The added complexity

© Finnish Institute of Occupational Health – www.ttl.fi

The added complexity of resources, employee well-being, and the quality of care

Tuula Oksanen , MD, PhD, Adjunct Professor

7th NOVO symposium 26 Nov, 2013 Helsinki Finland.


Sustainable Health Care Innovative health care organizations


Outline

• Psychosocial work environment and employee health:

- The role of occupation and context

• The added complexity- Resources- The quality of care


Psychosocialwork

environment

Employeehealth

and well-being


The Finnish Public Sector Study

VantaaEspoo

Naantali Raisio

Turku

TampereValkeakoski

Virrat

Nokia

Oulu

HUS (Jorvi, Hyks)

Varsinais-Suomen shp

Kanta-Hämeen shp

Pirkanmaan shp

Pohjois-Pohjanmaan shp

Vaasan shp

10-Town study – PI Professor Jussi Vahtera

Hospital personnel study- PI Professor Mika Kivimäki

includes employees from

10 towns

6 hospital districts

20% of the public sector employees in Finland


-97 -98 -99 -00 -01 -02 -03 -04 -05 -06 -07 -08 -09 -10 -11 -12 -13 -14 -15

Survey 2000-10Town(N=32 299, 67%)

-Hospitals(N=16 299, 67%)

Total 48 598

Survey 2004-10Town(N=32 322, 65%)

-Hospitals(N=15 879, 69%)

Total 48 201

Data collection phasesSurvey 2008-10Town(N=38 727, 70%) -

Hospitals(N=14 053, 72%)

Total 52 780

Survey 2012-10Town-(N=39 194, 69%)-Hospitals(N=13 861, 71%)

Total 53 055

Respond/survey

Responserate %

DOCTORS 1 804 56Teachers 4 541 69Special teachers 562 72Social workers 684 83NURSES 7 946 76Practical NURSES 3 623 68CLEANERS 2 637 63


The role of the occupational position


High job demands, low control %

0

20

40

60

80

1002000 2004 2008 2012


Effort reward imbalance %

0

20

40

60

80

1002000 2004 2008 2012


Organizational injustice %

0

20

40

60

80

1002000 2004 2008 2012


Work load exceeds own tolerance %

0

20

40

60

80

1002000 2004 2008 2012


Retirement intentions ( >55 year old) %

0

20

40

60

80

1002000 2004 2008 2012


Workplace social capital(mean)

1,0

1,5

2,0

2,5

3,0

3,5

4,0

4,5

5,0

2000 2004 2008 2012

2



Experience of violence at work: physical assaults by throwing items %

0

20

40

60

80

1002004 2008 2012


Experience of physical violence at work: kicking %

0

20

40

60

80

1002004 2008 2012


Experience of violence at work: being threatened with a weapon %

0

1

2

32004 2008 2012


0

10

20

30

40

502000 2004 2008 2012

Physical inactivity %


0

10

20

30

40

50

2000 2004 2008 2012

Smoking %


0

10

20

30

40

50

2000 2004 2008 2012

Obesity (BMI >30), %


Excess use of alcohol (>18 doses a week) %

0

10

20

30

40

50

2000 2004 2008 2012


Sickness absence 2000-2011(mean annual days by occupation)

0

5

10

15

20

25

30

35

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Laitosapul

Lähihoitaja

Sairhoitaja

Kaikki

Sos.työntekijä

Erityisopettaja

Lääkäri

Opettaja

Cleaners

Practical nurses

NursesALL

Social workers

Special teachers

Doctors

Teachers


The causes of sickness absence (% of annual sickness absence days)

Others

Injuries

Musculoskeletal

Cardiovascular

Mental


Job control- skill discretion - decision authority-participation in decision making

Job demandsLOW HIGH

LOW

HIGH

passive high

strain

activelowstrain

Job strain

Job Strain Model by Karasek and Theorell

Source: Karasek & Theorell 1990Karasek 1979; Karasek & Theorell 1990


Manager

Techn. expert

PhysicianOther teacher

Teacher

Kindergarten teacher

Special educ. teacher

Librarian

Psychologist

Social worker

Culture worker

Other expert

Tech specialist

Physiotherapist

Registered nurse

Dept secretary

Social adviser

Office worker

Cooker

childminder

Private childminder

Practical nurse

Dental assistant

Home helpFireman

Gardenist

Construction worker

Driver

Orderly

Cleaner

Kitchen maid

Real estate manager

LOW STRAIN

PASSIVE

ACTIVE

HIGH STRAINFinnish Public Sector Study 2012

Job control

Job demands


IPD-Work Consortium

FPSS,HeSSup, Still Working(n=72 847)

SLOSH, WOLF(n=29 246)

IPAW, COPSOQ,DWECS(n=9209)

Whitehall II(n=10 308)

Gazel(n=11 237)

POLS, NWCS(n=69 373)

BELSTRESS(n=14 226)


© Finnish Institute of Occupational Health – www.ttl.fi Kivimaki et al. IPD-Work. Lancet 2012

(n=2358/ 197,000)

© Finnish Institute of Occupational Health – www.ttl.fi Kivimaki et al. IPD-Work. Lancet 2012



The role of the context




Resources

Employee health and well-being

Patient health and well-being



Overcrowding in hospital wards 1

• In hospitals, overcrowding and excess staff workload has been widely recognised as a serious problem for both patients and staff.

• Overcrowding has been associated with increased hospital infections and patient mortality (Cunningham et al. Br J Nurs 2006; Tarnow-Mordi et al. Lancet 2000; Sprivulis et al. Med J Aust 2006) as well as staff burnout and job dissatisfaction (Aiken et al. JAMA 2002)

• Overcrowding can be indicated as excess bed occupancy.



• Participating hospitals routinely collect monthly figures on bed occupancy for each ward according to a standard procedure.

• Bed occupancy %= Sum of in-patient days• Beds available

• Beds available: number of beds x the number of days the ward is in use

• The day of admission but not the day of discharge for each person is included in the numerator.

• The rate above which a hospital ward is considered overcrowded is usually defined as > 85%.



• Timing of exposure changes continuously over time.

• A fixed time window would lead to inaccurate exposure estimateloss of power (a short time lag between exposure and treatment seeking likely)

• Solution: Monthly excess bed occupancy rates treated as time-dependent exposures that may change in value over the period of observation


80

0

75

0

79

0

115

30

89

4

103

18

120

35

75

0

80

0

85

0

103

18

75

0

Excess occupancy:•bed occupancy <85% coded as 0%•bed occupancy >85% coded as XX%-85%

Monthly bed occupancy

Excess occupancy

Measurement of overcrowding

18/6=3

(30+35+4)/6=12

(18+30)/6=8(18+30)/6=8

30/6=5(30+35)/6=11

(30+35+4+18)/6=15

00

0

1

0

00

Antidepressant treatment0 = no1 = yes


Overcrowding and antidepressant treatment among staff (n=7340)

Virtanen, Kivimäki, Oksanen et al. Am J Psychiatry2008


Overcrowding and new onset sickness absence due to depression among staff

Virtanen, Batty, Pentti, Vahtera, Oksanen et al. J Clin Psychiatry, 2010

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

2

Ylikuormitus

ei <=5% >5<=10% >10%*

Adjusted risk(HR)

1.000.99

(0.65-1.50)

1.44(0.90-2.30)

1.95(1.18-3.24)

-> no association with other causes

Overcrowding





Overcrowding in psychiatric wards and physical assaults on staff

Virtanen, Vahtera, Batty… Oksanen et al. Brit J Psychiatry, 2011

0,5

1

1,5

2

2,5

3

3,5

Ylikuormitus

ei <=5% >5<=10% >10%*

Adjusted risk(OR)

1.00

2.03(0.90-4.54)

2.76(1.32-5.77)

3.04(1.51-6.13)

-> no association on ward property

Overcrowding



Resources

Employee health and well-being

Patient health andwell-being



Psychosocial work environment in Primary Care Health Centers and Glycemic control (HbA1c<6.0) in Type2 Diabetes patients

Virtanen, Oksanen, Kawachi et al. Med Care, 2012

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

2

PäätöksenteonoikeudenmukaisuusKohtelun oikeudenmukaisuus

Ponnistelu-palkkio-epäsuhta

Innovatiivisuus

Tehtävään suuntautuminen

Adjusted risk(COR)

1. 54 (1.08-2.18)

0.70(0.47-1.05)

0.86(0.60-1.23)

1.53(0.93-2.53)

0.50(0.23-1.11)

Procedural justice

Relational justice

Effort-reward imbalanceSupport for innovation

Task orientation


Patients with infectious diseases, overcrowding and sickness absence among staff

0

0.5

1

1.5

2

2.5

3

Low prevalence of ID High prevalence of ID Low prevalence of ID High prevalence of ID

1.00 0.89 (0.53-1.73) 1.00

2.39 (1.09-5.26)

Virtanen, Terho, Oksanen et al. Arch Int Med 2011

No overcrowding Overcrowding

• Overcrowding increased the risk of sick leave 1.7 fold• We found an interaction with patients with infectious diseases


Conclusions

• Psychosocial work environment is not universally associated with employee health; differences by occupation occur.

• Overcrowding seems to increase morbidity among staff, especially mental ill-health, and experienced violence in psychiatric wards.

• Overcrowding is related to higher prevalence of infectious diseases among patients.

• High prevalence of patients’ infectious diseases seems to increase health problems among staff in overcrowded wards.

• Leadership might be important in the quality of care of people with type2 diabetes.



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The added complexity

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