Development and psychometric evaluation of a Total Worker Health® practice scale

OBJECTIVE

Occupational Safety and Health (OSH) professionals increasingly need to assess and mitigate a broad scope of worker safety, health, and well-being concerns that extend beyond traditional OSH training curricula. Work-related and non-work-related psychosocial hazards, chronic physical and mental health conditions, and changing work arrangements call for an integrative, public health approach to occupational risk management; this approach has been called, "Total Worker Health®" by United States public health authorities (Schulte et al. 2019). OSH professionals need education to ensure that Total Worker Health (TWH) practice approaches are consistently and effectively applied. This study sought to develop a valid, reliable scale that could be used to assess TWH skills gaps that can be addressed with tailored, competency-based curricula.

METHOD

We developed a survey scale to assess professional competency for specific TWH practice approaches described in prior literature (Lee et al. 2016; Punnett et al. 2020). The scale contained 11 statements and used a 5-point scale (not skilled to highly skilled) to rate the level of competency. We pre-tested and refined the statements for face validity then administered the scale with a convenience sample of 258 professionals from mixed OSH disciplines. A total of 210 OSH professionals (31% safety, 17% industrial hygiene, 12% occupational nurses, 11% occupational physicians, 29% other) who completed 50% or more of the questions were included in the analysis. Scale reliability was assessed with a Cronbach's alpha test. Scale validity and structure were assessed with exploratory factor analysis (EFA).

RESULTS

The 11-item scale had high internal consistency (Cronbach's α = 0.92). The initial EFA solution suggested 2 factors that explained 65.3% of variance, with one cross-loaded question. A final 10-item, 2-factor scale was developed that accounted for 66.0% of variance with no cross-loaded items (Cronbach's alpha α = 0.91). Factor 1 (6 items) contributed to 55.5% of the variance and captured skills related to TWH program leadership (e.g. leader commitment, integrating program systems, engaging with other program leaders and workers). Factor 2 (4 items) contributed to 10.5% of the variance and captured technical skills related to hazard identification and control (e.g. identifying hazards, designing work to reduce hazards). Internal consistency was very good for both TWH program leadership (Cronbach α = 0.89) and TWH risk assessment and control (Cronbach α = 0.80) subscales.

CONCLUSION

A novel 10-item TWH skill scale to assess specific TWH practice approaches was developed with very good reliability. Factor analysis revealed 2 latent constructs: TWH leadership skills and TWH risk assessment and control skills. This study offers an evidence-based tool to assess competency for specific TWH practices among OSH professionals. The results of this study contribute to the broader research base needed to formalize a TWH competency framework, as advocated by other scholars interested in TWH workforce education (Newman et al. 2020).

Let's Learn Together! A Mixed-Methods Study to Assess Readiness for Interprofessional Education on Total Worker Health® Practice

BACKGROUND

Occupational safety and health (OSH) professionals increasingly need interdisciplinary collaborative practice competencies to respond to complex worker safety, health, and well-being risks. Effective collaboration with non-OSH-trained professionals (e.g., health promotion, human resources) is critical for planning integrated interventions that address work and non-work risks, consistent with a "Total Worker Health" (TWH) approach. Interprofessional education (IPE) pedagogy offers skill-building for interdisciplinary collaboration, but little attention has been given to IPE in OSH education and training literature. The goal of this study was to assess OSH professionals' perceptions about IPE to guide application in postgraduate TWH education.

METHODS

The mixed-methods study involved 210 U.S. professionals in safety (31%), industrial hygiene (16%), occupational nursing (12%) and medicine (11%), and related disciplines (30%). Participants completed a 12-item Readiness for Interprofessional Education Scale (RIPLS) adapted for TWH. Nineteen survey-takers also participated in virtual focus groups to share opinions about IPE benefits, barriers, and desirable course features.

FINDINGS

Occupational safety and health professionals reported high overall readiness for IPE (RIPLS, 4.45 ± 0.47), endorsing IPE for interdisciplinary skill-building. Salient IPE motivators were learning new perspectives from diverse disciplines and industries; gaining new subject expertise; developing common ground across disciplines; and learning TWH best practices. Participants recommended case studies to practice interdisciplinary problem-solving through group work.

CONCLUSIONS/APPLICATION TO PRACTICE

Interprofessional education is a promising pedagogy for OSH continuing education to promote interdisciplinary collaboration skills needed for TWH practice in the workplace. Occupational safety and health educators need to build competency in IPE pedagogical theory and practice to ensure effective training design and evaluation.

Assessment of organizational readiness for participatory occupational safety, health and well-being programs

BACKGROUND

Organizational readiness for change measures were reviewed to develop an assessment tool for guiding implementation of an occupational safety and health program based on Total Worker Health (TWH) principles. Considerable conceptual ambiguity in the theoretical and empirical peer-reviewed literature was revealed.

OBJECTIVE

Develop and validate an assessment tool that organizations can use to prepare for implementation of a participatory TWH program.

METHODS

Inclusion criteria identified 29 relevant publications. Analysis revealed eight key organizational characteristics and predictors of successful organizational change. A conceptual framework was created that subject matter experts used to generate prospective survey items. Items were revised after pretesting with 10 cognitive interviews with upper-level management and pilot-tested in five healthcare organizations. Reliability of the domain subscales were tested based on Cronbach's α.

RESULTS

The Organizational Readiness Tool (ORT) showed adequate psychometric properties and specificity in these eight domains: 1) Current safety/health/well-being programs; 2) Current organizational approaches to safety/health/well-being; 3) Resources available for safety/health/well-being; 4) Resources and readiness for change initiatives to improve safety/health/well-being; 5) Resources and readiness for use of teams in programmatic initiatives; 6) Teamwork; 7) Resources and readiness for employee participation; and 8) Management communication about safety/health/well-being. Acceptable ranges of internal consistency statistics for the domain subscales were observed.

CONCLUSIONS

A conceptual model of organizational readiness for change guided development of the Organizational Readiness Tool (ORT), a survey instrument designed to provide actionable guidance for implementing a participatory TWH program. Initial internal consistency was demonstrated following administration at multiple organizations prior to implementation of a participatory Total Worker Health® program.

A mixed-method approach to tailor the implementation of a participatory Total Worker Health® program

Purpose –

Total Worker Health^® (TWH) programs, which represent a holistic approach for advancing worker safety, health and well-being, require an employer to adapt programmatic coordination and employee involvement in program design and delivery. Organizational readiness for such measures requires competencies in leadership, communication, subject expertise and worker participation. In the absence of documented methods for TWH readiness assessment, the authors developed a process to prospectively identify implementation facilitators and barriers that may be used to strengthen organizational competencies and optimize the organizational "fit" in advance.

Design/methodology/approach –

The mixed-method baseline assessment instruments comprised an online organizational readiness survey and a key leader interview; these were administered with key organizational and labor leaders in five US healthcare facilities. Findings about organizational resources, skills available and potential implementation barriers were summarized in a stakeholder feedback report and used to strengthen readiness and tailor implementation to the organizational context.

Findings –

The research team was able to leverage organizational strengths such as leaders' commitment and willingness to address nontraditional safety topics to establish new worker-led design teams. Information about program barriers (staff time and communication) enabled the research team to respond with proactive tailoring strategies such as training on participant roles, extending team recruitment time and providing program communication tools and coaching.

Originality/value –

A new method has been developed for prospective organizational readiness assessment to implement a participatory TWH program. The authors illustrate its ability to identify relevant organizational features to guide institutional preparation and tailor program implementation.

Emotional Labor and Depressive Symptoms Among Healthcare Workers: The Role of Sleep

BACKGROUND

Depression is the second leading cause of disability worldwide. Health care workers report a higher prevalence of depressive symptoms than the general population. Emotional labor has contributed to poor health and work outcomes. However, the mechanism for the potential association between emotional labor and depressive symptoms has not been well studied. This study examines the relationship between emotional labor and depressive symptoms and whether sleep plays a role in explaining this relationship.

METHODS

In 2018, health care workers (n = 1,060) from five public sector facilities in the northeast United States participated in this cross-sectional survey. The survey included questions on participants' surface-acting emotional labor (masking one's feelings at work), depressive symptoms, sleep duration and disturbances, and socio-demographic characteristics. Multivariable linear and Poisson regression modeling were used to examine associations among variables.

FINDINGS

There was a significant association between emotional labor and depressive symptoms (β = 0.82, p < .001). Sleep disturbances, but not short sleep duration, partially mediated this association. Neither sleep variable moderated this association.

CONCLUSIONS/APPLICATION TO PRACTICE

Depressive symptoms were prevalent among health care workers and were associated with emotional masking. Sleep disturbances play an important intermediate role in translating emotional labor to depressive symptoms in these workers. Effective workplace programs are needed to reduce health care workers' emotional labor to improve their mental health. Sleep promotion should also be emphasized to mitigate the negative effect of emotional labor and promote mental wellbeing.

Feasibility of Virtual Focus Groups in Program Impact Evaluation

Focus groups are often used for qualitative investigations. We adapted a published focus group method for evaluating impact of an organizational intervention for virtual delivery using video conferencing. The method entailed convening small groups of three to five participants for a 2-hour facilitated workshop. We delivered the virtual workshops, adding qualitative evaluation with researchers and participants, to assess the effectiveness of the protocol. We address the questions of how to structure the data collection procedures; whether virtual delivery permits cross participant interactions about a studied intervention; and how easy and comfortable the experience was for participants. Participants were university faculty members who were the focus of an institutional diversity program. The results indicated that the virtually delivered focus group workshop could be successfully implemented with strong fidelity to the original protocol to achieve the workshop goals. The workshops generated rich data about the impacts of the institutional program as well as other events and conditions in the working environment that were relevant to consider along with the observed program outcomes. A well-planned virtual focus group protocol is a valuable tool to engage intervention stakeholders for research and evaluation from a distance. Video conferencing is especially useful during the current COVID-19 pandemic, but also whenever geography separates researchers and evaluators from program stakeholders. Careful planning of privacy measures for a secure online environment and procedures for structured facilitation of group dialogue are critical for success, as in any focus group. This article addresses a gap in the literature on feasibility and methodology for using video conference technology to conduct qualitative data collection with groups.

750 Sleep disturbances mediates the association between emotional labor and depressive symptoms among healthcare workers

Introduction

Depression is the second leading cause of disability worldwide. Healthcare workers report a higher prevalence of depressive symptoms than the general population. Emotional labor has contributed to poor health and work outcomes. However, the mechanism for the potential association between emotional labor and depressive symptoms has not been well studied.

Methods

In 2018, healthcare workers (n=1,060) from five public sector facilities in the northeast U.S. participated in this cross-sectional survey. The survey included questions on participants’ surface-acting emotional labor (masking one’s feelings at work), depressive symptoms, sleep duration and disturbances, and socio-demographics.

Results

Nearly a quarter (21.7%) of the participants reported depressive symptoms, over a half (53.6%) reported short sleep duration (≤6 hours per day), and nearly one third (32.2%) reported sleep disturbances. There was a significant association between emotional labor and depressive symptoms (β=0.82, p&lt;0.001) among these workers. Sleep disturbances, not short sleep duration, partially mediated this association by 17%. Both sleep disturbances and short sleep duration did not modify this association.

Conclusion

Depressive symptoms were prevalent among healthcare workers and were associated with emotional masking. Sleep disturbances play an important intermediate role in translating emotional labor to depressive symptoms in these workers. Effective workplace programs are needed to reduce healthcare workers’ emotional labor in order to improve their mental health. Sleep promotion should be emphasized to mitigate the negative effect of emotional labor and promote healthcare workers’ mental wellbeing.

Support (if any)

The Center for the Promotion of Health in the New England Workplace is supported by Grant Number 1 U19 OH008857 from the National Institute for Occupational Safety and Health (CDC). This work is solely the responsibility of the authors and does not necessarily represent the official views of NIOSH. We are grateful to the CPH-NEW Research Team working together to collect the questionnaire data.

Safety and Health through Integrated, Facilitated Teams (SHIFT): stepped-wedge protocol for prospective, mixed-methods evaluation of the Healthy Workplace Participatory Program

BACKGROUND

Healthcare facilities are notorious for occupational health and safety problems. Multi-level interventions are needed to address interacting exposures and their overlapping origins in work organization features. Worker participation in problem identification and resolution is essential. This study evaluates the CPH-NEW Healthy Workplace Participatory Program (HWPP), a Total Worker Health® protocol to develop effective employee teams for worker safety, health, and wellbeing.

METHODS

Six public sector, unionized healthcare facilities are enrolled, in three pairs, matched by agency. The unit of intervention is a workplace health and safety committee, adapted here to a joint labor-management "Design Team" (DT). The DT conducts root cause analyses, prioritizes problems, identifies feasible interventions in light of the constraints and needs of the specific setting, makes business-case presentations to facility leadership, and assists in evaluation. Following a stepped-wedge (cross-over) design, one site in each pair is randomly assigned to "immediate intervention" status, receiving the full coached intervention at baseline; in the "lagged intervention" site, coaching begins about half-way through the study. Program effectiveness and cost-effectiveness outcomes are assessed at both organizational (e.g., workers' compensation claim and absenteeism rates, perceived management support of safety) and individual levels (e.g., self-rated health, sleep quality, leisure-time exercise). Targeted pre-post analyses will also examine specific outcomes appropriate to the topics selected for intervention. Process evaluation outcomes include fidelity of the HWPP intervention, extent of individual DT member activity, expansion of committee scope to include employee well-being, program obstacles and opportunities in each setting, and sustainability (within the available time frame).

DISCUSSION

This study aims for a quantitative evaluation of the HWPP over a time period long enough to accomplish multiple intervention cycles in each facility. The design seeks to achieve comparable study engagement and data quality between groups. We will also assess whether the HWPP might be further improved to meet the needs of U.S. public sector healthcare institutions. Potential challenges include difficulty in pooling data across study sites if Design Teams select different intervention topics, and follow-up periods too short for change to be observed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04251429 (retrospectively registered January 29, 2020), protocol version 1.

Defining 'Integration' for Total Worker Health®: A New Proposal

The effects of work and the conditions of employment on health behaviors and intermediate health conditions have been demonstrated, to the extent that these relationships should be addressed in efforts to prevent chronic disease. However, conventional health promotion practice generally focuses on personal risk factors and individual behavior change. In an effort to find solutions to the myriad of health challenges faced by the American workforce, the U.S. National Institute for Occupational Safety and Health (NIOSH) established the Total Worker Health® (TWH) program. Originally organized around the paradigm of integrating traditional occupational safety and health protections with workplace health promotion, TWH has evolved to a broader emphasis on workplace programs for enhancing worker safety, health, and well-being. Among the research programs and approaches developed by investigators at NIOSH Centers of Excellence for TWH and elsewhere, definitions of 'integration' in workplace interventions vary widely. There is no consensus about which organizational or individual outcomes are the most salient, how much to emphasize organizational contexts of work, or which program elements are necessary in order to qualify as 'Total Worker Health'. Agreement about the dimensions of integration would facilitate comparison of programs and interventions which are self-defined as TWH, although diverse in content. The specific criteria needed to define integration should be unique to that concept-i.e. distinct from and additive to conventional criteria for predicting or evaluating the success of a workplace health program. We propose a set of four TWH-specific metrics for integrated interventions that address both program content and process: (i) coordination and interaction of workplace programs across domains; (ii) assessment of both work and non-work exposures; (iii) emphasis on interventions to make the workplace more health-promoting; and (iv) participatory engagement of workers in pivotal ways during intervention prioritization and planning to develop self-efficacy in addressing root causes, skill transfer, building program ownership, empowerment, and continuous improvement. Thus we find that integration requires organizational change, both to engage two managerial functions with different goals, legal responsibilities, and (often) internal incentives & resources, and also to orient the organization toward salutogenesis. Examples from research activity within the Center for the Promotion of Health in the New England Workplace illustrate how these criteria have been applied in practice.

"Working on Wellness:" protocol for a worksite health promotion capacity-building program for employers

Background

In the United States, worksite wellness programs are more often offered by larger employers. The Massachusetts Working on Wellness (WoW) program is an innovative, statewide capacity-building model designed to increase the number of smaller employers (200 or fewer workers) adopting health promotion initiatives. This article describes the WoW program design and approaches to recruitment, implementation, and evaluation.

Methods/design

WoW provides employer training, technical assistance and seed funding, utilizing a Wellness Program Development framework based on recognized good practices. For-profit employers with 200 employees or fewer are eligible for and encouraged to apply for a Massachusetts Small Business Wellness Tax Credit. During the phase described in this paper, employer organizations applied to the program and committed to designating a champion responsible for program implementation. Interventions were to include policy and environmental supports, as well as those targeting individual behavior change through raising awareness and education. Supports provided to employers included seed grants for qualifying activities (up to $10,000 with matching required), community linkages, data collection and organization-specific feedback tools, an on-line curriculum supplemented with technical assistance, and an expert webinar series. Data collection at multiple time points, from the initial application through program completion, provides information for evaluation of recruitment, planned and completed activities.

Discussion

This model is grounded in literature on good practices as well as in local knowledge about Massachusetts employers. It does not directly address the influence of working conditions, which can affect both worker participation and health behaviors. Implementation may be less successful with some organizations, such as those with many workers who are part-time or geographically distributed rather than in a centralized physical location. Program evaluation will assess the extent to which WoW achieves its goals. The data are expected to increase understanding of the needs of smaller employers and industries not traditionally implementing employee wellness programs.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6405-1) contains supplementary material, which is available to authorized users.

Field tests of a participatory ergonomics toolkit for Total Worker Health

Growing interest in Total Worker Health® (TWH) programs to advance worker safety, health and well-being motivated development of a toolkit to guide their implementation. Iterative design of a program toolkit occurred in which participatory ergonomics (PE) served as the primary basis to plan integrated TWH interventions in four diverse organizations. The toolkit provided start-up guides for committee formation and training, and a structured PE process for generating integrated TWH interventions. Process data from program facilitators and participants throughout program implementation were used for iterative toolkit design. Program success depended on organizational commitment to regular design team meetings with a trained facilitator, the availability of subject matter experts on ergonomics and health to support the design process, and retraining whenever committee turnover occurred. A two committee structure (employee Design Team, management Steering Committee) provided advantages over a single, multilevel committee structure, and enhanced the planning, communication, and teamwork skills of participants.

Participatory design of integrated safety and health interventions in the workplace: a case study using the Intervention Design and Analysis Scorecard (IDEAS) Tool

Total Worker Health™ (TWH) interventions for improved employee safety, health and wellbeing depend on integrated approaches that involve changes to the workplace or work organisation as well as behavioural or lifestyle changes made by workers. Intervention Design and Analysis Scorecard (IDEAS) Tool to engage front-line employees in planning TWH interventions and obtaining needed management support. The IDEAS Tool consists of seven planning steps in a scorecard approach that helps front-line employees systematically examine root causes of health/safety problems/issues and develop intervention alternatives. A comprehensive business case is then developed for each proposed intervention through analysis of costs/benefits, resources and barriers, and scope of impact. A case study is presented in which maintenance technicians at a property management firm used the IDEAS Tool to plan and successfully implement multiple interventions to reduce work overload. A participatory systems taxonomy is used to help explain why such a structured approach to intervention planning is needed to create a sustainable program for the continuous improvement of employee safety, health and wellbeing for TWH.

Obesity/Overweight and the Role of Working Conditions: A Qualitative, Participatory Investigation

The rising U.S. prevalence of obesity has generated significant concern and demonstrates striking socioeconomic and racial/ethnic disparities. Most interventions target individual behaviors, sometimes in combination with improving the physical environment in the community but rarely involving modifications of the work environment. With 3.6 million workers earning at or below the federal minimum wage, it is imperative to understand the impact of working conditions on health and weight for lower income workers. To investigate this question, a university-community partnership created a participatory research team and conducted eight focus groups, in English and Spanish, with people holding low-wage jobs in various industries. Analysis of transcripts identified four themes: physically demanding work (illnesses, injuries, leisure-time physical activity), psychosocial work stressors (high demands, low control, low social support, poor treatment), food environment at work (available food choices, kitchen equipment), and time pressure (scheduling, having multiple jobs and responsibilities). Physical and psychosocial features of work were identified as important antecedents for overweight. In particular, nontraditional work shifts and inflexible schedules limited participants' ability to adhere to public health recommendations for diet and physical activity. Workplace programs to address obesity in low-wage workers must include the effect of working conditions as a fundamental starting point.

Health Behaviors and Overweight in Nursing Home Employees: Contribution of Workplace Stressors and Implications for Worksite Health Promotion

BACKGROUND

Many worksite health promotion programs ignore the potential influence of working conditions on unhealthy behaviors.

METHODS

A study of nursing home employees (56% nursing aides) utilized a standardized questionnaire. We analyzed the cross-sectional associations between workplace stressors and obesity, cigarette smoking, and physical inactivity.

RESULTS

Of 1506 respondents, 20% reported exposure to three or more workplace stressors (physical or organizational), such as lifting heavy loads, low decision latitude, low coworker support, regular night work, and physical assault. For each outcome, the prevalence ratio was between 1.5 and 2 for respondents with four or five job stressors. Individuals under age 40 had stronger associations between workplace stressors and smoking and obesity.

CONCLUSIONS

Workplace stressors were strongly associated with smoking, obesity, and physical inactivity, even among the lowest-status workers. Current working conditions affected younger workers more than older workers. Although this study is cross-sectional, it has other strengths, including the broad range of work stressors studied. Strenuous physical work and psychosocial strain are common among low-wage workers such as nursing home aides. Workplace health promotion programs may be more effective if they include measures to reduce stressful work environment features, so that working conditions support rather than interfere with employee health.

Healthy workplaces? A survey of Massachusetts employers

PURPOSE

This study examines worksite health promotion (WHP) and occupational health and safety (OHS) activities by Massachusetts employers, and the extent to which workplaces with programming in one domain were more likely to have the other as well.

DESIGN

In 2008, the Massachusetts Department of Public Health surveyed a stratified sample of Massachusetts worksites.

SETTING

A mailed questionnaire to be completed by workplace representatives.

SUBJECTS

Massachusetts worksites returning the questionnaire.

MEASURES

Questionnaire items about worksite characteristics, WHP, and some OHS practices.

ANALYSIS

We scored levels of WHP and OHS activity; examined the relationship between activities in the two domains by employer characteristics; and assessed self-reported coordination between them.

RESULTS

The 890 responding worksites had higher scores for OHS (mean = 48% of practices, SD = 24%) than WHP (mean = 20%, SD = 12%). The difference between these scores varied by a factor of two across industry sectors and was smallest for workforces of 100+ employees (p = .001). Employers with no unionized workers reported fewer activities in both domains (p < .0001). Only 28% of respondents reported always/often coordinating OHS and WHP efforts; these organizations had more activities overall in both domains.

CONCLUSION

Larger and unionized workplaces in Massachusetts were more likely to offer both WHP and OHS programming. Self-reported coordination was somewhat associated with more activity in both domains, although levels of WHP activity varied widely.

Work organization and health issues in long-term care centers

This qualitative study explored common and divergent perceptions of caregivers and managers regarding occupational health and safety, work organization, and psychosocial concerns in long-term care centers. Both common and differing issues were identified. Both groups agreed on the importance of ergonomic concerns, the high prevalence of stress, and receptiveness to participatory health promotion programs. However, numerous work organization issues and physical and psychosocial workplace hazards were identified by certified nursing assistants but were not mentioned by managers. The results suggest that different perceptions naturally arise from people's varying positions in the occupational hierarchy and their consequent exposures to health and safety hazards. Improved systems of communication that allow frontline workers to express their concerns would make it possible to create solutions to these problems.

Getting to Know You: Occupational Health Researchers Investigate Employee Assistance Professionals' Approaches to Workplace Stress

Workplace stress is strongly associated with health problems, including cardiovascular disease. The occupational health field is developing partnerships with a variety of health professions to prevent and address job stress at the organizational level. A review of literature for and about employee assistance professionals was conducted to explore their perspectives on these issues. Results show high awareness regarding the health effects of job stress and a wide range of approaches to address this problem. EAPs appear to be a potential strong partner in efforts to prevent workplace stress, but face obstacles to intervening at the level of the work environment.

Barriers to Workplace Stress Interventions in Employee Assistance Practice: EAP Perspectives

Occupational health literature links stressful working conditions with cardiovascular and other chronic diseases, injuries, and psychological distress. We conducted individual interviews with employee assistance professionals (EAPs) to understand opportunities and barriers for EAPs to address job stress through organization level interventions. EAPs described their primary role as assisting individual employees versus designing company wide interventions. The most salient barriers to organization level interventions cited were lack of access to company management and (for contracted EAPs) perceptions of contract vulnerability. Education about workplace stress interventions may be most effectively directed at EAPs who are already integrated with company level work groups.