Factors Associated With Staff Injuries in Intermediate Care Facilities in ...

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Factors Associated With Staff Injuries in Intermediate Care Facilities in British Columbia, Canada Annalee Yassi

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Marcy Cohen ▼ Yuri Cvitkovich ▼ Il Hyoek Park ▼ Pamela A. Ratner Aleck S. Ostry ▼ Judy Village ▼ Nancy Pollak

Background: Large variations in staff injury rates across intermediate care facilities suggest that injuries may be driven by facility-specific work environment factors. Objectives: To identify work organization, psychosocial, and biomechanical factors associated with staff injuries in intermediate care facilities, to pinpoint management practices that may contribute to lower staff injuries, and to generate a provisional conceptual framework of work organization characteristics. Methods: Four representative intermediate care facilities with high staff injury rates and four facilities with comparable low staff injury rates were selected from Workers’ Compensation Board (WCB) databases. Methods included on-site injury data collection and review of associated WCB data, ergonomic study of workloads, a telephone survey of resident care staff, manager-staff interviews, and focus groups. Pearson productmoment correlation coefficients identified associations between variables. Analysis of variance and t tests were used to determine differences between low and high staff injury rate facilities. Content analysis guided the qualitative analysis. Results: There were no significant differences between low and high staff injury rate facilities in terms of workers’ characteristics, residents’ characteristics, and per capita public funding. The ergonomic study supported the survey data in demonstrating a relation among low staffing levels, greater muscle loading, and greater risk of injury. As compared with facilities that had high staff injury rates, facilities with low staff injury rates had significantly more favorable staffing levels and supportive work environments. Perceived quality of care was strongly correlated with burnout, health, and satisfaction. Conclusions: Safer work environments are promoted by favorable staffing levels, convenient access to mechanical lifts, workers’ perceptions of employer fairness, and management practices that support the caregiving role. Key Words: nursing homes 䡠 organizational climate 䡠 organizational culture 䡠 staff injury rates

Nursing Research March/April 2004 Vol 53, No 2

T

he international literature shows high staff injury rates in the healthcare sector (Koehoorn, Lowe, Rondeau, Schellenberg, & Wagar, 2002; Yassi, Ostry, Spiegel, Walsh, & deBoer, 2002). Intermediate care (IC) facilities provide 24-hour nursing care for individuals who can no longer live safely in their homes yet still are somewhat mobile (Cohen et al., 2003). This population includes clients with advanced dementia or high and changeable needs related to activities of daily living (ADLs). Staff injury rates in IC facilities are as much as 50% higher than staff injury rates in the acute care sector. However, the Workers’ Compensation Board (WCB) of British Columbia (2000) 1995-1999 databases showed considerable variation in injury rates within the IC sector. The lowest quartile 5-year injury rate for “good” performers was four times better than the corresponding rate for “poor” performers (WCB of British Columbia, 2000). Annalee Yassi, MD, MSc, FRCPC, Founding Executive Director, Occupational Health and Safety Agency for Healthcare; Director of the Institute of Health Promotion Research, University of British Columbia, Vancouver, British Columbia. Marcy Cohen, MA (Education), Director of Research, Hospital Employees’ Union, Vancouver, British Columbia. Yuri Cvitkovich, MA (Gero), Researcher, Institute of Health Promotion Research, University of British Columbia, Vancouver, British Columbia. Il Hyoek Park, PhD, Post Doctoral Fellow, Institute of Health Promotion Research, University of British Columbia, Vancouver, British Columbia. Pam Ratner, RN, PhD, Associate Professor, Nursing and Health Behavior Research Unit, School of Nursing, University of British Columbia, Vancouver, British Columbia. Aleck Ostry, PhD, Assistant Professor, Department of Health Care and Epidemiology, University of British Columbia, Vancouver, British Columbia. Judy Village, MSc, School of Occupational and Environmental Hygiene, University of British Columbia, Vancouver, British Columbia. Nancy Pollak, MA (candidate), Researcher, Hospital Employees’ Union, Vancouver, British Columbia.

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88 Factors Associated With Staff Injuries

What Explains This Large Variation in Injury Rates? There is considerable evidence in the literature that work environment factors influence injuries. Amick et al. (2000) showed that organizations with a “people-oriented” culture (defined by worker participation in decision making, positive morale, nonadversarial labor relations, and an atmosphere of open communication) have lower injury rates than organizations without these features. Findings also have shown that workers’ perceptions of an organization’s fairness are crucial in maintaining staff morale and delivering good service (Elovainio, Kivimaki, & Vahtera, 2002; Janssen, 2000). Fairness is implicit in the employment contract, in which the employer promises to provide the worker with the necessary work environment, tools, and resources to do the job to the required standards. Several healthcare sector studies have demonstrated the influence of organizational factors (Feuerberg, 2000), management practices (Anderson, Issel, & McDaniel, 2003), and nurse staffing levels (Cho, Katefian, Barkauskas, & Smith, 2003) on resident outcomes as well as staff job satisfaction, retention and turnover, and injuries (Josephson & Vingard, 1998; Koehoorn, Kennedy, Demers, Hertzman, & Village, 1999; Lagerstrom, Hansson, & Hagberg, 1998; Yassi, Ostry, & Spiegel, 2003). High levels of job strain among registered nurses and nursing assistants in Canada have been associated with heavy psychological job demands, job insecurity, and insufficient social support (Sullivan, Kerr, & Ibrahim, 1999; Yassi et al., 2002). Baumann et al. (2001) documented that job strain, particularly heavy workloads, leads to increased sick time, higher healthcare costs, greater job dissatisfaction, and a high turnover. The aim of this project was to identify why some IC facilities have much lower injury rates than others. Accordingly, the factors associated with injuries among care aides and licensed practical nurses (LPNs) in IC facilities were examined. Most studies of organizational “culture and climate,” particularly those focused on injury outcomes, have addressed generic dimensions (e.g., “senior management buyin to health and safety” or a “good labor relations climate” in industrial sectors) (Amick et al., 2000; Fuerberg, 2000; Hunt, Habeck, VanTol, & Scully, 1993; Shannon, Robson, & Sale, 2001). These studies, useful because of their large sample sizes, have led managers and policy makers to recognize the importance of organizational-level determinants of injury and well-being. The Amick et al. (2000) and Fuerberg (2000) studies were general in scope (aggregating all occupations) and lacked in-depth exploration of direct care healthcare-specific factors. However, the Hunt et al. (1993) study was more comprehensive because it included 32 site visits to confirm the general findings from the 220 employers and to gain operational understanding of policies and practices contributing to low disability rates. The current study adds to this literature by incorporating not only site visits, but also ergonomic measures to provide in-depth examination of physical workload and work organizational factors for direct care workers (LPNs and care aides) in IC facilities. This study also proposed the development of a conceptual framework to explain the relation of organizational culture


and climate to injury in IC facilities. Several research groups (Koehoorn et al., 2002; Lowe, 2002; Ostry, Tomlin et al., in press; Ostry, Yassi et al., 2003; Shannon, Robson, Sale, 2001; Yassi et al., 2002) developed a theoretical framework of “healthy workplaces.” In general, these studies found that healthy workplaces are supportive and responsive to the personal needs of employees, treat workers as assets rather than costs, and address workplace hazards promptly to improve work conditions (Lowe, 2002). Healthy workplaces have been analyzed according to organizational “culture and climate” characteristics (i.e., communications, discretion in conducting tasks, fairness, support, and quality of care). This study hypothesized that IC facilities with low injuries ensure that “communication with frontline staff” is the highest priority, and thus deploys a variety of information-sharing strategies that encourage participation, enable discretion in conducting tasks, and provide meaningful input to care decision making. It was further hypothesized that “fairness” is a key component related to high levels of job satisfaction, and that workers invest more trust in management decisions and policies if the treatment they receive is perceived as fair. It also was hypothesized that workers in low-risk facilities experience more support and a greater variety of support from management, supervisors, coworkers, and the union than workers in high-injury facilities. Finally, it was believed that workers care about the “quality of care” they deliver. Workers who believe that they are providing quality care are more likely to feel satisfaction with their work environment. In this study, an explicit framework based on these principles for IC facilities was developed.

Methods The WCB of British Columbia provided 5-year (1995-1999) data of time-loss injury and facility size for 79 IC facilities in the province for which data existed. Linear regression was used to estimate the facility-specific trends in annual time-loss injury rates over the 5-year period. Four facilities with an increasing trend for injuries in the highest quartile of time-loss injury rates (HIRFs) were blindly selected and matched in terms of facility size and community size to four facilities with decreasing or stable injury trends in the lowest quartile of time-loss injury rates (LIRFs). The study was initiated by the Hospital Employees’ Union (HEU) on behalf of its members. Ethics approval was obtained from the Behavioral Research Ethics Board as a project within the Community Alliance for Health Research focused on making healthcare workplaces healthier with participatory partnerships (Yassi, Tomlin, Sidebottom, & de Boer, 2004). The HEU representatives kept their members informed throughout the process, and informed consent was obtained at the beginning of each interview and focus group. This multidisciplinary, multimethod (quantitative and qualitative) study combined descriptive-comparative and correlational features. Researchers based at the University of British Columbia and personnel from healthcare unions, nursing, medicine, ergonomics, gerontology, epidemiology, sociology, and social work collaborated in data collection and analysis to determine how multiple methods could be used to cross-reference and validate data measurement. Research

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methods included collecting and analyzing site-specific data from the facilities and the WCB covering the 30month study period (January 1999 to June 2001), then linking this information to a staffing database; collecting ergonomic data; conducting interviews and focus groups with managers and frontline staff; and conducting a telephone survey of care aides and LPNs employed at the selected facilities. The interviews, focus groups, and telephone survey were thematically based on the research questions presented in Appendix A. Focus groups and key informant interviews were a major source of information regarding work organization (practices and policies), psychosocial dynamics, and beliefs about injury causation and prevention. The telephone survey, developed for this study and not used in any previous publications, was the main source of information concerning organizational “culture and climate.” After a comprehensive literature search (19702001) of validated instruments, the study incorporated demand and control questions measuring psychosocial conditions of work, portions of the Maslach Burnout Inventory (Maslach, Jackson, & Leiter, 1997), instruments measuring organizational level work stressors, and questions assessing pain (Bernard, Sauter, Fine, Petersen, & Hales, 1994). The validity and reliability of the Maslach Burnout Inventory have been documented (Kalliath, O’Driscoll, Gillespie, & Bluedorn, 2000; Lee & Ashforth, 1990). The 6-item subscale for emotional exhaustion (Cronbach ␣ ⫽.73) was used because it was reported to be the most robust (Kalliath et al., 2000). A binary (yes/no) pain and discomfort variable was used. This variable was defined by the National Institute for Occupational Health and Safety as “extreme or moderate pain in the previous year that occurred once or more a month and lasted more than 1 week on any body part” and documented by Bernard et al. (1994). Other items assessing communication, discretion and choice, fairness, support, and quality of care were developed by the seven-member interdisciplinary team to confirm content validity through discussion based on the various disciplinary perspectives. Focus groups were conducted with managers and frontline staff from nonstudy facilities to develop the telephone survey questions related to fairness and respect, perceived ability of frontline staff to provide good quality care, and questions specific to the work environment in the IC setting. The telephone survey was piloted in September 2001 with 26 care aides and LPNs at a nonstudy IC facility in Vancouver. The pilot data were analyzed, along with respondents’ comments regarding survey wording, length, missing elements, and overall tone. After the pilot trial, the survey was modified, with the final version comprising 155 items (Cohen et al., 2003) divided into eight major sections: (a) personal characteristics, (b) workers’ perceptions of workload, (c) organizational “culture and climate” (10 variables), (d) working with abusive and aggressive residents, (e) safety environment (4 variables), (f) physical environment (4 variables: age of facility, bedroom size, bathroom size, and hall length), (g) job satisfaction and burnout, and (h) self-

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reported health, pain, and injury status. The items were presented as “agreement-disagreement” statements requiring a response on a 4-point Likert scale. Altogether, 310 care aides and LPNs participated in the survey, which generated a 72% response rate across all facilities. The response rates for individual facilities ranged from 58% to 84%. The average response rates were 74% for LIRFs and 70% for HIRFs. Informed consent was obtained from the care aides and LPNs before they were surveyed regarding education history, work history, work environment perceptions, healthrelated perceptions, and job satisfaction. The specific concepts tapped were communications (5 items, ␣ ⫽ .78), discretion in conducting tasks (1 item), fairness (4 items, ␣ ⫽ .83), support (1 management item and 3 supervisor items, ␣ ⫽ .83; 1 coworker item and 3 union items, ␣ ⫽ .74), and quality of care (Tables 2, 3, and 4). The LIRFs and HIRFs were compared with respect to characteristics of workers and facilities (Table 1), workload, organizational “culture and climate,” safety environment, and physical environment. Each of these compared characteristics consisted of several variables measured by at least two of the methodologic approaches. For example, the workload characteristic (Table 2) was measured by resident-to-worker ratios, ergonomic measures (cumulative spinal compression, peak spinal compression, peak neck and shoulder muscle activity, and perceptions of exertion), and survey respondents’ perceptions of work pressure, workload, physical demands of the job, and working short-staffed. The safety environment characteristic consisted of safety commitment (4 survey items, ␣ ⫽ .81), worry about work injury (1 survey item), accessibility of mechanical lifts (1 survey item), and direct measurement of the ratio of residents per mechanical lift. The physical environment characteristic comprised the age of the facility and direct measures of the bedroom and bathroom sizes and hall length. Facility Data Collection From personnel records, the care aides and LPNs (n ⫽ 560) who worked in the selected facilities during the period January 1999 to June 2001 were identified. Personspecific time-loss injury data for each study facility were obtained from the WCB databases and cross-referenced with time-loss incident data found in the personnel records at each facility. To protect the privacy of the participants, each was assigned a confidential, unique study identification number. Injury rates, resident-to-worker ratios, and resident dependency were calculated for each facility (Table 1). Time-loss injury claims for care aides and LPNs were calculated per 100 person years over the study period (January 1999 to mid-2001), with full-time equivalent positions as the denominator. To obtain time-loss injury rates, the numerator was based on WCB injury data, and the denominator was based on the number of full-time equivalent resident care staff members (care aides and LPNs). For each facility, the resident-to-worker ratio (a high ratio indicated a less favorable staffing level) was determined on the basis of applicable full-time equivalent positions of care aides and LPNs converted to the average “staff availability per hour.” To determine the resident-to-

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TABLE 1. Summary Profile of the Eight Facilities Low Injury-Rate Facilities

Injury ratea Number of reported injuries Number of residents Age of facility Ownership and governance Private-pay beds? Size of community Per diem funding Resident-to-worker ratiob Average resident dependencyd

High Injury-Rate Facilities

Willow Home

Elm Home

Larch Home

Cherry Home

Juniper Home

16.3 50 130 1985

17.8 57 101 ⬃1980 Nonprofit no ⬍100,000 $129 11:1 69.1

20.7 66 80 1961 Public facility no ⬍100,000 $119 11:1 70.0

24.3 64 117 ⬃1983

Nonprofit no ⬎100,000 $128 13:1 77.7

19.4 48 131 1970 Public facility no ⬎100,000 $108 12:1 80.4

Poplar Home

Sumac Home

Alder Home

34.0 44.3 71.1 44 53 65 66 95 160c 1989 1967 ⬃1970 Private Public-private Nonprofit facility partnership Nonprofit ⬃80% private 20% private no no ⬎100,000 ⬍100,000 ⬍100,000 ⬎100,000 $130 $133 $116 $110 13:1 16:1 18:1 15:1 72.3 78.9 79.2 71.7

Note. The facility names are pseudonyms. ainjuries per 100 person-years. ba high resident-to-worker ratio indicates a less favorable staffing level. cAveraged 139 residents in 2001. dResident dependency was measured using the Functional Independence Measure assessment (FIM™) instrument for each resident (Guide, 1997). Based on the FIM™ instrument copyright 1997, Uniform Data System for Medical Rehabilitation (UDSmr). All rights reserved. Used with permission of UDSmr University at Buffalo, Amherst, NY.

worker ratio, the number of residents was divided by the average staff availability per hour. The day shift ratio was used for analysis because, as compared with other shifts, it represented the most favorable staffing level. Resident dependency was measured using the Functional Independence Measure (FIM) instrument (Guide for the Uniform Data Set for Medical Rehabilitation, 1997). This tool is commonly used with patients in rehabilitation settings. Ottenbacher, Hsu, Granger, and Fiedler (1996) examined 11 studies reporting FIM reliability and found a median interrater reliability of .95 for the total FIM score, a median test-retest value of .95, and an equivalence reliability value of .92. Pollak, Rheault, and Stoeker (1996) tested the FIM instrument on individuals 80 years of age or older from a multilevel continuing care retirement community and reported that test-retest reliability ranged from .60 for cognitive subscales to .80 for motor subscales. At each facility, one knowledgeable care aide or LPN rated each resident with the FIM instrument. Subsequently, the research team aggregated these resident dependency scores to the facility level. To obtain resident-to-worker ratios, staffing-level databases were used for care aides and LPNs on all three shifts at the eight facilities. These databases had been verified previously by management and HEU representatives as part of the preparation for collective bargaining (March 2001) and collected by the HEU from the files of the Labor Relations Board. Ergonomic Data Collection State-of-the-art portable electromyography instrumentation measured cumulative and peak muscle activity in the

lower back (lumbar) and in the neck and shoulder (trapezium) region. Four care aides and LPNs at each facility working in the most physically demanding unit were instrumented. Observations and electromyelogram measurements were obtained for a full dayshift, with two workers studied per day. Ergonomists documented the number of resident lifts, transfers, repositionings, baths, uses of mechanical lifts, and beds made. The instrumented care aides and LPNs had at least 1 year of experience in the unit and had been pain free for 3 months. These care aides and LPNs were interviewed regarding demographic information, history of previous injuries and pain, subjective assessments of exertion during the day, and perceptions of the number of tasks performed. Ergonomists made observations about facility design (age of facility, floor plan, state of equipment and furniture, number of lifting devices) and performed direct measurements of the hall length and width, the resident bedrooms, and the bathrooms. Methods of data collection and analysis for the ergonomic portion are described in depth elsewhere (Village et al., 2003). Interviews and Focus Groups At each facility, 2-hour interviews were conducted with the administrator and/or the director of care and/or the assistant director of care, one or two registered nurses (RNs), and one or two HEU representatives from either the Joint Health and Safety Committee or the union local. A 3-hour focus group was conducted at each facility with the care aides and LPNs, who represented a variety of units and employment statuses (full time, part time, and casual).

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A total of 39 interviews and 8 focus groups were held across the study facilities. Information from the interviews and focus groups was subjected to content analysis (Appendix A) and subsequently assembled into an intrafacility “narrative” that compared views and experiences of administrators, supervisors, and frontline staff within each facility. Separate comparative analyses were conducted for organizational “culture and climate,” safety environment, and workload and job demands. To enable comparisons across low injury rate and high injury rate facilities, a single interfacility table was constructed using information from the eight intrafacility tables. This comparative table was organized around the project’s key research questions (Appendix A) regarding work environment including organizational culture, safety environment, workload/demand, and in-house and community resources. The interfacility table then was subjected to a partially blinded rating process by five members of the research team, who were asked to rate each category within each facility on a 4-point scale: 1 (poor), 2 (moderate), 3 (good), and 4 (very good). Interrater reliability was tested and found to be high. Each rated category then was assigned a numeric value. The combined scores of the four LIRFs were compared with the combined scores of the four HIRFs. The categories were assigned a “difference value” according to the degree of numeric spread between the LIRFs and HIRFs as follows: spread spread spread spread

of 0 to 4 points (no meaningful difference) of 5 to 9 points (minor difference) of 10 to 14 points (moderate difference) exceeding 15 points (major difference).

Data Analysis The analysis focused on facility level characteristics that could relate to each facility’s injury rate. Multi-item perception variables (Tables 2, 3, and 4) were created from the initial analyses of the survey data using exploratory factor analyses. For example, the variable “perceived workload pressure” was obtained by averaging four highly related items (Cohen et al., 2003). These perception variables were calculated for each worker, and the scores subsequently were aggregated to obtain facility-specific workers’ perceptions. Pearson product-moment correlation coefficients associated time-loss injury, self-reported health, burnout, and job satisfaction with the following variable groups: workload and job demands, organizational “culture and climate,” safety environment, and physical environment. The correlation of workload and job demands with physical environment was examined. Analyses of variance and t tests were used to determine differences between LIRFs and HIRFs for all the variables. Significant correlations are shown with their associated p values.

Results The interrelationship between the predictor and outcome variables across the eight facilities is shown in Tables 1 to 5. This report focuses on the differences between HIRFs and LIRFs in terms of these variables. The quantitative data show that there was a 4.4-fold difference in time-loss injury rates across the eight facilities ranging from 16.3 to 71.1 injuries per 100 person years (mean, 18.54 for LIRFs vs. 43.42 for HIRFs; t(6) ⫽ ⫺2.45; p ⫽ .05) (Table 1). The average duration of time loss associated with these injuries

TABLE 2. Correlations Between Workload and Job Demands, With Time-Loss Injury Rates, Pain, Burnout, Health, and Job Satisfaction

Workload and Job Demands Staffing Resident-to-worker ratio (days)c Physical workloada Cumulative spinal compression (lower back)c Peak spinal compression (lower back)c Peak muscle activity (neck/shoulder)c Number of tasksc Perceptions Work pressure (4 items, ␣ ⫽ .74) Workload (1 item) Physical demands of job (1 item) Working short-staffed (1 item) Exertiona,c

Time-Loss Injury Rate

Painb

Burnout (6 items, ␣ ⫽ .73)

Health

Job Satisfaction (1 item)

.72*

.64

.88**

⫺.61

⫺.89**

.84** .86** .42 .79*

.67 .47 .40 .71*

.41 .43 .90** .62

⫺.37 ⫺.34 ⫺.92** ⫺.63

⫺.41 ⫺.41 ⫺.81* ⫺.47

.61 .56 .27 .27 .76*

.78* .17 .79* .62 .25

.70 .80* .50 .09 .70

⫺.82* ⫺.53 ⫺.90** ⫺.19 ⫺.49

⫺.81* ⫺.57 ⫺.60 ⫺.28 ⫺.71*

⫽ ergonomic study; b ⫽ pain in any body part; c ⫽ direct measure. *p ⫽ .05 (2-tailed). **p ⫽ .01 (2-tailed).

a

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TABLE 3. Correlations Between Organizational “Culture and Climate” and Time-Loss Injury Rates, Pain, Burnout, Health, and Job Satisfaction

Organizational “Culture and Climate” Communication (5 items, ␣ ⫽ .78) Discretion in conducting tasks (1 item) Fairness to workers (4 items, ␣ ⫽ .83) Favoritism towards residents (1 item) Quality of care (1 item) Adequate staffing to provide quality care (1 item) Management support (1 item) Supervisor support (3 items, ␣ ⫽ .83) Co-worker support (1 item) Union support (3 items, ␣ ⫽ .74) aRepresents

Time-Loss Injury Rate ⫺.45 ⫺.77* ⫺.73* .70 ⫺.62 ⫺.56 ⫺.77* ⫺.61 ⫺.36 ⫺.39

Paina ⫺.63 ⫺.61 ⫺.64 .82* ⫺.66 ⫺.85** ⫺.62 ⫺.47 ⫺.38 ⫺.38

Burnout (6 items, ␣ ⫽ .73) ⫺.26 ⫺.73* ⫺.33 .43 ⫺.87** ⫺.55 ⫺.48 ⫺.08 ⫺.11 ⫺.13

Health .12 .61 .11 ⫺.32 .88** .75* .18 .17 .15 .57

Job Satisfaction (1 item) .47 .72* .46 ⫺.40 .87** .72* .59 .24 .002 .10

pain in any body part. *p ⫽ .05 (2-tailed). **p ⫽ .01 (2-tailed).

was higher at HIRFs (62.11 days) than at LIRFs (26.30 days) although the difference is not statistically significant (p ⫽ .126). The per capita public funding was not significantly different between LIRFs and HIRFs (p ⫽ .896). Although the facilities had similar resident populations with respect to the amount and type of care they required, the mean resident-to-worker ratio at LIRFs was one third more favorable (12:1 at LIRFs vs. 16:1 at HIRFs; p ⬍ .05). There were no significant differences between LIRFs and HIRFs in terms of workers’ age, marital status, number of dependents, and completion of a formal care aide education program. Although the percentage of casuals in the study ranged from 35.6% to 59.2% across the eight facilities, there was no statistically significant difference between LIRFs and HIRFs (p ⫽ .748). Workload and Job Demands Qualitative information from the interviews and focus groups showed that HIRF workers reported working too hard on the job and rated their job demands as “heavy” to “very heavy.” The telephone survey and ergonomic study

both found that physical workload (peak and cumulative load on the low back) and staffing level (expressed as the resident-to-worker ratio) had strong correlations with time loss injury rates and self-reported pain, burnout, health, and job satisfaction (Table 2). The number of tasks performed by care aides and LPNs in 1 day was strongly related to both time-loss injury rates and pain, and moderately related to burnout and poorer self-rated health. The daily total numbers of tasks, transfers, and repositionings were strongly correlated with cumulative low-back and peak spinal compressions, and to a lesser extent with peak neck and shoulder muscle activity (Village et al., 2003). The quantitative data from the telephone survey showed strong correlations between time-loss injury rates and workers’ perceptions of workload and job demands. Staff at HIRFs rated their exertion, workload, and physical demands higher than did LIRF workers. They also reported more pain and burnout, poorer health, and less job satisfaction. According to the qualitative data, HIRF workers were more likely to agree that they did not have enough time to do their job, that they were too rushed to

TABLE 4. Correlations Between Safety Environment and Time-Loss Injury Rates, Pain, Burnout, Health, and Job Satisfaction

Safety Environment Safety commitment (4 items, ␣ ⫽ .81) Worry about work injury (1 item) Accessibility of mechanical lifts (1 item) Number of residents per mechanical liftb a

Time-Loss Injury Rate ⫺.58 .31 ⫺.48 .08

Paina ⫺.88** .74* ⫺.73* .53

⫽ pain in any body part. b direct measure. *p ⫽ .05 (2-tailed). **p ⫽ .01 (2-tailed).

Burnout (6 items, ␣ ⫽ .73) ⫺.65 .72* ⫺.61 .50

Health .64 ⫺.84** .63 ⫺.73*

Job Satisfaction (i item) .78* ⫺.76* .68 ⫺.51

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work safely, that they often did not have enough time to use a mechanical lift, and that their facility did not have enough staff to provide good quality care. Organizational Culture and Climate Several major differences between LIRFs and HIRFs were discovered in the survey, focus groups, and key informant interviews with regard to organizational culture and climate. The personnel at LIRFs expressed more positive perceptions on the survey than the personnel at HIRFs. The focus group and key informant interviews showed the following: • The LIRFs were more successful at running meetings in which workers participated, initiated agenda items, or called meetings themselves. In contrast, the managers at HIRFs appeared to treat workers in a paternalistic fashion (e.g., insisting on attendance yet not encouraging participation; “feeding” information yet not being open to feedback). • The workers at HIRFs reported being poorly informed about new residents’ histories of aggression. The staff at LIRFs said they were told the relevant information (either in written form or at verbal report time with an RN). • At all LIRFs, care aides and LPNs attended care conferences for residents. At some facilities, they also attended preconference planning meetings with RNs and ad hoc meetings with family members. In contrast, only one group of care aides and LPNs did not attend care conferences and expressed resentment about not being included. • The HIRF workers often had a cynical attitude toward management’s claims about quality of care and respect for residents’ choices. In contrast, workers at LIRFs were more likely to talk about challenges with elder care such as the increasing dependency of residents or unfavorable staffing levels. They reflected on problems in the sector instead of expressing doubts about management’s sincerity. • The LIRFs and HIRFs had similar philosophies of care. However, there were major differences in how well these ideas and messages were absorbed and accepted. The workers in LIRFs showed greater understanding of and identification with their facility’s philosophy of care than workers in HIRFs. All the workers at LIRFs had a clear sense of the facility’s values and expectations (from orientations and from ongoing messages at meetings and other encounters with managers) and felt “in synch” with the philosophy. Workers at LIRFs talked about teamwork, the importance of patience and individualized approaches, and respect for residents’ desire for privacy. In contrast, at HIRFs, questions about the “philosophy of care” elicited remarks about defending the interests of the residents and feeling blamed and unsupported by management. • Workers at LIRFs reported more open, sympathetic, and responsive relationships with their director of care than workers at HIRFs. The LIRF staff considered their director to be approachable, knowledge-


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able about the demands they faced, a good communicator, and likely to change things when requested. In contrast, workers at three HIRFs reported difficult to hostile relationships with their director of care and a general climate of distrust. Organizational culture and climate variables were significantly related to injury rates, pain, burnout, selfreported health, and job satisfaction (Table 3). The LIRF workers had more positive pe rceptions of the organizational culture and climate than HIRF workers. Qualitative data showed that LIRF workers were more likely to agree that they could make choices about how they did their work, that their supervisor acted fairly in conflict situations, that management would deal with unsafe working conditions, that management would support them in a caring way if they were injured, that their facility had enough staff to provide good quality care and did indeed provide good to excellent care, that management did not show favoritism toward individual residents, that cooperation existed between care aides and LPNs and their supervisors, and that their supervisors listened to what they had to say. Safety Environment Differences were noted in the focus groups and key informant interviews across facilities for some safety environment variables. Qualitative data showed that the LIRFs did a much better job than the HIRFs in following up after incidents of resident aggression. The LIRFs, on the average, had slightly more effective and cooperative Joint Health and Safety Committees than the HIRFs. There was no difference between LIRFs and HIRFs in the area of staff training. All facilities made safety-oriented training available to their staff. The LIRFs had better lift resources than the HIRFs. For example, resident-to-lift ratios were better, lifts were more accessible, and the types of lifts were more useful. The LIRFs had clear “no manual lifting” policies, which were well understood by staff. In contrast, staff members at only two HIRFs were well aware of definite policies (in one case verbal only). Although care aide and LPN assessments of their own compliance with lift policies were similar at HIRFs and LIRFs, there was a major difference in terms of enforcement and follow-up action for noncompliance. In general, workers at LIRFs reported follow-up action, reminders, and guidance from managers and RNs if they were noncompliant, whereas workers at HIRFs reported a lack of follow-up action. The LIRFs and HIRFs had similar formal policies for dealing with potentially aggressive residents. However, there were major differences between LIRFs and HIRFs in practice. At LIRFs, workers saw themselves included in the follow-up action, and did not talk about being blamed or ignored when reporting an aggressive incident. In contrast, staff at HIRFs did not have a clear picture of the formal policy, did not perceive follow-up action and support after incidents to be genuine, and felt largely ignored in aggression incidents. The survey data supported the qualitative findings. The workers’ perceptions of the safety environment were correlated with their reports of pain, burnout, personal health, and job satisfaction (Table 4). The only appreciable

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relation with injury rates was a moderate association with safety commitment, which also was correlated with pain and job satisfaction. According to the interview data, LIRF workers were more likely to agree that their facility invested time and money to improve staff safety, that senior managers were active on the Health and Safety Committee, that managers would deal promptly with unsafe working conditions, and that their supervisors talked to them about working safely. The safety environment category included variables related to worries about injury on the job and accessibility of mechanical lifts. Overall, workers who had a positive perception of these factors reported less pain and burnout, better health, and more job satisfaction. There was a strong inverse correlation between the “number of residents per mechanical lift” and workers’ self-reported health. This variable also was moderately correlated with pain and job satisfaction.

and labor is exchanged for the employer’s promises to provide clear duties, a healthy psychosocial environment, a safe physical environment, a safe system of work, fair treatment, and a reasonable workload, as well as basic courtesy and respect (Anderson et al., 2003; Lowe, 2002; Requena, 2003; Shain, 2000; Tyler, Boeckmann, Smith, & Huo, 1997). The current results support the idea that fairness, social justice, and efforts to fulfill the employment “promise,” essentially, creating a match between what caregivers are expected to provide and what they can provide, are associated with safer work environments. The LIRFs seem to honor these spoken and unspoken contracts (promises) concerning quality care, equitable treatment, compassionate responses, open communication, supportive action, and personal safety by providing the necessary tools, mechanisms, and supports, including more favorable staffing levels. The LIRFs were able to fulfill their employment contract through

Physical Environment Although there were some correlations between the physical environment variables (age of facility, bedroom size, bathroom size, length of hallway) and workers’ reports of pain, health, and job satisfaction, most relations were not statistically significant. There was no significant association between the physical environment variables and the following variables: staffing level, cumulative spinal compression, peak lower-back compression, peak “neck and shoulder” muscle activity, number of tasks, “perceptions of workload,” “physical demands of the job,” “working short-staffed,” and exertion. The only statistically significant correlations were perception of work pressure relative to bedroom size (r ⫽ ⫺.83; p ⬍ .01) and bathroom size (r ⫽ ⫺.76; p ⬍ .05).

• care aide involvement in care planning and implementation • ongoing opportunities for input from care staff being provided and taken seriously by the management • more favorable staffing levels, expressed as lower resident-to-worker ratios • “no-lifting” policies communicated well and positively reinforced • mechanical lifts that are available and accessible • visible follow-up action for serious incidents of aggression • no favoritism toward residents or blaming of staff • positive staff view regarding the facility’s philosophy and quality of care.

Discussion This project, unique in its multimethod transdisciplinary approach, allowed for a detailed examination of the salient dimensions of work environments in an IC setting, a particularly high-risk subsector within the healthcare sector. The collaboration of several disciplines (social, physical, and health sciences incorporating medicine, nursing, ergonomics, social work, gerontology, kinesiology, union representatives, occupational health and safety) enabled the melding of perspectives for the choice of appropriate measures and for an understanding concerning the interplay of variables and their effect on injuries to direct care staff in IC facilities. The research had several innovative features. First, the examination of organizational culture and climate incorporated issues of fairness and social justice, which usually are not investigated in work organizational studies, but are increasingly recognized as necessary to a meaningful analysis. Furthermore, ergonomists used objective measures of care aides’ physical loads and examined their relation with organization level data. Finally, the findings on organizational “culture and climate” were linked to unusually accurate and objective injury and staffing data. In the social justice and fairness literature, the work environment is described, in relational terms, as an implied employment contract in which the employees’ commitment

At LIRFs, the management’s approach to resident care and services had a correspondingly positive impact on workers’ well-being, as expressed in terms of injuries, selfreported pain, burnout, health, and job satisfaction. A picture emerged suggesting links between organizational effectiveness, lower injury rates, and better quality of life. The connection between organizational effectiveness and injury rates has surfaced in other studies (Bru, Mykletun, & Svebak, 1996; Koehoorn et al., 2002; Ostry, Tomlin et al., in press, Ostry, Yassi et al., 2003; Yassi et al., 2003). The National Institute for Occupational Health and Safety has recognized that job stress and organizational health are linked. This organization has subsequently observed that organizational performance and worker well-being are not only compatible, but also mutually reinforcing (Sauter, Lim, & Murphy, 1996). Evidence of this relation was found in this research despite similar care demands and financial resources. Staffing levels at LIRFs were more favorable than at HIRFs. At LIRFs, workers not only had fewer injuries, less pain, and better self-reported health. They also reported feeling better able to provide quality care. This suggests that the management decision to provide better staffing levels reflects an organizational priority that supports the well-being (i.e., organizational effectiveness) of both workers and residents. These results have given rise to a conceptual framework (Table 5) that encapsulates the authors’ understanding of what makes some residential care facilities safer and

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TABLE 5. Conceptual Framework: Facility Comparison of Health and Safety in the Workplace

Concepts Observations about high-functioning LIRFs

General ideas

Atmosphere

Actions

—Interactional— (How People Relate) Engaged Environment

—Philosophical— (Why People Do What They Do) Substantive Philosophy

—Practical— (How They Do It) Concrete Practices

• teamwork is strong and multidisciplinary in approach • staff are more likely to take initiative • RNs are more likely to support flexibility and respond to care aides’ concerns about residents • in general, problems are visibly followed up by RNs and management • staff have positive attitude towards challenges of job, rather than cynicism or distrust • staff are viewed as agents, as a resource—management recognizes the centrality of frontline staff to resident care • there is a “respectful hierarchy:” roles are acknowledged, and roles fit together rather than being at odds • people are candid about conflicts and shortcomings: there is little or no structural resentment • respectful, courteous • collaborative (people are brought inside, rather than left feeling outside) • fair-minded, empathetic • management is accessible • trusting (honest efforts, few charges of “lip service”) • exchange information (ask for and give)—consult, communicate • teach (not blame) • support workers, acknowledge demands • involve staff—use their skills and capabilities

• clear and realistic expectations about the philosophy of care: it is a work in progress rather than a fait accompli • backed up by explicit training or reinforced by “value messages” that are perceived as trustworthy (i.e., more than rhetorical) • values are modeled by management in dealings with staff

• clear and visible policies (on use of mechanical lifts, for example) • enforced by whole team: peers, RNs, and management • appropriate staffing levels (as good as it gets) • sufficient, accessible, and appropriate mechanical lifts • comprehensive programming and services for residents

• beliefs, goals, projects are real (“management walks the talk”) and realistic (rather than token or idealistic) • the philosophy is actively applied • praxis: the goal is to have a consistent practice of putting beliefs into action

• policies and practices are conspicuous, observable, visible • communicated clearly—staff know what is expected of them, and are supported, instructed, and reminded • “practices” includes material and human resources: staffing levels, mechanical lifts, programming for residents, training for staff, etc.

• high expectations of self and others • honest about limitations • dynamic (not static, always room for improvement)

• consistent (not haphazard or dependent on individual) • resourceful (tap into existing resources or create opportunities) • practical (material results)

• deliberate implementation or reinforcement of values • consider the big picture (not just little pieces)—work towards comprehensive changes • try to model values in all settings (between management/staff; between staff/families; between residents/staff)

• provide human resources, materials, and training • communicate verbally (in person), as often as necessary • reinforce by multiple avenues (on paper, in person, at meetings, etc.) • visible follow-up, tracking, and evaluation are built into actions and policies

Note. LIRFs ⫽ Low injury-rate facilities.

healthier workplaces than others. The work of frontline staff is intimate and personal. To be done well, the work requires compassion and sensitivity as well as skills related to geriatric conditions. Of particular importance is the emphasis on resident-oriented rather than task-oriented care. It is not what workers do; it is how they interact. A staff person is expected to provide care in a manner that

respects resident preferences, acknowledges personal space, encourages the capacity for self-care, and stays alert to the changing needs, moods, and abilities of residents. Although the transdisciplinary approach allowed an indepth study of eight facilities, the sample size limited the interfacility analysis to bivariate relationships and made it impossible to control for confounding variables. Another

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96 Factors Associated With Staff Injuries unavoidable limitation was that some data were collected for different periods during the study. The healthcare sector was in considerable flux (e.g., new policies, contract negotiations, unilateral changes to collective agreements) during the telephone survey and during the focus group and key-informant interviews. Therefore, workers’ perceptions and experiences likely changed somewhat during the 21/2 years of the study of the injury data. Although these limitations were unavoidable for the in-depth analysis, future research should consider larger samples for elaboration of the relation among injuries, staffing levels, staff well-being, organizational factors, and workload. The small sample size also limited the generalizability of the findings to other contexts. In addition, the small sample resulted in relatively large correlations that were not statistically significant. This study does not show any evidence of causality between the variables. The study design and the small sample size did not allow the study to control for other variables (e.g., confounders). In addition, there was a temporal ambiguity in the measurement of the study variables. Thus, caution should be observed in drawing conclusions from the presented statistics. The sample facilities were selected from the top and bottom 25% of the facilities in terms of their injury rates. This may have caused overestimation of variances and correlations. Because of these limitations, this study should be regarded as a preliminary investigation. This study shows that managers who view care aides and LPNs as key members of the care delivery team are likely to have practices and policies that promote safer work environments, cooperative relations, and a positive outlook on caregiving. The key ingredients in such workplaces are an engaged environment, a substantive philosophy of care, and concrete policies and practices. ▼

Accepted for publication December 15, 2003. This project, initiated by the Hospital Employees’ Union, was funded by the Workers Compensation Board (WCB) of British Columbia and the Canadian Institute of Health Research through the Community Alliance for Health Research Program and through career awards to Drs. Yassi, Ostry, and Ratner. The authors are grateful for the support provided by staff from the Occupational Health and Safety Agency for Healthcare and the University of British Columbia Institute of Health Promotion Research. They also acknowledge with thanks the advice received from their stakeholder committee, which included representatives from WCB Prevention (Stephen Symon), the BC Nurses’ Union (Lorley Pachkowski), the Health Benefit Trust (Jan Mitchell), the Health Employers’ Association of BC (Linda Rose), the BC Ministry of Health (Stephanie Sainas), the Hospital Employees’ Union Executive (Mary Nicholls and Joanne Foote). Corresponding author: Annalee Yassi, MD, MSc, FRCPC, Institute of Health Promotion Research, University of British Columbia, 2206 East Mall Vancouver BC V6T 1Z3 (e-mail: [email protected]).

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Appendix A: Content of Focus Groups/Key Informant Interviews Organizational Culture Communication and Information Sharing/Participation and Decision Making The extent to which a facility invites input from its employees, responds to their concerns, and enables them to influence decisions. Support (Instrumental and Emotional)/Conflict and Cohesiveness Examining a series of relationships (e.g. between director of care and care aides/LPNs; between RNs and care aides/LPNs), with each party commenting on the nature of teamwork, cooperation, and responsiveness. Fairness and Congruency: Aspects of Job Satisfaction, Discretion, Choice, and Personal Well-Being The extent to which a facility enables staff to fulfill their role as caregivers in providing a quality of care and attention that resonates with the facility’s stated goals.

Safety Environment Staff Training Practical training (i.e., body mechanics, dementia), how it was delivered, and to whom. Safety Equipment: Mechanical Lifts Examining the number and type of mechanical lifts in the facility as well as management’s and workers’ perceptions of their adequacy and ease of use.

Commitment to Safe Resident Handling Examining policies and practices in relation to lifting and transferring residents. Exploring formal policies, actual practices, attitudes, reasons for noncompliance, and skill levels. Resident Aggression: Policies and Practices Determining the formal policies in place regarding incidents of verbal or physical abuse by residents, and workers’ perceptions of actual practices after such incidents. Joint Occupational Health and Safety Committee Examining management’s and frontline staff’s perceptions of the Joint Occupational Health and Safety Committee’s makeup, practices, and effectiveness.

Community and In-House Resources Funding for Resident Aids, Facility Upgrading, and Staff Training Examining allocations for these items, according to senior management. Relationship to Outside Health Services, Regional Health Authority, and Medical Coordinator Investigating the facility’s ability to manage and access outside health services (acute, mental health, occupational therapy/physical therapy) for residents. Examining the status, role, and expertise of the facility’s medical coordinator.

(continues)

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Appendix A: Content of Focus Groups/Key Informant Interviews (Contined) Resident Programming Examining the in-house activation and stimulation programs available to residents, as well as the use of community and volunteer services.

casuals). Determining management and care aides’/LPNs’ perceptions of the incidence of short-staffing.

Workload

Workload Distribution Examining management’s and care aides’/LPNs’ perception of how workload varies among different units or teams and the efforts to distribute work evenly (e.g., use of Added Care, moving workers to different units in response to increased dependency of some residents).

Workload: Perceptions of Care Aide/LPN Staffing Levels Asking managers and frontline staff to comment on staffing levels.

Use of Casuals Examining how often part-time and fulltime staff worked with casuals or inexperienced staff.

Replacement Policies and Short-Staffing Investigating the facility’s policy and practice with regard to replacing absent workers (whether through overtime or use of

Physical Layout Examining workers’ perceptions of how the physical layout affects their ability to provide effective care.

Specialized Staff Determining the presence of a social worker, assistant director of care, physiotherapist, or related positions.