Due to the multifaceted nature of organisational-level risk and health-promotive factors, in combination with the absence of earlier systematic reviews that could be used to guide the search, a broad scope that incorporates multiple study types rather than focusing on a single preferred study design had to be used. Thus, this study was carried out as a systematic search and review with a narrative summary (33) and reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 statement (34); see supporting information on-line Supplementary material (Prisma 2020 checklist). This study has not been reviewed by the Swedish Ethical Review Authority. This is not required for this type of study according to the Swedish Ethical Review Act. Informed consent to participate was not applicable in this study. No protocol exists for this review, since it was first commissioned as a part of a government assignment to the Swedish Agency for Work Environment Expertise and the absence of ethical review requirements.

Studies investigating health-related risk and health-promoting factors for healthcare professionals in the Nordic countries that were published in peer-reviewed journals between 1 January 2016 and 3 January 2023 were included. The start date of the searches was a pragmatic choice used to increase the relevance of the included studies by reflecting the current context and normal operations. The search strategy was structured according to SPIDER (sample, phenomenon of interest, design, evaluation, and type of research) as we expected a wide range of study designs, including quantitative, qualitative, and mixed method designs (35). Studies were included if they examined the relationship between health and illness in relation to risk and health-promoting factors at the organisational level, or employees’ experiences of these factors. Descriptive studies that described relationships without examine the relationship between health and illness in relation to risk and health-promoting factors at the organisational level were excluded. Outcomes that cannot be directly seen as an aspect of health or illness have also been excluded, although they may be an outcome of a risk or health-promoting factor and related to health or illness. For example, various performance-related outcomes, such as patient satisfaction, quality of care, or incidents, have been excluded since such outcomes do not directly reflect worker health. Outcomes related to employee turnover, such as the desire to leave or remain in the workplace or organisation, have also been excluded. Finally, studies conducted under non-ordinary or non-generalisable conditions, such as pandemics or crises, have been excluded. Complete inclusion and exclusion criteria can be found in Table 1.

Literature searches were developed and conducted by librarians/information specialists to reflect the concept outlined by the project team. A set of key articles were identified before the search process, which were used to generate search terms (MeSH and free-text terms) and test the effectiveness of the strategies in each database. A combination of three different thematic search terms (blocks) were used: (1) population (e.g., “healthcare worker*,” “healthcare personnel*,” “health professional*,” etc.), (2) the phenomenon of interest (e.g., “occupational health*,” “workplace health*,” “employee health*,” etc.), and (3) the context (e.g., “Sweden,” “Norway,” Denmark,” “Finland,”” Iceland.”). The complete list of search terms is presented in the on-line Supplementary material (Search terms). To cover a wide range of disciplines such as healthcare, psychology, and occupational health research, the search was performed using four different databases (Pubmed, Scopus, Cindahl, and PsycINFO) 3 January 2023.

Records found during the search phase were exported to a reference management software (EndNote) to identify and remove duplicates. To ensure adequate understanding and consistency in the application of inclusion and exclusion criteria, a calibration exercise was carried out within the project team prior to the formal screening. In this calibration exercise, the project team met to discuss inclusion and exclusion decisions on randomly selected records until adequate consensus and consistency was assessed to be reached within the group. The records were then screened based on the inclusion and exclusion criteria using Covidence, a web-based application for systematic reviews. The initial screening on the title/abstract level and the full-text assessments of each record were done independently by two of the authors (MA, JW, ALA, and/or ACFS). Cohen’s Kappa showed an agreement between 0.33 and 0.60 between the different evaluators. To increase the agreement between evaluators, the project team met up to discuss inclusion and exclusion decisions until adequate consensus and consistency was assessed to be reached. Disagreements were resolved by discussion until consensus was reached.

The methodological quality of each included study was assessed by two of the authors (MA and JW). To provide a nuanced view of study quality across multiple research designs, in line with the methodology of this systematic search and review, the 2018 Mixed Methods Appraisal Tool (MMAT) was used. MMAT is designed to review the quality of studies with different designs and varying methods (36). When using the MMAT, no scores or overall assessments, such as low/medium/high quality, are calculated; rather, the MMAT provides an in-depth picture of the quality of the studies. The quality review was conducted in two stages. In the first stage, each study was evaluated based on two screening questions (whether there were clear research questions and whether these questions could be investigated using the available data in the study). The assessment of these questions (yes, no, or cannot tell) determined whether the study should be included or excluded due to a lack of methodological quality. In the second stage, the included studies were evaluated using five additional and specific study design questions (with response alternatives: yes, no, or cannot tell), to provide an in-depth picture of the quality of the study. In this stage, the templates for qualitative studies, randomised controlled trials, non-randomised trials, and mixed methods studies were used. Any disagreement during the quality appraisal were resolved by discussion until consensus was reached.

Data extraction was performed by the authors (MA, JW, ALA, and ACFS) and cross-checked to ensure accuracy and consistency in the extracted data by another author (MA or ACFS). To include both information on the identified organisational-level risk or health-promoting factors and contextual and methodological information that may be used to support the analysis, a matrix, including: (A) country representing the context of the study, (B) study aim, (C) study design, (D) study period, (E) study population, (F) Size of the study population (G) outcomes, and (H) identified organisational-level risk or health-promoting factors was used and is provided in the on-line Supplementary material (Data extraction matrix). Any disagreements during data extraction were resolved by discussion until consensus was reached.

Since a large heterogenicity was expected in the included studies, the data synthesis was conducted with a narrative summary based on which aspects of the organisation of health care had been examined. This categorisation was done jointly by the authors (MA, JW, ALA, IA, ACFS) and was reported together with the more descriptive compilation of the included studies. Finally, overarching themes were also identified across these categories (i.e., meaningful patterns that contribute to a better understanding) (37). An example of the qualitative data synthesis process, including the identification of the categorisation and identification of overarching themes can be seen in Table 2.

The database searches identified 4,461 records, and 2,677 record were screened on the title/abstract level after removal of duplicates. Of these, 375 full-text articles were reviewed, and 95 were included for analysis (Supplementary Table S1). A flow diagram of the review process is shown in Figure 1. A list of excluded full-text articles are provided in the on-line Supplementary material (Excluded full-text articles).

Most of the included studies had a cross-sectional design (n = 34, 36%) or a longitudinal cohort design (n = 34, 36%). A total of 20 studies (21%) were qualitative, and two studies (2%) used a mixed methods design. The remaining five studies (5%) used a case–control design or examined the importance of organisational risk and health-promoting factors in connection with natural experiments under normal operations (quasi-experimental intervention or randomised field experiments) (Supplementary Table S1).

Two out of five studies (n = 38, 40%) included healthcare professionals from different professional groups, without examining the groups separately or specifying the groups in greater detail. The other studies (n = 57, 60%) focused on specific professional groups, including registered nurses (n = 37, 39%), physicians (n = 9, 9%), healthcare managers (n = 5, 5%), midwives (n = 4, 4%), dental hygienists and other dental professionals (n = 2, 2%), and psychotherapists (n = 1, 1%) (Supplementary Table S1).

There was an even distribution of studies from the Nordic countries, with 27 studies (28%) from Finland, 25 (26%) from Sweden, 22 (23%) from Norway and 22 (23%) from Denmark. Iceland was the exception with only one study (1%) (Supplementary Table S1). No overall differences in the identified factors could be seen between the Nordic countries.

A majority of the included studies studied organisational risk factors (n = 67, 71%) connected to a wide range of outcomes with a focus on both mental and physical illness and disease (Supplementary Table S1). The remaining studies (n = 28, 29%) focused on health-promoting factors connected to outcomes such as job satisfaction, motivation, engagement, etc. (Supplementary Table S1).

All reviewed studies were assessed to be of sufficient methodological quality and were included in the systematic review. In the in-depth assessments of the methodological quality of the included studies, most of the qualitative and mixed method studies were found to lack information on whether the authors had quality assured the article using a checklist for reporting the study (such as the “Consolidated criteria for reporting qualitative research” [COREQ] or similar resource). For the quantitative studies (17 out of 75 studies), questions were raised regarding whether the participants were representative of the intended study population due to low response rates and/or a non-random sample of the study population. The checklist for the evaluation of methodological quality is provided in the on-line Supplementary material (Quality assessment).

To obtain an overview of the results, all studies were categorised based on which aspects of the organisation of health care had been examined (Supplementary Table S1). Results identified risk and health-promoting factors in the organisation of health care in terms of the distribution of working time schedules (n = 39, 36%), design of operations and working methods (n = 28, 26%), ergonomic conditions (n = 18, 17%), terms of employment and personnel policy (n = 13, 12%), and the organisation’s ethical environment (n = 10, 9%), Table 3. These categories are described in detail below. In some cases, a single study contained risk and health-promoting factors associated with more than one of these categories, bringing the total number of studies in the above summary to more than 95.

Although there was a wide variety within and between the categories in terms of the risk and health-promoting factors on which the studies focused, there were also similarities. Within each category, the studies demonstrated that what the organisation does to control and manage the work to meet its goals has an impact on employee health. This applies, for example, to how the organisation allocates working hours and staffs its operations, manages its objectives, and provides aids and support. In addition, there were studies in all categories that pointed to the importance of the organisation’s culture and values and what it communicates to its employees, including through priorities that affect both the work environment and the opportunities for employees to work effectively.

Our findings indicate that organisational-level risk and health-promoting factors can be divided into five categories: distribution of working time schedules; design of operations and working methods; ergonomic conditions; terms of employment and personnel policy; and the organisation’s ethical environment. In terms of their effect on the health of healthcare workers, these categories are well known. It is common knowledge that the scheduling of shifts (duration, number, and frequency, as well as time for recovery between shifts) can be both a risk factor for physical and mental illness, for example, exhaustion and cancer (22, 23, 132–134), and a health-promoting factor that increases job satisfaction (133). Furthermore, Aust et al. (16) recently showed the importance of job and task modification, flexible work and scheduling, and changes in the physical work environment in improving healthcare workers mental health and wellbeing. The HR practices of organisations have been associated with nurse absenteeism (135), and ethical value conflicts in healthcare have been associated with the health of nurses (2, 136). However, what this systematic review adds is a deeper understanding of how these risk and health-promoting factors can be created at the organisational level – and hence a better understanding of how to address risks at their roots and create a hotbed for a healthy and attractive work environment through the active engagement of the top management. It also identifies similarities between categories, highlighting the importance of including multiple perspectives within the employer’s occupational safety and health management, since both the actions that employers take to fulfil the healthcare organisation’s goals and the ability of employees to provide good quality care were found to be important for the health and wellbeing of healthcare employees. Consequently, employee health and wellbeing can and should be managed at the organisational level, not only at the workplace or individual level by first-line managers, according to the principles of the hierarchy of controls for occupational safety and health (30, 31) and recommendations from peers (16, 18).

This review also shows that there is a lack of knowledge on measures to promote well-being and health compared to knowledge of measures to counteract illness and disease. This is highlighted by the fact that most of the studies investigated risk factors rather than health-promoting factors. The definition of health-promoting factors differed substantially between the included studies, and in some studies, measures that sought to address risk factors rather than add something positive were also defined as health-promoting factors (e.g., reducing quick returns or alleviating strain/workload through well-adapted aids). Such factors may reduce the risk of illness but likely do not promote health or well-being, since they simply mean that a risk factor has been addressed. The utilisation of health-promoting factors within the occupational health and safety management of organisations may be particularly important if the healthcare sector (19) is to remain attractive to professions that are both demanding for the individual and essential for a well-functioning society.

Some limitations need to be considered when interpreting the results of this review. The current study is limited to healthcare professions in the Nordic, countries and the findings cannot automatically be generalised to other professions or countries. Given the complex characteristics of healthcare organisations (20), future research would benefit from performing similar reviews for other contexts, rather than broadening the search criteria to include other professions and countries. Future research could also build on these findings to enable systematic reviews that include meta-analyses for individual categories of organisational-level risk-and health-promoting factors. The present review only considered studies published on or before 3 January 2023. We did not update the search further because we did not want to include studies that reflected the extraordinary circumstances following the COVID-19 pandemic, which currently influences research in this area. As a result, many studies published from 2021 an onwards were excluded during the study selection of this review.

A very broad approach was used to provide an overview of Nordic research on the work environment and health of healthcare professionals, with a focus on identifying organisational-level risk and health-promoting factors. This resulted in a wide range of study types across different healthcare professionals and settings, targeting a variety of outcomes. Although this heterogenicity did not allow for firm conclusions, it showed the large variety of studies within the area. Dividing these studies in five categories of organisational-level risk and health-promoting factors provided a better understanding of areas of interest when investigating potential risk factors within an organisation. However, due to this heterogenicity, it was not possible to perform a meta-analysis of the findings within each category.

It should also be pointed out that a large proportion of the included studies used a longitudinal cohort design. This means that they followed participants over time and investigated how factors related to health, illness, and the organisation of work changed in relation to each other. This is useful when pinpointing the risk and health-promoting factors in the work environment. A relatively large number of qualitative studies were identified. This helps to provide a deeper understanding of employees’ perceptions of risk and health-promoting factors. Two out of five studies included more than one occupational profession. This increases the generalisability of the results but at the expense of being able to comment on individual occupational groups. Many of the studies that reported results for individual occupational groups focused on registered nurses.

This review offers valuable information on how leaders within healthcare organisations can promote employee wellbeing through strategies that target the way work is organised, designed, and managed. Our results call for action on the strategic level within the occupational health and safety management in healthcare organisations, since it is at the organisational level that opportunities arise to not only manage but eliminate risks in the work environment, and it is also here that there is an opportunity to promote health in the workplace (16, 18).

In addition, our analysis of overall themes can also give an indication of which perspectives on the organisation of work in health care are important for both employer and employees, regardless of which specific areas are considered. To ensure a sustainable, safe, and healthy working life, the effect of actions that employers take to meet the health care organisation’s goals and provide employees with the ability to provide high-quality care must be given equal priority. Management must ensure that its staffing, distribution of working time schedules, and choice of working methods are adequate to meet society’s needs for healthcare and that their operations are designed in a way that ensures the organisation can fulfil its mission. Yet it is equally important that management prevents employees from being exposed to the risk of illness and provides them with the opportunity to conduct their work in accordance with their fundamental values regarding what constitutes good care. The organisation must ensure that working methods, aids, and the physical work environment enable employees to perform their work in a manner that is satisfactory to both patients and employees. The terms of employment and work must be adapted to the organisation’s need for flexibility and simultaneously provide sufficient security to meet the employees’ needs for security and rewards. The organisation’s ethical environment must consider not only care priorities, but also how these affect employees.