Understanding contextual instability, complexity and diversity in an organization undergoing a comprehensive job stress intervention: Implications for work environment, worker health and intervention effect
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Work environment interventions are frequently initiated to target and alleviate occupational risk factors, worker stress, worker health, and high sick leave. However, many interventions seem to fail to bring about anticipated results. The aim of the present thesis was to examine process and contextual elements assumed to impact on the effect of a work environment intervention focusing on job stress. The thesis comprises four individual studies sought to examine different elements in order to understand and explain why job stress interventions often fail in reaching their stated objectives. The thesis has a primary (psychosocial) work environment perspective. The research context is defined by an attempt to improve work environment and worker health in order to reduce sick leave in the Home Care Service in a Norwegian municipality, by means of implementing a comprehensive job stress intervention, in a situation with contextual instability in terms of concurrent organizational changes and rationalization measures. The overarching research design of the thesis is the case study design, yet different methodological approaches were employed in the four individual studies in order to answer the specific research question raised in each study. Both quantitative and qualitative methods were used. This is in accordance with recent methodological recommendations in intervention research. The municipal Home Care Service constituting the case in the present thesis received orders from the Norwegian Labor Inspectorate due to an identified unhealthy level of time pressure and corresponding high sick leave. As home care workers are at risk of various harmful occupational exposures, health complaints and sick leave, the first paper set out to identify occupational exposures related to shoulder-neck and low back pain, and to assess the comparative importance of such exposures, for this group of professionals. Results based on survey data indicated severe pain scores for both shoulder-neck and low back regions, with individual variations. Mental, social, emotional and physical work demands were significantly correlated with shoulder-neck pain, and all except social demands were significantly correlated with low back pain. However, stronger associations were found with perceived general tension (particularly for mental demands), which proved to be the strongest predictor of shoulder-neck and low back pain, indicating a mediating effect in the relationship between occupational exposures and musculoskeletal pain. The objective of the second paper was to identify critical factors in the interaction between work environment interventions and independent rationalization measures in order to understand a potential negative interfering effect from concurrent rationalizations on a comprehensive work environment intervention. The study included survey data, register data of sick leave, a time line of significant events and changes, and qualitative descriptions of employee appraisals of their work situation gathered through semi-structured interviews and open survey responses. Results indicated that the work environment interventions were in general regarded as positive by the home care workers. However, all units were simultaneously subjected to substantial contextual instability, involving new work programs, new technology, restructurings, unit mergers, and management replacements, perceived by the home care workers to be major sources of time pressure and stress. Findings suggest that concurrent changes induced through rationalization resulted in negative exposure effects that negated positive work environment intervention effects, causing an overall deteriorated work situation for the home care workers. The third paper was a follow-up study of factors contributing to an undesirable work environment and sick leave rate in the home care services despite a substantial effort to improve these areas. The study aim was to explore potential organizational discrepancies in the appraisals of factors relating to home care workers’ working conditions. The study included survey responses of home care workers, and qualitative descriptions of stakeholders’appraisals of organizational issues gathered through semi-structured interviews (interviews with stakeholders at three organizational levels). Results showed that employees at different organizational levels in the home care services expressed divergent appraisals of factors related to the working conditions of home care workers; i.e. time pressure, work tasks, a new work program, organizational changes, budget model, budget allocation and coping strategies. As decisions and actions concerning the organization and allocation system in the Home Care Services are determined by decision-makers organizationally removed from the shop floor level, organizational discrepancy contributes to actions and decisions that translate into a strenuous work situation for HCWs, and may further result in poor organizational and employee health and functioning. Thus, organizational discrepancy serves as an important barrier to a sustainable, well-functioning organization in general and to quality-enhancing changes to work procedures in particular. The fourth paper aimed to examine the effect of two measures involving organizational (job checklists) and technological (personal digital assistants) job aids on perceived work demands and musculoskeletal health. The purpose was to identify workers who fared well or struggled with these measures, and to examine changes in perceived work demands and musculoskeletal health. Survey data was collected in two waves (two years apart). Respondents were assigned into ‘high’, ‘moderate’ and ‘low’ strain groups based on their responses to open and closed survey questions regarding impact of the two measures. Group differences and development in variables were examined. Results indicated that perceived work demands and health effects over the two-year study period were unchanged overall, yet significant differences between subgroups were highlighted. Work demands and shoulder-neck pain remained high for high-strain workers, but were reduced for low and moderate strain workers. Thus; worker responses to quality-enhancing measures are diverse and indicate different effects for sub-groups. Results also indicate that perceived general tension at baseline is predictive of shoulder-neck pain two years later, independent of perceived working conditions and age. In conclusion, the present thesis demonstrates how process and contextual elements are of crucial importance when evaluating the effect of an intervention. Specifically, contextual instability in terms of concurrent organizational changes and rationalizations in particular, complexity in terms of organizational discrepancy, and diversity in terms of individual variations in perceptions and responses, are highlighted as significant obstacles to an overall positive intervention effect. The disruptive effects of these elements, in which concurrent changes and organizational discrepancy bring about new sources of time pressure and stress, whereas individual variations in perceptions and responses impair an overall good “person-intervention fit”, are important to take into account when trying to understand and explain why interventions often fail in reaching their stated objectives.