Evidence for the Relationship between Work...

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Evidence for the Relationship between Work Organization, Worker Safety, and

Patient/Resident Outcomes

Rebecca Gore, Alicia Kurowski, Supriya Lahiri, Saira Latif, Nadine Mpolla, Bora Plaku-Alakbarova, Laura Punnett,

& ProCare Research Team

University of Massachusetts LowellLowell, MA, USA

A NIOSH Center for Excellence to Promote a Healthier Workforce



“[Heathcare and Social Assistance] is burdened by the historical and entrenched belief that patient care issues supersede the personal safety and health of workers and that it is acceptable for HCSA workers to have less than optimal protections against the risks of hazardous exposures or injuries.”

Identification of Research Opportunities for the Next Decade of NORA: State of the Sector | Healthcare and Social Assistance. NIOSH Publication No. 2009-138.


Health Care Worker (HCW) Safety and Patient Safety

• Patients (& residents) and employees occupy a common environment, with common hazards.

• Patients affect employees’ health• Employees affect patients’ health

Patients and HCWs are both part of the samehealth care system. The environment of care and the environment of work are the same.

- Dr. Andrew Vaughn, Mayo Clinic


Promoting Caregivers' Physical & Mental Health via TransdisciplinaryIntervention (“ProCare”) Evaluate a safe

resident handling program (SRHP) (2004-06) & other employee health activities in a large chain of long-term care facilities.

4


Questions for this presentation

1. Is SRH program effectivenessaffected by work organization characteristics?

2. Are residents’ satisfaction or clinical outcomes affected by center organizational characteristics?

5


Direct Observations of CNA’s

F0: Baseline (Pre‐SRHP)

F1: 3 mos. post‐SRHP




Total Obs. Periods 60 56 100 88 57Total Obs. Moments 15,185 16,031 25,472 24,652 17,365

Exposure Categories:• Trunk, arm, and leg

postures• Weight in hands• Lifting equipment (yes/no)


0%

10%

20%

30%

40%

50%

60%

70%

80%

Baseline 3-Month 12-Month 24-Month 36-Month

Per

cent

age

of R

epos

ition

&Tr

ansf

er O

bser

vatio

ns

Equipment Use* While Repositioning† and Transferring†

Reposition

Transfer

0%

5%

10%

15%

20%

25%

30%

35%

BL 3-Month 12-Month 24-Month 36-Month

Perc

enta

ge o

f Res

iden

t H

andl

ing

Obs

erva

tions

Equipment Use While* Resident Handling† ††

0%

10%

20%

30%

40%

50%

60%

70%

80%

< 10 lbs 10 - 50 lbs > 50 lbs

Perc

enta

ge o

f Rep

ositi

on

and

Tran

sfer

Obs

erva

tions

Weight in Hands While Repositioning and Transferring

Baseline3-Month12-Month24-Month36-Month

*

Equipment Use and Weight in Hands, before/after SRHP

(% of investigator observations)

Equipment Use in Resident Handling

Weight in Hands (Reposition/Transfer)Equipment Use (Reposition/Transfer)


0.0

0.5

1.0

1.5

2.0

2.5

3.0

BL 3-Month 12-Month 24-Month 36-Month

Phys

ical

Wor

kloa

d In

dex

Nursing Assistants While Resident Handling

Nursing Assistants Nurses

Highest Workload

Composite Physical Workload Index: Nursing Assistants and Nurses

www.uml.edu/centers/CPH-NEW*p < 0.001 (Cochran-Armitage test of trend)

Variability among centers: Nursing aide equipment use while resident handling


Variability among centers in physical workload index (nursing aides)


Variability among centers: Influence of work environment characteristics

• Change in observed device use or physical workload index, plotted against features of the work environment (multiple data sources): – Time pressure (post-observation interviews)

– Adequacy of equipment (employee surveys)

– Communication among staff (employee surveys)

• Same 5 centers with direct observations and 24 months of follow-up


Observed Device Use in Resident Handling vs. Perceived Time Pressure

-200%

0%

200%

400%

600%

800%

1000%

1200%

1400%

0.000

0.002

0.004

0.006

0.008

0.010

0.012

0.014

Center B Center C Center E Center D Center A

Perc

ent C

hang

e in

Nev

er F

eelin

g T

ime

Pres

sure

Slop

e of

Equ

ipm

ent U

se W

hile

Res

iden

t Han

dlin

g

Slope of Equipment Use While Resident Handling Over Two Years

Percent Change in Never Feeling Time Pressure


Physical Workload Index vs. Adequacy of Supplies and Equipment

-20%

-10%

0%

10%

20%

30%

40%

50%

60%

-0.09

-0.08

-0.07

-0.06

-0.05

-0.04

-0.03

-0.02

-0.01

0.00Center B Center D Center E Center A Center C

Perc

ent C

hang

e in

Ade

quac

y of

Sup

plie

s R

atin

g

Slop

e of

Phy

sica

l Wor

kloa

d In

dex

Slope of Physical Workload Index Over Two Years

Percent Change in Rating of Adequacy of Supplies Over Two Years


Physical Workload Index vs. Perceived Staff-to-Staff Communication

-50%

0%

50%

100%

150%

200%

-0.09

-0.08

-0.07

-0.06

-0.05

-0.04

-0.03

-0.02

-0.01

0.00Center B Center D Center E Center A Center C

Perc

ent C

hang

e in

Sta

ff-t

o-St

aff

Com

mun

icat

ion

Rat

ing

Slop

e of

Phy

sica

l Wor

kloa

d In

dex

Slope of Physical Workload Index Over Two YearsPercent Change in Rating of Staff-to-Staff Communication Over Two Years


Workers’ compensation claims for resident handling incidents (129 SNF’s)

before/after SRHP implementation

0

0.5

1

1.5

2

2.5

Residenthandling

(all)

Helpinto/outof bed

Helpinto/outof chair,

toilet

Helpinto/outof bath

Helpmove in

bedResidenthandling,

NOC

First 3 yrsSecond 3 yrs

RR of 1.0 = no change vs.pre-SRHP rates

Rate Ratio


Total annualized net savings = $4.584 million Overall benefit-to-cost ratio at least 1.68

Average net savings = $143 per bed per year


Net savings per bed after implementation of Safe Resident Handling Program

Time post intervention: < 5 years (n = 38 )

≥ 5 years (n = 72 )

Avoided turnover costs $37 $67

Avoided workers’ comp.: Medical $124 $257

Avoided workers’ comp.: Indemnity $81 $148

Average net savings per bed $83 $258


Workplace Health Promotion (WHP) and average SRHP net savings

• Minimal evidence of WHP health benefits (similar prevalences of smoking, obesity, etc.)

• Perhaps those centers have other positive organizational features, which led to WHP activities and also more effective SRHP?– Better social support; lower intention to leave job

$0 $50 $100 $150 $200

Centers with WHP

Centers without WHP


Use of Lifting Devices by Individual Employees

• Survey data from 18 nursing homes • Four occasions after “baseline”

(implementation of the Safe Resident Handling Program): – 3 months (F1)– 12 months (F2)– 24 months (F3)– 36 months (F4)


Individual self-reported equipment use

0

10

20

30

40

Never Rarely Sometimes Often Always

3-mo 12-mo

If you don’t use a patient lifting device every time, why not?Device unavailable when needed 25%Residents dislike them 17%I feel I don’t need them 13% Not enough time 7% Too much extra effort 4%My co-workers don’t use them 2%

How often do you use a patient lifting device?


0

5

10

15

20

25

30

35

40

45

Never Rarely Sometimes Often Always

F2 (N=18) (N'=863) F3 (N=15)(N'=691) F4 (N=6)(N'=263)

Proportion of aides citing “Residents do not like” by frequency of equipment use(N= Centers; N'= Nurses Aides)


Is there a relationship between the experiences of nursing home workersand those of residents?


Work environment and residents’ satisfaction or adverse outcomes

• Employee satisfaction: third-party surveys of all employees (40% aides, 20% nurses)

• Resident satisfaction: third-party surveys of residents (35%) or their family members (65%)

• Rates of resident falls, pressure ulcers, and unexplained weight loss: data reported to CMS

• All variables summarized by center (n=194) for 2005-09


Overall employee satisfaction and resident satisfaction (2005-09), by center

Average Employee Satisfaction (2005-09)

Aver

age

Res

iden

t Sat

isfa

ctio

n (2

005-

09)


Safe Resident Handling Program effectiveness:- Resident handling equipment use increased- Ergonomic exposures decreased:

– Time in resident handling – Weight in hands– Non-neutral body postures– Composite biomechanical load index

- Compensation claim rates and costs decreased- Turnover rates in clinical staff decreased

(perhaps not all attributable to NLP)

Conclusions (I)


Conclusions (II)Work environment features explain some variability in: • Program effectiveness among centers • Use of lift devices by individual workers

– Not enough time; Devices unavailable; Residents do not like equipment

• Residents’ satisfaction• Residents’ risk of adverse outcomes (falls,

pressure ulcers, unexplained weight loss)


Selected Publications1. Kurowski A, et al. [2012] Changes in ergonomic exposures of

nursing assistants after the introduction of a no-lift program in nursing homes. International Journal of Industrial Ergonomics 42:525-532.

2. Kurowski A, et al. [2012] Differences among nursing homes in outcomes of a safe resident handling program. Journal of Healthcare Risk Management 32(1):35-51.

3. Kurowski A, et al. A physical workload index to evaluate a safe resident handling program for clinical staff in nursing homes. Human Factors (accepted).

4. Lahiri S, et al. [2013] An economic analysis of a safe resident handling program in nursing homes. American Journal of Industrial Medicine 56 (4): 469–478.


Contacts and Acknowledgements

The Center for the Promotion of Health in the New England Workplace is supported by Grant Number U19-OH008857 from the U.S. National Institute for Occupational Safety and Health. This material is solely the responsibility of the authors and does not necessarily represent the official views of NIOSH.

University of Connecticut

Dr. Jeff DussetschlegerEmail: [email protected]: 860-679-1393

CPH-NEW website at Univ. Conn.:www.oehc.uchc.edu/healthywork/ index.asp

University of Massachusetts LowellMs. Sandy SunEmail: [email protected] Tel: 978-934-3268

CPH-NEW primary website:www.uml.edu/centers/CPH-NEW

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