Mapping health and work provision in healthcare and business degrees in England

Abstract Ill-health currently keeps a quarter of the UK’s working age population out of employment, at a significant social and economic cost to both those individuals and the country as a whole. It is, therefore, essential that healthcare and business professionals have sufficient skills to manage the physical and mental health of their teams and support individuals to re-enter employment. This study looked at the extent to which six core health and work topics were included in the curricula and assessment of healthcare and business degree courses. It included a quantitative review of 221 healthcare and business degree programmes in England. This was supplemented with secondary analysis of existing literature on health and work education and qualitative interviews with course leaders in 38 universities. The study found that across all healthcare and business courses, there was relatively little explicit coverage of health and work topics in course curricula or assessment. When health and work was covered, most courses only included one health and work topic, and in some cases only a small component of a topic (such as managing stress, within the broader topic of self-care and resilience). The main reported reasons for this were a lack of space within curricula, little perceived demand from students and a view that some skills are best acquired in the workplace. There is a compelling need to promote the importance of work and health learning to both course leaders and students. Engaging regulatory bodies, whose degree standards play a major role in shaping course content, would also encourage Higher Education Institutions to prioritise health and work topics. There is also a need to conduct research with students to understand in more depth the health and work skills they acquire from their courses.

Abstract: Ill-health currently keeps a quarter of the UK's working age population out of employment, at a significant social and economic cost to both those individuals and the country as a whole. It is, therefore, essential that healthcare and business professionals have sufficient skills to manage the physical and mental health of their teams and support individuals to re-enter employment. This study looked at the extent to which six core health and work topics were included in the curricula and assessment of healthcare and business degree courses. It included a quantitative review of 221 healthcare and business degree programmes in England. This was supplemented with secondary analysis of existing literature on health and work education and qualitative interviews with course leaders in 38 universities. The study found that across all healthcare and business courses, there was relatively little explicit coverage of health and work topics in course curricula or assessment. When health and work was covered, most courses only included one health and work topic, and in some cases only a small component of a topic (such as managing stress, within the broader topic of self-care and resilience). The main reported reasons for this were a lack of space within curricula, little perceived demand from students and a view that some skills are best acquired in the ABOUT THE AUTHORS Peter Farrar is a social researcher with 8 years' academic and professional experience undertaking qualitative and quantitative research in support of public policy development. He has conducted research studies financed by various Government departments and agencies, including Public Health England. He has specific research interests in return to work and employability skills programmes, and health and social care transformation. He holds a Master's degree in Public Policy from Peking and bachelor's degree in Sociology from the University of Bath.
Ali Zaid is a social researcher with 10 years experience in conducting policy analysis and research, particularly focusing on the supply and demand of labour market skills and the effectiveness of vocational qualifications. He has undertaken studies for a range of public sector organisations including the Department for Education, Ofqual, the UK Commission for Employment and Skills and the European Commission. He has a bachelor's degree from the University of Liverpool and a Masters degree from the University of Huddersfield.

PUBLIC INTEREST STATEMENT
Work is an important factor that influences the health of individuals' and their families. Research shows that unemployment has a negative impact on mortality rates and also makes individuals more likely to have heart and obesity issues, as well as affecting their mental health. A bad working environment, characterised by low levels of job control and organisational fairness, and a high effort-reward imbalance, has also been shown to contribute to poor health.
Healthcare practitioners and business managers, therefore, need to have a good understanding of the positive benefits of health and work. However, recent research suggests some knowledge gaps in this area. This research maps the provision of health and work topics in healthcare and business degree courses, to identify the extent to which the courses provide students with a good grounding in this subject. It draws on a review of courses and interviews with course leaders and was undertaken between February and April 2017.

Introduction
There is a compelling need to reduce rates of sickness absence and health-related worklessness in the UK. Last year, 2.3 million (25%) of the UK's working age population were economically inactive due to ill-health (Office for National Statistics, 2017), while sickness absence and worklessness together are estimated to cost the UK economy more than £100 billion a year (Department for Work and Pensions & Department of Health, 2016).
There is evidence that healthier workplaces can help reduce rates of sickness-related absenteeism as well as raising staff productivity. However, this requires leaders and managers to have effective skills to support the health and well-being of employees, and healthcare professionals 1 to have skills in both supporting patients with workplace-related mental and physical health issues and managing the workplace mental and physical health needs of the teams they manage. It also requires better employer self-management of health in the workplace, though professionals' developing these skills in their course and if managers were encouraged to consider health in their people management strategies.

Background
Existing research suggests that there is much to be done to improve healthcare and business professionals' knowledge of health and work. A study by PricewaterhouseCoopers (2008) found that many UK employers still do not consider it as their role to improve the health and well-being of their workforce or do not understand the business case for doing so, and a recent survey of UK employees found only 40% have access to occupational health support or independent counselling through their workplace (Young & Bhaumik, 2011). A national survey of GPs recently found that although almost all GPs recognise they have a role to play in helping patients remain in or return to work, many do not feel confident in doing so (Hann & Sibbald, 2011).
The most effective way to ensure healthcare professionals and business managers acquire a consistent understanding of the importance of work to health and wellbeing is to ensure that these subjects are well-covered and assessed during their degree programmes. However, studies examining course content have generally not explored health and work coverage in depth, and often only viewed teaching within one subject area. Gillam and Bagade (2006) found that less than half of UK medical schools included content on occupational health, but did not explore the nature of this coverage. Other mapping studies have examined teaching topics not directly related to health and work. The most notable was Boon, Ridd and Blythe's (2017) study of medicine courses' taught content on primary care, which found only six of 30 courses addressed work and health in the course aims and objectives.
Beyond medicine, there is a little research on the teaching of health and work to dentistry, nursing, business or Allied Health Professional students; those that did generally only cover a small sample of courses or that are based on case study evidence. Nandakumar and Robinson (2011) examined a voluntary community outreach programme which was attended by dentistry students and found that outreach work helped students develop an understanding of how work-related factors might affect dental health. Similarly, Grant, Kinman and Baker's (2015) study of the inclusion of emotional resilience topics in social work curricula reported that the teaching of emotional resilience is not well established within social work degree programmes.
This study builds upon, and addresses, gaps in previous work by providing a large-scale review of the inclusion of health and work topics across a broad range of healthcare and business subjects, and exploring in depth some of the factors influencing their teaching and assessment.

Methods
This study was undertaken in March and April 2017. It mapped the coverage of health and work topics in a selection of healthcare, social work and business courses in England. This included examining: • Perceptions among course leaders on the importance of health and work topics for particular healthcare and business occupations; • The extent to which health and work was included in course objectives and curricula; • How health and work topics were assessed; and • Factors influencing the teaching of health and work.
The study examined the coverage of six core health and work topics that collectively ensure the learners are effectively able to manage the health of themselves and their team. They are organised under the broader headings of clinical skills and management skills and are presented in Table 1 below.
To examine the coverage of these six key topics, the study research comprised of the following: • A quantitative review of 221 healthcare and business courses. This included a structured examination of course specifications (including programme descriptions and learning objectives); lists of available units; module descriptions; assessment criteria; practical placement frameworks; and reading lists. This information was collected from provider websites and requesting additional course information.
• Qualitative interviews with 38 course leaders responsible for healthcare or business degree courses. The qualitative interviews were used to corroborate and address gaps in the data collected during the course review.

Course sample
The quantitative review examined 221 degree courses, comprising 120 undergraduate healthcare and social work courses and 101 undergraduate and postgraduate business courses. The selection of 120 healthcare and social courses included coverage of a mix of subject areas, as  Table 2 below. The selection of business courses included 41 undergraduate programmes and 58 postgraduate programmes, of which 37 were Master of Business Administration courses. These sample sizes enabled patterns across healthcare and business courses to be estimated with confidence intervals of 8.64 and 9.76, respectively.
Other than in medicine-where every course on offer was examined-the selection of courses contained a mixture of courses ranked in the top, middle and bottom thirds of their respective subject league tables to ensure any variation between providers of different quality would be captured in the analysis.

Supplementary interviews
A preliminary review of documentation for 10 courses found that the level of detail included was inconsistent, with some module or assessment descriptions providing little detailed information on the content of their courses (e.g. sometimes giving a broad outline of taught modules but not the exact topics covered or learning objectives). There was particularly little information on how health and work topics were assessed. Semi-structured qualitative interviews were, therefore, conducted with a sample of course leaders and department heads responsible for courses included in the quantitative review, to verify and address gaps from the quantitative mapping.
Thirty-eight qualitative interviews were conducted with heads of department or course leads from 14 medical departments, three dentistry departments, five nursing departments, three social work departments, seven Allied Health Professional (AHP) departments (covering paramedicine, occupational therapy, radiography, orthoptics and physiotherapy) and six business departments (covering five undergraduate and 14 postgraduate courses).

Quantitative review
Documentation was gathered from Higher Education Institution websites and online prospectuses, with requests for more information sent to Higher Education Institutions in instances where little was publicly available. This documentation included the following: • The course aims and objectives; • Course descriptions and learning outcomes; • The list of units available within each course; • Module descriptions; • Vocational frameworks/guidelines for work placement; • Assessment criteria; and • Reading lists. Almost all course webpages included their course's overall aims, a course description and a list of modules (including work placement units). Most of them provided information on the topics taught within modules and detailed the assessment methods used throughout the course, and a small number provided information on how course learning objectives were mapped against modules. However, details on assessment content (e.g. the specific topics included in assessments, weighing given to these topics in final marks) were only published by two courses. Information on assessment approaches was, therefore, drawn primarily from qualitative interviews.
Data from all course documentation were synthesised using a data extraction tool. This tool was created as an Excel workbook, within which the following information was recorded: • Course aims and objectives addressing health and work topics (and which topics they addressed); • Taught modules including content on health and work topics; • Whether or not these modules were optional or mandatory; • Health and work topics being covered during work placements; and • Health and work topics being included in student assessment.
Data were coded so that the number and subject areas of courses covering health and work topics could be calculated. Specific codes were assigned for coverage within each of the curriculum areas detailed in the bullet list above (e.g. coverage of a topic within overall course aims, coverage of a topic within mandatory taught modules).
The exact text used as evidence of coverage was also recorded. This text evidence was used to review the consistency with which researchers were coding instances of health and work topic coverage/non-coverage. It was also used during analysis to qualitatively illustrate the types of health and work coverage included within the coding.
The data were then analysed to examine the proportion of courses that contain health and work topics and the number of topics covered. This was disaggregated by occupational area and by the clinical and management subjects.

Interviews
Department heads and course leaders responsible for degree programmes examined during the quantitative review were sent requests to participate in interviews. Two email invitations were sent to each interviewee, followed by up to five attempts to make phone contact with anybody who did not respond to the email invitations. Those who agreed to participate were interviewed over the phone.
Interviews were semi-structured. A topic guide containing a set of open questions and conversation prompts was used by researchers to direct the flow of conversation and ensure that the key research questions were covered, but interviewees were free to answer questions with the information they felt was most relevant (rather than being given a pre-determined selection of answers to choose from) and could also have discussion towards additional issues that they felt were important.
The purpose of these interviews was to verify and address gaps in the information collected from the course mapping. They specifically explored: • How the six core topics are incorporated in courses and the rationale for this approach; • Tutors' knowledge and awareness of the six core topics, and perceptions of how effectively the topics are taught; • How health and work topics are assessed. This includes their inclusion in end-point assessments, coursework and clinical placements; • Any future organisational plans to improve coverage/quality of the teaching of the six core topics; and • Any factors that inhibit the organisation from more extensively embedding health and work topics.

Limitations
The level of detail available from course webpages was inconsistent, with some descriptions providing little detailed information on the content of their courses other than a broad outline of the study objectives. There was also relatively little published information on how health and work is assessed. In these cases, the findings were largely drawn from the information collected in the qualitative interviews.
The sample of healthcare courses gives greater overview of some areas than others. Coverage of medicine and dentistry courses was relatively comprehensive (almost all courses mapped and half of schools interviewed), but for other occupations, the research only covers a representative sample of the overall number of courses. In particular, the sample of AHP courses is representative of all AHPs as a group but analysis for individual AHP subjects is only indicative.
The large number of business courses in England means that the sample of business courses reviewed is relatively low compared with the total number of courses on offer. While the sample allows for representative analysis of business courses as a whole, the sample is too small to allow us to disaggregate findings by type of course (e.g. management courses tailored to specific sectors) with a reasonable degree of confidence.
There may also be evidence of respondent bias as course leaders over-report their coverage of health and work topics to promote their institution's programmes. This may also take place on course websites, but to a lesser extent.

Medicine and dentistry
Medicine and dentistry course leaders generally believed that it was important for undergraduate students to learn about the relationship between health and work, but most only highlighted one or two core topics that they felt were crucial. Medicine course leaders believed the most important health and work skill required by students was to be able to interpret a patient's work history for signs that their condition might be in some way related to the work they do. Dentistry course leaders stated that self-care was of key importance to dentists to ensure they avoid common health conditions such as back pain and carpal tunnel syndrome.
The standards governing medicine degrees explicitly include a requirement for courses to include content on the impact patients' occupations have on their health and taking action if colleagues' ill-health puts patients at risk. However, they do not cover students' skills for self-care and resilience. Dentistry standards cover students' self-care, and indirectly cover an understanding of the relationship between health and work (through specifying that students must learn to interpret a patient history). Neither set of standards makes explicit reference to understanding the positive impact of work on health or valuing and managing diversity in the workplace.
Relatively few medicine (7 of 35) or dentistry courses (4 of 8) explicitly included health and work topics in their course objectives or curricula. Most of those only included one topic, commonly as part of a wider module. Medicine courses mostly included topics on the occupational exposures that can impact on patients' health. The examined courses included learning aims such as "delivering whole-person care" and "apply social science principles, method and knowledge to medical practice". Although programme documentation did not specify people's workplaces as part of the social context of health, course leaders stated that this content would consider work as one of the several societal factors influencing health (alongside family, wealth or region).
Dentistry courses mainly included content on dentists' self-care and a broad objective on public health. They included topics such as: "[Understand] issues associated with being in a practice environment, e.g. health and safety at work"; and "Focus on. . . public health dentistry". Even when the topics were not explicitly mentioned in some module descriptions, most course leaders reported that they would expect that these topics to be covered in some clinical modules.
Very few medicine (2 of 35) or dentistry courses (2 of 8) contained content on managing the health of staff. Course leaders argued that these skills were best acquired in the workplace, where they could be contextualised for particular medical roles.
Most medicine course leaders reported that health and work skills were assessed through Objective Structured Clinical Examinations (OSCEs), when students take a patient's occupational history. However, the extent to which work factors were included in the assessment varied depending on the condition being covered. It is only covered extensively for conditions where work can be a major contributory factor, such as lung disease.
Course leaders stated that the main reason they did not include more provision on health and work was because there was little space in their curricula and so they prioritised topics that directly contributed to the professional standards. There was also perceived to be little initial student demand for health and work training, although interest commonly increases overtime. As one course leader stated Health and work is probably something that students are less aware of at the start, but I think they gain an appreciation of it through the practical exercises that they do and then come to realise how important it is to develop good and comfortable working habits whilst working over long periods of time.

Nursing and social work
Course leaders generally believed that it was crucial for nurses to understand the relationship between health and work, as they often support patients to implement recovery plans or manage long-term conditions. For social workers, the most important health and work skill was personal resilience to be able to deal with high workloads and potentially upsetting scenarios at work. As one course leader stated "If you're not caring for yourself, you're not going to be able to care for other people".
Nursing degree standards do not contain requirements that explicitly relate to clinical health and work skills. Social work standards cover students' self-care, but not an understanding of the relationship between clients' work and health. Neither set of standards include requirements that cover managing the health of staff or supporting diversity in the workplace.
Relatively few (4 of 23) nursing courses explicitly included clinical content on health and work topics in the course objectives or curricula, and those that did mostly included them in broader learning aims, such as "the determinants of health and well-being" and "public health and primary care". However, nursing course leaders reported that health and work topics were commonly embedded across a range of modules, including clinical modules and modules on public health and the determinants of health and well-being.
Six of 21 social work courses included clinical health and work topics, but this mostly focused on the student's own resilience. For example, one module had a learning aim of "With support, take steps to manage and promote own safety, health, well-being and emotional resilience". There was little provision on the relationship between client's health and their work, or valuing diversity in the workplace.
Eight nursing courses included content on management skills, and some of these courses explicitly included content on managing staff's safety and resilience. In social work, management skills were only taught on three courses.
In the qualitative interviews, most nursing course leaders reported that their courses assessed health and work topics through scenario-based testing, or in some cases through module exams. However, they stated that it was not done consistently or systematically across the course.

Allied health professions
Course leaders believed that an understanding of health and work was crucial to the diagnosis and/or treatment of some specific conditions. For occupational therapists, understanding the positive impacts of work on improving health was also considered as a key skill.
Health and Care Professions Council (HCPC) standards require all AHP course to teach students to work safely and maintain their own health. The standards also indirectly require courses to include content on understanding the relationship between patients' work and health, as students are required to recognise the socio-cultural factors that influence health. The HCPC standards also address management skills, although do not explicitly address managing the health of staff, or understanding the value of workplace diversity.
Only two of 33 AHP courses contained explicit reference to a health and work topic in their course objectives and only eight included content in the course curriculum. It was most commonly covered in occupational therapy courses, which included topics such as "explain the relationship between occupation, health and well-being and the factors that facilitate or challenge participation in occupations" and skills in "occupation-based intervention in a range of settings." However, in the qualitative interviews, almost all course leaders stated that their courses covered student self-care, usually as a cross-cutting theme across their programmes. Most also stated that they embedded content on the relationship between health and work when it was a major contributory factor for certain conditions, such as mental health or musculoskeletal problems. Occupational therapy and physiotherapy courses also included content on preparing patients to re-enter work Four of the 33 AHP courses included generic management modules, such as "developing leadership and management skills through teamwork." However, in the qualitative interviews, it was found that these courses did not generally cover managing staff health and well-being or valuing diversity. Most course leaders expected students to acquire these skills in the workplace.
Only one of the course leaders stated that health and work knowledge and skills were explicitly assessed in the course, although some stated that it would be covered through OSCE assessments when it was relevant to certain conditions. This was commonly attributed to a lack of space on the course. As one course leader stated: There is only so much time and you can only have so many formal assessments per module, so because the health and work topics are not a specific focus of any of the modules being taught, they are not really a large enough part of any of the modules to warrant being formally assessed in coursework or examinations.
A few course leaders felt that the variable coverage of health and work topics was because teachers had mixed views on the importance of these subjects and the extent to which work contributes to patients' health and well-being.

Business programmes
Health and work topics on resilience and stress management were widely regarded as important for business programmes. There was significant awareness among both students and industry of the importance of these topics. As one course leader stated: "We tend to offer modules that are in demand from employers, and traditionally this has not been an area of interest, but I think employers are becoming more engaged with these issues, so we may look into integrating [personal resilience] more going forward". However, there was little awareness of the importance of other health and work topics.
Very few business courses (6 of 101) included clinical health and work topics in their course objectives or the content of their modules. Where health and work content was included, it was primarily on how the working environment can affect staff's well-being. It was frequently expected that learners would acquire these skills once in the workplace (or, for many postgraduates, already have acquired them).
Very few business courses explicitly included content on managing health and work in their course curricula. When it was included, courses primarily covered diversity or managing stress and anxiety in the workplace. However, some course leaders stated that they embedded content on managing stress within people management modules.
hile business course leaders believed tutors largely recognised the importance of health and work, some stated that they did not always have the technical knowledge to deliver these topics effectively. Student demand for health and work (except for stress management) was also mixed, and consequently some courses included these topics in optional modules.

Health and work topics in course curricula
Across all healthcare and business courses, there was relatively little coverage of health and work topics. Where health and work was covered, most courses only included one health and work topic, and in some cases only a small component of a health and work topic (such as managing stress, within the broader topic of self-care and resilience). This is largely in-line with the findings from Boon Ridd and Blythe (2017), Gillam and Bagade (2006) and Grant et al. (2015). It suggests that current provision is unlikely to provide the step-change necessary to improve addressing the gaps in healthcare and business professionals knowledge of health and work, as cited by PricewaterhouseCoopers (2008) and Hann and Sibbald (2011).
The type of health and work topics covered in different subjects varied. For example, dentistry and social work courses were more likely to include content on self-care; whereas, medicine and nursing courses most commonly included information on the role work could play in causing illhealth in a patient. The only subject to consistently discuss the benefits of work (as opposed to its negative impacts) was occupational therapy. This reflects that some health and work topics are seen as more applicable for some occupations than others.
While some programmes included content on management skills, relatively few included content on managing the health of staff. In healthcare courses, course leaders generally believed that these skills should be acquired during students' professional work.
There was also very little evidence of the assessment of health and work skills. This may reflect that in many cases health and work topics were only covered as a small part of a broader module. As a result they were not a core part of end-of-module assessments. When course leaders reported that health and work was covered during assessments, this was most commonly during OSCEs. However, the limitation with this approach is that the assessment of health and work skills depends on the scenarios that are used. Clinical topics where work is not a major contributory factor are unlikely to effectively assess students' knowledge of health and work.
There are also some subjects, most notably self-care and resilience, that are regarded as crosscutting themes and covered outside of core provision, such as during student inductions and oneon-one support sessions with tutors during practical placements. This is rarely assessed, however, and consequently it is unclear to what extent students are actually being prepared for working in a difficult or stressful work environment.

Implications of findings
This study identified the following priorities for healthcare and business degree education if health and work is going to become more extensively addressed.
(1) Engage standards setting bodies to promote the importance of health and work. Most course leaders stated that their courses prioritised topics required by their respective degree standards, and some also reported making changes to their provision following guidance from degree-setting bodies. Working with these organisations would, therefore, be an effective route for promoting the importance of health and work to course leaders.
(2) Assess students' knowledge and awareness of health and work topics. The research found that in many courses health and work training was delivered through one-off sessions with students (e.g. introductory lectures, pre-placement workshops) or as within a broader module, which was not commonly assessed. Consequently, it would be valuable to assess students' knowledge and awareness of health and work topics to understand how effective these approaches have been.
(3) Promote the importance of all health and work topics to all degree course leaders, framed around the role it can play in improving health. The study found that there is relatively little health and work provision, and where it was included it was primarily focused on the role of work as a contributor to particular health conditions. Highlighting how work can lead to positive health outcomes will encourage course leaders to include more content on health and work.
(4) Focus on promoting the importance of skills to manage staff health and encouraging diversity and inclusion. Most healthcare courses contained little or no content on health and work management skills, either for managing staff health or for supporting inclusion and diversity. Where they did cover management skills, they generally only appeared to cover generic skills. These topics could be included in modules on professionalism or covered within students' work placements.
(5) Raise student awareness of the importance of health and work. At present, there is relatively little student demand for health and work provision, which means that even if provision is available through optional learning, very few students are taking it up. However, when students undertake optional learning on health and work, they come to appreciate health and work's relevance to their practice, indicating they would be receptive to more teaching on these topics.