Nurses and patient-care assistants in acute care settings hold as a central goal uninterrupted patient care. This exposes them to dynamic work environments that require reacting to unexpected situations quickly, performing tasks in short periods of time,¹ dealing frequently with emotional demands,² and providing around the clock care by working long shifts.³ These occupational challenges have an impact on the psychological health of the nursing population, whose prevalence of mental disorders has been found to be higher than that of the general population.⁴ Depression and anxiety are the most common mental health disorders in the general population and are often comorbid with other physical illness^5,6 and associated with unhealthy behaviors.^7,8 Anxiety and depression have been found to be comorbid with obesity,⁶ diabetes,^9,10 and multiple pain sites.^5,11 Depression is also related to behaviors that may diminish health such as smoking, physical inactivity,⁸ and poor adherence to treatment recommendations for other conditions.⁷ Identifying which work factors are tightly related to mental health in the nursing population may hold the potential to improve both the mental and the physical health of patient-care workers and in that sense preserve the health of the patients they care for. Working conditions of health care workers shape the safety of the patients they care for as evidenced in studies focusing on long working hours and patient outcomes^12,13. In the United States, sustaining the mental health of workers may also be beneficial to employer’s interests. In 2017, 56% of the US population was covered by employer-sponsored health programs.¹⁴

Given their proximity, the relationship between psychosocial working conditions and mental health has been widely investigated. The demand–control–support model from Karasek and Theorell’s^15,16 work has been used to study this relationship in and outside the nursing population. Evidence based on the model stipulates that a combination of high psychological demands and low job control (job strain) is detrimental to both physical and mental health, and this relationship is buffered by social support.¹⁵ Nevertheless, results are still conflicting. In European cohort studies with general population samples, a relationship between decision latitude^17–19 and mental health has not been established. In addition, studies focused on nurses were not able to establish the hypothesized mediating role of social support between job strain and mental health.^18,20,21

Fewer studies have focused on organizational working conditions and their relationship with psychological distress.^22,23 It is important to assess which other factors at work might influence mental health as health outcomes may be affected by multiple pathways.²⁴ Inadequate staffing,²¹ long hours of work,²⁵ and policies on flexible time²⁶ are organizational aspects of work potentially related to mental health. The culture of the workplace and how dedicated it is to provide social support through leadership training may also be influential on psychosocial outcomes such as emotional exhaustion.²⁷ Two systematic reviews focusing on interventions to improve and promote the mental health of primary care nurses found that most interventions (>50%) were focused on targeting the individual by promoting training in communication skills, techniques on relaxation and meditation, cognitive-behavioral therapy, and access to psychotherapy and counseling.^28,29 Both reviews found scarce evidence that worker-focused interventions decreased stress and/or burnout.^28,29 Individual-focused interventions may work in the short term, but may be difficult to sustain, whereas organizational interventions have the potential to integrate positive practices at a systems level and in that way influence trustful and cooperative relationships by providing a solid ground for positive interactions to occur.²⁴

The conceptual framework of the Harvard Center for Work, Health and Well-being is based on the evidence that multiple pathways impact workers’ health and well-being²⁴ and emphasizes the need for integrated approaches at a systems level when designing workplace interventions that aim to improve workers’ health and well-being. Most studies focusing on mental health outcomes study the relationship of individual working conditions with mental health, with a focus on psychosocial working conditions.^22,30 In addition, many workplace interventions aiming to reduce stress and improve mental health have used worker-centered interventions such as courses on mental health hygiene or leadership styles.^28,31 Few studies have expanded their research to take into account organizational factors and their relation to mental health, even though there is some evidence that changes at the organizational level may render better results than worker-centered interventions.^31,32 They may also be strongly related to mental health and other working conditions.³³ The aim of this study was to investigate the relationship between both psychosocial and organizational working conditions and both self-reported mental health and mental health expenditures. We hypothesized that organizational working conditions would influence mental health outcomes and reduce the strength of the relationship between psychosocial working conditions with mental health. This hypothesis is based on the premise that organizational culture trickles down to influence proximal working conditions, thereby affecting the mental health of workers.

Among the 1594 workers who completed at least 50% of the survey, 1462 (92%) were women, 1341 (84.1%) were white, and the mean age of respondents was 41.5 years (Table 1). For the subsample, distributions were similar: 841 workers (93.2%) were women and 757 (83.9%) were white. Mean scores of psychological distress were 2.56 (SD = 3.0) for the whole sample and 2.46 (SD = 2.9) for the subsample with health expenditure data. Mean scores are similar to scores in the general population (from 2.1 to 2.6).³⁸

This study aimed to assess the relationship of organizational and psychosocial work factors with perceived mental health and mental health expenditures. Bivariate analyses of work factors and perceived mental health showed expected results: lower scores in people-oriented culture, job flexibility, social support and decision latitude, and higher scores in job demands were associated with psychological distress. Analyses inclusive of all working conditions conducted in a forward stepwise approach, however, showed that people-oriented culture and coworker support were negatively associated with psychological distress, whereas job demands were positively associated. When looking at mental health expenditures, results reflected findings from the relationships of work factors and psychological distress: higher scores in people-oriented culture and coworker support were predictive of lower expenditures on mental health services during the year following survey completion. These results confirm our hypothesis that multiple pathways are related to mental health beyond the traditional perspective of psychosocial conditions of work and mental health.

The results of this study confirm previous associations found between organizational and psychosocial working conditions with psychological distress,^22,30,39 but it adds to the literature by studying the relationships of both of these groups of work factors in relation to perceived mental health and related mental health expenditures. Results showed that commonly studied pathways of work conditions and mental health, such as decision latitude and supervisor support, were not directly related to psychological distress when controlled for organizational culture. This finding may explain previous conflicting results of the demands–control–support model with mental health.^18,20,21,30 Findings from the present study suggest that organizational aspects of work may be upstream factors that trigger downstream work conditions that are often studied with respect to mental health. A people-oriented culture consists of a work environment supportive of cooperative relationships, open communication, and involvement of employees in decision-making which may set the stage for how work relations are carried out throughout the organization and in that sense have an impact on mental health. In line with our findings, previous evidence on organizational culture types and psychological distress showed that a group culture characterized by trust and cohesiveness was negatively associated with psychological distress, whereas a rational culture characterized by performance indicators, accountability, and competitiveness was positively associated with psychological distress.^33,39 Building this supportive work culture may rely as well on leadership support and commitment. Other studies have found that leadership training focused on interactional justice in the nursing population is related to attenuation of insomniac reactions due to changes in working conditions.⁴⁰

In this study, some results were unexpected, such as the strong relationship of coworker support, not supervisor support, on psychological distress regardless of organizational culture. Previous studies have established a relationship of both coworker and supervisor support with mental health⁴¹ with another longitudinal study, showing that conflict at work increased the likelihood of onset of psychological distress without observing any buffering effects from either supervisor or coworker support.¹⁹ A study with nursing staff found that only coworker support and not supervisor support was associated with emotional exhaustion.²¹ Coworker and supervisor support may differ in their relation to mental health given that coworkers are more proximal in everyday tasks than supervisors, and as a result may help in various fronts. Coworkers may collaborate more frequently in getting the work done than supervisors and may provide emotional relief on a more frequent basis in an occupation that requires emotional interactions with patients and family members.

Several issues need to be acknowledged with respect to this study. First, this is a cross-sectional study assessing working conditions and perceived mental health outcomes at the same point in time making it unfeasible to establish any causality. Nevertheless, findings of mental health expenditures within the year after survey completion parallel cross-sectional findings based on self-perceived mental health: higher scores in people-oriented culture and coworker support were associated with having either lower likelihood of a mental health visit or lower expenditures, and these two working conditions were also associated with higher self-perceived distress. One of the limitations to the longitudinal analysis of working conditions and mental health expenditures is that analyses were limited to a subsample of 902 workers who were enrolled in the employer-sponsored health plan. Within this subsample, survey data (K6 scores) were able to capture a higher prevalence of psychological distress than administrative medical claims. Nevertheless, we consider that mental health expenditures are a valuable source of information that reflects the financial burden for the workers and the organization, making promotion of mental health a valid case for the well-being of employers and employees alike. The generalizability of the study findings, especially with respect to mental health expenditures, may be limited as our study population consisted of patient-care workers, a population possibly open to the use of mental health services given the nature of their work in health care. Patient-care workers may have a higher health literacy rate and may also be more open to receiving mental health care. In addition, the population we studied is relatively homogeneous and has many structural advantages around access to mental health care; however, there is a possibility that physical medical claims may be related to mental health issues, but such information is not available in medical claims data.

The use of survey data and administrative data is a great strength in this study. Self-perceived mental health was correlated with having had a mental health visit during the 30 days before survey completion. This finding motivated us to assess mental health expenditures the year following measurement of self-perceived working conditions reducing any common method biases on self-reports of mental health and also on related expenditures. The observed lower relationship between working conditions and mental health claims and their cost, compared with self-reported psychological distress, is not surprising as there are many barriers to seeking mental health care such as stigma, time,⁴² and cost of care.⁴³ There is an increasing attention on improving work-related mental health problems through workplace interventions.⁴⁴ However, interventions at the workplace that target prevention and improvement of ill-mental health have been mostly focused on promoting activities and changes for the individual and not for the organization.^28,45 Such interventions include trainings and workshops on mindfulness, cognitive behavioral therapy, and leadership styles.^28,45 These approaches have been found to be effective with improving emotional exhaustion and coping strategies,^28,45 but they have not been effective on reducing rates of sick leave and consumption of antidepressants.⁴⁶ Furthermore, multidomain interventions that target also organizational aspects of work have been more effective than any one individual intervention.^28,45 The present study supports these findings in that organizational aspects of work are important in breeding a culture that prevents ill mental health, but also stresses the role of job demands and coworker support as key factors influencing mental health.

Findings from this study have implications for the design and implementation of workplace interventions that target mental health and for the economic costs that ill mental health represent to organizations. Interventions with a focus on the organization may render more sustainable in relation to prevention of ill mental health and may also provide groundwork for trustful and cooperative relationships, especially in an occupation where cooperativeness may make work more effective as it may also provide relief to workers when sharing more among themselves. Future studies may include what aspects of the organizational culture influence working conditions tightly related to mental health such as job demands.