Intervention studies in the health care work environment : Lessons learned

Abstract

While participating in a NIVA course in Finland in 1996 on prevention of stress and burn-out we found out that all three of us were involved in intervention studies in the health care sector. Each of us had had to launch his study without much guidance from previous research traditions in the field. In time we all became aware of the fact that intervention research in working life is fundamen-tally different from observational and experimental research on etiology of symptoms and diseases. To a lesser or greater degree, we were forced to step out from the principles of natural science. In our attempts to affect the conditions of work in health care, we had to engage in interactive communication/discussion with our thinking and reflecting "study objects". There went strict objectivity! And if we wanted to study not only individual employees but also groups of employees (such as the staffs of different hospital wards), it became very difficult to adhere to a randomised procedure when enrolling participants to a study. How were we supposed to proceed in questions like these? What could we learn from each other's experience? On the last day of the course we sat together at the lunch table, discussing how to keep up the contact between us and develop our projects together. We decided to apply for a grant from the Nordic Council of Ministers, who also sponsor the NIVA courses, in order to set up a network for developing intervention research in the health care field. After some deliberation the Council considered our initiative worth financial support and provided us with the resources we needed to convene five seminars over a period of 2 years. We then invited members from other research groups we knew were working in this field, to join our group. Our definite group thus consisted of eleven researchers from four countries. Denmark was represented by Tage Kristensen, Martin Nielsen and Bente Schibye from Copenhagen and Lone Donb¾k Jensen from Aarhus; Finland by Marjut Joki and Gustav Wickström from Turku; Norway by Morten Andersen and Reidar Mykletun from Stavanger; and Sweden by Mats Hagberg from Göteborg, as well as Monica Lagerström and Sarah Thomsen from Stockholm. During the years 1997 to 1999 we met five times, each time for 1-3 days. Our discussions were open and enthusiastic, at times a bit off the theme, but sooner or later returning to it again. The peak experience in trying to improve our under-standing of the relations between the questions and concepts we were interested in, was the formulation of the "Sirdal model", which is an attempt to combine the perspectives of the staff (a healthy and stimulating working environment) and the patients (high quality treatment, care and service) on health care work. We con-ceived this model in a remote mountain hotel in Norway, our discussions alter-nating between foggy and bright, just like the weather outside. The model was developed on the basis of Sarah Thomsen's introduction concerning the role of the patients in the work environment of health care workers and is presented in her and her co-worker's paper. This issue of "Arbete och Hälsa" includes chapters on all the main themes we discussed in our seminars: principles of research, alternative designs, choice of outcome variables, measuring of physical and psychological work load, the role of the patient, practical challenges in the field, description of the process, as well as ethical considerations. We decided to sum up our articles under the title "Lessons learned" rather than "Guidelines for" as we do not yet feel ready to proclaim any definite recommendations. Today the occupational strain on the health care personnel makes headlines all over Europe. The ageing populations and the increasing possibilities of examina-tions and treatment poses growing demands on the health care sector. At the same time it becomes difficult to find additional financial resources for the activities needed and harder to recruit qualified staff. Interest in actively monitoring and improving the working conditions of the health care employees has steadily increased over the last few years and so has the interest in evaluating the effec-tiveness of various approaches. This is why we think that our experiences may be of interest to others, who are carrying out projects to improve the working conditions in the health care sector and want to systematically evaluate the results of their endeavour. We frankly admit, that we find intervention research difficult in many aspects: to decide on the compromise between a design that is optimal for research and one that is facilitating active participation in changes, to initiate and implement interventions, to select significant processes to report and to include in analyses of cause-effect relations, as well as many others. From the researcher this requires a mix of rational thinking and interpretive speculation. In addition, it requires social competence to be able to react intuitively in a suitable way in varying, suddenly arising situations. We want to share our experiences and opinions with others, because we think interventions hold many promises of identifying causes and testing solutions, that are not possible in more traditional research. Ms Taru Koskinen has assisted with the technical preparation of the manuscripts and Ms Hilary Hocking has checked the language. June 2000 Reidar J. Mykletun, Martin L. Nielsen and Gustav Wickström