PubMed · 9355525
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D Leifer. 1997-08-13. Quality costs.. https://doi.org/10.7748/ns.11.47.14.s28
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BACKGROUND: There is wide, largely unexplained, variation in occupational health (OH) provision between UK employers. AIM: To explain the variation in OH provision across the UK university sector. METHODS: Analyses of data from a survey of university OH services and from the Higher Education Statistics Agency. The outcome variable was clinical (doctor + nurse) staffing of the university's OH service. The explanatory variables examined were university size, income, research activity score and presence or absence of academic disciplines categorized by an expert panel as requiring a high level of OH provision. RESULTS: All 117 UK universities were included and 93 (79%) responded; with exclusions and incomplete data, between 80 and 89 were included in analyses. There was wide variation in clinical OH staffing (range 0-8.4 full-time equivalents). Number of university staff explained 34% of the variation in OH staffing. After adjusting for other factors, neither the research activity nor the presence of high-needs disciplines appeared to be factors currently used by employers to determine their investment in OH. CONCLUSIONS: Government or other guidelines for university employers should take organizational size into account. Employers may need guidance on how to provide OH services proportionate to specific occupational hazards or other OH needs.
BACKGROUND: Healthcare workers can suffer from occupational stress which may lead to serious mental and physical health problems. OBJECTIVES: To evaluate the effectiveness of work and person-directed interventions in preventing stress at work in healthcare workers. SEARCH STRATEGY: We searched the Cochrane Depression Anxiety and Neurosis Group trials Specialised Register, MEDLINE, PsychInfo and Cochrane Occupational Health Field database. SELECTION CRITERIA: Randomised controlled clinical trials (RCT) of interventions aimed at preventing psychological stress in healthcare workers. For work-directed interventions interrupted time series and prospective cohort were also eligible. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed trial quality. Meta-analysis and qualitative synthesis were performed where appropriate. MAIN RESULTS: We identified 14 RCTs, three cluster-randomised trials and two crossover trials, including a total of 1,564 participants in intervention groups and 1,248 controls. Two trials were of high quality. Interventions were grouped into 1) person-directed: cognitive-behavioural, relaxation, music-making, therapeutic massage and multicomponent; and 2) work-directed: attitude change and communication, support from colleagues and participatory problem solving and decision-making, and changes in work organisation. There is limited evidence that person-directed interventions can reduce stress (standardised mean difference or SMD -0.85; 95% CI -1.21, -0.49); burnout: Emotional Exhaustion (weighted mean difference or WMD -5.82; 95% CI -11.02, -0.63) and lack of Personal Accomplishment (WMD -3.61; 95% CI -4.65, -2.58); and anxiety: state anxiety (WMD -9.42; 95% CI -16.92, -1.93) and trait anxiety (WMD -6.91; 95% CI -12.80, -1.01). One trial showed that stress remained low a month after intervention (WMD -6.10; 95% CI -8.44, -3.76). Another trial showed a reduction in Emotional Exhaustion (Mean Difference or MD -2.69; 95% CI -4.20, -1.17) and in lack of Personal Accomplishment (MD -2.41; 95% CI -3.83, -0.99) maintained up to two years when the intervention was boosted with refresher sessions. Two studies showed a reduction that was maintained up to a month in state anxiety (WMD -8.31; 95% CI -11.49, -5.13) and trait anxiety (WMD -4.09; 95% CI -7.60, -0.58). There is limited evidence that work-directed interventions can reduce stress symptoms (Mean Difference or MD -0.34; 95% CI -0.62, -0.06); Depersonalization (MD -1.14; 95% CI -2.18, -0.10), and general symptoms (MD -2.90; 95% CI -5.16, -0.64). One study showed that the difference in stress symptom level was nonsignificant at six months (MD -0.19; 95% CI -0.49, 0.11). AUTHORS' CONCLUSIONS: Limited evidence is available for the effectiveness of interventions to reduce stress levels in healthcare workers. Larger and better quality trials are needed.
UNLABELLED: The objectives of this study were (1) to describe the process of healthcare priority setting in Ontario-Canada, Norway and Uganda at the three levels of decision-making; (2) to evaluate the description using the framework for fair priority setting, accountability for reasonableness; so as to identify lessons of good practices. METHODS: We carried out case studies involving key informant interviews, with 184 health practitioners and health planners from the macro-level, meso-level and micro-level from Canada-Ontario, Norway and Uganda (selected by virtue of their varying experiences in priority setting). Interviews were audio-recorded, transcribed and analyzed using a modified thematic approach. The descriptions were evaluated against the four conditions of "accountability for reasonableness", relevance, publicity, revisions and enforcement. Areas of adherence to these conditions were identified as lessons of good practices; areas of non-adherence were identified as opportunities for improvement. RESULTS: (i) DESCRIPTION: at the macro-level, in all three countries, cabinet makes most of the macro-level resource allocation decisions and they are influenced by politics, public pressure, and advocacy. Decisions within the ministries of health are based on objective formulae and evidence. International priorities influenced decisions in Uganda. Some priority-setting reasons are publicized through circulars, printed documents and the Internet in Canada and Norway. At the meso-level, hospital priority-setting decisions were made by the hospital managers and were based on national priorities, guidelines, and evidence. Hospital departments that handle emergencies, such as surgery, were prioritized. Some of the reasons are available on the hospital intranet or presented at meetings. Micro-level practitioners considered medical and social worth criteria. These reasons are not publicized. Many practitioners lacked knowledge of the macro- and meso-level priority-setting processes. (ii) Evaluation-relevance: medical evidence and economic criteria were thought to be relevant, but lobbying was thought to be irrelevant. Publicity: all cases lacked clear and effective mechanisms for publicity. REVISIONS: formal mechanisms, following the planning hierarchy, were considered less effective, informal political mechanisms were considered more effective. Canada and Norway had patients' relations officers to deal with patients' dissensions; however, revisions were more difficult in Uganda. Enforcement: leadership for ensuring decision-making fairness was not apparent. CONCLUSIONS: The different levels of priority setting in the three countries fulfilled varying conditions of accountability for reasonableness, none satisfied all the four conditions. To improve, decision makers at the three levels in all three cases should engage frontline practitioners, develop more effectively publicized reasons, and develop formal mechanisms for challenging and revising decisions.