Safety and Health through Integrated, Facilitated Teams (SHIFT): stepped-wedge protocol for prospective, mixed-methods evaluation of the Healthy Workplace Participatory Program.

BACKGROUND: Healthcare facilities are notorious for occupational health and safety problems. Multi-level interventions are needed to address interacting exposures and their overlapping origins in work organization features. Worker participation in problem identification and resolution is essential. This study evaluates the CPH-NEW Healthy Workplace Participatory Program (HWPP), a Total Worker Health® protocol to develop effective employee teams for worker safety, health, and wellbeing. METHODS: Six public sector, unionized healthcare facilities are enrolled, in three pairs, matched by agency. The unit of intervention is a workplace health and safety committee, adapted here to a joint labor-management "Design Team" (DT). The DT conducts root cause analyses, prioritizes problems, identifies feasible interventions in light of the constraints and needs of the specific setting, makes business-case presentations to facility leadership, and assists in evaluation. Following a stepped-wedge (cross-over) design, one site in each pair is randomly assigned to "immediate intervention" status, receiving the full coached intervention at baseline; in the "lagged intervention" site, coaching begins about half-way through the study. Program effectiveness and cost-effectiveness outcomes are assessed at both organizational (e.g., workers' compensation claim and absenteeism rates, perceived management support of safety) and individual levels (e.g., self-rated health, sleep quality, leisure-time exercise). Targeted pre-post analyses will also examine specific outcomes appropriate to the topics selected for intervention. Process evaluation outcomes include fidelity of the HWPP intervention, extent of individual DT member activity, expansion of committee scope to include employee well-being, program obstacles and opportunities in each setting, and sustainability (within the available time frame). DISCUSSION: This study aims for a quantitative evaluation of the HWPP over a time period long enough to accomplish multiple intervention cycles in each facility. The design seeks to achieve comparable study engagement and data quality between groups. We will also assess whether the HWPP might be further improved to meet the needs of U.S. public sector healthcare institutions. Potential challenges include difficulty in pooling data across study sites if Design Teams select different intervention topics, and follow-up periods too short for change to be observed. TRIAL REGISTRATION: ClinicalTrials.gov NCT04251429 (retrospectively registered January 29, 2020), protocol version 1.

To Be Seen, Heard, and Valued: Strategies to Promote a Sense of Belonging for Women and Underrepresented in Medicine Physicians.

Lingering unconscious biases and daily cues continue to permeate and persist in academic medicine environments in the form of the exclusion of physicians who are women or racially/ethnically underrepresented in medicine. Academic medicine environments must change so that women and underrepresented in medicine racial/ethnic groups are seen, heard, and valued. A shared awareness among faculty, administrators, and trainees can inform the development of intentional strategies to alter individual behaviors, academic spaces, and institutional processes to cultivate a sense of belonging. Shifting the norms in medicine and the course of historical exclusion will require professional development in areas of inclusive teaching practices, skills to cultivate mentoring relationships with diverse trainees, and fostering discussions about the relevance of personal identity, as well as attention to the symbolism and imagery in institutional messages (e.g., portraits on the walls, website, marketing campaigns) and to the value of including community involvement in productivity metrics.

"Breaking" the Emergency Department: Does the Culture of Emergency Medicine Present a Barrier to Self-Care?

INTRODUCTION: Our goal was to critically examine emergency physician's (EP) beliefs about taking breaks for self-care on shift. Our operational definition of a break for self-care included time not engaging in direct patient care, eating, drinking, using the bathroom, or leaving a clinical area for a mental break. Using focus groups, the study aimed to accomplish the following: 1) identify barriers to why residents and faculty at our academic center may not take breaks in the emergency department; 2) generate hypotheses for empirical testing; and 3) generate solutions to include in a departmental breaks initiative. METHODS: We convened eight focus groups comprised separately of resident and faculty physicians. Group discussion was guided by eight questions representing a priori themes. The groups were recorded for transcription and subjected to a "cut-and-sort" process. Six themes were identified by consensus after independent review by three of the co-authors, which were confirmed by participant validation. RESULTS: We identified six themes that represented the pooled outcomes of both resident and faculty focus groups: 1) Physiological needs affect clinical performance, 2) EPs share beliefs around taking breaks that center on productivity, patient safety and the dichotomy of strength/weakness, 3) when taking breaks EPs fear worst-case scenarios, 4) breaking is a learned skill, 5) culture change is needed to allow EPs to engage in self-care; and 6) a flexible, individualized approach to breaking is necessary. Our central finding was that productivity and patient safety are of key importance to EPs when considering whether to take a break for self-care. We identified a dichotomy with the concept of strength related to productivity/patient safety, and the concept of weakness related to self-care. CONCLUSION: The current practice culture of emergency medicine and the organization of our unique work environment may present barriers to physicians attempting to engage in self-care.

A longitudinal ethnographic study of hospital staff attitudes and experiences of change in nutrition care.

BACKGROUND: Change promotes quality in healthcare, yet adopting change can be challenging. Understanding how change in nutrition care is adopted may support better design and implementation of interventions that aim to address inadequate food intake in hospital. The present study followed the process of change in a healthcare organisation, exploring staff attitudes, beliefs and experiences of the implementation of a mealtime intervention. METHODS: In total, 103 h of fieldwork were conducted in this longitudinal ethnographic study over a 4-month period. Over 170 staff participated, with data captured using observation, interviews and focus groups. Data were analysed using an inductive, thematic approach, informed by implementation theory. RESULTS: Attitudes and experiences of change in nutrition care are described by three themes: (i) staff recognised the inevitability of change; (ii) staff cooperated with the intervention, recognising potential value in the intervention to support patient care, where increased awareness of their mealtime behaviours supported adopting practice changes; and (iii) some staff were able to reflect on their practice after implementing the intervention, whereas others could not. A model illustrating the interconnectedness of factors influencing implementation emerged from the research, guiding future nutrition care intervention design and supporting change. CONCLUSIONS: The requirement to address the underlying perceptions of staff about the need to change should not be underestimated. Increased efforts to market the change message to specific staff groups and physical behavioural reinforcement strategies are needed. Nutrition care in the future should focus on helping staff feel positive about making practice changes.

Midwifery workplace culture in Australia: A national survey of midwives.

PROBLEM: The midwifery workforce in Australia is impacted by shortages and attrition. Workplace culture affects midwives' intentions to stay in the profession and their capacity to provide woman-centred care for mothers and infants. BACKGROUND: Staff attrition in maternity services often relates to midwives' workplace experiences and negative perceptions of organisational culture. Broad-based data are essential to fully understand midwifery workplace culture. AIM: This study aimed to examine Australian midwives' perceptions of workplace culture, using a specifically developed instrument. METHODS: A national online survey of Australian midwives, within a wider project on maternity workplace culture. Quantitative data were analysed descriptively. Qualitative data were analysed using content analysis. FINDINGS: Overall, 322 eligible midwives rated workplace culture and 150 provided further qualitative responses. Themes included 'the ability to be a midwife', 'support at work' and 'bullying'. Less than a third of midwives thought their workplace had a positive culture. Many respondents felt disengaged and unsupported by managers and described an inability to use all their midwifery knowledge in medically-dominated environments. Many attributed poor workplace culture to limited resources, poor communication, time pressure and a lack of leadership in their workplaces. Inadequate staffing levels and poor management left many midwives feeling disempowered and despondent about their workplace. Others, however, described highly positive workplace cultures and inspiring role models. CONCLUSION: The survey captured a snapshot of Australian midwifery workplace culture. Findings on leadership, workloads, management support and other aspects of workplace culture can inform future workforce planning and policies. A larger study of the midwifery workplace culture is needed.

Transition experiences of internationally qualified midwives practising midwifery in Australia.

BACKGROUND: Internationally qualified midwives comprise approximately 13% of the Australian midwifery workforce. Despite their central role in the Australian midwifery system, understanding of their transitional experiences is limited. AIM: To explore the transitional experiences of internationally qualified midwives practising in Australia. METHOD: A descriptive qualitative study was undertaken, as the second phase of a larger mixed methods study. In this paper we present in-depth insights from 11 internationally qualified midwives practising in Australia. Individual semi-structured interviews were conducted between May-August 2018, digitally recorded and then transcribed. Transcriptions were analysed using a thematic analysis approach. FINDINGS: Participants in this study identified that the different culture of the work environment, differences in midwifery practice, lack of autonomy in their practice and perceived discrimination influenced their transition into Australian midwifery practice. Four themes were identified: 'Differences in midwifery practice', 'Cultural incongruence', 'Discrimination' and 'Mixed emotions'. DISCUSSION: Success during the complex transition process depends on the migrant midwives' ability to build a sense of belonging, and to develop and adopt strategies that assist in dealing with new workplaces and an unfamiliar workforce. CONCLUSION: A structured transition program prior to commencing practice, as well as an evidence-based workplace mentorship program with a focus on Australian midwifery care and culture, may be effective strategies to facilitate their transition. To promote awareness of multiculturalism within the work environment, this study recommends actively encouraging host staff to further develop perspectives that enable them to create positive relationships with staff from other cultures.

Education is a private matter: Clinical midwives' experiences of being part-time master's students in midwifery.

When the master's degree in midwifery was introduced in Norway, clinical midwives with a professional diploma soon requested the possibility to upgrade their education to a master's degree. In 2014, a part-time master's program worth 40 ECTS credits was introduced at a Norwegian university. In this study, we aimed to explore clinical midwives' experiences of how taking a part-time master's program in midwifery was received at their workplace. We employed a qualitative research design and an explorative descriptive approach. A convenience sample consisting of 47 clinical midwifes with varying seniority was recruited in 2016 and 2017, and five focus group interviews were conducted at the end of the study programs. Systematic text condensation was used to analyze the data, generating three themes. The first concerns the midwives' experiences of learning new tools to advance their profession. Secondly, they expressed hope for support, but found that education was a private matter. Finally, they experienced that financial support depended on goodwill from their employers. The study demonstrates that a master's degree in midwifery can be instrumental to strengthen clinical practice, but also points towards the need to update and strengthen management and leadership to facilitate and implement new knowledge.

Impact of Key Workplace Breastfeeding Support Characteristics on Job Satisfaction, Breastfeeding Duration, and Exclusive Breastfeeding Among Health Care Employees.

Background: Although national breastfeeding rates have improved across recent decades, women continue to face barriers to achieving recommended breastfeeding targets. Returning to work presents a unique set of challenges for breastfeeding continuation, even in health care settings tasked with promoting breastfeeding among patients. This study examined the association between key workplace breastfeeding support characteristics, job satisfaction, and breastfeeding outcomes among health care employees. Materials and Methods: We used data from a cross-sectional survey of employees in a large integrated health care system. The study sample included female employees who had breastfed in the past 3 years (n = 165). The Employee Perceptions of Breastfeeding Support Questionnaire (EPBS-Q) measured organization, manager, and coworker support for breastfeeding. Regression analyses tested the association between workplace support factors and breastfeeding duration, breastfeeding exclusivity, and job satisfaction. Results: Managerial support increased median job satisfaction by 0.39 standard deviations (p < 0.001), and increased the odds of prolonging exclusive breastfeeding (odds ratio [OR] 1.47; confidence interval [CI] 1.03-2.09). Organizational support increased median job satisfaction by 0.27 standard deviations (p < 0.001), and increased the odds of exclusive breastfeeding by nearly twofold (OR 1.80; CI 1.05-3.09). No significant associations were found between workplace support factors (organizational, managerial, and co-worker support) and overall breastfeeding duration. Conclusions: Organizational and managerial support are key aspects of workplace lactation support, which may positively impact job satisfaction, rates of exclusive breastfeeding, and duration of exclusive breastfeeding among female health care employees. This intersection of outcomes salient for the business community and public health practitioners highlights opportunities for collaborations to improve workplace and breastfeeding outcomes.

Caring for Workers' Health: Do German Employers Follow a Comprehensive Approach Similar to the Total Worker Health Concept? Results of a Survey in an Economically Powerful Region in Germany.

Similar to 'Total Worker Health' in the United States (USA), 'Workplace Health Management' in Germany is a holistic strategy to protect, promote, and manage employees' health at the workplace. It consists of four subcategories. While the subcategories 'occupational health and safety' and 'reintegration management' contain measures prescribed by law, 'workplace health promotion' and 'personnel development' can be designed more individually by the companies. The present study focused on the current implementation of voluntary and legally required measures of the four subcategories, as well as companies' satisfaction with the implementation. A total of N = 222/906 companies (small, medium, and big enterprises of one German county) answered a standardized questionnaire addressing the implementation of health-related measures, satisfaction with the implementation, and several company characteristics. In the subcategory 'occupational health and safety', 23.9% of the companies fulfilled all of the legally required measures, whereas in the category 'reintegration management', that rate amounted to 50.9%. There was a positive correlation between company size and the implementation grade, and as well between company size and the fulfilling of measures required by law. Companies tended to be more satisfied with higher implementation grades. Nevertheless, a surprisingly high proportion of the companies with poor implementation indicated satisfaction with the measures' implementation.

Running too far ahead? Towards a broader understanding of mindfulness in organisations.

Current workplace mindfulness research and interventions assume that teaching mindfulness will have beneficial effects for people and organizations. While research shows that mindfulness trainings may increase resilience of working adults, assuming that mindfulness will have independent effects on outcomes at different levels of an organization is not well grounded. We assert that mindfulness training would, however, be beneficial for organizations when tailored to that context and shaped by an understanding of organizational theory and practice. We also envisage mindfulness as a beneficial property of teams, organizations and the individuals who constitute them. To close the evidence gap we propose building multi-level models of mindfulness in organizations, broadening training programs, and developing a novel competency framework for teachers in this context.

Postincident Support for Healthcare Workers Experiencing Occupational Violence and Aggression.

PURPOSE: To investigate the relative contributions of workplace type, occupational violence and aggression (OVA) strategies and interventions along with perceptions of the occupational health and safety (OHS) environment on the likelihood of receiving postincident support following the experience of OVA. DESIGN: We used a cross-sectional study design with an online survey to collect data from employees in nursing and midwifery in Victoria, Australia. METHODS: Survey data collected from 3,072 members of the Australian Nursing and Midwifery Federation (Victorian branch) were analyzed using logistic regression. FINDINGS: Of the 3,072 respondents who had experienced OVA in the preceding 12 months, 1,287 (42%) reported that they had received postincident support. Hierarchical logistic regression revealed that the OHS environment was the dominant factor that predicted the likelihood of workers receiving postincident support. Working in a positive OHS environment characterized by higher levels of leading indicators of OHS, prioritization of OHS, supervisor support for safety, and team psychological safety was the stronger predictor of postincident support. Being employed in a workplace that offered training in the management and prevention of OVA also increased the likelihood of receiving postincident support. CONCLUSIONS: While training in the management and prevention of OVA contributed to the likelihood of receiving postincident support, a greater emphasis on the OHS environment was more important in predicting the likelihood that workers received support. CLINICAL RELEVANCE: This study identifies workplace practices that facilitate the provision of postincident support for healthcare workers. Facilitating effective postincident support could improve outcomes for workers, their patients and workplaces, and society in general.

Managers' Support for Employee Wellness Programs: An Integrative Review.

OBJECTIVE: The aim of this integrative literature review is to synthesize the existing evidence regarding managers' support for employee wellness programs. DATA SOURCE: The search utilized multiple electronic databases and libraries. STUDY INCLUSION AND EXCLUSION CRITERIA: Inclusion criteria comprised peer-reviewed research published in English, between 1990 and 2016, and examining managers' support in the context of a worksite intervention. The final sample included 21 articles for analysis. DATA EXTRACTION: Two researchers extracted and described results from each of the included articles using a content analysis. DATA SYNTHESIS: Two researchers independently rated the quality of the included articles. Researchers synthesized data into a summary table by study design, sample, data collected, key findings, and quality rating. RESULTS: Factors that may influence managers' support include their organization's management structure, senior leadership support, their expected roles, training on health topics, and their beliefs and attitudes toward wellness programs and employee health. Managers' support may influence the organizational culture, employees' perception of support, and employees' behaviors. CONCLUSIONS: When designing interventions, health promotion practitioners and researchers should consider strategies that target senior, middle, and line managers' support. Interventions need to include explicit measures of managers' support as part of the evaluation plan.

Medical Surveillance, Continuous Health Promotion and a Participatory Intervention in a Small Company.

The workplace is an ideal setting for health promotion. The regular medical examination of workers enables us to screen for numerous diseases, spread good practices and correct lifestyles, and obtain a favourable risk/benefit ratio. The continuous monitoring of the level of workers' wellbeing using a holistic approach during medical surveillance enables us to promptly identify problems in work organisation and the company climate. Problems of this kind can be adequately managed by using a participatory approach. The aim of this paper is twofold: to signal this way of proceeding with medical surveillance, and to describe an organisational development intervention. Participatory groups were used to improve occupational life in a small company. After intervention we observed a reduction in levels of perceived occupational stress measured with the Effort/Reward Imbalance questionnaire, and an improvement in psychological wellbeing assessed by means of the Goldberg Anxiety/Depression scale. Although the limited size of the sample and the lack of a control group call for a cautious evaluation of this study, the participatory strategy proved to be a useful tool due to its cost-effectiveness.

Developing standards for an integrated approach to workplace facilitation for interprofessional teams in health and social care contexts: a Delphi study.

Integration of health and social care forms part of health and social care policy in many countries worldwide in response to changing health and social care needs. The World Health Organization's appeal for systems to manage the global epidemiologic transition advocates for provision of care that crosses boundaries between primary, community, hospital, and social care. However, the focus on structural and process changes has not yielded the full benefit of expected advances in care delivery. Facilitating practice in the workplace is a widely recognised cornerstone for developments in the delivery of health and social care as collaborative and inclusive relationships enable frontline staff to develop effective workplace cultures that influence whether transformational change is achieved and maintained. Workplace facilitation embraces a number of different purposes which may not independently lead to better quality of care or improved patient outcomes. Holistic workplace facilitation of learning, development, and improvement supports the integration remit across health and social care systems and avoids duplication of effort and waste of valuable resources. To date, no standards to guide the quality and effectiveness of integrated facilitation have been published. This study aimed to identify key elements constitute standards for an integrated approach to facilitating work-based learning, development, improvement, inquiry, knowledge translation, and innovation in health and social care contexts using a three rounds Delphi survey of facilitation experts from 10 countries. Consensus about priority elements was determined in the final round, following an iteration process that involved modifications to validate content. The findings helped to identify key qualities and skills facilitators need to support interprofessional teams to flourish and optimise performance. Further research could evaluate the impact of skilled integrated facilitation on health and social care outcomes and the well-being of frontline interprofessional teams.

Worksite-based cardiovascular risk screening and management: a feasibility study.

BACKGROUND: Established cardiovascular risk factors are highly prevalent and contribute substantially to cardiovascular morbidity and mortality because they remain uncontrolled in many Canadians. Worksite-based cardiovascular risk factor screening and management represent a largely untapped strategy for optimizing risk factor control. METHODS: In a 2-phase collaborative demonstration project between Alberta Health Services (AHS) and the Alberta Newsprint Company (ANC), ANC employees were offered cardiovascular risk factor screening and management. Screening was performed at the worksite by AHS nurses, who collected baseline history, performed automated blood pressure measurement and point-of-care testing for lipids and A1c, and calculated 10-year Framingham risk. Employees with a Framingham risk score of ≥10% and uncontrolled blood pressure, dyslipidemia, or smoking were offered 6 months of pharmacist case management to optimize their risk factor control. RESULTS: In total, 87 of 190 (46%) employees volunteered to undergo cardiovascular risk factor screening. Mean age was 44.5±11.9 years, 73 (83.9%) were male, 14 (16.1%) had hypertension, 4 (4.6%) had diabetes, 12 (13.8%) were current smokers, and 9 (10%) had dyslipidemia. Of 36 employees with an estimated Framingham risk score of ≥10%, 21 (58%) agreed to receive case management and 15 (42%) attended baseline and 6-month follow-up case management visits. Statistically significant reductions in left arm systolic blood pressure (-8.0±12.4 mmHg; p=0.03) and triglyceride levels (-0.8±1.4 mmol/L; p=0.04) occurred following case management. CONCLUSION: These findings demonstrate the feasibility and usefulness of collaborative, worksite-based cardiovascular risk factor screening and management. Expansion of this type of partnership in a cost-effective manner is warranted.

Development and Psychometric Properties of a Scale to Measure Hospital Organizational Culture for Cardiovascular Care.

BACKGROUND: Because organizational culture is increasingly understood as fundamental to achieving high performance in hospital and other healthcare settings, the ability to measure this nuanced concept empirically has gained importance. Aside from measures of patient safety culture, no measure of organizational culture has been widely endorsed in the medical literature, limiting replication of previous findings and broader use in interventional studies. METHODS AND RESULTS: We sought to develop and assess the validity and reliability of a scale for assessing organizational culture in the context of hospitals' efforts to reducing 30-day risk-standardized mortality after acute myocardial infarction. The 31-item scale was completed by 147 individuals representing 10 hospitals during August and September 2014. The resulting organizational culture scale demonstrated high level of construct validity and internal consistency. Factor analyses indicated that the 31 items loaded well (loading values 0.48-0.90), supporting distinguishable domains of (1) learning environment, (2) psychological safety, (3) commitment to the organization, (4) senior management support, and (5) time for improvement efforts. Cronbach α coefficients were 0.94 for the scale and ranged from 0.77 to 0.88 for the subscales. The scale displayed reasonable convergent validity and statistically significant variability across hospitals, with hospital identity accounting for 11.3% of variance in culture scores across respondents. CONCLUSIONS: We developed and validated a relatively easy-to-administer survey that was able to detect substantial variability in organizational culture across different hospitals and may be useful in measuring hospital culture and evaluating changes in culture over time as part performance improvement efforts.

Integrated Approaches to Occupational Health and Safety: A Systematic Review.

OBJECTIVE: The study objective was to conduct a systematic review of the effectiveness of integrated workplace interventions that combine health promotion with occupational health and safety. DATA SOURCE: Electronic databases (n = 8), including PsychInfo and MEDLINE, were systematically searched. STUDY INCLUSION AND EXCLUSION CRITERIA: Studies included were those that reported on workplace interventions that met the consensus definition of an "integrated approach," published in English, in the scientific literature since 1990. DATA EXTRACTION: Data extracted were occupation, worksite, country, sample size, intervention targets, follow-up period, and results reported. Quality was assessed according to American College of Occupational and Environmental Medicine Practice Guidelines. DATA SYNTHESIS: Heterogeneity precluded formal meta-analyses. Results were classified according to the outcome(s) assessed into five categories (health promotion, injury prevention, occupational health and safety management, psychosocial, and return-on-investment). Narrative synthesis of outcomes was performed. RESULTS: A total of 31 eligible studies were identified; 23 (74%) were (quasi-)experimental trials. Effective interventions were most of those aimed at improving employee physical or mental health. Less consistent results were reported from integrated interventions targeting occupational health and safety management, injury prevention, or organizational cost savings. CONCLUSION: Integrated approaches have been posed as comprehensive solutions to complex issues. Empirical evidence, while still emerging, provides some support for this. Continuing investment in, and evaluation of, integrated approaches are worthwhile.

Mandatory internal mobility in French hospitals: the results of imposed management practices.

AIM: To describe the impact of a mandatory internal mobility policy on nurses working in French state-funded health establishments. BACKGROUND: Public hospitals in France rely on the internal mobility of nursing staff to respond to organisational needs, to reduce costs and to increase productivity. However, there is very little data on the impact of such management practices on the nurses themselves. METHOD: A cross-sectional study, including 3077 nurses from 35 hospitals in the region of Paris, was conducted. Data were collected using a validated self-assessment questionnaire. RESULTS: Forty per cent of French nurses are required to work in different units. This mobility differs according to individual characteristics [age (P = 0.04), length of service (P = 0.017)] and type of environment [hospital (P < 0.0001), specialty (P < 0.0001)]. CONCLUSION: We can distinguish two types of approaches for implementing a mandatory staff nurse mobility policy. The first is an event that is regular, planned and lasts for several days. The second is an event that is irregular, short and organised the day before or the day of the change. Overall, while nurses are dissatisfied with all types of mandatory unit changes, this dissatisfaction is primarily a result of the irregular mobility events. IMPLICATIONS FOR NURSING MANAGEMENT: This study demonstrates the importance of implementing a planned inter-unit mobility event and proposes recommendations for this type of implementation.