Purpose This study describes the development of an evidence-based intervention to create a supportive work environment for employees with chronic conditions. Occupational physicians (OPs) play an important role in guiding organizations in this process of organizational change. Supportive work environments can aid in preventing work-related problems and facilitate sustainable employment. Current workplace interventions for employees with chronic conditions are mainly focused on return to work or a reduction in sick leave at the individual worker’s level. This study contributes to the literature an organizational- level intervention which utilizes a preventive approach. Methods Intervention mapping (IM) is a six-step, structured protocol that was used to develop this intervention. In step 1, a needs assessment was conducted to define the problem and explore the perspectives of all stakeholders involved. The program outcomes and the performance objectives of employees with chronic conditions and occupational physicians were specified in step 2. In step 3, appropriate methods and practical applications were chosen. Step 4 describes the actual development of the intervention, consisting of (1) a training for occupational physicians to teach them how to guide organizations in creating a supportive work environment; (2) a practical assignment; and (3) a follow-up meeting. The intervention will be implemented in a pilot study in which occupational physicians will put their acquired knowledge and skills into practice within one of their organizations, which is delineated in step 5. Conclusions IM proved to be a valuable and practical tool for the development of this intervention, aiming to facilitate sustainable employ- ment for employees with chronic conditions. Keywords Work · Chronic disease · Occupational health services · Organizations Abbreviations Electronic supplementary material The online version of this CO Change objective article (https ://doi.org/10.1007/s1092 6-020-09885 -z) contains IM Intervention mapping supplementary material, which is available to authorized users. OP Occupational physician PA Participatory approach * A. R. Bosma firstname.lastname@example.org C. R. L. Boot email@example.com Introduction F. G. Schaafsma firstname.lastname@example.org The number of people in the working population with one or more chronic conditions is increasing [1, 2]. Work participa- G. Kok email@example.com tion rates among those with a chronic condition are lower compared to participation rates of the general population. J. R. Anema firstname.lastname@example.org Working with a chronic condition can lead to certain physi- cal or psychological challenges, possibly resulting in sick Department of Public and Occupational Health, Amsterdam leave or job loss. Prevention of work-related problems, sick Public Health Research Institute, Amsterdam UMC, VU leave, and job loss among these employees is of great impor- University Amsterdam, Amsterdam, The Netherlands 2 tance since returning to work has proven to be difficult [2 , 3]. Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands Vol.:(0123456789) 1 3 Journal of Occupational Rehabilitation Much research has been conducted on factors associated small, however, and they mainly deal with employees with with sustainable work participation for employees with existing problems and cases of absenteeism [22, 23]. This chronic conditions, showing that personal, disease-related, is unfortunate given that OPs also have the desire to focus as well as work-related factors are of importance [4–6]. In more on prevention . Dutch occupational health and the last decade, a wide variety of interventions have been safety legislation stipulates that in case of work-related developed to support people with chronic conditions in their problems or sick leave, both the employer and employee work in order to prevent productivity loss, sick leave, or job must take responsibility for securing healthy and sustain- loss. However, these interventions, addressing factors such able employment [25, 26]. As a consequence of this shared as work accommodations, empowerment, and self-manage- responsibility, the distance of OPs to the organization is ment, have shown only limited effects [7 –10]. increasing, making them less visible as advisors to employ- In recent years, people with chronic conditions have been ers on health and the prevention of work-related problems encouraged by the Dutch government and society to take within organizations. control over their lives, including their work . Self-con- Based on the importance of the context in which self- trol is a concept that relates to controlling one’s responses control is exerted, it can be inferred that it is essential that an and behaviors with the purpose of reaching long-term goals intervention for employees with chronic conditions should [12, 13]. An interplay between impulse control, deliberate focus on changing the work environment. These interven- decision making, and the availability of certain cognitive tions aimed at organizational change can result in creating resources underlie the behavior that is carried out. One’s supportive environments, thereby providing employees with level of self-control can be seen as a benchmark for adapta- chronic conditions with the right conditions to exert self- tion [12, 14]. Although self-control is often described in control and leading to the prevention or early identification relation to health behaviors (e.g. healthy eating) , it may of work-related problems. By changing the OP’s role and also aid workers with adjusting to the new circumstances of making OPs an essential part of organizational-change inter- working with a chronic condition. Using Huber’s new defini- ventions, they are able to use their expertise on work and tion of health, “having the ability to adapt and self-manage” health to guide organizations in creating supportive work (p. 2) , having higher levels of self-control at work and environments for employees with chronic conditions. This the possibility of exerting self-control might improve well- role enables OPs to collaborate closely with organizations, being and health, thereby facilitating sustainable employ- reducing the distance between employer and OP and sup- ment for employees with chronic conditions. porting and guiding preventive measures within an organiza- Interventions aimed at increasing the exertion of self- tion. To the best of our knowledge, no intervention has been control can focus on an individual’s capacity to exert self- developed aimed at increasing the exertion of self-control control or on changing the context in which self-control is for employees with chronic conditions by changing the work exerted . Based on available literature, it is clear that context. The aim of this study is to develop an intervention a person’s level of self-control can be increased through for OPs with the purpose of creating supportive work envi- training and practice . However, a meta-analysis of the ronments for employees with chronic conditions by guiding ee ff ct of self-control training shows only a minor ee ff ct [ 18]. organizations in making these changes. For the develop- Changing the context in which self-control can be exerted ment process, we used intervention mapping (IM), which has been shown to be a more successful strategy in chang- “provides a framework for effective decision making during ing the desired behavior . This implies that employees planning of intervention programs, including the planning with chronic conditions are more likely to exert self-control of implementation and evaluation” . in a supportive work environment where they feel enabled to do so. Occupational health professionals could play a key role Intervention Mapping Process in increasing the exertion of self-control of employees with chronic conditions, both by supporting individual employ- IM is a stepwise protocol used for planning and develop- ees and by helping to create these supportive work environ- ing effective behavioral and environmental change inter- ments. In the Netherlands, occupational physicians (OPs) ventions, consisting of six steps (presented in Fig. 1). The have the task of supporting and advising employees and iterative nature of the IM protocol stimulates the use of organizations on issues related to work and health to facili- theory as well as existing and newly-acquired evidence tate sustainable employment . In recent years, the Dutch for the intervention development, with the flexibility to government has emphasised the role of OPs in the preven- go back and forth through the different steps. Involving tion of work-related problems, by obligating organizations stakeholders in the process enables the interventions to to ensure their employees access to preventive consultation be fit to the needs and wishes of all involved . The hours with OPs . The preventive role of OPs remains relevant stakeholders in this study are OPs, employees 1 3 Journal of Occupational Rehabilitation Fig. 1 The six-step interven- tion mapping protocol. Adapted from Ref.  with chronic conditions, and organizational representa- Employees with Chronic Conditions tives (e.g. supervisors/management, co-workers, and the human resources department within the organization). Self-control is defined as “the capacity for altering one’s The project team involved in the development of this own responses, especially to bring them into line with stand- intervention consisted of two health scientists and two ards such as ideals, values, morals, and social expectations, OPs. An IM expert advised the project team during the and to support the pursuit of long-term goals” (p. 351) . development process. In our study, sustainable employment is considered the long- term goal for employees with chronic conditions. Limited research has been conducted on self-control in the context Step 1: Logic Model of the Problem of work, focusing instead on organizational management [29, 30]. The literature available on self-control was not In the first step of the IM process, a logic model of the able to provide us with an understanding of which specific problem was created which helped in defining the prob- behaviors employees with chronic conditions should alter lem and depicting a representation of the causal relation- or express to help them reach the long-term goal of sustain- ship between the problem and its causes. As part of this able employment. Therefore, we explored available interna- step, a needs assessment was conducted with the aim of tional qualitative literature which examined factors enabling assessing the nature and extent of the problem (‘what is’) sustainable employment, specifying the desired self-control and the needs (‘what should be’) of all the stakeholders. behaviors important for preventing work-related problems The needs assessment consisted of a qualitative synthesis and the influence of the environment on the enactment of to gain insight into the concept of self-control and the these behaviors. Four self-control behaviors from the per- inf luence of the environment on the exertion of self-con- spective of employees with chronic conditions emerged from trol for employees with chronic conditions . In addi- this qualitative synthesis: (1) disclosure, (2) finding a healthy tion, the literature was reviewed and interviews were held balance, (3) requesting work accommodations and support, with all relevant stakeholders (employees with chronic and (4) management of symptoms and limitations in the conditions, OPs, as well as organizational representatives workplace. Disclosure of the condition at work can create including employers and human resource managers) to understanding and support among co-workers, supervisors, capture a complete overview of perspectives. and employers, and can facilitate both better management 1 3 Journal of Occupational Rehabilitation of the condition and the implementation of accommoda- communication and a supportive organizational culture on tions. Disclosure is influenced by the personal beliefs of the sustainable employment. In addition, OPs described their employee as to possible consequences of disclosure, disease- desire to have a more preventive role, instead of focusing related factors such as predictability and invisibility of the a large proportion of their time on return to work or sick disease, and workplace factors, including workplace cul- leave . ture and the employee’s relationship with their co-workers, supervisors, and employers. Finding a healthy balance is important for enabling employees with chronic conditions to Organizational Representatives continue working and relates to the decision-making process of an employee with a chronic condition. Employees make During the interviews, employers and human resource decisions in relation to strategies that make sustainable work managers highlighted the importance of collaborating participation possible, such as energy management or a job with OPs and employees and making sure that mutual change. Requesting accommodations and support is cru- expectations are clear. Currently, employers and human cial for fitting the job to the capacities of the employee and resource managers mainly focus on looking at an individ- adjusting to the chronic condition and limitations at work. ual employee’s work capacity and, in case of need, facili- An accepting and supportive work environment makes it tating work adjustments. Work adjustments can, however, easier to ask for support and accommodations. Management only be implemented to a certain extent. Adjustments such of symptoms and limitations in the workplace enables sus- as task redistribution or shifting work tasks to colleagues tainable work productivity. This requires an awareness of is not always possible. OPs and organizational representa- symptoms, an acceptance of the chronic condition and its tives pointed out the importance of having a clear organi- limitations, and for the employee to take responsibility for zational policy for working with a chronic condition and managing these symptoms and limitations. Based on this preventing work-related problems within an organization. synthesis, the work environment appears to have an impor- Literature on the needs and perspectives of organizational tant influence on employees expressing these self-control representatives has shown the important role of employers behaviors. An accepting workplace culture and an under- and human resource managers when it comes to support- standing and trusting relationship with co-workers, supervi- ing employees with chronic conditions [31, 32]. At the sors, and employers facilitates the exertion of self-control same time, the literature describes a lack of knowledge (e.g. by lowering the threshold to disclose the condition). and awareness among human resource managers and line- The main findings of the interviews with employees with managers of the impact of a chronic condition on work- chronic conditions underscored the same self-control behav- ing life [33, 34]. Having a clear company policy, provid- iors found in the qualitative synthesis and emphasized the ing early support and accommodations, facilitating good importance of a supportive work environment in enabling cooperation between managers and employees, and hav- the expression of these behaviors. In addition, employees ing employees take responsibility (e.g. communicating to spoke of a lack of knowledge, lack of organizational policies, managers and making decisions) are some of the factors and lack of compliance to organizational regulations, all of indicated by employers and human resource managers as which made disclosure and acquiring work accommodation facilitating sustainable employment [24, 35]. more difficult. The results of this first step provide clarity on the behaviors of an employee with a chronic condition, the Occupational Physicians influence of the environment (work environment and current support from OPs) and perspectives of OPs and During the interviews, OPs expressed the importance organizational representatives on sustainable employ- of early identification of work-related problems. Cur- ment. It is clear that preventing work-related problems rently, OPs do not have a clear overview of all employees and sustainable employment requires the commitment of with chronic conditions within the organization, as most all stakeholders involved. Employees exerting self-control employees with chronic conditions consult their OP only means executing the abovementioned desired behaviors. in cases of already existing work-related problems or sick However, employees must be enabled and supported by leave. Support from and collaboration with the work envi- the work environment to actually execute these behaviors. ronment were described by OPs as important prerequisites Organizational policies could thereby facilitate sustain- for sustainable employment for employees with chronic able employment for employees with chronic conditions. conditions. OPs also stated the importance of a positive OPs can fulfil their preventive tasks by offering advice on organizational attitude towards employees with chronic organizational policy development and guiding organiza- conditions and a supportive workplace culture. In a study tions towards more supportive work environments. by Abma et al., OPs also stated the importance of clear 1 3 Journal of Occupational Rehabilitation personal determinants on the behavioral and organizational Step 2: Program Outcomes and Objectives—Logic Model of Change levels that are associated with the performance objectives of employees with chronic conditions and the performance In this second step, a logic model of change was created (see objectives of OPs, respectively. Based on the determinants yielded from the needs assessment and the determinants online resource 1), visualizing the effects of the intervention on behavior and the environment. As a starting point, the described in behavior change theories (e.g. Reasoned Action Approach ), attitude, skills and self-efficacy, and per - behavioral outcome (the employee with a chronic condition will exert self-control) of the intervention to be developed ceived norms were selected. Subsequently, matrices of change objectives were constructed for the behavioral out- was identified, after which the performance objectives were specified. The performance objectives operationalize what come as well as for the environmental outcome by combin- ing performance objectives with determinants for employees needs to be done in the behavior of the employee with a chronic condition in order to accomplish the behavioral and OPs. Change objectives operationalize what employees with chronic conditions as well as OPs participating in the outcome. The performance objectives associated with the behavioral outcome of the employees with chronic condi- program need to learn or change to meet and/or maintain the performance objectives. Examples of matrices of change tions are listed in Table 1. These performance objectives are based on the four self-control behaviors described in the objectives for the behavioral outcome and environmental outcome are shown in online resource 2. needs assessment. Environmental outcomes can be categorized into different Step 3: Program Design levels, including interpersonal, organizational and commu- nity levels. In this organizational intervention, the focus was The intervention was conceptualised and designed in step on the environmental outcome at the organizational level (OPs collaborate with the work environment in supporting 3, based on the logic model of change created in step 2. In this step, an initial program plan was conceived with the employees with chronic conditions to exert self-control), which was considered the most relevant environmental program components, scope, and sequence. Additionally, theory- and evidence-based methods and practical applica- outcome level. Performance objectives were identified for the environmental outcome, with OPs being the environ- tions were chosen to influence the change objectives. The design of the intervention and selection of cho- mental agents of importance at the organizational level (see Table 2). These performance objectives show the direct sen methods and applications were extensively discussed within the project team to make sure that appropriate collaboration between OPs and an organization for creating an organizational policy and supportive work environment, methods were used to influence the relevant determi- nants. As the work environment is crucial for employees thereby indirectly supporting employees with chronic condi- tions to exert self-control. with chronic conditions to express the desired self-control behaviors in the workplace (e.g. disclosure and request- Determinants are factors underlying the performance of behavior. The needs assessment provided information on ing accommodations), the scope of the program was to Table 1 Performance objectives for an employee with a chronic condition 1. Decide in which cases disclosure of the chronic condition could be of help for sustainable employability and follow-up on these decisions (designating when to disclose, to whom and what information) 2. Ask for adjustments and support from employers, co-workers, the social environment, and health care providers 3. Make decisions with the aim of fitting the job to personal capacities and to maintain balance in life and follow-up on these decisions 4. Manage limitations and respond to symptoms at work Table 2 Performance objectives for OPs (environmental agents) 1. OP creates awareness within the organization of the need for an organizational policy to facilitate employees with chronic conditions staying at work 2. OP guides the employer in exploring organizational barriers which inhibit employees with chronic conditions from exerting self-control 3. OP guides the employer in exploring possible solutions for these organizational barriers which inhibit employees with chronic conditions from exerting self-control 4. OP helps to create an organizational policy and a supportive work environment to facilitate the ability of employees with chronic conditions to exert self-control and stay at work 1 3 Journal of Occupational Rehabilitation develop an organization-specific policy and to create a Step 4: Program Production supportive environment for these employees. By changing the role of OPs, they are able to focus more on prevention The methods and practical applications chosen in step 3 of work-related problems and support of organizational were operationalized into the final program in step 4. The preventive actions. OPs can fulfil their preventive tasks structure and organization of the program were explained in by guiding and advising organizations in the process of a protocol, program materials were developed, and existing organizational policy development and creating a support- materials were reviewed and adapted as needed to address ive work environment. Online resource 3 shows examples the change objectives. of the theoretical methods and practical applications cho- The program we developed consists of a training, a practi- sen for changing the attitudes, skills and self-efficacy, and cal assignment, and a follow-up meeting for OPs. It is suita- perceived norms among the OPs, enabling them to guide ble for all OPs, whether they are self-employed, working for organizations in developing an organizational policy and an occupational health services agency, or working within creating a supportive work environment. the occupational health services department of an organi- When developing an organizational policy and creating zation. The training provides the OPs with (a) theory and a supportive work environment, it is important to include evidence on the self-control behaviors of employees with all stakeholders within an organization in the process. chronic conditions and the importance of a supportive work The participatory approach (PA) is an effective evidence- environment in expressing these self-control behaviors, and based approach for addressing and tackling existing barri- (b) information on how to apply the PA and act as a process ers in an environment where different stakeholders could leader in an organization in order to help the organization have varying perspectives regarding these barriers. The create organizational policy and a supportive work environ- PA is a structured six-step process: (1) creating the right ment. During the training, theory on self-control behaviors conditions, (2) analysis of barriers, (3) analysis of solu- and the PA will be alternated with short exercises, giving tions, (4) plan of action, (5) implementation, and (6) the OPs the opportunity to practice certain steps of the PA. evaluation. It can be used at both the individual or the Additionally, these exercises offer ways to reflect on the level organizational level to facilitate sustainable employment of exertion of self-control behaviors in the organization the and the health of employees in an organization [37–39]. OP is working in. The training will be given by two mem- In this study, the PA will be used by OPs and applied at bers of the project team. At the start of the training, the the organizational level to develop an organizational pol- participating OPs will receive a training manual containing icy for employees with chronic conditions and to create (1) practical information, (2) the slides of the PowerPoint a supportive work environment. When applying the PA presentation to be used during the training, (3) information at the organizational level, OPs, employees with chronic on the practical assignment, and 4) background informa- conditions, and all other relevant organizational repre- tion. At the end of the training, the OPs will receive further sentatives (e.g. supervisors, human resource managers) instruction on the practical assignment. should be involved in the process. The likelihood of suc- In the practical assignment, the OPs will need to apply cessful organizational change is improved by the joint the six steps of the PA in one of the organizations they are effort of all relevant stakeholders within the organization. working for. OPs will start with creating the right conditions Having a process leader to guide all the stakeholders for applying the PA in the organization, one of which is through the different steps is essential when applying the creating a working group with employee and organizational PA. As OPs are considered suitable professionals to guide representatives. The OP will serve as a process leader to an organization into a supportive work environment for guide this working group during three meetings. During the employees with chronic conditions, the plan was to train first meeting, the workgroup members will analyze and iden- OPs in serving as a process leader when applying the PA tify existing barriers inhibiting the execution of self-control in an organization. In addition to the knowledge and skills behaviors within their organization. The second meeting will of the PA, it is also essential for the OPs to understand be used for brainstorming solutions for the identified bar - the concept of self-control and the associated self-control riers and a plan of action for the implementation of these behaviors. An understanding of the inf luence of the work solutions. OPs will thereafter monitor the implementation environment on the expression of self-control behaviors of these solutions within the organization. These solutions by employees with chronic conditions is also essential. provide input for organizational policy and contribute to the OPs can use this knowledge to create awareness within creation of a supportive work environment. During the third the organization and to provide organizational representa- meeting, the implemented solutions will be evaluated. Forms tives with information during the PA process. have been developed for guiding the PA process during the practical assignment. These forms are included in the man- ual (see online resource 4 for examples). Six months after 1 3 Journal of Occupational Rehabilitation the training, a follow-up meeting will be planned in which participate in the program. All OPs working for an organi- experiences with the practical assignment will be shared zation which they thought might be open to implementing between the OPs. the program were eligible for participation. Since OPs were targeted instead of organizations, it was unclear in advance Step 5: Implementation Plan what type of organizations would ultimately participate in the program. OPs working for a variety of organizations Considering program implementation began in step 1 and were willing to participate, including organizations in the extended to step 5. In step 5, a plan for the implementa- health care, financial, logistics, industrial and cultural sec- tion of the program was developed specifying the potential tors. Since the program developed for this pilot is a univer- implementers of the program. Program outcomes and perfor- sal intervention, it can be implemented in any organization mance objectives for adoption, implementation, and main- regardless of size, work sector, or the current number of tenance were written, after which matrices of change objec- employees with chronic conditions. Given the large portion tives for implementation were constructed. After selecting of the population living with one or more chronic conditions, the proper change methods and applications, a strategy for it was expected that the majority of organizations would adoption, implementation, and maintenance was designed. have at least some employees with chronic conditions. Prior Implementation of the program will occur in a pilot study to the training, participating OPs were sent preparatory ques- in which the practical assignment will be used to explore the tions, the answers of which could be used to further tailor usability, practicality, and effectiveness of the program. OPs the training to the needs of the participants. who participated in the training will put their knowledge and Given that each organization has a different structure, skills from the PA into practice in one of their organizations. relevant organizational representatives to involve in the Two important program outcomes were identified prior to program can differ. Identification of relevant stakeholders the start of the pilot study: (1) the organization is positive within the organization by OPs is therefore a first step in the about developing an organizational policy and creating a implementation phase. In order for employers to support the supportive work environment with use of the PA and (2) development of an organizational policy and organizational OPs are able to carry out the PA for the development of this change they need to be aware of the importance of such organizational policy. Since this program aims to include a policy and the influence that a supportive work environ- all relevant stakeholders in the process, OPs as well as the ment can have on employees with chronic conditions. At the organizations (including employees and relevant organiza- start of the implementation phase, OPs were advised that tional representatives) are important to the successful imple- members of the project team could assist in highlighting the mentation of the program. However, OPs and employers are urgency of an organizational policy and supportive work considered the most relevant implementers because of their environment and explaining the added value of the PA to the responsibility for initial implementation actions. Therefore, organization (performance objectives 2 and 3 for the OPs). performance objectives for both these environmental agents (OPs and employers) are specified (see Tables 3 and 4). Step 6 Evaluation Plan For this pilot study, OPs were targeted through the Neth- erlands Society of Occupational Medicine and a large Dutch In the final step of the IM protocol, a plan for evaluating the occupational health services agency, and were invited to effectiveness of the program on the change objectives and Table 3 Performance objectives for implementation by OPs (environmental agents) 1. OP identifies relevant stakeholders within the organization (e.g. employees with chronic conditions, supervisors, human resources managers) 2. OP makes the sense of urgency of implementing organizational policy clear to the relevant stakeholders 3. OP explains and convinces the employer of the added value of the PA for the development of organizational policy 4. OP initiates the start of the PA in the organization 5. OP guides the organization through the PA process Table 4 Performance objectives 1. The employer supports the development of an organizational policy for employees with chronic condi- for implementation by the tions employer (environmental 2. The employer approves the use of the PA for the development of an organizational policy agents) 3. The employer facilitates the PA by providing man hours and financial means 4. The employer actively participates in the PA for the development of an organizational policy 1 3 Journal of Occupational Rehabilitation the actual behavior was developed. Results of this evaluation offered, including the realization of work accommodations are expected in 2021. . A negative attitude towards employees with chronic conditions, not knowing how to support and accommodate these employees, and lack of organizational policy related Discussion to things like work accommodation can all contribute to this problem. In addition, a country’s occupational health This study describes the systematic development of a pro- and safety legislation influences the way employers respond gram for OPs using the IM protocol. The program consists to these employees [34, 54, 55]. This same legislation also of a training, a practical assignment, and a follow-up meet- delineates the roles and responsibilities of occupational ing for OPs. The program aim is to develop an organiza- health professionals and their subsequent tasks [56, 57]. tional policy and create a supportive work environment for Despite the renewed Dutch labor legislation and focal point employees with chronic conditions thereby enabling them of prevention in the mission statement of the Netherlands to exert self-control. Society of Occupational Medicine, prevention in occupa- Targeting the workplace has been a focus of many inter- tional health care remains difficult to enact . With their ventions aimed at maintaining health and employment pivotal role in occupational health care, OPs have the exper- among employees, either on the individual employee level tise and ability to encourage and support employers with or on the organisational level. Workplace interventions preventive actions and strategies for work-related problems have been developed focusing on issues such as improving that employees with chronic conditions may have. By posi- employees’ lifestyles (e.g. sitting time or nutrition) or pre- tioning OPs as process leaders during the PA in this inter- venting work-related stress and injuries [40–43]. In the last vention, they are in a better position to play a preventive role. decade, numerous workplace interventions have also been The use of OPs as process leaders in this intervention developed to prevent work disability for employees with also has limitations. Firstly, the intervention was tailored chronic conditions [44–47]. When taking a closer look at to the role of OPs in the Dutch context. In various other these workplace interventions, three things stand out. First, countries, the role of OPs differs from the role of Dutch the majority of these interventions have focused on employ- OPs [23, 59]. In these other countries, however, different ees on sick leave and strategies for reduction in the dura- occupational health professionals such as occupational tion of absences and for returning to work [45, 46, 48, 49]. health nurses, return to work coordinators, or organizational The number of interventions aimed at actually preventing psychologists could also fulfill the tasks of process leader work-related problems and promoting sustainable employ- [60, 61]. Secondly, occupational health care by OPs in the ment for employees with chronic conditions is lacking . Netherlands is not freely accessible to all types of workers Second, a large proportion of interventions are directed at . Self-employed workers, making up 12% of the Dutch employees with psychological or musculoskeletal disorders working population, are not able to use the services offered . Finally, prevention-focused interventions aimed at sus- by OPs , making the intervention not applicable to this tainable employment for employees with chronic conditions group of workers. On the other hand, since this intervention are almost always directed towards the individual employee is aimed at changes at the organizational level, all workers instead of the organization as a whole, including stakehold- within an organization are able to benefit from the changes. ers within the work environment [52, 53]. Different aspects This includes temporary agency workers within an organi- of an organization can be targeted in organizational-level zation, who, according to Dutch laws, otherwise would not interventions, such as job demands, work conditions, or have access to OPs. psychological or social factors (e.g. organizational support). Changing organizational culture and support is challeng- Methodological Considerations ing but interventions based at the organizational-level have been shown to provide a more sustained effect on employ - Workplace interventions are complex, with numerous ees’ health in comparison to individual-level interventions stakeholders involved. IM proved to be a valuable tool . The intervention described in this study adds to the for the systematic development of this intervention, with literature an innovative, organizational-level intervention several underlying reasons for the practicality of this with a preventive approach which is aimed at employees approach. IM provided us with a structure to start sort- with different types of chronic conditions. ing out the causal relationships of the problem and find- With the growing number of employees with chronic ing out the needs of all stakeholders involved. Based on conditions, a greater focus on prevention and sustainable the causal relations and stakeholders’ needs identified in employment within organizations is essential. Organiza- the IM steps, it was clear what changes were necessary. tions differ in their ways of dealing with employees with Evidence-based decisions could thereby be made to focus chronic conditions with regard to the level of support the intervention to match the context in which it must be 1 3 Journal of Occupational Rehabilitation implemented. Since the program was initiated to support Research Recommendations the development of knowledge and skills of OPs, our ini- tial thought was to develop an intervention focusing on It is to be expected that the effectiveness of the intervention the OP. However, the evidence gathered in the IM steps will vary for different work settings. Aspects such as the size shifted the focus of the intervention and its implementa- of the organization, the number of management layers and tion to the work environment in which OPs would need types of employees (e.g. white or blue collar) could influ- skills as process leaders. Additionally, IM also provided ence the effectiveness of the intervention. Further research an understanding of the complexity of the context, guid- should be conducted to investigate contextual factors and ance on deciding what methods to use, and subsequent the optimal conditions for implementing interventions in the practical applications. However, although IM was used workplace. The possibility of targeting organizations instead to optimize the development of the intervention, some of OPs could also be explored. drawbacks of this method could be identified. Following all the steps of the protocol is a time-consuming process. Authors’ Contributions AB, CB, FS and HA contributed to the devel- Furthermore, although IM aids in optimizing the effect opment of the intervention. GK had an advisory role during the inter- of the intervention, using IM is not a guarantee for suc- vention mapping process. AB was primarily responsible for the draft of cess, as pointed out by the review of Fassier et al. . In the manuscript. All authors contributed to the writing and revision of this study, the needs assessment (as a first step in the IM the manuscript. All authors read and approved of the final manuscript. protocol) showed the causal relations of the problem. In Funding This work was supported by Instituut Gak under Grant Num- addition to the employees and other actors within the work ber 2016-756 and is part of the larger research program ‘De werkende environment, the health care environment and the social centraal’. The funder had no role in the design of the study, the collec- environment both influenced the possibility of employees tion and interpretation of the data, or the writing of the manuscript. with chronic conditions exerting self-control. Because the work environment was of primary importance, the health Compliance with Ethical Standards care and social environments were not targeted in this intervention. Adding elements to the program aimed at Conflict of interest The authors declare that they have no conflict of interest. influencing the health care and social environments could further improve the effects of the program. IM contributed Ethics Approval The Medical Ethics Review Committee of the VU to the development of a clear implementation and evalu- University Medical Center confirmed that the Medical Research Involv - ation plan. ing Human Subjects Act (‘Wet Medisch-wetenschappelijk Onderzoek met mensen’) does not apply to this study and that an official approval is not required. Practical Implications Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- Changing employees’ behavior is difficult, especially when tion, distribution and reproduction in any medium or format, as long optimal conditions for carrying out certain behaviors are as you give appropriate credit to the original author(s) and the source, absent. The same applies for self-control of employees with provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are chronic conditions. Creating a supportive and understanding included in the article’s Creative Commons licence, unless indicated work environment provides these employees with the abil- otherwise in a credit line to the material. If material is not included in ity to exert self-control, while an organizational policy will the article’s Creative Commons licence and your intended use is not provide the organization with clear procedures for employ- permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a ers and employees on addressing the prevention of work- copy of this licence, visit http://creativ ecommons .or g/licenses/b y/4.0/. related problems. 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