Using Behavioral Theory to Enhance Occupational Safety and Health: Applications to Health Care Workers

Abstract

Work-related morbidity and mortality are persistent public health problems across all US industrial sectors, including health care. People employed in health care and social services are at high risk for experiencing injuries and illnesses related to their work. Social and behavioral science theories can be useful tools for designing interventions to prevent workplace injuries and illnesses and can provide a roadmap for investigating the multilevel factors that may hinder or promote worker safety and health. Specifically, individual-level behavioral change theories can be useful in evaluating the proximal, person-related antecedents (such as perceived behavioral control) that influence work safety outcomes. This article (1) provides a brief overview of widely used, individual-level behavior change theories and examples of their application to occupational safety and health (OSH)–related interventions that involve the health care community; (2) introduces an integrated theory of behavior change and its application to promoting the OSH of health care workers; and (3) discusses opportunities for application of individual-level behavior change theory to OSH research and practice activities involving health care workers. The use of behavioral science to consider the role of individual behaviors in promoting health and preventing disease and injury provides a necessary complement to structural approaches to protecting workers in the health care industry.

‘Health care workers often place patient needs above their own health and safety, even though substantial evidence suggests that patient safety and health care worker safety are inextricably linked.’

Health care is the fastest-growing sector of the US economy, employing more than 18 million workers. The health care sector is composed of numerous workplaces, including physicians’ offices, outpatient care centers, home health care services, hospitals, and nursing and residential care facilities.¹ Women represent nearly 80% of the health care labor force.² Health care workers face a wide range of job-related risks, including exposure to blood-borne pathogens, hazardous drugs, and other agents^3-7; musculoskeletal hazards^8-10; long work hours, shift work, and high work demands^11,12; and other psychosocial hazards such as stress, harassment, bullying, and violence.^13-15 Incidences of nonfatal occupational injury to and illness of health care workers are among the highest of any industry sector.² This article focuses on the role that individual-level behavior change theories can play in occupational safety and health (OSH) research and practice in the health care sector. It also focuses on the contribution these models could make to developing and implementing effective interventions that lead to reductions in the work-related injuries and illnesses among health care workers.

Magnitude of the Problem

National surveillance data and research indicate that people employed in health care face numerous physical and psychosocial hazards and are at high risk for experiencing injuries and illnesses related to their work.^16-18 Health care workers often place patient needs above their own health and safety,¹⁹ even though substantial evidence suggests that patient safety and health care worker safety are inextricably linked.^20-22 Recent national data demonstrate that although the health care and social services sector employs 14% of the workforce, its employees experienced more than 646, 000 occupational injuries and illnesses in 2018, 19% of the total for all public and private industries.^23,24

Because of underreporting, these numbers likely underestimate the true burden experienced by this high-risk worker population.²⁵ An Occupational Safety and Health Administration report suggests that in hospitals alone, which accounted for about 36% of total health care jobs in 2015,¹ a single, serious workplace injury to a health care worker can lead to losses of tens of thousands of dollars or more. These losses include costs related to workers compensation (lost wages and medical costs), temporary staffing, decreased productivity and well-being, turnover, and negative impacts on patient safety and satisfaction.^1,26

Social and Behavioral Approaches to Prevention

Methods and approaches from the social and behavioral sciences provide useable strategies for developing and implementing effective workplace protection activities for all employees, including those in health care. Specifically, behavioral theories are important tools researchers have at their disposal to facilitate the planning and testing of the effectiveness of interventions²⁷ that promote worker safety and health. The use of behavioral change theories in primary care settings²⁸ and in injury prevention²⁹ has been encouraged and these theories hold promise for designing programs and practices to prevent OSH-related injury and illness in health care settings.

According to Glanz and Bishop, knowledge of the influential factors and models for understanding health behaviors and behavior change “provide[s] a foundation for well-informed public health programs (p. 400).”²⁷ A clear understanding of health behavior theories and their potential application in OSH settings is warranted.³⁰ Simply put, public health interventions based in theory are more likely to be successful than are those lacking a theoretical foundation.^31-33

At the individual level, behavioral change theories such as the health belief model (HBM),^34-36 the theory of planned behavior (TPB, or theory of reasoned action),³⁷ and the transtheoretical model (TTM, or stages of change)^38-40 have been used extensively in public health research and practice to improve human health.²⁷ Despite calls to increase the use of behavioral theories in OSH,^30,41 relatively few published studies apply individual-level behavior change theories (including the HBM, TPB, and TTM) to safety research in general⁴² or to OSH specifically.³⁰

This gap in OSH research may be due to the theoretical orientation of the field as one that considers the primacy of structural changes in workplace environments to be the main focus for improving the health and safety of individual workers. In the United States, the regulatory regime reinforces this orientation, as by law⁴³ employers are required to provide employees with a safe and healthy workplace environment, free of known hazards. Moreover, a robust evidence base has demonstrated that group and organizational factors influence individual employees’ safety attitudes and behaviors^44-46 and are related to the incidence of (self-reported) occupational injuries.⁴⁷

This multilevel perspective⁴⁵ aligns with social ecological models in the behavioral sciences^48-50 in which individual behavior is situated within a context of intrapersonal, interpersonal, organizational, community, and policy/regulatory dimensions. Given the interactive aspect of individual and organizational factors in the workplace, even well-designed efforts to influence employees’ hazard-related beliefs and attitudes have a high likelihood of failure if the environment (including management and safety culture) is not supportive.^30,45,51 Moreover, as personal risk factors (such as obesity or other health conditions) increasingly interact with unhealthy work environments, there is a need to consider not only a worker’s behavior and attitudes as risk factors for intervention but also the multiple genetic, societal, cultural, environmental, and economic factors that contribute to workers’ ill health.^52,53

OSH interventions have typically focused on controlling the physical work environment,⁴¹ and a historical tension exists between injury prevention programs based on “active” (behavioral) versus “passive” (structural) strategies.⁵⁴ Active approaches assume people are able to take an active role in protecting themselves, even in the presence of hazards and other barriers in their environments. Some contend that active approaches have thus led to “blaming the victim.”⁵⁵ Although structural interventions might appear straightforward, changes to the (work) environment invariably require changes in workers’ response to it. In fact, it is rare to find a structural change that does not require some behavioral adaptation.^56,57 Whereas placing a guard on a machine at the workplace would be considered a passive approach, employee adaptation and compliance are required to ensure that the guard is not removed or modified in a way that compromises safety.⁵⁸

Behavioral science applications, including those that consider the role of individual behaviors in preventing disease and injury, provide a necessary complement to structural and environmental approaches to protecting people at work. Little is known about the effective application of theories or models—such as the HBM, TPB, and TTM—in OSH research broadly and specifically with regard to protecting health care workers. Given the documented occupational risks to health care workers, health care organizations may wish to consider using behavioral change theories as a basis for developing effective interventions that protect these high-risk employees.

To identify examples of the three most widely used individual-level health behavior theories or models used in public health research (HBM, TPB, and TTM) as applied to OSH studies, we conducted a search of multiple online databases (Medline, Embase, PsychInfo, and CINAHL). We searched for peer-reviewed publications from the period of January 2005 through May 2019 that involved either the application of a theory as a guide to development of a workplace safety and health program or the systematic use of a theory to test a program. The search returned 304 unique articles, which were further reduced to 53 after a review of the full abstracts. These articles were reviewed in full, and an additional 13 were eliminated because they did not focus on OSH or did not relate to an intervention. From the final list of 40 articles, we identified 9 studies with a focus on workers in the health care sector (the appendix includes a list of the 9 studies). In a final step, we selected 3 articles for further examination and for discussion: one for each theory or model introduced above (HBM, TPB, and TTM) related to studies in health care professions. These studies were selected for further evaluation because they provided useful demonstrations of the intersection of behavioral science and workplace safety and health applications across diverse settings and worker populations in the health care sector, both internationally and in the United States. The search was intended not to be exhaustive or systematic but rather to locate relevant articles that demonstrate the utility of behavioral theory in designing, testing, and evaluating interventions among health care workers.

The purpose of this article is therefore to (1) provide a brief overview of the 3 most widely used individual-level behavior change theories²⁷ and an example of their application to OSH-related interventions in the health care community, (2) introduce an integrated theory of behavior change and its application to promoting the OSH of health care workers, and (3) discuss opportunities for application of individual-level behavior change theory in OSH research and practice activities involving health care workers.

Health Behavior Theory and Applications to OSH

Health Belief Model

The HBM, developed in the 1950s, is one of the most widely used theories of health behavior²⁷ and posits that health behaviors are a function of whether a person (1) feels threatened, (2) believes that change of a specific kind will result in a beneficial outcome at an acceptable cost, (3) experiences an extrinsic stimulus (such as instructional information or a reminder system⁵⁹), and (4) feels competent to take the necessary action to overcome perceived barriers and successfully engage in or carry out the activity or action in question.^27,34-36,59 Thus, the key constructs of the HBM are perceived susceptibility and perceived severity, perceived benefits and perceived barriers, cues to action, and the most recent addition to the model, the construct of self-efficacy.^{27,34-36,59-61}

As Glanz and Bishop²⁷ note, the HBM has most often been applied to research related to asymptomatic health issues, such as health screening. The model has also been used in unintentional-injury research^28,29 and in OSH to explain safety-related behaviors of health care workers. An OSH-related example of the use of this model comes from Sadeghi and colleagues,⁶² who conducted a quasi-experimental study of infection control practices to prevent transmission of blood-borne illness among 100 emergency room workers in Iran. The study evaluated an educational intervention based on the HBM to modify the attitude and behavior of nurses in emergency centers (randomized to a treatment or control group) regarding awareness of and compliance with infection control practices (standard precautions, or SPs).

Pre- and postintervention data were collected from participants via questionnaires designed to reflect HBM constructs. Study results suggest that knowledge scores related to SPs increased in the intervention group, with significant differences (p < .001) in perceived susceptibility, perceived severity, perceived benefits and barriers, cues to action, and self-efficacy. No significant changes were detected in the control group. The results also demonstrated an increase in preventative health behaviors—such as checking blood for hepatitis B (HBsAb) antibody levels—among the intervention group versus the control group (statistical significance was not reported).

The authors concluded that the use of the HBM was effective for designing and testing an intervention to educate emergency personnel on infection control procedures and that the model should be used in future interventions with this high-risk group of workers.⁶² This example highlights the utility of the HBM for designing interventions and conducting research to encourage actions that may reduce the risk of future occupation-related injury or disease among health care workers.

Theory of Planned Behavior

The TPB, an extension of the theory of reasoned action,⁶³ has been demonstrated to explain a large proportion of the variance in intention to perform a number of health behaviors.⁶⁴ The TPB posits that attitude, subjective norms, and perceived behavioral control directly influence a person’s intention to engage in a behavior.^37,64

Attitude refers to the extent to which a person favorably or unfavorably evaluates a particular behavior.³⁷ Subjective norms refer to whether important others (such as family members and coworkers) approve or disapprove of a behavior and relate to the motivation to model the behavior of others.⁶⁴ Perceived behavioral control is conceptualized as the “perceived ease or difficulty of performing the behavior (p. 188).”³⁷ Under this model, behavioral intention is the most important predictor of a person’s actual behavior.^65,66

An example of the TPB used in an OSH intervention with health care workers comes from Rickett and colleagues,⁶⁷ who used the theory to examine the frequency of safe manual patient-handling practice. Specifically, the behavior under investigation was the use, among 189 health care workers in the United Kingdom, of a hoist to move patients with low physical functioning from bed to chair. The study assessed the role of social-cognitive variables from the TPB on intentions to use the hoist device.

Results of regression analyses suggest that an individual’s background and social-cognitive variables accounted for 59% of variance in intention to use a hoist and 41% of variance in hoist use assessed at a 6-week follow-up.⁶⁷ In terms of TPB variables assessed, the authors report that subjective norms and perceived behavioral control were predictive of hoist-use intention. They note that safety practices in the workplace, such as hoist use, appear to be normatively driven as they are influenced by the support of coworkers.⁶⁷

The authors also note that participant height and hoist availability were direct determinants of intention. Mediation analyses indicated that hoist availability indirectly predicted intention via perceived behavioral control. Having access to a limited number of hoists resulted in reports of low levels of perceived behavioral control over using a hoist to move patients.⁶⁷ Use of behavioral theory in this intervention allowed the authors to isolate a number of factors for future intervention that might increase health care workers’ use of hoists to move patients safely and that could potentially reduce the incidence of health care workers’ musculoskeletal injuries.

Transtheoretical Model/Stages of Change Model

The TTM posits that people are at different stages of readiness to adopt certain health behaviors^38-40 and that behavior change is a process that involves multiple, often non-linear steps, to achieving long term, behavior change.²⁷ The 6 steps outlined by Prochaska et al³⁹ are (1) precontemplation (no intention to take action in the next 6 months), (2) contemplation (considering taking action in the next 6 months), (3) preparation (planning for change within the next 30 days), (4) action (adopted new behaviors, <6 months), (5) maintenance (changed and continue to practice the health behavior, >6 months), and (6) termination (sustainable habit/behavior change achieved). Six processes of change (consciousness raising, dramatic relief, self-reevaluation, environmental reevaluation, self-liberation, and helping relationships) were also articulated to identify and predict the factors that facilitate a person’s movement from one phase of the model to another.³⁹

Processes of change have been demonstrated to be similar across a wide range of health behaviors.³⁹ For example, information-seeking and consciousness-raising are important for people entering the contemplation stage, whereas stimulus control and social support appear to be most relevant to those in the action and maintenance stages.³⁰

The TTM has been used extensively to include an application to a broad range of individual health risks and health-promoting or health-limiting behaviors.⁴⁰ Despite some applications to OSH research,³⁰ TTM use has been somewhat limited in public health more generally.²⁸ An example of an application of the TTM in an OSH-related study among health care workers involves workplace violence in medical-surgical units in a large suburban medical center in Maryland. In 2017, Ferrara et al⁶⁸ evaluated the effectiveness of de-escalation training, based on the TTM, on medical-surgical nurses’ confidence in dealing with aggressive patients. The authors used previously developed and tested questionnaires related to health care workers’ confidence to cope with patient aggression.

The study included a convenience sample of 57 full-time and part-time nurses working day or night shifts. Despite limitations due to the small sample size, the results revealed that after implementation of the de-escalation training, a significant increase (p < .001) occurred in the medical-surgical nurses’ scores for confidence in handling aggressive patients. The authors noted that the theoretical model is useful in determining the behavior-change stage of medical-surgical nurses in adoption of the techniques described in the de-escalation training.

Specific interventions may be targeted at health care providers, relevant to their location on the stages-of-change continuum, to decrease the likelihood that they become victims of patient aggression on the job. The TTM can be especially useful in identifying priority populations for intervention, as well as guiding the development of interventions to target priority populations at high risk for experiencing a work-related injury.

A Unifying Behavioral Theory Framework

Attempts have been made to create a unifying theory of behavior by combining the elements of many behavioral theories. For example, in 1991, the National Institute of Mental Health convened a workshop bringing together creators of behavioral theory to develop a unifying framework to facilitate health behavior change.⁶⁹ Their discussions led to an enumeration of 5 theories that, taken together, contain virtually all the variables that have been used in attempts to understand and change human behaviors:

• Health belief model^34-36

• Social cognitive theory⁷⁰

• Theory of reasoned action⁶³

• Theory of self-regulation and self-control⁷¹

• Theory of subjective culture and interpersonal relations⁷²

When all 5 theories and their many variables had been considered, consensus was reached on 8 factors that appear to account for most of the variation in health-related behaviors: (1) intentions, (2) environmental barriers, (3) skills, (4) outcome expectancies (or attitudes), (5) social norms, (6) self-standards, (7) emotional reactions, and (8) self-efficacy. It is likely that these same 8 variables might also regulate and predict change in injury risk–prevention behaviors in many settings, including the workplace (Dr Martin Fishbein, personal communication, 2003).

In translating this guidance into action, Fishbein and colleagues^73,74 concluded that in general, for a person to perform a given behavior, one or more of the following must occur. They:

1. Form a strong positive intention or make a commitment to perform the behavior;

2. Experience limited to no environmental barriers that make it difficult or impossible to perform the behavior;

3. Possess the skills necessary to perform the behavior;

4. Believe that the advantages (benefits, or anticipated positive outcomes) of executing the behavior outweigh the disadvantages (costs, or anticipated negative outcomes);

5. Perceive more social (normative) pressure to engage in the behavior than to not perform the behavior;

6. Perceive that carrying out the behavior is more consistent than inconsistent with their self-image or that its performance does not violate personal standards or norms that active negative emotions or consequences;

7. Have a more positive (than negative) emotional reaction to performing the behavior; or

8. Perceive themselves capable of performing the behavior under different circumstances (ie, the person has perceived self-efficacy to execute the behavior).

Factors 1 to 3 are viewed as necessary and sufficient for producing health-enhancing behaviors, whereas factors 4 to 8 are viewed as modifying variables influencing the strength and direction of intentions (Fishbein, personal communication, 2003).

By way of a hypothetical example, we can apply these notions to a specific workplace injury–control behavior: wearing protective googles when there is the possibility of contact with bodily fluids. If the health care worker is committed to always wearing protective goggles, has ready access to goggles when needed, and has the skills needed to successfully wear the goggles, then there is a high probability that they will perform the behavior. The probability that the individual will wear protection daily would be predicted to increase even more if the worker also (1) believes that wearing protective goggles is worth the time and trouble, (2) knows that fellow workers wear goggles, (3) believes that wearing goggles is consistent with their values as a responsible worker, (4) has no negative emotional reaction to wearing goggles, and (5) can successfully use protection under a variety of working conditions on the job. Under these circumstances, the probability that the health care worker would use goggles routinely when there is potential for exposure to bodily fluids would be predicted to reach nearly 100%.

To our knowledge, this integrated model has not been applied to this or any other intervention related to health care safety–related behavior, but it holds promise as an innovative approach in promoting workplace safety and health. We are just beginning to adapt and integrate models and theories, such as those discussed in this paper, at the individual level to investigate injury-prevention behavior. More work is needed to design, test, and evaluate interventions based on these behavioral models and theories with other illnesses and disease/environmental exposures.

Conclusions and Future Directions

Workplace illnesses and injuries cause substantial and often long-term physical, emotional, and economic hardship for businesses, workers, their families, and communities.^75,76 The persistent burden of work-related morbidity and mortality⁷⁷ calls for a concerted, sustained effort by public health researchers, practitioners, and health care providers to explore the personal and occupational risk factors that contribute to ill health in the health care workforce.^16-18,78,79 Increasingly, public health researchers, practitioners, and health care providers acknowledge that the artificial line separating “work life” from “home life” has blurred,⁸⁰ and illnesses and injuries experienced by workers across all industries, including health care, are caused by both personal and occupational risk factors.^78,79 As noted by Edington and colleagues,⁸¹ many occupational physicians, nurses, and other members of the American College of Lifestyle Medicine are trained in the lifestyle approach to patient care (ie, the adoption of current wellness initiatives) and have successfully integrated these strategies into their routine practice. However, there is a need to consider the workplace not only as a site for delivering health promotion programs to employees but also as a potentially risky environment that can threaten human health and well-being.^82,83

Theories can provide a useful roadmap for investigating factors that hinder and promote workers’ safety and health.^33,84 Broadly speaking, the use of theory in OSH research should be a research and practice priority. Theory is a necessary system of thinking and ordering ideas to understand public health challenges and to effectively evaluate the impact of interventions that are intended to address these problems.⁸⁴ Theory is a means to an end, with the end being a “tangible benefit to public health (p. 10).”⁸⁵

Social and behavioral science theories can be useful to the medical community and in lifestyle medicine applications for promoting OSH, by assisting researchers and practitioners in assessing the barriers and facilitators to health-related actions. Effective interventions and programs that aim to help people improve their health, reduce disease and injury risks, and manage illness will require behavior change at the individual, organizational, community, and societal levels.²⁷ The behavioral theories and models presented in this article—HBM, TPB, and TTM—can help explain why people engage in certain health-promoting (or health-hindering) behaviors and can guide the design and implementation of effective interventions in settings involving health care workers.

Individual-level behavioral change theories facilitate exploration of the proximal, person-related antecedents (such as perceived behavioral control and self-efficacy) that influence safety outcomes in the workplace. Social and behavioral science could inform culturally competent educational programs targeting the health and safety needs of health care workers who engage with diverse patient populations⁸⁶ and could guide the design and implementation of behavior change interventions at the workplace.^62,67,68 Additionally, although health care workers often place patient needs above their own safety, patient safety and worker safety can (and should) co-exist,¹⁹ and attitudes and beliefs around these topics could be explored with use of behavioral theories. For example, two possible targets of intervention could be (1) health care workers’ perceptions of social norms that value patient care over their own personal safety and (2) the belief that not putting patient care above their own safety could lead to negative outcomes for patients.

The use of individual-behavior theories does not obviate the need to focus on the work environment or context, because structural measures implemented by employers in the workplace are generally more effective for protecting all health care workers—as well as their patients—and, once achieved, are more likely to be sustained.⁸⁷ As demonstrated in the study from Rickett et al,⁶⁷ structural changes to the environment were required in order for individual-level behavioral change to occur, and coworker norms were particularly salient in determining individual health care workers’ choices related to the use of patient hoists. Coworkers, management, and organizational factors “hidden below the waterline (p. 96)”⁸⁸ may have lasting impacts on individual safety choices^41,45,51 and can influence workers’ risk of injury and illness. Systematically addressing all of the variables that influence individual work-related actions is therefore necessary.

Integrating behavioral science theories into a unified model holds promise to further accelerate behavior change; as aspects of several theories that are combined may amplify the overall effect. Behavioral science applications, including those that consider the role of individual behaviors in promoting health and preventing disease and injury, provide a necessary complement to structural and environmental approaches to protecting workers (and patients) in the health care industry.

Appendix

Appendix.

Examples of Studies in the Health Care Sector that Use Individual-Level, Behavior Change Theories (Identified for the Period January 2005 Through May 2019).

Author	Year	Country	Model(s)	Target Population (N)	Study Purpose
Ferrara et al68	2017	United States	TTM/SOC	Medical-surgical nurses (N = 11)	To determine the effectiveness of de-escalation training on medical-surgical nurses’ confidence levels in handling agitated patients
Heckemann et al89	2017	Switzerland	TPB	Nurse managers (N = 40)	To explore nurse managers’ behaviors, attitudes, perceived social norms, and behavioral control in the prevention and management of patient and visitor aggression in general hospitals
Ko et al90	2011	Taiwan	TPB	Nurses who reported blood and body fluid exposure incidents (N = 802)	To predict nurses’ intention to comply with occupational postexposure management
Kyaw et al91	2019	Singapore	HBM	Health care workers (N = 3873)	To assess knowledge, attitudes, and uptake of seasonal influenza vaccination
Martins et al92	2015	Brazil	HBM	Dentists, dental assistants in a public health system (N = 79)	To assess adherence of dentists and dental assistants to the recommendation not to recap needles
Peterson et al93	2017	United States	HBM	Sonographers (N = 27)	To develop a reliable survey instrument that addresses musculoskeletal injury (MSI) among practicing sonographers; to evaluate the factors influencing sonographers’ use of self-protective scanning practices
Rickett et al67	2006	England	TPB (also, protection motivation theory)	Health care workers (N = 379)	To evaluate a model hypothesizing that motivational variables will be direct determinants of intentions and hoist usage
Sadeghi et al62	2018	Iran	HBM	Emergency nurses (N = 100)	To investigate the impact of an educational intervention based on the HBM constructs on the behavior of nurses in the emergency venters regarding standard precautions
White et al94	2015	Australia	TPB	Nurses working in medium/high infection risk wards (N = 797)	To examine how likely behavioral beliefs (advantages and disadvantages), normative beliefs (important referents), and control beliefs (barriers) influencing hand hygiene decisions following the introduction of a national hand hygiene initiative

Abbreviations: HBM, health belief model; TPB, theory of planned behavior; TRA, theory of reasoned action; TTM, transtheoretical model; SOC, stages of change.