Abstract
The Acute Psychological Trauma (APT) Study was a collaboration between an acute care hospital, a specialized multidisciplinary program designed to meet the mental health needs of injured workers, and a large urban public transit system. The overall purpose was to evaluate a Best Practices Intervention (BPI) for employees affected by acute psychological trauma compared to a Treatment as Usual (TAU) group. The specific purpose is to discuss facilitators and barriers that were recognized in implementing and carrying out mental health research in a workplace setting. Over the course of the APT study, a joint implementation committee was responsible for day-to-day study operations and made regular observations on the facilitators and barriers that arose throughout the study. The facilitators to this study included the longstanding relationships among the partners, increased recognition for the need of mental health research in the workplace, and the existence of a community advisory committee. The significant barriers to doing this study of mental health research in the workplace included differences in organizational culture, inconsistent union support, co-interventions, and stigma. Researchers and funding agencies need to be flexible and provide additional resources in order to overcome the barriers that can exist doing workplace mental health research.
Keywords
Introduction
In view of the staggering social and economic costs due to mental illness among workers [1], there is a need to focus efforts to decrease the impact through evidence-based intervention approaches and develop workplace strategies to reduce loss of productivity and disability costs related to mental illness. In workplaces where there is a high risk of traumatic events, evidence-based approaches to disability management and Return-to-Work are needed in order to support individuals with PTSD and work related injuries [2]. However, such research endeavors in the workplace are not without challenges and obstacles. To date, there has been a general paucity of research that has attempted to identify systematic barriers that impede collaborative health research in the workplace.
The purpose of the current report is to discuss some of the facilitators and barriers that were recognized in implementing and carrying out mental health research in a workplace setting. In this report, the study methods are briefly presented, followed by a discussion of the facilitators and barriers of doing mental health intervention research within a workplace setting such as within a large urban public transit system. Separate reports will discuss the qualitative [3] and quantitative [4] results of this research.
Method
Acute Psychological Trauma (APT) Study was collaboration between an acute care hospital, a specialized multidisciplinary program designed to meet the mental health needs of injured workers, and large urban public transit system. The purpose of the APT study was to evaluate a Best Practices Intervention (BPI) against a Treatment as Usual (TAU) comparison group for employees exposed to an acute psychologically traumatic workplace event. The BPI consists of four main elements: Education and training for exposed workers, screening and surveillance, referral to specialty services, and return to work coordination. The study used a sequential mixed methods design to first understand workplace trauma by examining the issues for traumatized employees to get treatment and return to work using qualitative techniques, and then implementing and evaluating a “Best Practice Intervention” (BPI) using quantitative methods. During the TAU phase of the study, employees who experienced an acute traumatic event while at work were assessed at 1, 3, and 6 months post-event and the time to return to work was recorded as the primary outcome. For the BPI phase of the study, if PTSD symptomatology was detected, the participants were offered referral to the BPI and were again followed for 6 months post-event and the time to return to work was recorded. The project was successfully implemented and the BPI was delivered to traumatized workers. However, we were unable to recruit the full sample to BPI intervention in spite of lengthening the recruitment period by 12 months. The original sample size calculations called for 124 participants in the BPI and by the close of the study 79 participants had been recruited.
Over the course of the APT study, a joint implementation committee was responsible for day-to-day study operations. The committee included the representatives from the three participating organizations. During the regular bi-weekly meetings, the committee documented those processes that were considered facilitators and barriers to conducting applied mental health research in the workplace. This report arises from the committee’s observations made over the course of this research project.
Results
There were several factors identified by the joint implementation committee that facilitated conduct of workplace mental health research.
Facilitating factors
Existing relationships between collaborators
A longstanding relationship between the urban public transit system and the acute care hospital had existed for almost a decade working together on the issue of suicide prevention in the urban subway system. Rahel Eynan, research In addition, the specialized program for injured workers had an existing relationship with the Workplace Safety and Insurance Board (WSIB) that funded the rehabilitation of injured workers. These existing relationships allowed the three organizations to collaborate on the APT study and to come together to prepare the grant proposal for the Workplace Safety and Insurance Board Research Advisory Council that funded the APT study.
The rising national awareness for the need for health research in the workplace
During the time that the APT study was being implemented and carried out, several Canadian organizations were very active advocates for addressing mental health in the workplace. The Economic Round Table both in Canada and the US worked to raise awareness about the significance of mental health problems in the workplace. Founded in 1996 by Harvard School of Public Health, the Economic Round Table attempted to identify common best practices among businesses that would promote mental wellbeing among the workforce [5]. In addition, The Report of the Standing Senate Committee on Social Affairs, Science and Technology in Canada reported that a major private insurance company estimated that 30% of disability insurance claims were related to mental illnesses and of the remaining 70%, 25% or more had mental illnesses as a secondary or underlying condition [6]. The Mental Health Commission of Canada (MHCC) which was created out of the Report of the Standing Senate Committee had been advocating for key organizational personnel and resources to be allocated to programs that not only help reduce stigma, but also improve the mental health in the work environment.
Lastly, Mitacs is Canada’s top internship program as well as a not-for-profit research organization and they were offering graduate and postdoctoral students support in a wide range of research areas that build partnerships between businesses and the research community. Students are able to take their research experience and apply it to real-life cases and settings [7]. During the APT Study, two Graduate students were awarded Mitacs-Accelerate Program internship grants.
Forming a community advisory committee of knowledge users
Early during the creation of the APT research proposal, a community advisory committee consisting of representatives from national transit associations, local police and fire services, local emergency medical services, the armed forces, private insurance companies and the Workplace Safety Insurance Board was formed. This committee of knowledge users, or those making use of the study results, offered advice and guidance to the research implementation committee regarding the vision, mandate, the yearly study objectives, and reviewed the study’s progress for the purposes of knowledge translation.
The community advisory committee worked closely together with our research implementation committee to problem-solve the difficulties concerning recruitment and to develop approaches to transfer knowledge arising from the study program.
Barriers
In partnering with the workplace we marry two worlds of research and development. As in any collaborative or partnership endeavor, tensions arise in settings where conventions of one world (corporate) come up against the conventions of the other (academia) and vice versa.
The differences across the collaborating agencies regarding the “culture of research”
Organizational culture refers to a system of shared basic assumptions, beliefs, metaphors, values, and symbolic boundaries held by organizational members that are expressed through “what is done, how it is done, and who is doing it” [8]. According to Schein (1990) organizational cultures consist of two layers of concepts, which are visible and invisible characteristics [9]. The visible layer refers to the overt appearances or behaviors that can be seen. The invisible layer is the intrinsic values, norms and assumptions of organization members. Organizations convey cultural values by means of mission statements or corporate credos, or to a lesser extent through slogans, logos, or advertising campaigns. Other elements of culture appear tacitly in symbols and symbolic behavior. Culture can regulate social norms as well as work or task norms.
The three organizations were committed to carrying out the study; however, several differences in the organizations’ culture, priorities and purposes interfered with completing the study as proposed. The healthcare facilities had long standing commitments to clinical research that enabled them to dedicate resources to research activities for the duration of the study. Conversely, during the course of the study, the urban public transit system went through several changes in their key Occupational Health (OH) personnel associated with the study that hindered the recruitment process. As a result, the OH staff member responsible for referrals of employees to the study was replaced five times during the course of the study. These changes often interrupted the referral process and the recruitment of new participants into the study. During the course of the study, clinical staff turnover was also experienced by the specialized program for injured workers leading to delays in participants accessing BPI.
Full participation by the transit employees in the study was hampered because there were no standardized procedures to contact employees by email and the re transit operators had limited or no access to the corporate internal website; employees and drivers, in particular, worked very independently and had little interaction with the administrative office and also they were not required to attend regular staff events. As a result, it was difficult for researchers to contact potential participants and there was no systematic method to access and reach all the employees and inform them about the study and its progress was no central website utilized for employees.
All the collaborators understood the need for Research Ethics Board (REB) approval for the study. However, the time frames for ethics approval often did not mesh with the time frame of the urban transit system. For example, when we were preparing recruitment posters for the study, these materials were prepared by the in-house services of the transit system. They were done professionally and in a timely manner. However, all of the study promotional materials needed to be approved by the separate hospitals communication departments and then the REB offices. Each alteration would have to be re-approved by all of the collaborators. As a result, many aspects of the study experienced long delays while waiting for the final ethics approvals.
Union commitment inconsistent and dictated by events external to the study
The study collaborators felt that it was crucial to obtain the support of the local unions, to which most transit personnel (drivers, ticket collectors and maintenance workers) belong. However, the union’s support was driven by many factors external to the study and the level of support changed dramatically over the course of the study. The study coincided with two contract negotiating periods between the unions and the transit system (2008 and 2011) and union elections 2009. At the initiation of the APT study in December 2007, the union insisted on being a signatory to the collaborative agreement and the union’s Executive Vice President regularly attended the research implementation committee meetings. A few months into the study, after a change in the union elected representative, the union decided to adopt a neutral stance and no longer formally supported or endorsed the study. Two years later, in 2010, the union withdrew support from the research project and the study became one of the contentious issues in their contract negotiations with management. As a result, the union stance appeared to have discouraged employee participation in the research.
Co-interventions during the course of the study: Barriers for bus operators and safety initiatives from the TTC
During the course of the APT study, a few new programs were implemented by the urban transit system to help to improve workplace safety and increase mental health awareness. These new programs acted as co-interventions; a co-intervention being defined as a type of treatment outside of the study intervention that was applied to both the intervention and controlled groups. Some of these co-interventions included the installation of barriers around bus drivers, installation of video cameras on the subway station platforms and on-board vehicles, and a corporate wide safety initiative. Towards the end of the study period, the urban transit system also created a peer-to-peer support group that actively encouraged employees who had experienced a traumatic event to use the help of the peer support group and forgo referral to the BPI. In spite of the continued collaboration of the urban transit system with the study, they found it necessary to take steps as outlined above that clearly hampered the quality of the research study.
Impact of stigma
Stigma regarding mental illness can especially impact work opportunities by making it challenging to find and keep a job [10]. Stigma was identified as one of the main reasons to why the participation was lower than expected in the APT study from transit employees. Furthermore, employees who were impacted by a traumatic event at work had a hard time accepting mental health care because they did not want to be identified as needing psychiatric help and they did not want to be seen going to a hospital. There was some concern expressed that participation for the APT study was low due to stigma associated with attending a psychiatric hospital setting for treatment. In order to help with this matter, we informed participants that the specialized program for injured workers was off site and in an office building separate from the hospital.
Discussion
The APT study was successfully implemented and carried out as a partnership between an acute care hospital, a specialized multidisciplinary program designed to meet the mental health needs of injured workers and a large urban public transit system. The major difficulty with implementing and completing the APT study was the difficulty recruiting the proposed sample size. As this difficulty arose during the course of the study, the implementation committee made an effort to attend to those processes that were facilitating or hindering the successful completion of the study.
In terms of facilitators, the committee recognized that the external environment was ready and supportive of mental health interventions in the workplace. Many groups and agencies were raising awareness about the need for more research focused on mental health in the workplace. Carolyn Dewa (2007) wrote about “a sense of optimism” for the development of workplace interventions; however, she also highlighted the need for “high-quality research to provide evidence for best practices” (p. 344) [11]. This study was made possible because of the long-standing relationships that existed between the collaborators prior to start of the project. These pre-existing relationships allow for trust, openness and unity of purpose, which allowed the implementation committee to be effective at problem-solving most of the issues that arose during the course of the study. In addition, the study’s advisory committee of knowledge users had existed prior to the initiation of the APT study and as a result, this group became a very meaningful resource where problems could be aired and resolved.
Although the collaborating partners had existing relationships, the different cultures, practices and policies of the three organizations were perceived as main barriers to successful completion of the study. To successfully do mental health research in the workplace several of these barriers must be anticipated and overcome such as: 1) providing the needed continuity of applied research processes and recognizing this continuity may involve five-years or more of stable membership, 2) preparing for the unique communication issues in workplace settings such as the urban transit system and 3) adjusting REB processes to complement the timing and procedures that exist in the workplace. Funding agencies should provide adequate lead-in funding so that the participating agencies can develop solutions to coordinate practices and policies and influence cultures and thus enhance the success of working directly in workplace settings. Our experience highlight that mental health research in the workplace will be affected by union-employer relations and negotiations and by programmatic developments that may act as co-interventions during the completion of workplace clinical trials. Many of these barriers cannot be accurately predicted beforehand, so implementation groups need to be nimble, creative, and have the resources available to manage the changes that will always be necessary during the course of carrying out mental health research in the workplace. Stigma towards mental illness and treatment for mental illness is a difficult problem to overcome and remains a societal issue for Canadians. Stigma may be reduced by demonstrating and disseminating the value of workplace mental health interventions based on high-quality research [12].
In summary, our experience in planning and implementing the APT study made us aware of the facilitators and barriers to doing workplace mental health research. As this field is still new, we hope our experience will inform funders, researchers, workplace collaborators, unions and employees about possible directions for further growth and development. Participating in this research has confirmed our belief that collaborations between mental health researchers and workplace settings have great potential to advance the mental health of Canadians.
Conflict of interest
None to report.
Footnotes
Acknowledgments
This research project was funded by a grant from the Workplace Safety and Insurance Board Research Advisory Council.