Research has demonstrated that job stress and shift work, both of which nurses often experience, are risk factors for obesity. Zhao and Turner (2008) carried out a systematic review of studies focused on shift workers’ lifestyle. Findings from the 17 studies reviewed by the authors suggested that shift workers, as compared to non-shift workers, were more likely to be overweight, have adverse lifestyle behaviors, and eat less healthfully. In another study, a sample of 194 nurses from six hospitals participated in anthropometric measurements and self-administered surveys (Malik, Blake, & Batt, 2011). Results of the study showed that a majority of nurses were overweight and that their self-reported health, diet, and physical activity ratings were low. As researchers continue to find relationships between obesity and chronic illnesses and also the negative impact of unhealthy eating habits and lack of exercise on health, employers are considering new ways to help ensure a healthy work environment.
In 2011, the Surgeon General recommended a focus on Creating Healthy Worksites to make it easier for employees to participate in exercise programs and make nutritious food choices (Corporate Fitness Works, 2011). There are increasing numbers of employer-sponsored wellness programs that are designed to contain rising healthcare costs by encouraging healthy behaviors (Lessack, 2013). Behaviors that are targeted most frequently by wellness programs are exercise, smoking, and weight loss (Mujtaba & Cavico, 2013). The Patient Protection and Affordable Care Act (ACA) has allowed companies to provide financial incentives to employees for healthy behaviors (Berman, 2013; Madison, Volpp, & Halpern, 2011). ACA regulations distinguish between participatory and health-contingent wellness programs. Participatory wellness programs do not require employees to satisfy any particular standard, such as joining a gym or participating in a smoking-cessation program, in order to receive a reward. Health-contingent wellness programs require employees to perform specific activities related to a health factor or to achieve a specific health outcome in order to receive a reward (Lessack, 2013).
In theory, the primary ethical justification for employer-sponsored wellness programs is beneficence – the moral obligation to act for the benefit of others (Rothstein & Harrell, 2009). These programs appear to be a win-win situation: employees have opportunities to be healthier and save on healthcare costs, and employers can benefit from a more productive and healthier workforce (Voigt & Schmidt, 2013)
In spite of these advantages, however, implementation of these programs has raised some ethical concerns. The model of beneficence that is integrated by employee-sponsored wellness programs tends to be paternalistic, with health plans designed for economic leverage to encourage employees to adopt the type of healthy lifestyle activities selected by the specific health plan (Rothstein & Harrell, 2009). Privacy for employees is another concern, as coaches and others carrying out the programs collect sensitive health information about employee participants. There are risks of this information being stolen, as well as concerns with employee autonomy (Berman, 2013). In addition, there are concerns about potential discrimination of unhealthy employees that may occur if the incentive programs result in discouraging unhealthy job applicants, encouraging unhealthy employees to resign, or discouraging them from taking advantage of health benefit packages offered by the institution (Madison, Volpp, & Halpern, 2011). As increasing numbers and types of employer-sponsored healthy lifestyle programs increase, the question arises: At what point are incentives to participate or penalties for nonparticipation so great as to render participation in the program involuntary (Lessack, 2013)? Both the carrot (rewards) and stick (penalties) approaches to employee-sponsored healthy lifestyle program may raise some ethical concerns.
The Stick Approach
There is some evidence that penalties may be more powerful motivators for behavior change than rewards, as individuals may feel losses more acutely than gains (Conroy, 2013; Madison, Volpp, & Halpern, 2011). Thus, if program effectiveness of an employer-sponsored healthy lifestyle program is the goal, it may make sense to consider incorporating some type of penalties. Examples of sticks include higher healthcare premiums for unhealthy employees, a health insurance surcharge for smokers and obese employees, and denial of reimbursement of health expenses for employees who do not maintain a healthy lifestyle. It is estimated that in 2014, 40% of companies in the United States would use some form of penalty for employees who do not complete specific health-management activities; this number is anticipated to increase to 60% for 2015-2016 (Conroy, 2013).
Since penalties may serve as incentives for employees to adopt healthy behaviors and thus improve their overall health and wellbeing, this movement toward a positive outcome appears to be ethical. It is important to consider, however, whether coercion may be a factor in implementation of a program that carries a penalty for non-participation. A program that uses a penalty for an incentive could be considered coercive if it would worsen the situation or violate the rights of an employee who was unable to engage in healthy behaviors (Madison, Volpp, & Halpern, 2011). Other concerns relate to the potential for discrimination and harassment for failure to participate in wellness programs (Mujtaba & Cavico, 2013).
The Carrot Approach
ACA regulations stipulate that health-contingent wellness programs may offer rewards only if five requirements are met (Lessack, 2013; Mello & Rosenthal, 2008):
- Employees have the opportunity to qualify for the reward at least once per year
- Maximum reward is 30 percent of the cost of an employee’s health coverage (up to 50 percent for programs designed to prevent or reduce tobacco use)
- Program is reasonably designed to promote health or prevent disease
- All similarly situated individuals are eligible for the same reward
- Plan materials disclose that a reasonable alternative standard or waiver for obtaining the reward is available for employees whose medical condition makes it difficult to satisfy the standard. An example might be a smoker who would find it unreasonably difficult to quit smoking because of a medical condition diagnosed as addiction to nicotine.
Examples of carrots used in wellness programs include classes to reduce stress, exercise programs, healthy-eating counseling, and smoking-cessation programs, all of which may be offered free to the employee or at minimal cost. Other rewards may include reductions in health insurance premiums for employees with increased exercise, weight loss, lower cholesterol, improved blood pressure, or no smoking. A carrot approach targets incentives specifically toward unhealthy individuals who change their behavior to adopt more healthy lifestyles (Madison, Volpp, & Halpern, 2011). In spite of the obvious benefits to the employee from these reward incentives, however, there is some concern that carrot approaches may also constitute coercion and are not truly voluntary (Mujtaba & Cavico, 2013). The carrot approach may reflect ‘undue inducement,’ in which an employee may decide, based on anticipation of a substantial reward, to participate in an activity that has increased risk, such as strenuous exercise for unhealthy individuals (Madison, Volpp, & Halpern, 2011).
Employer-sponsored wellness programs should not only focus on promotion of healthy behaviors but also on protection of employee rights. The following represent important points to consider (Mujtaba & Cavico, 2013):
- Avoid discrimination when creating the wellness program
- Make sure the wellness program does not treat similarly situated employees differently
- Ensure rewards or penalties do not exceed 20% of cost of employee’s health coverage
- Do not reduce an employee’s pay for any healthcare issue
- Provide alternatives or exemptions for employees who have medical reasons for not participating in a wellness program or meeting certain healthcare goals
- Do not request health records before extending an offer of employment
- Keep employee’s healthcare information strictly confidential
Some people argue that wellness programs are ‘unethical’ because the employer’s main motivation is not to improve the employees’ health but to cut institutional costs for insuring smokers and other employees with ‘unhealthy’ lifestyles (Mujtaba & Cavico, 2013). Others are concerned that wellness policies may be a ‘slippery slope,’ with future penalties for such activities as relying on fast-food meals or drinking alcohol. Nurses can be important advocates for implementing worksite wellness programs that create a culture of wellness and encourage employees to take responsibility for their own health. Designing wellness programs that use ‘carrots’ and ‘sticks’ as incentives for participation and are careful to uphold ethical principles can make important contributions to the health and wellbeing of nurses and all employees.
Jeanne Merkle Sorrell, PhD, RN, FAAN