The Wiley Guide to Strategies, Ideas, and Applications for Implementing a Total Worker Health Program E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Addresses safety and health hazards through a holistic, organization-wide approach to worker wellbeing
The Wiley Guide to Strategies, Ideas, and Applications for Implementing a Total Worker Health® Program presents specific information and guidance for Total Worker Health (TWH) applications in a variety of industries as well as specific aspects of TWH. This book covers how existing safety and health activities can support and be integrated into TWH programs, exploring specific topics such as how TWH initiatives can benefit the construction industry, ways to borrow from successful safety committee operations, and the use of technology.
The innovative ideas and techniques from diverse fields, and from existing safety and health programs, help readers maximize efforts and increase the chance of long-term success. Case studies are included throughout to elucidate key concepts and aid in reader comprehension.
Written by safety, health, and wellness practitioners with real-world experience, this resource includes:
- Organizational approaches for implementing key prevention programs to solve problems across diverse worker populations
- Guidance for improving the organization and design of work environments, including innovative strategies for promoting worker wellbeing
- Evidence of program effectiveness for addressing work conditions that impact mental health, fatigue and sleep, and work-life conflict
- Perspective of traditional safety and health professionals, emphasizing practical advice for practitioners throughout all chapters and connecting the narrative as a whole
The Wiley Guide is an essential resource for safety, health, and industrial hygiene practitioners in industry, public services, government, insurance, and consulting, as well as others with safety and health responsibilities such as occupational medicine professionals.
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Table of Contents
Cover
Table of Contents
Title Page
Copyright
Preface
Reference
Author Biographies
1
Total Worker Health
®
: Introduction and Overview
1.1 Introduction and Definitions
1.2 Five Elements of TWH
1.3 Hierarchy of Controls
1.4 Getting Started
1.5 Organizational Core Values
1.6 Identification of Metrics
1.7 Strategy
1.8 Tools for a Comprehensive Approach
1.9 Why Use the TWH Approach
1.10 Expanding OSH Practice
References
2 Risk Assessment for
Total Worker Health
®
2.1 Introduction
2.2 Fundamentals of Risk Assessment
2.3 General Risk Assessment Tools
2.4 Tools Specific to TWH
2.5 Identifying the Top Risks to Worker Well-being in an Organization
2.6 Essential Elements of Applying TWH
2.7 Managing TWH Risk Through Hierarchy of Risk Treatment
2.8 TWH in Practice Focusing on Risk Management
2.9 Conclusion
References
3 Connecting the Dots: ESG/Sustainability, Human Capital, and
Total Worker Health
®
3.1 Introduction
3.2 The Case for People, Human Capital, and
Total Worker Health
®
3.3 The Purpose of People
3.4 What is ESG and Sustainability-Related Risk?
3.5 The People, Employees, Workers, and Human Capital Connection
3.6 Integrating into the Business
3.7 More about the #TrueNorthTest
3.8 People and TWH Value Creation
3.9 Jacobs: One Million Lives
3.10 Where to Start the ESG, Sustainability, Human Capital, and TWH Journey?
3.11 Keys to Success: Integrating TWH, HC, ESG, and Sustainability
3.12 Mapping It Out
3.13 Risk Management and Covering Your Bases
3.14 Integrated Risk Management
3.15 Integrated Reporting, Materiality Assessment, and Decision-Making
3.16 Summary and Conclusion
References
4 Bringing
Total Worker Health
®
into the Boardroom
4.1 Introduction
4.2 Human Capital Management
4.3 Board Structure and TWH
4.4 VUCA
4.5 Five Business Risks and TWH
4.6 The Business and Regulatory Environment Applied to TWH
4.7 What Safety and Health Professionals Need to Know About Corporate Governance
4.8 Advocating for TWH by Engaging the C-Suite
4.9 Understanding What Business Leaders Care About
4.10 Becoming an Indispensable Partner Across the Organization
4.11 Advancing TWH with CEOs and Boards of Directors
4.12 TWH and the Future
4.13 Bringing TWH into the Boardroom
References
5
Total Worker Health
®
and Insurance
5.1 Introduction
5.2 Types of Insurance
5.3 Health Insurance
5.4 Evaluating Your Insurance Program
References
6 TWH in Safety and Human Factors Accident Investigations and Development of Safety Interventions and Strategies
6.1 Introduction to
Total Worker Health
®, Safety, and Human Factors/Ergonomics
6.2 Sample Domains Within HF/E:
6.3 TWH Applied to Accident/Incident Investigations
6.4 Life Cycle of an Accident Investigation – Outside of Litigation
References
7 Technology Interventions and Support for
Total Worker Health
®
7.1 Introduction
7.2 Technology as Part of a TWH Program
7.3 Health and Safety Applications (Apps) to Support TWH
7.4 Wearable Technology for TWH
7.5 The Role of Gamification
7.6 Conclusion
References
Endnote
8 Ergonomics, the Aging Workforce, and
Total Worker Health
®
8.1 Introduction to an Aging Population
8.2 Introduction to Workplace Ergonomics
8.3 Ergonomics Programs
8.4 Ergonomics as a Leading Indicator for TWH
8.5 Ergonomics, Aging, TWH, and Business Metric Alignment
8.6 Ergonomic Design for an Aging Workforce
8.7 TWH Implementation Guideline as a Framework for Improved Ergonomics
8.8 Designing for the Future
References
9 Mental Health and
Total Worker Health
®
9.1 Introduction
9.2 Understanding Mental Health
9.3 Reasons for Mental Health Conditions
9.4 The Advantages of Addressing Mental Health in the Workplace
9.5 Mental Health and Safety in the Workplace
9.6 Burnout and the Toll of Toxic Workplaces
9.7 Rest
9.8 Approaches to Promote Mental Well-being in the Workplace
9.9 Cultivating Mental Health in the Workplace
9.10 Future Directions in Mental Health and Total Worker Health
9.11 Assessing Mental Health Programs
9.12 Conclusion: The Significance of Addressing Mental Health in the Workplace
References
10
Total Worker Health
®
for a Remote Workforce
10.1 Introduction
10.2 What Is Remote Working and Who Is a Remote Worker?
10.3 Balancing the Equation
10.4 The Impact of Physical Isolation on the Remote Workforce
10.5 Impact on Workforce Performance and TWH
10.6 The Dual Edges of Remote Work
10.7 Alternatives to in-Person Conversations and Their Impact on Remote Workers
10.8 Other Considerations
10.9 Personal Adjustment to the “Remote Work” Style
10.10 Solutions
10.11 Conclusion
References
11 Safety Committee Involvement in
Total Worker Health
®
(TWH)
11.1 Introduction
11.2 What Does a Dynamic Safety Committee Look Like?
11.3 Types and Structure
11.4 Participation
11.5 Practical Tips within the TWH Framework
11.6 Stretch and Flex Program Makeover … Mobility Program
11.7 Challenge Workplace Norms
11.8 Conclusion
References
12 Behavior Change Strategies and Tactics in
Total Worker Health
®
Programs
12.1 Introduction
12.2 Introduction to Behavior Change Strategies
12.3 Assumptions of Behavior Change
12.4 Paths of Behavior Change: Motivational Interviewing
12.5 Motivational Interviewing Components
12.6 The Process of Motivational Interviewing
12.7 Putting It All Together: A Motivational Interviewing Case Study
12.8 Learning from Related Fields
12.9 Summary
References
13
Total Worker Health
®
and Construction
13.1 Introduction
13.2 The Various Construction Risks That TWH Could Solve
13.3 Conclusion and Best Practices
13.4 The Future of Construction Depends on TWH
References
14
Total Worker Health
®
in the Transportation Industry
14.1 Industry Overview and Impact
14.2 Jobs and Risks
14.3 Supporting Worker Safety, Health, and Well-Being in Transportation
14.4 Case Studies
14.5 Driving Occupations
14.6 The Path Forward – Considerations for Transportation Worker Health and Well-Being
References
15
Total Worker Health
®
and Manufacturing
15.1 Introduction
15.2 Impacts of Manufacturing
15.3 Environmental Factors
15.4 Interventions
15.5 Worker Benefits
15.6 Challenges
15.7 Strategies
15.8 Summary
References
16 Case Studies Related to
Total Worker Health
®
16.1 Introduction
16.2 Case Studies and Management Support
16.3 Lessons Learned
16.4 Case Studies and Lessons Learned in Learning and Development
16.5 Total Worker Health® Case Studies in This Book
16.6 Additional Case Study Summaries Related to Total Worker Health®
16.7 Additional Case Studies
References
17 Resources
17.1 Websites
17.2 NIOSH Worker Wellbeing Questionnaire (NIOSH WellBQ) https://www.cdc.gov/niosh/twh/php/wellbq
17.3 Centers of Excellence for Total Worker Health®
17.4 Resources from Membership Organizations
17.5 Calculators
17.6 Recommended Books
Index
End User License Agreement
List of Tables
Chapter 2
Table 2.1 Comparison of hazards and resources for occupational safety and wo...
Table 2.2 Risk acceptance criteria table.
Table 2.3 Qualitative two-by-two matrix.
Chapter 3
Table 3.1 Definition of
Total Worker Health
®.
Table 3.2 Sustainability-related employee, worker, own workforce, value chai...
Table 3.3 Value creation: good ESG/sustainability-related risk (OHS) managem...
Chapter 8
Table 8.1 Civilian labor force by age, sex, race, ethnicity, 2002, 2012, 202...
Table 8.2 Overview of hypotheses and results.
Table 8.3 Task Design Example 1.0.
Table 8.4 Task Design Example 2.0.
Table 8.5 Task Design Example 3.0.
Table 8.6 Task Design Example 4.0.
Table 8.7 Task Design Example 5.0.
Chapter 10
Table 10.1 Characteristics of remote work types/options.
Table 10.2 Positive and negative considerations of remote working.
Chapter 13
Table 13.1 2021’s most common construction fatal events or exposures.
Chapter 14
Table 14.1 Data extracted from the May 2022 National Industry-specific and b...
List of Illustrations
Chapter 1
Figure 1.1 Adapted from BLS 2022 fatality data (2023).
Figure 1.2 Issues relevant to advancing worker well-being using
Total Worker
...
Figure 1.3 Proposed worker well-being framework.
Figure 1.4 Traditional hierarchy of controls.
Figure 1.5 Hierarchy of controls applied to
Total Worker Health
®.
Figure 1.6 Possible measurements of TWH success.
Figure 1.7 Intervention Design and Analysis Scorecard (IDEAS) tool.
Chapter 2
Figure 2.1 Framework for risk management.
Figure 2.2 Fishbone diagram (ASSP 2020, p. 99).
Figure 2.3 Semi-quantitative five-by-four matrix Lyon, Popov (2021) / with p...
Figure 2.4 Results of Health Risk Calculator (Colorado School of Public Heal...
Figure 2.5 Traditional hierarchy of controls.
Figure 2.6 Hierarchy of controls applied to
Total Worker Health
®.
Figure 2.7 HoRT Model (Lyon et al. 2019; ASSP 2021).
Figure 2.8 NIOSH framework for opioids use in the workplace (Research on Opi...
Chapter 3
Figure 3.1 #TrueNorthTest defined.
Figure 3.2 Operationalizing: an ESG/sustainability/HC/EHS framework (Seabroo...
Figure 3.3 Integrated risk management tool (Seabrook 2023b).
Chapter 4
Figure 4.1 All contribute to people’s right to a safe and healthy workplace....
Figure 4.2 Traditional hierarchy of controls.
Figure 4.3 Hierarchy of controls applied to
Total Worker Health
®.
Figure 4.4 Framework of environment, health, and safety themes, “The New Val...
Figure 4.5 Hierarchy of environment, health and safety value.
Figure 4.6 Board oversight of human capital (Feeney 2021).
Figure 4.7 Sustainable development goals (United Nations 2015).The conte...
Chapter 5
Figure 5.1 Issues relevant to advancing worker well-being using
Total Worker
...
Figure 5.2 Questions to consider when determining if your insurance programs...
Chapter 8
Figure 8.1 Population and labor force participation rate, by select age grou...
Chapter 11
Figure 11.1 Safety culture model.
Figure 11.2 Five Why’s analysis.
Figure 11.3 Sample safety suggestion box messages.
Figure 11.4 Neighborhood seating.
Chapter 12
Figure 12.1 The Readiness Ruler.
Figure 12.2 Overlap of Integrative health coaching and Motivational Intervie...
Chapter 13
Figure 13.1 The construction industry’s fatal four 2011–2020.
Figure 13.2 Average construction deaths by suicide vs. injury.
Figure 13.3 Worker and enterprise outcomes.
Figure 13.4 Nabholz construction LTIR.
Chapter 14
Figure 14.1 Fitness on the road illustrations.
Figure 14.2 Fitness on the road tools.
Figure 14.3 Recommended seat and headrest adjustments for best posture.
Chapter 15
Figure 15.1 Traditional hierarchy of controls.
Chapter 16
Figure 16.1 Creating lessons learned.
Chapter 17
Figure 17.1 Worksheet 1: Self-Assessment of Defining Elements of Total Worke...
Figure 17.2 Action plan.
Figure 17.3 Screenshot of the Wellable ROI calculator.
Guide
Cover
Table of Contents
Title Page
Copyright
Preface
Author Biographies
Begin Reading
Index
End User License Agreement
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“Total Worker Health” and “TWH” are trademarks of the U.S. Department of Health and Human Services (HHS). There is no express or implied endorsement of this book by HHS or its component agencies, the Centers for Disease Control and Prevention (CDC) and the National Institute for Occupational Safety and Health (NIOSH). For information on the Total Worker Health approach, visit https://www.cdc.gov/niosh/twh/about/index.html.
The Wiley Guide to Strategies, Ideas, and Applications for Implementing a Total Worker Health® Program
Edited by Linda Tapp
Copyright © 2025 by John Wiley & Sons, Inc.
All rights reserved, including rights for text and data mining and training of artificial intelligence technologies or similar technologies.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.
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Preface
As the field of safety and health evolves, so do the responsibilities of those working within it. Traditional ways of thinking about safety have focused on the worker while they were performing their work responsibilities and while in the workplace. A relatively new approach is to consider how those conditions and activities at work affect individuals after they leave the workplace. On the flip side, an individual’s activities and lifestyle at home can directly affect their health and safety at work. Sometimes, these “outside of work activities” include other jobs and often include unpaid work in the form of household responsibilities and caregiving, and therefore, more work.
Total Worker Health® grew out of NIOSH’s 2005 WorkLife Initiative, which in turn originated with NIOSH’s 2003 Steps to a Healthier Workforce program and was, and still is, about developing knowledge focused on the integration of occupational safety and health protection and health promotion.
Each of the chapters in this book, penned by experts in their respective fields, addresses a unique dimension of Total Worker Health® (TWH). From psychological well-being to ergonomic practices, from leadership engagement to legal considerations, the chapters collectively provide a wealth of information related to the implementation and management of TWH programs. The topics covered in several of these chapters introduce ideas and strategies from other fields and present ways they can benefit TWH programs. In NIOSH’s own words, “The comprehensive nature of Total Worker Health approaches requires innovative thinking to design programs and practices that advance worker well-being” (NIOSH 2024). I hope the reader approaches these new ideas with an open mind, as well as a willingness to learn and appreciate what can be learned from other disciplines.
This is not an academic-style book filled with research, though studies are referenced where appropriate. These are strategies, experiences, resources, and observations from professionals working in the field. These are ideas to be considered when creating and expanding TWH programs. Though these chapters touch on many different topics, they are all interconnected and support each other and TWH.
The principles of TWH are applicable across all industries, from construction to office work. There are similarities as well as differences that should be considered. In this book, experts from three specific industries, in particular construction, transportation, and manufacturing, have contributed chapters that share considerations unique to those industries.
TWH programs are not intended to stand alone from other safety and health programs. In fact, many existing safety and health programs directly support a TWH approach. Chapters on Risk Assessment, Behavior Change Strategies, Human Capital and ESG, Board Involvement, Insurance, Mental Health, Ergonomics and the Aging Workforce, Remote Work, and Safety Committees are included and provide ideas and examples of how TWH can be supported by, and in turn support, these topics that are often already part of successful safety and health programs.
Finally, chapters that touch on topics unlikely addressed elsewhere with respect to TWH are included, such as Technology and TWH and Accident Investigations through a TWH lens, with the hope of encouraging thinking around TWH and the way it can be supported.
The chapters in the book can be read in any order, but it is recommended that Chapter 1, Total Worker Health®: Introduction and Overview, be a starting point as it provides an excellent overview as well as a roadmap for any TWH program. The end of the book offers a chapter containing case studies that show TWH in action. These case studies can not only provide ideas for implementation and program design but also serve as success stories to share with company management when seeking support. An important step in gaining support is often tied to the ability to demonstrate a return-on-investment (ROI). With this understanding, an ROI calculator is provided in the Resources section. Chapter 17 includes a list of resources, some of which may seem unusual to be found in a book on TWH. The hope is that by including resources not normally associated with TWH, practitioners of TWH will find new ideas and possibly new approaches to consider.
This book is crafted for a diverse audience, including those with many years of experience in TWH and those just getting started. In addition to safety and health professionals, human resource professionals, organizational leaders, medical personnel, wellness professionals, and anyone else working to increase the safety, health, and well-being of the workforce can benefit from the information contained in these chapters.
I am incredibly grateful to the 15 authors who have lent their expertise to this book. Writing is never an easy undertaking, especially while working full time in occupational safety, health, and wellness. I hope that individual authors are as proud as I am of the work they have produced, both individually and collectively. Even if only one idea is adopted by one company or one organization decides to integrate TWH principles after reading this book, the many months of work that have gone into preparing it will have been worth it. A heartfelt thank you to all the chapter authors for unselfishly sharing their knowledge and expertise.
Special thanks are also given to reviewers and organizations that graciously granted permission for the use of select illustrations and diagrams. A note of appreciation is also needed for the organizations that have successfully implemented TWH programs, providing the chapter authors with case studies that offer lessons learned and real-world insights.
On a personal note, the journey of editing this book has been a tremendous experience – from crafting the first proposal based on an idea for a TWH book that was written by various women with very different backgrounds and areas of expertise, to the “hand-holding” of those with less writing experience, to the indexing of the final manuscript. It was and is my goal for this book to offer something new – new ways of thinking and new ideas related to TWH program design and implementation. Not all ideas will be a fit for every organization, but it is my hope that every reader will find “nuggets” that will have a significant impact on their TWH efforts. I encourage readers to approach these chapters with an open and curious mind. Grab a pencil, take notes, and dive right in.
For organizations that may still be considering the extent to which they will implement and support TWH principles, I encourage them to recognize the substantial ancillary benefits that a TWH approach can offer. Implementing related programs not only enhances overall employee well-being but also significantly contributes to improved job proficiency. This, in turn, leads to heightened engagement and elevated performance levels within the workforce. It is essential to acknowledge that helping those in the workforce stay safe and become healthier is not only a strategic business advantage but also a commendable pursuit in its own right. It’s simply the right thing to do.
July 2024
Linda TappMadisonNJ, USA
Reference
NIOSH (2024). Partnerships. [online] Total Worker Health.
https://www.cdc.gov/niosh/twh/partner/index.html
(accessed 2 October 2024).
Author Biographies
Deborah R. Roy, MPH, CSP, FAAOHN, FASSP is an Occupational Safety and Health keynote speaker and principal of SafetySpeaks with extensive experience in global safety management, Total Worker Health®, and risk assessment. She was the executive leader of Health, Safety and Wellness at L.L.Bean, where she led a staff and programs that impacted 10,000 employees globally for 12 years. A fellow of both the American Association of Occupational Health Nurses and the American Society of Safety Professionals (ASSP) and a former ASSP president, she brings strong leadership credentials and has over 30 years of experience in occupational safety and health.
Pam Walaski, CSP, FASSP is the owner of RiverLure OSH Services and an adjunct faculty member at multiple universities. With 30 years of experience in OSH, she has extensive experience working with organizations to develop and implement risk management, including the application of TWH principles. Pam contributes extensively to ASSP publications and committees, including serving as a member of the ANSI/ASSP Z16 committee as well as management systems committees – ISO TC 283 (ISO 45001) and ANSI/ASSP Z10. 78. She was awarded the honor of ASSP Fellow in 2022.
Kathy Seabrook, CSP, CFIOSH (UK), EurOSHM, FASSP is the CEO of Global Solutions, Inc. and a trusted advisor to corporations, governments, and NGOs worldwide. She is a recognized expert in ESG, human capital, and TWH. She currently co-chairs the Capitals Coalition Global Valuing Human Capital in OHS project group, contributes to the NSC New Value of Safety and Health project and serves on several ISO taskforces and working groups. She holds fellowships with ASSP and IOSH and frequently contributes to publications and standards within the field.
Fay Feeney, CSP, ARM, FASSP is the CEO of Risk for Good, providing strategic counsel on anticipating and approaching emerging risks and human capital opportunities. A safety veteran with over 40 years in the profession, Fay has spent the last 14 years bringing safety, health, and well-being thinking to corporate boardrooms. A National Association of Corporate Directors (NACD) Board Leadership Fellow, and Fellow of ASSP, she holds advisory roles on multiple boards within various industries.
Christine Sullivan, ARM, CSP is an insurance industry expert and is currently the Executive Vice President, head of Risk Control, North America at Sompo. She stresses risk management over compliance and encourages businesses to manage total risk so they can reduce incidents, better protect workers, and maximize financial performance. She has served in leadership roles within the American Society of Safety Professionals, including as Society President from June 2022 to 2023.
Dr. Rosemarie Figueroa-Jacinto, PhD, CHFP is a Principal Consultant at Rimkus, a board-certified Human Factors/Ergonomics professional, a director for the Board of Professional Ergonomists (BCPE), Secretary-Treasurer Elect for the Human Factors and Ergonomics Society (HFES), and CEO at belongIN. She has expertise in cognitive, perceptual, physical human factors, and occupational safety relating to accidents, injuries, and usability. She holds a PhD in industrial and operations engineering from the University of Michigan. Dr. Figueroa is also a National Occupational Safety and Health (NIOSH) Trainee.
Linda Tapp, ALCM, CSP, CPTD is the President of SafetyFUNdamentals, an occupational safety training consulting firm. With over 35 years of cross-industry experience, she often writes and presents on learning science in safety training, program development, and gamification for enhanced learning outcomes. Linda holds professional designations and certifications in insurance, safety, and talent development. As a result of her vast board service with BCSP, ASSP, and BCPE, she has received multiple awards for her work in safety and health, including the Board of Certified Safety Professional’s Lifetime Achievement Award.
Rachel Michael, CPE, CHSP is the Director of Consulting Services at Exponent EHF. She is President Emeritus of the Board of Directors for the Board of Certification in Professional Ergonomics (BCPE) and is a past Administrator of the Ergonomics Practice Specialty under the American Society of Safety Professionals (ASSP). With over 20 years of experience, she has implemented ergonomics controls across diverse industries. Rachel is a recognized speaker and currently co-chairs the National Ergonomics Conference. She holds a Master of Science in Ergonomics and has received multiple accolades for her contributions to safety and ergonomics.
Tanya Conole, COHSProf is an experienced safety professional with a diverse background in consulting, construction, manufacturing, and energy. She holds a postgraduate diploma in Occupational Hazard Management, is a Certified Generalist OHS professional with the Australian Institute of Health and Safety and is a former winner of the Australian National Safety Council of Australia Perpetual Trophy. Tanya is an active volunteer with the American Society of Safety Professionals, including participation on the ASSP/ANSI Z10 (OSH Management) Standard Review Committee.
Subena Colligan, CIH, CSP is CEO of EHS Transformation Consultants. She is an Air Force Veteran and Chair of the Board for Global EHS Credentialing. She has funneled her passion for the profession through leadership and community outreach, well-being, and equity related to occupational health and safety. She is a frequent presenter at conferences and is currently the blogger on Mindful Strategy for the OEHS profession, where she publishes articles monthly challenging the norms of health and safety leadership for a more influential profession.
Angela C. Ray, MBA, CSP, SMS is an Environmental, Health, and Safety Manager at Lyft and a seasoned safety professional with over 26 years of experience building OSH programs and mentoring safety committees, specializing in creating compliant programs that cater to the needs of workers. Her experience includes leveraging current technology to make these programs run efficiently. She holds CSP and SMS certifications, along with an MBA, demonstrating expertise in both safety and business management.
Devon Tapp, MS, CHES is the Director of Health Outreach, Promotion, Education, and Services at Stockton University and is responsible for leading health initiatives for a large student population. She was previously employed by the National Football League and NYU Langone Health. She holds a Master of Science in Health Promotion, is a Certified Health Education Specialist and is currently working toward a Doctorate of Health Science degree at Thomas Jefferson University (degree expected in 2025).
Tricia Kagerer, CPCU, CSP, ARM, CRIS has more than 20 years of experience and currently works as the Executive Vice President of Risk Management for Jordan Foster Construction, a large construction company performing civil, multifamily, and general contracting across Texas. Tricia leads the risk management, safety, and leadership teams. Tricia is a construction industry expert and speaker on various leadership, risk management, and safety topics, including crisis management, emergency response best practices, education across cultures, and servant leadership and diversity.
Alexi Carli, CSP is the President of Carli Consulting, LLC, specializing in OSH management systems, risk control, and leadership. Her 35+ years of experience include a leadership role at UPS, overseeing global safety and health. She holds an MS in Occupational Safety and Health and maintains her CSP certification. Alexi chairs the ANSI/ASSP Z16 Committee, focusing on safety and health performance metrics. Alexi holds degrees in business management and occupational safety and health.
Monique Parker, CSP, EIT is the CEO and Principal Consultant of SHE-MP, an occupational safety, health, and environmental consulting firm specializing in management systems, sustainability and ESG strategy development, and operational and compliance auditing. She has a rich background with 20 years of experience in various sectors such as textiles, food production, building materials, chemical manufacturing, and mining, with a significant focus on lithium mining and processing.
1Total Worker Health®: Introduction and Overview
Deborah R. Roy
SafetySpeaks, Falmouth, Maine, USA
1.1 Introduction and Definitions
Most Occupational Safety and Health (OSH) professionals are aware of the need to evolve strategies over time to continue to improve the safety and health of workers in the workplace. Although the traditional United States (US) approach was often compliance-based, and prescriptive, it became clear over time that compliance with regulations would not eliminate all work-related injuries and illnesses, or fatalities. In fact, even with 100% compliance by employers, more than 54% of workplace fatalities in 2022 would still likely have occurred because the exposure is not addressed by the current Occupational Safety and Health Administration (OSHA) regulations. Figure 1.1 shows fatalities by type. The transportation (38%) and violence (16%) occupational exposures are largely not addressed in the standards for all industries, yet those two categories of fatalities have persisted over 50% for multiple years.
More enlightened US employers and OSH professionals started moving away from a focus on compliance in the mid-1980s in this author’s experience. Often the strategy then was to embrace best practices from others in the same industry or other industries with similar hazards. Some focused on early safety and health management systems such as OSHA’s Voluntary Protection Program. Over the next 30 years or so, other management systems, such as the American National Standards Institute (ANSI)/American Society of Safety Professionals (ASSP) Z-10 OSH Management standard, became popular. Employers who fully implemented management systems approaches saw significant reductions in work-related injury and illness data. But zero worker illnesses and injuries, and even fatalities, remained an elusive goal.
Figure 1.1 Adapted from BLS 2022 fatality data (2023).
Source: Deborah R. Roy.
Clearly, the risk of injury, illness, and fatality still existed in the workplace. Some OSH professionals then began using strategies of risk assessment and later risk management based on the International Standards Organization (ISO) Risk Management family of standards beginning in 2009 and later updated in 2018. In 2020, ASSP also published a technical report – Risk Management – Techniques for Safety Practitioners (ASSP TR-31010-2020). This technical report provides guidance on the selection and application of techniques for assessing and managing risk within the risk management process. Again, considering the risks of the work and the workplace, and appropriately treating that risk, did often reduce injuries and illnesses. But sometimes high severity consequences still resulted from tasks that were low likelihood, and at times, employers did not see the value of spending capital dollars on risks that had not occurred at that company, in that plant, or on that job site. Sometimes it was too expensive to treat a risk after the fact. Preventing risk had long been espoused by the American Society of Safety Engineers (ASSE, now ASSP) and resulted in the standard, ANSI/ASSE Z590.3-2011, Prevention through Design: Guidelines for Addressing Occupational Hazards and Risks in the Design and Redesign Processes. Also, during this time, there became more awareness that the risks of Serious and Fatal Incidents (SIFs) had different causes than the usual high-frequency injuries and illnesses that were recorded by employers on the required OSHA 300 logs. All these approaches (if they were fully implemented) did reduce injuries and illnesses but not completely.
During the last 10-plus years, OSH professionals and some enlightened employers have realized the missing part of the equation. The goal has been to reduce the number of injuries, illnesses, and fatalities that already happened in the workplace. The focus has been on the data after the injury or illness has occurred. Beyond training workers, or providing standard operating procedures, most strategies did not consider the comprehensive view of the worker. Leaders and OSH professionals likely considered the traditional physical health of workers, specifically around ergonomics. Medium and larger employers may have had Employee Assistance Programs (EAPs) available to workers to address stress and mental health as well. But how workers perform work is also impacted by work organization, how safe the worker feels in the workplace, and whether they can be themselves and be authentic at work. Worker productivity is impacted by what happens outside the workplace as well, such as family dynamics or challenges, financial stress, substance abuse, and chronic health problems.
Emerging strategies now include Human and Organizational Performance. That is the understanding that humans may naturally make mistakes due to the systems around them and the fact that those systems are not error-tolerant. It is time to recognize that blaming the worker is not only ineffective, but that work designed with an understanding of the human condition can reduce or eliminate risks and, therefore, injuries, illnesses, and fatalities in those same workers. Leaders and OSH professionals have also begun to realize the toll of stress on workers. The COVID-19 pandemic has brought psychological health and well-being to the forefront of leaders’ attention in a way that has simply not happened before. To address these worker risks, the consensus standard ANSI/ASSP/ISO 45003-2021 Occupational Health and Safety Management – Psychological Health and Safety at Work – Guidelines for Managing Psychosocial Risks was published in 2021. It outlines examples of psychosocial hazards arising from work organization, social factors and work environment, equipment and hazardous tasks, and a range of control measures that can be used to eliminate hazards or minimize associated risks. But even with more enlightened workplaces, there remained opportunities to improve the overall well-being of workers.
“The Occupational Safety and Health Act of 1970 established the National Institute for Occupational Safety and Health (NIOSH) as a research agency focused on the study of worker safety and health, and empowering employers and workers to create safe and healthy workplaces” (NIOSH 2019, p. 1). During 2003, NIOSH began the NIOSH Steps to a Healthier US Workforce Initiative. (NIOSH 2022a). This initiative evolved over time to the Worklife Initiativein 2005, “which sought to improve overall worker health through better work-based programs, policies, practices, and benefits” and by 2011 it was renamed the Total Worker Health® Program, with a commitment “to developing knowledge focused on integration of occupational safety and health protection and health promotion” (NIOSH 2022a).
Total Worker Health® (TWH) as defined by NIOSH is “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” (NIOSH 2021b, p. 1). In practical terms, this approach prioritizes workplaces that are free of risks to workers and integrates all the resources and solutions, to not only keep workers safe but to improve their well-being over time because of their work. It means that employers can use a more comprehensive approach to addressing impacts on workers, as opposed to the typical siloed approach to safety vs. health vs. wellness that is common in traditional workplace settings. To illustrate the breadth of items that can be included in a TWH approach, NIOSH provides examples in Figure 1.2. These include emerging issues that may occur due to innovation or different forms of employment, and health situations that may not arise from work but may be impacted by work. OSH professionals should not be overwhelmed by this extensive list but use it to consider potential program gaps and future opportunities as their TWH strategy evolves over time.
To further focus efforts and resources, NIOSH has identified six priority areas that will advance worker well-being with the TWH approach, and they provide additional guidance for these. They are:
Opioid and Other Substance Use Disorders in the Workplace
TWH Outreach, Education, and Training
Measuring Worker Well-Being
Future of Work
Healthy Work Design and Well-Being
Mental Health in the Workplace
(NIOSH, 2023b, p. 1)
One of the terms that is used in the definition of TWH is worker well-being. In the article by Chari et al. (2018, p. 3), the authors describe worker well-being as:
“an integrative concept that characterizes quality of life with respect to an individual’s health and work-related environmental, organizational, and psychosocial factors. Well-being is the experience of positive perceptions and the presence of constructive conditions at work and beyond that enables workers to thrive and achieve their full potential.”
The idea is that worker well-being can’t just be evaluated by what occurs in the workplace. It must include the community setting and both worker perceptions and objective environmental conditions. This concept has sometimes been misconstrued by employers and organized labor organizations as focusing only on mandating individual behaviors and therefore outside of the purview of the employer, and that TWH will shift resources from occupational safety needs in a workplace. This was not the intention of this well-being definition or that of TWH programming. This worker well-being framework was intended to encompass the worker and their overall experience. It can also inform future development of measurement tools to be used in real-life workplace settings. The NIOSH Worker Well-Being Questionnaire (WellBQ) (NIOSH 2022b) is an example of how this framework can be used to see how employees are doing and to use the aggregate data to prioritize elements of the TWH strategy in an organization. Some of the data may apply directly to the organization, but other data may point to an opportunity to partner with a community organization where the employer doesn’t have control. For example, some employers have partnered with the community to make the town or city more walkable, or create social networks (Blue Zones 2022), or support events to improve substance use disorder treatment or mental health services, or host farmer’s markets or other healthy food options in areas that are food deserts.
Figure 1.2 Issues relevant to advancing worker well-being using Total Worker Health® approaches.
Source: National Institute for Occupational Safety and Health (NIOSH).
The WellBQ is based on the framework by Chari et al. (2018) and has five domains that constitute worker well-being. They are:
workplace physical environment and safety climate;
workplace policies and culture;
health status;
work evaluation and experience; and
home, community, and society.
This framework is intended to be comprehensive and can be visualized with the five domains in Figure 1.3. It helps to consider all the inputs that impact the worker and may help those new to the concept of well-being to see more opportunities to engage workers about their experiences, not just their day-to-day work tasks.
1.2 Five Elements of TWH
If an OSH professional or organization is looking for a simple way to get started with TWH, NIOSH (2016) has an online workbook called the Fundamentals of Total Worker Health® Approaches, which is a helpful place to begin. The workbook can be effective for small organizations, or medium to larger ones who want to try some early interventions to test the TWH concept. It outlines five elements of TWH and suggests that organizations determine where they are currently on the path to worker well-being, identify early steps to improve the safety, health, and well-being of the workforce, and finally evaluate progress toward improvement. Here are the five elements with some examples to illustrate each concept:
Demonstrate leadership commitment to worker safety and health at all levels of the organization.
This first element assesses leadership commitment. Organizations that have implemented a safety and health management system in the workplace should be familiar with this element. It is a critical component of developing any self-sustaining safety and health management system by creating a culture that values workers and their safety and well-being. One example would be to build safety and health into the organization’s mission and objectives so that all leaders are accountable for safety and health. Another would be that leaders support safety and health initiatives at all levels, and not only do they properly resource the initiatives, but they are visibly communicating the value of safety and health in the workplace. Bringing TWH into the Board room is discussed further in Chapter 4.
Figure 1.3 Proposed worker well-being framework.
Source: Chari et al. (2018)/U.S. Department of Health & Human Services/Public domain.
Design work to eliminate or reduce safety and health hazards and promote worker well-being.
This second element prioritizes a hazard-free work environment for all workers. This is where the traditional OSH protection principles, such as the Hierarchy of Controls (HoC), would be included. HoC will be addressed in detail later in this chapter.
After eliminating obvious conditions that contribute to injuries and illness in the workplace, an example of a further strategy to reduce safety and health hazards might be to redesign the work to minimize repetitive motion, excessive force, or awkward postures. Another would be to use Prevention through Design to eliminate the potential for hazards (or, more correctly, risks) and to design a building or process that avoids creating risks before it is constructed.
Promote and support worker engagement throughout program design and implementation.
Element three focuses on engagement. This ensures that workers and supervisory staff are engaged in identifying safety and health issues, contributing to design, and participating in program implementation and evaluation. An example would be to train front-line employees in risk assessment and have them prioritize the most important safety and health issues in a facility. Another would be to consider barriers to workers using the programs and procedures that are in place, such as unintended incentives to avoid using safety equipment or to skip breaks or take shortcuts.
Ensure confidentiality and privacy of workers.
Element four is to design and enforce appropriate privacy protections that go beyond ensuring that only authorized personnel have access to sensitive safety and health data.
An example here would be to structure health risk appraisals so that the data sources remain confidential. That might be done by using only aggregate data or using other identifiers instead of social security numbers for health records. Another would be to use aggregate data instead of individual data to inform the needs of future well-being programming.
Integrate relevant systems to advance worker well-being.
And lastly, element five takes a systems approach to policy, environmental, organizational, and social concerns. An example would be conducting an initial assessment of the organization’s existing workplace policies, programs, and practices. Often areas of concern may be out of the direct control of OSH professionals, such as the amount of paid sick leave. However, using a collaborative team to conduct the baseline assessment allows for more issues or gaps to be considered and prioritized. One situation where this became quite relevant was using contact tracing to identify workers who tested positive for COVID-19 during the pandemic beginning in 2020. Organizations that prioritized sending home and isolating sick employees and identifying and quarantining exposed employees were able to minimize the impact on the business and the remaining workers. Without the use of pandemic pay, most employees would not be able to afford to stay home and would have further spread this contagious virus to other employees and those who were at high risk, creating a lack of skilled workforce to perform the work.
1.3 Hierarchy of Controls
Traditionally, in OSH, the goal has been to control exposures to hazards in the workplace so that workers do not develop injuries or illnesses from working. A HoC (Figure 1.4) has been used to determine the best way to reduce or eliminate those hazards. The key is to focus efforts at the top of the inverse pyramid to be most effective. That means using Elimination or Substitution if possible, instead of administrative controls (such as policies, standard operating procedures, etc.) and personal protective equipment (PPE). For example, using robotics to routinely move objects instead of workers manually lifting would eliminate the ergonomic exposure to the workers. Or, substituting a less hazardous chemical in a process instead of a chemical that is highly toxic to humans. These approaches are also examples of Prevention through Design, where the risks are considered and designed out of the system. Although this may require investment upfront, in the long run, preventing exposure is often less expensive and protects more workers.
The TWH approach was intended by NIOSH to promote a hazard-free work environment for all workers. The HoC can be applied to TWH. It has a similar visual (see Figure 1.5) but is adapted to include the advancement of worker well-being. Like the traditional HoC, the top controls are prioritized and considered the most effective efforts to advance the safety, health, and well-being of all workers.
Figure 1.4 Traditional hierarchy of controls.
Source: NIOSH (2016)/U.S. Department of Health & Human Services/Public domain.
Figure 1.5 Hierarchy of controls applied to Total Worker Health®.
Source: NIOSH (2016)/U.S. Department of Health & Human Services/Public domain.
One of the keys to this TWH model is that it stresses the need for organizational-level interventions over those that expect the worker to have the sole responsibility for making behavioral changes. This is an important distinction, and organizations that embark on the TWH journey should understand this concept. Environmental changes are more effective and sustained than individual efforts. Both are needed, but the organization will need to focus on systems that change the environment, not just the behaviors of workers.
For example, if a job requires workers to pack products in boxes and causes awkward postures, high force, and repetition, based on the TWH HoC the following interventions could be used:
Automate the most repetitive and uniform packing tasks, with workers redeployed to other higher-level tasks.
Reorganize or redesign the packing tasks to avoid awkward postures, the amount of force, and/or the number of repetitions.
Engage workers to participate in design efforts.
Provide ergonomic evaluations of workers to improve the workstation layouts and job design.
Provide ergonomic training to workers and in-house design engineering teams.
Consider the age demographics and chronic health needs of the workforce. Provide voluntary conditioning programs or education on managing chronic conditions with stretching or other exercise (adapted from NIOSH, 2023a). Ergonomics, Aging Workforces, and TWH are further discussed in
Chapter 8
.
It is necessary to discuss hazards vs. risks. OSH practices have continued to evolve over time. Both OSHA and NIOSH have historically prioritized hazard-free workplaces. As noted in the introduction, risk is now a focus for many organizations. The difference is that although hazards may exist in a workplace, the priority for intervention should be based on whether workers are exposed to that hazard. So, the definition of risk is the likelihood of an occurrence and the severity of the consequence. The focus is on risk and the management of that risk. By prioritizing the workplace risks and then treating those risks with interventions to achieve an acceptable level, the overall risk in the workplace is reduced. This ultimately reduces injuries, illnesses, and fatalities – it just does so by focusing on the cause instead of the effect. More about this point of view can be found in Chapter 2 “Risk Assessment and TWH.”
1.4 Getting Started
Is the organization ready? Assessing readiness is one component to consider, as well as what programs related to safety, health, and well-being already exist. Since the accountable departments within an organization may be siloed, developing a team to assess readiness and determine the organization’s baseline will be critical. That team should represent all the areas of the organization that can address the elements to be assessed. It helps if the individual has knowledge of the current programs and potentially what is planned for the near future. The facilitator of the team may be chosen depending on interest, expertise in TWH, or the ability to lead a multidisciplinary team. This facilitator role is frequently held by an OSH professional. No matter what the team makeup is, everyone should be provided with an overview of TWH and grounding in the benefits to the organization. Safety committees and team involvement in TWH programs are discussed in Chapter 11.
There are a large variety of free tools available from CDC and NIOSH to plan, assess, or evaluate TWH in the workplace (NIOSH 2021a). Some examples follow. The first is intended as a short survey of employee perceptions in the workplace, and the second measures “worker” well-being from the “whole” employee perspective, not just “work-related” well-being. The third is a comprehensive tool to help employers determine if their programs are evidence-based health promotion interventions or strategies to improve the health and well-being of their employees. This tool is intended to be completed by OSH professionals and leaders, not employees as in the first two examples.
CDC National Healthy Worksite Program Health and Safety Climate Survey
https://www.cdc.gov/workplacehealthpromotion/tools-resources/pdfs/nhwp_inputs_survey.pdf
The NIOSH Worker Well-Being Questionnaire (WellBQ)
https://www.cdc.gov/niosh/twh/php/wellbq/?CDC_AAref_Val=https://www.cdc.gov/niosh/twh/wellbq/default.html
CDC Worksite Health Scorecard
https://www.cdc.gov/workplacehealthpromotion/initiatives/healthscorecard/index.html
One of the early tasks of the multidisciplinary team should be to review the many tools that are available to determine which elicits the baseline information desired and are the best fit for the organization. Keep in mind that the simple NIOSH Fundamentals of TWH approaches workbook mentioned earlier is still a good place to start for smaller companies or to test the concept. Other tools that are free from NIOSH have been developed, often by universities that are part of the 10 NIOSH Centers of Excellence for Total Worker Health® funded by NIOSH (NIOSH,2023b). One tool is from the Harvard T.H. Chan School of Public Health Center for Work, Health, and Well-being.
The Harvard T.H. Chan Workplace Integrated Safety and Health (WISH) Assessment (n.d.) is intended to be completed by OSH professionals at the middle management level who understand policies, practices, and programs currently implemented within the organization.
It considers leadership commitment; employee participation; policies, programs, and practices focused on positive working conditions; comprehensive and collaborative strategies; adherence to regulations and ethics; and health and safety data. The tool uses a Likert scale to determine the level of each item. Although organizations can use the tool as a baseline and then compare the responses in the future, it does not offer a way to total the score or have comparison ranges based on other companies.
The Center for the Promotion of Health in the New England Workplace (CPH-NEW) has another tool called The Healthy Workplace All Employee Survey (CPH-NEW 2019c, p. 1) that is designed to provide organizations with an overall assessment of employee attitudes related to health, safety, and wellness. CPH-NEW is a joint interdisciplinary initiative of UConn Health, the University of Connecticut Storrs, and the University of Massachusetts-Lowell. The survey asks employees about their “physical work environment as well as interpersonal and social interactions that support or detract from a healthy worksite culture. The survey also provides a general overview of employee perceptions on their health and health behaviors.”
For organizations whose culture is more competitive, the HERO Health and Well-being Best Practices Scorecard in Collaboration with Mercer© version 5 (HERO Scorecard 2021b) might be a good option. The Health Enhancement Research Organization (HERO) is a national think tank dedicated to advancing best practices in workplace health and well-being. This scorecard was developed “to help organizations learn about best practices for promoting workplace health and well-being, and to discover opportunities to improve and measure progress over time” (HERO 2021b, p.1). The tool is intended to be completed by a team of health and well-being stakeholders in the organization and will require some outcome data if available. Although this tool may still be valuable for organizations just beginning the well-being journey, it is focused on those who are already collecting data through health risk appraisal programs and already measure program performance. The scorecard collects demographic company data and then questions are organized into sections including strategic planning, organizational and cultural support, programs, program integration, participation strategies, and measurement and evaluation. HERO ([2021a]) reports the progress of companies who complete either the US-based or international scorecard by small, medium, and large size. It also identifies percent improvements for those who complete the scorecard over time and best practices that are more likely to produce a positive financial outcome.
1.5 Organizational Core Values
The core values and the culture of the organization make a difference when implementing any safety and health initiative. TWH is no different. That is why understanding those values and the culture is so critical. L.L.Bean, Inc. is a good example of a company with strong core values, one of the six is Safe and Healthy Living. That value states:
“We believe healthy people lead fuller, more productive lives. Our employees and other stakeholders should feel their association with L.L.Bean contributes to their health and well-being.”
Source: Deborah R. Roy
The core values of an organization not only impact the existing employees and other stakeholders but also impact the organization’s ability to hire new employees. And those values need to be supportive of employee well-being for TWH initiatives to be successful. That does not mean that a company with less focus on well-being can’t improve through TWH initiatives. But the process may take much more time unless the senior leadership has committed to enhance the vision and values, not just implement a program. So as interest develops in an organization to consider a systemic TWH approach, it is important to revisit the vision, mission, and/or values of the organization and consider whether they are aligned. Not all companies will have such a clear connection to health as the outdoor retailer L.L.Bean inviting customers and employees to benefit from being active outside. But all organizations can revisit the vision and mission to determine how employees’ health, safety, and well-being are supported.
1.6 Identification of Metrics
As the TWH strategy is developed, thoughts of how success will be measured later need to be considered. That is because, to show the benefits of the intervention, baseline data will need to be accessed or collected before it starts. Some organizations will be willing to improve worker well-being and/or implement comprehensive TWH systems because it is the “right thing to do” or that “good health is good business.” The former president and CEO of L.L.Bean Leon Gorman once said, “A business is in a unique and responsible position to effectively enhance the well-being of its employees,” (Hudson et al. 2019, p. 285). Despite the resounding support from the company CEO, this author collected pre- and post-intervention and cost data to calculate Return on Investment (ROI) and Value of Investment (VOI
