Cultural events provided by employer and occupational wellbeing of employees: A cross-sectional study among hospital nurses

Abstract

BACKGROUND: Occupational well-being in health care is essential for the quality of care and productivity. Some of the major challenges facing hospital nurses are the personnel turnover, emotional loading and health care reforms. After primary occupational safety and risk management, complementary positive health promotion approaches with cultural interventions can be experimented.

OBJECTIVE: To examine the association between well-being indicators of hospital nurses and their participation in cultural events provided by the employer (theater, concerts, exhibitions, museums, sight-seeing, and musicals) during past 6 months.

METHODS: Subjective well-being was measured by work engagement, workplace support for new ideas, work satisfaction and experienced stress.

RESULTS: A dose-dependent association was found between participation in cultural events and positive psychology parameters of occupational well-being (support for new ideas and work engagement), but the experience of stress was unrelated to participation in cultural events. Collective participation has a positive covariant effect on work engagement and seems to mediate the innovative work climate measured by workplace support for new ideas.

CONCLUSIONS: Collective cultural events for employees may promote positive aspects of occupational wellbeing.

Keywords

Art health promotion prevention stress work engagement

1 Introduction

The fundamental effects of workplace stress on the well-being, occupational safety, quality of care and productivity of hospital nurses are well documented [1 –4]. A range of technological, organizational, and structural interventions is being implemented to improve healthcare quality and patient safety [5]. Healthcare workers seem to have more than average level of work-related health risks. The nursing staff, in particular, have reported higher stress of the quantitative and qualitative job overload, and insufficient support from work-place [6].

The role of hospital nurses has become increasingly complicated due to the fact that health care is developing rapidly as a result of high technology, shortened lengths of stay in hospitals, cost effectiveness aims, and the downsizing of staff [7]. Increasing patient volumes challenge nurses’ capacity to prioritize, manage and plan team work, and to perform exact documentation [8]. Learning and using new highly developed technology and multitasking skills while simultaneously responding to patients’ individual needs in close interaction may lead to an emotional and cognitive overload.

Although some sources of nurses’ occupational stress are administratively manageable, there are still several unique stress-producing factors inherent in the work of nursing personnel that are immutable [4]. The ethical dilemmas of care, and frequent, close encounters with patients and their frustrations, fears, expectations, wishes, sorrows, and even trauma may expose nurses to specific dimensions of burnout, such as compassion fatigue and moral distress [9]. These are more difficult to recognize and handle on an organizational level than more concrete, visiblephenomena.

Health care administrators have to promote organizational commitment and occupational well-being among nurses due to the increasing demand and decreasing supply of nurses, and the costs of turnover [10, 11]. Understanding the mission of the organization and the professional roles, interdisciplinary respect and positive relations between health care professionals are important aspects of commitment. Social and professional interaction are essential components of job satisfaction among hospital nurses [12].

In addition to the major changes in the work environment, the composition of hospital personnel is also changing. Learning experiences, an innovative work climate and a culturally sensitive client-oriented approach are the possible benefits of the increasing cultural diversity of health care staff. However, diversity may interfere with team functioning if not managed properly by investing in professional development and improving group processes, conflict management skills, self-awareness, understanding of cultural style differences, and the ability to validate alternative points of view [13].

Well-being activities should offer channels for reflection on work experiences, and should stimulate creative learning processes, positive interaction, and coping strategies to deal with constant, unavoidable stressors. An active role of workers and resiliency capabilities are essential for developing strategies to adapt or respond to demands of the current situation [5]. In order to sustain well-being at work, supervision, workplace social support, systematic occupational safety, and worksite health promotion programs are needed. Health promotion covers a broad range of positive interventions, including cultural activities and art interventions.

2 Study background and hypothesis

Workplace art activities in the health care sector seem to reduce burnout [14] and increase occupational well-being [15]. In a qualitative study, hospital nurses’ job satisfaction and occupational well-being increased with art interventions at the workplace [16]. Emergency employees in highly stressful work seem to benefit from a broad range of cultural leisure activities in their private lives, which seem to offer better ability to cope with occupational stress [17]. Creative leisure activities are associated with creativeness at work, whereas participating in cultural events, or consuming culture, is associated with work engagement [18].

In Finland, occupational safety and occupational health care are highly developed, but health care reforms, increasing patient demands, and economic pressure present major challenges to the well-being of hospital nurses [19]. Since 2009, Finnish employers have had the option of offering their employees tax-free vouchers for cultural events and exercise. The purpose of these vouchers is to support and encourage employees’ healthy leisure activities.

Another approach is to bring art activity straight to workplaces, and to include and reach the whole work community. Art interventions at workplaces seem to have many benefits, such as sensitivity to working conditions, reflecting specific experiences of work and the objectives of the work community, and stimulating long-term learning processes [20].

An option exists between the two approaches described above: an intermediate intervention could target the whole work community but allow employees to choose according to their own preferences. The Helsinki University Central Hospital’s Medical Unit was among the first large-scale public sector employers in Finland offering all employees regularly organized collective cultural events.

The aim of this study was to examine the associations between participation in employer-provided cultural activity and occupational well-being. We hypothesized that cultural activity provided by the employer is associated with positive occupational well-being.

3 Materials and methods

The Medical Unit of the Helsinki University Hospital has organized cultural events for hospital personnel since 2011. These activities, provided by the employer, became regular on a monthly basis in 2012, and their availability was informed to all employees on the workplace website. The events were planned, organized and advertised by a group of employees, but took place outside the workplace, and outside working hours.

A digital questionnaire regarding participation in these cultural events over the last six months and current well-being was sent to all employees in the Medical Unit in September 2012. The cultural events available to employees were theater, concerts, exhibitions, museums, sight-seeing, and musicals. The response rate was 35% (769 respondents out of 2217). Most respondents were nurses (69%). This sub-sample of nurses is the focus and object of this study, and comprises the study population (N = 530).

An earlier qualitative study of the same cultural activity project describes in detail which of the respondents participated in cultural events, how and why [21]: The most often reported motives for participation were recreation and relaxation, the third reason for participation was the interest in art itself. Lack of information and lack of time were the most common obstacles reported by those who had not participated (59%).

The nurses who responded to the questionnaire were predominantly female with permanent, long-term employment; worked in shifts; and their mean age was 44 (Table 1). These characteristics reflect the overall structure of the nursing personnel of the hospital quite well, although the mean age is a little higher (47 years) and the amount of permanently employed a little lower (78%).

The primary occupational well-being outcome measures were work engagement and workplace support for new ideas, reflecting an innovative work climate. Other outcome measures were work satisfaction, and experienced stress. The mode of participation (solitary vs. collective) and the quality of the participation experience and background factors (demographic, working conditions, and individual, self-organized cultural leisure activities) were included in the analysis (Table 1).

Work engagement was measured by the Uwes-9 scale [22, 23], and innovative work climate was measured by a single Likert scale question on receiving support for new ideas at the workplace [24], which is related to the work climate in innovative organizations [25]. Agreement with this claim was expressed as follows: ‘My workplace shows interest in my new ideas or initiatives’. Job satisfaction and encountered occupational stress measured by Likert-scale questions were based on the standardized Occupational Stress Questionnaire [26, 27]. Statistical analysis was performed by the SPSS 22 program, using univariate analysis of variance, linear regression and the T-test.

Work engagement is a state of fulfilment, motivation and absorption related to several positive consequences at both the organizational and individual level, such as productivity, retention and commitment to work, other dimensions of occupational well-being, health, and functional capacity [28]. Work engagement belongs to the field of positive psychology [29], which seeks to find the resources for coping with stress and the components of wellness rather than focus on the etiology of stress and burnout. Higher burnout has been associated with lower work engagement [28].

In addition to work engagement, an innovative work climate is another positive force that is essential for coping with demanding, constantly changing working conditions and complex interactions. The climate of an innovative, productive organization is characterized by trust and openness, playfulness and humor, diversity of perspectives, and support of ideas [30]. Although challenges are essential for creativity, the innovativeness of the workplace atmosphere is reduced by constant occupational stress [31]. Lack of time, typically experienced in health care, may suppress innovation, unless time pressure is experienced as meaningful and tasks are limited enough to enable success and provide inner rewards [32].

The study was approved by the Ethical Committee of the Finnish Institute of Occupational Health and study permission was granted by the leader of Helsinki University Central Hospital’s MedicalUnit.

4 Findings

The frequency of participation in cultural events was associated with work engagement (Table 2). Higher frequency of visiting cultural events during the last six months was associated with higher work engagement (B = 0.123, p = 0.006) (Table 3).

The result was unaffected by adjustment for possible confounding factors (demographic, working conditions, and individual, self-organized cultural leisure activities). When adjusted for self-organized cultural activities, the association between employer-provided activity and work engagement still remained significant (F = 2.845, p = 0.010). Self-organized cultural activities had no statistically significant covariant effect (F = 2.563, p = 0.110) on work engagement. In the corrected model, adjusted for work community participation and quality of experience, the statistical significance (F = 3.54, p = 0.004) again remained unaffected. Work community participation (F = 4.12, p = 0.042) and quality of experience (F = 6.00, p = 0.015) had, however, significant positive covariant effects on work engagement.

The frequency of participation in cultural events was associated with workplace support of new ideas (beta 0.159, p = 0.000, Table 3), and the mean support of new ideas was significantly higher among participants than among non-participants (Table 2). When adjusted for individual cultural activities, the association remained significant (F = 2.79, p = 0.011). The effect of individual cultural activities on workplace support of new ideas was non-significant (F = 1.20, p = 0.274). When adjusted for community participation (F = 0.092, p = 0.762), the association was diluted to non-significant (F = 0.513, p = 0.766). Participation together with colleagues thus seems to mediate higher support of ideas among participants.

The variance of work engagement was not affected by background factors such as age (F = 1.154, p = 0.235), shift work (F = 0.414, p = 0.520), type of work contract (F = 2.54, p = 0.112) and length of employment (F = 0.152, p = 0.929). Gender, however had a statistical effect on work engagement (F = 4.573, p = 0.033), so that women scored higher scores (mean sum 41.7) than men (mean sum 37.6), but the covariant effect (F = 4.046, p = 0.045) did not explain the connection between participation and work engagement (F = 3.109, p = 0.005).

5 Discussion

We examined the association between participation in employer-provided cultural activities and occupational well-being among hospital nurses in a public hospital that was going through organizational restructuring. We found that work engagement and innovative work climate were associated with higher participation in cultural activity and the association was dose-dependent and linear: A greater frequency of participation in cultural events was associated with more positive indicators of wellbeing.

The positive outcomes can be explained by the stimulating effect of art and culture on individual employees and on the work community. An innovative work climate seems to be mediated by collective participation. The possible positive psychological mechanisms [33] behind well-being effects may include the strengthening and expression of positive affects by esthetic enjoyment during simultaneous social interaction with colleagues, and psychological growth by inspiration and immersion in cultural events.

Occupational well-being, measured here as a positive phenomenon, was generally better among nurses who participated in cultural activities than among those who did not participate. This trend of better well-being among participants was not found when comparing experienced stress. The possible positive effects of cultural activity may be thus better reflected in outcome measures of positive psychology – cultural interventions add something positive rather than reduce something negative.

Traditional occupational safety approaches are based on risk management through the prevention of occupational accidents and health impairment, and tend to focus attention on negative outcome measures. Health promotion, in turn, aims to increase both collective and individual resources and the elements of well-being, and focuses on positive outcomes. Positive phenomena, such as the elements of occupational well-being, may become more visible and better recognized by turning attention to them.

To ensure high quality medicine and care, health care professionals with high intrinsic motivation and high work engagement are needed. Work engagement is influenced by employees’ personal strengths, such as resilience and optimism, and by their working conditions [34].

5.1 Comparison to other studies on positive well-being outcome measures

The finding of improved work engagement among those who participated in cultural activities is in line with earlier findings of an association between work engagement and employees’ self-organized cultural leisure activities. The mean work engagement of 4.60 (corresponding to the sum of 41.4 reported here) was higher than the mean of a large (N = 16 335) Finnish working population sample, which was 4.26 [23]. It was also higher compared to the mean work engagement of 4.49 among health care nurses in Finland [23], and higher than the mean work engagement of 4.52 among a sample of health care employees that consisted mainly of nurses and doctors [18].

5.2 Comparison of two different health promotion approaches that offer cultural activity to employees

The organization of this study offered employees cultural vouchers before it began providing actual cultural events. The benefits of cultural vouchers have not been systematically studied, but they have been criticized as economically supporting previously established leisure activities of regular consumers rather than encouraging new consumers to participate in cultural activities. Culturally active employees appreciate the free choice that the vouchers provide. Cultural activity provided by the employer, in contrast, offers less freedom of choice, but seems to invite new participants instead of the “grand consumers” [21]. The social interaction between employees increased, as they preferred collective participation, which may have had a positive effect on work climate. Joint participation seems to explain the more innovative work climate among participants, and has an additive positive effect on work engagement.

5.3 Limitations of the study

The response rate was relatively low (35%), but comparable to that obtained in organizational studies [35]. However, the representativeness of the sample may be limited. The reasons for non-response were unknown, but the distributions of age, gender, and work characteristics of the study population were quite similar to those of the whole hospital personnel, suggesting no systematic selection in non-response.

This study did not focus on more severe negative work-related phenomena, such as burn out, which has been suggested to be a consequence of long-lasting occupational stress that exceeds the coping resources of an individual. The focus of this study was limited to health promotion, leaving out secondary prevention.

5.4 Positive causal effects of cultural activity, or parallel phenomena?

As the present study was cross-sectional, conclusions regarding causality are not justified, but the probability of causalities in both directions can be discussed. The strong, dose-dependent association between work engagement and innovative atmosphere might be explained by reverse causality if employees with better well-being were selected to participate in cultural activity. However, the reported amount of stress experienced by participants and non-participants was exactly equal, suggesting that our findings were not primarily driven by the level of initial well-being.

An earlier qualitative study with the same sub-sample of nurses [21] explored which participants selected the cultural events, how and why. The main reasons for participation were the need for recreation and relaxation, whereas the primary reasons for non-participation were random lack of information and inadequate timing. Only a minority of non-participants reported a lack of energy, and an equal amount reported priority of their own cultural activities, so that the exclusion effect of the most culturally active participants counteracted the possible exclusion effect of the most passive ones.

A plausible explanation is that participation in cultural activity has positive effects on occupational well-being, which is supported by earlier cohort studies [15, 36] and by the qualitative analysis of this sample [21], which indicated that participation in cultural activities served as a channel of detachment, relaxation, recreation, and collective positive experiences, reflected in the workplace atmosphere. The experience of cultural events was most often reported as positive (76%) or quite positive (21%). No-one reported the experience as negative (0%). Shared cultural experiences outside working environment seem to enhance positive interaction between work-mates, learning experiences and idea exchange also at work-place [21], which are essential for the commitment of health care professionals [37].

However, the link between occupational well-being and participation in cultural activity could still be explained by parallel phenomena possibly related to a third factor such as functional, collective workplaces, which also encourage active participation and foster well-being. Moreover, in the long run, the association may be reciprocal by nature: cultural activity increases well-being, which in turn enhances participation in cultural activities and so forth, thereby both influence each other in a cyclical manner.

6 Conclusions

Cultural activity provided by the employer is associated with better occupational well-being among hospital nurses, measured by positive psychology parameters. Work engagement and an innovative work climate were significantly better among nurses who had participated in cultural activities in the last six months. Enriched social interaction, brought about by collective participation in cultural events seems to mediate an innovative work climate. Although the direction of cause and effect could not be established in a cross-sectional study, a cultural activity-based intervention as a means of health promotion may enhance empowerment and stimulates positive psychosocial coping with the permanent stressors that are characteristic of highly interactive, responsible and multitasking work.

After standardized occupational safety and risk management, positive approaches of increasing occupational well-being have become increasingly important. Besides, measuring positive phenomena may also enhance them – what we look at is what we see. In the midst of organizational restructuring, collective cultural events for employees may promote wellbeing. Turning attention to positive elements of well-being might make them more visible.

Conflict of interest

The authors have no conflict of interest to report.

Footnotes

Acknowledgments

We thank the Medical Unit of the Helsinki Central Hospital for its participation, and we especially thank the Director of Nursing, Marja Renholm, Occupational Safety Officer, Eva Ihaksi and her predecessor, Occupational Safety Officer, Riitta Sahrman for their co-operation in the study design, and Development Manager Juho Mattila for carrying out the Digium questionnaire. One of the authors, LPR, was financially supported by the Juho Vainio Foundation, by The Signe and Ane Gyllenberg Foundation, and by the Bothnia Welfare Coalition for Research and Knowledge network.

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