the added complexity
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© 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.
© Finnish Institute of Occupational Health – www.ttl.fi
Sustainable Health Care Innovative health care organizations
© Finnish Institute of Occupational Health – www.ttl.fi
Outline
• Psychosocial work environment and employee health:
- The role of occupation and context
• The added complexity- Resources- The quality of care
© Finnish Institute of Occupational Health – www.ttl.fi
Psychosocialwork
environment
Employeehealth
and well-being
© Finnish Institute of Occupational Health – www.ttl.fi
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
© Finnish Institute of Occupational Health – www.ttl.fi
-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
© Finnish Institute of Occupational Health – www.ttl.fi
The role of the occupational position
© Finnish Institute of Occupational Health – www.ttl.fi
High job demands, low control %
0
20
40
60
80
1002000 2004 2008 2012
© Finnish Institute of Occupational Health – www.ttl.fi
Effort reward imbalance %
0
20
40
60
80
1002000 2004 2008 2012
© Finnish Institute of Occupational Health – www.ttl.fi
Organizational injustice %
0
20
40
60
80
1002000 2004 2008 2012
© Finnish Institute of Occupational Health – www.ttl.fi
Work load exceeds own tolerance %
0
20
40
60
80
1002000 2004 2008 2012
© Finnish Institute of Occupational Health – www.ttl.fi
Retirement intentions ( >55 year old) %
0
20
40
60
80
1002000 2004 2008 2012
© Finnish Institute of Occupational Health – www.ttl.fi
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
© Finnish Institute of Occupational Health – www.ttl.fi
© Finnish Institute of Occupational Health – www.ttl.fi
Experience of violence at work: physical assaults by throwing items %
0
20
40
60
80
1002004 2008 2012
© Finnish Institute of Occupational Health – www.ttl.fi
Experience of physical violence at work: kicking %
0
20
40
60
80
1002004 2008 2012
© Finnish Institute of Occupational Health – www.ttl.fi
Experience of violence at work: being threatened with a weapon %
0
1
2
32004 2008 2012
© Finnish Institute of Occupational Health – www.ttl.fi
0
10
20
30
40
502000 2004 2008 2012
Physical inactivity %
© Finnish Institute of Occupational Health – www.ttl.fi
0
10
20
30
40
50
2000 2004 2008 2012
Smoking %
© Finnish Institute of Occupational Health – www.ttl.fi
0
10
20
30
40
50
2000 2004 2008 2012
Obesity (BMI >30), %
© Finnish Institute of Occupational Health – www.ttl.fi
Excess use of alcohol (>18 doses a week) %
0
10
20
30
40
50
2000 2004 2008 2012
© Finnish Institute of Occupational Health – www.ttl.fi
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
© Finnish Institute of Occupational Health – www.ttl.fi
The causes of sickness absence (% of annual sickness absence days)
Others
Injuries
Musculoskeletal
Cardiovascular
Mental
© Finnish Institute of Occupational Health – www.ttl.fi
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
© Finnish Institute of Occupational Health – www.ttl.fi
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
© Finnish Institute of Occupational Health – www.ttl.fi
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
© 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
© Finnish Institute of Occupational Health – www.ttl.fi
© Finnish Institute of Occupational Health – www.ttl.fi
The role of the context
© Finnish Institute of Occupational Health – www.ttl.fi
© Finnish Institute of Occupational Health – www.ttl.fi
© Finnish Institute of Occupational Health – www.ttl.fi
Resources
Employee health and well-being
Patient health and well-being
© Finnish Institute of Occupational Health – www.ttl.fi
© Finnish Institute of Occupational Health – www.ttl.fi
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.
© Finnish Institute of Occupational Health – www.ttl.fi
Overcrowding in hospital wards 2
• 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%.
© Finnish Institute of Occupational Health – www.ttl.fi
Overcrowding in hospital wards 3
• 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
© Finnish Institute of Occupational Health – www.ttl.fi
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
© Finnish Institute of Occupational Health – www.ttl.fi
Overcrowding and antidepressant treatment among staff (n=7340)
Virtanen, Kivimäki, Oksanen et al. Am J Psychiatry2008
© Finnish Institute of Occupational Health – www.ttl.fi
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
© Finnish Institute of Occupational Health – www.ttl.fi
© Finnish Institute of Occupational Health – www.ttl.fi
© Finnish Institute of Occupational Health – www.ttl.fi
© Finnish Institute of Occupational Health – www.ttl.fi
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
© Finnish Institute of Occupational Health – www.ttl.fi
© Finnish Institute of Occupational Health – www.ttl.fi
Resources
Employee health and well-being
Patient health andwell-being
© Finnish Institute of Occupational Health – www.ttl.fi
© Finnish Institute of Occupational Health – www.ttl.fi
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
© Finnish Institute of Occupational Health – www.ttl.fi
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
© Finnish Institute of Occupational Health – www.ttl.fi
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.
© Finnish Institute of Occupational Health – www.ttl.fi
© Finnish Institute of Occupational Health – www.ttl.fi
Thank Youfor your attention!
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