3.1. Characteristics of study participants
A total of 78 participants completed a leadership interview (n=59) and/or an organizational readiness survey (n=56) between September 2017 and August 2018. The demographics of participants were observed to be similar across both instruments (Table 3). Study participants mostly were White (89.9%), non-Hispanic/Latino (95.6%), working as supervisors or higher rank (68.5%), providing clinical services (46.6%), and with an average tenure of 9.7 years (SD: 9.3). One quarter of participants held a union leadership role.
3.2. Survey of Organizational Readiness
The ORT survey response rate in four facilities ranged from 63% to 76% of invitees; in Facility 5, the response rate was 26%. As presented in Table 4, participants reported high recognition of OSH activities (except for facility 3) and low recognition of activities to advance worker health and well-being (except for facility 5). Across all facilities there was very low reporting of OSH and workforce health and well-being activities occurring together.
Across all five health care facilities, highest rated domains were Teamwork in Your Work Group (mean: 3.1; SD: 0.5) and Resources Available for Safety, Health and Well-Being (mean: 2.9; SD: 0.6). The lowest rated domain was Management Communication About Safety, Health and Well-Being (mean: 2.2; SD: 0.7). As shown in Table 5, the ANOVA test showed no significant differences in ratings between facilities, except in the domain of management communication in which Facility 1 scored higher than the other sites (mean: 2.7; SD: 0.4).
Looking within each ORT domain, we observed patterns in the participants’ responses to individual items that suggested common areas for improvement or further exploration. These items represented the domains of resources available for safety and health (domain 3), change initiatives (domain 4), and use of teams (domain 5, see Additional File 2). In four of five sites, most survey participants disagreed that management provides sufficient budget for safety and health training (item 4f). Most respondents in two sites reported unfavorable ratings about past history with success introducing new health and safety programs (item 4a). In four sites, the majority of respondents indicated concerns about staff time availability to meet regularly in teams. For instance, most respondents in facilities 1, 2, and 5 disagreed that staff time was available to meet bi-weekly (items 5c and 5d), and in facilities 2 and 3, most respondents disagreed with the statement related to employees having time available to work together on safety and health initiatives (item 3c).
3.3. Leadership interviews
Leaders from all facilities showed openness to addressing concerns beyond the traditional scope of physical occupational safety hazards. For example, respondents consistently reported employees’ workload and its impact on burnout and stress as a priority issue (Table 6). Interviewees from most facilities identified the leadership of the existing safety and health or Environment of Care committee as a strength. Participants reported that leaders were engaged, committed, and knowledgeable about safety and health. A majority of interviewees across facilities perceived alignment between the study goals and their facility’s mission. In addition, respondents from all facilities expressed that the planned health and safety assessment activities would yield valuable information about priority focus areas for safety and health improvement.
Across most facilities, participants reported that the main anticipated challenges to implementing HWPP was the limited resources that the facility could offer, including time available for meetings, having sufficient staff to participate in the study, and funding to implement changes (Table 7). Other reported potential obstacles included concerns about whether workers would participate in study-related activities and whether the large size of the facility and workforce would be a challenge for staff monitoring and communication. In addition, most leaders in three of the facilities reported prior difficulties in reaching agreement on which safety and health priorities should be the primary focus of the safety program. In one facility, researchers learned from the interviewees there was no functional safety committee and this perspective was stated again during in-person meetings with research team members. This was relevant based on the premise that HWPP would be introduced in the context of facilities’ existing safety and health committees.
3.4. Tailoring the implementation based on the baseline data findings
The research team, in partnership with stakeholders, carried out a number of actions where relevant to leverage facilitators and overcome potential barriers to the HWPP. A summary of tailoring actions is provided in Table 8.
3.4.1. Integration approach to OSH and workforce health and well-being
Leaders’ willingness to address an expanded set of concerns in their safety program (Table 6) was interpreted as a program implementation facilitator because it would give the Design Team freedom to select from a broad range of concerns as they designed local TWH interventions. The research team reinforced the leaders’ willingness to adopt TWH concepts in the messaging to the facility stakeholders at key stages in HWPP implementation. For example, during the in-person meetings with facility leaders to report baseline results; in the course of coaching DTs to develop intervention activities; and in the meeting in which the DT presents the intervention proposal to the SC.
3.4.2. Health and safety program resources
The research team used leaders’ appraisals about strengths and gaps in safety leadership when recruiting program participants to serve on their facility’s DT. For instance, in facilities where leaders reported highly favorable commitment and expertise among the safety committee leadership (Table 6), the research team involved safety specialists and managers as partners in recruiting appropriate personnel. In one site that did not discuss health and safety program strengths, the research team learned of historic difficulties in labor management relations which contributed to a lack of a functioning safety program. The research team identified this capacity gap as a serious barrier to the HWPP that needed attention in order to properly recruit employees willing to participate in the DT and the SC. Therefore, researchers met multiple times with representatives from each of the staff unions to discuss with them the relevance of their involvement for creating worker-driven interventions.
Resource limitations of funds, time, and staffing were frequently identified as potential barriers to the implementation of the HWPP (Table 7). These issues were prioritized for immediate discussion with the HWPP champion in order to secure the resources needed to implement the program. Similarly, the research team initiated discussions with the champion and other SC leaders early in the team formation phase to plan feasible strategies to provide staff release time and select DT members and co-facilitators who could fulfill those roles. In some cases, it took a period of time to arrive at a release time strategy that was successful. For example, in one facility, the champion and co-facilitators tested a meeting schedule of 30-minute meetings every 4 weeks, which proved infeasible for making progress, and they then switched to 90-minute meetings every 4 weeks, which the DT perceived as sufficient for advancing in the program.
3.4.3. Readiness and resources for teams and participation
In some facilities, leaders expressed previous difficulties with gaining consensus on priority safety issues and skepticism about whether workers would engage in the participatory program. (Table 7). The tailoring approach to address these concerns included providing detailed training to the Champion, SC members, and DT members about their roles and clarifying the procedures for issue identification and selection. For example, in the HWPP, DT members generate ideas for prioritizing issues then discuss them with SC and key leaders for approval. The training provided opportunities for participants to discuss how decisions would be taken, and to acknowledge uncertainty regarding worker participation. In those training discussions, SC members expressed support of the participatory program goals and committed to facilitating the team formation process.
Concerns about a lack of participatory culture were expressed by leaders in some facilities during the interviews (Table 7) and through the ORT (items 7a, 7d, and 7e in Additional File 2). The research team interpreted low participatory culture at baseline as a potential barrier to successful HWPP implementation because it indicated front line and managerial personnel were not used to interacting and communicating together about safety and health topics. The research team worked with all program participants to help them understand their roles in the HWPP, positive communication methods, and trust-building in the participatory process. The research team and co-facilitators demonstrated reliability and commitment to the process over time consistently following through on tasks, adhering to strict privacy protocols, and promoting decision making within team meetings. Senior managers on the SC allowed the team to select issues to target for interventions. The leadership in this facility showed intention to improve their participatory culture by starting weekly rounds in the facility to receive feedback and opportunities for improvement from employees.
3.4.4. Readiness for change
The ORT measures for participants’ “felt need for change” was consistently high across all facilities (item 4g in Additional File 2), as was leaders’ hope that the HWPP would identify areas in need of improvement (Table 6). These results suggested the need for training in the areas of planning for change management. The research team explained to leaders what kinds of deliverables could be expected and how the program components would accomplish some of their desired outcomes. This messaging was incorporated in program start-up meetings and in meetings with leaders and DT members during the implementation phase. We undertook this strategy to promote enthusiasm, motivation, and assurance of the commitment of staff time and other resources needed by the DT to develop and implement integrated interventions.
3.4.5. Communication
ORT score in management communication about safety, health, and well-being was revealed to be the lowest scoring domain across most facilities (Table 5). Leader interviews from most facilities also reported a desire for the study to improve organizational communication (Table 6). When low communication scores were discussed in the feedback reporting meetings, leaders acknowledged the need for improved communication and, in some cases, they expressed a desire to take action to strengthen capacity in this area. The research team prioritized communication as an important potential barrier to address with sites during the HWPP implementation.
To support the facilities’ communication efforts during the HWPP implementation, the research team developed and distributed sample program communication tools to help DT and SC members communicate with the workforce about the program. The intent was to raise employee awareness about the HWPP so that a broad range of workers would engage with and respond to the DT throughout the intervention design process. Examples of communications tools were sample HWPP program announcements and updates, and a template for constructing a poster board display to capture feedback from employees who were not part of the DT. The research team also initiated a monthly project newsletter for facility team members, including co-facilitators, SC, and DT members. The newsletter provided resource material on topics related to their intervention foci and personal stories from research team members to build relationships. The research team also added process evaluation instruments to the data collection protocol to monitor the quality, frequency, and the dynamics of organizational communication throughout the different phases of HWPP implementation.