Background
Methods
Setting and sample
Methods and study outcomes
Intervention
Analyses
Results
Intervention implementation
Work system factor (SEIPS) | Identified problems and issues for improvement | Solutions and respective improvement measures | #HCM / #SCM | Implementation status at follow-up |
Organization | Lack of personal breaks during work time (i.e., limited opportunities to take breaks while on duty; short duration of breaks; multiple short breaks instead of longer pauses) | Schedule additional nursing staff for short-term replacement of nurses taking breaks | HCM#2 / SCM#2, SCM#4 | Not feasible and declined after discussion in steering committee |
Short-term rotation across ED units to replace nursing staff in breaks | HCM#2/ SCM#2, SCM#4 | Partially completed | ||
Supervising physicians coordinate residents’ breaks | HCM#2/ SCM#2 | Fully completed | ||
Shift supervisor coordinates temporary replacement of nursing staff in breaks on a daily basis | HCM#2/ SCM#2, SCM#4 | Declined after discussion in steering committee | ||
Task | Unclear work agreements (i.e., lack of mutual agreement between ED units concerning patient transfers and admissions; unclear agreements with ICU and adjacent care units concerning specific care obligations, e.g., timing of transfusions) | Revise agreements for interdisciplinary occupancy of ED observation unit | HCM#3 / SCM#2, SCM#4 | Discussed with consulting physicians and head nurses; not implemented |
Agreement on transfusion process in ED observation unit | HCM#3 / SCM#2 | Discussed among attending physicians; completed | ||
Organization | Meeting with ICU representatives and revision of patient transfer agreements from ED observation unit | HCM#3 / SCM#2 | Not implemented | |
Organization | High pressure environment - point of triage (i.e., poor and narrow design of triage area; understaffing; lack of qualified personnel for triage; ongoing project on redesign of triage process and assisting technology) | Repeated discussion of various solutions for point of triage in ED management meeting (with the objective to manage exceeding work load during triage) | HCM#4, HCM#5, HCM#7 / SCM#3, SCM#4 | Few completed (e.g., blocking of external phone calls); but most solutions considered not feasible (e.g., separate room, free of distractions, permanent staffing of two qualified nurses at triage) |
Leadership (e.g., staff’s need for enhanced participation in meetings and ongoing reorganization) | External moderator for ED nursing staff meetings to allow for enhanced discussion and opportunities to ask questions | HCM#6 / SCM#3, SCM#4 | Agreed, but not implemented at follow-up | |
Ad hoc meeting for ED providers concerning reorganization of triage process | HCM#6 / SCM#3, SCM#4 | Completed | ||
Lack of staff information (i.e., lack of status information concerning ongoing projects and reorganization activities in the ED) | Provision of Q&A sheet on reorganization of triage process for nurses in intranet | HCM#6 / SCM#3, SCM#4 | Completed | |
Staff shortages (i.e., permanent understaffing, particularly during times of high patient load) | Schedule additional nursing and medical providers in shifts | HCM#8 / SCM#4 | Not implemented | |
Realistic HR planning of ED personnel and shift staffing levels of ED nurses and physicians | HCM#8 / SCM#4 | Not started at follow-up |
Sample description
Changes in work system factors
Study outcomes | Scale range | No. of items | Baseline (T1) | Follow-Up (T2) | Effect size | t-test | ||||
---|---|---|---|---|---|---|---|---|---|---|
Mean | SD | Mean | SD | (Cohen’s d) | t | df | p | |||
Work system factors | ||||||||||
Patient stressors | 1–5 | 3 | 4.10 | .63 | 4.11 | .71 | .02 | −.10 | .40 | .921 |
Job control | 1–5 | 4 | 2.63 | .76 | 2.90 | .74 | .36 | −2.57 | 39 |
.014
|
Participation opportunities | 1–5 | 4 | 1.81 | .70 | 1.83 | .70 | .03 | −.24 | 39 | .813 |
Work overload | 1–5 | 3 | 4.37 | .61 | 4.37 | .48 | – | .08 | 40 | .937 |
Personnel resources | 1–5 | 2 | 1.93 | .70 | 1.76 | .75 | .23 | 1.13 | 39 | .265 |
Information problems | 1–5 | 3 | 3.20 | .79 | 3.26 | .80 | .08 | −.55 | 40 | .583 |
Uncertainty | 1–5 | 4 | 3.46 | .65 | 3.64 | .61 | .29 | −1.73 | 39 | .091 |
Overtime (in hours) | – | 1 | 7.79 | 3.93 | 5.93 | 4.92 | .42 | 3.00 | 13 |
.010
|
Social support | 1–5 | 2 | 3.15 | .87 | 2.88 | .89 | .31 | 3.27 | 40 |
.002
|
Supervisor feedback | 1–5 | 2 | 2.05 | .90 | 2.30 | .93 | .27 | −1.96 | 39 | .058 |
Provider well-being | ||||||||||
Emotional exhaustion | 1–6 | 4 | 4.19 | .94 | 4.21 | 1.03 | .02 | −.18 | 40 | .855 |
Depersonalization | 1–6 | 4 | 3.18 | 1.23 | 3.54 | 1.22 | .29 | −2.29 | 40 |
.027
|
Depressive symptoms | 1–4 | 2 | 1.90 | 1.48 | 2.22 | 1.53 | .21 | −1.59 | 40 | .119 |
Job satisfaction | 1–7 | 1 | 4.42 | 1.24 | 3.79 | 1.49 | .46 | 2.60 | 37 |
.013
|
Turnover intentions | 1–5 | 1 | 2.29 | 1.01 | 2.72 | 1.28 | .37 | −3.12 | 40 |
.003
|
Quality of care (ED provider reports) | ||||||||||
Frequency of errors | 1–5 | 3 | 1.98 | .74 | 2.05 | .75 | .09 | −.54 | 40 | .591 |
Patient safety | 1–5 | 1 | 2.71 | .78 | 2.50 | .71 | .28 | 1.90 | 40 | .064 |
Study outcomes | ARIMA parameters | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Intercept | Trend pre-intervention | Level change | Trend post- intervention | Workload | Goodness of fit (Rsq) | ||||||
β |
p
| β |
p
| β |
p
| β |
p
| β |
p
| ||
Work system factors | |||||||||||
Time spent in breaks (in %) | 2.64 |
.060
| −.01 |
.834
| −.67 |
.635
| .04 |
.522
| −.14 |
.181
| .12 |
Interruption rates by patients | .46 |
.607
| −.01 |
.588
| −.31 |
.686
| .04 |
.210
| .02 |
.732
| .29 |
Interruption rates by relatives | .26 |
.434
| −.02 |
.067
| −.67 |
.029
| .02 |
.062
| .03 |
.285
| .37 |
Interruption rates by colleagues of the same profession | 3.84 |
.007
| −.07 |
.041
| 1.04 |
.334
| .06 |
.181
| −.11 |
.291
| .41 |
Interruption rates by colleagues of other ED professions | 2.36 |
.047
| −.05 |
.103
| −.98 |
.318
| .095 |
.026
| .02 |
.821
| .31 |
Provider well-being | |||||||||||
Work stress | 1.36 |
.002
| .01 |
.288
| .57 |
.127
| −.02 |
.155
| .03 |
.369
| .15 |
Quality of ED care (Patient reports) | |||||||||||
Overall satisfaction with ED care | 1.66 |
<.001
| .01 |
.205
| .08 |
.781
| −.02 |
.197
| .056 |
.016
| .33 |
Patient-oriented organization | 3.24 |
<.001
| −.01 |
.132
| .08 |
.658
| .02 |
.022
| .000 |
.980
| .67 |
Patient-oriented interaction | 4.63 |
<.001
| −.01 |
.045
| .16 |
.443
| .01 |
.304
| −.03 |
.093
| .30 |
Patient-oriented information | 4.03 |
<.001
| .00 |
.727
| .03 |
.866
| .01 |
.545
| −.01 |
.553
| .40 |
Satisfaction with waiting time | 4.09 |
<.001
| −.02 |
.011
| −.06 |
.778
| .03 |
.011
| −.04 |
.072
| .48 |