Participatory work place intervention for stress prevention in primary health care. A randomized controlled trial

When Illegitimate Tasks Threaten Patient Safety Culture: A Cross-Sectional Survey in a Tertiary Hospital

Objectives: The current study investigates the prevalence of illegitimate tasks in a hospital setting and their association with patient safety culture outcomes, which has not been previously investigated. Methods: We conducted a cross-sectional survey in a tertiary referral hospital. Patient safety culture outcomes were measured using the Hospital Survey on Patient Safety Culture questionnaire; the primary outcome measures were a low safety rating for the respondent's unit and whether the respondent had completed one or more safety event reports in the last 12 months. Analyses were adjusted for hospital department and staff member characteristics relating to work and health. Results: A total of 2,276 respondents answered the survey (participation rate: 35.0%). Overall, 26.2% of respondents perceived illegitimate tasks to occur frequently, 8.1% reported a low level of safety in their unit, and 60.3% reported having completed one or more safety event reports. In multivariable analyses, perception of a higher frequency of illegitimate tasks was associated with a higher risk of reporting a low safety rating and with a higher chance of having completed event reports. Conclusion: The prevalence of perceived illegitimate tasks was rather high. A programme aiming to reduce illegitimate tasks could provide support for a causal effect of these tasks on safety culture outcomes.

The Association of Work Overload with Burnout and Intent to Leave the Job Across the Healthcare Workforce During COVID-19

BACKGROUND

Burnout has risen across healthcare workers during the pandemic, contributing to workforce turnover. While prior literature has largely focused on physicians and nurses, there is a need to better characterize and identify actionable predictors of burnout and work intentions across healthcare role types.

OBJECTIVE

To characterize the association of work overload with rates of burnout and intent to leave (ITL) the job in a large national sample of healthcare workers.

DESIGN

Cross-sectional survey study conducted between April and December 2020.

SETTING

A total of 206 large healthcare organizations.

PARTICIPANTS

Physicians, nurses, other clinical staff, and non-clinical staff.

MEASURES

Work overload, burnout, and ITL.

RESULTS

The sample of 43,026 respondents (mean response rate 44%) was comprised of 35.2% physicians, 25.7% nurses, 13.3% other clinical staff, and 25.8% non-clinical staff. The overall burnout rate was 49.9% (56.0% in nursing, 54.1% in other clinical staff, 47.3% in physicians, and 45.6% in non-clinical staff; p < 0.001 for difference). ITL was reported by 28.7% of healthcare workers, with nurses most likely to report ITL (41.0%), followed by non-clinical staff (32.6%), other clinical staff (32.1%), and physicians (24.3%) (p < 0.001 for difference). The prevalence of perceived work overload ranged from 37.1% among physicians to 47.4% in other clinical staff. In propensity-weighted models, work overload was significantly associated with burnout (adjusted risk ratio (ARR) 2.21 to 2.90) and intent to leave (ARR 1.73 to 2.10) across role types.

LIMITATIONS

Organizations' participation in the survey was voluntary.

CONCLUSIONS

There are high rates of burnout and intent to leave the job across healthcare roles. Proactively addressing work overload across multiple role types may help with concerning trends across the healthcare workforce. This will require a more granular understanding of sources of work overload across different role types, and a commitment to matching work demands to capacity for all healthcare workers.

Testing middle range theories in realist evaluation: a case of a participatory organisational intervention

Purpose

Realist evaluation seeks to answer the question of “what works for whom in which circumstances?” through developing and testing middle range theories (MRTs). MRTs are programme theories that outline how certain mechanisms of an intervention work in a specific context to bring about certain outcomes. In this paper, the authors tested an initial MRT about the mechanism of participation. The authors used evidence from a participatory organisational intervention in five worksites of a large multi-national organisation in the US food service industry.

Design/methodology/approach

Qualitative data from 89 process tracking documents and 24 post-intervention, semi-structured interviews with intervention stakeholders were analysed using template analysis.

Findings

The operationalised mechanism was partial worksite managers’ engagement with the research team. Six contextual factors (e.g. high workload) impaired participation, and one contextual factor (i.e. existing participatory practices) facilitated participation. Worksite managers’ participation resulted in limited improvement in their awareness of how working conditions can impact on their employees’ safety, health, and well-being. Based on these findings, the authors modified the initial MRT into an empirical MRT.

Originality/value

This paper contributes to the understanding of “what works for whom in which circumstances” regarding participation in organisational interventions.

The Cost-Effectiveness Analysis of the Productivity Measurement and Enhancement System Intervention to Reduce Employee Work-Related Stress and Enhance Work Performance

Background: The study evaluates the cost-effectiveness of the Productivity Measurement and Enhancement System (ProMes) intervention to reduce employee work-related stress and enhance work performance. Methods: A prospective cohort study was used to undertake the evaluation from a business perspective. Objective workload data and stress were gathered repeatedly over a 17-month period (i.e., before and after intervention). Independent t-test and an interrupted time series (ITS) analysis were used in the analysis. The average cost-effectiveness ratio (ACER) was calculated as a ratio of the average cost of the intervention and the effect sizes of the different outcomes to reflect the average cost per clinician for each unit change in outcome. Results: Based on the results of the ITS analysis, an expenditure of EUR 41,487 was linked with no change in stress levels, according to the ACER for stress. In addition, the expenditures associated with each unit change were EUR 3319 for overall tasks per hour worked, EUR 2761 for visits per hour worked, EUR 2880 for administrative tasks, but EUR 9123 for answering phone calls. Conclusions: ProMes is not cost–effective in terms of work-related stress levels, but the intervention seemed to have increased efficiency in some objective work performance measures, albeit at a relatively high extra cost.

Work-related predictors of mental health, presenteeism, and professional quality of life following exposure to a potentially traumatic event in child protection workers

BACKGROUND

Exposure to potentially traumatic events (PTEs) at work can have a negative impact on the psychological health and work life of child protection workers (CPWs). The most common form of work-related PTE experienced by CPWs consists of aggressive behaviours from the youths or their parents.

OBJECTIVE

This study aims to identify modifiable work-related variables that might influence the probability of experiencing impaired mental health and professional adjustment following a PTE.

METHOD

The participants were CPWs from two youth social services organizations in Canada. A survey was administered to CPWs within one month of a work-related PTE (Time 1; n = 176), two months after the PTE (Time 2; n = 168), six months after the PTE (Time 3; n = 162), and 12 months after the PTE (Time 4; n = 161). Lagged linear mixed models allowed for the independent variables measured at Time 1, Time 2, and Time 3 to predict the outcome variables as measured on the next assessment (Time 2, Time 3, and Time 4, respectively). The outcomes of interest were insomnia symptoms, depressive symptoms, anxiety symptoms, and post-traumatic stress symptoms, as well as presenteeism (inadequate work performance) and professional quality of life.

RESULTS

Confidence in one's own ability to cope with service user aggression negatively predicted depressive, anxiety, and post-traumatic stress symptoms as well as presenteeism, and positively predicted professional quality of life. The perception of job safety negatively predicted depressive, anxiety, and post-traumatic stress symptoms, and positively predicted professional quality of life. Finally, psychological demands from work positively predicted all mental health outcomes as well as presenteeism, and negatively predicted professional quality of life.

CONCLUSIONS

This study identified work-related variables that could be modified in an attempt to prevent the negative impacts of exposure to work-related PTEs, especially, aggressive behaviours from the service users.

Development Work in Healthcare: What Supportive and Deterrent Factors Do Employees Working in a Hospital Department Experience in an Improved Work Environment?

Work-related mental health issues, accounting for high worker absenteeism in the world's developed economies, are increasing, with the main cause being workplace conditions. The health services sector is especially experiencing great problems with this, because of challenging psychosocial working conditions. The aim of this study was to explore employees' experiences of development work with a focus on the work environment within a hospital department with an outspoken special development assignment. The special assignment was decided by the highest management at the hospital and concerned work environment, caring processes, and ways of organizing the work. Eleven employees completed two individually semi-structured interviews, approximately 7 and 13 months after the start of the special assignment at the department. Interviews were analyzed using thematic analysis. The results reveal that both internal and external aspects influence the development work and highlight the importance of viewing the local development work in relation to how the rest of the organization functions. Important factors and conditions for a supportive and change-friendly work culture are discussed, as well as the need to plan for integration and change to create conditions for successful implementation of the results from organizational development and change initiatives.

Developing Initial Middle Range Theories in Realist Evaluation: A Case of an Organisational Intervention

(1) Background: Realist evaluation is a promising approach for evaluating organisational interventions. Crucial to realist evaluation is the development and testing of middle range theories (MRTs). MRTs are programme theories that outline how the intervention mechanisms work in a specific context to bring about certain outcomes. To the best of our knowledge, no organisational intervention study has yet developed initial MRTs. This study aimed to develop initial MRTs based on qualitative evidence from the development phase of an organisational intervention in a large multi-national organisation, the US food service industry. (2) Methods: Data were collected through 20 semi-structured interviews with the organisation's managers, five focus groups with a total of 30 employees, and five worksite observations. Template analysis was used to analyse data. (3) Results: Four initial MRTs were developed based on four mechanisms of participation, leadership commitment, communication, and tailoring the intervention to fit the organisational context to formulate 'what may work for whom in which circumstances?' in organisational interventions; (4) Conclusions: Our findings provide insights into 'how' and 'which' initial MRTs can be developed in organisational interventions.

Can the Human Resources Index (HRI) Be Used as a Process Feedback Measurement in a Structured Support Model for Systematic Work Environment Management?

The aim of the study was to estimate the level of the human resources index (HRI) measure among Swedish municipal employees, and to investigate the association between human resources index (HRI) and relational justice, short-term recovery, work environment-related production loss, and health-related production loss. A cross-sectional design was used with one sample of municipal employees (n = 6402). The results showed a positive association (r = 0.31) between human resources index (HRI) and relational justice; a positive (r = 0.27) association between HRI and short-term recovery; a negative association between HRI and work environment-related production loss (r = −0.37); and a negative association between HRI and health-related production loss (r = −0.23). The findings implicate that HRI captures important aspects of the work environment such as productivity, relational justice, and short-term recovery. The HRI measure is part of a support model used in workplaces to systematically address work environment-related issues. Monitoring changes in the HRI measure, it is possible to determine whether the measures taken effect production loss, perceived leadership, and short-term recovery in a work group. The support model using HRI may thus be used to complement traditional work environment surveys conducted in Swedish organizations as obliged by legal provisions.

A Participatory Intervention to Improve the Psychosocial Work Environment and Mental Health in Human Service Organisations. A Mixed Methods Evaluation Study

Work-related stress is a global problem causing suffering and economic costs. In Sweden, employees in human service occupations are overrepresented among persons on sick leave due to mental health problems such as stress-related disorders. The psychosocial work environment is one contributing factor for this problem, making it urgent to identify effective methods to decrease stress at the workplace. The aim of the study is to evaluate a participatory intervention to improve the psychosocial work environment and mental health using an embedded mixed methods design. The study is a controlled trial with a parallel process evaluation exploring fidelity and participants’ reactions to the intervention activities, experiences of learning and changes in behaviours and work routines. We collected data through documentation, interviews and three waves of questionnaires. Our results show small changes in behaviours and work routines and no positive effects of the intervention on the psychosocial work environment nor health outcomes. One explanation is end-users’ perceived lack of involvement over the process causing the intervention to be seen as a burden. Another explanation is that the intervention activities were perceived targeting the wrong organisational level. A representative participation over both content and process can be an effective strategy to change psychosocial working conditions and mental health.

H-WORK Project: Multilevel Interventions to Promote Mental Health in SMEs and Public Workplaces

The paper describes the study design, research questions and methods of a large, international intervention project aimed at improving employee mental health and well-being in SMEs and public organisations. The study is innovative in multiple ways. First, it goes beyond the current debate on whether individual- or organisational-level interventions are most effective in improving employee health and well-being and tests the cumulative effects of multilevel interventions, that is, interventions addressing individual, group, leader and organisational levels. Second, it tailors its interventions to address the aftermaths of the Covid-19 pandemic and develop suitable multilevel interventions for dealing with new ways of working. Third, it uses realist evaluation to explore and identify the working ingredients of and the conditions required for each level of intervention, and their outcomes. Finally, an economic evaluation will assess both the cost-effectiveness analysis and the affordability of the interventions from the employer perspective. The study integrates the training transfer and the organisational process evaluation literature to develop toolkits helping end-users to promote mental health and well-being in the workplace.

Process Evaluation of a Participative Organizational Intervention as a Stress Preventive Intervention for Employees in Swedish Primary Health Care

This study is a process evaluation of a trial examining the effects of an organizational intervention (Productivity Measurement and Enhancement System or ProMES) on employee stress. The aims were to explore the implementation process and fidelity to the intervention guidelines, examine the influence of contextual factors (hindrances and facilitators) and explore participants' experience of working with ProMES. We used the UK Medical Research Council (MRC) guidance to guide the process evaluation. The recruitment, reach and dose delivered were satisfactory and participation high. The employees felt ProMES clarified priorities, gave control and increased participation in decision-making. However, difficulty in obtaining statistical productivity data from the central administration office (a central feature of the intervention) hindered full implementation and regular feedback meetings. Staffing shortages interfered with the implementation process, while having seven design teams and one consultant prevented all occupational groups from working simultaneously. A detailed examination of access to necessary organizational data should be undertaken before implementing ProMES. We recommend a better introduction for new employees, more work on design and packaging and giving employees more training in how to use the software program. The study contributes to our understanding of process evaluations in research into organizational stress management interventions.

Experience of Stress Assessed by Text Messages and Its Association with Objective Workload-A Longitudinal Study

Exploring stress trajectories in detail and over a long time may give valuable information in terms of both understanding and practice. We followed a group of primary health care employees in a randomized controlled trial. The objective was to describe their experience of stress, explore the intra-individual variability and examine the association between the experience of stress and the objective workload. Weekly text messages with a single item stress question were distributed in two time series: 12 weeks at the beginning of the trial and 26 weeks after the 6-month follow up. Aggregated objective data about workload were collected from their administration office and related to stress levels. There was a seasonal variation, with higher stress during the fall than in spring and summer. The analysis comparing high and low stress subgroups showed that the stress trajectory of a high-stress subgroup was different from that of a low-stress subgroup. Individuals with high exhaustion scores had higher odds of belonging to a subgroup of individuals with high intra-individual variability in stress experience. The objective workload was measured in two ways and was strongly associated with the stress experience. We found that the lower the productivity, the higher the feeling of stress.

Design of a randomized trial testing a multi-level weight-control intervention to reduce obesity and related health conditions in low-income workers

Weight-control is a major public health focus for preventing multiple obesity-related health conditions. While clinic-based intensive lifestyle interventions are successful, low-socioeconomic-status (SES) populations, which have a higher burden of obesity, are difficult to reach; thus, the workplace offers a useful setting to target low-SES workers. The current paper presents the design of a study testing a workplace intervention aimed at low-SES employees. Partnering with a large healthcare system and affiliated university, this project will test an innovative multi-level intervention ("Working for You") adapted from existing group- and individual-level intervention models to promote healthy weight among low-wage workers. The individual-level component is an interactive obesity treatment approach (iOTA) program that involves assessment of behavior risks, collaborative goal-setting with a health coach, and interactive SMS text-messages for ongoing support and self-monitoring. This mHealth intervention is embedded in the group-level component, a workplace participatory program that involves worker teams engaged in the design and implementation of interventions to change their workplace environments. These nested interventions are being tested in a group-randomized trial among 22 work groups (~1000 total workers, ~300 workers with obesity). The primary outcome will be program effects on weight at 2-year follow-up, compared to control, and the secondary outcomes will be effects on diet and physical activity; iOTA adherence, process measures, and work environment/support will also be examined. This pragmatic clinical trial will test scalable interventions that can be translated to other work settings to reduce obesity and related health risks among low-SES workers. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02934113.