**1. Introduction**

Total Worker Health® (TWH) is defined as policies, programs, and practice that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being [1]. As the field of TWH gains research and practice support, it is important to study the role of organizational leadership. Several TWH frameworks call for attention to organizational leadership in the implementation and effectiveness of TWH approaches [2–4]. However, to date, leadership research has rarely integrated both health promoting leadership and safety leadership. Doing so can improve our understanding of how to assess and improve TWH-specific leadership practices to ensure TWH system effectiveness [5]. This is especially important in the small business environment where employees face significant health, safety, and well-being concerns [6,7] and employers face barriers to addressing these concerns (e.g., resources) [6,8]. Therefore, as a first

step, the purpose of this study was to improve our understanding of how small business leaders perceive employee health, safety, and well-being in the context of their own actions.

The field of leadership research has grown substantially over the past few decades. Dinh et al. [9] found 66 leadership theory domains in their review of the leadership literature. While the evidence base for each of these theories varies, it is generally agreed that leadership is a significant contributor to organizational culture and ultimately, organizational success [10]. Successful organizations primarily have leaders who adopt several leadership characteristics to best meet organizational needs [11]. A healthy business culture is derived from integrating leadership theories that align employee and organizational goals [12], though some leaders who use some styles of leadership have been more effective in promoting health than others.

Building positive relationships, empowerment and the ability to view the organization from an employee viewpoint are characteristics of successful leaders. Servant leaders are known for their supportive nature and how they achieve organizational goals by prioritizing needs of employees first [13]. Similarly, leaders who employ high quality relationships (leader-member exchange (LMX)) leverage employee relationships to meet organizational ambitions [14]. Successful leaders also place value in employee perceptions of meaningful work and contribution to the larger picture. Sirota's Three Factor Theory argues for building and maintaining employee enthusiasm through equal treatment, employee belief that work is meaningful, and camaraderie. Sirota's theory describes that when leaders champion these factors, workers will be enthusiastic and motivated to produce more, while enjoying what they do [15].

Leadership has an impact on employee physical and psychological health. Transformational leadership, specifically, has been positively associated with psychological well-being [16], stress [17], depression [18], and sleep quality [19]. In terms of safety-specific outcomes, several meta-analyses demonstrate that leadership (generally defined) and transformational leadership are related to better safety climate, better safety practices, and fewer occupational injuries [20–22]. However, employee health can also be compromised as a result of poor leadership. Researchers have found associations between poor management support and ischemic heart disease [23], elevated blood pressure [24], problem drinking [25], smoking [26], as well as mental health issues related to affective well-being [27] and job well-being [16,28,29]. For example, Skakon et al. found that when leaders have high stress and poor affective well-being, their subordinates also have high stress levels and poor well-being [27].

Recently, researchers have begun to investigate health promoting leadership. Health promoting leadership theory involves leadership characteristics that encourage wellness at work [30]. Research has shown that leaders who promote workplace health are hands-on, supportive [31], demonstrate health awareness, and value community and fairness [32,33]. It has also been suggested that work-related stress may be reduced when specific, health promoting transformational leadership skills are demonstrated at work [34]. Though research may be limited, all health promoting leadership studies suggest that health promoting leadership characteristics are likely to produce positive health outcomes. However, in the context of TWH, health promoting leadership fails to consider the role of safety leadership.

In contrast, the theory and evidence base for safety leadership gained traction over fifteen years ago [35]. The majority of the safety-specific literature focuses on Bass's multifactor leadership theory [36]. Some researchers developed safety-specific assessments of transformational and passive leadership and found them to be more associated with safety outcomes than general forms of leadership [37]. Studies have shown that the passive form of transactional safety leadership negatively impacts safety outcomes (e.g., injury rates) whereas transformational safety leadership positively impacts safety outcomes [38]. However, other more active forms of transactional leadership, contingent reward and active management-by-exception, have been linked to positive safety outcomes [39]. Safety leadership intervention studies have suggested that training leaders on transformational safety leadership skills can lead to positive safety outcomes [40,41]. Other researchers applied the LMX theory [42] and empowering leadership theory [43] to workplace safety and found both to be related

to positive safety outcomes. Although, similar to the singular focus of HP leadership, safety leadership research has focused solely on safety and has rarely included research on other outcomes.

The literature illustrates the segmented nature of leadership research in the employee health promotion and safety contexts. Health promoting and safety leadership are both "best practices" to support worker health and safety but we are unaware of a concerted effort to evaluate their use in synchrony. Furthermore, we are aware of only one study that assessed health promotion and safety leadership support amongst small businesses. They found that small business leaders who advocate for TWH have higher integration scores than leaders who do not [44]. However, this study did not define TWH leadership support or describe the ways in which TWH leaders advocate. Thus, while there is some indication that TWH leadership is important amongst small businesses, it is unclear how small businesses leaders can demonstrate support for TWH. For this reason, as a first step in understanding TWH leadership development needs, we sought to interview small business leaders to understand how they discuss their use of practices that demonstrate a commitment to health, safety, and well-being.

#### **2. Materials and Methods**

We conducted a qualitative study with small business leaders to understand their current approach to leadership for employee health, safety, and well-being (Appendix A). We recruited small business leaders (<500 employees) in Colorado and Wyoming from a variety of industries by phone and email from May 2017 to August 2017. Businesses were identified through existing networks including a workers' compensation insurer, chambers of commerce, and a community-based program, Health Links™. Leaders were eligible to participate if they had significant decision-making power in the organization (e.g., owner, senior executive, or CEO).

The first author conducted 30-min, semi-structured interviews in-person or by phone asking each leader how they perceive health, safety, and well-being in their organization and their role in shaping it. The authors generated eleven interview questions based on the following themes related to key theories used in previous health promotion or safety leadership research: organizational mission, organizational culture, leading by example as well as employee advancement, feedback, and recognition [11,15,37,45–47]. We chose these theories because they reflect important leader characteristics and actions for employee health, safety, and well-being. Beyond the transformational style commonly studied in safety leadership [11,37], other styles layer in important leadership aspects, including openness, ethics [45], equity [15], focus on follower needs [47], and relationships [46]. In keeping with the TWH framework, all questions inquired about leader actions associated with health, safety and well-being together. In keeping with leadership frameworks, all questions asked them about their own practices, not their general business practices. If the interview lasted less than 30 min, the first author asked additional follow-up questions. Follow-up questions were developed a priori, however they were chosen by the interviewer based on participant answers to main survey items. The interview questions can be read in the supplementary material. All interviews were recorded. We obtained verbal permission from all participants prior to recording. The first author transcribed the interview by hand in Microsoft Word and then imported it into Dedoose, qualitative data analysis software [48]. Our protocol and all study procedures were approved by the Colorado Multiple Institutional Review Board.

#### *Analysis*

The first and second authors analyzed the interview data using a qualitative coding approach described by Saldana [49]. We used descriptive codes to summarize content line by line into concise themes. The authors initially coded two transcripts individually with codes that best represented the interview content, allowing the codes to emerge from the content. The authors then met to compare codes and determine which codes best represented the content. Manuscripts were coded two at a time until all coding was complete. During this initial coding phase, three overarching themes became apparent. Thus, the authors decided to categorize all codes into one of three overarching themes. First, a *business* overarching theme included transactional policies, programs, and practices. To be coded within this overarching theme, the leader must have spoken about how their business operates in general and not specific to either what they do or say or what their employees do or say in a health and safety context. Second, an *employee* overarching theme represented a discussion of health, safety, and well-being from their employee's perspective. Finally, a *self* overarching theme represented a discussion of what they personally do for health, safety, and well-being.

The pair met after initial coding to compare and discuss their respective coding scheme. Codes were structured as: parent code (three overarching themes), child code (sub-code), grandchild code (sub-sub-code). It was agreed upon a priori that lines of code could be simultaneously coded as more than one code, if deemed necessary. When codes differed between investigators, a discussion took place and the most agreeable code was assigned. After each combined coding session, we transferred the finalized codes into Dedoose [48]. This process was followed until all transcripts were coded. Once the coding phase was completed, we extracted the coded data from Dedoose to Microsoft Excel. Finally, we conducted a descriptive, quantitative analysis of the overall frequency of codes.
