Abstract
BACKGROUND:
Risk assessment and work adjustment according to EU legislation may safeguard pregnant employees and their offspring. Knowledge on management perspectives in relation to implementation of protective measures is limited.
OBJECTIVES:
The primary aim was to describe Danish hospital managers’ engagement in pregnancy policy and work adjustment for pregnant employees. The secondary aim was to investigate how managers’ characteristics and the setting affect engagement and behaviour.
METHODS:
This was a cross-sectional study of survey data from 212 managers. Outcomes were within dimensions of health promotion, pregnancy policy, work adjustment, collaboration, manager support, and sick leave. Logistic and ordinal logistic regression models were applied to identify associations between background information and outcomes.
RESULTS:
Of the managers included, 84% arranged meetings and 76% conducted occupational risk assessment. Most managers (96%) engaged in dialogue with the employees before sick leave. Most managers felt competent in providing guidance for pregnant employees and 99% considered work adjustment important, mainly to safeguard mothers and children. The self-reported data showed positive associations between female managers and feeling competent to guide the employee. Further, management training was associated with meetings with pregnant employees. Seniority was associated with feeling competent to guide and dialogue. Midwifery support was associated with competence in guiding employees about risk factors.
CONCLUSION:
Work adjustment and risk assessment for pregnant employees are considered a priority by Danish hospital managers. Overall, managers feel competent guiding pregnant employees. However, managers experience midwifery support beneficial for the guidance of pregnant employees.
Introduction
The Healthy Workplace Framework and Model of the World Health Organization provides an international agenda for health protection at workplaces by considering exposure in the physical and psychosocial work environment [1]. European Union (EU) legislation pays further attention to pregnant employees and aims to protect their health by requiring that occupational risks are assessed and avoided [2]. Maternity protective legislation shares the same stepwise principles across countries, which include risk analysis, work adjustment or temporary reassignment to eliminate risks, and paid preventive leave if a safe working environment is not attainable [3]. The Danish Working Environment Authority’s (WEA) guidance on risk assessment during pregnancy focuses on exposures, including physical, biological, or chemical exposures, or night work, that may cause adverse pregnancy outcomes [4, 5]. In addition to adverse outcomes of pregnancy, some exposures, such as standing, lifting, and shift-work, are associated with increased sick leave during pregnancy [6].
Despite the international guidelines, challenges remain in terms of the implementation of risk assessment and work adjustment during pregnancy. One study found that only 29% of Danish employees participated in risk assessment during their pregnancy [7]. A review reported this challenge also applies in the European context [3]. Between 20% and 60% of pregnant employees in the United Kingdom, Switzerland, Norway, and Poland report a lack of sufficient risk assessment during pregnancy [3]. Considerable discrepancies between employees’ and employers’ experiences of actual risk assessment and work adjustment have been identified [3, 8–10], which may relate to different perceptions of when the needed adjustment is achieved [3]. A Swiss study reported the managers take varying levels of responsibility for regulating the safety of pregnant employees [8], which suggests the maternity protective measures applied may vary across workplaces.
Identifying the perspectives of both managers and pregnant employees is important to understand how pregnancy policies and work adjustment serve as protective measures. However, knowledge about managers’ attitudes, experiences, and behaviour regarding pregnancy policy is limited.
The primary aim of this study was to describe Danish hospital managers’ engagement in pregnancy policy and work adjustment for pregnant employees. The secondary aim was to investigate how managers’ characteristics and the setting affect this engagement and behaviour.
Methods
This was a cross-sectional survey among hospital managers at Randers Regional Hospital (RRH) and Aarhus University Hospital (AUH) in Denmark. The hospitals employ 1800 and 10200 employees, and 64 and 306 managers, respectively. The eligibility criterion was a management position with staff responsibility, either at the first line or at the strategic level. All hospital departments were included, and recruitment was accomplished through each hospital’s human resources department.
In Denmark, the employer is responsible for undertaking risk assessment for pregnant employees [5]. As part of antenatal care, general practitioners (GPs) perform a risk assessment at the first pregnancy visit. In cases of doubt about the occupational exposures, a pregnant employee is referred to a department of occupational medicine for further risk assessment, including guidance and recommendations on work adjustments. GPs and obstetricians may approve sick leave or preventive leave, the latter to avoid non-preventable occupational exposure. The two study hospitals have similar pregnancy policies [11–13].
Data collection
The questionnaire was thematized in dimensions based on a review of the literature and categorized at the individual, group, leadership, and organizational level (the IGLO model) [14]. The dimensions were background, health promotion, pregnancy policy and work adjustment, collaboration, manager support, organizational and cultural context, and sick leave.
The item wording was inspired by the three Danish questionnaires, Work Environment Effort Questionnaire (VAI) [15], Public leaders and leadership in the year 2017 [16], and Sickness absence efforts and the municipality’s support for managers [17].
The questionnaire went through several drafts involving repeated discussions of the background literature and thematic dimensions as well as interpretation of items among the authors. Further, we conducted pilot testing and obtained written feedback from internal and external managers about their interpretation of the survey items.
The background information (Table 1) includes gender (male, female), age group [25–40, 41–55, 56–70]; education level (<2.5, 3–4, >5 years); management training (basic, single course, 60 European credit transfer and accumulation system credits (ECTS) at bachelor’s level, 60 ECTS at master’s level, other); management experience (0–5, 6–15, 16–40 years); management level (manager of managers, first-line managers), span of management (0–25, 26–40, >41 employees); pregnant employees/year (<1, 1 < 3, ≥3), shift-work (yes/no), location of employment (RRH, AUH); and pregnancy support at the workplace (midwifery support offered to half the departments at AUH).
Characteristics of hospital managers (N = 370).
Characteristics of hospital managers (N = 370).
*Attendance in meetings between manager, pregnant employee and midwife.
The outcomes (Table 2) were, “It is my responsibility as a manager to promote health among my employees”; “Do you offer pregnant employees meetings regarding work adjustment?”; “Is risk assessment discussed during the meeting?”; “Do meetings with pregnant employees reflect a shared responsibility for work adjustment between the manager and employee?”; “Pregnant employees seek dialogue with me before sick leave”; “How competent do you feel in guiding on risk factors in the working environment?”; “How competent do you feel in guiding on preventing and coping with pregnancy discomfort?”; and “Work adjustment for pregnant employees is important”. Outcome data were collected as binary or as ratings on a five-point Likert scale.
Danish hospital managers’engagement in pregnancy policy and motivation to implement work adjustments for pregnant employees. Variables expressed as questions in survey. Years of management experience included as dependent variable.
*Management experience variable had 4 missing values, so frequences stratified for management experience does not necessarily add up to the total.
Data were collected from December 2022 to January 2023. Invitations were sent by e-mail, and up to three reminders were sent if needed. The data were collected and managed using RedCap (Research Electronic Data Capture), which is hosted at Aarhus University. Redcap is a secure, web-based software platform designed to support data collection for research studies [18, 19].
Categorical data were generated from the variables: age, years of management experience, number of employees, and mean number of pregnant employees per manager/year. Categories were defined according to the distribution of respondents and aimed to obtain an even distribution in each category rather than identical numeric intervals between categories. Categorical data are presented as n (%), and continuous data as median (IQR) (Tables 1 and 2).
Outcomes were stratified according to management experience, which was the background variable associated with the most outcomes. This stratification provides transparency about the risk of small frequencies in each category in the applied regression analysis.
Outcomes were adjusted for predefined covariates (gender, management training, management experience, number of employees, shift work in department, and midwifery support). Associations were explored using logistic regression for the binary outcome and ordinal logistic regression for outcomes on a Likert scale. The odds ratios (ORs) and 95% confidence intervals (CIs) are presented in Table 3.
Managers’ characteristics associated with managers’engagement i pregnancy policy expressed as odds ratio (OR) adjusted odds ratio (adj OR) with 95%confidence intervals.
Managers’ characteristics associated with managers’engagement i pregnancy policy expressed as odds ratio (OR) adjusted odds ratio (adj OR) with 95%confidence intervals.
Logistic regression for binary outcome, ordinal logistic regression for outcomes on Likert scales. *p < 0,05. *Attendance in meetings between manager, pregnant employee and midwife.
Data management and analysis were performed using Stata Statistical Software (2021 Release 17; StataCorp LLC, College Station, TX [20]).
Consent to participate was obtained from each participant, and participation was anonymous. The study did not need further ethical approval according to Danish law. The study was registered at the repository of the Central Denmark Region (1-16-02-95-22).
Results
All managers at the hospitals were invited to participate (N = 370), and 212 responded (57%). Information on gender and management level were available for non-respondents from an audit of email addresses and are presented in Table 1.
Most respondents were employed at AUH (84%), the majority were women (83%), with a median age at 53 years (IQR 47;60). Most (64%) of the managers held a bachelor’s degree and were employed as nurses, laboratory technicians, or physiotherapists or occupational therapists. Most participants (76%) had additional management training, which mostly was at the diploma level. The respondents had a median of 9 years of management experience (IQR 5;17). Most were first-line managers (79%) and managed a median of 35 (IQR 22;55) employees and 1.6 pregnant employees/year (IQR 0.7;3). Slightly more than half (55%) of the participants managed employees whose employment included shift-work, including day, evening, and nightshifts.
In Table 2, variables are presented according to the questions in the survey and numbers stratified according to years of management experience. Overall, only minor differences were found between groups according to the number of years of management experience. Nearly all (96%) of the managers either agreed or strongly agreed with the idea that health promotion within the workplace is a managerial responsibility. The majority of the managers (84%) reported meeting with pregnant employees to find ways to adjust work task, and most of these meetings included risk assessment (76%).
Most managers (63%) perceived work adjustment as a joint responsibility with pregnant employees and collaboration with employees before planning sick leave was reported by 71% of the managers. Stratification according to managers’ experience showed equal agreement between managers with 0–5 and 6–15 years of experience in manager-employee collaboration (dialogue before sick leave), whereas a higher percentage of managers with ≥16 years of experience reported to have this dialogue before sick leave.
Managers’ self-reported views of their competence showed that 95% felt moderately to very competent in guiding pregnant employees about risk factors in the working environment and around 87% of managers felt equally competent providing guidance about pregnancy discomfort.
All managers (99%) partly to strongly agreed that work adjustment during pregnancy is important. Of three reasons why work adjustment is important, safeguarding the mother and child was the most frequent reported reason (93%), whereas 57% were motivated by creating an attractive workplace, and 48% were motivated by the potential to retain the pregnant employees’ competence as long as possible. Contributing to an inclusive labour market and completing immediate work tasks seemed to be less important to the respondents (data not shown).
The following types of adjustments were used: adjusting working hours (79% of the managers), adjusting tasks (67%), prioritizing breaks during the workday (39%), ergonomic guidance (29%), and technical aids (6%) (Fig. 1).
Managers’ use of work adjustment.
Female gender (OR 2.84; CI 1.35;5.96) was positively associated with the managers’ perception of competence in providing guidance about preventing pregnancy discomfort (Table 3). Having had management training was positively associated with organizing meetings with pregnant employees (OR 3.2; CI 1.26;8.12).
Seniority was associated with positive ratings of dialogue and feeling competent to guide pregnant employees. Having >6 years’ management experience was associated with feeling competent to guide employees about risk factors in the working environment (OR 1.96; CI 1.01;3.81). More than 16 years of experience was associated with having a dialogue with pregnant employees before planning sick leave (OR 2.27; CI 1.10;4.69), feeling competent to guide employees about risk factors (OR 2.82; CI 1.31;6.09), and pregnancy discomfort (OR 2.21; CI 1.06;4.62).
Management in departments with shift-work was negatively associated with shared responsibility (OR 0.38; CI 0.2;0.7). Having midwifery support was positively associated with feeling competent to guide employees about risk factors.
Main results
Danish hospital managers in this study responded with very positive ratings of their engagement in pregnancy policy. They reported being dedicated to protecting the health of their employees and using risk assessment and work adjustment to protect pregnant employees. They perceived work adjustment to be a joint responsibility and engaged in dialogue with pregnant employees before any sick leave. Managers rated their own competence to guide pregnant employees as high and preferred adjusting pregnant employees’ working hours and tasks.
Female gender and experienced managers were reportedly feeling most competent in guiding pregnant employees and engaging in dialogue before pregnant employees took sick leave.
Management training was associated with arranging meetings, and midwifery support with feeling competent to guide employees about risk factors. Departments with shift-work was negatively associated with joint responsibility for work adjustment.
Interpretation
Health-promoting leadership has been introduced in the medical, psychological, and business literature in the past decades [21–25] and focuses on facilitating employees’ health, well-being, and work attendance through supportive leadership [21–25]. The present study show that managers generally accept employee health promotion as part of their managerial responsibility and as a priority for pregnant employees.
Overall, managers rated their engagement in pregnancy policy as very high. The finding that 84% reported facilitating meeting with pregnant employees contrasts with another Danish study, which examined the employee perspective and reported that only 44% of pregnant employees were invited to a meeting with their manager, 49% assessed their work tasks with a manager, and 55% had their work adjusted [26]. Other studies have shown discrepancies between employees’ and employers’ estimates of the risk assessment and work adjustment achieved [8, 9, 10, 27–30]. Thus, to understand how pregnancy policies serve as protective measures for pregnant employees, it is important to obtain the perspectives of both managers and employees.
Most managers perceive work adjustment as a shared responsibility with employees and engage in dialogue with them before they take sick leave. Dialogue before sick leave may reassure the employee that sick leave is a better solution than further work adjustments and may allow managers to look for solutions within the workplace. This is consistent with the work of Dellve et al., who reported that successful health-promoting leaders consider the organization rather than the individual employee as responsible for high sick leave rates [24].
In this study, we found a negative association between joint responsibility for work adjustment and shift-work. Shared responsibility may imply a close dialogue, which may be limited for employees who undertake shift-work due to less interaction in everyday work life.
A majority of senior managers reported dialogue before sick leave, which suggests close contact with employees is a specific priority among senior managers. Our findings are consistent with a qualitative study in which managers with an average of 12 years of experience in health-care institutions considered dialogue essential to identifying the needs of individual pregnant staff members [31].
Our study showed that female gender, years of management experience, and support from a midwife were associated with perceived competence to provide guidance about risk factors. The first two factors were also associated with competence to provide guidance about pregnancy discomfort. These results may be explained by the idea that pregnancy lies within the female domain and, perhaps, attracts less attention from male managers or that female managers guide through their own experience [32].
Access to midwifery support was related to managers feeling competent to provide guidance about risk factors. Thus, midwifery support may be a source of support for improving managers’ competence.
Managers considered work adjustments important to protect the pregnant employees and their foetuses, creating an attractive workplace, and retaining staff competence. The most frequent adjustments reported are in agreement with the findings of a Danish qualitative study, that reported managers’ effort in adjusting tasks and work schedules [31]. This may be a sound priority, as reducing evening work, night work, or shift-work lead to the greatest reduction in sick leave when needed [33]. Ergonomic guidance, and use of technical devices is limited and may represent other ways to support pregnant employees at their workplace.
Strengths and limitations
The main strength of this study is that it provides new knowledge in an area with limited research. The study focuses on current practices and the findings reflect managers’ self-perceptions about and intended engagement with pregnancy policy. It is important to understand whether managers are acting in accordance with the needs of pregnant employees and identifying whether managers and employees act differently.
The main limitation of this study is the lack of validated items in the survey. A search for validated tools of relevance was conducted, but none were found to be applicable. Another possible weakness is that selection bias may have affected the results as participation may have reflected stronger engagement in pregnancy policy among responders than non-responders.
The items “Risk assessment is completed in meetings with pregnant employees” and “Manager and employee are jointly responsible for work adjustment during pregnancy” had 34 missing, who may represent differences to the responders. The proportion of male responders in this study was low and may indicate an underestimated association between gender and competence to guide. Overall, the survey response rate was 57%, which may be considered adequate for surveys within social sciences and research in general business and management [34].
Reporting bias may have also led to overestimation of the results as hospital pregnancy policy implies risk assessment and work adjustment. Therefore, managers may, have reported according to the intended practice. Several tests of associations may increase the risk of type 1 error, and the sample size may be small for using regression analysis to explore some of the associations. Our conclusions should be interpreted with caution and the study design does not allow for conclusions of causality.
Generalizability
A concern regarding internal and external validity is information bias from non-validated questionnaire and responding according to intended practice. However, steps were taken to compensate for the non-validated tool and the external validity is considered overall good as the study population seemed to be representative of the source population. Therefore, cautious application of the results to similar hospital settings seems fair.
Conclusion
To secure the health and well-being of pregnant employees, Danish hospital managers consider risk assessment and work adjustment to be a priority. Hospital managers reported having dialogues with pregnant employees and prefer adjusting employees’ tasks and work hours and ensuring more breaks. Overall, managers reported feeling competent in guiding pregnant employees. However, managers may benefit from midwifery support for their guidance of pregnant employees.
Footnotes
Conflict of interest
None of the authors declare any conflicts of interest.
Funding
This research received funding from the Danish Working Environment Research Fund (grant number 20195100272), a grant from Public Health in Central Denmark Region –a collaboration between municipalities and the region (grant number A3015), the Danish Association of Midwives (Jnr. 56-094), and Central Denmark Region Health Sciences Research Fund (SVP).
Author contributions
All authors have contributed
substantially to the conception or design of the work; to drafting the work or revising it critically for important intellectual content; with final approval of the version to be published; and with agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Ethics statement
Consent to participate was obtained from each participant, and participation was anonymous. The study did not need further ethical approval according to Danish law. The study was registered at the repository of the Central Denmark Region (1-16-02-95-22).