Organisational and relational factors that influence return to work and job retention: The contribution of activity ergonomics

Abstract

BACKGROUND:

Work is a determinant of employee health, and the same conditions that contribute to an illness do not favour return to work; consequently, they hinder job retention, other employees can become ill and new leaves are generated.

OBJECTIVE:

To analyse the nursing technicians work in intensive and semi-intensive care units (ICUs and SICUs) and discuss the influence of organisational and relational factors on return to work and job retention. This study also discusses the contributions of activity ergonomics to these processes.

METHOD:

Qualitative case study based on ergonomic work analysis (EWA). Data were collected using documentary analyses, and global, systematic, and participant observations involving nursing technicians working in ICUs and SICUs.

RESULTS:

Task planning and the staff size adjustment to respond to the work demands of these units were ineffective in real-world situations and were aggravated by cases of absenteeism, medical leave, and employees returning to work.

CONCLUSIONS:

Work structure limits return to work and job retention. An EWA based on the activities developed by professionals is a valid tool for understanding working processes by applying transforming actions to real-world work situations.

Keywords

Emergency services vocational rehabilitation job security ergonomics

1 Introduction

The recent increase in the number of work-related diseases and medical leaves is primarily due to work organisation 1 . Moreover, these health conditions are diagnosed in advanced stages, limiting the establishment of a correlation between work and the illness process [2, 3]. The problems caused by the late diagnosis of work-related diseases also often leads to employees having work restrictions and being unable to fully perform their job activities [4].

Several studies, protocols, and work rehabilitation programmes have been developed in different countries to address work-related disease, work leave, return to work, and job retention. In addition, these studies and programmes propose to identify obstacles to effective return to work after medical leave and strategies to improve this process [2 , 5–16].

This study analysed the work of nursing technicians employed in intensive and semi-intensive care units (ICUs and SICUs) to discuss the influence of organisational and relational factors on return to work and job retention, as well as the contributions of ergonomics to these process. The demand for this study was generated by a hospital board to ensure that returning employees of different sectors would find success in their work activities after their medical leave. The data provided by the hospital human resources department were used to identify the employee population and conditions with the highest rates of absenteeism and medical leave. This review indicated that the ICUs and SICUs of the hospital best fit the criteria. In addition, these units were considered as a priority because of the severity of the patients’ health conditions under their responsibility, the numerous employees with medical restrictions, the hospital’s difficulty in finding replacements for employees on leave, and the effect of the situation on the care provided.

Studies with nursing teams in the hospital setting also have reported that the rates of absenteeism and medical leave are high among nurses working directly in ICUs [17 –20]. In the service sector, particularly healthcare, work organisations occasionally disregard the nature of the activities required. In hospitals, patient health condition severity, the imminent risk of death, the indisputable need for teamwork, complications, and unpredictability are part of the job and are not compatible with staff downsizing, goal setting, or individual performance assessment [20].

Although the effect of the context on return to work is known, most studies have found that this process is centred on individual factors and the health conditions of the employee. Therefore, knowledge about the illness processes and aspects of the work organisation that contribute to medical leave are not prioritised. Furthermore, the maintenance of inadequate procedures and employment conditions can undermine the ability to return to work, worsen illness, generate more medical leave, and (in severe cases) cause a permanent inability to work, ultimately leading to early retirement due to disability [2–5 , 21–26].

According to Young [2], return to work is not the end of the rehabilitation programme, and a follow up is necessary to promote job retention. In addition, the fundamental factors of job retention are the work environment, work organisation, and the relationship with one’s supervisors and peers. Other studies have indicated that the unwillingness and resistance of employers, supervisors, and peers to accept returning employees hinder return to work [3–5 , 21–28].

In addition, work situation with high rates of absenteeism and work leave, whether short- or long-term, affect the daily routines of employees in these environments, which must be managed with fewer employees to maintain the same level of quality and productivity. This situation limits the planning and division of work and favours the creation of partial and improvised solutions to meet daily demands, thereby disregarding the complexity of services and the employees who must work collaboratively [4 , 24–26].

Return to work is a fragile social process [29] in which the entire team must provide support to returning employees to maintain production levels and prevent work overload [5 , 31]. However, during the return-to-work process, those responsible for work organisation and the employees in charge of specific functions are often not involved in that process or in rehabilitation programmes, leading to fragmented practices among the actors involved in return-to-work services and work situations. Rather, these actions should be integrated to ensure the better functioning of the system as a whole.

2 Method

This qualitative study is part of a project entitled “The effect of organisational and relational factors on return to work and job retention: A case study” developed by the Laboratory of Research and Intervention and Health, Work and Occupational Therapy/Laboratory of Medical Research in Rehabilitation Sciences, Hospital das Clinics, FMUSP, (LIIST/LIM-34) of the Medical School and the Specialised Service in Safety Engineering and Occupational Medicine, both affiliated with the Universidade de São Paulo. The project was approved by the Research Ethics Committees of the Faculty and the university public hospital, where this research was conducted.

This study was designed as a case study [32] based on the theoretical principles of the Franco-Belgian Ergonomics approach and the ergonomic work analysis (EWA) method [1, 33]. Other studies have adopted ergonomics in hospital settings as a theoretical and methodological framework to identify the crucial factors that might generate work overload, stress, and fatigue [34 –40]. The presentation of the method, procedures, and results complied with the guidelines of the Consolidated Criteria for Reporting Qualitative Research (COREQ) [41] for all items compatible with the EWA.

2.1 The hospital

The study hospital is a public teaching institution affiliated with the state government of São Paulo. This hospital is medium-sized, with 81 administrative and clinical sectors, 1,818 employees, and 258 beds. It is a reference center for care services provided to the university community of 111,000 people and 48,000 additional individuals from communities near the hospital.

2.2 Participants

The ICUs and SICUs team consist of 21 nursing supervisors and 41 nursing technicians. These employees are public servants and remain in the institution for extended periods. Nursing technicians working in ICUs and SICUs and involved in direct patient care were included to participate. These professionals had undergraduate degrees (3 years of study) and perform clinical care procedures, hygiene, feeding, follow up, and patient transportation to other units for laboratory tests. Their work was supervised by nurses who performed complex care, supervision, and management activities, such as, determine the work schedules and activities. Workers on leave or those who only carry out administrative tasks were excluded.

The number of employees included in the EWA was not calculated a priori. The different work shifts (morning, afternoon, and night), the variability in the activities performed, and data saturation were considered for this purpose. Thus, all employees from each work shift were invited to participate during their working hours and volunteered for the study, totalizing 37 participants. Four workers did not meet the criteria for inclusion because they were on leave or only carrying out administrative tasks. The research team had no previous contact with the participants.

2.3 Data collection phases and procedures

The data collection followed the EWA guidelines [1, 33], which was selected because it meets the demands that arise across different work situations and is differentiated by the central role of the activity in the analysis and the involvement of the employees. It does not use a standard checklist because it privileges the singularity of each work situation studied. This method contributes towards an understanding of the work situation, the role and knowledge of the employee, and the correlations between work conditions, activities, and successful results and return to work and job retention [1 , 33].

The EWA was composed of three stages of analysis. The first, the demand analysis, consisted of initial data collection to contextualise the work situation under analysis, identify the employees involved in the situation, and understand and formulate the problem. The second stage, task analysis, aimed to obtain information about the predicted work (known in ergonomics as “task or prescribed work”) and identify the technical, environmental and organisational conditions that determine what should be done. This second stage guides the choice of the most critical situations to be analysed in depth in the next step. The third stage, activity analysis, seeks to understand the work that is performed by employees (i.e., “real work”) to accomplish what was established in the task. This stage involves systematic analyses when employees perform their work to understand how it is conducted, what conditions and resources are effectively made available and used, and what strategies and working methods are adopted to respond to the unexpected.

The stages of analysis are followed by the diagnosis of the work situation analysed in response to the demand that originated the process. Finally, the method includes the development of recommendations and a plan of action regarding the transformation of the work analysed [1, 33].

The ergonomic work analysis (EWA) method was performed from March to August 2014, including an analysis of the demand, the general information regarding work tasks and the employees, and an assessment of the planned and performed work. The following procedures were used, creating approximately 100 hours of analysis.

Demand analysis: Analysis of the documents provided by the hospital to understand the employee population (data related to the employees, medical leave, and return to work for all hospital units).

Task analysis: Analysis of the job description, technical and administrative procedures, training manuals and guidelines, and work schedules to understand the planned work at the ICUs and SICUs. Global observations were also performed through initial visits to these units to identify the job positions, tools, and equipment used, the available means of communication, and so on. These observations were performed by an ergonomist and two assistants on different weekdays over the three shifts to encompass work variability, help understand the work performed, and comprehend the general dynamics of patient care and employee interactions.

Activity analysis: Systematic and participant observations focused on the work situations of the nursing technicians to enable a better understanding of the time management, task division, job requirements, constraints, and number of unpredicted and simultaneous activities. The primary observation variables were the actions of the technicians and the sequences of the procedures, verbalisations, communications, collective and social factors, visual exploration, and data acquisition. Only manual records of the observations were created with respect to patients who were in the study environment but unable to consent to the recording of images. The activities of the nursing technicians were observed from the beginning of the workday until the next shift. During these observations, the researchers interacted with the nursing technicians asking questions to increase their understanding of the work from the perspective of the person who performed the activity. The questions covered issues such as job description, primary difficulties, demands to be managed, and strategies adopted when the employees or colleagues involved in patient care presented with work limitations. These interactions were also manually recorded.

2.4 Data analyses

The data obtained from the documents provided by the hospital, especially those related to absenteeism and work limitations, were subject to a descriptive statistical analysis to guide the other stages of the study.

A normative comparative analysis that combined the data obtained during the three stages of the EWA was conducted to understand the gap between the planned and performed work. In this context, we evaluated whether certain practices exceeded the planned work under conditions that were not necessarily adequate for such work [1, 33].

The observation records were organised to obtain a chronological description of the tasks and activities. The narrative reports of the observed actions were elaborated considering temporal references (beginning, end, and duration) to identify simultaneous actions. The descriptions were complemented with the participants’ statements, which were organised and subjected to an exploratory analysis. The ergonomic analysis was completed by validating the findings in meetings with the employees involved in this study [1, 33].

3 Results

The results were presented based on the different phases of the EWA. Thus, they include general information about the participants and their work in the analysed units, characteristics of the work restrictions of this population, and descriptions of the planned and performed work of the nursing technicians.

3.1 Participants and their work in the ICUs and SICUs

Of the 37 who participated in the study, more than 50%were over 40 years old with a length of employment of > 15 years.

To determine the staff size in each sector, the Nursing Department analysed the workload of each unit, the length of employment, and the technical safety index. Another factor that affected decisions related to team size were patient care demands based on the patients’ degree of dependence (intensive care, semi-intensive care, strong dependence, or moderate dependence) and the average number of patients assisted daily.

Furthermore, the staff size was determined based on the care activities to be developed, discounting idle periods. However, employees reported that idle periods do not exist. Employees performing direct patient care needed to monitor patients, check vital signs, and remain alert for emergencies that might require further action. Moreover, managerial activities, continued training, participation in internal hospital commissions, and training offered to university students were not considered with regard to staffing.

The nursing technicians who were allocated to care activities were divided into two 6-hour shifts (the morning shift [nine technicians and six nurses] and the afternoon shift [eight technicians and seven nurses]) and two 12-hour night shifts followed by 36 hours of rest (ten technicians and four nurses). On weekends, the morning and afternoon shifts were replaced by a single 12-hour shift, with professionals alternating between Saturdays and Sundays.

The nursing technicians took turns between the ICU and SICU each week, worked in pairs, and were responsible for up to four patients in the ICU and up to eight patients in the SICU. Each work pair was under the supervision of a nurse who alternated between sectors each month.

3.2 Work restrictions of the ICU and SICU nursing technicians

In the ICU and SICU, 12.9%of the nursing technicians presented with medical restrictions. The most common restrictions were related to musculoskeletal problems, including avoiding carrying weights > 5 kg; standing for more than 30 min; pulling, pushing, lifting, or lowering a load; bending or twisting at the trunk; and walking for extended periods. Approximately 35%of the ICU and SICU nursing technicians with work restrictions were instructed to avoid direct contact with patients. Other limitations included, for instance, avoiding exposure to chemical products and respiratory irritants. However, these activities are essential in the units studied.

The specific work restrictions of the nursing technicians were considered in the work schedule shifts created by the organisation’s nurse supervisors. To avoid compromising the work planned, professionals with similar limitations are not paired together. The non-replacement of employees on leave and employees with limitations further hindered the balanced distribution of the schedules, which required more work from some employees, contributing to an increased workload. This protocol risks employee health and the security and quality of the care provided to patients.

3.3 Planned vs. performed work among nursing technicians in the ICU and SICU

As in most sectors of the hospital, patient care occurs uninterruptedly 24 hours a day in the ICU and SICU. During the three shifts, each patient is followed up by a pair of nursing technicians and a nurse supervisor, all of whom are responsible for several tasks including administering medications, feeding, bodily and oral hygiene, changing clothing, monitoring the patient’s overall status, collecting blood, replacing equipment, and assisting in medical procedures. These tasks must be executed in sequence, and certain tasks (e.g., hygiene procedures and turning and moving the patient) should be performed together with one’s partner nursing technician.

Although the sequence of tasks performed by the technicians is planned, the severity of the patient’s condition might require performing different tasks simultaneously including administering drugs, helping with feeding, updating medical records, and assisting those who need help using the toilet. The working day in the ICU and SICU cannot be completely planned because of the uniqueness of each patient, the variability of their conditions, and the variabilities related to the employees and work environment demands. Thus, the decisions about the organisation and prioritisation of tasks occur in real time. In this sense, the interruption of certain activities requires the use of strategies that prevent errors.

Complications that modify actions in progress occur in emergency services. Although expected, how and when these events occur cannot be predicted; thus, they can occur at any time and often simultaneously. One example was the arrival of a patient to the emergency room in severe condition that required ten professionals for bed transfer. Although the team was aware that the patient was being referred to the ICU, they were not informed of the exact time, and the patient arrived when the team was unprepared. The patient arrived at the same time that the technician responsible for this patient was bathing another patient.

Another example of a complication and the consequent interruption of on-going activities was observed when a patient was being monitored by the attending physician and needed the assistance of two technicians (TEC 1 and 2) who immediately interrupted their activities: TEC 1 was preparing medications, while TEC 2 was taking care of another patient. The technicians responded to the physician’s request, and the patient was stabilised. At the end of the procedure, TEC 1 commented, “Now I am very late. I think I will not be able to finish what I need to do by the end of the shift”.

Many variables affect work including the time required to perform a procedure, which depends on the state of consciousness, autonomy, and cooperation of the patient. Patient gender, weight, and height also affect care provision. Therefore, it is difficult to predict what will be performed, the necessary effort, length of procedure, and the need for cooperation with colleagues throughout the workday. Importantly, conscious patients are not always able to eat independently. Occasionally, so many patients need care that technicians do not know where to start and even hope that some patients will not be hungry.

In this respect, work variability is evident within the ICU and SICU; each patient requires different care according to the participants and our real-time observations. Although all patients were in critical condition and presented with similar symptoms in certain cases (e.g., severe cardiac, respiratory, neurological, or postoperative conditions), the participants highlighted the uniqueness of each person and their care.

Another example was the case of a burn patient. Because of the patient’s condition, it was necessary to perform a sterile procedure for approximately 2 hours given the risk of infection. As certain participants emphasised, this situation requires transfer to another unit because the study hospital does not have the technical support necessary to care for these patients. One nurse technician was solely responsible for caring for this patient, while the other technicians cared for the other patients. This situation imposed team reorganisation in real time and affected the daily schedules of other technicians to the detriment of the day’s plan. In addition, work pace increased, which had consequences on the quality of care provided.

In addition, a high patient turnover is inherent to work in ICUs and SICUs. Each admission or discharge increases the period dedicated to each patient and changes the routine of care for other patients. In this respect, at least two daily admissions occurred > 70%of 2013 in the ICU and 65%of the same year in the SICU.

During an ICU stay, two situations can displace the professionals to other hospital sectors: the transfer of patients for specific exams (e.g., diagnostic imaging) or chirurgical procedures. In these situations, a nursing technician leaves the unit to transfer and care for the patient during the transfer, whereas his or her working partner is responsible for caring for three other patients in the case of the ICU or seven in the case of the SICU.

Moreover, the absence of nursing technicians, either because of medical leave or while accompanying the patient to another unit has consequences to the work of the nurse supervisors who are required to take on tasks assigned to the technicians. In these cases, patient care activities under the technician’s purview are assigned to a nurse, who adds that responsibility to his or her own supervision and care activities.

Considering and understanding the discrepancy between the prescribed and performed work reveals that task planning and staff size adjustment to respond to the demands of the units are not effective in real-world situations. This planning only partially considers the dynamics of the situation and emerging events. The work performed by nursing technicians varies with regard to employees, patients, and work activities and depends on patient health condition, case urgency, the number of simultaneous demands, and risk of imminent patient death. Such situations restrict work and limit the possibilities for employees to develop new working methods. This inability to regulate their work has consequences for the health of nursing technicians and can lead to medical leave or work restrictions.

4 Discussion

The need for the present study originated from the concerns of the board of directors at a public university hospital regarding the process of return to work after employee medical leave. This study reaffirmed work as a determinant of employee health, and the same conditions that contribute to an illness do not favour return to work; consequently, they hinder job retention. In addition, other employees can become ill, generating new leaves, thereby further complicating the work situation due to a reduction in the number of employees who occasionally return to work without being able to fully perform their duties.

Regarding the nursing technicians in the ICU and SICU, the analysis conducted showed that the accomplishment of work activities required integration and collaboration among members of the nursing team. The thin line between the life and death of patients in critical conditions required the constant evaluation of data from the monitored biological markers and the qualitative information that require constant attention throughout the workday. This information was vital and helped with regard to the diagnosis and prognosis of the patients’ health statuses. Employees were often required to monitor several patients simultaneously and (depending on the situation) were assisted by other colleagues to ensure that every patient received care. This approach requires both attention and experience, as well as the sharing and integration of knowledge among peers.

Although the nurse supervisors provided explicit instructions regarding the work limitations of returning employees to protect worker health, the reality of the work occasionally prevented these instructions from being followed. When having to choose between self-care and patient care, the professionals choose the latter, particularly during emergency situations. Therefore, it was not possible to guarantee that an employee with restrictions would not provide care when facing the effort and pace demands imposed by patient conditions, staff size, and (particularly) the urgency of care because certain cases required immediate interventions to keep the patient alive.

This behaviour also reflected the level of engagement and commitment to the team because professionals with work limitations knew that their colleagues, particularly their working partners, counted on them. Similarly, team members sought to understand the limitations of their peers and, in many cases, attempted to provide care in situations of work overload to reduce the risks to their partners.

On the other hand, it is also necessary to consider the resistance of supervisors and peers to the work restrictions placed on those returning to work, as other studies have highlighted [2–4 , 21]. These situations might favour conflict, feelings of injustice, and irritation among peers, as well as tend to hinder cooperation, acceptance, and the inclusion of employees with limitations who are considered as “problems”, thereby jeopardising their return to work. Furthermore, given that relationships with peers and supervisors are essential for job retention [1], this process might also be impaired.

To minimise the deterioration of work relationships and provide the necessary support to returning employees, supervisor mediation and active peer participation is necessary in work reorganisation [4 , 25].

Moreover, other effects of the work and health conditions of nursing technicians concerning the activities of other technicians were emphasised. Staff size was decreased by absenteeism, sick leave, and work reorganisation because situations occurred in which the nursing technicians left their units to perform patient follow-up assessments. These situations affected the staff size within the units and the task distribution, placing more demands on those working the same shift. Furthermore, the staff accumulates experience because of the extended length of employment but suffers the effects of ageing and job strain, which can lead to the development of age- and work-related health problems.

In addition to the diversity of the activities performed by the nursing technicians, the tasks were not accomplished in the sequence planned, nor was it possible to anticipate the amount of work within each shift. The sequence of planned activities scheduled at specific times of the workday, including administering medications, checking vital signs, and assessing patient hydration, was interrupted by other tasks and complications that might occur at any time and with variable levels of intensity and duration.

Importantly, much of the work performed by nursing technicians is invisible because it is a type of work related to care, in which many relational activities concerning the patients and their families are not considered in the planned tasks [42, 43]. In addition, certain situations might create apparent idleness or a lack of productivity in the ICU or SICU; however, the employees not involved in direct patient care were under a constant state of vigilance because they might need to act at any moment.

These particularities of the work, which affect the return-to-work process, were compounded by the staff size, which did not meet the real-world needs of the work for several reasons including the exclusive emphasis on care activities; the disregard for patient turnover, patient-to-patient variability, and patient care needs; the non-replacement of employees on leave; and the presence of employees with limitations who cannot perform certain activities.

4.1 Methodological considerations

This study was based on Franco-Belgian Ergonomics, particularly the EWA [1, 33] to better understand the work of ICU and SICU nursing technicians and discuss the organisational and relational factors that affect return to work and job retention. This method helped better understand the real-world working situations from the perspective of employees. Studies have reported that considering working condition and ensuring its suitability when employees return to work facilitates both this process and job retention [1 –3].

In this study, the EWA favoured the identification factors that affect return to work and job retention and that might contribute to the worsening of the health conditions of employees. Therefore, the EWA supports return to work and job retention by allowing employees to identify and collectively propose solutions for work reorganisation. Carayon et al. [33] emphasised that active participation and employee autonomy favour decision making in the face of complications, reduce occupational health risks, and improve quality of care and patient safety.

The EWA might help develop interventions aimed at modifying work to improve the conditions offered to employees and develop the professional activities and skills [40] that contribute towards preventing work-related diseases and promoting health. In this sense, the method might also favour the interruption of the cycle of illness and work leave that deteriorates work situations due to the reduction of the number of active employees.

One of the limitations of this study is that the results are based on observations and interviews with ICU and SICU employees. Other professionals involved in return to work, including those affiliated with the SESMT, were not included in this study. In addition, the study did not include any changes to the work situations studied.

The strengths of this study include its data triangulation that allowed us to better understand the work situations and the analysis of return to work and job retention based on real-world situations using the EWA, rather than focusing only on sick employees or those on leave.

Future studies might seek solutions to change work in the ICU and SICU, thereby minimising the factors with the potential to worsen the health status of employees and favour return to work and job retention. To achieve this goal, it is imperative to include other employees from other units.

5 Conclusions

The present studied revealed a discrepancy between the prescribed and performed work of nursing technicians in the ICU and SICU. In addition, it highlighted organisational and relational factors, as well as the work particularities of these professionals that reveal work restrictions where no margin for adjustment exists regarding the methods for performing one’s responsibilities. These factors contribute to employees becoming sick, taking leave, and having difficulties with returning to work and job retention. In the current study, the employees did not find any organisational changes aimed at promoting retention after returning to work (with or without limitations). These factors were not considered; therefore, neither staff size nor the work itself were adjusted to meet the needs of returning employees and to not overload other employees. The consequences for the quality of the care provided, including the risks in terms of patient security must also be considered.

The EWA can be used to stimulate the construction of a social process in which employees actively participate in identifying facilitating and hindering factors, understanding the interactions between these factors, and reorganising the work environment by considering both the demands of a specific sector and the activities of returning employees and their peers.

Footnotes

Acknowledgments

The Brazilian National Council for Scientific and Technological Development (CNPq-BR) funded this study (Process 483197/2012-2), and the Laboratory of Medical Research in Rehabilitation Sciences, Hospital das Clinics, FMUSP, (LIM-34).

Conflict of interest

None to report.

In this article, the term “work organisation” refers to the division of tasks and the assignment of employees involved in certain production process; the hierarchical structure; work and rest times; and the pace, quality, and productivity requirements. Relational aspects, for instance, interactions among peers, as well as between peers and supervisors are also emphasised [].

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