Two recently published studies show that employee health interventions may fail at the unit level, but can succeed if embraced as part of larger system change in a work culture.
“One of the lessons learned is that we really need to think about the systemwide norms and policies, the infrastructure that can be translated to the unit level,” said Jack Dennerlein, PhD, associate director of the Center for Work, Health, & Well-being, which is affiliated with Harvard’s T.H. Chan School of Public Health. A co-author of both studies, Dennerlein recently described the projects at a presentation for the Association of Safe Patient Handling Professionals.
First the proverbial bad news, which in this case was an attempt to implement worker safety and wellness education on four units of a Boston hospital. The study1 was a proof-of-concept trial designed to examine the feasibility and estimate the efficacy of a workplace intervention called “Be Well, Work Well.” The study was conducted in eight hospital units, with four serving as the control and the rest the trial arm. The intervention included consultation with nurse managers to implement changes on patient care units and education of patient care staff on safety and health behaviors.
“We talked to them about both safe patient handling and good, healthy eating habits,” Dennerlein said.
The intervention included feedback assessments to workers on ergonomics, held educational events, and created competitive challenges.
“In the end, we saw no effects in the units for any of the outcomes we measured, [including] safety practices, dietary patterns, physical activity, and sleep,” he said.
Surveys and evaluations with the healthcare workers revealed that the intervention was seen as a competing priority with the physical demands and time constraints already committed to patient care.
“We found that the workers were not engaging with us at all,” Dennerlein said. “A lot of that had to do with the fact that their patient care priorities were competing with the priorities that we were trying to promote. They had a big workload and they didn’t want to think about things like what they were eating. There were a lot of competing demands and barriers to having people participate [in behavior change].”
The take-home lesson was that it is extremely difficult at the patient care unit level to try to change behavior engrained by a larger work culture.
“They had a cultural commitment to put patients first, and we were not aligned with that message,” he said. “A lot of people [told us], ‘We have to live in this bigger system, which is not pushing us to go down the road you want us to go down.’ A lot of workplace safety is making sure that the goals of the program are aligned with the goals of the worker. It’s important to the healthcare workers that the safety is actually adding value to their work.”
In contrast, a large systemwide intervention2 at another Boston hospital yielded dramatic results, reducing patient handling injuries substantially.
The recuperative benefit of patient mobility has more hospitals trying to get patients moving to the highest degree possible.
“The big question we had is when such a program is initiated, what does it do in terms of the physical load on caregivers?” Dennerlein said. “Because the idea of more frequent mobilization would infer that the load on the healthcare workers could increase, as well as patient outcomes such as risk of patient falls.”
The solution at the Boston hospital was to create a hybrid program that focused on both safe patient handling and increased patient mobility.
“They saw this as an opportunity to develop a hospitalwide safe patient handling program and change a lot of the infrastructure and work practices,” he says. “Again, mobilize patients more frequently, but provide strategies for the staff to do it safely without injuries. The key was developing a hospitalwide infrastructure that supported and gave the resources at the bedside. So when they are at that moment of making decisions, do they have the equipment they need for safer worker practices?”
An overview of the challenge made it clear that for something like this to work, several key measures had to be in place, including management commitment, worker involvement, clearly stated policies, formation of key committees, and an initial needs assessment of both the organization as well as of patient function in terms of mobility.
“They discovered the hospital had been investing in [safe patient handling equipment], but the use of it was kind of sporadic,” Dennerlein said. “There were just a few isolated areas that seemed to be using the equipment consistently. There was really no ownership of this, and as a result there was no involvement of hospital leadership and staff beyond a few advocates in the organization. They had a lot of equipment but no organization structure that supported its use and maintained that at a system level. They realized they didn’t have enough slings to keep the system going all the time, so they made a huge investment in slings.”
Sustainable ongoing training was performed through a mentoring program, with policies requiring use of equipment for all patient handling. Manual patient movement was only to be done in medical emergencies.
“They made sure they had the equipment and training, followed by surveillance and evaluation,” he said. “At the hospitalwide infrastructure, it was necessary for the program to maintain and service equipment, provide clean [patient] slings to the units, and make sure that the patient practices were embedded in the care plans.”
That included identifying the safe lifting protocols and tools in the patient care plan, even to the point of adding new fields in the electronic medical records. In addition to slings, the hospital added more ceiling lifts, sit-to-stand devices, air-assisted lateral transfer devices, and portable floor-lift equipment.
Training on the equipment was critical, so the hospital called in extra employees so others could be trained during work hours. “That took several months, but it was key in showing people and demonstrating how to integrate the use of the equipment and practices into patient care,” he said.
It took about eight months to completely roll out the program. Researchers looked at worker injury rates for 12 months pre-rollout, and then one year after the full program was in place.
“We saw about a 13% reduction in the injury rate in the hospital,” he said. “The big area where we saw the most significant reductions was [worker] injuries associated with lift and exertion — we saw that being reduced by almost 25%. We also saw a reduction in neck and shoulder injuries as well.”
In comparing the two studies, Dennerlein said the key difference was the commitment from hospital administration.
“There is a huge need for leadership commitment, especially by the upper-middle level managers,” he said. “Because they can create on the unit the climate and support for policy implementation. They can also provide the support and necessary resources for workforce training. This really points to the need for embedding system-level efforts into a systemwide initiative.”
- Sorensen G, Nagler EM, Hashimoto D, et al. Implementing an Integrated Health Protection/Health Promotion Intervention in the Hospital Setting: Lessons Learned From the Be Well, Work Well Study. J Occup Environ Med 2016;58(2):185-194.
- Dennerlein JT, O’Day ET, Mulloy DF, et al. Lifting and exertion injuries decrease after implementation of an integrated hospital-wide safe patient handling and mobilisation programme. Occup Environ Med 2016: Oct 25: [Epub ahead of print] doi: 10.1097/JOM.0000000000000592.