Individual and organisational factors in the psychosocial work environment are associated with home care staffs' job strain: a Swedish cross-sectional study

BACKGROUND

Home care staff (HCS) provide essential service to enable older adults to age in place. However, unreasonable demands in the work environment to deliver a safe, effective service with high quality has a negative impact on the individual employee's well-being and the care provided to the older adults. The psychosocial work environment is associated with employees´ well-being, although, knowledge regarding which individual and organisational factors that contribute to job strain for HCS is limited. These factors need to be identified to develop targeted interventions and create sustainable work situations for HCS. This study aimed to explore how HCS´s perceived job strain is associated with, and to what extent can be explained by, individual and organisational factors of the psychosocial work environment and psychosomatic health.

METHOD

An explorative cross-sectional questionnaire survey design was used in a large Swedish county. Five home care agencies with a total of 481 HCS were asked to respond to a questionnaire regarding their perceived level of job strain (Strain in Dementia Care Scale), psychosocial work environment (QPS_Nordic³⁴⁺), and psychosomatic health (Satisfaction with Work Questionnaire). Multiple linear regression (MLR) analyses were conducted to explore the association between job strain and individual and organisational factors.

RESULTS

In total, 226 (46%) HCS responded to the questionnaire. Both individual and organisational factors were significant predictors of job strain and explained a variance ranging between 39 to 51% (p = 0.001). The organisational factor job demand and the individual factor feeling worried and restless was most frequently represented in these MRL models. A higher job strain was also associated with adverse outcomes regarding leadership, organisational culture and climate, and control at work.

CONCLUSION

This study indicates that there is an intertwined complexity of individual and organisational factors that are associated with the HCS´s perception of job strain. Implementation of new multidimensional work strategies, such as a reablement approach, could support the development of efficient strategies for HCS and reduce the level of job strain. Policy changes for the provision of home care are also needed to support the development of a sustainable and healthy psychosocial work environment.

The Coding Conundrum: A Workplace Perspective

Over the last few decades clinical coding has grown in complexity and importance in the eyes of bureaucrats, administrators and clinicians, as new uses for this valuable resource are constantly being identified. Anecdotal evidence suggests that many Australian hospitals are currently experiencing difficulty in both recruiting and retaining clinical coders. The current shortage of clinical coders is a national problem, rather than being peculiar to any one state, and has a multitude of causes. This paper discusses a wide range of issues that have been identified as being relevant to this situation, and they are elaborated from a number of viewpoints, including that of health information management. In this article suggestions for changes that could help rectify this situation are made.

Ways to evaluate staff

Evaluating how staff use their time can be done in different ways. One approach is to ask staff members to record how they spend their time. Another way, called "patient flow analysis," collects time data from clients, by having each staff member enter time of arrival and departure on a form carried by the client as the client moves through the clinic. Yet another approach, more expensive and time-consuming, is known as a "time-motion" study, based on actually observing how personnel spend their time. In general, the time-motion approach to cost analysis, in which staff are observed, tends to be more accurate, says John Bratt of FHI, who has coordinated several large cost studies. Unproductive staff time tends to be recorded more accurately using this approach. A recent study compared the provider interview and patient flow analysis approaches to actual time observed in clinics, a time-motion model. "The provider interview approach was particularly weak, substantially overestimating contact time with clients and underestimating nonproductive time," says Bratt, who coordinated the study with the Population Council. "The magnitude of error in these estimates calls into question the validity of studies that use provider interviews for measuring staff time." The researchers were hoping the study would provide a way to substitute less costly methods of time measurements for time-motion studies. "But the outcome indicates that these other methods perform far less well than does the time-motion method," Bratt says. "We are now looking at ways to use time-motion in a small number of sites and extrapolate from that to the full system. But we need to do more research to see if that is as reliable."

The clinical competency of community health workers in the eastern highlands province of Papua New Guinea

A case study of the clinical competency of community health workers employed in the Eastern Highlands Province of Papua New Guinea was conducted in March 1993. Of the 79 who graduated from the Onamuga Community Health Worker Training School between 1989 and 1992, only 24 were currently employed in the province. Current knowledge and clinical competency were compared with results on completion of basic community health worker training. Results showed that 22 of the 24 maintained their knowledge competency, and 15 maintained clinical competency. It was found that those community health workers (CHWs) employed at a health subcentre use 40% to 50% of their skills, whilst those at a district health centre or provincial hospital use only 20% to 30% of their skills. Only 8% of the CHWs studied used all the skills obtained in their basic training. This study indicates that the CHW is being viewed by some health managers as a replacement for the nurse aide. If CHWs' skills are to be maintained, certainly good supervision, inservice training and adequate logistic support are needed, but so also is a change in management thinking. The CHW has been trained specifically to improve the access to essential primary health care services of people living in rural areas, especially in preventive and maternal and child health care. If in practice the CHW is not given the opportunity to practise and hence maintain these skills, the whole logic of the CHW training scheme will need to be reexamined.

Improving primary health care through systematic supervision: a controlled field trial

Most primary health care services in developing countries are delivered by staff working in peripheral facilities where supervision is problematic. This study examined whether systematic supervision using an objective set of indicators could improve health worker performance. A checklist was developed by the Philippine Department of Health which assigned a score from 0 to 3 on each of 20 indicators which were clearly defined. The checklist was implemented in 4 remote provinces with 6 provinces from the same regions serving as a control area. In all 10 provinces, health facilities were randomly selected and surveyed before implementation of the checklist and again 6 months later. Performance, as measured by the combined scores on the 20 indicators, improved 42% (95% Cl = 29% to 55%) in the experimental group compared to 18% (95% Cl = 9% to 27%) in the control group. In the experimental, but not in the control facilities, there was a correlation between frequency of supervision and improvements in scores. The initial cost of implementing the checklist was US $ 19.92 per health facility and the annual recurrent costs were estimated at $ 1.85. Systematic supervision using clearly defined and quantifiable indicators can improve service delivery considerably, at modest cost.

Integration of mother and child health services in Ethiopia

In Wollo region of Ethiopia, various non-governmental officers have been working closely with each other and with the Regional Health Department to implement the policy of daily integrated mother and child health services. The record cards, registers, procedures and training courses of the separate 'vertically' organized services were brought together to enable the development of a model integrated service. There were improvements in accessibility, acceptability and output of the services. The system was evaluated by a joint Ministry of Health and UNICEF team, and was adopted for use in the rest of Ethiopia.

Survey of community health aides in Jamaica (1987-1988)

The Community Health Aide (CHA) programme was initiated in 1967, and, by the early 1980s, 1,328 CHAs had been trained and over 1,100 remained in the service. The aim of the programme was to train CHAs to assist in the delivery of basic health care. During the restructuring of the health services in 1985-1986, many CHAs were made redundant. As part of a large study aimed at assessing the current status of the CHA programme, this paper reports results of interviews with 415 CHAs still in service in 1987-1988 and 134 CHAs no longer employed in the programme at that time. The survey of CHAs still employed as such showed that they continued to perform duties in the community and in health centres with emphasis on the maternal and child health services and the management of diabetics and hypertensives. The survey of CHAs no longer employed as such showed that the majority remained unemployed through many continued to use their skills on a voluntary basis. These CHAs felt that home visiting had been reduced and environmental health was being neglected since they left, and that problems were not being regularly reported to the professionals at the health centres. It was recommended that all CHAs be offered training in the taking of blood pressure levels and in the giving of insulin injections to diabetics. Recommendations included improved methods of selection, longer training, greater community outreach, especially to the elderly, post-training evaluation, regular assessment of the CHAs' performance, and improved upward mobility opportunities and job security.

Development management for nursing administration

What are the needs of a nurse administrator in a developing country? For that matter, what are the requirements for a nurse administrator in areas of lesser developed delivery in this country (e.g., care of the homeless, care of indigent populations)? Heyden, Luyas, and Henry look at the educational needs of these nurse managers and compare the needs to the typical education received in nursing administration programs.

Priority for primary health care: its development and problems

National health policies of many countries stress priority for primary health care (PHC). This emphasis has arisen as a reaction to large expenditures on hospitals and sophisticated technology in major cities of developing countries, while vast rural populations have been virtually ignored. The paradox developed from colonial and neo-colonial emulation of European and North American medical models. In 1978, an international conference of WHO/UNICEF at Alma-Ata, USSR defined the meaning of PHC, along with several principles of organization and equity under which it should be provided. To reach rural people with PHC, thousands of community health workers have been prepared and stationed in villages. Their training, however, is very brief and, with weak supervision, their performance has been disappointing. To achieve the WHO goal of "Health for All" through PHC requires greatly expanded education of public health leaders, who can supervise and inspire community personnel.

Paramedicals' clinical accuracy in 102 cases referred to a provincial hospital

A random sample of 102 cases referred in 1983 by paramedicals to the Southern Highlands Provincial Hospital, Papua New Guinea, was analysed for agreement with the final hospital diagnosis and with standardized primary care therapies. Health centre diagnosis was judged accurate in 45% of cases; inaccuracies in a further 17% had no projected health consequences. However, resulting serious sequelae could be projected in half of the incorrect diagnoses. Diagnosis of surgical cases was more often accurate (P<0.05) than in medical cases.

Treatment which was adequate or standard for the diagnosis made at the health centre had been given there in 80% of cases. However, there were serious diagnostic inaccuracies in 38% of all referral cases; this study suggests a need for problem-based paramedical education in diagnosis, especially in non-surgical problems. Visits by doctors to health centres could reinforce this diagnostic teaching and better evaluate paramedicals' clinical accuracy in the health centre.

Methodological issues in collecting data from traditional birth attendants

Information on the activities, practices and social context of pregnancy and delivery care provided by traditional birth attendants (TBA) is a critical requirement in planning, monitoring and evaluating maternal health programs in many countries. As a result of experimental studies in which such information was obtained by a variety of methods, and a review of alternative methodologies, a set of guidelines has been developed for the collection of such information. High-lighted are the need for good background knowledge on the local situation, involving TBAs themselves in design and collecting methods, a system of supervision to ensure adequate training and careful monitoring, and finally sharing the findings with the TBAs as well as with health officials.

Smallpox eradication: selected management issues

The eradication of smallpox was dependent on the attainment of a high level of herd immunity during the consolidation and maintenance phases of the eradication program, after mass vaccination effort had reduced the incidence of the disease to a few endemic areas in the world. Immunity was possible through the immunization of susceptible population. Attainment of effective immunization in both large and small countries, with both concentrated and dispersed population settlement patterns, was dependent not only on improved vaccination technology, notably the widespread availability of heat-stable freeze-dried vaccine and the use of the bifurcated needle, but also on the way eradication programs were designed and implemented. This paper will outline important components of the smallpox eradication program, particularly, information management, personnel management, and material resources management. Although they were critical to the eventual success of the program, there has been little consolidated effort to review these management strategies. The paper, to a large extent, concentrates on the eradication programs of Bangladesh, India, and West Africa, given that these come to the forefront in terms of reviewing management strategies in the internationally available literature.

Ecological factors predicting adolescent contraceptive use: implications for intervention

Questionnaires addressing areas expected to relate to contraceptive use were completed by 230 female adolescents. Contraceptive use among the 130 sexually active subjects were predicted by a model composed of 12 scales assessing social permissiveness, costs and benefits of contraception, parent communication, boyfriend support, sex education and knowledge, attitudes about pregnancy and contraception, and access to contraception services. Scales from the predictive model which raise ideas for potential intervention strategies assessed parent communication, boyfriend support, and perceived costs and benefits related to contraception. Since there has been public concern that intervention programs for enhancing adolescent contraceptive use might also stimulate sexual activity, correlations were computed between the predictive scales and the measure of sexual experience among all 230 subjects. These data indicated that positive parent communication about sexuality and a perception of high benefits and low costs associated with contraceptive use were not positively correlated with sexual experience. Implications for the prevention of adolescent pregnancy are discussed with an emphasis on designing innovative sex education, improving parent-child communication, resolving conflicts in contraceptive decisionmaking, and supporting the role of boyfriends in contraceptive use.

Providing primary health care with non-physicians

The definition of primary health care is basically the same, but the wide variety of concepts as to the form and type of worker required is largely due to variations in economic, demographic, socio-cultural and political factors. Whatever form it takes, in many parts of the developing world, it is increasingly clear that primary health care must be provided by non-physicians. The reasons for this trend are compelling, yet it is surprisingly opposed by the medical profession in many a developing country. Nonetheless, numerous field trials are being conducted in a variety of situations in several countries around the world. Non-physician primary health care workers vary from medical assistants and nurse practitioners to aide-level workers called village mobilizers, village volunteers, village aides and a variety of other names. The functions, limitations and training of such workers will need to be defined, so that an optimal combination of skills, knowledge and attitudes best suited to produce the desired effect on local health problems may be attained. The supervision of such workers by the physician and other health professionals will need to be developed in the spirit of the health team. An example of the use of non-physicians in providing primary health care in Sarawak is outlined.