Working environment, work engagement and mental health problems among occupational and physical therapists

Abstract

Background

Working environment, work engagement and health among occupational and physical therapists in Norway have rarely been investigated.

Objectives

(1) To compare the psychosocial working environment, work engagement and mental health problems of occupational therapists with those of physical therapists; (2) to compare the same measures among occupational therapists working in the specialist and municipal healthcare services, respectively; and (3) to identify job demands and resources that influence the work engagement and mental health problems of occupational therapists.

Material and methods

The Survey for Health Promoting Workplaces was used to collect data from 170 occupational therapists and 273 physical therapists (response rate =35%) working in specialist and municipal health care in Norway. Student’s t-test, Pearson correlations and multiple regression analysis were used.

Results

Occupational therapists experienced higher job demands and poorer health than physical therapists. Occupational therapists in the municipal healthcare services were slightly more satisfied with their job resources than colleagues in specialist healthcare services. Meaningful work and the opportunity to use one’s strengths and potential contributed the most to high work engagement. Low work engagement was the most important contributor to poor mental health.

Conclusion and significance

The mental health of occupational therapists seems to be closely related to the opportunity to perform high-quality therapy. It is important that work is organised so that occupational therapists have meaningful work tasks and opportunity to use their strengths and potential.

Keywords:

• Burnout
• health promotion
• mental health
• occupational therapist
• physiotherapist
• sick leave
• work engagement
• working environment

Introduction

Working life is an important pillar in all societies, and the working situation of workers affects their health [1]. When workers fare well, it improves not only their health but also the productivity of enterprises and countries, the provision of high-quality welfare services and ultimately the well-being of a country’s total population [2].

The WHO [3] definition of health includes not merely the absence of disease and infirmity but also physical, mental and social well-being. Nevertheless, most research on health among employees has used diseases as their outcome measures and not so much positive health measures related to the different types of well-being [4,5]. In the context of work, it has been argued that work engagement may serve as a positive health measure because it is closely related to happiness and productivity and because the environmental resources of the workplace drive engagement [6,7]. Engagement has also the potential of preventing mental disorders such as depression and anxiety [8]. According to the job demands–resources model [9], two distinct processes lead to poor health and to positive organisational outcomes: the energetic process and the motivational process [10]. The energetic process is driven by job demands (such as quantitative and qualitative demands and role conflict) leading to burnout and ultimately poor health and diseases. The motivational process is driven by job resources (such as decision authority, social support and meaningful work), leading to work engagement, which results in positive organisational outcomes (such as identification with the workplace, intention to stay in work and high productivity). It seems reasonable that the motivational process may also result in workers feeling healthier.

Healthcare personnel are often dedicated and engaged in their work [11,12] but they are also exposed to demands and stress that may result in burnout and mental disorders. Most studies on work-related health among healthcare personnel have focussed on nurses and doctors and rarely on occupational and physical therapists. When occupational and physical therapists are included in studies, they are often treated as one occupational group, possibly because they have a similar education and often work in the same department with the same patient groups. Norway’s National Institute of Occupational Health monitors the working environment and health of Norway’s working population [13]. In their studies, they include both physical and occupational therapists (and some other minor healthcare personnel) in the same group, which is among the groups reporting the highest work demands in Norway but also a rather good psychosocial working environment (such as social support and decision authority). Nevertheless, they report being exhausted after work more often than the average of all Norway’s occupational groups. In a study of various related occupations in Norway (such as police officers and nurses), physical therapists reported the highest work engagement (occupational therapists were not included). A recent study among occupational therapists in Sweden reported rather high job demands, leading to stress, difficulty in doing a good job and increased turnover [14]. The same study revealed that about 20% of the occupational therapists had symptoms of exhaustion disorder and that 35% had seriously intended to leave their profession during the past year. High emotional exhaustion has also been reported among occupational therapists in Canada [15], and relevant practice issues were excessive demands on time, conflicts, lack of autonomy and lack of respect. Lloyd et al. [16] have shown similar results among occupational therapists in Australia related to mental health stress. Particularly interesting in that study is that conflicts with other professionals and professional self-doubt were highly correlated with stress.

In 2020, Norway had 18,824 occupational and physical therapists, with 14,765 working in health and social care services [17] (34 occupational or physical therapists per 10,000 population). Norway’s healthcare system is primarily publicly funded through taxes, and most services are free of user charges. The system is in principle divided into two sectors: the specialist healthcare sector (with primarily highly specialised hospitals) and the municipal healthcare sector (with nursing homes, home care services, health centres and rehabilitation clinics). How healthcare services are organised differs from country to country, and the working environment and health of employees may also differ. To our knowledge, no studies have specifically focussed on the working environment and health of occupational therapists in Norway. To improve or maintain the health of occupational therapists in Norway with effective measures, it is important to survey the working environment of these workers and to compare occupational therapists working in various sectors within the healthcare sector.

This cross-sectional questionnaire study from Norway had three aims: (1) to compare the working environment, work engagement and health of occupational therapists with those of physical therapists; (2) to compare the same measures among occupational therapists working in the specialist and municipal healthcare services, respectively; and (3) to identify job demands and resources that influence the work engagement and mental health problems of occupational therapists.

Material and methods

Sample and procedure

This study used single-source self-report data collected by using a web-based and cross-sectional questionnaire survey [18]. We invited all occupational and physical therapists working in three of four regional hospital trusts (22 hospitals) to recruit therapists from the specialist healthcare services and from 17 municipalities to recruit therapists working in municipal healthcare services. The web-based questionnaire was distributed to 1260 therapists between 23 April and 8 May 2020. A reminder was sent after 2 weeks, and the whole study ended on June 3. Of the 1260 questionnaires distributed, 443 were returned, by 170 occupational and 273 physical therapists (approximate response rate =35%). The relative distribution of occupational and physical therapists in the healthcare system is not known, and the exact number of therapists receiving the questionnaire is uncertain because the researchers did not have the e-mail addresses of the respondents (because of anonymity matters) but depended on the department heads, who distributed the questionnaire to their respective subordinates.

This study was conducted after the COVID-19 pandemic began. The work situation of the included therapists would be expected to differ from the usual when they answered the questionnaire. We therefore asked the respondents to answer based on how their work situation was in the weeks before the Norwegian government implemented COVID-19 restrictions on 12 March 2020.

Measures

We used a modified version of the Norwegian Survey for Workplace Health Promotion (SHEFA) [19,20] that contains various well-known and validated measures collected from other instruments such as Copenhagen Psychosocial Questionnaire (COPSOQ) [21] and the Demands–Control–Support Questionnaire [22]. SHEFA includes various mental, social, and organisational characteristics of the job, work engagement, sick leave, general health and mental health problems. Two physical therapists and one occupational therapist tested SHEFA before it was distributed to the participants. The questionnaire was regarded as too extensive, and we therefore removed nine items related to two indexes regarding cooperation within and between departments or services. Table 1 presents all indexes and items included in this study, with their descriptive data.

Table 1. Questions, descriptive data, and internal consistency of indexes among 443 occupational and physical therapists.

Variables	Cronbach’s α	Mean	SD	Range	Questions included
Job demands (composite)	0.70	2.25	0.39	1.3–3.9
General demands	0.72	3.28	0.40	2.0–4.6	How often do you have a lot to do at work? Do you have enough time to do your job at the quality you want? Is the workload unevenly distributed so that there are work peaks? Do you have duties that you consider professionally difficult? Does your job set high demands, so you have to constantly perform new duties? Does your job require you to have an overview and relate to many things at once? Do you make job decisions that you deem as complicated?
Role conflict	0.81	2.11	0.61	1.0–5.0	Do you receive conflicting requests or demands from superiors and/or colleagues? Do you perform tasks that you think should have been done differently? Do you perform tasks that you think are unnecessary? Does your job include tasks that conflict with your personal values? Do you compromise your professional standards to get your work done?
Conflicts	0.43	1.17	0.38	1.0–4.0	Have you been in conflict with one or more people at your workplace in the past 12 months? Have you been bullied or exposed to unwanted behaviour in the past 12 months?
Fragmented work tasks	0.76	2.46	8.80	1.0–5.0	Do you have so many different tasks that it is difficult to achieve continuity during the working day Does your work include work tasks that diverge in all directions?
Job resources (composite)	0.92	3.74	0.47	2.0–5.0
Meaningful work	0.77	3.30	0.54	1.5–5.0	Are your tasks meaningful? Do you get motivated by your tasks? Do you have tasks that provide work engagement?
Job control	0.77	3.30	0.54	1.5–5.0	Do you have any influence on what specific activities or tasks in which you are involved? Can you choose which method or methods you will use in carrying out your job responsibilities? Can you influence the amount of work that you have? Do you have any influence on the deadlines and time allocated for your job responsibilities? Can you influence decisions regarding the people with whom you work? Can you influence decisions that are important for your work?
Predictability	0.79	3.40	0.61	1.0–5.0	Do you get the information needed in time for important decisions, changes and plans? Are you given the opportunity to participate in organisational changes that affect your work? Are you capable of keeping up with the organisational changes at work? Do you get the information needed for executing work in a good way? Do you generally know what your tasks are 6 months ahead?
Opportunity to use one’s strengths and potential	0.84	3.76	0.62	1.7–5.0	Does your job allow you to be creative and take initiatives? Does your job allow you to use your academic skills and competence? Does your job contribute to your academic development? Do you learn new things in your job? Is your job well aligned with your education and experience? Is there a reasonable relationship between your job development or career and the efforts you make in the job?
Feedback from leader	0.88	3.38	0.87	1.0–5.0	Is your immediate superior willing to listen when you want to take something up? Do you get the help and support you need from your immediate superior? Does your immediate superior ask you how you feel? Does your immediate superior talk to you about the quality of your work?
Social support	0.88	4.06	0.64	1.5–5.0	Do you get the help and support you need from your colleagues? Do you get feedback from your colleagues on your job performance? Do you have a close colleague at work? Is there a good atmosphere between you and your colleagues? Are the colleagues collaborating well at your workplace? Do you feel you are part of a fellowship at your workplace?
Work engagement	0.94	5.28	1.21	1.1–7.0	I am full of energy at work. I feel strong and energetic at work. I am enthusiastic about my job. I am inspired by my job. When I get up in the morning, I look forward to going to work. I feel happy when I am absorbed in my work. I am proud of the work I do. I am absorbed by my job. I am completely taken in by my job.
Mental health problems	0.85	2.04	0.71	1.0–4.5	During the last 4 weeks: How often have you been emotionally exhausted? How often have you felt worn out? How often have you been irritable? How often have you been stressed?

SD: standard deviation.

Working environment

We included four job demands variables: general demands, role conflict, conflicts and fragmented work tasks. General demands involved seven items, including both quantitative and qualitative demands, with a response scale ranging from ‘very little’ (=1) to ‘very much’ (=5). We measured role conflict by using five items, including aspects such as receiving conflicting requests or demands from superiors and/or colleagues and having work that includes tasks that conflict with personal values. The response scale ranged from ‘to a little degree’ (=1) to ‘a very high degree’ (=5). Conflicts at the workplace were measured with two items, including conflicts with one or several people at the workplace or whether one has been mobbed in the past 12 months on a scale from ‘no’ (=1) to ‘yes, daily’ (=5). Fragmented work tasks included two questions regarding difficulties in having continuity in work during the working day and conflicting work tasks. The five-point response scale ranged from ‘no’ (=1) to ‘yes, to a very high degree’ (=5).

We included six job resources variables: meaningful work, job control, predictability, the opportunity to use one’s strengths and potential, feedback from leader, and social support. All questions had a five-point scale ranging from ‘no’ or ‘to a very little degree’ (=1) to ‘to a very high degree (=5). The meaningful work measure comprised three items, including the level of perceived motivation according to one’s work tasks. Job control, resembling the decision authority dimension of the Demands–Control–Support Questionnaire (Theorell, 2000), comprised six items. Predictability comprised five items, including getting all the information needed to carry out work tasks optimally and knowing what the main work tasks will be 6 months ahead. The opportunity to use one’s strengths and potential comprised six items and included a question on whether the job allowed the respondents to make use of their strengths, including non-professional strengths. Feedback from leader was measured with four items related to various aspects for support, related to both mental support and caring and to the quality of work performed by the worker. Social support comprised six items, including aspects of support from colleagues and the social community at the workplace.

In addition to the four demands variables and the six resource variables, we constructed two composite indexes called job demands and job resources by summing the scores of all included variables in the two respective main categories.

Work engagement

Work engagement was assessed by using the 9-item version of the Utrecht Work Engagement Scale (UWES) [23]. This measure contains three subindexes: vigour (three items), dedication (three items) and absorption (three items). The response scale ranged from ‘never during the past year’ (=1) to ‘daily’ (=7). As recommended by Schaufeli & Bakker [24], we used the composite measure including all nine items.

Mental health problems

Mental health problems in the past 4 weeks were measured using four items from COPSOQ, including questions on stress and mental exhaustion. The response scale ranged from ‘all the time’ (=1) to ‘not at any time’ (=5).

Sick leave

Sick leave was measured by a question regarding absenteeism because of health problems (disease, treatment or clinical examination) for the past 12 months. The respondents were asked to provide the number of days.

Sickness presenteeism

The respondents were asked to respond how many days in the past 12 months they had gone to work despite their health being so poor that they should have stayed at home to recover.

Occupation

Occupation and sector were measured by a question on whether the participants worked as an occupational or physical therapist and a question on whether they worked in the specialist or municipal healthcare services.

Background data

We collected data on sex, age (in whole years) and seniority in the current position (in whole years). In addition, we asked about percentage of full-time employment. This variable was dichotomised into full time (37.5 h per week) and part time (<37.5 h per week).

Statistics

We recoded the item response scales so that high scores indicated high job demands, job resources, work engagement, mental health problems, sick leave and presenteeism. For all the multiple item variables, we constructed indexes by summing the scores and dividing the sum by the number of items included (Table 1). Expressed by Cronbach’s alpha, the internal consistency of all the indexes, except for the two-item variable conflicts (α = 0.42), exceeded 0.7, which is regarded as satisfactory internal reliability for indexes in population studies [25,26].

We performed descriptive analysis (Tables 1 and 2), independent samples t-tests (Tables 3 and 4), bivariate Pearson correlations (Table 5) and multivariate ordinary least square (OLS) regression analysis (Tables 6 and 7). The descriptive analysis and the comparison of occupational and physical therapists included participants from both occupational groups. The other analyses included only occupational therapists. We investigated whether work engagement mediated how the working environment factors affects mental health problems by using the macro called PROCESS v4.0 for SPSS [27,28] using a bootstrapping technique (1000 bootstrap samples). We tested the normal distribution of the data by using the Novgorod–Smirnov test, and we analysed data by using the non-parametric test Mann–Whitney U-test. Not all data were entirely normally distributed, but the results of the non-parametric tests did not result in any significantly different results than the parametric tests. Therefore, the results of the non-parametric tests are not shown in this article. No data were missing because questions could not be omitted when filling out the electronic questionnaire. For all analyses, we used the computer package IBM SPSS Statistics, version 28. We set the significance level at 0.05 (two-tailed).

Table 2. Overview of demographic variables among occupational and physical therapists.

Demographic variables	All participants (n = 443)	Physical therapists (n = 273)	Occupational therapists (n = 170)	Occupational therapists in specialist healthcare (n = 65)	Occupational therapists in municipal healthcare (n = 105)
Age, mean (range/SD)	41.7 (22–67/10.7)	41.4 (22–65/10.4)	42.1 (23–67/11.0)	43.3 (22–67/11.7)	40.2 (22–67/9.4)
Sex, n (%)
Women	378 (85.3)	220 (80.6)	158 (92.4)	178 (84.0)	200 (86.6)
Men	65 (14.7)	53 (19.4)	12 (7.1)	34 (16.0)	31 (13.4)
Sector, n (%)
Specialist healthcare	212 (47.9)	147 (53.8)	65 (38.2)	NA	NA
Municipal healthcare	231 (52.1)	126 (46.2)	105 (61.8)	NA	NA
Seniority, mean (range/SD)	9.0 (0–34/7.5)	8.9 (0–34/7.6)	9.2 (0–27/7.4)	7.9 (0–27/10.3)	7.0 (0–27/8.4)
Working hours, n (%)
Full time	351 (79.2)	220 (80.6)	131 (77.1)	52 (80.0)	79 (75.2)
Part time	92 (20.8)	53 (19.4)	39 (22.9)	13 (20.0)	26 (24.8)

Range: minimum and maximum years; SD: standard deviation; NA: not applicable.

Table 3. Differences between occupational and physical therapists.^a

	All participants (SD) (n = 443)	Physical therapists (SD) (n = 273)	Occupational therapists (SD) (n = 170)	Mean difference	95% CI for difference	p
Job demands	2.25 (0.39)	2.20 (0.39)	2.33 (0.37)	–0.13	−0.20–−0.06	<0.001
Job resources	3.74 (0.47)	3.75 (0.48)	3.73 (0.45)	0.02	−0.07–0.11	0.67
Work engagement	5.28 (1.21)	5.29 (1.20)	5.28 (1.22)	0.01	−0.22–0.24	0.93
Mental health problems	2.04 (0.71)	1.92 (0.64)	2.24 (0.77)	–0.33	−0.46–−0.19	<0.001
Sick leave (days/year)	9.06 (20.70)	7.72 (19.14)	11.22 (22.88)	–3.50	−7.64–0.63	0.10
Sickness presenteeism (days/year)	4.07 (10.11)	2.90 (6.37)	5.95 (14.01)	–3.05	−5.30–−0.80	0.01

^aIndependent samples t-test. SD: standard deviation; CI: confidence interval.

Bold values help the reader to see what is statically significant as defined in this study (that is, below the 5% level). 

Table 4. Differences between occupational therapists working in specialist and municipal healthcare services.^a

	All participants (SD) (n = 170)	Specialist health care (SD) (n = 65)	Municipal health care (SD) (n = 105)	Mean difference	95% CI for difference	p
Job demands	2.33 (0.79)	2.31 (0.37)	2.35 (0.37)	–0.04	−0.16–0.07	0.46
Job resources	3.73 (0.45)	3.63 (0.43)	3.79 (0.45)	–0.16	−0.30–−0.02	0.02
Work engagement	5.28 (1.22)	5.26 (1.15)	5.29 (1.27)	–0.03	−0.41–0.35	0.87
Mental health problems	2.24 (0.77)	2.36 (0.74)	2.18 (0.78)	0.17	−0.06–0.41	0.15
Sick leave (days/year)	11.22 (22.88)	8.06 (13.25)	13.17 (27.07)	–5.11	−11.25–1.03	0.10
Sickness presenteeism (days/year)	5.95 (14.03)	3.97 (5.86)	7.17 (17.15)	–3.20	−6.81–0.41	0.08

^aIndependent samples t-test. SD: standard deviation; CI: confidence interval.

Bold values help the reader to see what is statically significant as defined in this study (that is, below the 5% level).

Table 5. Bivariate correlations (Pearson r) for all variables among occupational therapists (n = 170).

	1	2	3	4	5	6	7	8	9
Background variables
1. Sex (1 = women; 2 = men)	1
2. Age	–0.11	1
3. Seniority	–0.12	0.64***	1
4. Working hours	–0.02	0.03	0.05	1
5. Sector (1 = specialist; 2 = municipality)	0.03	–0.10	–0.13	0.03	1
Job demands
6. General demands	0.04	–0.04	–0.02	0.06	0.17*	1
7. Role conflict	0.07	0.05	0.12	0.01	0.01	0.25**	1
8. Conflicts	–0.13	0.10	0.11	0.04	0.01	0.14	0.28***	1
9. Fragmented work tasks	0.05	0.01	0.13	–0.00	0.02	0.42***	0.36***	0.10	1
Job resources
10. Meaningful work	–0.03	0.08	0.01	–0.03	–0.01	0.10	–0.33***	–0.09	–0.16*
11. Job control	–0.08	0.02	–0.02	0.03	0.30***	–0.08	–0.27***	–0.06	–0.16*
12. Predictability	–0.01	0.06	–0.02	0.03	0.19*	–0.19*	–0.46***	–0.20**	–0.30***
13. Use strengths and potential	–0.15	–0.07	–0.09	0.04	0.02	0.11	–0.37***	–0.12	–0.10
14. Feedback leader	0.00	–0.18*	–0.21**	0.01	0.20**	–0.05	–0.30***	–0.28***	–0.14
15. Social support	0.09	–0.13	–0.12	0.05	0.07	–0.08	–0.40***	–0.34***	–0.23**
Health
16. Work engagement	–0.08	0.08	–0.07	0.02	0.01	0.09	–0.32***	–0.22**	–0.19*
17. Mental health problems	–0.01	–0.11	–0.03	–0.03	–0.11	0.23**	0.37***	0.26***	0.32***
18. Sick leave	–0.07	0.04	0.05	–0.06	0.11	0.03	0.28***	0.26***	0.08
19. Presenteeism	–0.05	0.01	–0.03	–0.01	0.11	0.17*	0.36***	0.41***	0.11
	10	11	12	13	14	15	16	17	18
Job resources
10. Meaningful work	1
11. Job control	0.29***	1
12. Predictability	0.40***	0.52***	1
13. Use strengths and potential	0.54***	0.40***	0.47***	1
14. Feedback leader	0.19*	0.34***	0.58***	0.36***	1
15. Social support	0.33***	0.27***	0.45***	0.36***	0.44***	1
Health
16. Work engagement	0.54***	0.23**	0.36***	0.56***	0.32***	0.31***	1
17. Mental health problems	–0.21**	–0.21**	–0.41***	–0.18*	–0.34***	–0.37***	–0.39***	1
18. Sick leave	–0.16*	–0.12	–0.16*	–0.14	–0.15	–0.17*	–0.25**	0.27***	1
19. Presenteeism	–0.11	–0.08	–0.30***	–0.20**	–0.17*	−0.43***	−0.21**	0.45***	0.32***

*p < 0.05, **p < 0.01, ***p < 0.001.

Table 6. Linear multiple regression analysis measuring how work-related factors affect work engagement among occupational therapists (n = 170).

	Model 0^a	Model 1^b	Model 2^b	Model 3^b
Background variables
Sex (women = 1, men = 2)	–0.08	–0.08	–0.02	–0.03
Age	0.08	0.12	0.12	0.13*
Job demands
General demands	0.09	0.26**		0.10
Role conflict	–0.32***	–0.27**		–0.04
Conflicts	–0.22**	–0.18*		–0.13
Fragmented work tasks	–0.19*	–0.17*		–0.12
Job resources
Meaningful work	0.54***		0.32***	0.30***
Job control	0.23**		–0.07	–0.03
Predictability	0.36***		0.03	–0.05
Opportunity to use one’s strengths and potential	0.56***		0.35***	0.35***
Feedback from leader	0.32***		0.17*	0.15
Social support	0.30***		0.06	0.01
Adjusted R^2		0.17	0.40	0.41

*p < 0.05, **p < 0.01, ***p < 0.001. ^aBivariate (Pearson r). ^bMultivariate (standardised β), adjusted for the effects of the other variables included in the regression model.

Table 7. Linear multiple regression analysis measuring how work-related factors affect mental health problems among occupational therapists (n = 170).

	Model 0^a	Model 1^b	Model 2^b	Model 3^b	Model 4^b
Background variables
Sex (women = 1, men = 2)	0.01	–0.03	0.01	–0.01	–0.01
Age	–0.11	–0.14*	–0.15*	–0.16*	–0.12
Job demands
General demands	0.23**	0.06		0.07	0.10
Role conflict	0.37***	0.25**		0.13	0.12
Conflicts	0.26***	0.18*		0.10	0.06
Fragmented work tasks	0.32**	0.19*		0.14	0.11
Job resources
Meaningful work	–0.21**		–0.05	–0.03	0.06
Job control	–0.21**		–0.02	0.02	0.00
Predictability	–0.41***		–0.23*	–0.12	–0.13
Opportunity to use one’s strengths and potential	–0.18*		0.08	0.06	0.16
Feedback from leader	–0.34***		–0.16*	–0.16	–0.12
Social support	–0.37***		–0.24**	–0.16	–0.16
Work engagement	–0.39***				–0.32***
Adjusted R^2		0.20	0.20	0.26	0.31

*p < 0.05, **p < 0.01, ***p < 0.001. ^aBivariate (Pearson r). ^bMultivariate (standardised β), adjusted for the effects of the other variables included in the regression model.

Results

The overview of demographics in Table 2 shows that mean age was about 41 years, with 9 years as a therapist in the current position, 85% were women, about half worked in specialist and municipal healthcare services, respectively, and about 20% worked part time. Compared with the physical therapist group, there were significantly (p < 0.01) fewer men, fewer who worked in specialist healthcare services and slightly longer seniority among the occupational therapists. Among the occupational therapists, demographics did not differ between those who worked in specialist and municipal healthcare services.

Differences between occupational and physical therapists

Although the occupational therapists were as highly engaged in their work as the physical therapists (mean =5.28 on a scale ranging from 1 to 7) (Table 3), they reported higher job demands, more mental health problems, more presenteeism (3 days per year), and more sick leave (3.5 days per year) (p < 0.1). Of the four factors constituting the composite job demands variable in this analysis, the general demands factor and the fragmented work tasks factor contributed the most (that is, showed significant differences between the two groups) to this significant difference (this analysis is not included in a table). We investigated the significant differences between occupational and physical therapists shown in Table 3 in an OLS regression analysis including sex, seniority and sector (that is, the demographics that differed for the two groups shown in Table 2), and these variables did not at all explain the differences in demands, mental health problems, presenteeism and sick leave among the two groups (this analysis is not included in a table).

Differences between occupational therapists working in the specialist and municipal healthcare services

The occupational therapists working in specialist versus municipal healthcare services differed very little regarding the working environment, work engagement and health problems (Table 4). The exception was that occupational therapists in the municipal healthcare services reported more job resources than those working in specialist healthcare services. Of the six factors constituting the composite job resources variable, the factors job control, predictability, and feedback from the leader contributed the most to this significant difference between the two groups (this analysis is not included in a table).

Relationships between job demands, job resources, sick leave and presenteeism among occupational therapists

The background variables correlated relatively little with all the included variables (Table 5). The job demands variables correlated positively with each other, and so did the job resources variables. The highest correlation was 0.54 (between meaningful work and opportunity to use one’s strengths and potential), indicating a low possibility for multicollinearity in the regression analysis (Tables 6 and 7). The correlations were mostly negative between job demands and resources, meaning that occupational therapists who experienced high work demands (such as role conflict and fragmented work tasks) reported that their resources (such as meaningful work and social support) were lower than those who experienced low demands. Somewhat surprisingly, working generally hard did not correlate significantly with any of the resources, unlike role conflict, which showed relatively high correlations with all the six resource variables (r =−0.27 to −0.46).

Role conflict and conflicts correlated positively with both sick leave and presenteeism, whereas predictability and social support correlated negatively with these outcomes. In particular, social support seemed to prevent presenteeism (r =−0.43). Scoring high on mental health problems was highly correlated with much presenteeism (r = 0.45).

Relationships between working environment and work engagement among occupational therapists

Table 6 shows the results of a multiple regression analysis investigating how job demands and resources affect work engagement. Overall, sex and age did not contribute much to the variance in work engagement in any of the models. Bivariately, all the demands variables, except for general demands, correlated negatively and significantly with engagement, whereas the resource variables correlated positively (β =−0.32 to 0.54) (model 0). When the demands variables were entered simultaneously into the regression model (model 1), the relationship between general demands and engagement changed to a positive relationship, whereas the negative coefficients were slightly reduced for the other demands variables. When the job resources variables were entered simultaneously (model 2), the strength of all relationships was reduced and only meaningful work, opportunity to use one’s strengths and potential and feedback from the leader remained significant. When all job demands and resources variables were entered simultaneously (model 3), the relationships between the demands variables and engagement were reduced to non-significance whereas the rather strong relationships between engagement and the two resource variables meaningful work and opportunity to use one’s strengths and potential were retained (β = 0.30 and 0.35, respectively). The included variables explained a total of 41% of the variance in work engagement. Overall, occupational therapists who experienced that their work tasks were highly meaningful and that they had opportunity to use their strengths and potential in work were more engaged as therapists than the colleagues who experienced their work as more or less meaningless and that they did not get the opportunity to use their strengths as therapists.

Relationships between working environment, work engagement and mental health problems among occupational therapists

Table 7 shows a multiple regression analysis investigating how job demands and resources and work engagement affect mental health problems. When controlled for job demands and resources, the older occupational therapists reported somewhat fewer mental health problems than their younger colleagues. Bivariately, all job demands variables correlated positively and significantly with mental health problems, and all the job resources variables and work engagement correlated negatively and significantly with mental health problems (β =−0.38 to 0.54) (model 0). When the demands variables were entered simultaneously into the regression model (model 1), the coefficients were reduced for all the variables and general demands was reduced to non-significance. Likewise, the correlations for the job resources variables were reduced when entered simultaneously, and only predictability, feedback from the leader and social support retained their significance (model 2). When all job demands and resources variables were entered simultaneously (model 3), the relationships between mental health problems and job demands and resources were reduced to non-significance but still explained as much as 26% of the variance in the mental health problems. When work engagement was included in the regression model together with all the job demands and resources variables, the working environment variables remained non-significant whereas work engagement retained a rather strong correlation (β =−0.32). The included variables explained a total of 31% of the variance in mental health problems (model 4). Overall, occupational therapists who experienced their working environment as rather poor with high job demands and few resources reported more mental health problems than their colleagues who experienced their working environment as being good. Interestingly, no factor was particularly important compared with the other factors included in this study. The only exception was work engagement, and that factor (Table 5) depended on experiencing work as meaningful and having the opportunity to use one’s strengths and potential as a therapist.

A mediation analysis [27,28] showed that work engagement had a partial mediation effect on the relationships between mental health problems and the three significant job resources variables predictability (95% CI=−0.25 to −0.05), feedback from the leader (95% CI=−0.17 to −0.03) and social support (95% CI=−0.21 to −0.04) (Table 7, model 3).

Discussion

This study shows that occupational therapists in Norway experienced higher job demands and more mental health problems than their physical therapist colleagues. Occupational therapists working in the municipal healthcare services were slightly more satisfied with their job resources than the occupational therapists in the specialist healthcare services. The occupational therapists were on average highly engaged in their work, and this study indicates that the most important contributors to this engagement were that they experienced work as meaningful and that they had the opportunity to use their strengths and potential in their work. Job demands and resources showed respectively positive and negative effects on mental health problems. Occupational therapists who were very engaged in their work reported fewer mental health problems than therapists with lower levels of work engagement.

Differences between occupational and physical therapists

Compared with the physical therapists, the occupational therapists reported higher job demands, more mental health problems, more sickness presenteeism and more sick leave (borderline significant). A recent study from Norway compared working environment and mental health problems among nurses, social workers, physical therapists and occupational therapists 6 years after completed education [29]. Bonsaksen et al. [29] found no differences between occupational therapists and physical therapists regarding self-reported job demands, control or social support at the workplace. Although the difference was not significant, the occupational therapists in that study were the occupational group reporting the poorest mental health whereas the physical therapists reported the best. Interestingly, the occupational therapists were the group in which work-related factors, including job demands, by far accounted for the greatest proportion of the variance in mental distress (32% versus 21% for physical therapists). In Norway’s healthcare services, occupational therapists are a small profession, often having leaders from other professions such as physical therapists. Being few of one occupation at the workplace might result in high experienced demands because few (or no) colleagues can share the work tasks when times get tough. This may be one reason that the occupational therapists in this study reported higher demands and subsequently also a higher prevalence of mental health problems than the physical therapists. The higher sickness presenteeism may particularly be explained by such a theory, since handing over demanding work tasks to only one or two colleagues can be difficult when sick, since they probably already have a demanding working situation. In accordance with this, Lexèn et al. [14] found that ‘difficulties doing a good job’ together with ‘increased stress’ were the most reported reasons for a heavy workload among occupational therapists in Sweden. Similarly, occupational therapists reported in a qualitative study [15] that high demands kept them from doing their job the way they wanted to and that they experienced a mismatch between their professional values and the demands set by the employer and a lack of professional respect in multidisciplinary teams. Interestingly, despite the reported challenges among the occupational therapists in the current study, they were as engaged in their work as the physical therapists, who have been shown to have the highest work engagement among six groups of health and social care workers in Norway (not including occupational therapists) [30]. Using the same UWES scoring scale as in the current study, the occupational therapists scored higher than Norwegian industry workers [31], engineers [32] and employees in a high-competency enterprise [19].

Differences between occupational therapists working in the specialist and municipal healthcare services

To our knowledge, this is the first study to compare the working environment, work engagement and health of occupational therapists between the specialist and municipal healthcare services. There were very few significant differences, but those working in specialist healthcare services experienced fewer job resources than those working in a municipal setting. More specifically, this difference could be explained by lower job control, predictability and feedback from the leader in the specialist healthcare. Lately, the number of patients in specialist hospitals has increased, and the time patients spend there has markedly declined [33]. In addition, the work is largely governed by written clinical procedures and policies driven by measures to achieve efficiency [34]. Occupational therapists in hospitals may experience fewer job resources or at least less job control and predictability than colleagues in municipalities, where the therapists work with their patients for a longer period, which gives them the opportunity to have more influence on timelines and how the work tasks should be executed.

Relationships between working environment and work engagement among occupational therapists

Job demands as predictors of work engagement

Occupational therapists experiencing much role conflict, conflicts and fragmented work tasks reported significantly lower work engagement than the occupational therapists reporting fewer such demands in both the bivariate analysis and the analysis in which the effects of these variables were controlled for the effects of each other. The most interesting in this analysis was that occupational therapists experiencing high workload such as high work pace and difficult work tasks were more engaged than their colleagues reporting a less heavy workload (when controlled for the effects of the other demands variables). This may indicate that occupational therapists get engaged in their work when they have much to do if the work tasks are clear and coherent and if they can concentrate and finish work without being disturbed (that is, low scores on role conflict and fragmented work tasks). This might be described as doing a qualitatively good job. This is in accordance with the challenge-hindrance framework [35,36] predicting that some demands are regarded as primarily negative on health and vitality, called hindrance demands, whereas other demands may be potentially stressful but simultaneously result in potential gains for the worker, called challenge demands [36]. In accordance with our results, Mauno et al. [11] found that healthcare workers with high time pressure were more engaged than workers with less pressure. We hypothesise that the occupational therapists in Norway enjoy working. Hard if they are learning new things and think that they can give high-quality therapy but that they are partly prevented from doing that because of excessive hindrance demands such as conflicts, role conflicts and fragmented work tasks. Such a hypothesis is partly supported by a study among occupational therapists in Australia [37] showing that those who worked the most and thought the most about their work even after work were more engaged than those who worked less and thought less about work.

Job resources as predictors of work engagement

The most important predictors of work engagement were the job resources meaningful work and having the opportunity to use one’s strengths and potential. The significant effects of both the hindrance and challenge demands were reduced to non-significance when entered together with the resources variables in the regression model. Job resources being more important than demands for predicting work engagement is congruent with the job demands–resources model, maintaining that work engagement is primarily driven by resources in a motivation process rather than in the energetic process driven by demands, resulting in burnout and mental disorders [5,9,10]. For occupational therapists, work engagement is primarily related to performing meaningful work tasks and high-quality therapy rather than organisational factors not directly associated with occupational therapy such as social support and job control.

Relationships between working environment, work engagement and mental health problems among occupational therapists

Working environment as a predictor of mental health problems

In the bivariate analysis, all the demands and resources variables correlated significantly and respectively positively and negatively with mental health problems among the occupational therapists, but none of the variables correlated significantly with the health problems when all variables were entered simultaneously in the regression model (model 3 in Table 7). Nevertheless, the working environment must be regarded as rather important for mental health problems since the working environment variables explained as much as 26% of the variance in health problems and 31% together with work engagement. Interestingly, the most important resources differed from the resources important for work engagement, and general demands were not an important predictor of health problems. The findings are not coherent with the job demands–resources model [9], since that model maintains that job demands are the main drivers for the energetic health impairment process. Also, the findings are not quite congruent with the findings of other studies among occupational therapists showing that work demands are of great importance for mental distress [29] and burnout [15], but these studies did not include such a variety of variables concerning both job demands and resources as in the current study.

Work engagement as a predictor of mental health problems

What is probably the most interesting finding related to mental health problems among occupational therapists in this study is the great effect of low work engagement on mental health problems and that engagement partly mediated the effects of poor working environment on mental health problems. To our knowledge, such a mediation effect has not been shown in occupational therapists before but is in accordance with another study among a general working population in Norway [8].

Relevance and implications for occupational therapy

In this study, the most important predictor of poor mental health among the occupational therapists was low work engagement. Therefore, to improve the health of occupational therapists, focussing on the work-related predictors of engagement seems reasonable.

Interestingly, high general demands predicted high engagement but did not have any significant effect on mental health problems. Therefore, it seems that reducing occupational therapists’ total work workload would not be a fruitful way of improving health. Role conflicts, in contrast, increased mental health problems and reduced work engagement. When working in interdisciplinary groups, we believe occupational therapists often experience that their core experience is not fully understood by other professions and that their holistic social health approach is not valued among other groups and in specialised hospitals in particular. Therefore, occupational therapists may often take a coordination role in interdisciplinary groups and therefore must cover a very broad range of work tasks, and possibly ones they are not fully competent to solve. This may result in role conflicts and in less opportunity to use one’s potential and strengths (the most important predictor of poor work engagement). Therefore, to strengthen occupational therapists’ position in interdisciplinary work, more and better information about and specification of occupational therapists’ competencies are needed at the national, institutional and department levels. Expectations clarification related to occupational therapists’ work in particularly hospitals with short length of patient stays may reduce feelings of not performing high-quality therapy. In addition, more specialisation for occupational therapists might strengthen their position in interdisciplinary work together with professions with a clearer specialty, such as physicians and physical therapists.

In departments, occupational therapists are most often few, and they have managers from other professions. Having more occupational therapists in hospitals and municipalities would benefit both the patients and the occupational therapists. This is difficult to achieve and relies on more information and lobbying from occupational therapy unions and universities educating occupational therapists. In the same vein, occupational therapists need management training to take on leadership positions in which they can promote occupational therapy’s core competencies. We believe that this would result in less role conflict, more meaningful work tasks and greater opportunities to use one’s strengths for occupational therapists and ultimately to higher work engagement and fewer mental health problems.

The main purpose of the Norwegian Working Environment Act [38] is ‘to secure a working environment that provides a health promoting and meaningful working situation’ (§ 1–1a). When addressing health and safety issues for occupations such as occupational and physical therapists, it is important to underline the importance of psychosocial working environment not only to prevent mental health problems but also to improve work engagement as part of the workers’ ‘positive’ health. Thus, meaningful working tasks and opportunities to use one’s personal and professional strengths should be as important for health and safety discussions as physical and ergonomic working factors. We believe that awareness about health promotion (and not only disease prevention) needs to be improved both among managers and the workers’ elected health and safety representatives.

Since this study indicates that performing high-quality occupational therapy is important for job engagement and preventing mental health problems, it seems wise to investigate more in depth, possibly with qualitative methods, what occupational therapists regard as high-quality therapy within particular work settings such as in mental, orthopaedic, and geriatric healthcare. We did not investigate professional conflicts between occupational and physical therapists, but it may be interesting to investigate whether the revealed differences can be explained by such factors since studies from other countries [15] have shown that occupational therapists report that conflicts with other professionals and professional self-doubt result in stress. More research on these issues is needed in a Scandinavian context. These avenues for further research are also relevant to pursue in every workplace setting aiming to improve health and safety for occupational and physical therapists.

Study limitations

SHEFA is constructed from standardised and validated indexes from other well-known instruments. After trying out the questionnaire before distributing it to the participating therapists, we realised that the questionnaire was too extensive. Therefore, we omitted two indexes on cooperation within and between departments. This change may have increased the response rate but, in retrospect, the omitted variables could have shed light on the interpretation of the results. As in the current study, SHEFA has documented satisfactory validity and internal reliability among other occupational groups such as industry workers and middle managers [31,39]. The main methodological limitation of this study is the cross-sectional design, which creates difficulty in drawing firm conclusions regarding causality. Nevertheless, cross-sectional studies are useful in identifying risks and groups of risks when the field is poorly investigated [40]. Working environment, work engagement and health among occupational therapists is such a field. Another limitation is that the data were collected using self-reporting, which may overestimate the correlations investigated because of common method variance [41]. Nevertheless, the rather homogeneous group of respondents may lead to restricted variance and thereby underestimate the correlations. The single differences between groups and correlations shown in this study were not very strong [42], but in total the working environment explained as much as about 30% of mental health problems and 40% of work engagement, indicating that improving the working environment has great potential for promoting health and engagement.

An important limitation is that we do not know exactly how many therapists received the questionnaire and thus not the exact response rate. A response rate of 35% is relatively common [43] but must be regarded as low. The respondents might differ from nonrespondents and thus challenge the validity of the study. Nevertheless, a large public health study from Norway [44] found only few and modest differences in prevalence estimates and sociodemographic distribution between respondents and nonrespondents, and the associations between independent and dependent variables did not differ at all between the groups. We have difficulty in seeing why there should be significant differences in response rate between physical and occupational therapists or between the two occupational therapy groups from the specialist and municipal healthcare services. Although this study was conducted after the outbreak of the COVID-19 pandemic and we asked about how working environment, engagement and health were before the outbreak, we believe that the results of this study are representative for occupational therapists in Norway and that they may also be relevant for therapists working in similar healthcare services outside Norway.

Conclusion

This study documents that occupational therapists regard their job demands and health as poorer than that of physical therapists and few differences in working environment, work engagement and health between occupational therapists working in specialist and municipal healthcare services. The working environment does influence the work engagement and mental health among occupational therapists, and poor work engagement is the most important factor for poor mental health. The working environment factors that influence both engagement and mental health problems seem to be those that hamper the occupational therapists’ opportunity to perform high-quality therapy. Therefore, it seems wise to increase work engagement by improving occupational therapists’ opportunity to execute their therapy in accordance with high professional standards and thereby improve their mental health. This will not only be important for the occupational therapists themselves but also to benefit their patients and the overall healthcare services.

Ethical approval

The Norwegian Social Sciences Data Service approved this study (reference 926830, April 6, 2020). All participants received written information about the study, gave informed consent to participate and answered the questionnaire anonymously.

Acknowledgements

We are grateful to the people who enabled the questionnaires to be distributed and to all the occupational and physical therapists that returned the completed questionnaires.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data are available from the corresponding author on request.