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Alf Trojan, Stefan Nickel, Silke WernerUniversity Medical Center Hamburg-Eppendorf

Center of Psycho-Social Medicine

Department of Medical Sociology

The 13th International Conference on Health Promoting Hospitals (HPH)

Dublin, May 18-20, 2005

Staff surveys: An empowering intervention for improving staff health and patient care quality?

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Objective and method

Goal: To test the short and medium term effects of new working hours arrangements (including shift work) in one hospital

Tool: Standardised medical staff survey in written form administered at two points in time

• t1: about 7 months after implementation (incl. measurement of remembered situation at t0)

• t2: about 17 months after implementation

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Characteristics of the responders at t2

Response rate of 48% (n=35 of 73 doctors)

77% were already working in hospital unit before conversion of stand-by-for emergency duties into shift work

72% were or are currently employed in shift work (compared with t1: 58%)

Comparison of responders with all doctors in unit shows substantial similarity in:

• function• age• sex

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Scope of the questionnaireOrganisational viewIndividual view

Compatibility with “normal“ family life

Recreational activities Family / child care Income equity

Abiding by legal norms Maximum hours of work Recreation time and breaks Transparency / documentation

Job strains Psychophysical strains Communication and cooperation

Organisational procedures Effectivity and efficiency of work Flexibility of staff roster

Patient orientation Daily activities of patients Doctor-patient communication

Working hours preferences Actual working hours Wishes for future working hours

Participation

Staff‘s job satisfaction and health

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Statistical evaluation

Describing the changes in respect to their practical significance and imputability

Topics to be dealt with:• Working hours strains and preferences

• Working conditions and staff health changes over time (quality scales)

• Comparison of groups with / without shift work

• Relevance of the changes measured

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Actual, requested und contracted hours of workMeans in hours per week

First survey (n=31)

39.0

42.6

49.3

0 36,4

Requestedhours

Actualhours at t1

Actualhours at t0

Contracted hours at t1: 36.4

Second survey (n=35)

38.0

45.8

48.8

0,0 36,7

Requestedhours

Actualhours at t2

Actualhours at t0

Contracted hours at t2: 36.7

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Working hours preferences (only measured at t1)6 most mentioned wishes in % of respondents

32.3

32.3

35.5

48.4

48.4

58.1To work infrequently at weekends

Choice between forms of overtimecompensation (free time vs. payment)

To complete a job punctually

To have long blocks of free time

More participation in working schedule

Long term planning (e.g. for the month afternext)

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Working conditions changes over timeMeans of our 6 quality scales

(Effect sizes [ES] t0-t1 and t0-t2 in brackets°)

1, 91

2. 33

2. 12

2. 80

2. 392. 312. 32

( . 60)

2. 42

( . 12)2. 33

( . 37)

2. 91

( . 25)

2. 42

( . 05)

2. 41

( . 18)2. 15

( . 35)

2. 17

(- . 21)

2. 17

( . 09)

2. 89

( . 20)

2. 27

(- . 12) 2. 10

(- . 38)

1

2

3

4

Abiding by

legal norms

Psychophysical

strains

Organisational

procedures

t0 t1 t2Best score

° ES .20 „small“; .50 „medium“; .80 „large“ effect

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Staff health changes over timeMeans of Zerssen‘s list of complaints (B-L): Best score = 0, worst = 3

(Effect sizes t0-t1 and t0-t2 in brackets°)

.53

.44(.20)

.53(.00)

0,00

0,59

B-L at t0 B-L at t1 B-L at t2

Norm (1976) =

° ES .20 „small“; .50 „medium“; .80 „large“ effect

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Quality of working hours arrangements from t0 to t2

Frequency of ratings in % of respondents

.0

30.8

42.3

26.9

3.2

35.538.7

22.6

.0

23.5

38.238.2

0%

25%

50%

75%

poor moderate good very good

t0 t1 t2

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Effects of the new arrangement t0-t1 comparing groups with and without experience of shift

workQuality scales Changes t0-t1

(Effect sizes)

Doing shift work

(n=18)

Doing no shift work (n=13)

Total (n=31)

Abiding by legal norms .47 .73* .60**

Compatibility with family life -.66* .93** .12

Psychophysical strains .31 .42 .37*

Communication and cooperation .19 .30 .25

Organisational procedures -.18- .23 .05

Patient orientation .16 .22 .18

Staff health -.12- .39 .20

* p<.05, ** p<.01 (t-test)

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Effects of the new arrangement t0-t2 comparing groups with and without experience of shift workQuality scales Changes t0-t2

(Effect sizes)

Yes, but cur-

rently not

(n=5)

Yes, cur-

rently in rota-

tion (n=10)

Yes, perma-nently (n=10)

No (n=10)

Total (n=35)

Abiding by legal norms n/a -.68* .10 .47 .35

Compatibility with family life n/a -1.46* -1.41- .27 -.21-

Psychophysical strains n/a -1.38** -.06- .19 .09

Communication and cooperation n/a .03 .77* .21 .20

Organisational procedures n/a -.60- .03 .28 -.12-

Patient orientation n/a -1.10* -.20- .16 -.38-

Staff health n/a -.71- -.20- -.03- .00

n/a = not analysed; * p<.05, ** p<.01 (t-test)

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Relevance of new working hours arrangements (staff‘s view)

New working hours arrangements play a major role in the process of innovation in hospitals.

Ranking of the most important factors for quality of working conditions in the last 2 years (at t2):

1. Implementation of new working hours arrangements2. General changes in work organisation3. Other internal changes in hospital unit4. Collateral arrangements for working hours5. Other

Pre-post-results correspond to self-perceived changes reported by the doctors.

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Summary and discussion As intended, the surveys yielded data suitable for

intervention aimed at improving staff and patient well-being.

For a short time some improvements were found (e.g. increased abiding by legal norms), but for doctors doing shift work most areas worsened.

In the medium term (about 17 months after implemen-tation) the overall situation worsened. Particularly negative impact was reported on

• “normal“ family life, and on

• patient care (in the staff‘s view).

In the staff‘s view the deterioration is a result of too few doctors.

The hospital management emphazises the difficult economic situation of the hospital.

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Are staff surveys an empowering intervention for improving staff health and patient care quality?

In principle yes, because they can show critical developments and specific areas of concern;

in practice no, because alerting results at t0 did not lead to measures for improvement (the effects of the t2-results are as yet unclear).

From qualitative research results we conclude that economic values dominate, even when staff health is severely endangered by working hours arrangements.