Mental wellbeing at work

Why the committee made the recommendations

The committee noted that the range and nature of workplaces and organisations (especially in terms of the number of employees) made it challenging to make generic recommendations for all organisations. They agreed that some organisations might need to tailor the recommendations to make them relevant.

The committee agreed on the need for organisations to embed strategic approaches to mental wellbeing into their organisational policies and practices, based on their understanding that this approach was fundamental to mental wellbeing at work and based on the evidence and expert testimony.

The committee recognised that the ability of organisations to promote and support mental wellbeing is negatively affected by health inequalities and by work stressors such as bullying, poor communication, job insecurity (including zero-hours contracts), workload, monotony, isolation and poor prospects. In contrast, it is enhanced by good job quality (including a fair wage), role autonomy, organisational fairness, respect, recognition, peer support and clear communication. The committee were clear that some of these factors were outside of the remit of this guideline.

A wide range of evidence from the UK showed that organisation-wide interventions may help to improve mental wellbeing and stress outcomes for employees, and may also benefit employers. The committee agreed that, in their experience, 1 of the key foundations of mental wellbeing in the workplace was an organisational commitment to it, together with a recognition that mental wellbeing is a spectrum and poor mental wellbeing is not a weakness. Organisations that took a strategic and whole-hearted approach to improving mental wellbeing from the top down tended to have the most success. The committee agreed that this was best demonstrated by organisations with a preventive and proactive approach to mental wellbeing – that is, they proactively took steps to promote mental wellbeing rather than simply tackling poor mental wellbeing. They agreed that because these organisational-level responses were so important, the first recommendations in the guideline should establish that organisation-wide strategic approaches were the foundation of good mental wellbeing at work, and that individual and targeted approaches could enhance these but were not a substitute for them. In the committee's experience, it is unlikely that individual or targeted interventions would be successful without an organisation-wide approach, but it noted the temptation for organisations to start with individual approaches because it seems easier.

The committee also agreed with expert testimony on the impacts of the pandemic on mental wellbeing in the workplace that highlighted the need to view mental wellbeing as equally important to physical wellbeing in the workplace and to take it into account when drafting polices or introducing new practices.

Expert testimony about the long-term impacts of the COVID‑19 pandemic on mental wellbeing in the workplace highlighted that employers of all sizes are legally required to carry out a stress risk assessment for each role (and record it if they have more than 5 employees) under the Health and Safety at Work etc Act 1974. The committee saw this as a good opportunity for organisations to identify risks to employees' mental wellbeing, and subsequently take steps to reduce stressors.

The committee also highlighted that employees may have poor mental wellbeing as a result of external factors that are beyond the control of the employer, such as caring responsibilities, health concerns and discrimination (such as homophobia or racism). But they agreed that it is important for organisations to ensure that they provide additional support to groups affected by these issues.

The committee also agreed, based on their experience, that it is important for any interventions to be evaluated and monitored as part of an ongoing strategy of employee engagement, and that validated measures of wellbeing need to be part of this process.

The committee noted that further research is needed to understand how data and outcomes could best be used to improve mental wellbeing in the workplace. In particular, research could investigate which outcomes would be useful in a core outcome set for research into workplace mental wellbeing, and to understand how more detailed reporting of the nature of organisation and employee characteristics can be included in research into workplace mental wellbeing (see the recommendations for research on core outcomes for study reporting and addressing study reporting).

How the recommendations might affect practice

The use of tiered approaches to support mental wellbeing at work reflects best practice and therefore would not have a large resource impact in organisations that have already adopted best practice. This may have more of an impact for other organisations. Smaller organisations may not always have the resources to offer all aspects of the tiered approach. They can best use resources by concentrating on ensuring that they have an organisation-wide approach in place. Improving employee wellbeing might lead to less absenteeism and presenteeism and may improve staff retention and productivity.

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Why the committee made the recommendations

The committee agreed that overall, a supportive, inclusive work environment and climate is crucial for good mental wellbeing in the workforce. Social interactions, including those between managers and employees, play an important role in this.

Having the right policies can help to create a supportive workplace environment and culture. It can help to ensure that leadership is supportive and engaged, that there are effective peer support networks and there is good organisational-wide mental health literacy. A supportive work environment can be achieved by adhering to existing legal obligations (such as health and safety) and statutory requirements (such as the ACAS codes of practice), and engaging with employees to draft and refine policies such as anti-bullying.

Organisations can also promote mental wellbeing interventions by reducing any potential barriers to using them and supporting employees to access them. This would embed the importance of mental wellbeing into the organisational culture (see the section on engaging with employees and their representatives).

Despite the lack of strong evidence for leadership interventions, the committee were confident that management buy‑in is important for promoting the wellbeing of employees. They cited the government review Thriving at work, which provides an evidence-based whole-settings approach to improving mental wellbeing, including the importance of leadership, culture and effective people management.

The committee noted that there was little evidence on the views of organisations about mental wellbeing. (See the recommendation for research on supportive work environment.)

How the recommendations might affect practice

The recommendations reflect current good practice around communication across the organisation, active leadership involvement and engagement with employees. The committee noted that many organisations would already have structures in place like those they recommended, and that to align them with the recommendations would not have a large resource impact. The committee agreed that for organisations that were resource poor and that had not previously invested in a supportive work environment, the use of freely available external resources could help minimise costs.

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Why the committee made the recommendations

The committee agreed that supporting mental wellbeing in the workplace might be particularly challenging for organisations with limited resources, especially micro, small and medium-sized ones. They agreed that it was important to help employers find external, low-cost or free resources to support them in promoting mental wellbeing.

Based on expert testimony from a mental health and productivity pilot and their experience, the committee agreed that it was the responsibility of employers and local and regional authorities to be aware of sources of support available in their area. These sources could be national, local or within the organisation, for example an occupational health service or an employee assistance programme (if the organisation has these). By being able to direct employees to these, employers will be helping and supporting employees by providing them with tools and resources.

The Department for Work and Pensions' access to work mental health support service has guidance to help employers understand mental ill health and how to support employees with mental health concerns. It can also support employees by offering eligible employees an assessment to find out their needs and help them develop a support plan.

How the recommendations might affect practice

The recommendations encourage employers to use expertise and resources that are external to their organisation when appropriate. These sources of support are freely available and will provide employers with information and resources to support their employees. They will also help organisations who are committed to improving the mental wellbeing of their employees to manage the resource impact.

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Why the committee made the recommendations

Evidence from the UK showed that organisation-wide interventions may help to improve mental wellbeing and stress outcomes for employees and may also benefit employers. Although the evidence had some limitations in terms of its quality, the committee concluded that the work environment can be improved in 2 ways: employers can work with their employees to identify work stressors and put in place solutions to deal with these stressors, or employers can use evidence-based methods that are specifically tailored to their organisation. The committee clarified their use of the word 'stress' to be the adverse reaction people have to excessive pressures or other types of demand placed on them.

Based on the evidence and their experience, the committee strongly advised that organisational-level approaches are the best starting point when considering strategies to improve mental wellbeing at work. These approaches demonstrate a commitment to mental wellbeing at work, which is essential for encouraging employees to take up interventions. The committee emphasised that individual-level approaches are not a suitable alternative to organisational-level approaches because these are less likely to be effective on their own. They noted that because of the variation in the size and structure of workplaces, many interventions might need to be tailored to match the specific workplace in which they were going to be delivered. This could be done through staff surveys, for example.

The committee heard expert testimonies about insights from the Thriving at Work Leadership Council, the mental health and productivity pilot, participatory organisational interventions, and prevention and management of work-related stress and mental ill health. They agreed with the experts that striving to attain workplace charters or accreditation was a useful way for organisations to work with external bodies to improve mental wellbeing and make their organisation a more attractive place to work. These would also allow employers to access external support and advice about improving and maintaining mental wellbeing at work. The committee also agreed that existing guidance, such as the Health and Safety Executive's Management Standards for work-related stress, would be useful.

The committee agreed that employee assistance programmes and occupational health services are good options for supporting employees' mental wellbeing, although they noted that there was a lack of evidence about how effective they are. They agreed with expert testimony about major challenges to small and medium-sized enterprises in improving the mental wellbeing of staff, what they can do to improve staff mental wellbeing and that low-cost schemes such as Mindful Employer may be useful for smaller organisations with limited resources. The committee also discussed that some employees in occupations that are not generally considered high-risk may be exposed to traumatic events at work – for example, because of a pandemic or terror attack – and that employers need to have plans in place to support employees in case such events do occur.

The lack of published evidence about the effectiveness of employee assistance programmes led the committee to make a recommendation for research on organisational-level approaches for all organisations because evidence on this could help NICE to make more specific recommendations on this topic in future.

How the recommendations might affect practice

The recommendations reflect good practice in communication across the organisation, in active leadership involvement and in engaging with employees. There should not be an extensive resource impact because the recommendations involve adhering to existing best practice.

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Why the committee made the recommendations

The committee agreed it was important that all line managers received training and support. They considered that this was good practice in all industries and all sizes of organisation, and that managers benefit in terms of their mental wellbeing from feeling skilled to perform their line management duties.

There was a range of evidence showing that manager training interventions were effective (especially in terms of outcomes for the manager who had been trained) or had no effect, although the committee noted that much of this evidence was uncertain. There was no evidence of unintended consequences associated with these interventions. There was some higher quality evidence that manager training can help to increase managers' knowledge of how to reduce stigma, and also help to increase their confidence in identifying and supporting employees who may be at risk of poor mental health. This agreed with the experience of the committee, who found that training managers in mental health awareness can increase their knowledge and willingness to discuss mental health.

Reducing stigma and equipping managers with skills to have conversations with employees about mental health is likely to facilitate conversations between managers and employees about any concerns about their mental wellbeing. This makes it more likely that managers can support employees with mental health issues. Providing managers with skills to discuss mental wellbeing improves the relationship between manager and employee so that they can identify and reduce work stressors. The evidence also showed that increasing managers' knowledge leads to more employees using the support services on offer. Although the evidence was not strong in this area, the committee agreed some points that would be a useful core for the content of mental health training for managers. They also agreed it was important for people to be able to suggest topics they thought were important.

The committee agreed with the qualitative evidence that manager training interventions delivered in groups had added benefit because they allow managers to learn from each other and to reinforce best practice. Therefore, the committee agreed, based on their experience and the evidence, that it can be helpful to offer group training as part of mental health awareness training. But they acknowledged that this might not be possible, for example in smaller organisations. Expert testimony about major challenges to small and medium-sized enterprises in improving the mental wellbeing of staff and what they can do to improve staff mental wellbeing, managing mental health in the workplace during and after COVID‑19, and committee experience, highlighted that managers have additional pressures related to their role, and that delivering any training in a group format would provide peer support. The committee also discussed that because of the increased pressures faced by managers, it is important that they are supported by human resources, occupational safety, and health and wellbeing professionals.

The committee discussed expert testimony about managing mental health in the workplace during the COVID‑19 pandemic and about the likely long-term impacts of COVID‑19 on mental wellbeing in the workplace. It helped them to make recommendations about the content of management training to support mental wellbeing. They agreed that managers should be empowered to make reasonable adjustments to the workload or intensity to reduce stressors for employees. This would give employees relief from work stress sooner because requests would not need to be escalated before support could be given. This expert testimony also highlighted the value of peer-to-peer support for managers, which the committee agreed matched their own expert experience.

The committee further discussed that although there was some data on the effectiveness of the interventions reviewed in terms of employee outcomes, overall, there was insufficient data and they had to extrapolate from their expertise and experience along with the small amount of evidence they had. They suggested that this may be because interventions had a short follow up of 3 months. This might be sufficiently long to show a difference in manager outcomes, but it may not be long enough to show a change in employee outcomes, including mental wellbeing. Therefore, the committee agreed that further research is needed on employee outcomes with longer follow ups (see the recommendation for research on training for managers).

How the recommendations might affect practice

The committee agreed that most organisations with a management structure would have some form of manager training programme, and that these recommendations reflect good practice in training managers. If the recommendations are built into those existing training structures, the committee agreed the resource impact of these recommendations would be small. For other organisations, the committee agreed that buying in external training could be expensive, but that training costs could be minimised by using free training resources.

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Why the committee made the recommendations

The committee agreed that within the 3‑tiered approach covered in the section on strategic approaches to improving mental wellbeing in the workplace, it was important for organisations to prioritise an organisational approach to improving mental wellbeing in the workplace. The committee emphasised that individual-level approaches are not a suitable alternative to organisational-level approaches because these are less likely to be effective on their own. So, individual approaches need to be additional to organisational approaches and not a substitute for them.

The committee recognised the importance of good relationships between managers and employees, and of employees being able to approach managers to discuss any concerns. Making opportunities – for example, for small talk – to develop good relationships could help with this. This would help employees to discuss issues they may have outside work and it may help to identify support that could be put into place. The committee also highlighted that in some cases, a manager could have a negative impact on an employee's mental wellbeing. Therefore, mechanisms are needed for employees to discuss any concerns with an appropriate person.

The committee saw evidence on a range of individual-level interventions that aimed to improve mental wellbeing in an unselected population. They were clear that these were not a substitute for organisational-level approaches. The evidence they were presented with had some limitations, but the committee agreed that mindfulness, meditation and yoga were most effective overall in reducing job stress and mental health symptoms and having a positive effect on employee mental wellbeing. The evidence showed that these interventions were effective when delivered either in a group or online. The committee decided that employees should be able to choose how the interventions are delivered (see the section on engaging with employees and their representatives).

The committee noted a lack of evidence about the long-term effectiveness of universal individual-level interventions in all organisations (see the recommendation for research on individual-level interventions) and a lack of evidence about the specific needs of different groups, for example different age groups or employees from different cultural backgrounds that prevented them from making specific recommendations about this. (See the recommendations for research on the needs of different employee groups.)

How the recommendations might affect practice

The committee recognised that many small businesses would not have the resources to provide mindfulness, yoga or meditation interventions, but noted that there are free or low-cost options for all of these, which would only need signposting by employers.

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Why the committee made the recommendations

The committee raised concerns that managers may face difficulties around confidentiality if they think that an employee is at risk of harming themselves or others. To reduce the burden placed on individuals, the committee decided that organisations should have clear policies on confidentiality.

The committee discussed that a preventive approach is important for reducing poor mental wellbeing. But they acknowledged that some employees will already have poor mental health and others will be at increased risk of poor mental health. Therefore, these employees should be offered support. The committee suggested that, although there was no specific evidence for them, wellness action plans were likely to be a useful way to open a dialogue between managers and employees about mental health concerns and what support could be put in place to help employees. They could also help to highlight needs for organisational change.

The evidence agreed with the committee's collective experience and showed that cognitive behavioural therapy, mindfulness and stress management were effective in improving mental wellbeing outcomes in employees with poor mental health. However, there was more limited evidence for cognitive behavioural therapy than for the other 2 options. They noted that if treatment is commissioned by the employer, they are required to check that the provider has the necessary qualifications and is accredited and regulated by relevant professional organisations to offer the interventions.

The committee noted that there was a potential resource impact for offering these and that for smaller organisations, free or low-cost options existed (for example, online resources such as the local Improving Access to Psychological Therapies scheme). The committee thought it was important that employees were made aware of the option to not have an intervention and to take up an offer of it at a later date, or to stop an intervention at any time and restart it later. This avoids employees feeling pressured to start or continue an intervention. They also agreed it was important that employers recognise that an employee may prefer a particular type of intervention, possibly because of their previous experiences with interventions.

The committee noted the lack of evidence about which strategies can be used to identify employees at risk of poor mental wellbeing. (See the recommendation for research on identifying employees at risk of poor mental wellbeing.)

How the recommendations might affect practice

The recommendations reflect good practice around managing and supporting employees. The committee noted a potential resource impact to implement interventions, both in terms of work hours and financial resources. But this could be limited by using free resources.

They noted that there may be a resource impact to offering flexible working hours, job changes or other organisational support to people at risk of poor mental health but assessed that this would often be very low.

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Why the committee made the recommendations

If the psychosocial risk assessment (see the section on strategic approaches to improving mental wellbeing in the workplace) for a role indicates that it is high risk, it is important that organisations have additional processes in place to support employees. The committee agreed that it was important to make sure these processes conformed to best practice in the field, and from their experience, they were able to identify Mind's Blue Light Programme as an example of best practice.

There was good evidence showing that when police and healthcare professionals were given the skills to deal with stressful occupational events through task-focused skills training (including imagery and simulation), mental health symptoms were reduced, and mental wellbeing and quality of life improved. Based on this evidence, the committee decided that organisations should provide task-focused skills training for employees in high-risk occupations. They also recommended, in line with the evidence, that employees in high-risk occupations are offered support after a traumatic event.

The committee noted that there were exceptional circumstances, for example, the COVID‑19 pandemic, which could cause stressful occupational events more widely (for example, some people might find homeworking or social distancing in the workplace stressful).

How the recommendations might affect practice

All high-risk occupations should already have policies and procedures in place on how to deal with predictable and stressful occupational events. These recommendations will not affect the resources needed for this.

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Why the committee made the recommendations

The committee suggested that consulting employees about the type and format of organisational approaches and individual interventions offered would help employers understand what good mental wellbeing would look like in their organisation. It would also help them to tailor their approach to the needs of their employees and the organisation. They believed that this would give employers the opportunity to raise awareness about why the interventions are being implemented, which could improve employee support for them.

The committee discussed that by providing interventions during the working day, employers would give employees a beneficial break from work and send a clear message about the importance of mental wellbeing. However, organisations should be flexible because employees may also prefer to access interventions outside work hours. The committee also noted that people will have different preferences about how they learn. For example, some employees would benefit from a group setting, whereas others would prefer one-to-one or online interventions. This highlights the importance of engaging with employees to ensure that their needs are considered, and that if online interventions are offered, digital exclusion does not prevent any employee from accessing the intervention.

The committee also discussed, based on their experience, that the effectiveness of certain interventions may be different for different groups. Factors may include socioeconomic factors such as low income and whether people have disabilities, work in urban or rural locations or have good digital access. The committee agreed that staff surveys and consultation could be used to regularly monitor intervention accessibility.

How the recommendations might affect practice

The committee discussed the resource implications of these recommendations but overall did not think they would be significant in most cases. They noted that some organisations may not be able to provide interventions during work hours for financial reasons. In these cases, it may be better to provide interventions outside work hours rather than not making them available at all. They also noted that some organisations may not have the space to provide certain interventions on site, and this may affect the type or format of intervention offered.

Return to recommendations

Why the committee made the recommendations

The committee discussed that local and regional authorities should be role models in ensuring that their own workplaces actively promote mental wellbeing, given their role in public health. The committee highlighted that many local and regional authorities already have strategies in place to improve physical wellbeing in their population, and that these could be expanded to include mental wellbeing as part of a more holistic approach to wellbeing. This includes working with employers to ensure they know about resources or services that can help them improve the mental wellbeing of their employees and minimise the resource impact that this will have, especially for small and medium-sized enterprises and micro-enterprises. This could be done together with local enterprise partnerships and chambers of commerce. This can also be tailored to the needs of each organisation.

The committee heard expert testimony about a mental health and productivity pilot that included the possibility of local authorities using financial incentives to encourage employers to think about job quality and wellbeing in their workplaces. The committee discussed this and also discussed that in times of financial hardship, there may be non-financial incentives that are more achievable for local authorities. Because there was limited evidence about this, the committee agreed that it would not be appropriate to recommend incentive schemes, but that any authorities interested in them could introduce them as a pilot or as an evaluation.

Local and regional authorities will have ethical procurement frameworks in place, and a duty under the Social Value Act to consider wider social, economic and environmental factors during procurement. Therefore, the committee suggested that local and regional authorities could consider how organisations in their supply chains value job quality and mental wellbeing in the workplace.

How the recommendations might affect practice

Local and regional authorities already have schemes in place to help employers improve mental wellbeing in their workplaces, including the Department for Work and Pensions' access to work mental health support service. Many sources of support have already been curated by organisations such as Mind and Business in the Community, and local and regional authorities would only need to signpost employers to these.

The committee were aware that some local authorities may be having funding difficulties and did not want to place too much of a burden on them. Expert testimony about a mental health and productivity pilot discussed the possibility of local authorities using financial incentives to encourage employers to think about job quality and wellbeing in their workplaces. However, the committee noted that local and regional authorities may be able to provide other forms of incentives that do not need extra funds, for example dedicated advice and guidance.

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Why the committee made the recommendations

The committee heard from expert testimony from the Thriving at Work Leadership Council that many business owners are at risk of poor mental health and exhaustion as a result of the pandemic. They noted that leaders need to ensure that they also consider their own mental wellbeing.

The committee noted that a lot of the evidence was from larger organisations, and that small and medium-sized enterprises (SMEs) are likely to have fewer resources to help them address mental wellbeing in the workplace, such as occupational health and human resource professionals. The committee discussed that taking a preventive approach to ensuring good mental wellbeing could avoid problems later on (for employees and for the organisation). They agreed that employers could find a lot of guidance and resources on how to do this through the Mental Health at Work website, and Health and Safety Executive resources.

Public bodies such as local authorities and local enterprise partnerships should also be able to signpost employees of SMEs to information on how to prevent poor mental wellbeing at work and promote positive mental wellbeing, as well as signposting them to resources and services to support employees with poor mental health, such as the Department for Work and Pensions' access to work mental health support service. The committee suggested that SMEs may also want to sign up to the Mental Health at Work Commitment, which is a framework to help organisations improve the mental wellbeing of their employees.

The committee agreed that further research into SMEs was needed – particularly on the specific needs of SMEs for implementing individual-level interventions and the long-term effectiveness of universal individual-level interventions in both larger organisations and SMEs. So they made a recommendation for research on specific needs of different kinds of micro, small and medium-sized enterprises (SMEs) in promoting mental wellbeing in the workplace, including organisational, targeted and individual-level approaches and a recommendation for research on long-term effectiveness of universal individual-level interventions in different kinds of SMEs. These would enable NICE to make more specific recommendations for SMEs in future.

How the recommendations might affect practice

The committee were aware that, compared with larger organisations, SMEs may face additional constraints in terms of time and resources. The recommendations reflect ways that smaller organisations can look after the mental wellbeing of their workforce, without needing too much time or specialist knowledge about mental wellbeing.

The committee also discussed that employee assistance programmes and occupational health services may be a useful way of helping employees, and that smaller organisations may benefit from free or low-cost services such as the Department for Work and Pensions' access to work mental health support service or Mindful Employer.

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