Can Better Leadership Reduce Nursing Home Staff Turnover?

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

Workplace Integrated Safety and Health Program Uptake in Nursing Homes: Associations with Ownership.

Workers in nursing homes are at high risk of occupational injury. Understanding whether-and which-nursing homes implement integrated policies to protect and promote worker health is crucial. We surveyed Directors of Nursing (DON) at nursing homes in three US states with the Workplace Integrated Safety and Health (WISH) assessment, a recently developed and validated instrument that assesses workplace policies, programs, and practices that affect worker safety, health, and wellbeing. We hypothesized that corporate and for-profit nursing homes would be less likely to report policies consistent with Total Worker Health (TWH) approaches. For each of the five validated WISH domains, we assessed the association between being in the lowest quartile of WISH score and ownership status using multivariable logistic regression. Our sample included 543 nursing homes, 83% which were corporate owned and 77% which were for-profit. On average, DONs reported a high implementation of TWH policies, as measured by the WISH. We did not find an association between either corporate ownership or for-profit status and WISH score for any WISH domain. Results were consistent across numerous sensitivity analyses. For-profit status and corporate ownership status do not identify nursing homes that may benefit from additional TWH approaches.

Aligning research and practice: The role of academic-community partnerships for improving measurement and process.

OBJECTIVE: Community programs addressing social determinants of health are growing in prominence and are increasingly expected to provide metrics of success. Our objective is to assess the role of an academic-community partnership for a community health worker program targeting social and medical needs, and determine factors impacting its effectiveness. METHODS: We draw on a 4.5-year partnership that includes both quantitative and qualitative data collection and analysis. Quantitative data collection mechanisms evolved as a result of the partnership. Qualitative interviews were conducted with community health workers and leadership. RESULTS: To align medical and social support services in a sustainable and measurable manner, our academic-community partnership found that creating and maintaining a mutually beneficial space through small wins enabled us to then address larger problems and needs. Ongoing self-study and process evaluation allowed quick adjustments. Unique partnership elements such as having consistent funding and flexible timelines and objectives were essential. CONCLUSIONS: When integrating health and social services, academic-community partnerships create pathways for bidirectional learning than can quickly turn research into practice and support sustainability, especially when based on incrementally built trust and a history of small wins.

How to ask: Surveying nursing directors of nursing homes.

BACKGROUND AND AIMS: Nursing home research may involve eliciting information from managers, yet response rates for Directors of Nursing have not been recently studied. As a part of a more extensive study, we surveyed all nursing homes in three states in 2018 and 2019, updating how to survey these leaders effectively. We focus on response rates as a measure of non-response error and comparison of nursing home's characteristics to their population values as a measure of representation error. METHODS: We surveyed Directors of Nursing or their designees in nursing homes serving adult residents with at least 30 beds in California, Massachusetts, and Ohio (N = 2389). We collected contact information for respondents and then emailed survey invitations and links, followed by three email reminders and a paper version. Nursing home associations in two of the states contacted their members on our behalf. We compared the response rates across waves and states. We also compared the characteristics of nursing homes based on whether the response was via email or paper. In a multivariable logit regression, we used characteristics of the survey and the nursing homes to predict whether their DON responded to the survey using adjustments for multiple comparisons. RESULTS: The response rate was higher for the first wave than for the second (30% vs 20.5%). The highest response rate was in Massachusetts (31.8%), followed by Ohio (25.8%) and California (19.5%). Nursing home characteristics did not vary by response mode. Additionally, we did not find any statistically significant predictors of whether a nursing home responded. CONCLUSION: A single-mode survey may provide a reasonably representative sample at the cost of sample size. With that said, however, switching modes can increase sample size without potentially biasing the sample.

Movers and Stayers: What Birthplaces Can Teach Us About Rural Practice Choice Among Midwestern General Surgeons.

PURPOSE: This study compares practicing rural Midwestern general surgeons born in urban areas to those born in rural areas to describe the association between birthplace and current practice location. METHODS: The 2017 AMA MasterFile was used to study general surgeons in the Midwest Census Division. Surgeons were assigned to categories based on birthplace and current practice locations: urban-urban stayers, urban-rural movers, rural-rural stayers, and rural-urban movers. Urban and rural classifications corresponded to the metropolitan and nonmetropolitan definitions with Rural-Urban Continuum Codes (urban, RUCCs 1-3; rural, RUCCs 4-9). Bivariate tests and logistic regression were used to determine factors associated with rural practice choice. FINDINGS: There were 3,070 general surgeons in the study population: 70.6% urban-urban stayers, 13.1% urban-rural movers, 10.7% rural-urban movers, and 5.7% rural-rural stayers. Rural areas netted 74 surgeons (327 rural-urban movers versus 401 urban-rural movers). Logistic regression results found different factors predicted rural practice among urban-born versus rural-born surgeons. Older urban-born surgeons were more likely to practice rurally, as were male surgeons, DOs, and those trained in less-urban residency programs. Among rural-born surgeons, more rural birthplaces and having trained at a less-urban residency were associated with practicing rurally. CONCLUSIONS: Recruiting urban-born surgeons to rural areas has proven successful in the Midwest; our findings show urban-born surgeons outnumber rural-born surgeons in rural communities. Given the ongoing need for surgeons in rural areas, urban-born surgeons should not be overlooked. Findings suggest educators and community leaders should expand less-urban training opportunities given their potential influence on all general surgeons.

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

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

An Integrative Total Worker Health Framework for Keeping Workers Safe and Healthy During the COVID-19 Pandemic.

OBJECTIVE: The aim was to recommend an integrated Total Worker Health (TWH) approach which embraces core human factors and ergonomic principles, supporting worker safety, health, and well-being during the COVID-19 pandemic. BACKGROUND: COVID-19 has resulted in unprecedented challenges to workplace safety and health for workers and managers in essential businesses, including healthcare workers, grocery stores, delivery services, warehouses, and distribution centers. Essential workers need protection, accurate information, and a supportive work environment with an unwavering focus on effective infection control. METHOD: The investigators reviewed emerging workplace recommendations for reducing workers' exposures to the novel coronavirus and the challenges to workers in protecting their health. Using a theoretical framework and guidelines for integrating safety and health management systems into an organization for TWH, the investigators adapted the framework's key characteristics to meet the specific worker safety and health issues for effective infection control, providing supports for increasing psychological demands while ensuring a safe work environment. RESULTS: The recommended approach includes six key characteristics: focusing on working conditions for infection control and supportive environments for increased psychological demands; utilizing participatory approaches involving workers in identifying daily challenges and unique solutions; employing comprehensive and collaborative efforts to increase system efficiencies; committing as leaders to supporting workers through action and communications; adhering to ethical and legal standards; and using data to guide actions and evaluate progress. CONCLUSION: Applying an integrative TWH approach for worker safety, health, and well-being provides a framework to help managers systematically organize and protect themselves, essential workers, and the public during the COVID-19 pandemic. APPLICATION: By using the systems approach provided by the six implementation characteristics, employers of essential workers can organize their own efforts to improve system performance and worker well-being during these unprecedented times.

Where Is the Break-even Point for Community Health Workers? Using National Data and Local Programmatic Costs to Find the Break-even Point for a Metropolitan Community Health Worker Program.

BACKGROUND: Community health worker (CHW) programs take many forms and have been shown to be effective in improving health in several contexts. The extent to which they reduce unnecessary care is not firmly established. OBJECTIVES: This study estimates the number of hospitalizations and emergency department (ED) visits that would need to be avoided to recoup program costs for a CHW program that addressed both medical and social needs. RESEARCH DESIGN: A programmatic cost analysis is conducted using 6 different categories: personnel, training, transportation, equipment, facilities, and administrative costs. First, baseline costs are established for the current program and then estimate the number of avoided ED visits or hospitalizations needed to recoup program costs using national average health care estimates for different patient populations. MEASURES: Data on program costs are taken from administrative program records. Estimates of ED visit and hospitalization costs (or charges in some cases) are taken from the literature. RESULTS: To fully offset program costs, each CHW would need to work with their annual caseload of 150 participants to avoid almost 50 ED visits collectively. If CHW participants also avoided 2 hospitalizations, the number of avoided ED visits needed to offset costs reduces to about 34. CONCLUSIONS: Estimates of avoided visits needed to reach the break-even point are consistent with the literature. The analysis does not take other outcomes of the program from the clients' or workers' perspectives into account, so it is likely an upper bound on the number of avoided visits needed to be cost-effective.

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

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

The work of sterile processing departments: An exploratory study using qualitative interviews and a quantitative process database.

BACKGROUND: The sterile processing of surgical instruments and equipment is an essential part of surgical operations. Although clean instruments prevent infections, little is known about the departments that conduct this work. We sought to describe sterile processing departments (SPDs) and to identify factors impacting them. METHODS: We analyzed data from 22 qualitative interviews of staff and managers and a quantitative benchmarking database. RESULTS: Qualitative results indicated 4 primary factors impacting sterile processing work: (1) role and visibility, (2) relationships and communication with other departments and vendors, (3) staffing and management, and (4) technical problems and solutions. Quantitative analysis revealed significant differences in SPD responsibilities and scope. DISCUSSION: Relationships with operating room staff were of paramount importance in the ability of the SPD to accomplish its job and in staff motivations and feelings. Differences in management practices, communication strategies, and problem-solving resources were also emphasized. Both quantitative and qualitative data showed concern for the role of the SPD in patient safety, particularly concerning practices such as the use of immediate-use steam sterilization. CONCLUSIONS: To more completely address adverse patient events and surgical patient safety, we must move toward examining the entire surgical process, including the vital role of SPDs.

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

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

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

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

Examining public knowledge and preferences for adult preventive services coverage.

INTRODUCTION: To examine (1) what individuals know about the existing adult preventive service coverage provisions of the Affordable Care Act (ACA), and (2) which preventive services individuals think should be covered without cost sharing. METHODS: An online panel from Survey Monkey was used to obtain a sample of 2,990 adults age 18 and older in March 2015, analyzed 2015-2017. A 17-item survey instrument was designed and used to evaluate respondents' knowledge of the adult preventive services provision of the ACA. Additionally, we asked whether various preventive services should be covered. The data include age, sex, race/ethnicity, and educational attainment as well as measures of political ideology, previous insurance status, the number of chronic conditions, and usual source of care. RESULTS: Respondents correctly answered 38.6% of the questions about existing coverage under the ACA, while on average respondents thought 12.1 of 15 preventive services should be covered (SD 3.5). Respondents were more knowledgeable about coverage for routine screenings, such as blood pressure (63.4% correct) than potentially stigmatizing screenings, such as for alcohol misuse (28.8% correct). Blood pressure screening received the highest support of coverage (89.8%) while coverage of gym memberships received the lowest support (59.4%). Individuals with conservative ideologies thought fewer services on average should be covered, but the difference was small-around one service less than those with liberal ideologies. CONCLUSIONS: Overwhelmingly, individuals think that most preventive services should be covered without cost sharing. Despite several years of coverage for preventive services, there is still confusion and lack of knowledge about which services are covered.

Healthy Eating and Leisure-Time Activity: Cross-Sectional Analysis of that Role of Work Environments in the U.S.

OBJECTIVE: The aim of this study was to evaluate relationships between work context and two health behaviors, healthy eating and leisure-time physical activity (LTPA), in U.S. adults. METHODS: Using data from the 2010 National Health Interview Survey (NHIS) and Occupational Information Network (N = 14,863), we estimated a regression model to predict the marginal and joint probabilities of healthy eating and adhering to recommended exercise guidelines. RESULTS: Decision-making freedom was positively related to healthy eating and both behaviors jointly. Higher physical load was associated with a lower marginal probability of LTPA, healthy eating, and both behaviors jointly. Smoke and vapor exposures were negatively related to healthy eating and both behaviors. Chemical exposure was positively related to LTPA and both behaviors. Characteristics associated with marginal probabilities were not always predictive of joint outcomes. CONCLUSION: On the basis of nationwide occupation-specific evidence, workplace characteristics are important for healthy eating and LTPA.

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

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

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

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

Validation of a New Metric for Assessing the Integration of Health Protection and Health Promotion in a Sample of Small- and Medium-Sized Employer Groups.

OBJECTIVE: To conduct validation analyses for a new measure of the integration of worksite health protection and health promotion approaches developed in earlier research. METHODS: A survey of small- to medium-sized employers located in the United States was conducted between October 2013 and March 2014 (n = 111). Cronbach α coefficient was used to assess reliability, and Pearson correlation coefficients were used to assess convergent validity. RESULTS: The integration score was positively associated with the measures of occupational safety and health and health promotion activities/policies-supporting its convergent validity (Pearson correlation coefficients of 0.32 to 0.47). Cronbach α coefficient was 0.94, indicating excellent reliability. CONCLUSIONS: The integration score seems to be a promising tool for assessing integration of health promotion and health protection. Further work is needed to test its dimensionality and validate its use in other samples.

Health-related employer support, recurring pain, and direct insurance costs for a self-insured employer.

BACKGROUND: Poor psychosocial workplace factors have been found to cause or exacerbate a variety of health problems, including pain. However, little work has focused on how psychosocial workplace factors, such as health-related employer support, relate to future medical expenditures after controlling for health. Health-related support has also not been well explored in previous literature as a psychosocial factor. This study estimated the association of health-related employer support and pain with future medical expenditures, after including many additional controls. METHODS: This study used a restricted data set comprised of medical claims and survey data for one company in the U.S. Participants were included in the sample if they had worked for their employer for at least 12 months prior to the survey and if they were continuously eligible for health insurance (N=1,570). Future medical expenditures were measured using administrative claims data covering inpatient, outpatient, mental health and pharmaceutical insurance claims during a year. Health-related employer support was measured using participants' answers about whether the employer would support their efforts to positively change their emotional or physical health. Pain was measured as recurring pain from any condition over the previous year. RESULTS: Having any physical health-related employer support was associated with a 0.06 increase in the probability of having future medical expenditures greater than zero, 95% CI [0.01, 0.11], but not with total expenditures. Having pain was associated with a 0.06 increase, 95% CI [0.04, 0.09], in the probability of having future medical expenditures greater than zero and with $3,027 additional total expenditures, 95% CI [$1,077, $4,987]. CONCLUSIONS: After controlling for health and pain, psychosocial workplace factors were not robustly associated with future medical expenditures. Pain was associated with increased medical expenditures for the self-insured employer in this study, adjusting for a variety of factors.

Recurring pain and the potential of employer support to improve participant health.

OBJECTIVE: This study describes the relationships between a set of workplace psychosocial factors, including health-related employer support and recurring pain. METHODS: This study used a pooled sample of participants from 14 US employers (N = 34,359) from 2010 (for one employer, 2008). Multiple logistic regression was used to estimate the relationships, after controlling for many additional factors. RESULTS: Emotional, but not physical, health-related employer support was associated with reduced probability of pain. Job satisfaction, getting to use strengths at work, and having a supervisor who created a trusting and open environment were also associated with a reduced probability of pain. CONCLUSIONS: Although more research is needed to firmly establish the causal nature of the relationships, psychosocial workplace factors were associated with reduced probability of pain in this study.