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Maxime Paquet, PhD, and Serge Gagnon, PhD, Research and Intervention Centre for Healthy Workplaces (CRISO), affiliated with the McGill University Health Centre

Can the improvement of various aspects of the psychosocial environment have an effect on the quality and safety of care? If so, what indicators can help decision-makers in health services to make informed decisions?

In December 2008, the Research and Intervention Centre for Healthy Workplaces (CRISO; www.criso.ca) received a major research grant from the Canadian Health Services Research Foundation (CHSRF) as part of the Research, Exchange and Impact for System Support (REISS) competition. CRISO partnered with Montreal’s Hôpital du Sacré-Cœur to complete this project within the four-year allotted time frame (2008-2012). The project concerns the stabilization of clinical teams and the improvement of safety and quality of care by intervening directly with leaders responsible for ensuring the development of psychosocial environments and operational systems that produce excellent health care.

Briefly stated, this study aims to examine the role of psychosocial factors in the workplace in accounting for the stability of care teams and the safety and quality of care provided by clinical teams, while measuring the effect of a simultaneous intervention to improve the decision-makers’ leadership with regard to reflexive practices and change management, as well as to correct operational problems in systems.

In winter and spring 2008, we carried out a survey of all employees in the units taking part in the REISS/CRISO program. The goal of this survey was to provide managers with evidence to guide their decisions concerning the improvement of their units’ psychosocial environment. Out of 1827 employees targeted for the survey, 588 employees from 60 different administrative units completed the questionnaire.

The survey dealt with the perception of employees’ psychosocial environment. More precisely, we measured the perception of the work climate (Gagnon, Paquet, Courcy, & Parker, 2009), the degree of balance between effort and recognition (Siegrist, 1996), the degree of balance between psychological demands and latitude in making decisions, the perception of social support (Karasek, Brisson, Kawakami, Houtman, & Bongers, 1998), and the quality of the relationship between nurses and physicians (Lake, 2002).

In September and October 2009, with the goal of establishing a link between psychosocial factors in the work environment and the stability of care teams as well as the safety and quality of care, we obtained administrative data on the participating units. These data were collected over the four administrative periods during which the survey was carried out. Specifically, the variables for team stability are: the short-term absenteeism rate, the external turnover rate, the job occupancy rate, the overtime rate, and the proportion of hours worked by agency personnel. The variables for safety and quality of care are: the frequency of medication errors, the average length of stay, and patient satisfaction with nursing care. In order to put each unit’s situation into context, we also collected data on the nurse/patient ratio and on bed occupancy rate.

Our theoretical model

The creation of an evidence-based theoretical model allows us to identify the variables with the greatest impact on the care safety and quality indicators and thereby to orient decision-makers towards the more suitable indicators.

As for the research on this issue, very few studies have examined the effect of the psychosocial environment on patient-related indicators. Several studies deal with the impact of the psychosocial environment on the stability of work teams, while others measure the effect of the stability of work teams on the patients, but these two fields have advanced in parallel, separately (Aiken, Sochalsky and Lake, 1997). Therefore, an interesting innovation for CRISO’s program is to combine these fields in order to obtain an integrated model. The following figure illustrates the indicators chosen in light of the results obtained for their impact on the quality and safety of care (path analyses). The subsequent section expresses in simple terms the effect of the various indicators measured on the stability of teams and the quality and safety of care.

What should be done to improve the stability of care teams?

Which indicators in the psychosocial work environment most strongly influence the reduction of short-term absentee rates?

We found that the indicators most strongly associated with a reduction in absenteeism rates are: the degree of imbalance in effort/recognition, the social support by supervisors, and two work climate indicators: workload perception (Role), and pride in belonging (Team).

Our results indicate that when a unit shows a reduction in its absenteeism rate, 27% of that reduction can be attributed to concrete actions aiming to improve the above-mentioned aspects of the psychosocial work environment.

The scientific and professional literature already tells us that the major causes of absenteeism in the nursing profession are musculoskeletal injuries and job difficulties leading to physical and/or psychological exhaustion (Shamian, O’Brien-Pallas, Thomson, Alksnis, & Kerr, 2003). One of the interesting aspects of this updated model is that all five psychosocial job environment indicators discussed have a demonstrated effect on the physical and psychological health of employees. They can therefore be approached synergistically in an integrated action plan. Of course, since the effect of these indicators accounts for about a third of the variation in absentee rates, safety and work environment optimization must not be neglected, for the sake of our nurses’ health!

What should be done to improve safety and quality of care?

In order to affect the frequency of medication errors, the average length of patient stay, and patient satisfaction, and thereby to improve a unit’s average results, the main indicators to examine are: the short-term absenteeism rate, the turnover rate, the overtime rate, and the nurse/patient ratio. Analysis of the data reveals that:

When a unit reduces the average frequency of medication errors, 59% of this reduction can be attributed to concrete actions to reduce the nurse/patient ratio, the absenteeism rate, the turnover rate, and the overtime rate.
When a unit’s average length of patient stay is reduced, our results show that 73% of this reduction can be attributed to concrete actions to:
- Reduce the nurse/patient ratio, the absenteeism rate, and the overtime rate;
- Improve the degree of patient satisfaction with nursing care
When a unit shows improvement in the degree of patient satisfaction with nursing care, 71% of this improvement can be attributed to concrete actions to reduce length of patient stay, the nurse/patient ratio, the absenteeism rate, and the overtime rate

Final words…

The main objective of this study, which takes part in the REISS/CRISO program was to discover which indicator, related to the psychosocial work environment can have an impact on the quality and security of care, considering the role of work team stability. Our analyses lead us to conclude that if a manager works to improve psychosocial aspects such as the degree of imbalance in effort/recognition, the social support by supervisors, workload perception, and the pride in belonging to the work team, positive effects on team stability indicators can be expected. These indicators are: short-term absenteeism, overtime, turnover rate and nurse/patient ratio. Moreover, these positive effects will also have an impact on security and quality of care indicators. In our study, these indicators were: medication errors, length of stay and patient satisfaction with nursing care.

In conclusion, please note that more details of these results are available on the French section of the CRISO website, in the section dedicated to the progress report at the end of the first year of the REISS-CRISO intervention research program, at: http://www.criso.ca/Category.aspx?NavID=223&CultureCode=fr-CA

References

Aiken, L. H., Sochalski, J., & Lake, E. T. (1997). Studying Outcomes of Organizational Change in Health Services. Medical Care, 35(11), NS6-NS18.

Gagnon, S, Paquet, Courcy, F., & M., Parker (2009). Measurement and Management of Work Climate: Cross-Validation of the CRISO- Psychological Climate Questionnaire. Healthcare Management Forum. Spring 2009 Edition.

Karasek, R., Brisson, C., Kawakami, N., Houtman, I., Bongers, P., & Amick, B. (1998). The Job Content Questionnaire (JCQ): An Instrument for Internationally Comparative Assessments of Psychosocial Job Characteristics. Journal of Occupational Health Psychology, 3(4), 322-355.

Lake, E. T. (2002). Development of the Practice Environment Scale of the Nursing Work Index. Research in Nursing & Health, 25, 176-188.

Shamian, J. O’Brien-Pallas, L., Thomson, D., Alksnis, C., & Kerr, M. S. (2003). Nurse Absenteeism, Stress and Workplace Injury: What are the Contributing Factors and What Can/Should Be Done About It? International Journal of Sociology and Social Policy, 23, 8/9, 81-103.

Siegrist, J. (1996). Adverse Health Effects of High-Effort/Low-Reward Conditions. Journal of Occupational Health Psychology, 1(1), 27-41.