Addressing Mental Health Needs Among Frontline Health Care Workers During the COVID-19 Pandemic.

Frontline workers experienced inordinate stress levels during the COVID-19 pandemic, as historically high volume and acuity in our hospitals was accompanied by concerns about our safety. We suggest that supporting frontline workers is an essential part of the pandemic response plan. We propose strategies to address the emotional and mental health (MH) needs of frontline health care workers during and after a pandemic that integrates knowledge from the disaster MH literature with the lessons learned during the COVID-19 pandemic. The disaster MH literature emphasizes distinguishing development of defined psychiatric disorders from emotional distress representing normative responses to disaster trauma and stress. Differentiating psychopathology from distress requires diagnostic assessment by a trained clinician. Where shortages of psychiatrists exist, primary care physicians may be trained to assist with disaster-related psychiatric assessment and initiation of treatment for psychopathologic features. The first component of a pandemic MH plan for critical frontline workers is to distinguish psychiatric illness from normative distress and to provide adequate treatment of psychopathologic symptoms. A second component of the comprehensive pandemic MH response is the provision of supportive care interventions and resources for normative distress. These interventions may include psychological first aid, individual or group counseling, broadening the pool of frontline workers, and buddy systems. Although these interventions were unknown or difficult to put in place at the beginning of the COVID-19 pandemic, we now have an opportunity to implement postpandemic MH response plans and to create response planning for subsequent COVID-19 surges integrating MH care into the front lines.

Exploring the self-preparedness of frontline healthcare workers in a low- and middle-income country from a humanitarian context during the COVID-19 pandemic: A constructivist grounded theory study.

Background: While research has been conducted on the availability, accessibility, and affordability of personal protective equipment for healthcare workers during the COVID-19 pandemic, little information is available on the ways in which health workers, especially those in humanitarian settings see themselves, and engage in self-preparedness for social, physical, and mental health and practical care in the pandemic. We sought to address this gap. Methods: We followed a constructivist grounded theory approach to guide in-depth interviews with 30 frontline doctors, nurses, and community healthcare workers recruited from the Rohingya refugee camps in Bangladesh using the purposive and snowball sampling methods. Analyses were carried out through the identification of codes in three phases: an initial line-by-line open coding, then focused axial coding, and finally selective coding. Findings: An emergent-grounded theory of "Navigating Self-Preparedness through Pandemics" was developed as we built a five-phased theoretical framework examining health worker responses with the following pillars: (a) pandemic shock; (b) pandemic awareness; (c) pandemic learning; (d) pandemic resilience, and (e) pandemic resurgence. Interpretation: The theory emerged as a realistic, socially, and culturally sensitive COVID-19 strategy to support healthcare workers. Self-preparedness was characterized by two interwoven processes: (1) the experiences of the daily life span of healthcare workers attempting to improve their own protection using all their potential while providing care for patients in a vulnerable setting and time and (2) the inseparable role of physical, psychological, social, and spiritual factors in each stage of learning during the pandemic to achieve better outcomes.

"I Carry the Trauma and Can Vividly Remember": Mental Health Impacts of the COVID-19 Pandemic on Frontline Health Care Workers in South Africa.

We know from research that pandemics and disease outbreaks expose HCWs to an increased risk of short and long-term psychosocial and occupational impacts. We conducted qualitative research among 44 frontline health care workers (FHCWs) practicing in seven South African hospitals and clinics. FHCWs were interviewed on their experiences of working during the first-wave of the COVID-19 pandemic and its perceived impact on their wellness. In this study, FHCWs included the non-medical and medical professionals in direct contact with COVID-19 patients, providing health care and treatment services during the COVID-19 pandemic. Most of the FHCWs reported stressful and traumatic experiences relating to being exposed to a deadly virus and working in an emotionally taxing environment. They reported depression, anxiety, traumatic stress symptoms, demoralization, sleep difficulties, poor functioning, increased irritability and fear of being infected or dying from COVID-19. The mental health impacts of COVID-19 on HCWs were also associated with increased poor physical wellbeing, including fatigue, burnout, headache, and chest-pains. FHCWs reported professional commitment and their faith as critical intrinsic motivators that fostered adaptive coping while working on the frontline during the first-wave of the COVID-19 pandemic. Many alluded to gaps in workplace psychosocial support which they perceived as crucial for coping mentally. The findings point to a need to prioritize interventions to promote mental wellness among FHCWs to ensure the delivery of quality healthcare to patients during pandemics or deadly disease outbreaks.

Vaccine hesitancy towards COVID vaccine among unvaccinated frontline health care workers working in a designated COVID care center: A cross-sectional study.

Background: Frontline health care workers (FLHCW) like doctors and nurses are bound to treat COVID patients being themselves not immune to disease are at a greater risk of COVID infection than the general population. The study was started with objectives to find out the vaccine hesitancy towards the COVID vaccine and to find out the factors associated with vaccine hesitancy among FLHCW working in a designated COVID care center. Materials and Methods: The present study was a cross-sectional study carried out for a period of 6 months from Jan 2021 to June 2021 at a designated COVID care center. FLHCWs who were part of treating COVID patients were our study participants. Among them, FLHCWs who had not received even one dose of COVID vaccine (Covishield) were included in the study. FLHCWs who had been part of the COVID vaccine trial were excluded from the study. The sample size calculated based on a previous study found to be 240. The data collected were entered into a Microsoft office excel sheet, analyzed using SPSS v 22(IBM Corp). Descriptive statistics were applied, and parametric tests were used to compare among the groups with statistically significant P value lesser than 0.05. Results: A total of 121 (52.6%) of FLHCWs were aged more than 30 years, 118 (51.5%) were male participants, 100 (43.5%) were paramedics by occupation, 51 (22.1%) had contracted COVID infection, 202 (87.8%) had received information, education, and communication (IEC) regarding COVID vaccine. FLHCWs more than 30 years, male participants, currently not working in COVIDward, FLHCWs who had not received IEC about COVIDvaccination and paramedics had higher scores of Vaccine hesitancy, and the difference was statistically significant indicating vaccine hesitancy. Conclusion: Vaccine hesitancy remains a persistent global threat. Awareness campaigns can be tailored to specific locales to address identified concerns regarding vaccines.

Effectiveness and Cost-Effectiveness of Mental Health Interventions Delivered by Frontline Health Care Workers in Emergency Health Services: A Systematic Review and Meta-Analysis.

This systematic review is to evaluate the effectiveness and cost-effectiveness of mental health interventions delivered by frontline health care workers in disasters and public health emergencies. Six databases and trial registries were searched, and manual searches were conducted. Of the 221 studies identified, 21 were included. Meta-analyses assessed differences between the intervention and control in terms of PTSD outcomes. Eleven studies of 1802 participants were incorporated in the meta-analysis. Interventions delivered or prompted by specialist health care workers showed significant and large effects in improving PTSD-related symptoms with a SMD = 0.99 (95% CI: 0.42-1.57, p = 0.0007). Interventions delivered or prompted by frontline non-specialist health care workers showed significant but small effects in improving PTSD-related symptoms with SMD of 0.25 (95% CI: 0.11-0.39; p = 0.0007). The results showed that most mental health interventions delivered by frontline health care workers effectively supported affected people. Mental health interventions delivered by mental health care professionals are effective in reducing PTSD-related disorders in natural disasters. Future adequately powered RCTs are needed to evaluate the effectiveness of mental health interventions delivered by trained non-specialists. Economic modelling may be useful to estimate cost effectiveness in low- and middle-income countries given the difficulties of conducting studies in disaster and emergency settings.

Estimation of Prevalence and Comparing the Levels of Stress, Anxiety, Depression, and Psychological Impact Before and After COVID-19 Lockdown Among Front Line Health Care Workers.

The main objective of the study is to estimate the prevalence and compare the levels of psychological impact, anxiety, depression, and stress experienced by the frontline health care workers (HCWs) during the lockdown and post lockdown periods at Apollo Institute of Medical Sciences and Research, Hyderabad, India. All participants involved in the study were evaluated by using depression, anxiety and stress scale 21, the impact of event scale revised scale for post-traumatic stress disorder (PTSD), and a standardized questionnaire. During the lockdown period, the score for depression was observed mean scores to be more in front desk people (2.70) followed by pharmacists and technicians (2.60) and security (2.28) in the lockdown period. During the lockdown, the highest levels of anxiety were seen in security staff (4.72) and housekeeping (4.8), with a considerable increase after the lockdown situation. During the lockdown period, the mean score of pharmacists and technicians (10.33) were more stressed than other HCWs, and the second-highest levels of stress were observed in security (10.11) and front desk workers (10.09), respectively. Our results show that there was a worsening of the psychological impact of the pandemic and an increase in PTSD, stress, anxiety, and depression among HCWs. Female gender, pharmacists, and technicians were the most vulnerable group to develop psychiatric comorbidities.

COVID-19: Vaccination Side Effects and Sick Leave in Frontline Healthcare-Workers-A Web-Based Survey in Germany.

(1) Background: The COVID-19 vaccination has caused uncertainty among employees and employers regarding vaccination reactions and incapacitation. At the time of our study, three vaccines are licensed in Germany to combat the COVID-19 pandemic (BioNTech/Pfizer (Comirnaty), AstraZeneca (Vaxzevria), and Moderna (Spikevax). We aim to assess how often and to what extent frontline healthcare workers had vaccination reactions after the first and second vaccination. The main focus is on the amount of sick leave after the vaccinations. (2) Methods: We create a web-based online questionnaire and deliver it to 270 medical directors in emergency medical services all over Germany. They are asked to make the questionnaire public to employees in their area of responsibility. To assess the association between independent variables and adverse effects of vaccination, we use log-binomial regression to estimate prevalence ratios (PR) with 95% confidence intervals (95%CI) for dichotomous outcomes (sick leave). (3) Results: A total of 3909 individuals participate in the survey for the first vaccination, of whom 3657 (94%) also provide data on the second vaccination. Compared to the first vaccination, mRNA-related vaccine reactions are more intense after the second vaccination, while vaccination reactions are less intense for vector vaccines. (4) Conclusion: Most vaccination reactions are physiological (local or systemic). Our results can help to anticipate the extent to which personnel will be unable to work after vaccination. Even among vaccinated HCWs, there seems to be some skepticism about future vaccinations. Therefore, continuous education and training should be provided to all professionals, especially regarding vaccination boosters. Our results contribute to a better understanding and can therefore support the control of the pandemic.

COVID-19 Infection and Symptoms Among Emergency Medicine Residents and Fellows in an Urban Academic Hospital Setting: Cross-sectional Questionnaire Study.

Background: COVID-19, an illness caused by the novel coronavirus SARS-CoV-2, affected many aspects of health care worldwide in 2020. From March to May 2020, New York City experienced a large surge of cases. Objective: The aim of this study is to characterize the prevalence of illness and symptoms experienced by residents and fellows in 2 New York City hospitals during the period of March to May 2020. Methods: An institutional review board-exempt survey was distributed to emergency medicine housestaff in May 2020, and submissions were accepted through August 2020. Results: Out of 104 residents and fellows, 64 responded to our survey (a 61.5% response rate). Out of 64 responders, 27 (42%) tested positive for SARS-CoV-2 antibodies. Most residents experienced symptoms that are consistent with COVID-19; however, few received polymerase chain reaction testing. Out of 27 housestaff with SARS-CoV-2 antibodies, 18 (67%) experienced fever and chills, compared with 8 out of 34 housestaff (24%) without SARS-CoV-2 antibodies. Of the 27 housestaff with SARS-CoV-2 antibodies, 19 (70%) experienced loss of taste and smell, compared with 2 out of 34 housestaff (6%) without SARS-CoV-2 antibodies. Both fever and chills and loss of taste and smell were significantly more commonly experienced by antibody-positive compared to antibody-negative housestaff (P=.002 and <.001, respectively). All 13 housestaff who reported no symptoms during the study period tested negative for SARS-CoV-2 antibodies. Conclusions: Our study demonstrated that in our hospitals, the rate of COVID-19 illness among emergency department housestaff was much higher than previously reported. Further studies are needed to characterize illness among medical staff in emergency departments across the nation. The high infection rate among emergency medicine trainees stresses the importance of supplying adequate personal protective equipment for health care professionals.

Exposure risk and COVID-19 infection among frontline health-care workers: A single tertiary care centre experience.

BACKGROUND: There is limited data on frontline health-care workers and risk of COVID-19 from the developing nations. It is imperative to identify those at higher risk to prevent further transmission. We assessed the relationship between exposure risk and COVID-19 among front-line health-care workers who were primary contacts of a COVID-19 patient. METHODS: A retrospective cohort study was conducted among front-line health-care workers in a tertiary care hospital who were exposed to a COVID-19 patient. Information on demographic factors, medical history, exposure related factors and subsequently COVID-19 lab reports were collected. An exposure risk assessment designed collating various exposure related factors categorized the participants into those with high and low risk. We used logistic regression to estimate the odds ratio of our primary outcome, a positive COVID-19 test when the independent variables were exposure risk, age, gender and occupation. RESULTS: Among1858 frontline workers who were primary contacts of a COVID-19 patient at the hospital, 106 (5.7%) incident reports of a positive COVID-19 test were recorded. None of the exposure related factors had any significant association with a positive COVID-19 test. However, high exposure risk category was significantly associated with COVID-19 positive test at the end of quarantine. CONCLUSION: COVID-19 was more frequent among front-line health-care workers who belonged to high exposure category. Education at different levels of service delivery at hospitals is required for best practice in order to prevent COVID-19 among health care providers. There is need to develop additional strategies to ensure that the information is translated in to practice.

Reliability and validity of the Pittsburgh Sleep Quality Index among frontline COVID-19 health care workers using classical test theory and item response theory.

STUDY OBJECTIVES: The applicability of sleep-related scales to frontline medical staff for the COVID-19 pandemic has not been fully proved, so sleep survey results lack credibility and accuracy, creating difficulties for the guidance and treatment of frontline medical staff with sleep disorders, which is not conducive to the prevention and control of COVID-19. This study sought to analyze the reliability and validity of the Pittsburgh Sleep Quality Index (PSQI) among frontline medical staff fighting the COVID-19 pandemic. METHODS: A network questionnaire survey was used to investigate the PSQI among frontline medical staff who fought COVID-19 in Wuhan, China from March 19 to April 15, 2020. Combined with classical test theory and item response theory, the content validity, internal consistency, construct validity, and other aspects of the PSQI were evaluated. RESULTS: According to classical test theory, content validity, criterion validity, and construct validity of the PSQI were good. But the internal consistency was better after the deletion of the "daytime dysfunction" subscale. With regard to item response theory, difficulty, the differential item function, and the Wright map performed well. CONCLUSIONS: The original PSQI showed acceptable applicability in frontline COVID-19 medical staff, and its characteristics moderately improved after the "daytime dysfunction" subscale was removed. CITATION: Wang L, Wu Y-X, Lin Y-Q, et al. Reliability and validity of the Pittsburgh Sleep Quality Index among frontline COVID-19 health care workers using classical test theory and item response theory. J Clin Sleep Med. 2022;18(2):541-551.

Supporting Health-Care Workers and Patients in Quarantine Wards: Evidence From a Survey of Frontline Health-Care Workers and Inpatients With COVID-19 in Wuhan, China.

Objective: Frontline health-care workers and patients with COVID-19 have been identified as high-risk groups for psychological problems. Experience of working or staying in quarantine wards generated psychological stressors for health-care workers and patients with COVID-19. The present study aimed to investigate the psychological symptoms of hospitalized patients with COVID-19 and the health-care workers treating them during the outbreak period, examine the effects of psychological stressors on mental health in both populations and perceived coping resources for both sides. Methods: Three hundred and eleven health-care workers working in a COVID-19 designated hospital in Wuhan, China, and 148 hospitalized patients with COVID-19 in the same hospital participated in this cross-sectional survey conducted in February 2020. Psychological symptoms, psychological stressors, and perceived coping resources were reported by both groups. Results: Thirty-three percent of health-care workers and 35.2% of patients with COVID-19 had significant psychological symptoms that were indicative of a high risk for psychological disorders. Pandemic-related psychological stressors contributed to psychological symptoms for both populations. Concern about patients was one aspect of psychological stressors of frontline health-care workers and both groups perceived support from the opposite side as an important external coping resource. Conclusion: The results shed light on the need to provide psychological support to both frontline health-care workers and patients with COVID-19 and suggest enhancing the treatment alliance might be effective to improve mental health for both populations during the crisis.

Perceptions of Mobile Health Apps and Features to Support Psychosocial Well-being Among Frontline Health Care Workers Involved in the COVID-19 Pandemic Response: Qualitative Study.

BACKGROUND: Frontline health care workers are experiencing a myriad of physical and psychosocial challenges amid the COVID-19 pandemic. There is growing recognition that digital technologies have the potential to improve the well-being of frontline workers. However, there has been limited development of wellness interventions using mobile health (mHealth) technology. More importantly, little research has been conducted on how frontline workers perceive mHealth-based support to promote their well-being. OBJECTIVE: This study aimed to explore frontline workers' experience of conventional psychological wellness programs and their perceptions of the usefulness of mHealth apps and features for promoting well-being. It also sought to identify factors that could potentially influence uptake and retention of an mHealth-based wellness program. METHODS: We conducted semistructured interviews using purposive sampling with frontline workers involved in the COVID-19 response. Various visual materials, collated from existing mHealth app features, were presented to facilitate discussion. Interviews were audio-recorded and transcribed verbatim. Thematic analysis based on grounded theory was undertaken. Themes were subsequently mapped to key nudge strategies-those commonly used for mHealth development-to assess participants' preferences for particular features and their reasoning. RESULTS: A total of 42 frontline workers participated in 12 one-on-one interviews or focus group discussions. Frontline workers generally had a limited ability to identify their own psychological problems and liked the reminders functionality of the app to track their mood over time. A personalized goal-setting feature (ie, tailoring) and in-app resources were generally valued, while frequent coaching and messages (ie, framing) were seen as a distraction. The majority of participants desired a built-in chat function with a counselor (ie, guidance) for reasons of accessibility and protection of privacy. Very few participants appreciated a gamification function. Frontline workers commonly reported the need for ongoing social support and desired access to an in-app peer support community (ie, social influence). There were, however, concerns regarding potential risks from virtual peer interactions. Intrinsic motivational factors, mHealth app technicality, and tangible rewards were identified as critical for uptake and retention. CONCLUSIONS: Our study highlights the potential of mHealth apps with relevant features to be used as wellness tools by frontline health care workers. Future work should focus on developing a nonintrusive and personalized mHealth app with in-app counseling, peer support to improve well-being, and tangible and extrinsic rewards to foster continued use.

Sleep Disturbances in Frontline Health Care Workers During the COVID-19 Pandemic: Social Media Survey Study.

BACKGROUND: During the COVID-19 pandemic, health care workers are sharing their challenges, including sleep disturbances, on social media; however, no study has evaluated sleep in predominantly US frontline health care workers during the COVID-19 pandemic. OBJECTIVE: The aim of this study was to assess sleep among a sample of predominantly US frontline health care workers during the COVID-19 pandemic using validated measures through a survey distributed on social media. METHODS: A self-selection survey was distributed on Facebook, Twitter, and Instagram for 16 days (August 31 to September 15, 2020), targeting health care workers who were clinically active during the COVID-19 pandemic. Study participants completed the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI), and they reported their demographic and career information. Poor sleep quality was defined as a PSQI score ≥5. Moderate-to-severe insomnia was defined as an ISI score >14. The Mini-Z Burnout Survey was used to measure burnout. Multivariate logistic regression tested associations between demographics, career characteristics, and sleep outcomes. RESULTS: A total of 963 surveys were completed. Participants were predominantly White (894/963, 92.8%), female (707/963, 73.4%), aged 30-49 years (692/963, 71.9%), and physicians (620/963, 64.4%). Mean sleep duration was 6.1 hours (SD 1.2). Nearly 96% (920/963, 95.5%) of participants reported poor sleep (PSQI). One-third (288/963, 30%) reported moderate or severe insomnia. Many participants (554/910, 60.9%) experienced sleep disruptions due to device use or had nightmares at least once per week (420/929, 45.2%). Over 50% (525/932, 56.3%) reported burnout. In multivariable logistic regressions, nonphysician (odds ratio [OR] 2.4, 95% CI 1.7-3.4), caring for patients with COVID-19 (OR 1.8, 95% CI 1.2-2.8), Hispanic ethnicity (OR 2.2, 95% CI 1.4-3.5), female sex (OR 1.6, 95% CI 1.1-2.4), and having a sleep disorder (OR 4.3, 95% CI 2.7-6.9) were associated with increased odds of insomnia. In open-ended comments (n=310), poor sleep was mapped to four categories: children and family, work demands, personal health, and pandemic-related sleep disturbances. CONCLUSIONS: During the COVID-19 pandemic, nearly all the frontline health care workers surveyed on social media reported poor sleep, over one-third reported insomnia, and over half reported burnout. Many also reported sleep disruptions due to device use and nightmares. Sleep interventions for frontline health care workers are urgently needed.

Mental Health Outcomes among Frontline Health-Care Workers at Eka Kotebe National COVID-19 Treatment Center, Addis Ababa, Ethiopia, 2020: A Cross-Sectional Study.

Background: The COVID-19 pandemic has resulted in many frontline health-care workers vulnerable to developing various mental health conditions. This study aimed to determine prevalence and associated factors of such conditions among frontline workers at Eka Kotebe National COVID-19 Treatment Center in Addis Ababa, Ethiopia. Methods: This institution-based cross-sectional study was conducted between May and June 2020 on 280 frontline workers. Mental health outcomes (depression, anxiety, insomnia, and posttraumatic stress disorder) were assessed using the Patient Health Questionnaire9, Generalized Anxiety Disorder 7 questionnaire, PTSD Checklist - civilian version, and Pittsburgh Sleep Quality Index. Responses were coded, entered into EpiData 3.1 and analyzed using SPSS 20. Associations between outcomes and independent variables were identified using bivariate and multivariate logistic regressions, statistical significance set at p<0.05. Results: A total of 238 subjects participated in the study, with a response rate of 85%. Estimated prevalence was 31.1% (95% CI 24.8%-37%) for anxiety, 27.3% (95% CI 21.8%-32.4%) for depression, 16% (95% CI 11.3%-21%) for PTSD, and 40.8% (95% CI 33.6%-47.5%) for insomnia. Female sex (AOR 2.99, 95% CI 1.49-5.97), being married, (AOR 13.2, 95% CI 3.42-50.7), being single (AOR 11.5, 95% CI 3.38-39.8), duration of exposure 1-2 hours (AOR 0.29, 95% CI 0.14-0.64), and assigned place of work (critical ward -AOR 2.26, 95% CI 1.03-4.97; ICU - AOR 4.44, 95% CI 1.51-13.05) were found to be significant predictors of depression. Conclusion: We found a high estimated prevalence of mental health outcomes. Sex, marital status, duration of exposure, and assigned place of work were found to be associated with depression.

Are community health workers effective in retaining women in the maternity care continuum? Evidence from India.

OBJECTIVES: Despite the recognised importance of adopting a continuum of care perspective in addressing the care of mothers and newborns, evidence on specific interventions to enhance engagement of women along the maternity care continuum has been limited. We use the example of the Accredited Social Health Activist (ASHA) programme in India, to understand the role of community health workers in retaining women in the maternity care continuum. METHODS: Using the Indian Human Development Survey data from 2011 to 2012, we assess the association between individual and cluster-level exposure to ASHA and four key components along the continuum of care-at least one antenatal care (ANC) visit, four or more ANC visits, presence of a skilled birth attendance (SBA) at the time of birth and postnatal care for the mother or child within 48 hours of birth, for 13 705 women with a live birth since 2005. To understand which of these services experience maximum dropout along the continuum, we use a linear probability model to calculate the weighted percentages of using each service. We assess the association between exposure to ASHA and number of services utilised using a multinomial logistic regression model adjusted for a range of confounding variables and survey weights. RESULTS: Our study indicates that exposure to the ASHA is associated with an increased probability of women receiving at least one ANC and SBA. In terms of numbers of services, exposure to ASHA accounts for a 12% (95% CI: 9.1 to 15.1) increase in women receiving at least some of the services, and an 8.8% (95% CI: -10.2 to -7.4) decrease in women receiving no services. However, exposure to ASHA does not increase the likelihood of women utilising all the services along the continuum. CONCLUSIONS: While ASHA is effective in supporting women to initiate and continue care along the continuum, it does not significantly affect the completion of all services along the continuum.

Healthcare organization-education partnerships and career ladder programs for health care workers.

Increasing concerns about quality of care and workforce shortages have motivated health care organizations and educational institutions to partner to create career ladders for frontline health care workers. Career ladders reward workers for gains in skills and knowledge and may reduce the costs associated with turnover, improve patient care, and/or address projected shortages of certain nursing and allied health professions. This study examines partnerships between health care and educational organizations in the United States during the design and implementation of career ladder training programs for low-skill workers in health care settings, referred to as frontline health care workers. Mixed methods data from 291 frontline health care workers and 347 key informants (e.g., administrators, instructors, managers) collected between 2007 and 2010 were analyzed using both regression and fuzzy-set qualitative comparative analysis (QCA). Results suggest that different combinations of partner characteristics, including having an education leader, employer leader, frontline management support, partnership history, community need, and educational policies, were necessary for high worker career self-efficacy and program satisfaction. Whether a worker received a wage increase, however, was primarily dependent on leadership within the health care organization, including having an employer leader and employer implementation policies. Findings suggest that strong partnerships between health care and educational organizations can contribute to the successful implementation of career ladder programs, but workers' ability to earn monetary rewards for program participation depends on the strength of leadership support within the health care organization.