Can Better Leadership Reduce Nursing Home Staff Turnover?

OBJECTIVES: To assess whether a measure of leadership support for worker safety, health, and well-being predicts staff turnover in nursing homes after controlling for other factors. DESIGN: This paper uses administrative payroll data to measure facility-level turnover and uses a survey measure of nursing home leadership commitment to workers. In addition, we use data from Medicare to measure various nursing home characteristics. SETTING AND PARTICIPANTS: Nursing homes with at least 30 beds serving adults in California, Ohio, and Massachusetts were invited to participate in the survey. The analysis sample included 495 nursing homes. METHODS: We used a multivariable ordinary least squares model with turnover rate as the dependent variable. We used an indicator for nursing homes who scored above the median on the measure of leadership that supports worker safety, health, and well-being. Control variables include bed count (deciles), ownership (corporate/noncorporate × for-profit/not-for-profit), percent of residents on Medicaid, state, being in a nonmetropolitan county, and total nurse staffing per patient day in the 2 quarters before the survey. RESULTS: The unadjusted turnover rate was lower for those nursing homes that scored higher on leadership commitment to worker safety, health, and well-being. After controlling for additional variables, greater leadership commitment was still associated with lower turnover but with some attenuation. CONCLUSIONS AND IMPLICATIONS: We find that nursing homes with leadership that communicated and demonstrated commitment to worker safety, health, and well-being had relatively fewer nurses leave during the study period, with turnover rates approximately 10% lower than homes without. These findings suggest that leadership may be a valuable tool for reducing staff turnover.

Validation of the Workplace Integrated Safety and Health (WISH) assessment in a sample of nursing homes using Item Response Theory (IRT) methods.

OBJECTIVES: To validate and test the dimensionality of six constructs from the Workplace Integrated Safety and Health (WISH) assessment, an instrument that assesses the extent to which organisations implement integrated systems approaches for protecting and promoting worker health, safety and well-being, in a sample of nursing homes in the USA. DESIGN: Validation of an assessment scale using data from a cross-sectional survey. SETTING: Nursing homes certified by the Centers for Medicaid and Medicare services in three states of the USA: Ohio, California and Massachusetts. PARTICIPANTS: 569 directors of nursing from nursing homes serving adults and with more than 30 beds participated in the study. RESULTS: Graded response Item Response Theory (IRT) models showed that five out of six constructs were unidimensional based on balanced interpretation of model fit statistics-M2 or C2 with p value >0.05, Comparative Fit Index >0.95, lower bound of the root mean squared error of approximation 90% CI <0.06 and standardised root mean square residual <0.08. Overall measure and construct reliability ranged from acceptable to good. Category boundary location parameters indicated that items were most informative for respondents in lower range of latent scores (ie, ß1, ß2, ß3 typically below 0). A few items were recommended to be dropped from future administrations of the instrument based on empirical and substantive interpretation. CONCLUSIONS: The WISH instrument has utility to understand to what extent organisations integrate protection and promotion of worker health, safety and well-being; however, it is most informative in organisations that present lower scores.

The relationship of occupational injury and use of mental health care.

INTRODUCTION: Symptoms of depression and anxiety are a common consequence of occupational injury regardless of its cause and type. Nevertheless, mental health care is rarely covered by workers' compensation systems. The aim of this study was to assess the use of mental health care post-injury. METHODS: We used a subsample of patient-care workers from the Boston Hospital Workers Health Study (BHWHS). We matched one injured worker with three uninjured workers during the period of 2012-2014 based on age and job title (nurse or patient-care associate) and looked at their mental health care use pre- and post-injury using medical claims data from the employer sponsored health plan. We used logistic regression analysis to assess the likelihood of mental health care use three and six months post-injury controlling for any pre-injury visits. Analyses were repeated separately by job title. RESULTS: There were 556 injured workers between 2012 and 2014 that were matched with three uninjured workers at the time of injury (n = 1,649). Injured workers had a higher likelihood of seeking mental health care services than their uninjured counterparts during the six months after injury (OR = 1.646, 95% CI: 1.23-2.20), but not three months post-injury (OR = 0.825, 95% CI: 0.57-1.19). Patient-care associates had a higher likelihood to seek mental health care post-injury, than nurses (OR: 2.133 vs OR: 1.556) during the six months period. CONCLUSIONS: Injured workers have a higher likelihood to experience symptoms of depression and anxiety based on their use of mental health care post-injury and use is more predominant among patient-care associates; however, our sample has a small number of patient-care associates. Practical Applications: Treating depression and anxiety as part of the workers' compensation system has the potential of preventing further physical ailment and improving the return to work process regardless of nature of injury.

The Use of High-Risk Criteria to Assess Mortality Risk among Unsheltered Homeless Persons.

We assessed the ability of high-risk criteria developed by Boston Health Care for the Homeless Program to identify increased mortality during a 10-year cohort study (January 2000-December 2009) of 445 unsheltered adults. To qualify as high-risk for mortality, an individual slept unsheltered for six consecutive months or longer plus had one or more of the following characteristics: tri-morbidity, defined as co-occurring medical, psychiatric, and addiction diagnoses; one or more inpatient or respite admissions; three or more emergency department visits; 60 years old or older; HIV/AIDS; cirrhosis; renal failure; frostbite, hypothermia, or immersion foot. A total of 119 (26.7%) individuals met the high-risk criteria. The remaining 326 individuals in the cohort were considered lowerrisk. During the study, 134 deaths occurred; 52 (38.8%) were among high-risk individuals. Compared with sheltered individuals, the age-standardized mortality ratio for the high-risk group was 4.0 (95% confidence interval 3.0, 5.2) times higher and for the lower-risk group was 2.2 (1.8, 2.8) times higher. The hazard ratio, a measure of survival, for the high-risk group was 1.7 (1.2, 2.4) times that of the lower-risk group. High-risk criteria predicted an increased likelihood of mortality among unsheltered individuals. The lower-risk group also had high mortality rates compared with sheltered individuals.

Ensuring Organization-Intervention Fit for a Participatory Organizational Intervention to Improve Food Service Workers' Health and Wellbeing: Workplace Organizational Health Study.

OBJECTIVE: Food-service workers' health and wellbeing is impacted by their jobs and work environments. Formative research methods were used to explore working conditions impacting workers' health to inform intervention planning and implementation and to enhance the intervention's "fit" to the organization. METHODS: Four qualitative methods (worker focus groups; manager interviews; worksite observations; multi-stakeholder workshop) explored in-depth and then prioritized working conditions impacting workers' health as targets for an intervention. RESULTS: Prioritized working conditions included: ergonomics; work intensity; career development; and job enrichment. Data revealed necessary intervention mechanisms to enhance intervention implementation: worker and management communication infrastructure; employee participation in intervention planning and implementation; tailored worksite strategies; and ensuring leadership commitment. CONCLUSIONS: These targeted, comprehensive methods move away from a typical focus on generic working conditions, for example, job demands and physical work environment, to explore those conditions unique to an organization. Thereby, enhancing "intervention-fit" at multiple levels within the company context.

Organizational and Psychosocial Working Conditions and Their Relationship With Mental Health Outcomes in Patient-Care Workers.

OBJECTIVE: The aim of this study was to investigate the relationship between both psychosocial and organizational working conditions with self-reported mental health and mental health expenditures. METHODS: This study used worker survey and medical claims data from a sample of 1594 patient-care workers from the Boston Hospital Workers Health Study (BHWHS) to assess the relationship of psychosocial (job demands, decision latitude, supervisor support, coworker support) and organizational (job flexibility, people-oriented culture) working conditions with mental health outcomes using validated tools RESULTS:: People-oriented culture and coworker support were negatively correlated with psychological distress and were predictive of lower expenditures in mental health services. Job demands were positively correlated with psychological distress. CONCLUSIONS: Working conditions that promote trustful relationships and a cooperative work environment may render sustainable solutions to prevent ill mental health.

Paradoxical Impact of a Patient-Handling Intervention on Injury Rate Disparity Among Hospital Workers.

OBJECTIVES: To test whether a comprehensive safe patient-handling intervention, which successfully reduced overall injury rates among hospital workers in a prior study, was differentially effective for higher-wage workers (nurses) versus low-wage workers (patient care associates [PCAs]). METHODS: Data were from a cohort of nurses and PCAs at 2 large hospitals in Boston, Massachusetts. One hospital received the intervention in 2013; the other did not. Using longitudinal survey data from 2012 and 2014 plus longitudinal administrative injury and payroll data, we tested for socioeconomic differences in changes in self-reported safe patient-handling practices, and for socioeconomic differences in changes in injury rates using administrative data. RESULTS: After the intervention, improvements in self-reported patient-handling practices were equivalent for PCAs and for nurses. However, in administrative data, lifting and exertion injuries decreased among nurses (rate ratio [RR] = 0.64; 95% confidence interval [CI] = 0.41, 1.00) but not PCAs (RR = 1.10; 95% CI = 0.74,1.63; P for occupation × intervention interaction = 0.02). CONCLUSIONS: Although the population-level injury rate decreased after the intervention, most improvements were among higher-wage workers, widening the socioeconomic gap in injury and exemplifying the inequality paradox. Results have implications for public health intervention development, implementation, and analysis.

Mental Health Expenditures: Association With Workplace Incivility and Bullying Among Hospital Patient Care Workers.

OBJECTIVE: Bullied workers have poor self-reported mental health; monetary costs of bullying exposure are unknown. We tested associations between bullying and health plan claims for mental health diagnoses. METHODS: We used data from 793 hospital workers who answered questions about bullying in a survey and subscribed to the group health plan. We used two-part models to test associations between types of incivility/bullying and mental health expenditures. RESULTS: Workers experiencing incivility or bullying had greater odds of any mental health claims. Among claimants, unexposed workers spent $792, those experiencing one type of incivility or bullying spent $1557 (P for difference from unexposed = 0.016), those experiencing two types spent $928 (P = 0.503), and those experiencing three types spent $1446 (P = 0.040). CONCLUSION: Workplace incivility and bullying may carry monetary costs to employers, which could be controlled through work environment modification.

Measuring Best Practices for Workplace Safety, Health, and Well-Being: The Workplace Integrated Safety and Health Assessment.

OBJECTIVE: To present a measure of effective workplace organizational policies, programs, and practices that focuses on working conditions and organizational facilitators of worker safety, health and well-being: the workplace integrated safety and health (WISH) assessment. METHODS: Development of this assessment used an iterative process involving a modified Delphi method, extensive literature reviews, and systematic cognitive testing. RESULTS: The assessment measures six core constructs identified as central to best practices for protecting and promoting worker safety, health and well-being: leadership commitment; participation; policies, programs, and practices that foster supportive working conditions; comprehensive and collaborative strategies; adherence to federal and state regulations and ethical norms; and data-driven change. CONCLUSIONS: The WISH Assessment holds promise as a tool that may inform organizational priority setting and guide research around causal pathways influencing implementation and outcomes related to these approaches.

Assessment of Ambient Exposures Firefighters Encounter While at the Fire Station: An Exploratory Study.

OBJECTIVE: Firefighters are at an increased risk for many types of cancer. Although most studies on this topic focus on exposures encountered while fighting fires, exposures at the fire station are also cause for concern. This pilot study aimed to describe air quality within a few fire stations in and around Boston, Massachusetts, and to investigate physical and organizational factors that may influence levels of contaminants in stations. METHODS: Air sampling of particulate matter less than 2.5 µm in diameter (PM2.5) and particle-bound polycyclic aromatic hydrocarbons (PAHs) was completed at four fire stations in Spring, 2016. Sampling occurred in the kitchen, truck bay, and just outside the station. Data were analyzed to assess differences between and within stations. Interviews (n =7) were conducted with officers at each station to explore health and safety-related organizational policies and practices. Interviews were transcribed and analyzed for thematic content. RESULTS: At each station, levels of contaminants were higher in the truck bays than either the outdoors or kitchen, and varied the most throughout the day. The station with the highest exposures in the truck bay had the lowest levels in the kitchen, which was possibly explained by new building materials and effective separation between building zones. The age and layout of the stations appeared to determine the extent to which policies favoring exhaust capture were implemented. CONCLUSION: Levels of PM2.5 and PAH inside fire stations may contribute to firefighter cancer risk. Through understanding contaminant variability, we can begin to design and test interventions that improve cancer prevention.

Impact of Occupational Injuries on Nonworkers' Compensation Medical Costs of Patient-Care Workers.

OBJECTIVE: The aim of this study was to estimate the extent to which work-related injuries contribute to medical expenditures paid for by group health insurance. METHODS: Administrative data on OSHA recordable injuries spanning 2010 to 2013 were obtained for female patient care workers (n = 2495). Expenditures were aggregated group health insurance claims for 3 and 6-month periods before/after injury. Group health insurance plan type, age group, and job category were control variables. RESULTS: Being injured is associated with the odds of having expenditures at both 3 months, odds ratio (OR) 2.17 [95% confidence interval (95% CI) 1.61 to 2.92], and 6 months, 2.95 (95% CI 1.96 to 4.45). Injury was associated with $275 of additional expenditures (95% CI $38 to $549) over 3 months and $587 of additional expenditures (95% CI $167 to $1140) over 6 months. CONCLUSIONS: Injury was associated with increased odds of positive expenditures and increased expenditures paid for by group health insurance.

Key Organizational Characteristics for Integrated Approaches to Protect and Promote Worker Health in Smaller Enterprises.

OBJECTIVE: The aim of this study was to investigate relationships between worksite organizational characteristics (size, industrial sector, leadership commitment, and organizational supports) and integrated approaches to protecting and promoting worker health implemented in smaller enterprises. METHODS: We analyzed web-based survey data of Human Resource Managers at 114 smaller enterprises (<750 employees) to identify organizational factors associated with levels of integrated approaches among their worksites. RESULTS: The companies' mean integration score was 13.6 (SD = 9.6) of a possible 44. In multivariate analyses, having a safety committee (P = 0.035) and top leadership support for health promotion (HP) (P = 0.004) were positively associated with higher integration scores. CONCLUSIONS: Smaller enterprises in one U.S. region have relatively low levels of implementing integrated safety and promotion approaches. Having a safety committee and leadership support for HP may be important contributors to implementing integrated approaches in smaller enterprises.

Effects of a worksite tobacco control intervention in India: the Mumbai worksite tobacco control study, a cluster-randomised trial.

OBJECTIVES: We assessed a worksite intervention designed to promote tobacco control among workers in the manufacturing sector in Greater Mumbai, India. METHODS: We used a cluster-randomised design to test an integrated health promotion/health protection intervention, the Healthy, Safe, and Tobacco-free Worksites programme. Between July 2012 and July 2013, we recruited 20 worksites on a rolling basis and randomly assigned them to intervention or delayed-intervention control conditions. The follow-up survey was conducted between December 2013 and November 2014. RESULTS: The difference in 30-day quit rates between intervention and control conditions was statistically significant for production workers (OR=2.25, p=0.03), although not for the overall sample (OR=1.70; p=0.12). The intervention resulted in a doubling of the 6-month cessation rates among workers in the intervention worksites compared to those in the control, for production workers (OR=2.29; p=0.07) and for the overall sample (OR=1.81; p=0.13), but the difference did not reach statistical significance. CONCLUSIONS: These findings demonstrate the potential impact of a tobacco control intervention that combined tobacco control and health protection programming within Indian manufacturing worksites. TRIAL REGISTRATION NUMBER: NCT01841879.

Obscured by administrative data? Racial disparities in occupational injury.

Objectives Underreporting of occupational injuries is well documented, but underreporting patterns may vary by worker characteristics, obscuring disparities. We tested for racial and ethnic differences in injury reporting patterns by comparing injuries reported via research survey and administrative injury database in the same group of healthcare workers in the US. Methods We used data from a cohort of 1568 hospital patient-care workers who were asked via survey whether they had been injured at work during the year prior (self-reported injury; N=244). Using the hospital's injury database, we determined whether the same workers had reported injuries to the hospital's occupational health service during that year (administratively reported injury; N=126). We compared data sources to test for racial and ethnic differences in injury reporting practices. Results In logistic regression models adjusted for demographic and occupational characteristics, black workers' odds of injury as measured by self-report data were 1.91 [95% confidence interval (95% CI) 1.04-3.49] compared with white workers. The same black workers' odds of injury as measured by administrative data were 1.22 (95% CI 0.54-2.77) compared with white workers. Conclusions The undercount of occupational injuries in administrative versus self-report data may be greater among black compared to white workers, leading to underestimates of racial disparities in workplace injury.

Integrating worksite health protection and health promotion: A conceptual model for intervention and research.

There is increasing recognition of the value added by integrating traditionally separate efforts to protect and promote worker safety and health. This paper presents an innovative conceptual model to guide research on determinants of worker safety and health and to inform the design, implementation and evaluation of integrated approaches to promoting and protecting worker health. This model is rooted in multiple theories and the premise that the conditions of work are important determinants of individual safety and health outcomes and behaviors, and outcomes important to enterprises such as absence and turnover. Integrated policies, programs and practices simultaneously address multiple conditions of work, including the physical work environment and the organization of work (e.g., psychosocial factors, job tasks and demands). Findings from two recent studies conducted in Boston and Minnesota (2009-2015) illustrate the application of this model to guide social epidemiological research. This paper focuses particular attention on the relationships of the conditions of work to worker health-related behaviors, musculoskeletal symptoms, and occupational injury; and to the design of integrated interventions in response to specific settings and conditions of work of small and medium size manufacturing businesses, based on a systematic assessment of priorities, needs, and resources within an organization. This model provides an organizing framework for both research and practice by specifying the causal pathways through which work may influence health outcomes, and for designing and testing interventions to improve worker safety and health that are meaningful for workers and employers, and responsive to that setting's conditions of work.

Beyond access: barriers to internet health information seeking among the urban poor.

OBJECTIVE: Communication inequalities deepen health disparities even when internet access is achieved. The goal of this study is to understand how a range of barriers may inhibit individuals from low socioeconomic position (SEP) from engaging with online health information even when it is freely available. MATERIALS AND METHODS: Detailed data were collected from 118 low-SEP individuals from a randomized controlled trial providing internet access. Measures triangulated the health-seeking experience through internet use tracked in real-time, call log data, and self-reported barriers. Negative binomial regression models were fitted with technology and perceived predictors, and our outcome, health information seeking, and then stratified by medical status. RESULTS: Participants experienced a median of two computer issues (median 6 days) and two internet issues (median 6.5 days). Duration of internet problems was associated with a decrease in the rate of internet health information seeking by a factor of 0.990 (P = .03) for each additional day. Participants with a medical problem who were frustrated in their search for health information had half the rate of health information seeking of those who were not frustrated (incidence rate ratio = 0.395, P = .030). DISCUSSION: Despite IT support, participants still experienced internet connectivity issues that negatively impacted their health information seeking. Frustration in their search to find information may serve as an additional barrier to those who have medical issues. CONCLUSION: After initial internet access, a second-level digital divide emerged due to connectivity issues, highlighting the need to understand the complex network of barriers experienced by low-SEP internet users.

Validation and Dimensionality of the Integration of Health Protection and Health Promotion Score: Evidence From the PULSE Small Business and VA Medical Center Surveys.

OBJECTIVE: To conduct validation and dimensionality analyses for an existing measure of the integration of worksite health protection and health promotion approaches. METHODS: A survey of small to medium size employers located in the United States was conducted between October 2013 and March 2014 (N = 115). A survey of Department of Veterans Affairs (VA) administrative parents was also conducted from June to July 2014 (N = 140). Exploratory factor analysis (EFA) was used to determine the dimensionality of the Integration Score in each sample. RESULTS: Using EFA, both samples indicated the presence of one unified factor. The VA survey indicated that customization improves the relevance of the Integration Score for different types of organizations. CONCLUSIONS: The Integration Score is a valid index for assessing the integration of worksite health protection and health promotion approaches and is customizable based on industry. CLINICAL SIGNIFICANCE: The Integration Score may be used as a single metric for assessing the integration of worksite health protection and health promotion approaches in differing work contexts.

Measurement Tools for Integrated Worker Health Protection and Promotion: Lessons Learned From the SafeWell Project.

OBJECTIVES: To describe (a) a conceptual approach, (b) measurement tools and data collection processes, (c) characteristics of an integrated feedback report and action plan, and (d) experiences of three companies with an integrated measurement approach to worker safety and health. METHODS: Three companies implemented measurement tools designed to create an integrated view of health protection and promotion based on organizational- and individual-level assessments. Feedback and recommended actions were presented following assessments at baseline and 1-year follow-up. Measurement processes included group dialogue sessions, walk-through, online surveys, and focus groups. RESULTS: The approach and measurement tools generated actionable recommendations and documented changes in the physical (eg, safety hazards) and psychosocial (eg, health and safety culture) work environment between baseline and 1-year follow-up. CONCLUSIONS: The measurement tools studied were feasible, acceptable, and meaningful to companies in the SafeWell study.

Entertainment or Health? Exploring the Internet Usage Patterns of the Urban Poor: A Secondary Analysis of a Randomized Controlled Trial.

BACKGROUND: Important gaps remain in our knowledge of how individuals from low socioeconomic position (SEP) use the Internet for resources and in understanding the full range of activities they perform online. Although self-report data indicate that low SEP individuals use the Internet less than high SEP people for health information and for other beneficial capital-enhancing activities, these results may not provide an accurate overall view of online use. OBJECTIVE: The aim of this study was to determine the ways in which low SEP individuals use the Internet, including for entertainment, social networking, and capital-enhancing functions, and how they are associated with health information seeking. METHODS: Detailed Web tracking data were collected from 118 low SEP individuals who participated in the intervention group of a randomized controlled trial that provided Internet access. Websites were grouped by topic, including categories of capital-enhancing websites that provided access to resources and information. Different types of online activities were summed into an Internet use index. Single and multiple negative binomial regression models were fitted with the Internet use index as the predictor and health information seeking as the outcome. Next, models were fitted with low, medium, and high Web usage in capital-enhancing, entertainment, and social network categories to determine their associations with health information seeking. RESULTS: Participants used the Web for diverse purposes, with 63.6% (75/118) accessing the Internet for all defined types of Internet use. Each additional category of Internet use was associated with 2.12 times the rate of health information seeking (95% CI 1.84-2.44, P<.001). Higher use of each type of capital-enhancing information was associated with higher rates of health information seeking, with high uses of government (incident rate ratio [IRR] 8.90, 95% CI 4.82-16.42, P<.001) and news (IRR 11.36, 95% CI 6.21-20.79, P<.001) websites associated with the highest rates of health information seeking compared to their lowest use categories. High entertainment website use (IRR 3.91, 95% CI 2.07-7.37, P<.001) and high social network use (IRR 2.06, 95% CI 1.08-3.92, P=.03) were also associated with higher health information seeking. CONCLUSIONS: These data clearly show that familiarity and skills in using the Internet enhance the capacity to use it for diverse purposes, including health and to increase capital, and that Internet usage for specific activities is not a zero sum game. Using it for one type of topic, such as entertainment, does not detract from using it for other purposes. Findings may inform ways to engage low SEP groups with Internet resources.

Implementing an Integrated Health Protection/Health Promotion Intervention in the Hospital Setting: Lessons Learned From the Be Well, Work Well Study.

OBJECTIVE: This study reports findings from a proof-of-concept trial designed to examine the feasibility and estimates the efficacy of the "Be Well, Work Well" workplace intervention. METHODS: The intervention included consultation for nurse managers to implement changes on patient-care units and educational programming for patient-care staff to facilitate improvements in safety and health behaviors. We used a mixed-methods approach to evaluate feasibility and efficacy. RESULTS: Using findings from process tracking and qualitative research, we observed challenges to implementing the intervention due to the physical demands, time constraints, and psychological strains of patient care. Using survey data, we found no significant intervention effects. CONCLUSIONS: Beyond educating individual workers, systemwide initiatives that respond to conditions of work might be needed to transform the workplace culture and broader milieu in support of worker health and safety.