Workload as a Determinant of Staff Injury in Intermediate Care

A framework for studying risk factors for lower extremity musculoskeletal discomfort in nurses

Lower extremity musculoskeletal discomfort (MSD) is prevalent, but understudied, in nurses. A comprehensive, theoretical, aetiological model of lower extremity work-related MSD in hospital in-patient staff nurses was developed through a review of the literature to provide a framework for aetiological and intervention research. The framework informed the design of a survey of 502 hospital staff nurses. Symptom prevalence ranged from 32% in hip/thigh to 59% in ankle/foot regions. Logistic regression modelling using survey data showed that different work and personal factors were associated with discomfort in different regions of the lower extremity. Individual factors (e.g. older age, higher BMI or having any foot condition), physical factors (e.g. higher frequency of patient handling), psychosocial factors (e.g. lower job satisfaction) were associated with discomfort in one or more parts of the lower extremity. Future research should target these factors for intervention, to attempt to reduce occurrence of lower extremity discomfort in nurses. Practitioner Summary: Practitioners may find useful the illustrated, theoretical aetiological model of factors that could influence the prevalence of lower extremity discomfort in nurses. The model could guide conversations with nurses and observational analyses of nursing work. The model and survey results may provide ideas for intervention exploration. Abbreviations: MSD: musculoskeletal discomfort; BMI: body mass index; MSK: musculoskeletal; ICU: intensive care unit; NLERF: nurses' lower extremity MSD risk factor; NASA-TLX: NASA-task load index.

The relationship between nurse practice environment, nurse work characteristics, burnout and job outcome and quality of nursing care: a cross-sectional survey

AIM

To explore the mechanisms through which nurse practice environment dimensions are associated with job outcomes and nurse-assessed quality of care. Mediating variables tested included nurse work characteristics of workload, social capital, decision latitude, as well as burnout dimensions of emotional exhaustion, depersonalization, and personal accomplishment.

BACKGROUND

Acute care hospitals face daily challenges to their efforts to achieve nurse workforce stability, safety, and quality of care. A body of knowledge shows a favourably rated nurse practice environment as an important condition for better nurse and patient outcome variables; however, further research initiatives are imperative for a clear understanding to support and guide the practice community.

DESIGN

Cross-sectional survey.

METHOD

Grounded on previous empirical findings, a structural equation model designed with valid measurement instruments was tested. The study population was registered acute care nurses (N=1201) in two independent hospitals and one hospital group with six hospitals in Belgium.

RESULTS

Nurse practice environment dimensions predicted job outcome variables and nurse ratings of quality of care. Analyses were consistent with features of nurses' work characteristics including perceived workload, decision latitude, and social capital, as well as three dimension of burnout playing mediating roles between nurse practice environment and outcomes. A revised model adjusted using various fit measures explained 52% and 47% of job outcomes and nurse-assessed quality of care, respectively.

CONCLUSION

The study refines understanding of the relationship between aspects of nursing practice in order to achieve favourable nursing outcomes and offers important concepts for managers to track in their daily work. The findings of this study indicate that it is important for clinicians and leaders to consider how nurses are involved in decision-making about care processes and tracking outcomes of care and whether they are able to work with physicians, superiors, peers, and subordinates in a trusting environment based on shared values. The involvement of nurse managers at the unit level is especially critical because of associations with nurse work characteristics such as decision latitude and social capital and outcome variables. Further practice and research initiatives to support nurses' involvement in decision-making process and interdisciplinary teamwork are recommended.

Effectiveness of staffing models in residential, subacute, extended aged care settings on patient and staff outcomes

BACKGROUND

A key concern for managers and nurse administrators of healthcare settings is staffing. Determining and maintaining an appropriate level and mix of staff is especially problematic for those working in the long-term aged-care sector, where resident needs are complex and recruitment and retention of staff is challenging.

OBJECTIVES

To identify which staffing models are associated with the best patient and staff outcomes.

SEARCH STRATEGY

We searched the Effective Practice and Organisation of Care (EPOC) Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness (DARE) in The Cochrane Library and the databases MEDLINE, EMBASE, Ageline, CINAHL, and Dissertation abstracts. We also handsearched the reference lists and bibliographies of all retrieved articles.

SELECTION CRITERIA

This review considered interrupted time series studies and studies with concurrent control designs of care staff or residents of residential or subacute or extended aged-care settings that evaluated the effectiveness of staffing models and skill mixes on resident and care staff outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors critically appraised all studies that were retrieved based on the screening of titles and abstracts according to the EPOC Group's data collection checklist.The same two review authors independently extracted and summarised details of eligible studies using the data abstraction form developed by EPOC.

MAIN RESULTS

We included two studies (one interrupted time series and one controlled before-and-after study); both evaluated a primary-care model compared with a either a team-nursing model or a usual-care model. The primary-care model was found to provide slightly better results than the comparator for some outcomes such as resident well-being or behaviour. While nursing staff favoured the primary-care model in one study, neither study found significant improvements in staff outcomes using the primary model compared with the comparator. One study evaluated the uptake of the primary-care model within their facilities and found incorporation of this model into their practice was limited.

AUTHORS' CONCLUSIONS

Apart from two small studies evaluating primary care, no evidence in the form of concurrently controlled trials could be identified. While these two studies generally favour the use of primary care, the research designs of both ITS and CBA studies are considered prone to bias, specifically selection and blinding of participants and assessors. Therefore, these studies should be regarded with caution and there is little clear evidence for the effective use of any specific model of care in residential aged care to benefit either residents or care staff. Research in this area is clearly needed.

The relationship between staff skill mix, costs and outcomes in intermediate care services

Background

The purpose of this study was to assess the relationship between skill mix, patient outcomes, length of stay and service costs in older peoples' intermediate care services in England.

Methods

We undertook multivariate analysis of data collected as part of the National Evaluation of Intermediate Care Services. Data were analysed on between 337 and 403 older people admitted to 14 different intermediate care teams. Independent variables were the numbers of different types of staff within a team and the ratio of support staff to professionally qualified staff within teams. Outcome measures include the Barthel index, EQ-5D, length of service provision and costs of care.

Results

Increased skill mix (raising the number of different types of staff by one) is associated with a 17% reduction in service costs (p = 0.011). There is weak evidence (p = 0.090) that a higher ratio of support staff to qualified staff leads to greater improvements in EQ-5D scores of patients.

Conclusions

This study provides limited evidence on the relationship between multidisciplinary skill mix and outcomes in intermediate care services.

Building capacity to secure healthier and safer working conditions for healthcare workers: A South African-Canadian collaboration

Healthcare workers face difficult working conditions, particularly where HIV and tuberculosis add to understaffing. Questionnaires, workplace assessments, and discussion groups were conducted at a regional hospital in South Africa to obtain baseline data and input from the workforce in designing interventions. Findings highlighted weaknesses in knowledge, for example regarding the use of N95 respirators and safe handling of sharps, and suggested the need for improved training. Access to supplies and personal protective equipment was the major reported reason for failure to follow proper procedures; this was confirmed by workplace assessments. Discussion groups highlighted the important role for worker Health and Safety Committees (HSC), including in combating stigma and encouraging reporting. Interest in data to support decision-making resulted in development of the Occupational Health and Safety Information System (OHASIS); further training of HSCs is still needed. Multi-stakeholder international collaboration aimed at building HSC capacity is well-received.

Regions, hospitals and health outcomes over time: A multi-level analysis of repeat prevalence among a cohort of health-care workers

BACKGROUND

The relative importance of region, workplace, and individual determinants of health burden is debated.

OBJECTIVE

To model the contribution of hospital characteristics to employee mental and musculoskeletal disorders.

METHODS

We linked employment records of nurses and support services' staff with health records, neighbourhood census, and hospital administrative data. We conducted multi-level logistic regression analyses with three levels: year (I), employee characteristics (II), and hospital characteristics (III).

RESULTS

Northern region hospitals experienced lower disorder prevalences (odds ratios (OR) 0.58, 95% confidence intervals (0.40, 0.82) for mental and 0.56 (0.44, 0.73) for musculoskeletal disorders). Hospitals with yearly workloads of the highest versus lowest quintiles of inpatient days/1000 employee hours (>86.0 vs. <42.6) and surgical cases/1000 employee hours (>10.5 vs. <3.9) had greater odds of mental (1.29 (1.05, 1.57); 1.22 (1.05, 1.42)) and musculoskeletal (1.38 (1.21, 1.58); 1.21 (1.09, 1.34)) disorders.

CONCLUSION

Opportunities exist for reduction in burden with hospital workload reduction. Further exploration of regional effects is needed.

Low back injury risk during repositioning of patients in bed: the influence of handling technique, patient weight and disability

The objective of the study was to investigate the low back load during repositioning of patients in bed and to assess the influence of patient's weight and disability. Nine female health care workers (HCWs) carried out six patient-handling tasks with different patient weight (59 +/- 1, 83 +/- 2 and 110 +/- 4 kg) and handicap (hemiplegia, paraplegia and near-paralysis). The tasks were performed with optional use of simple, low-tech assistant devices (draw and sliding sheets). Peak low back compression exceeded the National Institute for Occupational Safety and Health action level of 3400 N in 25% of all trials (418). The influence of the HCW, i.e. the technique and assistive devices used, was higher than the effect of weight and disability in all tasks studied. ANOVA showed that on average for the six tasks 37%, 10% and 6% of the variance in low back loading was caused by variation in the factors HCW, patient's weight and disability, respectively. The result of this study is relevant for HCWs. It is shown that the repositioning technique and use of friction-reducing devices have higher influence on the low back load of the HCW than the patient's weight and disability.

Competent patients' refusal of nursing care

Competent patients' refusals of nursing care do not yet have the legal or ethical standing of refusals of life-sustaining medical therapies such as mechanical ventilation or blood products. The case of a woman who refused turning and incontinence management owing to pain prompted us to examine these situations. We noted several special features: lack of paradigm cases, social taboo around unmanaged incontinence, the distinction between ordinary versus extraordinary care, and the moral distress experienced by nurses. We examined this case on the merits and limitations of five well-known ethical positions: pure autonomy, conscientious objection, paternalism, communitarianism, and feminism. We found each lacking and argue for a 'negotiated reliance' response where nurses and others tread as lightly as possible on the patient's autonomy while negotiating a compromise, but are obligated to match the patient's sacrifice by extending themselves beyond their usual professional practice.

Electromyography as a measure of peak and cumulative workload in intermediate care and its relationship to musculoskeletal injury: an exploratory ergonomic study

Injury rates in Intermediate Care (IC) facilities are high and the factors related to these injuries are unclear. The objectives of this exploratory sub-study, which is part of a large multi-faceted study in 8 IC facilities are to: (1) evaluate EMG measured over a full-shift in the back and shoulders of 32 care aides (CAs) as an indicator of peak and cumulative workload (n = 4 x 8 facilities); investigate the relationship between EMG measures and injury indicators; and explore the relationship between EMG measures and other workload measurements. Lumbar EMG was converted to predicted cumulative spinal compression and ranged in CAs from 11.7 to 22.8 MNs with a mean of 16.4 MNs. Average compression was significantly different during different periods of the day (p < 0.001) with highest compression during pre-breakfast when CAs assist most with activities of daily living. Significant differences were found in average compression between low and high injury facilities for 3 of 5 periods of the day (p < 0.010). Peak compressions exceeding 3400 N occurred for very little of the workday (e.g. 11.25s during the 75 min period pre-breakfast). Peak neck/shoulder muscle activity is low (99% APDF ranged from 8.33% to 28% MVC). Peak and cumulative spinal compression were significantly correlated with lost-time and musculoskeletal injury rates as well as with total tasks observed in the CAs (p < 0.01). Perceived exertion was only correlated with peak compressions (p < 0.01). Facilities with low injury rates provided significantly more CAs (p < 0.01) to meet resident needs, and subsequently CAs performed fewer tasks, resulting in less peak and cumulative spinal loading over the day.