Picking low hanging fruit – A scoping review of work environment related interventions in the home care sector

ABSTRACT

Home care for elderly people is an important part of the social welfare system. The sector employs many people, especially women, and work environment issues are common. This review explores the scientific literature on organizational interventions that target the home care work environment. Altogether, 16 studies of varying quality met the inclusion criteria. The interventions identified involved organizational change, education and training, digitalization and scheduling. Many interventions were concerned with changing specific behaviors or with introducing new technology rather than tackling complex issues such as sick leave, stress or gender inequality. Employee participation increased the likelihood of success.

KEYWORDS:

• Home care
• gender
• work environment
• interventions
• organizational change

Introduction

This literature review investigates the existing knowledge on how home care for elderly people can be organized to create a good work environment. In the near future, the need for home care is estimated to increase in many countries due to the growing elderly population (European Commission, 2015). In Sweden, for example, there is a need to increase the workforce in eldercare by 170,000 people by 2035 (Statistics Sweden, 2017). Similarly, in the official statistics in the U.S., it is estimated that the cluster of occupations that entails home care aides will grow by 36% between 2018 and 2028 (U.S. Department of Labor, 2020). One of the most obvious features of the home care sector is that it is dominated by women. For example, in Sweden, close to 90% of the occupational cluster including the home care workforce consists of women (Statistics Sweden, 2017).

Considering the size of the sector and the increasing future needs, it is worrisome that problems in terms of injuries, stress, sick leave and staff turnover appear common in this occupation (Andersen & Westgaard, 2014; Butler, Simpson, Brennan, & Turner, 2010; Denton, Zeytinoglu, Davies, & Lian, 2002; Dill & Cagle, 2010; Elovainio et al., 2015; Elstad & Vabo, 2008; Vänje, 2015). For example, in Sweden, the occupational cluster that includes home care personnel (i.e., assistant nurses and nurse aides as well as social and care workers) had the highest number of cases resulting in long-term sickness absence in the year 2014 (AFA-insurance, 2016). While it is well known that home care struggles with work environment related issues, less is known regarding what to do about it. Knowledge on actual work environment related interventions and their applicability for home care appears to be sparse. For these reasons it is of paramount interest to explore the actual knowledge base concerning how the work environment in home care can be improved.

Objectives

This scoping review investigates the existing knowledge about interventions and organizational changes intended to improve the home care work environment.

The aim is to answer four questions:

1. What kind of organizational interventions, or other types of changes that can affect the home care work environment, are described in the scientific literature?

2. What effects are attributed to these organizational interventions and/or changes in the home care work environment?

3. What kind of mechanisms can have led to these effects?

4. What knowledge gaps exist in the current body of organizational intervention and/or change research regarding the home care work environment?

Materials and methods

Search strategy

The study design was inspired by the PRISMA 2009 structured search methodology taking into consideration that it is an iterative, and at the same time systematic process, with distinct concepts guiding the search (Moher, Liberati, Tetzlaff, & Altman and The PRISMA group, 2009). Figure 1 illustrates the review process. The data was obtained from the Scopus and Web of Science databases. Home care work can take many different forms; in some cases it is regarded as part of the health care sphere, in others as social care. In addition, it does not always refer to paid work, but includes volunteer work or family members who take care of their elderly relatives. Thus, a broad search strategy was necessary. The search was constrained to the following fields: title, abstract and keywords. On the first level, the following search terms were used in the field title to identify studies that could possibly concern home care: home care, home health services, home nursing care, domiciliary care, social care, in-home care, home health care, elder care, eldercare, and elderly care. On the second level, the following search terms were used in the fields title, abstract and keywords to sort out the studies that in some way concerned the work environment: work environment, occupational health, gender, stress, organi* (to capture organizational change and other references to the organization or the organizing of work), ergonomics and human factors. To be included in the review, an article had to be written in English and published in a scientific journal between January 1, 2008 and March 14, 2017. A search was conducted for each of the first level terms separately. For the term home care, the complete search string in Scopus looked like this:

(TITLE (“home care”) AND TITLE-ABS-KEY (“work environment” OR “occupational health” OR gender OR stress OR organi* OR ergonomics OR “human factors”)) AND DOCTYPE (ar OR re) AND PUBYEAR > 2007 AND PUBYEAR < 2018 AND (LIMIT-TO (LANGUAGE, “English “))

Figure 1. An overview of the review process including the number of articles identified or removed in each step.

Criteria for inclusion and exclusion

Only interventions and organizational changes in home care work-like organizations were included, defined here as, organizations with employed care workers distributing help and support in the homes of elderly and disabled citizens and which were funded by the public via general taxation. Thus, volunteer work or family members who take care of their elderly relatives were not included. To be included, it was required that interventions affected the working environment in some way, but it did not need to be the main purpose or even a subordinate purpose. Evaluations of organizational changes were included only if it was plausible that they had an effect on the working environment. For both interventions and organizational changes, it was a required that it should be possible to discern if there was an impact on the working conditions from the description. The exclusive focus on home care also meant that articles that covered nursing, home care nursing or nursing homes, were removed. The main difference between home care and nursing is the professional boundaries and education. While nurses need a license, home care workers do not. Thus, home care nursing, which is not included in this review, deals with licensed nurses working in the patient’s home.

Data extraction and analysis

The articles that remained after this final assessment and were included in the review, were described according to type of intervention, main aim, study design, main results, and whether the intervention/change was regarded as successful or not. The type of intervention item consisted of categories describing what focus area the intervention/organizational change primarly concerned, for example digitalization or scheduling. It was also noted whether the intervention/organizational change applied a participatory approach. Here, a participative approach implies that the research subjects or participants have influence over the research process and content. The degree of participation could vary from participants being consulted in the research design to the participants taking a more collegiate role in relation to the researchers (Cornwall & Jewkes, 1995).

Results

The results from the search are presented in Figure 1. In total, the initial search resulted in 2715 articles. After the removal of duplicates, the remaining 1539 articles were screened. After the second screening, 37 articles remained. These were obtained as fulltext and after a final assessment, 16 studies were included in the review. An overview of the 16 studies is presented in Table 1.

Table 1. Overview of the 16 articles included in the literature review.

Study	Main aim	Study design	Type of intervention	Main results	Success
Nabe-Nielsen, Garde, and Diderichsen (2011) The effect of work-time influence on health and well-being: a quasi-experimental intervention study among eldercare workers	Of the study: “to investigate the effect of increasing work-time influence among eldercare workers” (Nabe-Nielsen et al., 2011, p. 684), and of the interventions: “to increase the employees’ influence on their work schedule” (ibid, p. 686).	Quasi-experimental intervention study with one year follow-up consisting of questionnaires and physical measurements.	Scheduling Participatory approach	There was no effect on health or well-being as a result of involvement in the intervention. However, the interventions containing self-scheduling resulted in increased employee involvement in work-time scheduling.	Yes
Czuba et al. (2012) Ergonomic and safety risk factors in home health care: Exploration and assessment of alternative interventions	To discover unexplored opportunities for intervention related to risk factors for home health care aides and test those intervention ideas.	Multiple intervention study with several interventions tested over a 3-week period. Follow-up consisted of fatigue ratings and diary studies. The interventions were originally identified and designed using a variety of methods.	Scheduling Participatory approach	A number of interventions were identified and tested. The most promising included rescheduling of patients with higher needs to achieve a more even distribution between employees with opportunities to rest between visits.	Yes
Nilsson and Engström (2015) E-assessment and an e-training program among elderly care staff lacking formal competence: results of a mixed-methods intervention study	To study the effects of e-training programs for home caregivers lacking formal competence.	Intervention program in several steps spanning from 2009 to 2011. Follow-up consisted of pre- and posttest questionnaires and interviews after the interventions.	Education and training Digitalization	Work-life and well-being improvements rated higher for those who completed the program.	Yes
King et al. (2012) A restorative home care intervention in New Zealand: perceptions of paid caregivers	To “explore paid caregiver perceptions of a restorative home care intervention in comparison with usual home care.” (King et al., 2012, p. 70)	Randomized controlled trial. Intervention with a follow-up consisting of focus groups at baseline and after 14 months.	Education and training	Substantial positive impact on paid caregiver job satisfaction in comparison with usual care.	Yes
Hauer et al. (2012) Developmental intervention, learning climate and use of knowledge in elderly care	To examine learning climate and effect of formal training in home care and residential care.	Intervention with a follow-up questionnaire five months after the intervention and a base line questionnaire before.	Education and training	Mixed results on the improvement of learning climate. Positive for home care workers through formal training and collaborative informal training.	Mixed
Skoglind-Öhman and Kjellberg (2011) Factors that influence the use of safe patient transfer technique in home care service	“ … to explore whether home care service personnel having participated in transfer technique training programmes used their knowledge and skills in their daily work” (Skoglind-Öhman & Kjellberg, 2011, p. 434).	Intervention with a follow-up consisting of focus groups and interviews.	Education and training	Personnel tried to use their knowledge and skills but there were both hindering and supporting factors in the environment for the use of safe work techniques. Thus, safe work technique interventions should not be implemented without considering the context as well.	Mixed
Amuwo et al. (2013) Reducing occupational risk for blood and body fluid exposure among home care aides: an intervention effectiveness study	To reduce blood and body fluid exposure among home care aides through use of approved sharps containers.	Participatory intervention design process involving training. The follow-up consisted of a pretest questionnaire and a posttest questionnaire 6 months after the intervention.	Education and training Participatory approach	Participatory intervention had a statistically significant impact on the use of proper sharps containers among the clients of home care aides	Yes
Flannery (2011) Creating and sustaining an effective coaching culture in home care: one organization’s performance improvement related to aides and aide retention	To change unproductive conversations between home caregivers and supervisors.	Intervention focused on training and role-playing scenarios. There was no clear follow-up strategy but they present feedback collected from participants as well as turn over data.	Education and training Participatory approach	Improved communication skills resulting in less conflicts and a better psychosocial work environment.	Yes
Rasmussen et al. (2017) Processes, barriers and facilitators to implementation of a participatory ergonomics program among eldercare workers	To identify risk factors for low back pain and solutions, and reveal barriers and facilitators for implementation.	Randomized controlled trial. Analysis of action plans created by participatory ergonomics work groups resulting in suggested interventions. Follow-up consisted of data on the implementation rate of the interventions after the program.	Education and training Participatory approach	A number of risk factors were identified; most were concerned with physical ergonomics. However, most of the identified solutions were organizational. 38% of the suggested solutions were regarded as fully implemented after the intervention. The study highlights the complexity of risk factors for low back pain and the importance of involving the workers in the process.	Yes
Olson et al. (2015) The COMPASS pilot study: a Total Worker Health™ intervention for home care workers	To “ … develop and test the feasibility of a Total Worker Health™ intervention for HCWs and estimate intervention effects on workers’ well-being and health and safety behaviors in order to inform sample size in a planned prospective randomized efficacy trail” (Olson et al., 2015, p. 408).	Intervention groups participated in a series of monthly 2-hour meetings designed as ritualized, scripted peer-led sessions to increase knowledge, practice skills and build support for healthy actions.	Organizational change Participatory approach	COMPASS is a feasible intervention model.	Yes
Olson et al. (2016) Safety and health support for home care workers: the COMPASS randomized controlled trial	“To determine the effectiveness of the COMmunity of Practice and Safety Support (COMPASS) Total Worker Health intervention for home care workers” (Olson et al., 2016, p. 1823) and facilitate the establishment of professional communities of practice.	Randomized controlled trial. Intervention groups participated in a series of monthly 2-hour meetings designed as ritualized, scripted peer-led sessions to increase knowledge, practice skills and build support for healthy actions. Follow-up at 6 and 12 months consisting of questionnaires and physical measures	Organizational change Participatory approach	COMPASS is effective for improving the social resources of the workers. It also had positive effect on the workers’ health and safety.	Yes
Håland et al. (2015) Care pathways as boundary objects between primary and secondary care: Experiences from Norwegian home care services	To explore how care pathways can act as tools for translation between specialist health care services and home care services.	Intervention with a follow-up consisting of interviews and focus groups conducted between 2 and 5 years after the change project was initiated.	Organizational change Participatory approach	Care pathways can push boundaries and provide home care workers with “a language for articulating their knowledge and competence” (Håland et al., 2015, p. 649), as well as make their work more visible and acknowledged.	Yes
Janse et al. (2016) Do integrated care structures foster processes of integration? A quasi-experimental study in frail elderly care from the professional perspective	To explore “ … the impact of an integrated care intervention for frail elderly patients on the professionals’ perception of and satisfaction with processes of integration” (Janse et al., 2016, p. 377).	Quasi-experimental design with a control group. Follow-up consisted of a questionnaire distributed 18 months after the intervention.	Organizational change	The intervention improved integration.	Yes
Andersen et al. (2015) Work demands and health consequences of organizational and technological measures introduced to enhance the quality of home care services – a subgroup analysis	To examine effect of two measures involving job checklists and personal digital assistants on perceived work demands and musculoskeletal health.	Intervention with a follow-up consisting of a questionnaire administrated in the beginning of the study and after two years.	Digitalization	Perceived work demands and health effects were unchanged overall, but with significant differences between subgroups. Work demands and shoulder-neck pain remained high for high-strain workers, but were reduced for low and moderate strain workers.	Mixed
Nielsen and Mathiassen (2013) Interpretive flexibility in mobile health: lessons from a government-sponsored home care program	To examine a mobile health implementation program to understand how the technology was used differently across home care agencies.	Longitudinal case study of an implementation program with multiple data sources. Follow-up data collection focused on the last two years of the program.	Digitalization	Strong support from government and other stakeholders helped to initiate the program. Later, technology ran counter existing norms in individual agencies.	Mixed
Ede and Rantakeisu (2015) Managing organized insecurity: the consequences for care workers of deregulated working conditions in elderly care	To evaluate the consequences of a political reform that entitled home care workers to hold full-time positions.	Intervention with a follow-up consisting of Individual and group interviews conducted over a 4-year period while the intervention was running.	Organizational change	Deterioration of work environment due to organized insecurity in scheduling requiring flexibility and adaptation	No

Articles on interventions and organizational changes

A variety of interventions and organizational change initiatives were identfied. Most of the studies originated in the Scandinavian countries, Western Europe and the United States. The study designs and the quality of the studies varied considerably, from randomized controlled trails (RCT) to single case studies with more descriptive data and in some cases, even anecdotic evidence.

Analysis

Four overarching categories could be identified among the included studies: organizational change (five studies), education and training (seven studies), digitalization (three studies), and scheduling (two studies).

Several of the five articles on organizational change were about the introduction of care pathways as a way to integrate health care services and to collaborate across organizational boundaries (Håland, Røsstad, & Osmundsen, 2015; Janse, Huijsman, de Kuyper, & Fabbricotti, 2016). The studies by Olson et al (Olson et al., 2016, 2015) applied a holistic approach in the sense that their methodology focused on “the impact of work on the whole person” (Olson et al., 2016, p. 1824). The effects documented primarily concerned an increased acknowledgment of health care worker’s competence, increased sense of control and influence, and improved intraprofessional collaboration. Olson et al. (2016) and Olson et al. (2015) described the same intervention, the latter being the pilot study. Ede and Rantakeisu (2015), though, had a different approach, analyzing the gendered consequences of a political reform that entitled home care workers to hold full-time positions.

The seven articles on education and training covered interventions to promote safety, improve the work climate or increase effectiveness. One training intervention concerned the adoption of new practices for safe lifts (Skoglind-Öhman & Kjellberg, 2011), while another focused on implementing new practices to reduce exposure to blood and body fluids (Amuwo, Lipscomb, McPhaul, & Sokas, 2013). Rasmussen et al. (2017) described a participatory ergonomics program composed of physical and psychological training. Another study was concerned with the effects of a formal training intervention in restorative home care from the work force point of view (King, Parsons, & Robinson, 2012). Two articles described interventions consisting of training for an improved work climate (Flannery, 2011; Hauer, Nordlund, & Westerberg, 2012). The Hauer et al. (2012) study focused on improving the personnel’s competence both through formal training and collaborative informal learning to promote a learning climate. Flannery (2011) described an intervention in which both managers and employees were involved in adopting a relational leadership model to improve communication between them.

There were three studies in the third category, which was primarily concerned with digitalization in home care organizations. Two of them focused on the introduction of mobile technologies, in particular different mobile health systems and the introduction of Personal Digital Assistants (PDAs) (Andersen, Bendal, & Westgaard, 2015; Nielsen & Mathiassen, 2013). Andersen et al. (2015) investigated how the introduction of two digital job aids, that were intended to make work more efficient, affected the employees’ perception of work demands and shoulder-neck pain. Nielsen and Mathiassen (2013) studied a large mHealth implementation program in Denmark. Their results showed that in some cases, the implementation of mHealth services went contrary to established professional values, and could be perceived as a tool for increased managerial control over the employees. The third study, by Nilsson and Engström (2015), focused on e-training and e-assessment, thus it could also be regarded as being part of the education and training category.

The fourth and last group of interventions, consisting of only two studies, concerned scheduling. Nabe-Nielsen, Garde, and Diderichsen (2011) analyzed several parallel scheduling interventions including the use of self-scheduling with a computer program, training in flexible work, and a discussion group. While the self-scheduling succeeded in increasing the employees’ involvement in work-time scheduling (i.e., reached the goal of the intervention), the intervention failed to show any positive health effects from involvement in work-time scheduling. Czuba, Sommerich, and Lavender (2012) identified risk factors causing injuries among home care workers. Based on these factors, they categorized clients according to needs in order to schedule the workers in a way that decreased their risk for injuries.

Eight of the studies applied a participatory approach. Among them, the forms for participation differed. Rasmussen et al. (2017) used an established framework for participatory ergonomics (Haines, Wilson, Vink, & Koningsveld, 2002). Others provided the participants with some influence over the content of their intervention (Czuba et al., 2012; Håland et al., 2015) and some (e.g., Olson et al., 2016, 2015) applied an action learning inspired approach, in which the participants themselves defined goals to work with between group meetings (Pedler & Burgoyne, 2008).

The evaluation methodology and quality differed between the studies. Rasmussen et al. (2017), King et al. (2012) and Olson et al. (2016) stood out in the sense that they were RCTs. Both Rasmussen et al. (2017) and Olson et al. (2016) applied a systematic approach to participation, in the sense that its forms were designed and explicit. Many of the studies were designed as interventions with a follow-up study or as a case study. In some cases, a control group was included (Janse et al., 2016), while no clear follow-up strategy was reported in others (Flannery, 2011).

Few of the studies applied a gender perspective, that is problematized the results in relation to gender inequality. Most studies did not even have gender as a variable in their analysis, the exceptions being Amuwo et al. (2013), Janse et al. (2016) and Ede and Rantakeisu (2015). Ede and Rantakeisu (2015), specifically discussed the gender-related implications of their intervention. In their case, the conversion of part-time to full-time jobs through the introduction of unscheduled work hours for home care personnel paradoxically resulted in reduced control over their work time. Consequently, conflicts arose with their private life obligations.

Discussion

In this review, we identified 16 studies that describe interventions and organizational changes related to work environment in home care. This is a small number compared to the many articles that deal with interventions in nursing and care at hospitals and nursing homes. Obviously, this discrepancy raises questions about the scarcity of home care interventions studies. One reason could be that the work is perceived as too difficult and cumbersome to study. Indeed, home care workers are spread out geographically to a greater or lesser extent, and they work in many different home environments. This makes it particularly difficult to find the ideal conditions for controlled interventions. A hospital ward or nursing home, on the other hand, can provide a more well-defined context, that is, a more controlled environment because it is defined physically and with clearer professional boundaries and rules. Thus, it is probably also easier to stage interventions in such settings. The few initiatives could also be the result of a lack of resources for organizational change, or a lack of interest from management, politicians and other stakeholders. Another possible reason is perhaps a lack of interest from the research community. Such explanations can be linked to the low status of the home care occupation, which in turn is can be connected to perceptions of gender and class that mark the home care sector and its workers (Andersson, 2012; Vänje, 2015). Recent events related to deaths in home care and elder care facilities caused by the Covid-19 pandemic, suggests that there is a lack of resources in the form of protective gear. While protecting the staff from Covid-19 infection is a problem that many healthcare providers face (Rosenbaum, 2020), this also indicates that home care is not always prioritized. Which, in turn, also can be an indication of its low status.

Despite the low number of included studies, we note that the quality of the studies differed to a great extent, from RCTs to studies based on almost anecdotal evidence. The typical study design was an intervention or organizational change with some sort of follow-up data being collected, but without a control group. In one sense this is troublesome because it can be difficult to evaluate the evidence and make generalizations. However, as so few studies were found, we find it important to highlight also those studies that are of lesser quality from a purely scientific perspective, as they can serve as inspiration for both practitioners and new scientific studies. It is obvious that more studies are needed, and that it would be beneficial with studies that apply a more controlled methodology. However, given the circumstances surrounding home care, it is clear that these types of studies could not be commenced without overcoming quite substantial challenges.

The interventions were successful in most of the 16 studies, but there are exceptions. The study by Ede and Rantakeisu (2015), shows that the conversion of part-time to full-time jobs with unscheduled work hours, in fact can create new problems. This could be due to the lack of participation of the home care personnel in the design of the intervention, resulting in a solution that did not consider their entire situation. While the participants gained full-time employment, which corresponds to an increase in job-related demands and potentially more economic control and stability in their private lives, it is also clear that control over their own time decreased due to the unscheduled work hours. According to the demand-control model, this arguably corresponds to a move toward a more strained work situation (Karasek & Theorell, 1990). The studies concerned with digitalization also stood out in the sense that the results were mixed in two of the three (Andersen et al., 2015; Nielsen & Mathiassen, 2013). This indicates that digitalization of home care may be more difficult than sometimes imagined. One speculation is whether home care digitalization initiatives are driven by needs identified in the home care domain, or are primarily inspired and driven by digitalization trends in society (Frennert, 2019). In contrast to several of the other studies in the review, none in the digitalization category focused on user participation.

The analysis indicates that a participatory approach, that is, interventions involving home care workers in the defining of needs and in designing the initiatives, appears to give positive results. Even though the level of participation varied, this suggests that involving home care workers in designing interventions is an important factor for the success of an intervention. Presumably, involving the employees will increase their understanding of the intervention’s aims and increase the chances that employees feel invested and take ownership. It will also increase the likelihood that the interventions really tackle problems that the personnel themselves perceive as relevant and to ensure “a fit between the employees and their environment” (Nielsen, 2013, p. 1045). Participation is also positively related to achieving change-related goals and negatively related to resistance to change (Lines, 2004).

A compelling question is why the interventions do not target underlying reasons behind the problems faced by home care workers indicated by previous research? That is, factors on a systems level such as low wages, or issues (e.g., stress, sick leave) related to the overall organization of home care work that in part can be related to the occupation being dominated by women (i.e., female coding) and is low status (Denton et al., 2002; Elovainio et al., 2015; Elstad & Vabo, 2008; Vänje, 2015). It should be noted, though, that some interventions of this type may have failed to meet the inclusion criteria of this review because they operated and were evaluated on a higher level in an organization than home care work practice. However, the interventions that gave home care workers more control over their schedules, validated their competence and promoted a more respectful treatment can be seen as attempts to address some of these issues on an individual or work group level (e.g. Flannery, 2011; Hauer et al., 2012; King et al., 2012; Nilsson & Engström., 2015).

The largest category of intervention types was concerned with education and training. Overall, many of the studies focused on increasing the individuals’ skills, the introduction of new technology, or the avoidance of injuries. To some degree, these deal with the symptoms rather than the causes. For example, personnel who conduct ergonomically unsound lifts that result in back pain, or who inadequately handle needles that result in blood exposure, may only represent the active failure components of the problems (Reason, 1997). These types of initiatives that focus on the active components of the risks or organizational shortcomings are referred to here as low hanging fruit because they are relatively easy to comprehend and approach. However, the results of these initiatives may not be as sustainable as imagined if the underlying conditions remain unchanged. We acknowledge, though, the need for these types of initiatives, but at the same time would like to see more that make a sincere effort to try to tackle the underlying causes in all their complexity.

Conclusions

First, home care work is a sparsely researched sector, especially when it comes to interventions intended to improve the work environment. The initiatives identified in this review consisted of efforts regarding organizational change, education and training, digitalization, and scheduling. Second, many of the studies were concerned with changing specific behaviors or the introduction of specific types of new technology. Third, few studies focused on the reduction of urgent issues such as stress or sick leave. Fourth, few studies focused on problems on the systems level, such as gender aspects of work and the role of status and reward systems. Fifth, employee participation in the interventions appears to be a mechanism that increased its likelihood for success. For these reasons, future home care interventions studies should concentrate more on the underlying causes of the work environment related problems in home care, especially their psychosocial components, and relate them to outcomes such as care quality and patient safety. The latter in order illuminate the role and importance of home care on the societal level, which potentially could increase the status of home care. They should also acknowledge how gender affects the work environment, and should apply a participatory approach. With these measures, future research can be steered away from the low hanging fruit toward more essential and complex issues. Rest assured that the low hanging fruit will be picked anyway, when appropriate.

Disclosure statement

The authors declare no conflicts of interest.

Additional information

Funding

The work was funded by FORTE – the Swedish Research Council for Health, Working Life and Welfare (grant number 2016-07151).