Beskæftigelsesudvalget 2020-21
BEU Alm.del Bilag 151
Offentligt
2325999_0001.png
Applied Ergonomics 90 (2021) 103265
Contents lists available at
ScienceDirect
Applied Ergonomics
journal homepage:
http://www.elsevier.com/locate/apergo
Which work environment challenges are top of mind among eldercare
workers and how would they suggest to act upon them in everyday
practice? Process evaluation of a workplace health literacy intervention
Pernille Kold Munch
a, *
, Charlotte Diana Nørregaard Rasmussen
a
, Marie Birk Jørgensen
b
,
Anne Konring Larsen
a
a
b
National Research Centre for the Working Environment, Lersø Parkall
´
105, 2100, Copenhagen
Ø,
Denmark
e
Health and Safety, Municipality of Copenhagen, Enghavevej 82, 2450, Copenhagen SV, Denmark
A R T I C L E I N F O
Keywords:
Communication
Musculoskeletal pain
Workers
Nursing homes
A B S T R A C T
The purpose of this study was to identify challenges and action plans from 2.497 structured communication
sessions between employee and supervisor and to gain insight into the processes of a quasi-experimental stepped
wedge clustered intervention, which implemented workplace health literacy for reducing musculoskeletal pain
among eldercare workers.
Most challenges concerned staffing (17%), organisation of tasks (15%) and team work (14%). Most action
plans concerned communication (18%), team-work (16%) and handling residents (14%). Half of the plans were
solved at another level in the organisation than the challenge appeared. Actions planned on the individual level
had the highest implementation rate (52%).
The results underline the advantages in considering solutions to work environment and health challenges
broadly at all levels in the organisation and the relevance of involving both the employee and the organisation/
management in identifying and implementing solutions.
1. Introduction
Currently many high-income countries face a shortage of healthcare
workers jeopardizing the capacity to deliver the eldercare needed
(Campbell
et al., 2013).
The demographic shift with increasingly more
elderly people, will lead to increased demands on the health care sector,
for example with a need of more eldercare workers (Hussain
et al.,
2012).
To uphold the same quality and standard in the healthcare sys-
tem, it is essential to maintain health professionals in the sector. One
way to do that is to prioritize initiatives to improve and adjust the work
environment, so it fits the health level of the eligible workforce. Several
initiatives have therefore been introduced to try to improve the work
environment for the eldercare workers during the past decades in
Denmark and other countries (Miranda
et al., 2015; Clausen et al., 2012;
Aust et al., 2010; Kongstad et al., 2015).
However, despite these efforts, implementation and improvement in
work environment and health remains a challenge. While improving
individual employee health and resources have proved doable,
employee-targeted interventions do not build a work environment that
* Corresponding author.
E-mail address:
[email protected]
(P.K. Munch).
can include less resourced workers such as aging workers or workers
with functional limitations (i.e. back pain). Meanwhile organisational
level interventions addressing the work environment more systemati-
cally have proved hard to implement (Aust
et al., 2010; Montano et al.,
2014).
Also, systemic interventions may address important overall fac-
tors, however, everyday challenges with work environment and health
for the individual employee may be so diverse, that they cannot be
handled from the top down.
Therefore, we developed an intervention that targeted both the in-
dividual employees’ health situation and their abilities to navigate work
environment improvements and the organisational level (targeting
management and implementing structured communication between
employees and supervisors), that we called a workplace health literacy
intervention (Larsen
et al., 2015).
An effect evaluation showed that the
intervention was feasible and that it decreased the overall employees’
musculoskeletal pain by 7%, with an accentuated effect among em-
ployees with pain levels
>3
(on a numeric rating scale from 0 to 10)
(Larsen
et al., 2019).
However, knowledge of what happens during the
intervention is crucial to determine why the intervention worked or did
https://doi.org/10.1016/j.apergo.2020.103265
Received 4 November 2019; Received in revised form 19 August 2020; Accepted 29 August 2020
Available online 7 September 2020
0003-6870/© 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
 BEU, Alm.del - 2020-21 - Bilag 151: Orientering om NFA-artikel om hvilke udfordringer SOSU’er oplever i deres arbejde, fra beskæftigelsesministeren
2325999_0002.png
P.K. Munch et al.
Applied Ergonomics 90 (2021) 103265
not work (Linnan,
2002; Kristensen, 2005; Oakley et al., 2006).
There-
fore, what exactly happened from the meetings between employees and
supervisors to an improvement in musculoskeletal pain remains to be
investigated. The structured communication between employee and
supervisor was supposed to address the employee’s most current chal-
lenge, and therefore, investigating the topics of the communication may
give new insights into what types of challenges that are top of mind
among eldercare workers.,.
We conducted a quasi-experimental stepped wedge clustered work-
place health literacy intervention trial consisting of four elements; 1) a
preparation phase, 2) courses, 3) structured communication and 4)
maintenance. The aim of the intervention was to increase individual,
interpersonal and organisational health literacy and reduce pain and
consequences of pain among eldercare workers (see
Fig. 1).
The aim of this study is to identify challenges and action plans from
the structured communication sessions between employee and super-
visor and to gain insight into the processes of the intervention. To illu-
minate the overall aim of the study we investigated the following
research questions:
1) Which work environment challenges do the eldercare workers
experience?
2) What solutions (action plans) do employees and their supervisors
decide upon to overcome the challenges?
3) Are the action plans founded at the same organisational level as the
challenge?
4) What characterize action plans with a high implementation success?
2. Material and methods
This study is based on data from a workplace intervention in nursing
homes (Larsen
et al., 2015).
In short, the intervention aimed to
strengthen workplace health literacy (building knowledge, competences
and structures for communication and action) to prevent and reduce
pain.
The initial part of the intervention was a thorough formative eval-
uation of each workplace. Based on this, we developed courses tailored
to employees and supervisors at each workplace. The courses were based
on cognitive behavioural training, and the aim was to build common
knowledge about pain management and communication. Furthermore
the courses emphasized the participatory approach and allowing the
needs and perceptions of each employee to steer the communication
sessions. Next step was introducing structured communication
regarding work environment and health. Every third week each
employee and his/her supervisor met and briefly discussed the work
environment and current challenges for the employee and together they
identified a plan for action. Information regarding challenges and plans
for action were registered on a tablet and uploaded making it possible
for the researchers to track challenges and plans for action and thereby
gain knowledge about why and how the intervention worked.
This study focuses on the structured communication between em-
ployees and supervisors. This is described further in the section
regarding the intervention. The Danish Data Protection Agency (Journal
number 2014-38/28350-3) approved the trial. The trial was reported to
the local ethical committee (Protocol H-1-2013 FSP) and was conducted
in accordance with the Helsinki declaration.
2.1. Study population
Six nursing homes participated in the study and all permanent staff at
the nursing homes were part of the intervention and invited to be a part
of the evaluation. A total of 509 employees (primarily nurses’ aides)
participated in the intervention. The six nursing homes were located in
the Eastern region of Denmark, in two different municipalities. See
Larsen et al., 2019
for further characteristics of the employees enrolled
at baseline.
2.2. The intervention
The intervention was conducted as a quasi-experimental stepped
wedge cluster trial with six clusters (Larsen
et al., 2015). Fig. 1
illus-
trates the intervention elements (preparation phase, courses and struc-
tured communication) and the outcome objectives (short, intermediate
and long term).
The first nursing home stepped into the intervention in October 2013
and the last nursing home initiated the intervention in January 2015.
Courses were held within the first months and then the structured
communication was initiated.
2.3. Structured communication
The purpose of the structured communication was to facilitate flow
of information about work environment and health challenges from
employees to supervisor and making it possible for supervisors to sup-
port employees in handling the challenges. For example by supplying
information about opportunities for actions at the workplace. The
structured communication had three primary aims: 1) To generate a
space where the employee felt comfortable to discuss work and health
related challenges, 2) To provide the supervisor with tools for facili-
tating a constructive communication focused on identifying possible
solutions and 3) To identify current work or health challenges for each
employee and use knowledge from the courses (step one) to generate a
plan for specific, realistic and effective actions. A tablet-based guide was
developed and used to facilitate and focus the communication on work
environment and health challenges and on identifying solutions. In the
structured communication sessions employees were asked to identify
their current biggest challenge at work, i.e. a situation or factor during
work, that impacted negatively on their health (i.e. for a worker with
Fig. 1.
The program logic of the intervention aiming to reduce pain and pain-related sickness absence. The intervention elements (preparation phase, courses,
structured communication (the black box) and the maintenance effect on the short, intermediate and long term outcomes. Since this study focuses on the structured
communication this element is highlighted.
2
 BEU, Alm.del - 2020-21 - Bilag 151: Orientering om NFA-artikel om hvilke udfordringer SOSU’er oplever i deres arbejde, fra beskæftigelsesministeren
2325999_0003.png
P.K. Munch et al.
Applied Ergonomics 90 (2021) 103265
back pain a specific situation at work may be perceived a challenge,
whereas for a worker without pain the same work situation may not be
considered a challenge). To overcome the specific challenge the
employee in collaboration with the supervisor developed a plan for ac-
tion (defined solution). The plan could involve everything from ergo-
nomics (e.g. lifting equipment or changes in the organisation of the
work) to health-promoting initiatives such as physical or cognitive
training or a combination of these. A log-on system ensured that only
information about one specific employee was available on the tablet at a
time. Finally, an email to remind employees and supervisors about the
plan and that they had to fulfil it before the next session was sent.
2.4. Data collection
In the communication sessions, the supervisor and the employee
logged into the tablet-based guide and were asked:
“Think
about you
workday and a situation that is challenging. Please write the challenge”
(open-ended). The next question was:
“Write
a plan (keywords are ok)”
(open-ended). The plan was registered in the guide. At each of the
following communication sessions the first question was:
“On
a scale
from 0 to 10, to what degree, have you fulfilled the action plan from the
last session? (0 being not implemented and 10 being fully implemented).
The registration was uploaded to a web-interface, available to the re-
searchers. If the structured communication was not held as planned, an
omission was registered. Workplace supervisors then received a monthly
report with their implementation rate for each supervisor (number of
structured communication sessions held compared to the expected). The
first structured communication session was held the December 16, 2013
and the last session was held the April 21, 2016.
Based on the data from the communication sessions we developed a
dataset consisting of a row for each communication session with a
unique number per session, a unique number for the employee, infor-
mation about the date of the communication session, workplace, the
work environment or health challenges and the action plan to overcome
the challenge.
2.5. Categorization of challenges and action plans
The categorization of challenges and action plans was inspired by the
grounded theory and an open coding (Foley
and Timonen, 2015).
Two
researchers coded the challenges and action plans following six steps.
First step - overview; two researchers independently read through
the data regarding challenges and plans for action with special attention
to similarities, differences and trends in the challenges and plans to get
an overview of the data and identify different overarching themes for the
challenges and action plans respectively. The overarching themes were
discussed between the researchers.
Second step
–
categories; the aim of this step was to turn the themes
into categories. Based on the identified themes in step one, a first draft of
the categorization was developed in collaboration between the re-
searchers. Then overall categories were defined along with sub-
categories. We made short explanations of the different sub-categories.
Third step
–
test and category adjustment; 50 randomly selected
structured communication sessions were coded according to the first
draft of the categorization by the two researchers. We performed a
statistical analysis (Cohen’s Kappa) to test for agreement between the
two researchers. The agreement ranged from 0,09 to 1,00 (see
Table 1
for a detailed evaluation). Based on the experience from the first coding
and the results from the Cohen’s kappa analysis, the sub-categories were
discussed. During the discussion new sub-categories were allowed to
arise. Based on the discussion, an extended and adjusted description of
the sub-categories was developed.
Fourth step
–
test and finally category adjustment; 50 new randomly
selected structured communication sessions were coded according to the
adjusted sub-categories by the same two researchers. We performed a
statistical analysis (Cohen’s Kappa) to test for agreement between the
3
Table 1
Statistical analysis (Cohen’s Kappa) to test for agreement between the two re-
searchers in step three and four. For each sub-category the agreement is pre-
sented for both the first and the second test, and for the final agreement between
the two researchers for all 2.497 communication sessions.
Challenges
First
test
(n
=
50)
No challenges
Without
explanation
Individual
Work task
Handling
residents
Physical
challenges
Private
circumstances/
challenges
Team work
Staff
Physical work
environment
Communication
Organisation of
tasks
No action plan
Individual
Self-
management of
physical
challenges
Self-
management of
psychosocial
challenges
Handling
residents
Work task
Team work
Staff
Upgrading of
qualifications
Organizing
workplace
Communication
–
0,37
0,38
1,00
0,34
1,00
0,65
0,81
0,66
–
0,78
0,41
0,09
Second
test (n
=
50)
1,00
1,00
0,48
0,70
0,91
1,00
0,85
1,00
0,79
1,00
0,76
0,88
0,59
Final
test (n
=
2.497)
0,92
0,54
0,43
0,81
0,87
0,78
0,76
0,89
0,58
0,43
0,67
0,82
0,74
Team
Management/
organisational
Action plans
0,37
0,50
0,57
0,88
a
0,73
0,23
0,60
1,00
0,66
0,59
0,64
0,60
0,36
0,62
0,85
0,71
0,41
0,65
Team
Management/
organisational
0,58
–
0,88
0,25
0,73
a
The category did not exist in the first test.
two researchers. The agreement ranged from 0,23 to 1,00 (see
Table 1
for a detailed evaluation). Based on the results from the second statis-
tical test, a discussion and a final adjustment of the sub-categories were
carried out. One column for each of the final subcategories within both
the challenges and action plans, were then added to the dataset.
The overall categories for the challenges and action plans were
divided into three overall levels in the organisation (individual, team
and management/organisational), or no challenge, challenge without
explanation or no action plan. Each of the overall levels consisted of a
number of sub-categories (challenges: nine different sub-categories
within the three overall categories. Plans: eight different sub-
categories within the three overall categories).
In
Table 2,
the final type of challenges and actions is presented with a
description of the category and the level in the organisation.
Fifth step
–
coding; two researchers coded the structured communi-
cation sessions independently, according to the sub-categories. For each
structured communication session, it was possible to code more than one
challenge and action plan if more than one challenge and/or action plan
were identified in the structured communication session. The agreement
on the 2.497 communication sessions ranged from 0,36 to 0,92 (see
Table 1
for a detailed evaluation).
 BEU, Alm.del - 2020-21 - Bilag 151: Orientering om NFA-artikel om hvilke udfordringer SOSU’er oplever i deres arbejde, fra beskæftigelsesministeren
2325999_0004.png
P.K. Munch et al.
Applied Ergonomics 90 (2021) 103265
Table 2
Type of challenge and action, description and level in the organisation.
Type of challenge
No challenge
Staffing
Description
Blank dialog box or a positive
challenge including words as: happy,
satisfied or no challenges.
Temporary workers, the quality of the
temporary worker, sickness absence
among colleagues, understaffing or
duty roster (general or according to
holidays).
Organizing and planning of work
tasks, challenges which covers the
employees’ lack of influence at own
work, the experience of feeling busy,
time pressure and disruption.
Lack of or bad communication or
misunderstanding between
colleagues, challenging work
relationship or partnership. It also
includes colleagues’ lack of work, the
quality of the performed work or the
performance.
Relates to the resident, new-, heavy or
a demanding resident. It could be a
specific work task, but it also cover
communication, miscommunication
or disagreement between the
employee and the resident or
relatives.
Physical demands, reduced
movement, pain and/or work posture.
Physical work environment, physical
distance, lack of equipment (for
person lifting and moving or IT-
systems) or inappropriate workspace.
Challenges on the individual level. It
could be daily work tasks as
documenting, administrative, laundry
or computer tasks.
Lack of communication or bad
communication between employee
and management or between
departments.
Challenges not related to any work
challenges. Examples could be
“then
I
bring my private life to work”.
Challenges without explanation, no
causes, unspecified or unclear.
Examples could be:
“every
day is a
challenge” or
“it
is a challenge to meet
at work”.
Better or improved communication/
relations between employees and the
management or between teams.
Further it also covers the quality of
the management and a supportive
management.
Better or improved communication
within the team. Furthermore it also
includes social events and networking
among team-colleagues.
Plans for work tasks related to the
resident or communication between
the employee and the resident or
relatives.
Structure or organisational changes.
It includes reorganisation of work
tasks, new procedure, and
responsibility. Change of physical
work environment, changing the
workplace of the surroundings and
new equipment.
Level in the
organisation
N/A
Management/
organisational
a
Table 2
(continued )
Type of challenge
Description
Blank dialog box, or words/sentences
as:
“no
plan”,
“think
about it” or
“continue".
Self-management of the individuals’
action plan to handle pain or other
physical challenges. Examples could
be: contact the physiotherapist, use
existent assistive devices or ask for
help.
Self-management of the individuals’
action plan to psychosocial
challenges. Examples could be: Enjoy
the holiday, work independent or ask
for help.
Management tasks covering staffing.
All plans including temporary
workers, new employees, duty roster
during holidays or sickness absences
and management/employee ratio.
Covers a plan which upgrades
permanent and temporary workers.
The plan covers introduction, further
training, training in correct use of
assistive devices e.g.
Daily or specific work tasks. It could
be action plans as: Close the door,
continue working with or
documenting.
Level in the
organisation
Self-man. of physical
challenges
Individual
c
Organisation of
tasks
Management/
organisational
a
Self-man.
psychosocial
challenges
Staffing
Individual
c
Team work
Team
b
Management/
organisational
a
Handling residents
Individual
c
Upgrading of
qualifications
Management/
organisational
a
Work task
Individual
c
Physical challenges
Physical work
environment
Work task
Individual
c
Management/
organisational
a
Individual
c
Communication
Management/
organisational
a
Individual
c
N/A
N/A
=
not applicable.
a
The challenge/action plan was related to the management level or con-
cerned the organisational structure at the workplace i.e. the coordination or
communication with the management and or other teams or departments.
b
The challenge/action plan concerned something that would impact on both
the individual worker but also the colleagues (i.e. related to the procedure of a
task performed by several colleagues in a team or an issue related to coordina-
tion between colleagues).
c
The challenge/action plan concerned only the individual worker.
Private
circumstances
Without explanation
Sixth step
–
agreement; all categorized challenges and action plans
were compared to assess whether there were agreement or disagree-
ments between the two researchers‘ categorizations. If there were any
disagreement, the challenge and/or plan was discussed between the
researchers, until agreement was reached.
2.6. Rating of implementation success
Type of action
Communication
Management/
organisational
a
Team work
Team
b
To investigate the implementation success the following classifica-
tion was used, based on the question about to what degree the action
plan had been fulfilled (scale from 0 to 10): the values 0-2 were defined
as
“no
or low implementation success”, the values 3-7 were defined as
“partly implementation success” and the values 8-10 were defined as
“high implementation success”.
2.7. Statistical analysis
Handling residents
Individual
c
Organizing
workplace
Management/
organisational
a
No plan
N/A
To test the agreement between the two researchers a simple Cohen’s
Kappa was performed. Cohen’s Kappa measures the percentages of data
values within each of the sub-categories and adjusts for the amount of
agreement that could be expected by chance alone (Cohen,
1960).
The
purpose of the Cohen’s Kappa in our study was to gain insight into the
agreement/disagreement between the researchers in the classification of
the challenges and action plans within each of the sub-categories. We
were guided by the Fleiss’ Kappa Benchmark Scale (<0.40 were defined
as poor agreement, 0.40 to 0.75 as intermediate to good agreement and
>0.75
as excellent agreement (Gwet
and Advanced Analytics, 2014))
in
the development of the sub-categories to evaluate whether the category
needed further adjustment to aim for a high agreement between the two
4
 BEU, Alm.del - 2020-21 - Bilag 151: Orientering om NFA-artikel om hvilke udfordringer SOSU’er oplever i deres arbejde, fra beskæftigelsesministeren
2325999_0005.png
P.K. Munch et al.
Applied Ergonomics 90 (2021) 103265
researchers. In sub-categories with poor or intermediate to good
agreement we made further adjustment of the sub-categories.
Descriptive statistics was used to illustrate the distribution of the
challenges and plans across the overall categories. Analyses of the plans
to overcome the challenge were based on the overall categories (indi-
vidual, team and management/organisational) and therefore performed
without the sub-categories: no challenges, challenges without explana-
tion and no action plans. Analyses were performed using IBM SPSS
Statistics version 24.
3. Results
3.1. Structured communication
During the period from December 16, 2013 to April 21, 2016, a total
of 2.497 structured communication sessions were held between em-
ployees and supervisors. A total of 412 employees participated in the
structured communication. For each employee between 1 and 19
structured communication sessions were held, with a mean of 5,24
(standard deviation: 4744) sessions per employee. For further details
about the organisational and employee characteristics and intervention
activities see
Larsen et al., 2019.
3.2. Work environment challenges and suggested solutions to overcome
the challenges
85% of the 2.497 challenges from the structured communication
sessions was coded into one of the sub-categories, no challenge or
without challenge category. In the remaining 15% of the sessions more
than one challenge was identified and the challenges were therefore
coded into more than one of the sub-categories, which resulted in 2.919
identified work environmental or health challenges.
In 24% of the 2.919 work environmental or health challenges, no
challenge was identified (either uncompleted challenge or a positive
statement). Among the most frequent challenges, 17% were related to
staffing, 15% to organisation of tasks and 14% related to teamwork.
In 58% of the structured communication sessions action plan was
coded into one of the sub-categories or no plan category. In the
remaining 42% of the structured communication sessions, more than
one action plan was identified, and the action plans were therefore
coded into more than one of the sub-categories, which resulted in 3.848
identified action plans (data not shown). Among the most frequent ac-
tion plans (n
=
3.848), 18% were related to communication, 16% to
teamwork and 14% to handling residents.
Fig. 2
shows the distribution of the challenges, which are top of mind
among eldercare workers and the action plans suggested by the em-
ployees and supervisors to handle the challenges experienced by the
employees.
3.3. Are the plans for action related to the same level in the organisation
as the challenges?
Table 3
illustrates the distribution of actions plans to overcome the
challenge. Of the 2.497 communication sessions, 1.300 (52%) of the
sessions had an action plan on the same level in the organisation as the
challenges occurred (data not shown).
Of the 1.062 challenges at the individual level, 50% of the challenges
were handled with an action plan on individual level, 12% on team level
and 38% on management/organisational level. For the 728 challenges
on team level, 24% of the challenges were handled with an action plan
on individual level, 33% on team level, and 43% on management/
organisational level. Finally, 1.744 challenges were identified on man-
agement/organisational level. Of those, 31% had an action plan on in-
dividual level, 14% on team level and 55% on management/
organisational level (Fig.
3).
Table 3
shows in detail the challenges and the distribution of the
5
Fig. 2.
Overview of the work environment and health challenges that are top of
mind of the eldercare workers (n
=
2.919), and the solutions by the employees
and supervisors to overcome the challenge (n
=
3.848) (distribution shown
in percent).
corresponding action plans. E.g. the 235 challenges categorized in the
category
“work
task”, resulted in action plans at all levels at the orga-
nisation, including 17% with an action plan related to organizing
workplace and 20% related to communication on management/organ-
isational level.
Overall most of the action plans were identified as plans related to
“communication” at the management/organisational level. Between
12% and 32% of the plans for all challenges lead to a plan regarding
communication.
The same analyses were conducted on structured communication
sessions with only one challenge (2.123 sessions) and sessions with
authentication key (2.213 sessions). These analyses supported the
overall trend in the distribution shown in
Table 3.
3.4. Implementation success
In 2.252 of the communication sessions (90%), the employee and
supervisor rated the implementation of the action plans. No or low
implementation success was found in 15% of the action plans, partly
implementation success was found in 41% of the action plans and high
implementation success was found in 44% of the action plans (data not
shown).
 BEU, Alm.del - 2020-21 - Bilag 151: Orientering om NFA-artikel om hvilke udfordringer SOSU’er oplever i deres arbejde, fra beskæftigelsesministeren
2325999_0006.png
P.K. Munch et al.
Applied Ergonomics 90 (2021) 103265
Communication
15
17
20
17
17
27
26
195
11
82
148
6
Organizing
workplace
10
11
17
10
16
10
88
65
15
139
98
4
40
40
61
5
13
27
13
19
%
81
49
38
147
48
68
66
13
n
12
20
32
20
%
Management/organisational
Upgrading of
qualifications
Fig. 3.
Action plans to the identified challenges. The distribution of action
plans for the challenges on the levels in the organisation are shown in percent
(individual, team and management/organisational).
%
n
3
3
5
6
2
0
4
26
29
1
11
23
7
0
42
10
2
25
n
6
4
2
3
Table 3
Decided action plans to overcome the challenge. For each sub-category the absolute number and percentages for the suggested action plans can be seen.
Of the 789 action plans on the individual level, 52% had a high
implementation rate. Of the 377 action plans on team level, 45% had a
high implementation rate and of the 1086 plans on management/
organisational level, 39% had a high implementation rate (Fig.
4).
See appendix for examples of challenges and action plans and ex-
amples of plans with high, partly and no/low implementation success
(appendix,
Table 1).
4. Discussion
This study aimed to gain insight into the process of a workplace
intervention in nursing homes that was effective in reducing employee
pain. A central component of the intervention was 3-weekly structured
communication sessions. Through categorization of the 2.497 sessions,
2.919 challenges and 3.848 plans for action were identified. These data
provided insight into the employees’ perception of work environment
and health challenges, possible solutions to overcome these challenges
and the level of success in the implementation of the plans.
The majority of the challenges were categorized as challenges related
to staffing, organisation of tasks and teamwork, and most action plans
were categorized as plans related to communication, team-work and
handling residents. Half of the plans were solved at another organisa-
tional level than the challenge, indicating a complexity in the challenges
where solutions at other organisational levels are relevant. Thus, for
example challenges at the individual level were solved with action plans
on both the individual, team and management/organisational level. The
same diversity was found for challenges on team and management/
organisational level. The highest implementation rate was found among
actions planned on the individual level (52%), actions planned on team
and management/organisational level were implemented at a lower rate
(45% and 39%).
Staffing
13
14
12
16
8
13
33
240
1
6
11
82
Team
Team
work
133
5
Handling
residents
2
14
1
0
%
2
0
22
0
4
58
4
0
n
12
20
32
17
4
8
Work task
121
7
75
40
15
143
20
4
2
20
3
2
2
3
39
26
3
43
6
11
3
6
36
14
12
74
5
6
10
10
75
69
17
4
n
11
17
13
19
%
5
4
0
8
1
2
0
1
74
30
28
108
29
64
33
6
n
11
12
23
15
%
231
0
5
30
32
2
1
12
4
1
12
n
50
0
4
4
%
3
6
0
3
1
2
2
Self-man.
=
self-management.
*n for the challenges at the overall category (including all the subcategories) and the action plan.
**% distribution within the same overall challenge level.
Self-man. of psychosocial
challenges
9
11
6
8
6
33
14
32
24
16
5
9
42
4
11
35
165
2
1
2
3
2
2
8
10
1
%
Self-man. of Physical
challenges
86
4
Action plan
Individual
%
5
6
49
2
27
11
%
All communication sessions included
(2.497)
No plan
270
4
No challenge
Without explanation
Individual
Work task
Handing residents
Physical challenges
Private circumstances
Team
Teamwork
Management organisational
Staffing
Physical work environment
Communication
Organisation of tasks
Challenge
10
n
1
21
n
3
64
N
9
Fig. 4.
The distribution of no or low, partly and high implementation success in
percentages for individual, team and management/organisational level.
6
 BEU, Alm.del - 2020-21 - Bilag 151: Orientering om NFA-artikel om hvilke udfordringer SOSU’er oplever i deres arbejde, fra beskæftigelsesministeren
P.K. Munch et al.
Applied Ergonomics 90 (2021) 103265
4.1. Work environment challenges experienced by the eldercare workers
Overall, our study found that eldercare workers experienced work
environment and health challenges founded at all levels in the organi-
sation. Thus, our finding are in line with previous research emphasizing
the complexity of work environment challenges and that multiple fac-
tors at work can influence employee health and therefore encouraging
complex initiatives (Rasmussen
et al., 2017; da Costa and Vieira, 2010;
Burton et al., 2005).
In our study most challenges were related to staffing
and organisation of work tasks, such as for example lack of influence at
work, feeling busy, time pressure and disruption during work. These
factors are previously found to be associated with employee health and
turnover. For example high workloads were found to be related to
turnover and turnover intentions among nursing staff (Hayes
et al.,
2012).
Further
Clausen et al., 2014
found that low influence at work was
a reason for resigning a position in the Danish eldercare services. Also
low and medium influence at work has shown to be a predictor for LBP
among female eldercare workers (Clausen
et al., 2013).
To maintain the
same quality and standard in the healthcare system, it is important to
find solutions and develop plans for action to overcome these challenges
and improve the work environment (Clausen
et al., 2014).
4.2. Solutions (action plans) to overcome the challenges
Some challenges lead to more than one plan for action underlining
the need for targeting challenges with multiple solutions at several
levels. The overall variety of solutions indicates that multiple in-
terventions are necessary to meet the challenges at the nursing home
workplaces and supports the notion that tailored solutions maybe more
effective than one-size-fits-all solutions compared technique training or
single factor interventions (Rasmussen
et al., 2017).
Most action plans
were categorized on the management/organisational level in the orga-
nisation (48%). A previous study also found that most solutions to
challenges regarding low back pain among eldercare workers, were
found at the organisational level (54%) (Rasmussen
et al., 2017).
In the
present study most plans made by employees and supervisors were at the
individual or management/organisational level and seldom at the team
level. This may be explained by the structure of the communication
sessions, that only the employee and the supervisor (and not colleagues)
participated. To capture the advantages of team-based solutions, future
interventions may benefit from integrating a focus on solutions at the
team level.
4.3. Half of the challenges lead to solutions at another level in the
organisation
We found that challenges at one level in the organisation could lead
to action plans at all levels in the organisation. The discrepancies be-
tween the organisational level of the challenge and the action plans
match the findings by
Rasmussen et al., 2017),
who found that different
risk factors for low back pain also were solved on different levels in the
organisation. These results highlight the importance of considering so-
lutions at all levels of the organisation even though the challenge is
identified at a specific level in the organisation.
4.4. Implementation of solutions
Overall, we found that 44% of all rated plans had a high imple-
mentation success, and 37% were partly implemented. Previous studies
have reported that the percentage of solutions that were implemented to
a high degree ranged between 33% and 38%, while other studies have
pooled partially and full implementation and reported about 60%
(Rasmussen
et al., 2017; Anema et al., 2003; Loisel et al., 2001; Peh-
konen et al., 2009).
These studies had between 3 and 6 months of follow-up time. Thus,
in the present study we found a higher degree of implementation even
7
though the time for implementation was shorter. This could be due to
several reasons. It could be explained by the set-up in the sessions with
only the employee and the supervisor (and not the team or colleagues)
placing the full responsibility for executing the plan on these two per-
sons and not on a group where each individual may not have the same
degree of ownership (May
et al., 2007).
The relatively high degree of
implementation of the action plans may be explained by the develop-
ment of skills among employees and supervisors (through the courses) to
communicate and make plans that comprised small adjustments in the
work environment and were realistic to integrate in the existing rou-
tines. Finally, an email was sent to remind employees and supervisors
about the action plan and that they had to fulfil it before the next session
and this follow-up may have facilitated the implementation.
4.4.1. The lower the level in the organisation
–
the higher the degree of
implementation
We found that the action plans on the individual level led to a higher
degree of implementation (52%) compared with action plans on team
(45%) and management/organisational level (39%). The evaluation of
the completion happened at the next session approximately 3 weeks
after the action plan was generated which was a narrow time frame
compared to other studies (Rasmussen
et al., 2017; Driessen et al.,
2010).
The variety in the content of the action plans meant that different
plans required different efforts to reach implementation success. Plans at
the individual level primarily involved the individual and adjustments
in his or her daily routines, whereas plans at the organisational level
could involve changing systems or structures at the workplace and often
involved more than one individual. These differences between plans at
the different levels and the short follow-up period may explain the
varying degree of implementation within the different levels in the
organisation. This is in line with previous studies suggesting that some
ergonomic solutions such as acquisition of or better use of assistive de-
vices were hampered because the solutions were too comprehensive to
implement within the study duration of three months (Rasmussen
et al.,
2017; Driessen et al., 2010).
Furthermore, a previous study has found
that changes in the systems and routines can be difficult to integrate into
health care organisations (Scott-Cawiezell
et al., 2005).
4.5. Strengths and limitations
A strength of the present study is the huge dataset including 2.497
structured communication sessions from more than 400 eldercare
workers continuously throughout up to 28 months. Data regarding
challenges and action plans was entered directly into the tablet in the
communication sessions, which allowed the researchers to access the
exact wording of the challenges and action plans. Data from the sessions
were analysed using a systematic stepwise approach, with two re-
searchers going through each step and using statistical test of agreement
to support development of independent and robust categories.
Previous studies have pointed at the limitations in the literature
indicating that studies are more effective in emphasizing the problem
(for example stress among nurses) than identifying solutions and
therefore studies must focus on involving the workers in the process and
start moving from discussion to action (Happell
et al., 2013).
The so-
lutions identified in this study contribute with important knowledge
regarding types of possible initiatives to improve the work environment
and health for this job group and to what degree the employees and
supervisors succeed in implementing the different categories of
solutions.
The structured communication sessions requires an open and trustful
relation between the supervisor and employee. A possible limitation in
this study is therefore the set-up in the structured communication ses-
sion. The communication and development of an action plan is highly
dependent on the relation between the supervisor and the employee, and
the supervisors’ abilities to facilitate the communication and support the
employee in developing a plan and the trust and confidence between the
 BEU, Alm.del - 2020-21 - Bilag 151: Orientering om NFA-artikel om hvilke udfordringer SOSU’er oplever i deres arbejde, fra beskæftigelsesministeren
2325999_0008.png
P.K. Munch et al.
Applied Ergonomics 90 (2021) 103265
employee and supervisor. However, the intervention approach with
courses for employees and supervisor and the use of the tablet-based
guide in the sessions, was supposed to strengthen the starting point for
constructive development of specific and effective action plans.
A limitation to the study is that all involved workplaces belong to the
same geographical location in Denmark, which might limited the
external validity of the study. Further we also experienced some meth-
odological and technical limitations in the rating of the implementation
of the plans. The methodological limitation covered the disadvantage
related to the measurement of the degree of implementation, which was
measured by a question posed in the guide in the following session and
therefore, all participants had at least one missing measurement of
implementation success. Furthermore, a system error in the program
downloading data from the communication sessions led to missing in-
formation regarding identification number and workplace in 284 ses-
sions (11%).
5. Conclusions
This workplace intervention, shown effective in reducing pain
among employees in nursing homes, was successful in implementing a
high number of small actions to improve the work environment and
health among employees. The structured communication sessions
revealed which challenges the eldercare workers experienced with most
challenges identified at the management/organisational level. The ma-
jority of the plans for action were also related to initiatives at the
management/organisational level. Further, we found that challenges on
one level (on individual, team or management/organisational level)
could lead to action plans on all levels (on individual, team and man-
agement/organisational level).
This study contributes to the knowledge base regarding what kind of
work environment initiatives could be introduced to improve the work
environment for employees in eldercare. We found that employees
experienced various challenges, which naturally resulted in various so-
lutions and pointing at the importance of considering the specific
challenges of each individual, and identifying relevant solutions for this
challenge and specific employee. Furthermore, this study underlines the
advantages in considering solutions to work environment and health
challenges broadly at all levels in the organisation. Additionally this
study points at the relevance of involving both the employee and the
management/organisation identifying and implementing solutions.
Finally, action plans were rarely settled at team level, indicating that
possibly other actions than structured communication between super-
visor and employee is needed to mobilize team level initiatives.
Abbreviations
Not applicable.
Ethics approval and consent to participate
The trial was approved by the Danish Data Protection Agency
(Journal number 2014-38/28350-3) and reported to the local ethical
committee (Protocol H-1-2013 FSP). The trial was conducted in accor-
dance with the Helsinki declaration.
Consent for publication
Not applicable.
Availability of data and materials
The datasets generated and analysed during the current study are
available from the corresponding author on reasonable request.
Funding
The study is based on data from a study funded by the Danish
Working Environment Research Fund (grant number: 20130069210).
The analysis, interpretation and writing of the manuscript were funded
by the Danish Government through a grant to the FOR-SOSU program
(SATS, 2004) at the National Research Centre for the Working Envi-
ronment. The funders had no role in study design, data collection and
analysis, decision to publish, or preparation of the manuscript.
CRediT authorship contribution statement
Pernille Kold Munch:
contributed to the design of the study, coded
the data, did the analyses, drafted the first version of the manuscript,
and wrote the final version of the manuscript. read and approved the
final manuscript.
Charlotte Diana Nørregaard Rasmussen:
acquired
funding for the project, participated in discussions around the study, and
critically revised the manuscript. read and approved the final manu-
script.
Marie Birk Jørgensen:
acquired funding for the project,
designed the original study (the dataset the study is based on), and
critically revised the manuscript. read and approved the final manu-
script.
Anne Konring Larsen:
acquired funding for the project, designed
the study and participated in discussions around the study, and critically
revised the manuscript. read and approved the final manuscript.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgements
We thank Mathilde Bendix Søgaard, who contributed to the coding,
and all supervisors and employees who participated to the study.
Appendix
Table 1
Examples of challenges at different levels in the organisation and sub-category, including the action plan for each challenge
(and the implementation success).
Challenge
Individual (I)
Team (T)
Action plan
Individual (I)
Team (T)
Management/
organisational (M/O)
(continued
on next page)
8
 BEU, Alm.del - 2020-21 - Bilag 151: Orientering om NFA-artikel om hvilke udfordringer SOSU’er oplever i deres arbejde, fra beskæftigelsesministeren
2325999_0009.png
P.K. Munch et al.
Applied Ergonomics 90 (2021) 103265
Table 1
(continued )
Challenge
Individual (I)
Team (T)
Management/
organisational (M/
O)
Management/
organisational (M/
O)
When you feel that
you do not have
the time to do your
work tasks (M/O
organizing
workplace)
Prioritize the most
important work
tasks first and keep
a sense of
perspective. Do less
important work
tasks the day after (I
- self-management
physical)
Action plan
Individual (I)
Team (T)
Management/
organisational (M/O)
When there are
unsettled work tasks.
When there is a lack of
communication (M/O
-communication and
organizing workplace)
There are many sick
notes in the team(M/O
- staff)
Improved
planning the
day before
including
distribution of
tasks. Especially
at events (T -
team)
When the
relatives are
visiting the
resident, the
resident has
fallen, and
the relatives
are worried (I
–
resident)
When the
distribution of
work tasks
within the
team is not
equal (T -
team)
When the distribution
of work tasks within
the team is not equal
(M/O organizing
workplace)
Ask the relatives to
leave the room,
while we are lifting
(I- Resident) Use the
assistive devices/
ceiling hoist (I
–
Self-management of
physical challenges)
Lack of staff (M/O
staff)
Employee: talk
to the colleague
about problem
(T - team)
Review of sick
absence for each
employee in the
team. Conversations
when needed! (M/O
communication)
Supervisor: Wait for
response if a meeting
is necessary (M/O -
communication)
If possible,
participate in the
manual handling
training, so we can
learn how to use the
new ceiling hoist (M/
O
–
upgrading)
Lower resident/staff
ratio
High implementation success
Partly implementation success
No/low implementation success
References
Anema, J.R., Steenstra, I.A., Urlings, I.J.M., Bongers, P.M., de Vroome, E.M.M., van
Mechelen, W., 2003. Participatory ergonomics as a return-to-work intervention: a
future challenge? Am. J. Ind. Med. 44 (3), 273–281.
Aust, B., Rugulies, R., Finken, A., Jensen, C., 2010. When workplace interventions lead to
negative effects: learning from failures. Scand. J. Publ. Health 38 (3_Suppl. l),
106–119.
Burton, A.K., Balague, F., Cardon, G., Eriksen, H.R., Henrotin, Y., Lahad, A., et al., 2005.
How to prevent low back pain. Best Pract. Res. Clin. Rheumatol. 19 (4), 541–555.
Campbell, J.D.G., Buchan, J., Pozo-Martin, F., Guerra Arias, M., Leone, C., Siyam, A.,
Cometto, G., 2013. A Universal Truth: No Health without a Workforce. Forum Report
TGFoHRfH. Global Health Workforce Alliance and World Health Organization,
Geneva.
Clausen, T.B.S., Carneiro, I.G., Bong, V., Aust, B., 2012. Arbejdmsiljø, helbred og trivsel i
ældreplejen i ni danske kommuner fra 2005 til 2008. Det Nationale Forskningscenter
for Arbejdsmiljø, Copenhagen, Denmark.
Clausen, T., Andersen, L.L., Holtermann, A., Jorgensen, A.F.B., Aust, B., Rugulies, R.,
2013. Do self-reported psychosocial working conditions predict low back pain after
adjustment for both physical work load and depressive symptoms? A prospective
study among female eldercare workers. Occup. Environ. Med. 70 (8), 538–544.
Clausen, T., Tufte, P., Borg, V., 2014. Why are they leaving? Causes of actual turnover in
the Danish eldercare services. J. Nurs. Manag. 22 (5), 583–592.
Cohen, J., 1960. A coefficient of agreement for nominal scales. Educ. Psychol. Meas. 20
(1), 37–46.
da Costa, B.R., Vieira, E.R., 2010. Risk factors for work-related musculoskeletal
disorders: a systematic review of recent longitudinal studies. Am. J. Ind. Med. 53 (3),
285–323.
Driessen, M.T., Proper, K.I., Anema, J.R., Bongers, P.M., van der Beek, A.J., 2010.
Process evaluation of a participatory ergonomics programme to prevent low back
pain and neck pain among workers. Implement. Sci. : ISCUS 5, 65.
Foley, G., Timonen, V., 2015. Using grounded theory method to capture and analyze
health care experiences. Health Serv. Res. 50 (4), 1195–1210.
Gwet, K.L., 2014. Benchmarking inter-rater reliability coefficients. In: Advanced
Analytics (Ed.), Handbook of Inter-rater Reliability: the Definitive Guide to
Measuring the Extent of Agreement Among Multiple Raters, 4 edition. LLC.
Happell, B., Dwyer, T., Reid-Searl, K., Burke, K.J., Caperchione, C.M., Gaskin, C.J., 2013.
Nurses and stress: recognizing causes and seeking solutions. J. Nurs. Manag. 21 (4),
638–647.
Hayes, L.J., O’Brien-Pallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes, F., et al.,
2012. Nurse turnover: a literature review - an update. Int. J. Nurs. Stud. 49 (7),
887–905.
Hussain, A., Rivers, P.A., Glover, S.H., Fottler, M.D., 2012. Strategies for dealing with
future shortages in the nursing workforce: a review. Health Serv. Manag. Res. 25 (1),
41–47.
Kongstad MC, Jeanette; Sjøgaard, Gisela ; Søgaard, Karen. The Effect of Physical Fitness
and Physical Exercise Training on Work Productivity Among Health Care
Workers2015.
Kristensen, T.S., 2005. Intervention studies in occupational epidemiology. Occup.
Environ. Med. 62 (3), 205–210.
9
 BEU, Alm.del - 2020-21 - Bilag 151: Orientering om NFA-artikel om hvilke udfordringer SOSU’er oplever i deres arbejde, fra beskæftigelsesministeren
P.K. Munch et al.
Larsen, A.K., Holtermann, A., Mortensen, O.S., Punnett, L., Rod, M.H., Jorgensen, M.B.,
2015. Organizing workplace health literacy to reduce musculoskeletal pain and
consequences. BMC Nurs. 14, 46.
Larsen, A.K., Thygesen, L.C., Mortensen, O.S., Punnett, L., Jorgensen, M.B., 2019. The
effect of strengthening health literacy in nursing homes on employee pain and
consequences of pain a stepped-wedge intervention trial. Scand J Work Environ
Health.
https://doi.org/10.5271/sjweh.3801.
Linnan, L.S.A., 2002. Process Evaluation for Public Health Interventions and Research.
Jossey-Bass SF, California.
Loisel, P., Gosselin, L., Durand, P., Lemaire, J., Poitras, S., Abenhaim, L., 2001.
Implementation of a participatory ergonomics program in the rehabilitation of
workers suffering from subacute back pain. Appl. Ergon. 32 (1), 53–60.
May, C., Finch, T., Mair, F., Ballini, L., Dowrick, C., Eccles, M., et al., 2007.
Understanding the implementation of complex interventions in health care: the
normalization process model. BMC Health Serv. Res. 7 (1), 148.
Applied Ergonomics 90 (2021) 103265
Miranda, H., Gore, R.J., Boyer, J., Nobrega, S., Punnett, L., 2015. Health behaviors and
overweight in nursing home employees: contribution of workplace stressors and
implications for worksite health promotion. Sci. World J. 2015, 10.
Montano, D., Hoven, H., Siegrist, J., 2014. Effects of organisational-level interventions at
work on employees’ health: a systematic review. BMC Publ. Health 14, 135.
Oakley, A., Strange, V., Bonell, C., Allen, E., Stephenson, J., 2006. Process evaluation in
randomised controlled trials of complex interventions. BMJ (Clinic. Res. ed) 332
(7538), 413–416.
Pehkonen, I., Takala, E.P., Ketola, R., Viikari-Juntura, E., Leino-Arjas, P., Hopsu, L.,
et al., 2009. Evaluation of a participatory ergonomic intervention process in kitchen
work. Appl. Ergon. 40 (1), 115–123.
Rasmussen, C.D.N., Lindberg, N.K., Ravn, M.H., Jorgensen, M.B., Sogaard, K.,
Holtermann, A., 2017. Processes, barriers and facilitators to implementation of a
participatory ergonomics program among eldercare workers. Appl. Ergon. 58,
491–499.
Scott-Cawiezell, J., Jones, K., Moore, L., Vojir, C., 2005. Nursing home culture: a critical
component in sustained improvement. J. Nurs. Care Qual. 20 (4), 341–348.
10