How to Create an Attractive and Supportive Working Environment for Health Professionals

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POLICY BRIEF 15
HEALTH SYSTEMS AND POLICY ANALYSIS
How to create an attractive
and supportive working
environment for health
professionals
Christiane Wiskow, Tit Albreht and
Carlo de Pietro

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on Health Systems and Policies 2010
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Keywords:
HEALTH PERSONNEL
PERSONNEL MANAGEMENT
JOB SATISFACTION
WORKPLACE - organization
and administration -
standards

Authors
Christiane Wiskow, Independent Health
Services Specialist, Switzerland
Tit Albreht, Centre for Health System Analyses,
Institute of Public Health of the Republic of
Slovenia, Slovenia
Carlo de Pietro, Centre for Research on Health
and Social Care Management, Bocconi University,
Italy
Editors
WHO Regional Office for
Europe and European
Observatory on Health
Systems and Policies
Editor
Govin Permanand
Associate Editors
Josep Figueras
Manfred Huber
John Lavis
David McDaid
Elias Mossialos
Managing Editors
Kate Willows Frantzen
Jonathan North
Caroline White
Guest Editors
Leen Meulenbergs
Willy Palm
Matthias Wismar
The authors and editors are
grateful to the reviewers
who commented on this
publication and contributed
their expertise.
Contents
Page
Key messages
Executive summary
Policy brief
Policy issue: poor work environments
compromise health-workforce supply
and quality of care 1
How can attractive and supportive work
environments be described? 4
What can be done to improve the
health-sector work environment? 6
Implementation considerations 23
Summary 25
References 26
Annexes 33
No: 15
ISSN 1997-8073
How to create an attractive and supportive
working environment for health professionals

Key messages
Policy issue and context: poor work environments compromise health-
workforce supply and quality of care
• Health policy-makers face the challenge of matching increasing demand
for health care with a sufficient supply of health professionals in times
of existing and projected health-workforce shortages.
• The work environment constitutes an important factor in the recruitment
and retention of health professionals, and the characteristics of the
work environment affect the quality of care both directly and indirectly.
Addressing the work environment, therefore, plays a critical role in
ensuring both the supply of a health workforce and the enhancement,
effectiveness and motivation of that workforce.
• The purpose of providing attractive and supportive work environments is
to create incentives for entering – and remaining in – the health professions,
and to provide conditions that enable health workers to perform effectively
(to achieve high-quality health services).
Policy options
• Given the complexity of the work-environment issues to be addressed,
policy responses need to be multidimensional, cross-cutting and inclusive.
For coherent policies, policy action has to be considered at four levels:
international/regional level; national level; sectoral level; and local/
organizational level. Effective solutions are context-related and therefore
priority has to be given to the local and organizational level. The other
levels provide the legislative and regulatory framework and provide
guidance and support for the development of workplace policies.
• Two examples of what can be done to improve the quality of the work
environment in the health professions include policy approaches to promote
a healthy balance between family life and work, and the enhancement of
the protection of workers’ health.
• In order to encourage health-sector employers to make a commitment to
positive work environments, the development of workplace assessment/
recognition programmes could be considered.
How to create an attractive and supportive working environment for health professionals

Implementation considerations
• As many factors influencing the work environment operate outwith
the health sector, intersectoral collaboration is required. In particular,
the interface between labour and health-policy mandates needs to
be strengthened.
• Here, the use of social dialogue can help to ensure sustainable and
cross-sectional implementation with multiple stakeholders.
Policy brief

Executive summary
Policy issue: poor work environments compromise health-workforce
supply and quality of care
European countries face common challenges in ensuring a well-performing
health workforce in times of existing and projected shortages. One of the
multiple aspects that determine the supply and performance of health workers
is the work environment, which plays a critical role.
Given the demographic changes expected in the coming decades, labour
markets will experience increased competition for talent. Recruitment and
retention of health professionals are priorities in the health sector. Evidence
suggests that the work environment is an important factor in the recruitment
and retention of health workers.
Furthermore, the work environment can influence the quality of care. Its
characteristics affect organizational functionality, individual satisfaction, the
balance between work and family life, continuous development, and the
organizational culture. Poor work environments contribute to medical errors,
stress and “burn-out”, absenteeism and high levels of staff turnover, which,
in turn, compromise the quality of care.
As a working definition, an attractive and supportive workplace can be described
as an environment that attracts individuals into the health professions, encourages
them to remain in the health workforce and enables them to perform effectively.
In order to develop coherent policies to ensure a work environment that
attracts and retains health professionals, policy responses have to be considered
at four levels: international/regional level; national level; sectoral level; and
local/organizational level. Improvement of the work environment will require
the use of measures that are relevant to (and applicable in) the specific context
of a given health system. These measures should also observe international
standards and take account of regional harmonization efforts.
Effective solutions are context-related and therefore priority has to be given
to the local and organizational level; the other levels provide the legislative
and regulatory framework, guidance and support for the development of
workplace policies.
Policy options
One main trend observed in the health workforce is the drive towards
an improved work–life balance. A family-friendly work environment is of
particular concern in the health sector because of the gender dimension of
this issue. The majority of the health workforce is female, and an increasing
How to create an attractive and supportive working environment for health professionals

feminization of traditionally male-dominated professions can be observed.
Work arrangements that allow a reconciling of family and work needs can
enhance equal employment and career opportunities at times when family
responsibilities are largely borne by women. Similarly, maternity protection
is highly relevant with regard to the mainly female health workforce and the
potential exposure to health risks in this workplace sector. Thus, the promotion
of “family-friendly” workplace options and the enhancement of workers’
health protection are domains in which concerted policy approaches can
be pursued.
More-specific policy responses here include the use of flexible working-time
arrangements, specific protection from exposure to occupational risks, job
security, compensation for reduced employment, maternity/parental leave and
the provision of child-care opportunities. These areas primarily require action
at organizational level, with support from national policies and legislation.
Additionally, health workers are exposed to a broad range of occupational
health risks because of the nature of their work: one-third of health workers
perceive their health to be at risk because of their work. Thus it is crucial to
implement policies to ensure that the health work environment is as safe as
possible. The following areas are of particular relevance to the health workplace:
exposure to biological risks, including infections caused by “sharps” injuries;
and psychosocial risks, including stress and violence at work. Consequences
at the organizational level include absenteeism, reduced productivity, accidents
and errors.
There is a consensus that comprehensive occupational safety and health
management systems are a solid way of establishing sustainable health
protection at organizational level. Central to such systems are the prevention
and control of health risks.
In terms of helping to advance work-environment issues, a promising approach
lies in the development and adoption of processes and tools capable of assessing
work environments at organization level, comparing them, recognizing best
practice and applying them across the system. This approach ideally combines
elements that address the attractiveness of an organization for recruitment
and retention of health staff with elements of quality assurance for better
health outcomes.
More specifically, the use of workplace assessment and certification programmes
could be considered. While some existing schemes may demonstrate certain
limitations regarding their application within the health sector (such as focusing
on a single professional group, lacking a quality-of-care aspect or emphasizing
health promotion in hospital settings), the development of a new framework
for assessment and certification programmes that could be used in the health
Policy brief

sector in different European countries might be useful. The role of national- and
sectoral level measures is to encourage commitment (by health-sector employers)
to improvements in work environments, for example through the support of
benchmark studies and recognition programmes.
Implementation considerations
Many factors influencing the work environment operate outwith the health
sector. Intersectoral collaboration is therefore indispensible for approaches that
are effective at improving the working environment for the health workforce. In
particular, the interface between labour and health-policy mandates should be
strengthened. Health policy-makers need to ensure that a systematic capacity
for addressing labour issues is available at all levels of the health system.
Social dialogue is a major means of achieving sustainable improvements in
health services, and it is positively associated with improvement in working
conditions at the organizational level. At the European level, the Social
Dialogue Committee for Hospitals of the European Union (EU) aims to improve
the quality of employment and the quality of services in the hospital sector by
means of constructive social dialogue. There is a need to build the capacity of
the social partners at national, sectoral and organizational levels in a number
of European countries.
How to create an attractive and supportive working environment for health professionals

1
How to create an attractive and supportive working environment for health professionals
Policy brief
Policy issue: poor work environments compromise health-workforce
supply and quality of care
European countries face common challenges in ensuring a well-performing
health workforce in times of existing and projected shortages (1). Among the
multiple aspects that determine the supply and performance of health workers,
the work environment plays a critical role.
This Policy Brief considers policy approaches that can be employed to help
create positive work environments, thus improving the recruitment and
retention of health professionals and contributing to the achievement of high-
quality health services. Work-environment issues generally apply to all health
workers in all types of health services – with variations according to the
characteristics of professional functions or work settings. Without excluding
their relevance for other professional groups in the health sector, this Policy
Brief focuses on approaches for physicians and nurses, as they represent the
largest constituents of the health workforce.
Recruitment and retention
The recruitment and retention of health professionals are priorities in the health
sector. In particular, the global debate on the international migration of health
professionals has triggered an increased interrogation of the reasons why health
workers leave or stay. Related research has shown that the work environment
is an important factor in the recruitment and retention of health workers.
The main drivers for departure, the so-called “push factors”, are related to
the work environment, and include low pay, poor working conditions, limited
educational and career opportunities, unsafe workplaces and a lack of resources
for effective working. Also, elements of the wider socioeconomic environment
– such as political and economic instability, the impact of the human
immunodeficiency virus, or security issues – influence decisions to move. Health
workers move to where they can find better conditions for work and life, so the
“pull factors” mirror the push factors, and include higher pay, better-resourced
health systems, and opportunities for professional development (2,3).
Shortages in the health workforce induced research into the determinants of
early exits from the health professions and the reasons why young people do
not choose a health career. While dissatisfaction with pay levels is particularly
pronounced in the nursing professions (58–90% in several European countries),
other factors such as low esteem, limited work control and dissatisfaction with
working conditions appear to be even more-decisive reasons for leaving the
profession. With regard to physicians, a study from Germany found that

decision-making, recognition, job security, continuous education and collegial
relationships directly affected the level of job satisfaction (4).
The demographic changes (ageing populations and the decline of young
cohorts) in many countries in Europe (3,4) suggest that European labour
markets will experience increased competition for talent in the coming decades.
Health sectors are vital parts of national economies and constitute an important
labour market in Europe: health-sector employment accounts for 10% of
overall employment (5). Health professionals can compete well in the labour
market and are much sought after. Moreover, the health labour market will
have to compete with other employers for the younger generations taking
decisions about their careers. As the health sector cannot change some of the
unfavourable working conditions that characterize it, such as night work and
work during weekends and holidays, it will have to provide other incentives
that will encourage young people to consider it.
Attracting more young candidates is also important in view of the fact that
the health workforce is ageing in tandem with the overall population. This is
necessary partly because of the differences in age cohorts and partly because
of the oscillating numbers of students across different periods (6). In most
countries, more restrictions were introduced for admission to health studies at
the end of the twentieth century. These factors may affect developments within
individual professional groups and could further complicate planning for human
resources in health.
Health services also face the paradoxical challenge of having to meet increasing
demand with reduced or limited resources. Demographic and epidemiological
transitions have an important impact on the development of health needs.
Health care systems are still largely adjusted to the needs and expectations of
the patterns commonly seen in acute patients with slow responsiveness and
difficult logistics. An alternative approach will have to be provided, not only
in integrating different aspects of medical and health care, but also in offering
integration across the different sectors, relevant for the needs of such patients.
At present, the health workforce in Europe is not structured to meet health
needs and demands together with the challenges of the current and (short-
term) projected epidemiological situations. It appears that the following
needs will require consideration: more skills (predominantly in nursing care)
for dealing with patients with chronic conditions; specialization of key health
professionals (medical doctors, nurses, physiotherapists) to deal with new
demands; and long-term care services (human resources as well as skills).
These, in turn, should offer greater flexibility in organizing working time and,
in particular, regarding working in different environments (such as patients’
homes, homes for the elderly and nursing homes).
2
Policy brief

In Europe, approximately 70% of the health budget is allocated to salaries and
employment-related costs (7). Consequently, the focus on cost containment
has marked many health-sector reforms with direct implications for the health
workforce, such as increased employment insecurity (accompanying the more
flexible employment practices) and increased workloads (because of staff
cuts or greater performance pressures) (WHO unpublished document 2005).
Recent examples of responses to a loss of public funding include measures
such as increased working hours for Estonian clinical staff, freezing of salaries
in Bulgarian and Hungarian public hospitals, and cuts announced for public-
service salaries in Ireland (with 14% losses in income expected for mid-level
cadre nurses and midwives) (8).
The costs associated with improvements in work environments need to be
balanced against the costs arising from turnover, absenteeism and medical
errors caused by poor work environments. It has been estimated that the direct
and indirect costs of turnover, per nurse, accounted for US$ 16 600 in Australia,
US$ 10 100 in Canada, US$ 10 200 in New Zealand and US$ 33 000 in the
United States (4).
Work environment and quality of care
It is generally acknowledged that work environments influence the quality
of care provided. Despite the intuitive nature of this link, assessing it requires
measurable concepts and indicators. Figure 1 illustrates, as a rough model, the
3
How to create an attractive and supportive working environment for health professionals
Work Environment
Quality of Care
Organizational
functionality
Burn-out Turnover
ErrorsExperience
Individual
satisfaction
Work–family
balance
Continuous
training/education
Work culture/
trust
Fig. 1. Links between the work environment and quality of care

links between some of the main elements associated with work-environment
issues and quality of care. While most of the available literature relates to the
nursing profession, the data seem to be relevant for the general workforce in
health care organizations.
The links shown in Fig. 1 highlight the major relationships analysed in the
literature. However, the true dynamics are more complex, involving various
other links between the elements shown in the figure. For example, there are
intuitive links between turnover and the concept of trust, and burn-out is a
predictor of turnover (9).
Apart from the link (established in the literature) between nurse staffing
levels and the quality of care (9,10,11,12), the characteristics of the working
environment affect, and are partly affected by:
•organizational functionality, e.g. internal communication systems able
to give the right information to the right people at the right time;
•individual satisfaction, e.g. support of professionals by the management,
and appreciation from patients or society at large;
•family–work balance, e.g. provision of kindergarten services and reduction
of work recalls;
•staff development (professional and educational), e.g. giving staff the
opportunity to attend courses; and
•organizational culture, e.g. engendering trust as a key element for work
effectiveness, and competent leadership.
The first three dimensions have consequences for the various dimensions of
quality of care via errors, burn-out and turnover. This has been demonstrated
by several studies in which the quality of care was usually measured in terms
of mortality rates, failure to rescue, readmissions, quality (as perceived by
patients), patient satisfaction, quality (as perceived by nurses), length of stay,
etc. (13,14,15,16). Positive effects can also been supposed for continuous
development and – despite weaker evidence – for trust.
How can attractive and supportive work environments be described?
There are no agreed definitions of the terms “working environment” or
“working conditions”. For the most part, both terms are used synonymously.
Intuitively, one imagines that “working conditions” concern issues directly
related to employment and work, whereas the “working environment” seems
to embrace a broader approach including aspects that influence life and work.
Furthermore, both terms commonly encompass sets of elements in combinations
that may vary in focus and scope. Aspects frequently referred to in the literature
Policy brief
4

include terms of employment (e.g. types of contracts), income (payment and
benefits), working time, safety and health at work, professional development
(including education and training) and work organization (including staffing
and division of work). Nevertheless, the work environment generally could be
described as the place, conditions and surrounding influences in which people
carry out an activity (17,18).
An “attractive and supportive work environment” refers to the quality dimension
of work. In this regard, an attractive and supportive work environment can be
described as an environment that attracts individuals into the health professions,
encourages them to remain in the health workforce and enables them to perform
effectively. The purpose of providing attractive work environments is to create
incentives for entering the health professions (recruitment) and for remaining
in the health workforce (retention). In addition, supportive work environments
provide conditions that enable health workers to perform effectively, making
best use of their knowledge, skills and competences and the available resources
in order to provide high-quality health services. This is the interface of the work
environment and quality of care.
In the EU, improvement of the quality of work has been an integrative part of
the European Social Agenda and the European Employment Guidelines since
2000, as illustrated in the strategy motto “more and better jobs” (19,20). Since
then there has been debate as to what “quality of work” encompasses and
how it could be measured, reflecting the changes in socioeconomic realities
and developments in the world of work (21).
In this context, a recent review of quality indicators proposed a general model
for the quality of work (22). The authors distinguished two main dimensions:
“work quality” – the material characteristics of the task performed and the
environment within which it is performed; and “employment quality”, referring
to the contractual relationship between employer and employee. Both areas
influence the overall quality of the work environment or, as the authors called
it, “job quality”. Table 1 captures the main dimensions and elements of work-
environment quality.
With regard to the health sector, different approaches for describing the quality
of work can be used. They may tackle the subject from different angles according
to the viewpoints from which they are derived; for example, in the case of the
Magnet hospitals concept, the emphasis is on aspects that are particularly
important from the perspective of nursing professionals.
The Positive Practice Campaign, jointly launched by world health-professional
associations in 2008, describes characteristics of work environments that ensure
the health, safety and well-being of staff, while simultaneously supporting
high-quality patient care (23). These characteristics mainly reflect the elements
5
How to create an attractive and supportive working environment for health professionals

Policy brief
6
of work-environment quality described above, albeit complemented by
professional recognition, effective management practices, fair workloads
and safe staffing levels.
What can be done to improve the health-sector work environment?
Overall framework: integrative approaches for policy coherence
Improving the work environment requires measures that are relevant and
applicable in the specific context of a given health system while observing
international standards and considering relevant regional harmonization efforts.
Policy responses should therefore be considered at four levels: international/
regional; national; sectoral; and local/organizational level, in order to ensure
policy coherence and enhance the sustainability of interventions.
Policies and instruments intended to improve the work environment are
available in the form of standards, legislation, resolutions and framework
agreements. International standards, in conjunction with regional and national
legislation, are instruments for enforcing the application of set standards in
quality care and for safeguarding workers’ rights. However, standards and
legislation in themselves are not sufficient to address the challenges of attracting
and retaining health professionals associated with the work environment. With
regard to occupational safety and health, for instance, the European Commission
Table 1. Quality of work environment: dimensions and elements
Dimension Elements
Employment quality Wages
Type of contract
Working hours, including work schedules and family–work balance
Social benefits
Participation
Professional development (training and skill development)
Work quality Work autonomy
Work organization (including division of work and staffing)
Organizational culture and trust
Safety and health
Pace of work
Social work environment
Source: adapted from the job-quality model of Muñoz de Bustillo et al. (22).

observed shortcomings in the application of Community legislation, especially
in sectors at risk and for vulnerable workers (24). As many instruments at
international and national levels are general in their scope, the role of the
sectoral level is to identify relevant standards and policies and adapt them
to the specificities of a given health-sector work environment.
In view of the pace of socioeconomic and technological changes and their
considerable impact on employment and working conditions, policy responses
need to reflect emerging challenges on a continuous basis. It is the organizational
level that faces the challenge of translating policies into practice and adapting
interventions (in a timely manner) to trends and changes in the work realities.
Effective solutions are context-related and so priority has to be given to the local
and organizational level; the other levels provide the legislative and regulatory
framework, guidance and support for the development of workplace policies.
The organizational level is concerned with monitoring trends and providing
feedback on emerging new challenges that require action at other levels.
Figure 2 summarizes examples of interventions and issues relating to each
of the four levels.
Fig. 2. Levels of policies and interventions
There are a multitude of challenges concerning the work environment and
they can be responded to using a variety of policies. Improving remuneration
is one of the obvious policy options that are usually discussed. However, pay
increases alone are not the solution, as other factors appear to be even more
important (4). Indeed, the factors influencing the work environment are
multidimensional and often interrelated, so strategies should include different
sets of combined interventions – perhaps including remuneration – and might
imply action at different policy levels at the same time. Box 1 illustrates two
examples of national policies intended to improve the supply of nurses.
7
How to create an attractive and supportive working environment for health professionals
• Standards
• Codes of practice
• Directives
• Guidelines
• Legislation
• Regulation
• Guidelines
• Compliance with
international/
regional legislation
and policies
• Surveillance
• Identification of
relevant standards/
legislation
• Translating
standards/
legislation to
health sector
• Tailoring guidelines
to health sector and
health occupations
• Monitoring
application
• Implementation in
the work setting:
• Compliance with
legislation and standards
• Measures tailored to
health facility and
workplaces
• Monitoring and
feedback on trends
and emerging needs
International/
regional National Sectoral
(health sector) Organizational

Policy brief
8
Box 1. Examples of national policies designed to improve nurse recruitment
and retention
Czech Republic
To address a serious shortage of nurses, the Czech Republic launched a programme
of “stabilization measures” in 2008. The mix of interventions included the following:
• financial measures – grading nurses into higher salary grades and improving benefits
in public-health facilities;
• professional development – better access to nurse-specialist education, with
subsidies from government; support of modern continuous professional
development programmes;
• professional autonomy – negotiations and legislative changes to broaden nurse
competences;
• family–work balance – support to assist return from maternity leave, including
provision of child-care facilities, flexible working hours and part-time contracts; and
• workforce data – monitoring of workforce and student numbers via a register of
health care professionals.
By 2009, the shortage was reduced by half, partly as a result of these measures,
but probably also because of the economic situation (increased unemployment).
Belgium
With the aim to improving the attractiveness of the nursing profession and the quality
of care, a four-year national plan was launched in 2008, supported by significant public
investment. A combination of interventions are being implemented in the following four
main action areas.
• Workloads and stress levels of nurses are being eased (via more staff, supportive action
for upgrading auxiliary qualifications, and provision of information technology systems
for reducing administrative work).
• Qualifications are being addressed (using more continuous training, more specialization,
and the introduction of master’s degrees).
• Remuneration is being changed (i.e. bonuses were paid for work done during “unsocial
hours”, and pay was increased for recognized specialties and nurse-executive positions).
• Social recognition and participation in decision-making are being addressed (through
support of nurse representation within health authorities and bodies).
Sources: presentations by national experts at the Policy Dialogues, Leuven, April 2010 (unpublished);
(Safrankova A, Di Cara V, Czech Republic; Lardennois M, Belgium).

This section explores two policy approaches designed to address specific work-
environment issues. It focuses on selective examples of issues illustrating the
possibilities at a pragmatic level, i.e. in terms of the work/family-life balance
and health and safety at work.
The aspiration towards work–life balance models is one of the main trends
observed in the literature, and it has been noted that family-friendly policies
improve the retention of health professionals (25). Safety/health concerns
are major reasons for early exit from the health professions, and can result
in considerable costs in relation to ill-health, absenteeism and staff turnover.
These two examples are relevant for all professional groups and work settings
and also offer a low-threshold entry point with possibilities for action at the
organizational level.
Promotion of family-friendly workplace options to improve the
work environment
The health workforce is characterized by the large proportion of women
involved in it. Apart from nursing, which has traditionally been a profession
predominantly consisting of women, now more professions, such as physicians,
have experienced an increasing feminization of the workforce (Fig. 3). The
9
How to create an attractive and supportive working environment for health professionals
Women physicians as % of total physicians
1990
2004
0 10 20 30 40 50 60
Iceland1
Luxembourg2
Switzerland
Belgium
Norway1
Italy3
Greece
Austria
Ireland
United Kingdom
Germany1
France
Netherlands
Denmark
Sweden
Spain
Portugal
Hungary
Czech Republic
Poland
Finland
Slovak Republic
Source: Organisation for Economic Co-operation and Development, 2008 (health data
for 2007). 1data for 1991; 2data for 1992; 3data for 1993) (4).
Fig. 3. Female physicians, as a percentage of total physicians, in selected countries
belonging to the Organisation for Economic Co-operation and Development, 1990
and 2004

majority of medical students in most European countries are women: women
constitute 70% of the medical school intake in the United Kingdom and
represent 59.5% of new graduates in Belgium (26,27). This is a result of more
equal opportunities in career choice. Such a development, however, brings new
challenges, as it requires the consideration of the specific needs of women and
men at work. Indeed, women participate in the health workforce differently in
comparison with men. Female physicians tend to work fewer hours, to leave
practice completely (or practice at low levels), particularly during childbearing
age, and are more likely to leave early for retirement (28).
As women carry the major part of family responsibilities, they often face more
obstacles in their career development compared to their male colleagues. This
is often evidenced by the expectations that a career-oriented person should
work longer hours, not be absent due to various family obligations, and so on.
Such attitudes can cause major disadvantages for professionals with family
responsibilities, notably women. An equal-opportunity approach is therefore
necessary in order not to discriminate against female health professionals,
especially in the early phases of their careers. The conflict between the demands
of work and those of family life is also affecting men where they share child-
care and other family duties. The pressure for change towards a more equitable
and gender-balanced workplace is increasing, not just because of the growing
numbers of women pursuing careers, but also because many of them are now
taking up management roles.
A specific element here is that of maternity-related issues. The work environment
needs to accommodate pregnancy as a normal event in the career of a female
health professional, and offer adequate workplace arrangements to support
the needs of pregnant women. Only such an organizational culture can provide
an environment in which female health professionals will feel that they are
equal to their male counterparts and that they have an incentive to combine
their family and work lives. Supporting these needs may become an important
incentive for young people seeking to pursue careers in health care.
Failure to address the conflict between the demands of work and those of
family life may lead to adverse consequences, such as stress and burn-out
syndrome (29), increased absenteeism, the need to leave employment in
order to take care of family responsibilities, and reduced interest in the health
professions among young people deciding on their careers. Such developments
have already been described and are relevant to almost any country in Europe,
especially where failure to reconcile family life and professional life ends in
“non employment” (30).
By building on existing instruments, positive approaches and experiences,
different interventions can be developed at each of the four different levels,
as follows.
Policy brief
10

International level
Various international conventions are available that provide frameworks and
standards for family-friendly workplace policies. Besides various conventions on
maternity protection, the 1981 International Labour Organization Convention
on Workers with Family Responsibilities provides for equal opportunities for –
and treatment of – women and men with family responsibilities. This Convention
has been ratified by a number of European countries (31). At EU level, the 2008
guidelines for employment policies of the Member States suggested, for example,
the use of benchmarks for child-care provision at national level, to promote
reconciliation between work life and family life (20).
National level
Maternity protection differs from country to country, but the most important
features of the social state policies with respect to pregnancy include job security,
protection at the workplace, maternity leave and financial compensation for
reduced employment (32). Regulation may include flexible-hours arrangements,
possibilities for reduced working hours, restrictions on work during night shifts,
less exposure to risky work conditions, and protection of pregnant women at
the workplace. Box 2 provides an example of how national legislation can
influence gender equality in the context of parenthood.
Health-sector level
Regulations should be adapted to the specific requirements of a health workplace,
with support being provided to organizations that seek to implement family-
friendly workplace policies. For example, additional requirements could be
provided to regulate the certification of health care providers with respect
to family-friendly workplaces, such as incentives for solutions that support
employment of parents with small children.
11
How to create an attractive and supportive working environment for health professionals
Box 2. Family–work balance and equal opportunities
Iceland, which is a country with a female labour participation level of 90% and high birth
rates, introduced new legislation in 2000 that structured maternity/paternity leave in a way
that was designed to ensure gender equality. Upon the birth or adoption of a child, both
parents are entitled to three months of paid leave, which is not transferable. Should one
of them decide not to take this leave, then it is lost. Both parents have a joint entitlement
to an additional three months of leave at 80% pay, which they can share and use flexibly.
After three years, there has been a significant increase in the proportions of men taking
paternal leave (92% of fathers using the first three months of paternal leave).
Sources: presentation by a national expert at the Policy dialogues, Leuven, April 2010 (unpublished);
Ministry of Social Affairs and Social Security (33).

Organizational level
With regard to maternity protection measures at organizational level, the
following areas can be covered:
• seamless passage from “regular” workplace loads to “adapted”
workloads, whenever necessary and required by pregnancy;
• securing of workplaces so that exposure to harmful agents is minimized
to reduce danger for both the mother and the baby; and
• allowing flexible working hours.
Arrangements that encourage a balance between family and work can include:
• parental leave;
• company leave because of a sick child;
• the right to reduced working hours for a period of time; and
• support for, or the offer of, child-care facilities.
Box 3 provides examples of family-friendly policies in practice in various
German hospitals.
Policy brief
12
Box 3. Elements of family-friendly policies in German hospitals
Lutherhaus Protestant Hospital, Essen, introduced a scheme of 50 different part-time
models, including:
• qualified part-time employment (15–93% of full-time employment);
• job-sharing, particularly for managerial functions;
• coordination of duty rosters of couples across different departments;
• establishment of time accounts (plus and minus hours); and
• flexible working hours (“flexitime”), with family-oriented core times.
The University Hospital Charité, Berlin, established a “fathers representative”, who advises
men on questions concerning family–work balance.
The Medical University, Hannover, provides financial incentives for departments that attract
female doctors back to work from parental leave within one year.
Northwest Hospital Sanderbusch, Sande, is a member of the network “Success Factor Family”
and attracts qualified professionals to its remote area with its “family and children service
department”, supporting child-care solutions, including the option of partly working from home.
Sources: Bundesministerium für Familie, Senioren, Frauen und Jugend, 2009 (34); Müller B, 2005 (35).

Enhancing the protection of health workers’ health to ensure a safer
work environment
Working in health care is hazardous: the health sector has been identified, in
particular, as one of the dangerous employment sectors (36). In 2000, one in
three health and social workers (32%) in the EU15 perceived that their health
at risk because of their work (37), and in 2005, nearly 40% of health workers
in the EU27 felt that their work had an impact on their health (38).
Health workers are exposed to a broad range of occupational health risks
because of the nature of their work, including:
• biological risks, such as infections caused by sharps injuries or other
contact with pathogens;
• chemical risks, such as disinfectants or certain types of drugs;
• physical risks, such as ionizing radiation;
• ergonomic risks, arising from patient handling or extensive standing
and walking; and
• psychosocial risks, such as stress, violence and shift work. (39)
Without negating the importance of other hazards, such as ergonomic risks
(40, 37), we focus here on two risk categories of particular concern – biological
and psychosocial risks.
Exposure to biological risks is substantially higher in the health sector compared
to the mean exposure in other EU employment sectors (38), the following
issues being particularly relevant to health workers.
• Re-emerging and drug-resistant types of infectious diseases, such as
tuberculosis or malaria, pose potential risks.
• Newly emergent infectious diseases pose a threat where transmission
pathways are unknown and protective equipment is inadequate (41) –
e.g. the outbreak of SARS (severe acute respiratory syndrome), during
which health care workers representing up to 50% of reported cases (42).
• Injuries can be sustained from handling contaminated waste, particularly
needlesticks and other sharps. It has been estimated that one million
needlestick injuries occur annually in Europe, each of which has the
potential to transmit more than 20 dangerous blood-borne pathogens,
including hepatitis B, hepatitis C and human immunodeficiency virus.
Most at risk are nurses and doctors. However, other staff members that
handle waste must also be considered, for example auxiliaries, cleaners
and laundry staff (43). A study in Germany found that 500 000 sharps
injuries occurred in hospitals annually; in the United Kingdom,
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How to create an attractive and supportive working environment for health professionals

Policy brief
14
100 000 incidents per year were estimated to occur. The Scottish National
Health Service estimated the costs associated with needlestick injuries as
ranging from several thousand Euros per case (for post-exposure prophylaxis)
up to one million Euros (for an injury resulting in transfer of a serious
blood-borne virus) (44).
Exposure to psychosocial risks is particularly high in health care compared to the
overall workforce. In 2005, the health sector featured prominently on the list of
sectors with the highest prevalence of stress at work (28.5%, compared with
22% for all EU workers). Across the EU, at least one in five health and education
workers reported work-related stress, with the highest rates occurring in
Slovenia, Greece and Latvia (60, 54 and 52%, respectively); see Fig. 4.
Fig. 4. Stress levels in health and education workforces, by country (2005)
Source: European Agency for Occupational Safety and Health, 2009 (45).
Work-related stress is experienced when the demands of the work environment
exceed the workers’ ability to cope with (or control) them, as defined by the
European Agency for Occupational Safety and Health. Ongoing or intense
stress at work can result in symptoms such as chronic fatigue, burn-out,
depression, insomnia, anxiety, headaches, emotional upsets, stomach ulcers
and allergies (46). Furthermore, it is associated with cardiovascular and
musculoskeletal diseases and immunological problems (45). At organizational
0
10
20
30
40
50
60
70
UKSVFISKSIROPTPLATNLMTHULULTLVCYITIEFRESELEEDEDKCZBGBE
%
27
22 22
26
21 21
31
23
40 41
45 44
54
25
35 34 36
30
45
38
29
33
23
28
52
60
25

level, the consequences include absenteeism, high staff turnover, reduced
productivity, accidents and errors (47).
The job characteristics that contribute to stress are mostly related to the
way in which the work is organized (e.g. long hours and irregular work,
high workloads, tight time constraints, lack of control, job insecurity). In
Switzerland, for example, one-third of primary care doctors in a representative
survey reported experiencing excessive stress due to overall workload, patients’
expectations, difficulties in balancing professional and private life, economic
constraints in relation to the practice, medical care uncertainty and difficult
work relations (48). According to one model, stress levels are mitigated where
workers are supported by their colleagues and supervisors, but are increased
where social support is missing (45,46).
Work strain can also result from organizational change – such as socioeconomic
transformation – in the health-sector context. A Bulgarian survey explored
stress at work in the context of transition, where differing paces in the
implementation of financing reforms led to conflicts between various health
units, provoked by significant differences in the salaries of health workers.
Tension between patients and health staff emerged when a number of free
services were abolished (49).
It has been highlighted that of all the work sectors in the EU27 Member
States, the health sector has the highest level of incidents involving violence
and harassment at work (15.2%). Health workers have been shown to be eight
times more likely to experience the threat of physical violence than workers in
the manufacturing sector (38). The most-affected health professionals include
ambulance staff, nurses and doctors. Recognized risk factors – including working
with the public, working with people in distress, and working alone – are all
prevalent in the health sector. Most incidents of aggressive behaviour experienced
by staff were at the hands of patients, while psychological abuse was associated
with supervisors and colleagues. Psychological violence was more prevalent than
physical violence as shown in a synthesis of several country case studies (50). In
Portugal, for example, a survey of a health-centre complex and a large hospital
found that 51% and 27% of staff, respectively, had experienced verbal abuse,
23% and 16%, respectively, had experienced bullying/mobbing, while the
experience of physical violence was limited to 3% at both study sites
The negative impact on affected staff (as confirmed by case studies in several
countries) include post-traumatic stress symptoms, such as disturbing memories
and thoughts, and a tendency to become highly vigilant. At the organizational
level, the impact is similar to that of stress, causing absenteeism, high staff
turnover and reduced productivity (50).
15
How to create an attractive and supportive working environment for health professionals

Policy responses to occupational health challenges
Protecting the health of workers at work is a legal, if not moral, responsibility
of employers. Workers, too, have their own responsibilities here in complying
with safety regulations and taking care of their health in their own scope of
influence. There is a consensus that comprehensive occupational safety and
health management systems are a solid way of establishing sustainable health
protection at organizational level. Central to this system is the prevention or
control of health risks using a widely applied hierarchy of priorities: elimination
of the risk; control of the risk; minimization of the risk; and provision of
protective equipment (51).
While priority has to be given to action at organizational level, international
and regional policies are important for encouraging initiatives in countries. In
2007, the World Health Assembly adopted a resolution on the World Health
Organization’s Global Plan of Action on Workers’ Health, 2008–2017. This
provides for the establishment of specific programmes for the occupational
health and safety of health care workers (52). With regard to health workers,
WHO’s own programme of work for 2009–2012 focuses on six areas, including:
• needlestick/sharps-injury prevention
• musculoskeletal injuries/ergonomics
• stress/work organization
• pharmaceutical-associated risks
• respiratory risks
• risk assessment/risk-management tools and information dissemination.
Examples of projects that have been initiated under this programme in the
European region are listed in Table 2.
The initiatives taken to address the insufficient prevention of sharps injuries
are an example of advocacy by health professional associations in influencing
policies at European level. Following a campaign, a consultation process
was launched which resulted in negotiation and signature of the Framework
Agreement on the Prevention from Sharp Injuries in the Hospital and
Healthcare Sector. The signatories were the following European social partners:
the European Hospital and Healthcare Employers’ Association (HOSPEEM) the
European Federation of Public Service Unions (EPSU). With the recent adoption
of a European Commission proposal for a Council Directive, it is expected
that the Framework Agreement will be given legal status, making it binding
for Member States (54,55). Figure 5 plots the chronology of this prospective
EU legislation.
Policy brief
16

Fig. 5. Advocacy initiative and process for introduction of European binding measures
for protection from needlestick injuries and other medical sharps injuries
Source: based on De Raeve, 2010 (56), and EU Issue Tracker, 2009 (54).
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How to create an attractive and supportive working environment for health professionals
Table 2. WHO projects on occupational health for health workers in Europe,
2009–2012 (53)
Projects Countries
Countries in transition: how to promote health at work in health organizations
Main objective: to raise awareness and improve knowledge and skills of health
care workers in tackling work-related stress.
Croatia,
Macedonia,
Montenegro,
Serbia
How to maintain health care workers’ workability and quality of life
Main objective: to produce a guidance document that includes a range of
successful initiatives adopted by the Croatian Ministry of Health and Social
Welfare in order to improve health care workers’ work ability and quality
of life.
Croatia
Assessment of exposure to antineoplastic agents in pharmacy and
hospital personnel
Objective: examination of safe working conditions related to the handling of
antineoplastic drugs during drug preparation or administration in hospitals.
Germany
2004
2006
2006–2009
2009
• EFN Awareness Campaign European Parliament
• Joint EFN–ICN statement: Nurses call for EU action aimed at safer needle devices
• European Commission launches consultation process with social partners
• European social partners (HOSPEEM & EPSU) negotiation on a framework
agreement
• Framework Agreement on the prevention from sharp injuries in the hospital
and healthcare sector signed by HOSPEEM & EPSU
• Request to submit the Agreement to the Council for a Council Directive
• EC adopts proposal for a Council Directive to give legal effect to the Framework
Agreement signed by HOSPEEM & EPSU
• European Parliament resolution with recommendations to the Commission on
protecting European healthcare workers from blood-borne infections due to
needlestick injuries (2006/2015(INI))

WHO suggests that a combination of measures using a hierarchy of controls
is the most effective way of reducing the number of needlestick injuries. Core
elements include the use of safer instruments, regular training and instruction,
and established safe working procedures (57). Accordingly, the Framework
Agreement recommends establishing an integrative approach at the workplace,
consisting of risk assessment, risk prevention, training, information, awareness-
raising and monitoring. Both risk assessment and risk prevention should cover
the following areas: technology; organization of work; working conditions;
level of qualification; work-related psychosocial factors; and the influence of
factors on the work environment. Furthermore, the Framework Agreement
provides for the vaccination of health workers according to national practice (58).
Interventions addressing the complexity of psychosocial risk factors and their
causes are grouped into the following three categories.
• Organizational level interventions aim to reduce the risk of stress,
addressing organizational structure, infrastructure or work processes.
• Interventions at the interface between organizational and individual
levels may include improving collegial relationships at work, or training
individuals to adapt better to the work-environment measures for optimal
professional autonomy.
• Individual-level interventions aim to reduce the stress and disease risk of
those who have already symptoms, by strengthening the capacity to cope
with stress (45).
Box 4 presents an example of an approach designed to prevent burn-out
among hospital staff.
In many jurisdictions, violence and harassment continue to be perceived by
health workers as “part of the job”. Therefore, awareness and recognition of
violence as a risk at the health workplace are necessary first steps on the way
to violence prevention and the protection of staff. The specific societal and
cultural context of the work environment needs to be considered, as well as
the gender dimension, in reaching a shared understanding of the phenomenon.
Any approach intended to address workplace violence should be integrated,
participative, culture- and gender-sensitive, non-discriminatory and systematic.
The main areas of action include the prevention and control of workplace
violence and the management and mitigation of its impact, with an emphasis
on the support of workers affected by workplace violence (60). As Box 5
highlights, research initiatives have the potential to raise awareness and act
as a trigger for processes of policy development.
Policy brief
18

19
How to create an attractive and supportive working environment for health professionals
Box 4. “Take Care” – a team-based burn-out intervention programme in the Netherlands
The Take Care intervention project was carried out in 1997–1998 in order to prevent burn-
out among oncology care workers, through a team-based stress-management approach.
The programme consisted of six training sessions of three hours each, one per month,
which were supervised by counsellors.
During the first session, the focuses of action were determined. During the training, small
problem-solving teams were formed that collectively designed, implemented, evaluated
and reformulated plans of action for coping with the most important stressors at work.
Counsellors also provided training in more general communication and collaboration skills,
and participants were their own “agents of change”, with the counsellors as their “coaches”.
The problems that were most frequently addressed were those concerned with coping with
high emotional demands in relationships with cancer patients, and those involving dealing
with communication problems between members of different professional disciplines.
The results of a qualitative evaluation showed that participants considered the approach to
be very instructive and useful for charting work stressors and for formulating and evaluating
plans of action designed to tackle these stressors. The most appreciated part of the activity
was the building of a network of (social) support among colleagues.
Source: European Agency for Occupational Safety and Health, 2002 (59).
Box 5. From lack of awareness to the development of measures as part of the
national collective agreement
As part of the ILO/ICN/WHO/PSI Joint Programme (involving the International Labour
Organization, the International Council of Nurses, WHO and Public Services International)
on Workplace Violence in the Health Sector, Bulgaria’s first survey in 2001 revealed that
health workers and the public were unaware of the problem. Results showed that its
significance was largely underestimated and was interpreted rather as a hardship facing
people in their daily life, and stress due to the negative consequences of Bulgaria’s then
reform process.
In 2003, a tripartite national workshop was organized by the Federation of Health Trade
Unions affiliated to the Confederation of Independent Trade Unions in Bulgaria and the
Medical Federation of the Confederation of Labour Podkrepa. The main findings of the
country study were discussed, and the Bulgarian version of the ILO/ICN/WHO/PSI Framework
Guidelines on workplace violence was launched. The delegates adopted a 2003–2005 action
plan, with a commitment to further action.
One of the most important achievements at national level was the inclusion of the issue of
workplace violence in the health-sector collective agreement for 2004. Other activities were
aimed at awareness-raising, capacity-building and prevention of violence, and included
seminars on security measures, reporting procedures and victim support.
Source: Kokalov, 2006 (61).

Advancing work-environment issues among employers, though
workplace screening and certification
A third policy approach, this time focusing on the process aspects of how work-
environment issues can be taken forward at organizational level, considers
programmes for workplace assessment and certification. These may provide
incentives encouraging employers to commit to the concept of positive work
environments. The role of national- and sectoral-level actions here could be to
provide a framework, as well as political and financial support. This approach
can be illustrated by the following two examples. The first example involves
ranking initiatives, with lists of the best companies, such as those generated by
the Great Place to Work Institute. The second example – the Health Promoting
Hospitals Network – represents an integrative approach that provides
possibilities for self-assessment.
The Great Place To Work®model
The Great Place To Work®model is a method for assessing and optimizing
organizational culture, and was developed by the Great Place To Work Institute,
an American consultancy firm. The Institute uses a questionnaire survey for
employees and interviews with the management in order to assess the
organizational culture. Two-thirds of the evaluation is based on the employee-
survey results.
The German branch of the Great Place To Work Institute, in collaboration
with the Ministry of Labour and other partners, has carried out an annual
benchmarking survey specifically addressing the health sector. Participating
health-service organizations are ranked and the best are awarded the “Best
Health Sector Employer” Certificate (Beste Arbeitgeber im Gesundheitswesen).
Sixty-three health-service organizations participated in the 2010 survey on
workplace culture, and the results show that health and well-being, recognition
and work–life balance are critical issues, with remuneration as a key (but less
important) element (Great Place to Work Institute Germany, unpublished
document 2010).
This model is based on the conviction that organizational culture is a decisive
factor in the productivity of a company. The value-based approach emphasizes
trust as a core component of a positive workplace environment. Trustful
relationships at work, specifically between management and staff, are critical
for successful operations. Values include credibility, respect, fairness, pride and
team spirit. In this approach, a positive work environment is characterized by
trust in the leadership of an organization, pride in the work carried out, and
cooperation with the people in the workplace.
Policy brief
20

The model applies to all industries and, above all, to manufacturing, information
and communication technologies and financial institutions. The strengths of the
model include the following features.
• Its key concept/element, i.e. trust, is fundamental in a working
environment involving information asymmetries and professionals
(e.g. health care organizations).
• The questionnaires are easy to use but they do not involve self-assessment,
as the survey and evaluation are carried out by the Institute.
A weakness of the model is that it does not link to quality of health care or
patient outcomes. However, some health facilities have been using the assessment
as a complementary instrument in combination with the regular quality-
management system, sometimes also alternating with patient-satisfaction surveys.
Box 6 profiles the “Magnet hospital” model in the United States, which aims
to improve the work environment for nurses.
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How to create an attractive and supportive working environment for health professionals
Box 6. “Magnet” hospitals and the Magnet Recognition Program
The concept of the Magnet hospital was developed initially in the 1980s in the United
States by the American Academy of Nursing (62). The initial focus was to identify the
human-resource practices and organizational characteristics that enabled some hospitals
to attract and retain staff in a context of acute shortages (see Annex 1). The basic features
of Magnet hospitals involve investment in staff development, quality management, front-
line management supervisory ability, and good relationships with physicians (63). The
characteristics of “magnetism” have been summarized in a Nursing Work Index, measured
using questionnaires filled out by nurses (64). This idea has been developed over successive
decades through research and the implementation of a voluntary programme of hospital
accreditation, the Magnet Recognition Program, undertaken by the American Nurses
Credentialing Center (a subsidiary of the American Nurses Association) (63).
The nursing practice environment characteristics of Magnet hospitals refer to nurses’
participation in hospital affairs, nursing foundations for quality of care (e.g. written, up-to-
date nursing care plans for all patients), nurse-manager ability, leadership and support of
nurses, staffing and resource adequacy, and collegial nurse–physician relationships (65).
Despite some lack of clarity in study results, along with some counter-intuitive evidence (15),
general hospitals possessing the organizational traits of “magnetism” show lower mortality
rates (13), lower rates of 30-day mortality, fewer complications, and reduced “failure to
rescue” (death following a complication (14)). The Magnet hospital approach also appears
to be able to reduce the likelihood of burn-out and to minimize staff turnover, having a
positive impact on the quality of care (66).
The main limits of this programme are its focus on the nursing profession, its concentration
almost exclusively on the United States (340 accredited hospitals out of 344 were based in
the US; http://www.nursecredentialing.org/MagnetOrg/searchmagnet.cfm) and the sometimes
weak evidence of impacts on quality of care. The first Magnet hospital outside the United
States was in England, but it was not supported by the United Kingdom National Health
Service and was terminated. Western Europe does not currently have any Magnet hospitals.

Health Promoting Hospitals network
Health promotion is a core dimension of quality in hospital services, along with
patient safety and clinical effectiveness. With the rise in chronic diseases, the
provision of health-promotion services has become an important factor for
sustained health, good quality of life and efficiency. The Health Promoting
Hospitals approach therefore combines specific quality-of-care concerns with
aspects of a healthy work environment in hospitals.
The objectives of this network coordinated by the WHO Regional Office for
Europe are to:
• change the culture of hospital care towards interdisciplinary working,
transparent decision-making and the active involvement of patients, staff
and partners;
• evaluate health-promotion activities in the health care setting and build
an evidence base in this area; and
• incorporate standards and indicators for health promotion in existing
quality-management systems at hospital level and national level (67).
For quality assurance, a self-assessment manual that formulates five standards
and related indicators is available (68). With regard to the work environment,
one of the standards requires that “the management establishes conditions
for the development of the hospital as a healthy workplace” (see Annex 2).
This includes:
• the development and implementation of a healthy and safe workplace;
• the development and implementation of a comprehensive human-
resources strategy that includes training and development of the health-
promotion skills of the staff; and
• the availability of procedures for developing and maintaining staff
awareness about health issues.
For the assessment of the work environment, the manual suggests some
complementary indicators, including:
• the score from the survey of staff members’ experience of the
working conditions;
• the percentage of short-term absence;
• the percentage of work-related injuries; and
• the score on a burn-out scale.
Policy brief
22

These standards and indicators are meaningful in terms of improving the
working environment and, in conjunction with those for patient outcomes,
are elements of a broader health-promoting function of hospitals. This
framework, developed over more than ten years, can represent an effective
basis for benchmarking and organizational development of European hospitals
and health services.
These two examples of accreditation schemes designed to improve work-
environment issues have their own particular strengths and limits. It may
be worth considering whether the development of a common framework
for workplace assessments and certification for organizations in the health
sector would be a helpful option. Such a framework could be based on
the aforementioned quality-of-work elements in combination with quality-
of-care standards.
Implementation considerations
It is often the case that issues concerning working conditions lie within the
mandates of ministries of labour and associated authorities, such as labour
inspectorates. Intersectoral collaboration is, therefore, indispensible for
implementing and sustaining effective approaches towards improving the
work environment in the health sector. This is not evident everywhere. Creating
attractive and supportive work environments is challenging, not only because of
the complexity of the issues to be considered, but also because implementation
needs to operate at the interface of health and labour policy mandates with
multiple stakeholders that do not always speak a common language. Usually,
labour policies do not take account of the specific needs of particular sectors,
such as health, so relevant legislation and regulation need to be adapted to fit
the characteristics of the health sector. At the same time, a lack of awareness
and systematic knowledge of labour issues in the health sector can be observed
in many countries. Health policy-makers need to ensure that a systematic
capacity for addressing labour issues is available at all levels of the health
system. Moreover, labour-related policy action requires the involvement of
the core social partners – the employers and workers. One approach, here,
concerns the concept of social dialogue.
Social dialogue is a means of achieving sustainable improvements in health
services, including the work environment, because it aims to involve the key
stakeholders. Social dialogue in the health services has been described as
involving all types of negotiation and consultation, starting with the exchange
of information between and among representatives of governments, employers
and workers on issues of common interest relating to economic and social
policy (69). Social dialogue requires strong and independent social partners,
but this is not available in the health sectors of a number of countries (70).
23
How to create an attractive and supportive working environment for health professionals

While social dialogue has a long tradition in the EU, this has not always been the
case in the health sector, which may reflect the difficulty of organizing this highly
fragmented sector. At the EU level, the establishment of the Social Dialogue
Committee for Hospitals was formalized in September 2006. It aims to improve
the quality of employment and the quality of services in the hospital sector and
has proven successful in advancing issues of concern to both employers and
workers. The recognized social partners are HOSPEEM and EPSU.
Evidence confirms that social dialogue is positively associated with improving
working conditions at the organizational level (21). Yet, against the background
of different traditions of industrial relations in Europe, there is considerable
variety in the role of social dialogue in the context of working conditions across
countries. Bargaining, for example, takes place principally at the sector level in
north and centre-west European countries (e.g. Sweden, Germany, Austria) and
at company level in centre-east countries (e.g. the Czech Republic); it varies in
southern European countries (e.g. Spain, France). The bargaining style has been
characterized as being conflict-oriented in southern countries, acquiescent in
centre-eastern countries and integrating in northern and centre-west countries.
While industrial relations are based on social partnership in some countries,
others have more state-centred, polarized or fragmented regimes. All these
characteristics shape the practice and scope of social dialogue and its impact
on working conditions at enterprise level.
A number of case studies in various health facilities in different countries have
testified to the importance of social dialogue processes in management and for
employees. For management, the priority interest is on improving the working
environment to achieve high-quality care and enhanced competitiveness – for
which a qualified and motivated workforce is indispensible. For health workers’
representatives, engaging in social dialogue and bargaining serves to counter
the worsening of working conditions from the viewpoint of the individual
worker. Lessons learnt from these case studies point to certain factors that
make social dialogue successful:
• a participatory organizational culture and a cooperative mode of
decision-making;
• mutual trust of the stakeholders involved;
• institutionalized dialogue and binding outcomes;
• defined priorities, targets and tasks; and
• the active commitment and competence of employee representatives.
The concrete achievements in terms of improved working conditions covered
a broad range of areas, including better occupational health and safety, better
24
Policy brief

working-time schemes, the introduction of conflict-mediation practices
and social-support initiatives, family-friendly work policies and improved
communication (21).
Summary
This Policy Brief looked into the question of why a good work environment for
health professionals matters for policy-makers, and explored options regarding
how to create attractive, supportive, positive work environments. Importantly, it
has also pointed to the importance of the work environment for the recruitment
and retention of health professionals as well as for the quality of care.
There are a multitude of challenges concerning the work environment,
and these can be tackled using a variety of policies. This, together with the
diversity of the European health systems and socioeconomic situations of
countries, make it difficult to formulate an off-the-shelf list of actionable policy
items. However, a rough framework can be sketched out, with the following
“cornerstones”.
• Whatever issue is identified as a priority concern, it is important to
consider policies that operate at different levels, to ensure a coherent
and sustainable approach. Improving the work environment will require
measures that are relevant and applicable in the specific context of a given
health system while observing international standards and considering
regional harmonization efforts. Effective solutions are context-related
and therefore priority has to be given to the local/organizational level.
• Policy responses need to be designed with two layers: one layer would
relate to the content (what issues need to be addressed), and one would
relate to the process (how issues should be tackled).
• Many factors impacting on the work environment of health professionals
are beyond the scope of influence of health policy-makers. Therefore
intersectoral collaboration and social dialogue are core means of developing
effective and sustainable responses.
The aim is to provide a work environment that attracts individuals into the
health professions, encourages them to remain in the health workforce and
enables health workers to perform effectively.
25
How to create an attractive and supportive working environment for health professionals

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Policy brief
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Policy brief
32

Annexes
Annex 1. Magnet hospitals and the 14 “Forces of Magnetism”
33
How to create an attractive and supportive working environment for health professionals
The original Magnet study from 1983 identified 14 characteristics that differentiated
organizations able to recruit and retain nurses. These characteristics became the
American Nurses Credentialing Center (ANCC) Forces of Magnetism, the conceptual
framework for the Magnet appraisal process.
1Quality of
nursing
leadership
Knowledgeable, strong, risk-taking nurse leaders follow a well-
articulated, strategic and visionary philosophy in the day-to-day
operations of the nursing services. Nursing leaders, at all levels of
the organization, convey a strong sense of advocacy and support
for the staff and for the patient. (The results of quality leadership
are evident in nursing practice at the patient’s side.)
2Organizational
structure
Organizational structures are generally flat, rather than tall,
and decentralized decision-making prevails. The organizational
structure is dynamic and responsive to change. Strong nursing
representation is evident in the organizational committee structure.
Executive-level nursing leaders serve at the executive level of the
organization. The Chief Nursing Officer typically reports directly to
the Chief Executive Officer. The organization has a functioning and
productive system of shared decision-making.
3Management
style
Health care organization and nursing leaders create an
environment supporting participation. Feedback is encouraged
and valued and is incorporated from the staff at all levels of the
organization. Nurses serving in leadership positions are visible,
accessible and committed to communicating effectively with staff.
4Personnel
policies and
programmes
Salaries and benefits are competitive. Creative and flexible
staffing models that support a safe and healthy work environment
are used. Personnel policies are created with direct-care nurse
involvement. Significant opportunities for professional growth
exist in administrative and clinical tracks. Personnel policies and
programmes support professional nursing practice, work–life
balance and the delivery of quality care.
5Professional
models of care
There are models of care that give nurses the responsibility
and authority for the provision of direct patient care. Nurses are
accountable for their own practice as well as the coordination of
care. The models of care (i.e. primary nursing, case management,
family-centred, district, and holistic) provide for the continuity of
care across the continuum. The models take into consideration
patients’ unique needs, and provide skilled nurses and adequate
resources to accomplish desired outcomes.

Policy brief
34
6Quality of care Quality is the systematic driving force for nursing and the
organization. Nurses serving in leadership positions are responsible
for providing an environment that positively influences patient
outcomes. There is a pervasive perception among nurses that they
provide high-quality care to patients.
7Quality
improvement
The organization has structures and processes for the measurement
of quality and programmes for improving the quality of care and
services within the organization.
8Consultation
and resources
The health care organization provides adequate resources, support
and opportunities for the utilization of experts, particularly
advanced practice nurses. In addition, the organization promotes
involvement of nurses in professional organizations and among
peers in the community.
9Autonomy Autonomous nursing care is the ability of a nurse to assess and
provide nursing actions as appropriate for patient care, based on
competence, professional expertise and knowledge. The nurse is
expected to practice autonomously, consistent with professional
standards. Independent judgement is expected to be exercised
within the context of interdisciplinary and multidisciplinary
approaches to patient/resident/client care.
10 Community
and the
health care
organization
Relationships are established within and among all types of health
care organizations and other community organizations, to develop
strong partnerships that support improved client outcomes and
the health of the communities they serve.
11 Nurses as
teachers
Professional nurses are involved in educational activities within the
organization and community. Students from a variety of academic
programmes are welcomed and supported in the organization;
contractual arrangements are mutually beneficial. There is a
development and mentoring programme for staff preceptors for all
levels of students (including students, new graduates, experienced
nurses, etc.). Staff in all positions serve as faculty and preceptors
for students from a variety of academic programmes. There is a
patient-education programme that meets the diverse needs of
patients in all of the care settings of the organization.
12 Image of
nursing
The services provided by nurses are characterized as essential by
other members of the health care team. Nurses are viewed as
integral to the health care organization’s ability to provide patient
care. Nursing effectively influences system-wide processes.

35
How to create an attractive and supportive working environment for health professionals
13 Interdisciplinary
relationships
Collaborative working relationships within and among the
disciplines are valued. Mutual respect is based on the premise
that all members of the health care team make essential and
meaningful contributions in the achievement of clinical outcomes.
Conflict-management strategies are in place and are used
effectively, when indicated.
14 Professional
development
The health care organization values and supports the personal
and professional growth and development of staff. In addition
to quality orientation and in-service education (addressed earlier
in Force 11 –Nurses as teachers), career-development services
are emphasized. Programmes that promote formal education,
professional certification and career development are evident.
Competency-based clinical and leadership/management development
is promoted and adequate human and fiscal resources for all
professional development programmes are provided.
Source: http://www.nursecredentialing.org/Magnet/ProgramOverview/ForcesofMagnetism.aspx
(accessed 8 April 2010).
Annex 2. Health Promoting Hospitals and Health Services network –
self-assessment standards
Standard 4: promoting a healthy workplace
The management establishes conditions for the development of the hospital
as a healthy workplace.
Objective
To support the development of a healthy and safe workplace, and to support
health-promotion activities by staff.
Sub-standard 4.1
The organization ensures the development and implementation of a healthy
and safe workplace.
• 4.1.1. Working conditions comply with national/regional directives and
indicators (evidence: e.g. national and international (EU) regulations
are recognized).
• 4.1.2. Staff comply with health and safety requirements, and all workplace
risks are identified (evidence: e.g. check data on occupational injuries).

Policy brief
36
Sub-standard 4.2
The organization ensures the development and implementation of a
comprehensive human-resources strategy that includes training and the
development of the health-promotion skills of staff.
• 4.2.1. New staff receive an induction training that addresses the hospital’s
health-promotion policy (evidence: e.g. interviews with new staff).
• 4.2.2. Staff in all departments are aware of the content of the organization’s
health-promotion policy (evidence: e.g. annual performance evaluation
or staff participation in the health-promotion programme).
• 4.2.3. A performance appraisal system and continuing professional
development including health promotion exists (evidence: e.g. documented
by review of staff files or interview).
• 4.2.4. Working practices (procedures and guidelines) are developed by
multidisciplinary teams (evidence: e.g. check procedures, check with staff).
• 4.2.5. Staff are involved in hospital policy-making, audit and review
(evidence: check with staff; check minutes of working groups for
participation of staff representatives).
Sub-standard 4.3
The organization ensures the availability of procedures to develop and maintain
staff awareness about health issues.
• 4.3.1. Policies for awareness about health issues are available for staff
(evidence: e.g. check for policies on smoking, alcohol, substance misuse
and physical activity).
• 4.3.2. Smoking-cessation programmes are offered (e.g. evidence on
availability of programmes).
• 4.3.3. Annual staff surveys are carried out: these include an assessment of
individual behaviour, knowledge of supportive services/policies, and use of
supportive seminars (evidence: check questionnaire used for – and results
of – staff survey).
Source: Groene O, ed. 2006, Implementing health promotion in hospitals: manual and
self-assessment forms. Copenhagen, WHO Regional Office for Europe, 2006:47–50.

Joint policy briefs
1. How can European health systems support investment in and the
implementation of population health strategies?
David McDaid, Michael Drummond, Marc Suhrcke
2. How can the impact of health technology assessments be enhanced?
Corinna Sorenson, Michael Drummond, Finn Børlum Kristensen, Reinhard Busse
3. Where are the patients in decision-making about their own care?
Angela Coulter, Suzanne Parsons, Janet Askham
4. How can the settings used to provide care to older people be balanced?
Peter C. Coyte, Nick Goodwin, Audrey Laporte
5. When do vertical (stand-alone) programmes have a place in health systems?
Rifat A. Atun, Sara Bennett, Antonio Duran
6. How can chronic disease management programmes operate across care settings
and providers?
Debbie Singh
7. How can the migration of health service professionals be managed so as to
reduce any negative effects on supply?
James Buchan
8. How can optimal skill mix be effectively implemented and why?
Ivy Lynn Bourgeault, Ellen Kuhlmann, Elena Neiterman, Sirpa Wrede
9. Do lifelong learning and revalidation ensure that physicians are fit to practise?
Sherry Merkur, Philipa Mladovsky, Elias Mossialos, Martin McKee
10. How can health systems respond to population ageing?
Bernd Rechel, Yvonne Doyle, Emily Grundy, Martin McKee
11. How can European states design efficient, equitable and sustainable funding
systems for long-term care for older people?
José-Luis Fernández, Julien Forder, Birgit Trukeschitz, Martina Rokosová,
David McDaid
12. How can gender equity be addressed through health systems?
Sarah Payne
13. How can telehealth help in the provision of integrated care?
Karl A. Stroetmann, Lutz Kubitschke, Simon Robinson, Veli Stroetmann,
Kevin Cullen, David McDaid
14. How to create conditions for adapting physicians’ skills to new needs and
lifelong learning
Tanya Horsley, Jeremy Grimshaw, Craig Campbell
15. How to create an attractive and supportive working environment for health
professionals
Christiane Wiskow, Tit Albreht, Carlo de Pietro
The European Observatory has an independent programme of policy briefs (see
http://www.euro.who.int/en/home/projects/observatory/ publications/policy-
briefs/joint-hen-obs-policy-briefs).
HEN produces synthesis reports and summaries (available at
http://www.euro.who.int/en/what-we-do/data-and-evidence-network-hen).

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This Policy brief was prepared for the Belgian EU Presidency Conference
on Investing in Europe's health workforce of tomorrow: scope for
innovation and collaboration (La Hulpe, 9–10 September 2010).
This publication is part of the joint policy brief series of the Health
Evidence Network and the European Observatory on Health Systems
and Policies. Aimed primarily at policy-makers who want actionable
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(http://www.euro.who.int/en/what-we-do/data-and-evidence/health-
evidence-network-hen).
The European Observatory on Health Systems and Policies is a
partnership that supports and promotes evidence-based health policy-
making through comprehensive and rigorous analysis of health
systems in the European Region. It brings together a wide range of
policy-makers, academics and practitioners to analyse trends in health
reform, drawing on experience from across Europe to illuminate policy
issues. The Observatory’s products are available on its web site
(http://www.healthobservatory.eu). ISSN 1997-8073