THE TOTAL WORKER HEALTH APPROACH The many factors contributing to the Great Resignation are complex and variable, and it would be naïve to think that a simple solution could slow or reverse this international phenomenon. Nevertheless, a systems-level framework that values, protects, and engages workers and is adaptable to the needs and resources of small, medium, or large organizations may be effective. One such framework is the NIOSH Total Worker Health (TWH) program. NIOSH defines TWH as “policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being.” Other defining elements of the TWH approach are demonstrating leadership commitment, designing work to eliminate hazards (for example, using the TWH hierarchy of controls), engaging workers, and ensuring confidentiality. The TWH hierarchy of controls is consistent with the traditional OEHS model (elimination, substitution, engineering controls, administrative controls, and personal protective equipment) but incorporates actions to advance worker well-being. It begins with eliminating hazardous working conditions and progresses to substitution of health-enhancing policies, programs, and practices; redesigning the workplace; educating workers about safety and health; and encouraging personal change. The TWH approach examines how work organization and work itself can influence safety, health, and well-being. It embraces voluntary, participatory interventions; protects workers’ rights and privacy; and contributes to a culture of care for the organization, employees, and communities. A growing body of literature points to the benefits of TWH for both employers and workers. According to a 2016 NIOSH publication, “employers tell us they accrue competitive advantages related to recruitment, retention, employee satisfaction, community engagement and reputation, and sustainable workforce culture by emphasizing a TWH focus” (PDF). NIOSH guidance cites real-world examples of higher-than-industry-average retention rates, positive returns on investment, lower costs associated with absenteeism, improved job engagement, and better work/life balance. The overarching goal of the TWH approach is to improve the well-being of the U.S. workforce by reducing occupational risk, protecting worker safety, and enhancing worker health and productivity—in other words, providing benefits beyond the fence line. As explained in a 2016 paper in the Annals of Internal Medicine, the benefits of the TWH approach could be documented as reduced injury or illness rates but are often reported as improvements in leading indicators—that is, increased utilization of behaviors leading to reduced risk of occupational injury or illness. The authors of a 2015 paper published in the Journal of Occupational Health Psychology conducted a comprehensive literature review of published studies of programs that integrated occupational health and safety and health promotion (HP), and which reported both OHS and HP results. Of the 17 studies that met these criteria, all but one reported improvements in injury and chronic illness risk factors, and four reported improvements in 10 or more risk factors. For example, one study demonstrated that smoking cessation rates were twice as high at companies with integrated OHS and HP programs than at companies that implemented HP alone. Another study, published in the International Journal of Environmental Research and Public Health in 2018, evaluated an integrated approach that included an ergonomics program combined with a work-site-based “health week” intervention at commercial construction sites. Results after one month included improved ergonomic practices and reduced incidence of pain and injury; after six months, the program had achieved a reduction in physically demanding work, an increase in recreational physical activity, and greater consumption of fruits and vegetables by workers. A study of hearing conservation programs (HCP) in maintenance garages demonstrated that employee participation can further improve the outcome of integrated OHS and HP programs. Employees who participated in the design of the HCP used hearing protection devices more often than either recipients of the program or the control group. The evidence is building that TWH interventions are effective in improving worker health, safety, and well-being. Another way to view the overall benefits of TWH is through the lens of job attitudes. A 2018 doctoral study on this topic concluded, “There is overwhelming support by researchers for a positive correlation between a high level of employee job satisfaction to a low level of turnover intent.” A conceptual model published in Organizational Psychology and Behavior: An Integrated Approach to Understanding the Workplace connects contributing factors such as employees’ trust in their organization and supervisor, the characteristics of their job, and the support they receive from their employer to levels of job satisfaction and turnover rates. Or, as Melissa Swift, Mercer’s U.S. transformation leader, told CNBC, “It makes a huge difference as to whether or not people actually enjoy their jobs and want to stay at them.” As OEHS professionals, we recognize the importance of eliminating and managing chemical, physical, biological, and psychosocial stressors in the workplace. Wouldn’t the “culture of care” recommended by Forbes also include a commitment to and investment in job satisfaction and employee health, safety, and well-being? Aren’t building trust, prioritizing flexible work organizations that value the needs of families, and creating mental and emotional safe spaces for every worker also ways of building a culture of care? The TWH approach can accommodate work-related risk reduction and the values and actions that support a culture of care. When the TWH approach is implemented, employees at all levels are recognized as valued members of the workplace community. While TWH can’t address all the concerns of workers like Carlos, Marta, Carroll, and Tanya, employers should solve as many problems affecting their workers as possible. As the Great Resignation continues, perhaps employers shouldn’t ask whether they can afford to build a culture of care any more than they ask whether they can afford to comply with regulations. Perhaps acting now to stem the tide of the Great Resignation by advancing worker well-being is a risk worth taking. A TWH WORK PLAN Carlos, Marta, Carroll, and Tanya’s employers recently attended a civic club meeting where they met Michael, a mid-career OEHS professional. The employers shared their concerns about the Great Resignation and declining productivity, formed a TWH working group, and asked Michael to advise them. He has attended professional development courses on the TWH approach at AIHce and at meetings of his AIHA local section. Michael has also participated in online training sessions presented by NIOSH TWH Centers of Excellence. The 2019 text Total Worker Health is on his nightstand. Michael’s current role in occupational risk focuses on awareness, anticipation, recognition, evaluation, control, confirmation, and communication (AARECCC) of chemical, physical, biological, and psychosocial stressors. He has relied on his professional knowledge to help workers, friends, and family make comparative risk decisions on issues beyond the workplace—for example, should they vaccinate or not? Take the bus or drive? Send kids to school or keep them at home? His participation in the TWH working group provides opportunities to develop awareness of work-related psychosocial stress and engage in TWH training, teambuilding, advocating, and championing. After reviewing the Fundamentals of Total Worker Health Approaches: Essential Elements for Advancing Worker Safety, Health, and Well-Being, Michael decides to encourage each working group member to prepare a work plan that includes the following actions: • Gather basic information about the organization, such as its size, type, and structure. A national grocery chain will have different needs and resources than a medium- sized hospital, a small privately-owned investment firm, or a large public school district. Does the organization have in-house legal, occupational health, or human resource departments or arrangements with external partners? • Assemble the organization’s TWH team. A team of partners with a range of knowledge and experience will produce the best outcome. Consider including concerned workers, OEHS staff, human resources and workers’ compensation professionals, healthcare practitioners, Employee Assistance Program professionals, and members of the health, safety, and wellness committees. • With the TWH team, conduct a TWH needs assessment of the organization. The NIOSH document “Fundamentals of Total Worker Health Approaches” (PDF) suggests comparing where the organization is now and where it wants to be for each defining element of TWH: leadership commitment, design of the work environment, worker engagement, worker confidentiality and privacy, and program integration. • Have the TWH team prepare an action plan for reaching these goals. For each defining element, ask who should be involved, what obstacles may exist, and how they can be overcome. • Conduct periodic evaluations of progress toward goals. Employers can assess their progress with the Workplace Integrated Safety and Health (WISH) Assessment. This online tool covers six core constructs: leadership commitment, participation, policies, collaborative strategies, adherence to regulations and ethical norms, and data-driven change. As their advisor, Michael reminds the TWH working group members to engage employees at each step of the way, especially if worker involvement in OHS has been identified as an opportunity for their organizations to improve. He encourages group members to start small and build on successes and to remember that TWH describes a framework that each organization can adapt to its own needs and resources. Six months later, as a result of the initial successes of the TWH working group, Michael has decided to pursue formal training in the TWH approach. He reviews the NIOSH website to identify educational opportunities. He’s also looking forward to joining the Total Worker Health professional society and attending the 3rd International Symposium to Advance Total Worker Health in Bethesda, Maryland, Oct. 11–14. And now, dear reader, it’s your turn. How can the grocery store, the hospital, the investment firm, and the school district navigate the Great Resignation? What impact do you think the ongoing pandemic has had on their actions? How have their actions affected the decisions made by workers who were considering leaving their jobs? And where do you think Carlos, Marta, Carroll, and Tanya are today? DEBORAH IMEL NELSON, PhD, CIH, FAIHA, has been a member of AIHA since 1977. Deborah served on the AIHA Board as a director from 1998 to 2001 and as secretary from 2002 to 2005. In 2015 she was elected as AIHA’s vice president and in 2017 assumed the presidency. The author thanks Fred Boelter, Natalie Schwatka, Mary O’Reilly, and Andrew W. Nelson for their valuable suggestions. Send feedback to The Synergist.