How to improve hospital employees' health and well-being: a staff consultation.

OBJECTIVE: Explore perspectives from healthcare workers in a large public hospital (11,000 staff) on employers supporting their health and well-being. METHODS: Heads of departments/services were invited to convene focus groups, facilitated by a moderator using a semi-structured discussion guide.  RESULTS: Over 450 members of staff participated in 28 focus groups. Themes identified were: 1)unique nature of working in a large hospital, 2)hospital management agenda and relationship with staff, 3)working environment, and 4)staff health and well-being initiatives. CONCLUSIONS: Optimal uptake of health-promoting initiatives was hindered in part due to lack of staff awareness and a range of barriers. Key requirements for improving staff health were perceived to be sufficient staffing, time and space to work safely and comfortably. Engaging with staff to hear their views, build trust and identify their needs is an essential first step.

A case management occupational health model to facilitate earlier return to work of NHS staff with common mental health disorders: a feasibility study.

BACKGROUND: The NHS is the biggest employer in the UK. Depression and anxiety are common reasons for sickness absence among staff. Evidence suggests that an intervention based on a case management model using a biopsychosocial approach could be cost-effective and lead to earlier return to work for staff with common mental health disorders. OBJECTIVE: The objective was to assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of an early occupational health referral and case management intervention to facilitate the return to work of NHS staff on sick leave with any common mental health disorder (e.g. depression or anxiety). DESIGN: A multicentre mixed-methods feasibility study with embedded process evaluation and economic analyses. The study comprised an updated systematic review, survey of care as usual, and development of an intervention in consultation with key stakeholders. Although this was not a randomised controlled trial, the study design comprised two arms where participants received either the intervention or care as usual. PARTICIPANTS: Participants were NHS staff on sick leave for 7 or more consecutive days but less than 90 consecutive days, with a common mental health disorder. INTERVENTION: The intervention involved early referral to occupational health combined with standardised work-focused case management. CONTROL/COMPARATOR: Participants in the control arm received care as usual. PRIMARY OUTCOME: The primary outcome was the feasibility and acceptability of the intervention, study processes (including methods of recruiting participants) and data collection tools to measure return to work, episodes of sickness absence, workability (a worker's functional ability to perform their job), occupational functioning, symptomatology and cost-effectiveness proposed for use in a main trial. RESULTS: Forty articles and two guidelines were included in an updated systematic review. A total of 49 of the 126 (39%) occupational health providers who were approached participated in a national survey of care as usual. Selected multidisciplinary stakeholders contributed to the development of the work-focused case management intervention (including a training workshop). Six NHS trusts (occupational health departments) agreed to take part in the study, although one trust withdrew prior to participant recruitment, citing staff shortages. At mixed intervention sites, participants were sequentially allocated to each arm, where possible. Approximately 1938 (3.9%) NHS staff from the participating sites were on sick leave with a common mental health disorder during the study period. Forty-two sick-listed NHS staff were screened for eligibility on receipt of occupational health management referrals. Twenty-four (57%) participants were consented: 11 (46%) received the case management intervention and 13 (54%) received care as usual. Follow-up data were collected from 11 out of 24 (46%) participants at 3 months and 10 out of 24 (42%) participants at 6 months. The case management intervention and case manager training were found to be acceptable and inexpensive to deliver. Possible contamination issues are likely in a future trial if participants are individually randomised at mixed intervention sites. HARMS: No adverse events were reported. LIMITATIONS: The method of identification and recruitment of eligible sick-listed staff was ineffective in practice because uptake of referral to occupational health was low, but a new targeted method has been devised. CONCLUSION: All study questions were addressed. Difficulties raising organisational awareness of the study coupled with a lack of change in occupational health referral practices by line managers affected the identification and recruitment of participants. Strategies to overcome these barriers in a main trial were identified. The case management intervention was fit for purpose and acceptable to deliver in the NHS. TRIAL REGISTRATION: Current Controlled Trials ISRCTN14621901. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 12. See the NIHR Journals Library website for further project information.

Anxiety and depression are common causes of sickness absence in the NHS. This can harm patient care. Previous research has shown that offering early support to NHS staff on sick leave with a common mental health disorder is important to aid recovery and rehabilitation. However, it is not currently known how best to support staff in returning to work. The purpose of this research was to test the feasibility of a large-scale study to see if specially trained occupational health nurses would be effective in getting NHS staff with these problems back to work quicker. We reviewed the recent scientific literature and did a survey of NHS occupational health departments to find out what was currently offered to such staff. We developed a new work-focused case management intervention and trained six occupational health nurses to deliver it. We recruited 24 NHS staff who were on sick leave with a common mental health disorder (such as depression or anxiety) and allocated 11 to receive the new intervention and the rest to receive usual support. Participants were invited to complete three questionnaires and we collected information from the participating occupational health sites. We also interviewed participants, managers, human resource staff and occupational health nurses to find out what they thought about being involved in the study. We found that the new case management intervention had potential benefits. However, it would not be possible to run a trial to evaluate the intervention until a better way can be found to encourage the early referral of sick staff to occupational health.

A behaviour change package to prevent hand dermatitis in nurses working in health care: the SCIN cluster RCT.

BACKGROUND: Although strategies have been developed to minimise the risk of occupational hand dermatitis in nurses, their clinical effectiveness and cost-effectiveness remain unclear. OBJECTIVES: The Skin Care Intervention in Nurses trial tested the hypothesis that a behaviour change package intervention, coupled with provision of hand moisturisers, could reduce the point prevalence of hand dermatitis when compared with standard care among nurses working in the NHS. The secondary aim was to assess the impact of the intervention on participants' beliefs and behaviour regarding hand care, and the cost-effectiveness of the intervention in comparison with normal care. DESIGN: Cluster randomised controlled trial. SETTING: Thirty-five NHS hospital trusts/health boards/universities. PARTICIPANTS: First-year student nurses with a history of atopic tendency, and full-time intensive care unit nurses. INTERVENTION: Sites were randomly allocated to be 'intervention plus' or 'intervention light'. Participants at 'intervention plus' sites received access to a bespoke online behaviour change package intervention, coupled with personal supplies of moisturising cream (student nurses) and optimal availability of moisturising cream (intensive care unit nurses). Nurses at 'intervention light' sites received usual care, including a dermatitis prevention leaflet. MAIN OUTCOME MEASURE: The difference between intervention plus and intervention light sites in the change of point prevalence of visible hand dermatitis was measured from images taken at baseline and at follow-up. RANDOMISATION: Fourteen sites were randomised to the intervention plus arm, and 21 sites were randomised to the intervention light arm. BLINDING: The participants, trial statistician, methodologist and the dermatologists interpreting the hand photographs were blinded to intervention assignment. NUMBERS ANALYSED: An intention-to-treat analysis was conducted on data from 845 student nurses and 1111 intensive care unit nurses. RESULTS: The intention-to-treat analysis showed no evidence that the risk of developing dermatitis was greater in the intervention light group than in the intervention plus group (student nurses: odds ratio 1.25, 95% confidence interval 0.59 to 2.69; intensive care unit nurses: odds ratio 1.41, 95% confidence interval 0.81 to 2.44). Both groups had high levels of baseline beliefs about the benefits of using hand moisturisers before, during and after work. The frequency of use of hand moisturisers before, during and after shifts was significantly higher in the intensive care unit nurses in the intervention plus arm at follow-up than in the comparator group nurses. For student nurses, the intervention plus group mean costs were £2 lower than those for the comparator and 0.00002 more quality-adjusted life-years were gained. For intensive care unit nurses, costs were £4 higher and 0.0016 fewer quality-adjusted life-years were gained. HARMS: No adverse events were reported. LIMITATIONS: Only 44.5% of participants in the intervention plus arm accessed the behaviour change package. CONCLUSION: The intervention did not result in a statistically significant decrease in the prevalence of hand dermatitis in the intervention plus group. FUTURE WORK: Participants had a high level of baseline beliefs about the importance of using hand moisturisers before, during and after work. Future research should focus on how workplace culture can be changed in order for that knowledge to be actioned. TRIAL REGISTRATION: Current Controlled Trials ISRCTN53303171. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 58. See the NIHR Journals Library website for further project information.

This study was designed to prevent nurses from developing hand dermatitis (eczema). The study recruited student and intensive care unit nurses who were at high risk of hand dermatitis. Overall, 35 study sites took part. Each site was randomised to be in either the 'intervention plus' or the 'intervention light' group. Participants in the intervention plus sites received access to a web-based intervention to change nurses' behaviour to improve hand care together with a written leaflet with advice on how to prevent dermatitis. The student nurse participants in the intervention plus group were provided with personal supplies of hand moisturisers to use during their clinical placements and the study team ensured that the intensive care unit nurses in the intervention plus arm had access to moisturising creams on the wards. Those in the intervention light group received only the written leaflet with advice on how to prevent dermatitis. All participants were reminded to contact their occupational health service early on if they developed hand dermatitis during the study. The main aim was to see if there was a difference between the proportion of participants in the intervention plus and intervention light groups who had hand dermatitis at the beginning of the study and at the end. The study collected photographs of hands at the time of recruitment and after 12 months. Participants completed questionnaires about their skin. The results showed that there was no evidence that the risk of developing hand dermatitis in the intervention light group was greater than that in the intervention plus group.

Current research priorities for UK occupational physicians and occupational health researchers: a modified Delphi study.

OBJECTIVES: Studies identifying national occupational health (OH) research priorities have been conducted in several countries to establish where OH research should be focused and where funding should be targeted. However, the UK findings are now over 20 years old, and OH practice is continuously evolving. The aim of this study was to identify current research priorities for UK occupational physicians (OPs) and occupational health researchers (OHRs). METHODS: Current research priorities in OH were identified using a modified Delphi technique. This was conducted in two rounds to achieve consensus. Research priorities were rated, and then ranked using questionnaires developed from expert panel discussions, key research topics identified from the medical literature and participant feedback. Overall and intergroup comparisons were completed for the ranking scores. RESULTS: Consensus among OPs and OHRs was high with almost all (9/10) primary domains rated as 'very important' or 'absolutely necessary' by more than 54% of respondents. The research priority areas ranked highest were jointly economic evaluation/cost effectiveness studies and disability management followed by occupational disease/injury/illness. Occupational health policy was ranked lowest after sickness absence management and health promotion. The secondary domain analysis identified priority emphasis on mental health and psychosocial hazards within the workplace and the need to further develop evidence-based guidance for clinical OH practice. CONCLUSIONS: We identified the current research priorities for UK OPs and OHRs. The findings will inform future national OH research strategy and support research that addresses important knowledge gaps within OH and other interdisciplinary specialties.

A behavioural change package to prevent hand dermatitis in nurses working in the national health service (the SCIN trial): study protocol for a cluster randomised controlled trial.

BACKGROUND: Hand dermatitis can be a serious health problem in healthcare workers. While a range of skin care strategies and policy directives have been developed in recent years to minimise the risk, their effectiveness and cost-effectiveness remain unclear. Evidence now suggests that psychological theory can facilitate behaviour change with respect to improved hand care practices. Therefore, we will test the hypothesis that a behavioural change intervention to improve hand care, based on the Theory of Planned Behaviour and implementation intentions, coupled with provision of hand moisturisers, can produce a clinically useful reduction in the occurrence of hand dermatitis, when compared to standard care, among nurses working in the UK National Health Service (NHS) who are particularly at risk. Secondary aims will be to assess impacts on participants' beliefs and behaviour regarding hand care. In addition, we will assess the cost-effectiveness of the intervention in comparison with normal care. METHODS/DESIGN: We will conduct a cluster randomised controlled trial at 35 NHS hospital trusts/health boards/universities, focussing on student nurses with a previous history of atopic disease or hand eczema and on nurses in intensive care units. Nurses at 'intervention-light' sites will be managed according to what would currently be regarded as best practice, with provision of an advice leaflet about optimal hand care to prevent hand dermatitis and encouragement to contact their occupational health (OH) department early if hand dermatitis occurs. Nurses at 'intervention-plus' sites will additionally receive a behavioural change programme (BCP) with on-going active reinforcement of its messages, and enhanced provision of moisturising cream. The impact of the interventions will be compared using information collected by questionnaires and through standardised photographs of the hands and wrists, collected at baseline and after 12 months follow-up. In addition, we will assemble relevant economic data for an analysis of costs and benefits, and collect information from various sources to evaluate processes. Statistical analysis will be by multi-level regression modelling to allow for clustering by site, and will compare the prevalence of outcome measures at follow-up after adjustment for values at baseline. The principal outcome measure will be the prevalence of visible hand dermatitis as assessed by the study dermatologists. In addition, several secondary outcome measures will be assessed. DISCUSSION: This trial will assess the clinical and cost effectiveness of an intervention to prevent hand dermatitis in nurses in the United Kigdom. TRIAL REGISTRATION: ISRCTN53303171 : date of registration, 21 June 2013.

Measuring how well the NHS looks after its own staff: methodology of the first national clinical audits of occupational health services in the NHS.

RATIONALE, AIMS AND OBJECTIVES: Little is known about the quality of occupational health care provided to National Health Service (NHS) staff. We designed the first national clinical audits of occupational health care in England. We chose to audit depression and back pain as health care workers have high levels of both conditions compared with other employment sectors. The aim of the audits was to drive up quality of care for staff with these conditions. The object of this paper is to describe how we developed an audit methodology and overcame challenges presented by the organization and delivery of occupational health care for NHS staff. METHODS: We designed two retrospective case note audits which ran simultaneously. Sites submitted up to 40 cases for each audit. We used duplicate case entry to test inter-rater reliability and performed selection bias checks. Participants received their site's audit results, benchmarked against the national average, within 4 months of the end of the data entry period. We used electronic voting at a results dissemination conference to inform implementation activities. RESULTS: Occupational Health departments providing services to 278 (83%) trusts in England participated in one or both audits. Median kappa scores were above 0.7 for both pilot and full audits, indicating 'good' levels of inter-rater reliability. In total, 79% of participants at a dissemination conference said that they had changed their clinical practice either during data collection (52%) or following receipt of their audit results (27%). CONCLUSIONS: Clinical audit can be conducted successfully in the occupational health setting. We obtained meaningful data that have stimulated local and national quality improvement activities. Our methodology would be transferable to occupational health settings outside the NHS and in other countries.

Concise guidance: diagnosis, management and prevention of occupational contact dermatitis.

Occupation is an important risk factor for contact dermatitis that presents in adulthood. Occupational contact dermatitis often has significant adverse effects on quality of life and the long-term prognosis is poor unless workplace exposures are addressed. The condition often presents to general practitioners, physicians or dermatologists who will be responsible for facilitating management of the workplace issues in the event that an occupational health service is not accessible. This concise guidance summarises three sets of guidance from the Occupational Health Clinical Effectiveness Unit, the British Occupational Health Research Foundation and the British Association of Dermatologists respectively. It is aimed at physicians in primary and secondary care, covering the clinical aspects of case management but also drawing attention to the important actions they should take to address the workplace issues, either in liaison with an occupational health provider or in the absence of occupational health input.

Work relatedness of chronic neck pain with physical findings--a systematic review.

OBJECTIVES: This paper systematically reviews the work-relatedness of neck-shoulder disorders with associated physical findings. METHODS: Studies incorporating a physical examination were focused upon. Four detailed reviews were searched, and a systematic search of the MEDLINE, Embase BIDS, and Psychinfo databases was conducted until May 2006, the key words for the outcome and various occupational exposures being combined. The quality of each paper was rated by criteria related to study design, power, sampling methods, response rate, potential for bias, or confounding, and approaches to the assessment of exposure outcome. Weight was given to studies with objective exposure-response information. RESULTS: Twenty-one relevant reports (four prospective) were found. Most considered the outcome neck pain with palpation tenderness (tension neck syndrome) or mixed neck-shoulder disorder (predominantly tension neck syndrome). Most investigations shared common limitations--small sample size, potential for confounding, incomplete blinding, and crude exposure assessment. The overall quality of the information was rated as excellent for only two reports. Exposures included repetitive work (14 studies), static loading (12 studies), neck flexion (7 studies), force (5 studies), and occupational psychosocial factors (7 studies). Moderate evidence was found for a causal relation for repetition at the shoulder and for neck flexion allied with repetition. Limited evidence was found for hand-wrist repetition, neck flexion with respect to static loading and force in the absence of repetition, and high job demands, low control, low job support and job strain. CONCLUSION: There is some evidence that neck pain with palpation tenderness is causally related to workplace exposures. However, evidence is lacking on the validity, clinical course, and functional importance of this diagnostic entity.

Influenza immunisation: attitudes and beliefs of UK healthcare workers.

AIM: To explore attitudes to influenza immunisation and rates of uptake among staff working in acute hospitals in the UK. METHOD: A cross-sectional survey of 11,670 healthcare workers in six UK hospitals was carried out using a postal questionnaire. RESULTS: Among 6302 responders (54% of those mailed), 19% had taken up influenza immunisation during winter 2002/3. Vaccination was well tolerated, with a low prevalence of side effects (13%) and associated time off work (2%). The majority of subjects who accepted vaccination (66%) were most strongly influenced by the personal benefits of protection against influenza. Prevention of sickness absence and protection of patients were the prime motivation for only 10% and 7% of subjects, respectively. Among 3967 who declined vaccination, the most common primary demotivators were concern about safety (31%) and efficacy (29%). 22% were most strongly deterred by lack of time to attend for vaccination. Free text answers indicated that 37% declined because of a perceived low ratio of personal benefits to adverse effects. Subjects said they would be persuaded to take up vaccination in future by easier access (36%), more information about personal benefit and risk (34%) and more information about effects on staff absence (24%). CONCLUSIONS: These findings indicate that the uptake of influenza immunisation among UK healthcare workers remains low. There is some scope for increasing uptake by improving accessibility and encouragement from professional peers. However, the results suggest that perception of small personal benefit in relation to risk mitigates, importantly, against higher uptake of routine annual influenza vaccination. Thus, resource might better be allocated to ensuring efficient management in epidemic years. The effect of publicity about pandemic influenza on risk perception and vaccine uptake among healthcare workers during winter 2005/6 warrants further study.

Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial.

OBJECTIVE: To determine whether vaccination of care home staff against influenza indirectly protects residents. DESIGN: Pair matched cluster randomised controlled trial. SETTING: Large private chain of UK care homes during the winters of 2003-4 and 2004-5. PARTICIPANTS: Nursing home staff (n=1703) and residents (n=2604) in 44 care homes (22 intervention homes and 22 matched control homes). INTERVENTIONS: Vaccination offered to staff in intervention homes but not in control homes. MAIN OUTCOME MEASURES: The primary outcome was all cause mortality of residents. Secondary outcomes were influenza-like illness and health service use in residents. RESULTS: In 2003-4 vaccine coverage in full time staff was 48.2% (407/884) in intervention homes and 5.9% (51/859) in control homes. In 2004-5 uptake rates were 43.2% (365/844) and 3.5% (28/800). National influenza rates were substantially below average in 2004-5. In the 2003-4 period of influenza activity significant decreases were found in mortality of residents in intervention homes compared with control homes (rate difference -5.0 per 100 residents, 95% confidence interval -7.0 to -2.0) and in influenza-like illness (P=0.004), consultations with general practitioners for influenza-like illness (P=0.008), and admissions to hospital with influenza-like illness (P=0.009). No significant differences were found in 2004-5 or during periods of no influenza activity in 2003-4. CONCLUSIONS: Vaccinating care home staff against influenza can prevent deaths, health service use, and influenza-like illness in residents during periods of moderate influenza activity. TRIAL REGISTRATION: National Research Register N0530147256.

Epidemiological differences between back pain of sudden and gradual onset.

OBJECTIVE: To explore possible differences in risk factors for low back pain according to its speed of onset. METHODS: We analyzed longitudinal data from 1366 hospital nurses in England who initially had been free from low back pain for at least one month. Risk factors were ascertained from a self-administered baseline questionnaire, and outcomes from serial followup questionnaires. Hazard ratios (HR) for developing a first new episode of low back pain during followup were derived by Cox regression. RESULTS: Low back pain with gradual onset was significantly associated with psychological symptoms measured at baseline [HR 1.7 (95% CI 1.2, 2.4) and higher], but no such association was seen for sudden pain. Low back pain with sudden onset while at work was associated with exposure to specific patient-handling tasks [HR 1.8 (95% CI 1.1, 3.0) to 2.8 (95% CI 1.4, 5.5)]. However, symptoms that came on suddenly elsewhere were not related to occupational activity, and low back pain of gradual onset showed little relation to patient-handling. CONCLUSION: These findings suggest that a useful distinction can be made according to the speed and circumstances of onset of low back pain. If confirmed, they have important implications for the evaluation of ergonomic interventions aimed at reducing back pain.

Impact of ergonomic intervention on back pain among nurses.

OBJECTIVES: This study assessed the impact of ergonomic intervention on rates of low-back pain among hospital nurses. METHODS: Altogether 1239 female nurses from two hospitals in southern England completed a baseline postal questionnaire about low-back pain and associated risk factors. Between 18 and 28 months after the baseline survey, major intervention was implemented at one hospital to minimize unassisted patient handling and high-risk nursing tasks. At the other, no intervention was initiated, and efforts to improve patient handling were more limited. Thirty-two months after the baseline survey, a second postal survey was carried out in both hospitals (1,167 respondents) to reassess the prevalence of symptoms and risk factors. RESULTS: After adjustment for nonoccupational risk factors, prevalent low-back pain at baseline was associated with low job satisfaction and the performance of patient-handling activities without mechanical aids. After the intervention, the prevalence of occupational risk factors was somewhat lower, but similar improvements occurred at the comparison hospital. At the intervention site the prevalence of symptoms increased slightly (from 27% to 30%), whereas at the comparison site there was no change, the prevalence remaining constant at 27%. Calculations based on the association of risk factors with symptoms at baseline and the observed changes in their prevalence indicated that the change in risk factors was insufficient to produce a substantial reduction in back pain. CONCLUSIONS: These findings cast doubt on the means by which many hospitals are attempting to improve the ergonomics of nursing activities. More effective methods of implementing changes in work systems are needed.