Emotional Exhaustion in Healthcare Workers: Moving Beyond Coping Skills to Improve Organizational Conditions.

OBJECTIVE: Emotional exhaustion (EE)-the first stage of burnout-is related to preventable work environment exposures. We examined the understudied impact of organizational support for safety (OSS) and safety hazards (SH) on EE in a mixed licensed and unlicensed population of healthcare workers (HCWs). METHODS: A work environment exposures survey was conducted in five US public healthcare facilities in 2018-2019. A total of 1059 questionnaires were collected from a predominantly female population of mixed HCWs. RESULTS: Mean EE scores were higher among women, direct care workers, and younger subjects. In linear regression models, EE was positively associated with SH, emotional labor, psychological demands, physical demands, job strain, assault, and negative acts, while OSS was negatively associated. Safety hazard s both mediated and moderated the relationship between OSS and EE. CONCLUSIONS: When perception of SH is high, OSS has less impact on reducing EE, suggesting a need to effectively put safety policies to practice for improving EE in HCWS.

Participatory ergonomics: What works for whom and why? A realist review.

Participatory workplace interventions to improve workforce musculoskeletal health are infrequently analysed regarding why they work, for whom or under what circumstances. This review sought to identify intervention strategies which achieved genuine worker participation. In total, 3388 articles on participatory ergonomic (PE) interventions were screened; 23 were suitable to analyse within a realist framework identifying contexts, mechanisms of change, and outcomes. The interventions which succeeded in achieving worker participation were characterised by one or more of these contexts: workers' needs as a core starting point; a positive implementation climate; clear distribution of roles and responsibilities; allocation of sufficient resources; and managerial commitment to and involvement in occupational safety and health. Interventions that were organised and delivered in this way generated relevance, meaning, confidence, ownership and trust for the workers in an interrelated and multi-directional manner. With such information, PE interventions may be carried out more effectively and sustainably in the future.Practitioner summary: This review focuses on the question: which mechanisms support genuine worker participation, in what context and with which necessary resources, to reduce musculoskeletal disorders. Results emphasise the importance of starting with workers' needs, making the implementation climate egalitarian, clarifying the roles and responsibilities of all involved, and providing sufficient resources.Abbreviations: PE: participatory ergonomic(s); WMSD: Work-related musculoskeletal disorders; EU: European Union; MSD: Muskuloskeletal disorders; OSH: Occupational health and safety; C: context; M: mechanism; O: outcome; CMOCs: CMO configurations; NPT: Normalization process theory; OECD: The Organisation for Economic Co-operation and Development: EU-OSHA: European Occupational Safety and Health Agency.

Work-Family Conflict and Depression Among Healthcare Workers: The Role of Sleep and Decision Latitude.

BACKGROUND: Healthcare workers report a higher incidence of depression than the general population. Work-family conflict is a risk factor, but the mechanisms explaining its association with depression are not well understood. This study examines the potential mediating and moderating role of sleep and decision latitude in translating work-family conflict into depression. METHODS: In 2018, a cross-sectional survey was collected from healthcare workers (n = 1,059) in five public sector facilities in the northeast United States. The survey included questions on participants' work-family conflict, depression, sleep duration and disturbances, decision latitude, and other work environments and socio-demographic characteristics. Multivariable linear and Poisson regression modeling were used to examine associations among variables. FINDINGS: There was a significant association between work-family conflict and depression (ß = 2.70, p < .001). Sleep disturbances, although not short sleep duration, partially mediated this association. The association between work family-conflict and depression was stronger among workers with low decision latitude. CONCLUSIONS: Depression was prevalent among healthcare workers and was associated with work-family conflict. Sleep disturbances served as a significant mediator, while decision latitude modified the strength of the association. APPLICATION TO PRACTICE: Evidence-based interventions seeking to alleviate the effect of work-family conflict and improve healthcare workers' mental health should consider promoting employee sleep quality and improving employees' decision-making on the job.

Health Care Organization Policies for Employee Safety and COVID-19 Pandemic Response: A Mixed-Methods Study.

OBJECTIVE: The coronavirus (COVID-19) pandemic impacted the well-being of health care workers. We examined the association between prepandemic perceptions of perceived organizational support for safety (using NOSACQ-50), safety hazards and the pandemic's impact on individual workers and institutions. METHODS: Questionnaires from health care staff of five public health care facilities were collected in 2018 ( n = 1059) and 2021 ( n = 1553). In 2021, 17 workers were interviewed from the same facilities. RESULTS: Interviewees reported that their organizations struggled to communicate due to changing guidelines, inadequate personal protective equipment, training, and infection control, early in the pandemic. Questionnaire reports of decreased staffing and increased workload during the pandemic were associated with lower baseline NOSACQ scores. CONCLUSION: Survey findings predicted some variation in organizational response to the pandemic. Better organizational policies for employee safety and pandemic planning could improve health care institutions' preparedness.

Adherence to Mediterranean Diet and Depressive Symptomatology Among Boston Area Puerto Ricans.

BACKGROUND: Higher Mediterranean diet (MeD) adherence has been linked with lower depressive symptomatology, but research examining this association is limited, especially among Latinos, including mainland U.S. Puerto Ricans. Hence, we examined cross-sectional and longitudinal associations between MeD adherence and self-reported depressive symptomatology in Boston area Puerto Rican adults. METHODS: The Center for Epidemiologic Studies Depression Scale (CES-D) was used to evaluate depressive symptoms. Adherence to MeD was assessed at all 3 visits. We used multivariable linear regression for baseline cross-sectional analysis, and linear mixed effects modeling over 3 waves of follow-up for longitudinal analysis. We also assessed whether baseline MeD adherence affected 5y CES-D trajectory. We conducted sensitivity analyses among participants without diabetes, and among participants with complete MeD and CES-D measures at all visits. RESULTS: MeD adherence was significantly associated with CES-D score at baseline (ß = -2.0, 95% confidence interval [CI] -4.0, -0.04 for highest vs lowest tertile, p trend = .04) and across 3 waves (ß = -1.9, 95% CI = -3.0, -0.8 for highest vs lowest tertile, p trend = .0005). Results were similar in analyses restricted to participants without diabetes, as well as among participants with complete CES-D and MeD scores at all visits. CONCLUSIONS: While CES-D score was consistently lower in those with higher MeD adherence over 5 years of follow up, no relationship between baseline MeD adherence and 5y CES-D trajectory was observed.

Risk factors for surgically treated cervical spondylosis in male construction workers: a 20-year prospective study.

BACKGROUND CONTEXT: Degenerative changes due to cervical spondylosis (CS) can detrimentally affect work ability and quality of life yet understanding of how physical exposure affects disease progression is limited. PURPOSE: To assess the associations between occupational physical exposures and occurrence of surgically treated cervical spondylosis (ST-CS) and early exit from the labor market via disability pension. STUDY DESIGN/SETTING: Prospective register study with 20 years follow-up period. PATIENT SAMPLE: Swedish construction workers participating in a national health surveillance project conducted between 1971 and 1993. OUTCOME MEASURES: Surgically treated cervical spondylosis (ST-CS) and early labor market exit at a minimum rate of 25% time on disability pension. METHODS: Associations between occupational physical exposures (job exposure matrix) and subsequent ST-CS (National Hospital in-patient register) and early labor market exit via disability pension (Swedish Social Insurance Agency register) were assessed in a cohort of male construction workers (n=237,699). RESULTS: A total of 1381 ST-CS cases were present and a 20 years incidence rate of 35.1 cases per 100,000 person years (95% confidence interval (CI) 33.2-36.9). Increased relative risk (RR) for ST-CS was found for workers exposed to non-neutral (RR 1.40, 95% CI 1.15-1.69), and awkward neck postures (1.52, 1.19-1.95), working with the hands above shoulder height (1.30, 1.06-1.60), and high upper extremity loading (1.35, 1.15-1.59). Increased risk was also present for workers who reported frequent neck (3.06, 2.18-4.30) and upper back (3.84, 2.57-5.73) pain in the 12 months prior to survey. Among workers with elevated arm exposure, higher risk was seen in those who also had more frequent neck pain. ST-CS cases took early retirement more often (41.3%) and at a younger age (53 years) than the total study cohort (14.8% and 56 years of age, respectively). CONCLUSIONS: Occupational exposure to non-neutral neck postures, work with hands above shoulders and high loads born through the upper extremities increased the risk for ST-CS and early retirement due to disability. Decreasing postural and load exposure is salient for primary, secondary, and tertiary prevention of CS. Neck pain was shown to be a prognostic factor for ST-CS, which stresses the importance of acting early and taking preventative action to reduce workplace exposure, and the need for systematic medical check-ups within primary or occupational care to mitigate disease progression and early labour market exit due to disability.

Response to NIOSH Request for Information on Interventions to Prevent Work-Related Stress and Support Health Worker Mental Health.

The root causes of health care worker strain and depression include excessive job demands, extended work schedules, little decision-making opportunity, assault, bullying, and fear of injury. Potential links between working conditions and opioid overuse have also been discussed, beginning with psychological job strain or with physical pain leading to medication use. Promising solutions have been identified and many would be cost-effective, as enhanced working conditions could improve workers' mental health, job satisfaction, retention, and patient outcomes. Considering the number of health care workers leaving work during the global COVID-19 pandemic, it is urgent to address preventable root causes. In 2021, the US Congress called for educating health workers and first responders on the primary prevention of mental health conditions and substance use disorders. The CDC issued a Request for Information; this submission summarized research from CPH-NEW, a NIOSH Center of Excellence in Total Worker Health®, supplemented by a selective literature review.

High Emotional Demands at Work and Poor Mental Health in Client-Facing Workers.

This study investigated the association between emotional demands and depression or anxiety in a wide range of jobs. We used data from the third Korean Working Conditions Survey (n = 50,032) for all occupational classifications, with no limitations placed on job title or employment type. Among the full set of regular paid workers in addition to self-employed, unpaid family workers, and informal employees such as independent contractors, 23,989 respondents worked with "customers, passengers, students, or patients" (i.e., clients). Emotional demands were evaluated using two questions: handling angry clients and needing to hide feelings for work performance. Any depression or anxiety over the last 12 months was taken to indicate poor mental health. Multivariable logistic regression modeling was performed to calculate adjusted ORs with 95% confidence intervals for the influence of emotional demands on mental health, adjusting for demographic factors (age, gender, education, income), occupational psychological demands, decision latitude, social support, weekly work hours and job insecurity. The prevalence of emotional demands was higher in self-employed and informal employees than in regular paid employees. The more frequent the exposure to the two emotional demands combined was, the higher the risk of depression or anxiety. High psychological demands, low social support, and low job security each further increased the risk of poor mental health. Emotional demands turned out to be widespread in the entire economy, were not limited to service or sales occupations, and were more evident in precarious work. The contribution of emotional demands and other preventable job stressors to the burden of depression or anxiety in society may be substantial.

Using Participatory Ergonomics to Improve Health and Safety in Commercial Lobstering in the United States: 2 Case Studies.

The lobster-harvesting industry has a high occupational injury incidence compared to land-based industries. Participatory ergonomics methods were used to partner with lobstermen to develop and implement ergonomic improvements. The model included training in ergonomics principles, a forum for ergonomics discussions, and a sequence of meetings planned to focus on problem identification, intervention, evaluation, and dissemination of findings. One crew initiated 3 specific actions: the introduction of a conveyor belt to assist material handling at a local lobstering pier, the installation of a star block at the space for hauling traps onto the boat, and the initiation of a design process for improved mechanical assistance for hauling traps onto the boat. The other crew took action to reduce force and postural exposures by creating a short video intended to disseminate ergonomic ideas to other lobstermen. The influence of important cultural norms was observed for future research and development in the community.

Biomechanical Exposure to Upper Extremity Musculoskeletal Disorder Risk Factors in Hospital Laboratories.

Exposure to ergonomic risk factors has been reported for laboratory workers over decades. However, these exposures are not well characterized with respect to the type of laboratory or work organization. This study compared biomechanical exposure to upper extremity (UE) postures and hand activity levels (HALs) in general hospital laboratories by job, work, and laboratory type. The study used observational data gathered using a revised version of the Posture, Activity, Tools, and Handling (PATH) method, generating frequencies of categorized exposures. Eighteen workers were observed in 11 job titles (seven laboratories) in a single hospital by two investigators over a 7 month period. A taxonomy was constructed to categorize the extent to which the laboratory operations were automated. Overall, there were markedly high exposures to postural strain for the distal UE, especially wrist/forearm deviation (73% of observations), gross grasp (71%), and pinch grip (49%). For the HAL categories, 61% of the observations were in the moderate range (3.3-<6.7). Shoulders and elbows tended to remain in the neutral postural range. Posture frequencies were similar among the job categories studied and laboratory types. HAL was higher when the hand was in a pinch grip. Manual operations represented a higher proportion of work time than semi-automated or automated operations. Biomechanical exposure can be documented more extensively and diversely when using the revised PATH approach along with the taxonomy, with respect to exposure variables, such as the type of job, work, or organization in the industry including the hospital laboratories.

Use of a Mobile App for the Process Evaluation of an Intervention in Health Care: Development and Usability Study.

BACKGROUND: Process evaluation measures the context in which an outcome was or was not achieved through the ongoing monitoring of operations. Mobile apps are a potentially less burdensome tool for collecting these metrics in real time from participants. Research-driven apps are not always developed while paying attention to their usability for target users. Usability testing uncovers gaps in researchers', developers', and users' mental models of what an efficient, effective, and satisfying product looks like and facilitates design improvement. Models may vary by user demographics. OBJECTIVE: This study describes the development of a mobile app for collecting process evaluation metrics in an intervention study with health care workers that uses feedback at multiple stages to refine the app design, quantify usage based on workers' overall adoption of the app and the app's specific function, and compare the demographic and job characteristics of end users. METHODS: An app was developed to evaluate the Center for Promotion of Health in the New England Workplace Healthy Workplace Participatory Program, which trains teams to develop solutions for workforce health obstacles. Labor-management health and safety committee members, program champions, and managers were invited to use the app. An accompanying website was available for team facilitators. The app's 4 functions were meeting creation, postmeeting surveys, project time logs, and chat messages. Google Analytics recorded screen time. Two stages of pilot tests assessed functionality and usability across different device software, hardware, and platforms. In stage 1, student testers assessed the first functional prototype by performing task scenarios expected from end users. Feedback was used to fix issues and inform further development. In stage 2, the app was offered to all study participants; volunteers completed task scenarios and provided feedback at deployment. End user data for 18 months after deployment were summarized and compared by user characteristics. RESULTS: In stage 1, functionality problems were documented and fixed. The System Usability Scale scores from 7 student testers corresponded to good usability (mobile app=72.9; website=72.5), whereas 15 end users rated usability as ok (mobile app=64.7; website=62.5). Predominant usability themes from student testers were flexibility and efficiency and visibility of system status; end users prioritized flexibility andefficiency and recognition rather than recall. Both student testers and end users suggested useful features that would have resulted in the large-scale restructuring of the back end; these were considered for their benefits versus cost. In stage 2, the median total use time over 18 months was 10.9 minutes (IQR 23.8) and 14.5 visits (IQR 12.5). There were no observable patterns in use by demographic characteristics. CONCLUSIONS: Occupational health researchers developing a mobile app should budget for early and iterative testing to find and fix problems or usability issues, which can increase eventual product use and prevent potential gaps in data.

Evaluation of the HearWell Pilot Program: A Participatory Total Worker Health® Approach to Hearing Conservation.

Our objective was to pilot test HearWell, an intervention created to preserve hearing among highway maintainers, by using a participatory Total Worker Health® (TWH) approach to designing, implementing and evaluating interventions. Regional maintenance garages were randomized to control (n = 6); HearWell (n = 4) or HearWell Design Team (n = 2) arms. Maintainer representatives from the HearWell Design Team garages identified barriers to hearing health and collaborated to design interventions including a safety leadership training for managers, a noise hazard management scheme to identify noise levels and indicate the hearing protection device (HPD) needed, and a comprehensive HearWell training video and protocol. These worker-designed interventions, after manager input, were delivered to the HearWell Design Team and the HearWell garages. Control garages received standard industry hearing conservation training. Periodic surveys of workers in all 12 garages collected information on the frequency of HPD use and a new hearing climate measure to evaluate changes in behaviors and attitudes over the study period and following interventions. An intention-to-treat approach was utilized; differences and trends in group HPD use and hearing climate were analyzed using a mixed-effects model to account for repeated measures from individual participants. The HearWell Design Team maintainers reported the highest frequency of HPD use. Hearing climate improved in each group 6 months following intervention implementation, with the largest increase and highest value for the HearWell Design Team workers. The HearWell pilot intervention showed promising results in improving HPD use through a participatory TWH approach to hearing conservation. Furthermore, results suggest that employee participation in hearing conservation programs may be necessary for maximal effectiveness.

Emotional Labor and Depressive Symptoms Among Healthcare Workers: The Role of Sleep.

BACKGROUND: Depression is the second leading cause of disability worldwide. Health care workers report a higher prevalence of depressive symptoms than the general population. Emotional labor has contributed to poor health and work outcomes. However, the mechanism for the potential association between emotional labor and depressive symptoms has not been well studied. This study examines the relationship between emotional labor and depressive symptoms and whether sleep plays a role in explaining this relationship. METHODS: In 2018, health care workers (n = 1,060) from five public sector facilities in the northeast United States participated in this cross-sectional survey. The survey included questions on participants' surface-acting emotional labor (masking one's feelings at work), depressive symptoms, sleep duration and disturbances, and socio-demographic characteristics. Multivariable linear and Poisson regression modeling were used to examine associations among variables. FINDINGS: There was a significant association between emotional labor and depressive symptoms (ß = 0.82, p < .001). Sleep disturbances, but not short sleep duration, partially mediated this association. Neither sleep variable moderated this association. CONCLUSIONS/APPLICATION TO PRACTICE: Depressive symptoms were prevalent among health care workers and were associated with emotional masking. Sleep disturbances play an important intermediate role in translating emotional labor to depressive symptoms in these workers. Effective workplace programs are needed to reduce health care workers' emotional labor to improve their mental health. Sleep promotion should also be emphasized to mitigate the negative effect of emotional labor and promote mental wellbeing.

The Contribution of Occupation-Specific Factors to the Deaths of Despair, Massachusetts, 2005-2015.

OBJECTIVES: In the USA, deaths from poisonings (especially opioids), suicides, and alcoholic liver disease, collectively referred to as 'deaths of despair', have been increasing rapidly over the past two decades. The risk of deaths from these causes is known to be higher among certain occupations. It may be that specific exposures and experiences of workers in these occupations explain these differences in risk. This study sought to determine whether differences in the risk of deaths of despair were associated with rate of occupational injuries and illnesses, job insecurity, and temporal changes in employment in non-standard work arrangements. METHODS: Usual occupation information was collected from death certificates of Massachusetts residents aged 16-64 with relevant causes of death between 2005 and 2015. These data were combined with occupation-level data about occupational injuries and illnesses, job insecurity, and non-standard work arrangements. We calculated occupation-specific mortality rates for deaths of despair, categorized by occupational injury and illnesses rates and job insecurity. We calculated trends in mortality according to changes in non-standard work arrangements. RESULTS: Workers in occupations with higher injury and illnesses rates and more job insecurity had higher rates of deaths of despair, especially opioid-related deaths. Rates of deaths of despair increased most rapidly for occupations with increasing prevalence of workers employed in non-standard work arrangements. CONCLUSIONS: The findings suggest occupational factors that may contribute to the risk of deaths of despair. Future studies should examine these factors with individual-level data. In the meantime, efforts should be made to address these factors, which also represent known or suspected hazards for other adverse health outcomes.

Promoting Opioid Awareness Through a Union-Based Peer Training Model.

Work factors, including physical job demands, appear to be risk factors for opioid overdoses. We collaborated with unions representing workers in high-risk occupations and offered resources to develop tailored educational interventions for their members. An ironworkers' local, a statewide nurses' union, and a Teamsters local union participated, at levels higher than we had anticipated. The three unions trained 285 workers, including apprentices, stewards, and those nearing retirement. Short surveys assessed pre- and post-training knowledge, attitudes, confidence in helping others, and related domains. Seventy percent of respondents reported heavy or very heavy physical demands at work, and one-half had experienced work-related pain. After training, participants reported more knowledge about opioids, less concern about stigma related to help-seeking, and more ability to provide help to a co-worker struggling with opioids. Peers with recovery experience provided a unique contribution to training. Tailored job-specific and peer-delivered educational interventions may be able to reduce the potential impact of opioids on working people.

Feasibility of Virtual Focus Groups in Program Impact Evaluation.

Focus groups are often used for qualitative investigations. We adapted a published focus group method for evaluating impact of an organizational intervention for virtual delivery using video conferencing. The method entailed convening small groups of three to five participants for a 2-hour facilitated workshop. We delivered the virtual workshops, adding qualitative evaluation with researchers and participants, to assess the effectiveness of the protocol. We address the questions of how to structure the data collection procedures; whether virtual delivery permits cross participant interactions about a studied intervention; and how easy and comfortable the experience was for participants. Participants were university faculty members who were the focus of an institutional diversity program. The results indicated that the virtually delivered focus group workshop could be successfully implemented with strong fidelity to the original protocol to achieve the workshop goals. The workshops generated rich data about the impacts of the institutional program as well as other events and conditions in the working environment that were relevant to consider along with the observed program outcomes. A well-planned virtual focus group protocol is a valuable tool to engage intervention stakeholders for research and evaluation from a distance. Video conferencing is especially useful during the current COVID-19 pandemic, but also whenever geography separates researchers and evaluators from program stakeholders. Careful planning of privacy measures for a secure online environment and procedures for structured facilitation of group dialogue are critical for success, as in any focus group. This article addresses a gap in the literature on feasibility and methodology for using video conference technology to conduct qualitative data collection with groups.

A mixed-method approach to tailor the implementation of a participatory Total Worker Health® program.

Purpose ­: Total Worker Health® (TWH) programs, which represent a holistic approach for advancing worker safety, health and well-being, require an employer to adapt programmatic coordination and employee involvement in program design and delivery. Organizational readiness for such measures requires competencies in leadership, communication, subject expertise and worker participation. In the absence of documented methods for TWH readiness assessment, the authors developed a process to prospectively identify implementation facilitators and barriers that may be used to strengthen organizational competencies and optimize the organizational "fit" in advance. Design/methodology/approach ­: The mixed-method baseline assessment instruments comprised an online organizational readiness survey and a key leader interview; these were administered with key organizational and labor leaders in five US healthcare facilities. Findings about organizational resources, skills available and potential implementation barriers were summarized in a stakeholder feedback report and used to strengthen readiness and tailor implementation to the organizational context. Findings ­: The research team was able to leverage organizational strengths such as leaders' commitment and willingness to address nontraditional safety topics to establish new worker-led design teams. Information about program barriers (staff time and communication) enabled the research team to respond with proactive tailoring strategies such as training on participant roles, extending team recruitment time and providing program communication tools and coaching. Originality/value ­: A new method has been developed for prospective organizational readiness assessment to implement a participatory TWH program. The authors illustrate its ability to identify relevant organizational features to guide institutional preparation and tailor program implementation.

Workplace Sexual Harassment and Vulnerabilities among Low-Wage Hispanic Women.

Workplace sexual harassment is particularly widespread in industries with many low-wage jobs where Hispanic women are likely to work. This qualitative study examines the experiences of Hispanic women in low-income jobs to identify workplace sexual harassment situations, support seeking actions, barriers to report, and forms of retaliation. A qualitative research design with one-on-one structured interviews provided an in-depth understanding of the experiences of Hispanic women in low-wage jobs regarding workplace sexual harassment situations and potential contributing factors. Second, a conceptual framework is proposed to integrate the reported organizational factors and social vulnerabilities that interact, eroding the individual's ability to cope effectively with workplace sexual harassment. These include organizational resources for preventing and reporting, community and family resources for support, and health effects attributed to sexual harassment. Workplace sexual harassment was described by participants as escalating over time from dating invitations, sex-related comments, unwanted physical contact to explicit sexual propositions. Temporary workers reported being very often subject to explicit quid pro quo propositions. While these patterns might not differ from those reported by other groups, work organization factors overlap with individual and social characteristics of Hispanic women in low-income jobs revealing a complicated picture that requires a systems approach to achieve meaningful change for this vulnerable population.

Surface-acting emotional labor predicts depressive symptoms among health care workers over a 2-year prospective study.

OBJECTIVE: Surface-acting emotional labor (SaEL) is the requirement to hide or suppress felt emotions to achieve acceptable job performance. It is a common feature of jobs featuring interactions with the public, such as customers or patients. Resulting emotional inauthenticity is associated with psychological strain, but there have been few prospective studies of mental health outcomes. METHODS: A self-administered questionnaire was distributed in 24 skilled nursing facilities at baseline and 23 facilities 2 years later. Permanent full-time and part-time employees in all jobs were eligible to participate. Respondents in these analyses provided survey information on the frequency of SaEL at baseline and depressive symptoms on both occasions. Those without depression at baseline were deemed at risk. Multivariable logistic regression modeling estimated adjusted odds ratios (aOR) for SaEL, other job features, and demographic characteristics. RESULTS: A total of 939 eligible participants had no depression at baseline; 15% developed depressive symptoms. About two-thirds were direct care providers, including 38% nursing and medical assistants. Adjusted for potential confounders, workers with intermediate and high SaEL had a higher risk (aORs around 2). Symptom onset was also predicted by high work-family conflict, younger age and low decision latitude at work. CONCLUSIONS: In this prospective study of long-term care workers, those who reported experiencing high SaEL at the time of the baseline survey were at higher risk of developing depressive symptoms 2 years later. Both exposure and outcome could have suffered some misclassification. Future studies should examine a broader range of strategies for coping with emotional labor demands.