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
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“[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.
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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
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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.
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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?
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Direct Observations of CNA’s
F0: Baseline (Pre‐SRHP)
F1: 3 mos. post‐SRHP
F2: 12 mos. post‐SRHP
F3: 24 mos. post‐SRHP
F4: 36 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)
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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)
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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
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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
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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
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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
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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
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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
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Total annualized net savings = $4.584 million Overall benefit-to-cost ratio at least 1.68
Average net savings = $143 per bed per year
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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
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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
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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)
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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?
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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)
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Is there a relationship between the experiences of nursing home workersand those of residents?
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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
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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)
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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)
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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)
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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.
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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