Inside the black box of workplace interventions : investigating the influence of context and process on outcomes

Abstract: Introduction: Staff working in healthcare and residential care for older people are continuously required to learn and develop competencies to keep up with medical, technological and social developments. At the same time, they experience a work situation generally characterized by high demands. Workplace interventions aiming to improve competence and work environment have been highlighted as a way to improve working conditions for staff. However, these interventions are complex and challenging to implement, difficult to evaluate and have resulted in mixed effects. Not only the intervention content but also the context and process factors may influence the outcomes of workplace interventions. Yet, although several factors that may influence implementation have been identified, these factors have rarely been linked to the outcomes of such interventions. Aim: The aim of this thesis was to investigate how factors related to the context and implementation process of workplace interventions in healthcare and residential care for older people influenced the implementation and intervention outcomes. Methods: This thesis is based on the evaluation of three workplace interventions. Both qualitative and quantitative methods were used to study the context, process and outcomes. Study I was a workplace learning intervention conducted in three residential care facilities for older people. Six facilities served as a comparison group. The intervention’s effect on organizational learning was evaluated using questionnaires at baseline and at 6- and 12-month follow-up. Context and process factors influencing outcomes were investigated using semi-structured interviews with line managers on two occasions (6- and 14-month follow-up) and with staff on one occasion (6-month follow-up). Study II was an organizational-level occupational health intervention conducted at a hospital with six departments included in the intervention group and six in a comparison group. Implementation fidelity regarding the two core components in the intervention was evaluated using questionnaires administered to all employees in the intervention departments at 6-month follow-up as well as with an analysis of organizational documents. Context and process factors influencing implementation fidelity were assessed with semi-structured interviews with line managers and key individuals, as well as with questionnaires administered to employees at baseline and at 6-month follow-up. Study III was a workplace learning intervention conducted in 78 primary healthcare centers. Employees’ openness to change, concerning both the process and the content of the change, and the work group’s openness to the content of change were measured with questionnaires at baseline. These were used to predict two types of outcomes, improvements in competence regarding information and communication technologies (ICT) and the use of acquired competence, which were evaluated using questionnaires administered to all staff at baseline and at18-month follow-up. Results: Both context and process factors influenced the implementation and intervention outcomes. More specifically, stakeholders’ low ownership of the intervention, an insufficient learning climate, insufficient prerequisites for change and managers’ attitudes and actions were found to hinder the creation of organizational learning in study I. In study II, implementation fidelity varied between the departments that participated in the intervention. Factors related to the omnibus context (i.e., having a well-established quality improvement system, group collaboration), the discrete context (i.e., changes in management), the intervention and implementation (i.e., line managers’ attitudes and actions, perception of information and communication, level of participation, the roles of the drivers of change), and participants’ mental models (i.e., outcome expectancy, perceptions of the intervention activities) were found to explain the differences in implementation fidelity. In study III, baseline individual-level openness to both change process and change content as well as group-level openness to change content predicted intervention outcomes at the time of the follow-up. Conclusions: Overall, the findings suggest that successful workplace interventions are shaped by several factors related to the intervention’s content, the context in which the intervention takes place and the process by which the intervention is implemented. Thus, rather than waiting until after an intervention to evaluate why it succeeded or not, context and process factors should be taken into account already when planning and implementing an intervention. Workplace interventions in which context and process factors, as well as implementation outcomes, are continuously monitored and used to tailor the intervention may have greater potential to improve employees’ work conditions.