneity of health challenges faced by employers and employees that cannot be resolved through prevention alone.

Accommodations

How can such challenges best be met so that employers retain a functional workforce, with employees able to do their jobs? A starting point may be to frame the objective of overcoming them as concerning sustained work ability rather than sustained return to work. Work ability simply means ability to work.[17] Since it is not tied to a location it allows for the possibility that: working may not be at work; workers may undergo repeated periods of resuming work as part of test and trace, and that rehabilitation isn't necessarily a time bound process but an ongoing journey that continues through the ebbs and flow of condition management.[18]

It follows that the 'work ability house' provides a potentially useful framework for organising strategies for overcoming the health challenges described. [17,18,19] This framework groups intra-organisational workability enablers according to health/functional capacity, competence, values and the work environment.

Work environment: In keeping with High Reliability Organisation attributes,[20] flexibility could prove key to successful adaptation to unavoidable health challenges. At the organisational level, swift workload reallocation to accommodate flux workforce health needs, along with readjustment of line manager productivity targets according to changing team health needs, could facilitate workforce responsiveness. Teams may also need to possess sufficient agility within their competency base so that members can seamlessly step into the shoes of colleagues that go off sick. While this may conflict with Covid-19 risk controls that limit the number of colleagues with which each employee physically interacts, it could be viable for teams working online. Inter-dependency could therefore increasingly become a hallmark of the social contract[21] by which teams operate.

Values: Functional presenteeism [22] beliefs combined with 'worker social responsibility', chronic unease[23], trust, and compassion may help define organisational cultures conducive to sustaining work ability. In particular, the perception surrounding presenteeism as undesirable may need to become more nuanced. Providing there's an appropriate balancing of health needs with job requirements, some degree of 'working while recovering' could be rehabilitative. Evidence indicates that it can circumvent the downward spiral of reduced self-efficacy, reduced mastery, and increase illness behaviour associated with not working.[3,24] Temporary 'functional' presenteeism may therefore be necessary in the new normal to permit speedier resumption of usual functioning levels. More research into the Covid-19 recovery process will of course be necessary to clarify the boundaries around appropriate resumption of work activities.

Corporate social responsibility refers to how ethical an organisation is in its treatment of internal and external stakeholders.[25] Ensuring associated values are mirrored within each individual could help employees to remain mindful about how their social distancing behaviour affects the health risks both of their colleagues and the wider community network with which they connect. Reminders that risk is a function of likelihood and severity could also help foster such 'worker social responsibility'. This should mean that even if employees experience less severe Covid-19 symptoms, they are less likely to underestimate the risk posed to vulnerable individuals via transmission routes within and outside the organisation's boundaries. As another high reliability organisation attribute, a continual sense of collective chronic unease, or shared propensity to 'stay worried' may also be necessary to sustain this level of vigilance.[23]

The surge in compassion apparent during lockdown reflects another value-set potentially instrumental to sustaining work ability. A compassionate organisation is more likely to be a trusted one; an essential precondition of rule compliance.[26] Compassionate leadership entails 'listening [to employees] with fascination', 'arriving at a shared understanding', 'empathising' and 'taking [supportive] action'.[27] Accordingly, an ability to notice and provide timely support to employees struggling with health issues, potentially across remote working arrangements, could become a valuable leadership quality for sustaining work ability.

Competencies: Given limited access to occupational health support, line managers' competencies could become still more critical. Likely competencies may comprise: maintaining rapport remotely; understanding absence management policies; conducting constructive health conversations including allaying fears over disclosure; instilling positive work ability beliefs; jointly agreeing job modifications or phased resumption of usual activity, and capturing decisions within regularly reviewed action plans.[3] Training to enable this may therefore need to become more widespread.

Individual health status: For more controllable health outcomes, having some intrinsic sense of control over symptoms has been associated with more adaptive coping.[28] Since a larger proportion of the workforce may need to manage job demands alongside health condition(s), enhancing perceptions of control could help workers achieve this balance. This could stem from their continual involvement in creation of health risk assessment or action plans and in decision-making generally. In may also stem from providing sufficient time for: self-management activities including building up resilience through physical exercise; deriving social support from colleagues; and for pacing work especially where fatigue is implicated.[15] Similarly, stress levels of managers and employees will need careful management to mitigate any detriment to health, recovery and Covid-19 vigilance levels.

To conclude, exclusively preventative health strategies is clearly not going to be enough for containing the described unavoidable, highly flux health consequences of the pandemic. Managing these could require organisational cultures and systems characterised by and mix of compassion, Covid-19 vigilance, flexibility and trust, all of which will need be channelled by line managers as the interface between the workforce and senior leadership. This may seem a tall order, but striving for these conditions may both sustain workability, and help offset the pandemic's potential to create greater health and social inequity across the working age population.[29]

References

1. Office for National Statistics (2018). Sickness absence in the UK labour market: 2018. 
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4. Maslowski, A. K., LaCaille, R. A., LaCaille, L. J., Reich, C. M., & Klingner, J. (2019). Effectiveness of Mental Health First Aid: a meta-analysis. Mental Health Review Journal, 24(4), 245-261. https://doi.org/10.1108/MHRJ-05-2019-0016

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14. Liu, H., Chen, S., Liu, M., Nie, H., & Lu, H. (2020). Comorbid Chronic Diseases are Strongly Correlated with Disease Severity among COVID-19 Patients: A Systematic Review and Meta-Analysis. Aging and disease, 11(3), 668–678. https://doi.org/10.14336/AD.2020.0502

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24. Varekamp, I., Heutink, A., Landman, S., Koning, C. E., de Vries, G., & van Dijk, F. J. (2009). Facilitating empowerment in employees with chronic disease: qualitative analysis of the process of change. Journal of occupational rehabilitation, 19(4), 398–408. https://doi.org/10.1007/s10926-009-9188-x

25. Jones, D. A., Willness, C. R., & Glavas, A. (2017). When Corporate Social Responsibility (CSR) Meets Organizational Psychology: New Frontiers in Micro-CSR Research, and Fulfilling a Quid Pro Quo through Multilevel Insights. Frontiers in psychology, 8, 520. https://doi.org/10.3389/fpsyg.2017.00520

26. Feather, N.T. , and Rauter, K. A. (2004), 'Organizational citizenship behaviours in relation to job status, job insecurity, organizational commitment and identification, job satisfaction and work values', Journal of Occupational and Organizational Psychology, 77, 81–94.

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28. Karekla, M., Karademas, E. C., & Gloster, A. T. (2019). The Common Sense Model of Self-Regulation and Acceptance and Commitment Therapy: integrating strategies to guide interventions for chronic illness. Health psychology review, 13(4), 490–503. https://doi.org/10.1080/17437199.2018.1437550

29. Marmot,M, Allen, J, Boyce, T, Goldblatt, P Morrison. (2020). Health equity in England: The Marmot Review 10 years on.