literature review about health and safety

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• v.55(3); 2017 May

Occupational safety and health in construction: a review of applications and trends

Fabián alberto suÁrez sÁnchez.

1 Universidad de Nariño, Department of Civil Engineering, Colombia

Gloria Isabel CARVAJAL PELÁEZ

2 Universidad de Medellín, Department of Civil Engineering, Colombia

Joaquín CATALÁ ALÍS

3 Universidad Politécnica de Valencia, Department of Construction Engineering and Civil Engineering Projects, España

Due to the high number of accidents that occur in construction and the consequences this has for workers, organizations, society and countries, occupational safety and health (OSH) has become a very important issue for stakeholders to take care of the human resource. For this reason, and in order to know how OSH research in the construction sector has evolved over time, this article–in which articles published in English were studied–presents an analysis of research conducted from 1930 to 2016. The classification of documents was carried out following the Occupational Safety and Health Cycle which is composed of five steps: regulation, education and training, risk assessment, risk prevention, and accident analysis. With the help of tree diagrams we show that evolution takes place. In addition, risk assessment, risk prevention, and accident analysis were the research topics with the highest number of papers. The main objective of the study was to contribute to knowledge of the subject, showing trends through an exploratory study that may serve as a starting point for further research.

Introduction

In most industrialized countries, the construction industry is one of the most significant industries in terms of contribution to gross domestic product (GDP). It also has a significant impact on the health and safety of workers. The construction industry is both economically and socially important 1 ) . In construction, workers perform a great diversity of activities, each one with a specific associated risk. The worker who carries out a task is directly exposed to its associated risks and passively exposed to risks produced by nearby co-workers 2 ) . Building design, materials, dimensions and site conditions are often unique, which requires adaptation and a learning curve from site to site. Injuries may occur in a number of ways and at every juncture of the process 3 ) .

As a result of this situation there is a high frequency of accidents in construction, which makes it an unsafe industry. Degree of safety in this selected sector of the economy is not indicated by a single accident but by a set of accidents that have occurred within a specified time interval. Knowledge about the noticeable trends in accidents is required in order to assess the level of safety and also directions for changes 4 ) .

Occupational safety and health is an area concerned with the development, promotion, and maintenance of the workplace environment, policies and programs that ensure the mental, physical, and emotional well-being of employees, as well as keeping the workplace environment relatively free from actual or potential hazards that could injure employees 5 ) . However, the number of articles regarding OSH in construction was small until fifteen years ago. Since 2001 the number of OSH publications relating to construction has increased. From different perspectives and using different tools researchers have studied occupational hazards in construction. Sousa, Almeida, and Dias 6 ) state that there are several tools and methods to investigate and understand occupational accidents in the construction industry.

In a systematic review of construction safety studies, Zhou et al. 7 ) found that of all the research topics 44.65% were pertinent to safety management process, 20.27% to the impact of individual and group/organizational characteristics, and 33.03% to accident/incident data. The body of research on safety management process involves safety planning, safety monitoring, safety assessment, safety measurement, safety performance etc.

Taking into account the previously stated remarks, the aim of our paper was to review the literature and define current trends in research in occupational safety and health applied to the construction industry. Trends were obtained through chronological evolution. Thus, they can be properly analyzed and further research can be developed from them.

Methodology

Our literature search analyzed only peer-reviewed papers associated with occupational safety and health in construction, because the state-of-the-art of a discipline is defined in these forums; some very relevant articles from conferences were also considered, and the scope of the research was determined by the following parameters:

• – Language: English.
• – Period: from 1930 to 2016
• – Key descriptors: occupational risk; occupational accident; occupational safety; occupational prevention; occupational health; occupational safety and health and construction
• – Databases: Ebsco Host, Science Direct and Scopus. These were selected as sources of information due to their size and the quality of the publications found in them, however for future research other sources may be considered

The first problem needing to be addressed was how to suitably classify all the information. Occupational safety and health is not a homogenous issue; quite the opposite, there are many stakeholders involved. Besides, it can be considered a multi-stage process. This process approach has already been suggested by many authors in risk management, as traditionally applied to project management 8 ) which proposes a similar process based on four stages: identification, analysis, response, and control. Moreover, the OHSAS 18001:2007 Standard 9 ) proposes a cycle based on continuous improvement which comprises of: establish corporate policies, plan, implement and operate, check and correct, review, and improve. These steps are compatible with the ISO 9001:2008 quality management system 10 ) . Finally, Carvajal 11 ) proposed a five-step cycle: regulation, education and training, risk assessment, risk prevention, and accident analysis. A new Occupational Safety and Health Cycle that includes safety climate was developed, adapting the cycle suggested by Carvajal, which is created in phases of education and training, risk assessment and risk prevention ( Fig. 1 ).

Occupational Safety and Health Cycle. Adapted from Carvajal, G. I. (2008). Modelo de cuantificación de riesgos laborales en la construcción: RIES-CO . (Doctoral Thesis). Universidad Politécnica de Valencia, Valencia, España.

However, a shortcut in this Occupational Safety and Health Cycle could appear if regulations (either from the company or from public agencies) are not analyzed, improved on, or at least implemented; and later, if education and training is not provided.

A company that does not seriously apply an occupational safety and health management system may enter into a spiral of unsafeness, trying to take the easiest way out of the cycle, and making it shorter and shorter each time until a serious accident takes place. In any event, a “culture of construction safety” should be implemented; this is defined 12 , 13 ) as the whole group of knowledge, habits, and behaviors that drive companies to the willing application of safety and health approaches and procedures in the construction industry. This is a good way to achieve a “climate of safety”, which implies a subjective perception and evaluation of safety issues related to the organization, its members, structures and processes, based on experience of the organizational environment and social relationships 14 ) .

For this article, the previous cycle was taken as an example of a logical and continuous process with feedback, which allowed for an analysis of the evolution of research in occupational safety and health in construction. Risk assessment comprises risk identification and analysis, as stated in traditional risk management literature. Likewise, risk prevention consists of response and control. In order to highlight the importance of setting objectives and of organizational learning through time, two previous steps and a final one are added. Regulation is included to emphasize the significance of corporate policies issued by companies on one hand, and laws and standards issued by public agencies on the other. Training and education reflects the impact that the former steps have upon the people involved if some improvement needs to take place. Finally, accident analysis is needed to investigate the cause of accidents; thus, lessons can be learned and other accidents may be avoided in the future - obviously, this step is skipped if no accident occurs.

Articles were analyzed and classified in the Occupational Safety and Health Cycle, according to the suitability of their content according to each of the steps. Nevertheless, our goal was not to develop a bibliometric study, but to define chronological trends in research by using noteworthy articles to display the main milestones. Thus, in our second analysis of the papers, we chose only those significant articles that offered an added-value and could be used as references in a research trend. In this opportunity, the selection was developed by taking several aspects into consideration. Mainly, in order to be chosen, a paper must have enough qualitative references from other papers even if it does have many citations. Besides, we have rated the paper’s degree of importance according to our assessment of the novelty of its ideas and the future influence of this particular manuscript on others. The analysis of the evolution of research was conducted following a logical sequence of ideas in the selected papers.

Bibliographic analysis

In the first search we undertook, 285 articles were selected from 32 journals or proceedings. Papers chosen by journal and by time period are displayed in Table 1 . It can be noted from this table that the number of papers has recently increased: in the period between 2001 and 2010, a total of 129 papers related to OSH in construction were published. This amounts to 45.3% of all articles included. Likewise, in the period between 2011 and 2016, a total of 57 papers were published. Although this period is shorter, it can be observed that the amount of published papers is greater than that of the periods prior to 2001. The Journal of Construction Engineering and Management is the one with the most articles selected, followed by Safety Science and the International Journal of Project Management.

Selected articles are displayed in Table 2 according to topic, showing absolute and relative values. Risk assessment is the most popular topic, appearing in 35.4% of the papers. Accident analysis and risk prevention each get more than 20% of the share.

It is surprising not to find many papers on regulations, either from the company’s point of view (corporate policies) or from public agencies’ point of view (standards and norms). Maybe the reason is that some articles deal not just with regulations, but also with other approaches to occupational safety and health; thus, they are categorized under other steps of the cycle, mainly risk assessment or risk prevention. In our study, we observed how research has influenced the development of laws and regulations by providing new forms and tools for risk assessment and for the implementation of preventive measures at the workplace. The analyzed papers propose measures to assess results achieved and to know whether regulations are being applied and if they are meeting the objectives for which they were created.

It is not so unexpected to discover that education and training get very little attention from researchers. Pietroforte and Stefani 15 ) already found that only 1.8% of the papers published in the Journal of Construction Engineering and Management from 1983 to 2000 were related to education and professional development. Furthermore, in their analysis of trends in project management, Crawford, Pollack, and England 16 ) selected forty-seven topics relevant to the field of project management; none of them was related to education and training. Because so few articles are found for these two steps, no research trends are developed for regulations and for education and training. Safety culture and safety climate are new factors that have also few publications. According to research on occupational safety and health applied to the construction industry, three main topics obtained from our previous bibliographic analysis are described: risk assessment, risk prevention, and accident analysis (which represent 85% of the total), and this paper focuses on those subjects.

Trends in risk assessment

For the topic of risk assessment, the search started with Fine’s seminal article “Mathematical evaluation for controlling hazards” 17 ) , in which a formulation to quantify risks is proposed. It is based on three factors that define risk: probability of the accident happening, personnel exposure to the risk, and consequences of the accident (or severity). From his approach, three basic lines of research were identified: management of occupational safety and health, quantifying occupational risk through modeling, and quantifying risk through probability analysis. They are displayed in Fig. 2 .

Trends in risk assessment.

Al-Bahar and Crandall 18 ) applied traditional risk management approaches to the construction industry to obtain a useful strategic tool for managers. Mohamed 19 ) introduced the influence of management and risk systems at the workplace. Koehn and Datta 20 ) analyzed ISO Standards (9000 for quality, 14000 for environment, and 18000 for safety and health), and proposed an integrated system for construction companies. Sparer and Dennerlein 21 ) created and evaluated different approaches for establishing rewards based on a threshold score, for use in safety incentive programs. Pinto 22 ) introduced safety climate variables within the calculation of the level of risk in a Qualitative Occupational Safety Risk Assessment Model (QRAM).

On the issue of quantifying risk through modeling, Knab 23 ) put forward a mathematical model based on insurance premiums. Whereas Jannadi and Almishari 24 ) developed a computer model based on Fine’s formulation. Mitropoulos and Namboodiri 25 ) developed a technique for measuring the safety risk of construction activities according to the characteristics of the activity and independent of the workers’ capabilities, and Liu and Tsai 26 ) proposed a fuzzy risk assessment method which related hazard types with construction items and hazard causes with hazard types.

On the other hand, Kaplan and Garrick 27 ) followed Fine’s assumptions to calculate the probability factor of his formulation. Using this work as reference, Cuny and Lejeune 28 ) analyzed the severity factor. Then, to solve the problem of uncertain and insufficient statistical data Gürcanli and Müngen 29 ) used fuzzy logic. Bowers 30 ) approached the probability factor by using quantitative data (e.g., historical ratios) or qualitative data (e.g., interviews). Santoso et al. 31 ) identified, analyzed, and categorized potential risk factors in construction.

In summary, three main branches of research were identified: management of occupational safety and health in construction, risk quantification through modeling, and probability applied to risk quantification. From them, twelve active lines of research were highlighted, and a representative paper for each was pointed out.

Trends in risk prevention

Heinrich’s seminal article 32 ) is the starting point of the two other topics: risk prevention and accident analysis. He suggested the concept of risk prevention based on historical accident statistics, and focused on cost reduction due to the adoption of prevention techniques. Fifty years later, Helander 33 ) discussed several interesting issues: high accident ratios, increasing costs due to accidents, lack of research, and inexperience in implementing policies and plans; unfortunately, many of these problems still remain in today’s construction industry. From this line of thought on risk prevention, three main trends were outlined, one concerning business strategy, and the other two regarding the main phases of the project life cycle: design and construction. They are displayed in Fig. 3 .

Trends in risk prevention.

Business strategy to achieve better safety performance in construction was introduced in work by Jaselskis, Anderson, and Russell 34 ) . Their article analyzes the main factors that lead to success in occupational safety and health in the construction industry. Two branches are developed from this idea, depending on the emphasis of the implementation: laws and standards at the managerial level 35 ) and plans, guidelines and checklists at the operational level 36 ) .

Hinze and Wiegand 37 ) were the first to show the importance of safety prevention in the design phase. They state the important role of designers in occupational safety and health because the success of construction works depends on their decision-making. Gambatese et al. 38 ) deepened this idea through several interviews, revealing keys for successful implementation of designing for safety. Fonseca et al. 39 ) proposed a model of risk prevention integrating production and safety through three different levels of anticipation (analysis of design, planning/scheduling of services and implementation). One year later, Zhang et al. 40 ) applied Building Information Modeling BIM-based safety to fall hazard identification and prevention in construction safety planning.

Nevertheless, most work produced on the topic of risk prevention focuses on the construction phase. Many authors explore different approaches. Hinze 41 ) analyzed human behavior in risk prevention and Chi and Han 42 ) analyzed 9,358 accidents that occurred in the U.S. construction industry between 2002 and 2011 and incorporated systems theory into Heinrich’s domino theory to explore the interrelationships of risks. Laufer and Ledbetter 43 ) assessed the efficiency of several safety tools used in the construction workplace through surveys; according to these authors, simultaneous methods should be used to achieve better levels of safety. Burkart 44 ) called for site-specific safety plans, adapted to each workplace, and useful and reliable for every stakeholder.

Along another line, Hinze 45 ) analyzed the influence of economic incentives, concluding that low-value incentives, combined with good prevention tools, are more successful, and Imriyas 46 ) developed a workers´ compensation insurance (WCI) premium-rating model for building projects.

Summing up, our exploration detected ten lines of research within risk prevention in construction. Three of them deal with business strategy, three with the design phase, and six others with the construction phase.

Trends in accident analysis

Accident analysis (or accident investigation, as it could also be called) makes it possible to determine the what, how, and why of an accident; thus, in the future, similar accidents can be avoided based on the lessons learned. This topic also originates from Heinrich’s work (1930). He considered accident statistics as the baseline for any analysis of occupational safety and health. Many years later, Leplat 47 ) approached the principle of accident causation, discussing the relationship between accidents and the work in progress at the time of the accident. Kjellen and Larsson 48 ) proposed a conceptual model to investigate accidents across two levels: the sequence of facts about an accident, and factors affecting work at the time of an accident. From these articles, three main branches are displayed in Fig. 4 .

Trends in risk analysis.

The first branch deals with different models of workplace accident causation. DeJoy 49 ) focused on human factors. Abdelhamid and Everett 50 ) reviewed different techniques and offered a theoretical explanation for root causes of accidents. Suraji et al. 51 ) described a global model for the project cycle. Rozenfeld et al. 52 ) developed a structured method for hazard analysis and assessment for construction activities called Construction Job Safety Analysis (CJSA).

The second branch is about the statistical analysis of accidents. Kisner and Fosbroke 53 ) analyzed injuries from 1980 to 1989 in the United States. Hinze et al. 54 ) supported by Occupational Safety and Health Administration (OSHA) data from 1985 to 1995, categorized accident causes and sources of injures. Huang and Hinze 55 ) also examined OSHA data on construction worker’s accidental falls from 1990 to 2001. Cheng et al. 56 ) used data mining to establish the cause–effect relationships within occupational accidents in construction in Taiwan during the period 2000–2007. Finally, Irumba 57 ) investigated the causes of construction accidents in Kampala, Uganda using ordinary least squares regression and spatial regression modeling.

The last branch evaluated occupational accidents in terms of their cost. Leopold and Leonard 58 ) assessed several British construction firms to analyze accident costs in relation to their insurance premiums. On the other hand, Everett and Frank 59 ) showed a comparative study on the actual costs of accidents and injuries in the construction industry.

The main lines of research in accident analysis can be summarized within three topics: causal model of accidents, statistical analysis of accidents, and economic cost of accidents.

Conclusions

Our paper sought to establish current research trends in occupational safety and health in the construction industry. We described an “Occupational Safety and Health Cycle” based on traditional risk management approaches with five basic steps: regulations, education and training, risk assessment, risk prevention and accident analysis. Because of a scarcity of articles in the first two steps, no trends were proposed for regulations, education or training.

Three main branches (i.e. management of occupational safety and health in construction, risk quantification through modeling and probability applied to quantifying risk) were outlined within the topic of risk assessment, which is the topic with the highest amount of publications, and were subsequently broken up until obtaining the twelve current trends. Likewise, three main branches (business strategy, focus on the design phase and focus on the construction phase) were obtained for risk prevention. These were in turn split into the ten current trends. Finally, there were three solid trends within accident analysis: a causal model of accidents, their statistical analysis, and their economic cost.

The findings of this study show the following future subjects as trends of research and implementation in OSH in construction: rewards in safety incentivization programs; increasing the usage of information technology tools; production process automation; implementing proactive measures rather than reactive measures; integrating quality, environmental and OSH management system standards and using technological tools to train workers.

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• Do healthcare professionals work around safety standards, and should we be worried? A scoping review
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• http://orcid.org/0000-0002-7356-0397 Debbie Clark 1 , 2 ,
• http://orcid.org/0000-0002-5832-402X Rebecca Lawton 3 , 4 ,
• Ruth Baxter 3 , 4 ,
• Laura Sheard 5 ,
• Jane. K. O'Hara 6
• 1 Faculty of Medicine and Health , University of Leeds , Leeds , UK
• 2 School of Health and Social Care , Sheffield Hallam University , Sheffield , UK
• 3 School of Psychology , University of Leeds , Leeds , UK
• 4 Yorkshire Quality and Safety Research Group , Bradford Institute for Health Research , Bradford , UK
• 5 Health Sciences , University of York , York , UK
• 6 The Healthcare Improvement Studies Institute , University of Cambridge , Cambridge , UK
• Correspondence to Debbie Clark; hcdjc{at}leeds.ac.uk

Background Healthcare staff adapt to challenges faced when delivering healthcare by using workarounds. Sometimes, safety standards, the very things used to routinely mitigate risk in healthcare, are the obstacles that staff work around. While workarounds have negative connotations, there is an argument that, in some circumstances, they contribute to the delivery of safe care.

Objectives In this scoping review, we explore the circumstances and perceived implications of safety standard workarounds (SSWAs) conducted in the delivery of frontline care.

Method We searched MEDLINE, CINAHL, PsycINFO and Web of Science for articles reporting on the circumstances and perceived implications of SSWAs in healthcare. Data charting was undertaken by two researchers. A narrative synthesis was developed to produce a summary of findings.

Results We included 27 papers in the review, which reported on workarounds of 21 safety standards. Over half of the papers (59%) described working around standards related to medicine safety. As medication standards featured frequently in papers, SSWAs were reported to be performed by registered nurses in 67% of papers, doctors in 41% of papers and pharmacists in 19% of papers. Organisational causes were the most prominent reason for workarounds.

Papers reported on the perceived impact of SSWAs for care quality. At times SSWAs were being used to support the delivery of person-centred, timely, efficient and effective care. Implications of SSWAs for safety were diverse. Some papers reported SSWAs had both positive and negative implications for safety simultaneously. SSWAs were reported to be beneficial for patients more often than they were detrimental.

Conclusion SSWAs are used frequently during the delivery of everyday care, particularly during medication-related processes. These workarounds are often used to balance different risks and, in some circumstances, to achieve safe care.

• Patient safety
• Quality improvement
• Standards of care

Data availability statement

No data are available. Data sharing not applicable as no datasets generated and/or analysed for this study. Not applicable. This study is a scoping review.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjqs-2024-017546

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Healthcare professionals use workarounds to achieve different goals, but little is known about the circumstances and implications of safety standard workarounds (SSWAs) explicitly, which limits our understanding of how safe care is really achieved.

WHAT THIS STUDY ADDS

This review found SSWAs are performed frequently and are caused by a multitude of factors, including situations when professional responsibilities conflict with standards. SSWAs are perceived to both improve and diminish care quality at times and are viewed differently by stakeholders at different levels of the healthcare system.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Despite workarounds being prolific in healthcare there is little evidence to guide professionals or policy makers to know if, or when it might be desirable, to work around standards. This review emphasises the need for further research to explore when and how flexibility can be safely incorporated into current risk management strategies to improve care.

Introduction

For two decades, standardisation has been regarded as the cornerstone of improving healthcare safety by increasing reliability and reducing variation. 1 2 This approach has led to significant reductions across a variety of patient harms. 3 However, variation in the delivery of healthcare remains high, 4 and there is uncertainty about the extent to which the unquestioning application of standards supports patient-centred care, particularly when healthcare systems are under pressure. 5 6

Recent developments in the field of safety theory have begun to question if standardisation is a universal foundation for healthcare improvement. This includes interest in ‘Safety II’, a theory that views healthcare as a complex system and safety as the ability to succeed under varying conditions. 7 At the heart of this theory is the assumption that variation is not inherently risky, and that resilient systems actually rely on the ability of individuals, teams and organisations to adapt their actions in response to changing work environments. 6

While not adhering to standards was once regarded as a ‘violation’, 8 deviations have been described more neutrally as ‘workarounds’. 9 Perspectives regarding what workarounds achieve are divided. From one viewpoint there is some evidence that workarounds have a negative effect on safety through reducing the reliability of the intended work processes, 9–13 but from another position there is emergent evidence that workarounds can be beneficial for safety in some circumstances, such as in clinical emergencies 9 or when technology fails. 13 14

Previous reviews have recognised the importance of investigating healthcare workarounds. 9 10 15–18 While some reviews have focused on workarounds performed by diverse professional groups, 10 18 others have concentrated on workarounds performed by individual groups. 9 16 17 Similarly, some reviews have looked broadly at healthcare workarounds, while others have concentrated on specific obstacles, most commonly, health information technology systems, being worked around. 16 18 These important reviews have contributed to current conceptualisations of workarounds in healthcare, progressing understanding of the causes, mechanisms of proliferation and potential consequences of workarounds in healthcare. 9 10 16–18

Given the proliferation of standardisation to address safety concerns in healthcare and a failure to make significant progress in this area, 6 there is an imperative to review the literature on safety standard workarounds (SSWAs) performed by healthcare professionals to improve our understanding of the circumstances of SSWAs and explore what these very specific workarounds are perceived to achieve. This could be beneficial to improving safety and move us beyond conversations which focus on compliance with rules with little appreciation of complex nature of healthcare work.

In this review, our research question was developed using the Population, Context, Concept framework and through consultation with key stakeholders including patients, carers and healthcare staff. Our research asked: what are the circumstances and perceived implications of working around safety standards in healthcare as reported within primary studies in published peer-reviewed literature?

As the objective of this review was to construct a thorough picture of working around safety standards in patient-facing healthcare, rather than categorically answer a specific question to make recommendations for practice, the scoping review method was adopted. Scoping reviews are useful for examining emerging evidence, clarifying definitions, identifying knowledge gaps and identifying key characteristics of a concept. 19 20 The review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews. 21 Full details of the search strategy can be found in online supplemental file 1 . In brief, we conducted a systematic search across multiple databases (MEDLINE, CINAHL, PsycINFO and Web of Science) using keywords for workarounds (eg, workaround*, work* around, improvisat*, violat*, deviat*) combined with keywords for healthcare delivery (eg, health care delivery, healthcare delivery, clinical practice). We identified empirical peer-reviewed papers that used qualitative or mixed methods. We included papers from 1990 to 26 January 2024 and limited the search to papers written in English to allow the review team to effectively engage with the papers. No patients or members of the public were included in this study; ethics approval was not required.

Supplemental material

Defining terms.

A definition by Debono et al 9 was initially used to identify workarounds. Safety standards were more challenging to define at the outset, therefore, the research team interpreted this concept as a written rule designed to promote safety. Through the review process and as the research team became sensitised to both the workaround and safety standard concepts, the team drew on a wider body of literature 9 22–24 to define an SSWA as ‘an adaptation, improvisation or change, to an existing work rule designed to promote safety, in order to overcome, or lessen the impact of obstacles that are perceived as preventing that work system or its actors from achieving a desired goal’.

Results were imported into Covidence for screening and selection. Our eligibility criteria ( online supplemental file 1 ) required papers to take a ‘safety II’ perspective and make explicit reference to the workaround of at least one rule designed to promote safety. Occasionally, workarounds were not the primary focus of the paper. Data charting was undertaken by two researchers (DC/RB). A data charting form based on the JBI template 21 was developed and tested. This form extracted information about the circumstances and implications of SSWAs. A narrative synthesis 25 of qualitative and mixed methods studies was conducted, with the aim of summarising the current state of knowledge on the use of SSWAs in healthcare. Inductive categories 26 were developed to organise the data within the papers under review objectives. This process included drawing on the types of SSWAs described in the literature, 8 27 then categorising the causes of the workarounds which involved expanding the causes previously described in the literature. 9 11 15 Multiple reviewers (DC/JO'H/RL) categorised the perceived implications of SSWAs deductively using the Institute of Medicine’s (IOM) 28 six domains of quality (safe, effective, patient centred, timely, efficient, equitable) and by stakeholder position in the healthcare system (patient, staff, organisation). These frameworks were used to understand the implications of workarounds holistically and move beyond binary perspectives of workarounds as good or bad. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was used to report on the review.

Searches of electronic databases conducted on 22 April 2022 returned 14 293 records, 4109 duplicates were removed. Initial screening of titles and abstracts on the remaining 10 184 was undertaken, resulting in 325 papers being identified for full text review. Following in-depth review against the inclusion criteria 298 articles were rejected, leaving 27 papers in the review. The electronic searches were run again on 26 January 2024. No further papers were found that met the review inclusion criteria. The PRISMA diagram summarises the search process ( figure 1 ).

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Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram summarising search process.

The findings of this scoping review are organised into three sections: (1) key characteristics of the papers (also summarised in table 1 29–54 ); (2) the circumstances of SSWAs; and (3) the perceived implications of SSWAs. Reported proportions have been calculated as the percentage of papers providing commentary on extracted features. The specific papers reporting on each feature are provided. Importantly, some papers report on more than one characteristic in each category.

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Key characteristics of papers

Study characteristics

The earliest paper included in this review was published in 2008. 67% of papers were published from 2017 onwards. A third of papers reported on studies that were conducted in the UK, 15% in the USA and 15% in the Netherlands, suggesting that this topic is of particular relevance in a UK context.

Over three-quarters of the papers reported on studies that were conducted in acute hospital settings, with the majority of studies taking place in university teaching hospitals. Studies conducted within an acute setting were based within medical and surgical units [48%; 13 31 37 40 41 43 44 46–48 50 52 54 ], intensive care units [22%; 34 37 40 47 50 52 ] and emergency departments [19%; 30 32 36 37 50 ]. Seven studies were conducted in a community healthcare setting [26%; 29 35 38 45 49 51 54 ], including four pharmacies [15%; 29 38 49 51 ], one general practitioner (GP) practice, 35 one nursing home 45 and one unspecified community setting. 54 Half of the papers reported on studies conducted in more than one healthcare organisation.

Circumstances of SSWAs

21 different kinds of safety standards were reportedly worked around across the 27 papers ( table 1 ). Some papers reported on more than one type of SSWA, therefore the categories are not mutually exclusive. Over half of the papers described working around standards related to medicine safety [59%; 29 37 38 40–46 48–52 54 ]. Consequently, SSWAs were reported to be performed by registered nurses in 67% of papers, 13 30 31 34 35 37 39–46 48 52–54 doctors in 41% of papers 13 30–33 40 41 43 50 54 and pharmacists in 19% of papers. 29 38 43 49 51

The review identified a range of potential causes of SSWAs as illustrated in table 2 . Causes of individual SSWA were inductively attributed to categories by multiple reviewers (DC/RL/JO'H), where sufficient information was provided in the paper to enable categorisation. Where there were disagreements, reviewers discussed their decisions and recategorised if required. During categorisation, reviewers differentiated between professional and relational causes of workarounds because distinction was possible and appeared important. Most SSWAs were found to have multiple causes and consequently are listed here under more than one category.

Categories of potential causes of safety standard workarounds, frequency and papers

Organisational causes of SSWAs were reported in over 90% of papers [93%; 13 29–34 36–38 40–54 ] and included workarounds caused by workload and time pressures, 29–31 33 36–46 48 49 52–54 lack of training, 30 31 37 41 42 48 54 local availability of adequate resources 29 40 41 43 50 and conflicting rules leading staff with no choice but to break a rule to deliver care. 32 33 53

SSWAs caused by task-related factors were reported in over half of the papers [59%; 13 29 31 33 36 38 40–42 45 46 49–52 54 ]. Task-related factors described situations that led to staff choosing to work around the situation if they could conceive an alternative way to proceed that was perceived to be more efficient. The context in which work needed to be achieved influenced the use of the workarounds. Several papers reported that tasks undertaken in emergency or exceptional circumstances caused SSWAs. 33 43 46 52 54 For example, one paper 46 reported nursing staff deviated from bar code medication administration policies by not scanning medication in an emergency. One paper 33 reported that routine and straightforward cases may lead to SSWAs.

SSWAs were reportedly caused by individual clinician factors in over half of the papers [56%; 13 30–33 35–37 40–42 44 45 48 53 ]. Individual clinician factors were related to a range of features, including age that was perceived to influence willingness to adopt new technology and created additional work for colleagues, 31 fatigue and cognitive load. 33 36 54 Individual preferences were often reported as a cause of workarounds, 35 36 40 42 44 54 for example, one paper 35 described how a GP preferred to review the results of all tests they had ordered, this was inconsistent with the organisation’s policy. An individual’s familiarity with a person or task was perceived to cause workarounds, with some papers describing how having considerable clinical experience increased the likelihood of adopting an SSWA. 31 32 42 Other papers 13 31 40 42 44 53 discussed insufficient awareness of standards or lack of proficiency with technology resulted in SSWAs.

Professional factors led to SSWAs in over half the papers [52%; 13 29–32 34 38 40 47–52 ]. In 30% of papers, healthcare staff chose to exercise professional judgement to manage risk when they perceived this was necessary, often knowingly working around policies [30%; 29 30 32 38 40 49–51 ]. For example, one paper reported 73% of physicians transferred concentrated potassium solutions from prefilled syringes into empty syringes to enable the administration of a restricted medication when they perceived this was required to provide effective care. 50 In these situations, ensuring professional accountability and responsibility for delivering safe, effective care was regarded as of greater importance than organisational policies, despite them being in place to promote safety. Some papers described situations where healthcare professions went beyond the requirements of safety standards to create safety. 13 29 30 50 52 For example, one paper described how nurses would label intravenous lines when this was not required in policies. 52

Assumptions about professional boundaries led to SSWAs in some papers. 29–31 40 52 For example, one paper reported pharmacists were observed to omit subtasks that they believed were not their responsibility, such as checking medicines complied with local clinical guidelines, which they believed to be the responsibility of the prescriber . 29

SSWAs were in part caused by relational factors in over 40% of papers [41%; 29–32 35 37 41 43 49 51 52 ]. SSWAs were used to either preserve relationships with team members or because strained relationships within the team inhibited communication. In some circumstances, SSWAs were used to explicitly help other healthcare team members to work effectively. 30 31 37 41 49 52 One paper 41 described situations where doctors would prescribe antibiotics based on what nurses could realistically administer with the number of patients they were caring for, rather than the medication recommended in the policy.

Environmental, technical and patient factors were partly responsible for some SSWAs. In one paper, nurses were reported to have worked around standards for safe medication administration by omitting to scan the bar code on patients’ wristbands due to patients self-removing their wristbands (patient factor), the location of mediation and patients (environmental factor) and equipment failure (technical factor). 46 There were examples of staff prioritising patient needs over the use of a standard in one-third of papers [33%; 29 40 43 45–47 50 52 54 ]. For example, a female patient was temporarily admitted to a male bed to receive prompt and effective care that breached gender standards. 47

Implications of SSWAs

The majority of papers reported that SSWAs had perceived implications for care quality. 13 29–45 47–54 This was assessed by deductively categorising the implications of SSWAs using the IOM domains of quality (safe, effective, efficient, timely, patient centred, equitable), where this information was reported in each paper. Table 3 provides illustrative examples of reported SSWA implications for quality. Within the review papers, perceptions that SSWAs were being used to improve care were evident in all quality domains, although positive perceptions of SSWAs were most often reported as supporting person-centred, timely, efficient and effective care.

Illustrative examples of quality implications

Papers also reported that SSWAs both support and diminish care quality within specific quality domains. For example, focusing on effectiveness, three papers 42 50 51 reported workarounds performed in one part of the system to improve effectiveness, might lead to less effectiveness elsewhere. Similarly, papers articulated healthcare professionals perceive at times there is a need to balance or trade off competing quality goals. For example, in one paper, nursing staff reported they actively tried to balance risk and efficiency rather than follow procedures mechanistically by stopping infusions when patients leave the ward for investigations, so the nurse does not have to accompany the patient when staffing resources were stretched. 40

Perceived implications of what SSWAs achieve for safety were found to be diverse across the included papers. Several papers described SSWAs as unsafe. 13 31 36 41–43 45 51 54 For example, one paper reported that using workarounds during patient registration processes led to lapses in patient care. 36 Other papers did not describe SSWAs as beneficial for safety but discussed how the SSWA did not result in error or harm. 30 34 35 39 44 49 Some papers reported SSWAs had both positive and negative implications for safety simultaneously. 29 37 38 40 48 50 52 53 These papers, published from 2016 onwards, recognised healthcare staff are frequently balancing more than one risk and are juggling processes that compete to create safety. For example, double-checking intravenous medication may make the medication process safer but, if performing the double check leads to delays, the double check may make the process less safe. 48 Overall, these findings illustrate the importance of considering the implications of SSWAs across all aspects of quality.

Papers were analysed to understand the perceived implications of SSWAs for patients, staff and the organisation. SSWAs were perceived to be positive, negative and simultaneously both positive and negative for each group as illustrated in figure 2 .

Perceived implications of safety standard workarounds for patients, staff and organisation.

SSWAs were perceived to be beneficial for patients more often than they were perceived to be detrimental in over 20% of papers [22%; 31 34 39 40 49 50 ]. For example, one study 31 found that nurses worked around electronic health record protocols to provide what they felt was better care. In another study, efficient care, achieved through an SSWA, was perceived to be beneficial, although it was acknowledged the workaround may have negatively impacted on the patients’ experience of care. 47 Negative implications of SSWAs for patients were described in 15% of papers [15%; 13 36 41 44 ], while 15% of other papers reported SSWAs neutrally [15%; 37 48 52 54 ].

Perceived implications of SSWAs for healthcare staff were reported in 89% of papers [89%; 30–41 43–54 ]. Perceptions were positive in one-third of papers, describing how SSWAs enabled the management of heavy workloads. However, in three papers, 34 47 53 SSWAs were perceived to increase staff workload. Over a quarter of papers perceived SSWAs enabled staff to deliver high-quality care in challenging circumstances [26%; 39–41 44 48 51 52 ]. There were indications that SSWAs were encouraged or at least tolerated by managers for this reason. 38 45 Staff perceived SSWAs were used to balance risks when delivering care. 35 40 52 There was acknowledgement that operating outside of standards to provide care may make staff professionally vulnerable. 32 34 50

Perceived implications of SSWAs for healthcare organisations were reported in 85% of papers [85%; 29–38 40–43 45–53 ]. From an organisational perspective, workarounds were reported to be concerning in some papers, 41 48 53 as they can hide problems within the service and potentially shift safety margins by routinely pushing performance to the edge of acceptability in normal circumstances. 29 33 37 53 However, if known about, workarounds were regarded as an important source of organisational learning in 44% of papers, 13 29 30 33 35 38 40–43 48 53 highlighting when the system is vulnerable and illuminating strategies to overcome challenges in a complex system. 37 40 42 53 However, insufficient mechanisms to learn from work as it is done in organisations was reported as a limit to learning in some papers. 30 37 42

Papers reported workarounds are one form of adaptation healthcare staff use to respond to challenging conditions 37 40 47 52 53 or in response to unworkable or overly prescriptive standards. 29 30 38 40 50 These papers described how standards are not achievable or adherence even desirable 100% of the time. This perspective recognised policies alone do not create safety and the adaptations made by staff can be resilient actions. For example, one study reported nurses contributed to system resilience by adapting rules rather than following them mechanistically. 52 Within some papers, it was suggested that developing flexible standards or adopting safety goals based on core values may be beneficial. 29 30 48 52

This review builds on previous literature reviews concerned with workarounds in healthcare 9 10 15–18 to explicitly explore the circumstances and perceived implications of working around safety standards. We found 27 papers that addressed our aim.

Theoretical implications

First, our findings have added to the theoretical understanding of workarounds. Our review has expanded the causes of healthcare workarounds previously described in the literature 9 11 18 by discriminating between professional factors and relational factors. In our review, professional causes of SSWAs underlined how organisational standards are sometimes in conflict with professional obligations. This makes it challenging for healthcare professionals to know how to proceed at times and can result in difficult decisions to follow standards or work around them being made by individuals. McCord et al 17 found conditions that provoke stress in healthcare settings are correlated with the use of workarounds by nurses and contribute to burnout. Further, the use of workarounds by individuals reconciling professional responsibilities with organisational standards increases variation in care processes. This may not be undesirable 55–59 but may have implications for the wider system. 59 60

As discussed by Hollnagel, 55 ‘any living system that has a modicum of awareness of its own existence will show trade-offs in one way or the other.’ While our review found frequent SSWAs, it was difficult to establish what workarounds were perceived to accomplish. Indeed, it is clear that SSWAs are viewed differently by different groups of stakeholders. For patients, SSWAs were sometimes perceived to support better care. Healthcare staff seemed to perceive SSWAs as supporting them to manage their workload, balance risks and deliver high-quality care in challenging circumstances. Our review found indications that SSWAs were tolerated by managers for these reasons as previously described in the literature. 61–63 Our findings also found there is some concern that this form of frontline dynamic adjustment, made in the moment, allows managers to protect themselves from inconvenient truths and shift accountability for failures to frontline workers which has been a concern of others. 64

Our review found that from an organisational perspective there were theoretical fears that SSWAs may contribute to system migration. 65 66 This occurs as frontline workers adapt in response to pressures, create borderline-tolerated conditions, 67 which over time become normalised, 68 and cause the entire system to drift closer towards the very boundaries of safe performance. But our review also found SSWAs were regarded as a potential source of organisational resilience that enabled healthcare staff to adapt to challenges to maintain high-quality care, 69 as proposed in other research, 9 70–72 and could be used to improve system performance. 63 73

Policy and practice implications

From our review, we were not able to fully understand what SSWAs achieve across the healthcare system. Scoping reviews are useful for mapping emerging evidence but there are limitations to using this approach. Empirical studies that specifically explore the highly nuanced implications of workarounds across the healthcare system are required to address this gap in the evidence. We found SSWAs were perceived as useful for achieving efficient, effective, person-centred care in some circumstances. But, consistent with previous literature, the perceived implications for safety were equivocal. 11 13 72 74 Nevertheless, our review found that papers frequently described unintended consequences for safety of both adhering to standards and deviating from standards, highlighting an inherent paradox in the use of standards to achieve safe care. This predicament centres on the fact that while standards can be used to promote safety, 75 unwavering adherence to standards can be a cause of harm 76 and stifle resilience. 59 77 One reason for this is the nature of healthcare work, where it is difficult to fully specify how tasks should be carried out at all times, such as when two standards are in conflict or when following a standard would result in a worse outcome for a patient. This also includes situations where healthcare staff find it necessary to go beyond rules to achieve goals. 72 75 78 In these circumstances, adjustments and compromises are valuable; effective performance relies on this variability. 55 This perspective acknowledges healthcare staff mediate the formal functioning of standards. 24 59 However, there are challenges accepting safety is achieved through both adherence to and adaptation from rules. Yet, we argue that the current status quo is intolerable for frontline staff who, to maintain safety, need to adhere to rules predictably and reliably, but not so rigidly or inflexibly as to fail, 6 7 79 without acknowledgement that this is the world they inhabit or any guidance.

To tackle this problem, there is an urgent need for research that explores the safety implications of SSWAs used by healthcare professionals. To be meaningful and to support the healthcare system to improve, this work will need to acknowledge safety is never the only ambition of a healthcare system, 55 80 and explore how the dynamic trade-offs between safety and other competing quality goals can be managed flexibly. This will be challenging, and further research will be needed to explore if different levels of the healthcare system can come to a collective understanding of what SSWAs achieve for diverse stakeholders in varying circumstances. This shared understanding will be important to determining how healthcare organisations and regulators can operationalise more flexible approaches to safety, 59 79 81 82 which may include developing flexible standards or adopting safety goals based on core values which account for the variability of conditions in the real world.

Strengths and limitations

To our knowledge, this is the first review to explore the circumstances and perceived implications of working around safety standards in the delivery of healthcare. The review was designed in collaboration with key stakeholders and offers new insights into the causes of SSWAs.

The review process aimed to ensure all papers concerned with working around safety standards were included; however, the review was limited to English language only, which may have excluded some relevant papers.

Conclusions

Our review has found the causes of SSWAs are aligned with causes of general workarounds previously described in the literature, 9 11 18 and that organisational causes are the most prominent reason for SSWAs. We found it was necessary to differentiate professional factors from other causes of SSWAs to reflect how healthcare professionals use SSWAs to achieve what they perceive to be effective care when organisational standards conflict with professional obligations.

In our review, workarounds were perceived positively for achieving efficient, effective, person-centred care. But, consistent with previous literature, 10 11 13 72 the perceived implications for safety were equivocal, with papers reporting diverse perspectives regarding what SSWAs achieve for safety. The review drew attention to a contradiction in the use of standards to achieve safe care, identifying unintended consequences for safety with both adhering to and deviating from standards, and found working around standards, at times, was a potential source of organisational resilience that helped healthcare staff to succeed. We propose further research is needed to explore the safety implications of healthcare professionals using SSWAs which will have implications for improving the healthcare system.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

Acknowledgments.

The authors would like to thank Deb Debono for early conversations regarding search terms and insights related to studying workarounds. The authors would also like to thank clinical stakeholders for taking part in conversations which were drawn upon to shape the review.

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X @deb_clark2, @LawtonRebecca, @laurainbradford

Contributors DC, JO'H and RL conceived the review. DC conducted the review. All authors appraised the sources. DC, supervised by JO'H and RL, developed the analysis. DC drafted the manuscript with support from all authors. All authors reviewed and agreed with the current version. DC is the guarantor for this review.

Funding This work forms part of a research fellowship awarded to DC with The Healthcare Improvement Studies (THIS) Institute. The fellowship was funded by the Health Foundation as part of a grant to the University of Cambridge supporting THIS Institute. This research was supported by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Research Collaboration (NIHR YHPSRC). The views expressed are those of the authors and not necessarily those of the NIHR, or the Department of Health and Social Care.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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What is safety leadership? A systematic review of definitions.

Adra I, Giga S, Hardy C, et al. What is safety leadership? A systematic review of definitions. J Safety Res. 2024;90:181-191. doi:10.1016/j.jsr.2024.04.001.

Leadership commitment to safety strongly influences staff commitment to safety. This review sought to identify definitions and themes of "safety leadership." Three themes were derived from the definitions: 1) safety leadership improves safety performance; 2) safety leaders lead by influence and example, not authority; and 3) safety leadership can be practiced by leaders at all levels of the organization. Transformational and transactional leadership formed the foundation for many definitions, though the authors advise adopting multiple forms of leadership styles. The authors propose that future research focus on the relationship between leadership style and safety climate.

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Exploring pharmacist experiences of delivering individualised prescribing error feedback in an acute hospital setting. January 16, 2019

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. June 13, 2011

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021

Families as partners in hospital error and adverse event surveillance. April 24, 2018

Preventable deaths in patients admitted from emergency department. June 25, 2009

Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety incidents: an observational study. September 7, 2022

Supporting error management and safety climate in ambulatory care practices: the CIRSforte study. May 1, 2024

Improving handoffs in the emergency department. July 13, 2010

Patient safety: Part I. Patient safety and the dermatologist. August 19, 2009

Examining the Impact of Artificial Intelligence (AI) on Healthcare Safety (R18). July 22, 2024

Quality and safety of artificial intelligence generated health information. June 5, 2024

Systematic review on the frequency and quality of reporting patient and public involvement in patient safety research. May 15, 2024

Feeling safe in the context of digitalization in healthcare: a scoping review. April 10, 2024

Conceptualising learning from resilient performance: a scoping literature review. January 10, 2024

Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series. August 9, 2023

Mitigating bias in AI at the point of care. July 26, 2023

Annual Perspective

A risk science perspective on the discussion concerning Safety I, Safety II and Safety III. January 22, 2022

Patient and family engagement as a potential approach for improving patient safety: a systematic review. October 30, 2019

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Assessing Occupational Safety and Health Training – A Literature Review

Dhhs (niosh) publication number 98-145.

More than 100 Occupational Safety and Health Administration (OSHA) standards for hazard control in the workplace contain requirements for training aimed at reducing risk factors for injury or disease; others limit certain jobs to persons deemed competent by virtue of special training. A literature review was undertaken to assess the merits of such training rules to achieve this objective and to sort out factors of consequence. The review focused heavily on published reports, primarily drawn from the period 1980 through 1996, wherein training was used as an intervention effort to reduce risk of work-related injury and disease. Eighty (80) such reports were found and gave overwhelming evidence to show the merits of training in increasing worker knowledge of job hazards, and in effecting safer work practices and other positive actions in a wide array of worksites. Reports from select surveys and investigations of worker injuries and workplace fatalities were also accessed with many implicating lack of training as a contributing factor to the mishaps. In still other studies, workplace training devoted to first aid instruction showed linkage to reduced worker injury rates, suggesting that even this kind of training has benefits to job safety overall.

A critical analysis of the above findings found certain qualifications in viewing training impacts and successes with regard to current workplace standards. For example, most of the reported training intervention studies did not address OSHA training rules per se, and knowledge gain and safe behavior measures were used in many evaluations as opposed to actual injury/disease indicators. Also, in some instances, the training was coupled with other forms of intervention to make attribution difficult. Training deficits noted in some surveys of work injury cases lacked for confirmation and no information was available on the quality of the instruction if given at all.

Despite the above reservations and uncertainties, training’s role as a necessary element in developing and maintaining effective hazard control activities remained firmly supported by the available literature. What did emerge from this review and analysis was an appreciation of meaningful training procedures and the recognition of factors both within and beyond the training process that could greatly affect its impact. In this regard, the OSHA voluntary training guidelines were described along with illustrations from the reports to show how the various steps contained within them can be met in realistic ways and have merit in framing an effective program. In addition, factors both within and beyond the training process were assessed for their effects on training outcomes based on data found in the reviewed literature. Variables such as size of training group, length/frequency of training, manner of instruction, and trainer credentials were each shown to be significant determinants to the training process. Equally important were extra-training factors such as goal setting, feedback and motivational incentives along with managerial actions to promote the transfer of learning to the jobsite.

Based on the literature review, follow-on efforts to address outstanding issues and needs regarding effective occupational safety and health training were noted.

Assessing Occupational Safety and Health Training – A Literature Review

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• Published: 27 September 2024

Factors influencing the formation of balanced care teams: the organisation, performance, and perception of nursing care teams and the link with patient outcomes: a systematic scoping review

• Senne Vleminckx   ORCID: orcid.org/0000-0001-9647-4785 1 ,
• Peter Van Bogaert 1 ,
• Kim De Meulenaere 2 ,
• Lander Willem 3 , 4 &
• Filip Haegdorens 1  

BMC Health Services Research volume  24 , Article number:  1129 ( 2024 ) Cite this article

Metrics details

The composition of care teams is crucial for delivering patient-centered healthcare, yet assembling a well-balanced team remains a challenge. This difficulty stems from the intricate dynamics of team capacity, culture, context, and the demands of the job. The current literature offers limited guidance for decision-makers on how to effectively navigate these dynamics to compose a balanced care team.

We conducted a systematic scoping review of literature spanning from 2009 to 2022. The aim was to identify factors that significantly influence the work environment, team performance, nursing outcomes, and patient outcomes within healthcare settings. Our review focused on extracting and synthesizing evidence to uncover these influencing factors.

Our analysis identified 35 factors that play a significant role in shaping the work environment and influencing team performance, nursing outcomes, and patient outcomes. These factors were categorized into nine key domains: workload, leadership, team composition, stress and demands, professional relationships, safety, logistics and ergonomics, autonomy and responsibility, and transparency and task clearness.

Conclusions

To improve patient care and nursing job satisfaction, policymakers and decision-makers can consider these influencing factors in the design and management of care teams. The findings advocate for strategic adjustments in these domains to enhance a team’s balance. Furthermore, our review underscores the need for further research to fill the identified gaps in knowledge, offering a directive for future studies into optimal care team composition. This systematic approach to team composition can significantly impact patient outcomes and nurse satisfaction, providing a roadmap for creating more effective and harmonious teams.

Peer Review reports

Nursing staff constitute half of the global healthcare workforce. However, there are growing concerns about chronic nursing shortages and high turnover rates in many healthcare organizations. Several countries have reported an increasing gap between the number of practicing nurses and the rising needs of the population due to aging populations and a growing burden of chronic diseases [ 1 , 2 , 3 , 4 ]. These factors have resulted in a quantitative shortage of nurses, which is further exacerbated by high turnover rates [ 5 ], global competition for skilled workers [ 6 ], and nurses’ growing preferences for alternative jobs [ 7 , 8 , 9 ]. In addition, care complexity is increasing due to highly demanding technological innovations [ 10 ] and patient-tailored healthcare, which increases the need for qualified and well-trained staff in changing environments [ 11 ]. The World Healthcare Organization (WHO) estimated a 7.6 million shortfall in nurses by 2030 [ 12 ]. The COVID-19 pandemic proved to be a catalyst for accelerated levels of absenteeism and nurses who permanently leave the profession [ 13 ].

Understaffing and suboptimal skill-mix within care teams could result in missed care, adverse patient outcomes including mortality, and failure to rescue [ 14 , 15 , 16 , 17 ]. The latter also affects nursing staff outcomes such as job satisfaction, potentially leading to increased staff turnover [ 18 , 19 ].

Attracting and, most importantly, retaining nurses is an important global challenge [ 20 ]. Policymakers attempt to address the need for qualified staff by increasing the number of nurses entering the workplace as a first key strategy. However, simply increasing the supply of nurses will be insufficient to address the current staffing problems in healthcare [ 3 , 21 ]. Previous research has shown that experienced and highly educated nurses are essential to provide high-quality care [ 22 , 23 , 24 ]. Therefore, a second and complementary strategy to cope with limited nursing staff is to focus on the composition of care teams and to optimize care through the appropriate allocation of nursing skills across teams. Research has shown that nurses are sometimes overqualified for some tasks, which indicates options for improvement [ 21 ].

At this moment, many decision-makers lack the tools to address the complex interactions between a team’s capacity and job demands and the role of culture and context. As such, building a balanced team adapted to their specific context and the needs of their patient population is complex, although it improves the quality of care and potentially the retention of experienced staff [ 20 ]. In a balanced care team, there is a strategic alignment among the team’s capacity, its operational processes, and the demands of care, all aimed at optimizing outcomes for both the team and the patients. This approach underscores the importance of maintaining a crucial equilibrium between the capabilities of the team and their assigned tasks. It ensures that the design of work systems enhances patient safety, promotes the well-being of staff, and boosts organizational effectiveness. By maintaining this balance, balanced care teams contribute to the sustainability of high-quality care and the achievement of positive outcomes for both healthcare providers and patients.

Despite the potential benefits of a balanced care team, there is currently discussion on how to optimally compose such a team or which factors should be taken into consideration. Additionally, the interactions between these factors can be complex and not well understood. By better understanding which factors influence the development of a balanced care team and how the factors interrelate, healthcare organizations can develop more data-driven strategies to attract and retain nurses, improve patient outcomes, and promote job satisfaction among healthcare professionals.

The objective of this systematic scoping review is to comprehensively examine the literature on the elements that contribute to the formation of balanced healthcare teams, guided by Donabedian’s model [ 25 ] which organizes healthcare quality into three interconnected domains: structure, process, and outcomes. The structure encompasses the characteristics of the healthcare settings and impacts the work environment; the process includes the interactions between patients and providers, reflecting team performance; and the outcomes represent the health effects on patients and nursing staff, aligning with our focus on their respective outcomes. This review aims to explore the interrelationships among the structural conditions of the work environment, the processes of team performance, and the resulting outcomes, offering insights into what could make or break high-performance and balanced care teams and to identify variables that could be effectively utilized in practice to enhance both care quality and workforce stability.

This systematic scoping review was conducted with the guidance of the Preferred Items in Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) [ 26 ].

Data sources and search strategy

Starting from the definition of balanced working teams outlined in the introduction and guided by Donabedian’s model [ 25 ], we identified four dimensions to be included in the search query: work environment, team performance, nurse outcomes, and patient outcomes. In this review, “dimensions” refer to broad categories that encapsulate various factors influencing the functioning of balanced care teams. This terminology is intended to capture the multifaceted nature of these factors, reflecting the broader scope of their impact beyond singular outcomes. By categorizing these aspects as dimensions, we aim to highlight their interconnected roles in shaping the overall performance and effectiveness of healthcare teams, consistent with the holistic approach of the balanced care team framework. In line with PRISMA-ScR guidelines, eligibility criteria were determined by three researchers (SV, FH and PvB) prior to screening. Based on these eligibility criteria and exploratory searches, we defined the queries presented in Fig.  1 . We searched for papers in PubMed and ISI Web of Knowledge on factors influencing the work environment on November 9th, 2022. We restricted the search to papers published from June 2009 onward to obtain information related to the current situation in the continuously evolving healthcare system. Original research papers (quantitative, qualitative, and mixed methods) and reviews were included when they focused on factors influencing the organization of nursing care teams on the work environment and/or team performance and/or nurse outcomes and/or patient outcomes. Papers were excluded if they did not concern the organization of care teams, did not discuss influencing factors or if no significant effects were found.

The search query for the Pubmed and ISI Web of Knowledge databases used on November 9th, 2022

Identification of articles and data extraction

Two researchers independently screened titles, abstracts, keywords, and full texts if necessary to assess the eligibility of the paper (SV and FH). Discrepancies were resolved through discussion with a third reviewer (PvB). During the full-text screening, SV and FH used an electronic matrix to facilitate a structured and systematic extraction of data from each study. The matrix required them to input detailed information about each study, starting with the methodology employed. This included specifying the type of study design (e.g., RCT, cross-sectional, longitudinal), the population studied, and the setting. Next, this process involved identifying the independent variables examined in each study, ensuring a comprehensive understanding of the factors being investigated. Furthermore, our analysis extended to categorizing the impact of these independent variables on the four dimensions of this review: work environment (e.g., the physical work environment, physician‒nurse relations, organizational support, etc.), team performance (e.g., teamwork, team efficacy, task performance, etc.), nurse outcomes (any outcome related to the work attitude or behavior of nurses or affiliated staff:, e.g., job satisfaction, burnout, etc.) and patient outcomes (all outcomes that affect patients, e.g., nurse-sensitive outcomes, mortality, etc.). Lastly, the electronic matrix facilitated the recording of exclusion reasons or supported the inclusion decision-making process. The list of influencing factors was iteratively refined during data extraction by employing a thematic combination approach. This method involved grouping individual factors into broader domains based on their thematic similarities or their interconnectedness within the context of the research findings. The iterative nature of this refining process meant that the list of influencing factors was dynamic as we delved deeper into the literature. Discrepancies in the categorization or interpretation of factors were resolved by a third reviewer (PvB), whose role was to provide an additional layer of scrutiny and consensus, thereby ensuring the reliability and accuracy of the analysis.

Using the online databases PubMed and ISI Web of Knowledge, we identified 2,394 unique articles published between 2009 and 2022 that matched our search criteria. Based on the screening of the title, abstract and keywords with predefined eligibility criteria, we excluded 1,909 articles. Of the remaining 485 full-text articles, we excluded another 122 for which the topic did not concern the organization of care teams, if no influencing factors were studied, no significant effect was found, or if no full text could be retrieved. Finally, 363 studies were included for data extraction and qualitative synthesis. The PRISMA-ScR diagram is shown in Fig.  2 . Due to the large number of included articles, we did not include a citation for every article but provided one reference as an example in the Results section and provided a summary table in Appendix 1 with a complete set of references including study characteristics.

PRISMA-ScR flow diagram of the scoping review process

Study setting

Among the 363 included studies, we found that most of the research was conducted in the acute hospital care setting and in residential care (Table 2 ). A minority of the included papers were carried out in home care (8 articles), revalidation care (9), geriatric care (13) and psychiatric care (18). A descriptive cross-sectional design was used in nearly 70% of studies. In contrast, an experimental study design (RCT, CT) was used in only two included studies. We included 3 meta-analyses and 36 systematic reviews using qualitative data synthesis. Most of the literature has focused on nursing and patient outcomes. Table 1  outlies the number of included articles per context, per evidence level and per studied dimension.

Influencing factors

We utilized a matrix to compile a comprehensive list of factors that influenced the nursing team, the work environment, team performance, and patient outcomes. In total, we identified 35 such factors. As shown in Table 2 , we classified these factors into nine overarching domains: (1) autonomy and responsibility, (2) leadership, (3) logistics and ergonomics, (4) professional relations, (5) stress and physical demands, (6) team compositions, (7) transparency and task clearness, (8) safety, and (9) workload. Not surprisingly, the domain that has received the most research attention is the workload domain ( n  = 298), mostly with a focus on nurse staffing levels ( n  = 206). The two other frequently studied domains are leadership ( n  = 212) and team composition ( n  = 171), the latter with a clear focus on the impact of the educational level of nurses ( n  = 71). The least studied domain was that of transparency and task clearness, yet 23 studies have been published in the area. For the three largest domains (workload, team composition and leadership), Fig.  3 displays the number and evolution of published papers over the period between 2009 and 2022 and demonstrates a noticeable rise in the number of papers, particularly since 2019. To improve the readability of the graph, we only included the three largest domains, although we discuss all domains in the main text. In what follows, we will discuss the literature and research findings for each of these nine domains.

The number of studies included in select domains over time. Legend: Green: Blue: Leadership; Workload; Grey: Team composition. The gray marked area represents the Covid-19 pandemic

Autonomy and responsibility

We found a link in the literature between professional autonomy and educational level, the involvement of direct managers, transformational leadership, and the nurse‒physician relationship [ 27 ]. Unclear responsibilities were identified as counteractive and researched in combination with team composition and leadership [ 28 ]. The papers in this domain focus predominantly on nurse and patient outcomes. Notably, autonomy and responsibility have demonstrated a positive impact on job satisfaction [ 29 ].

Within this domain, we found papers on transformational leadership. In 68% of the included studies, this was linked with the involvement of direct managers (listening to concerns, acknowledgment of problems, and inspirational leadership) [ 28 ]. A management style focused on engaging and empowering nurses has shown a positive effect on both nurse and patient outcomes and has often been studied simultaneously with the involvement of direct managers and transformational leadership [ 30 ]. Seven studies found an effect of the conflict management style of the direct managers and the organization on the outcome measures. The impact on organizational decision-making, perceived trust in management and unfair treatment by management were described as important for nursing team outcomes [ 31 ] and patient outcomes [ 30 ]. Finally, adequate conflict management by the direct manager and a qualified and trusted chief nursing officer (CNO) mostly described the nurse outcomes and team performance.

Logistics and ergonomics

This domain covers the lack of (up-to-date) medical and nursing equipment and the physical work environment of nurses. These factors mainly influence patient outcomes, the work environment and nursing outcomes. However, there was one study that found an effect on team performance, where (physical) work organization had a positive influence on team performance and reduced care left undone [ 32 ]. Several studies where logistics and ergonomics were found to have an effect were conducted on job (dis)satisfaction [ 33 ] and burnout [ 34 ].

Professional relations

Nursing teams encounter many types of interactions and professional relationships. The physician‒nurse relationship has been proven to influence all four dimensions, although most studies focus on nurse outcomes. A positive relationship with physicians has a positive impact on nurses’ job satisfaction [ 35 ] and their intention to leave [ 35 ] and reduces burn-out [ 36 ], mortality [ 37 ] and other outcomes. The relationship between nurses and patients and their families influences both nurse and patient outcomes [ 38 ]. Two studies also showed a link with team performance.

Stress and physical demands

All four studied dimensions were significantly linked with perceived work-related stress and moral or physiological stress due to patient care in combination with emotional and physical demands. In particular, nurse outcomes have been described in various nursing contexts [ 29 ]. Work-life balance in this domain is considered an influencing factor, for example, the effect of a healthy work-life balance on occupational fatigue [ 39 ]. However, work-life balance is also a nurse outcome measure influenced by shift working [ 39 ], overtime [ 40 ] and lack of control [ 27 ]. Therefore, work-life balance is considered a mediator: shift work, overtime and lack of control influence work-life balance, which in turn influences occupational fatigue. The benefits and rewards nurses receive (e.g., salary) had an impact on job (dis)satisfaction and intention to stay [ 41 ].

Team composition

The educational level of nurses within a team had a clear positive effect on patient outcomes and has been researched extensively in acute hospitals and residential care [ 14 ]. Some papers have also shown the effect on nurse outcomes [ 39 ]. In 31 of the identified papers, the educational level was researched jointly with the nurse staffing level. Team cohesion and climate showed an effect on all four dimensions. It relates to the involvement of direct managers and nurse‒physician relationships [ 42 ]. In addition, some studies have discussed the impact of team ‘coreness’, which denotes whether one is in the right team, place, and time [ 30 ]. The deployment of supplemental or agency nurses showed a negative effect on patient outcomes in nine studies [ 43 ]. Only a small number of studies have investigated the effect of team demographics on patient and nurse outcomes, although they have reported significant effects [ 44 ]. Figure  3 shows that the research domain of the composition of care teams is gaining interest in the research community. Especially since 2019, we can see an increasing number of publications about this topic.

Nurse-perceived staffing levels (nurse-reported unsafe staffing situations) were reported to impact both patient and nurse outcomes negatively and are influenced by leadership (involvement of direct managers, impact on organizational decisions and nurse engagement) [ 45 ], nurse staffing levels [ 46 ] and nurse‒physician relations [ 47 ]. It has been described in two systematic reviews regarding the organizational context of nursing [ 45 , 48 ]. Safety culture within a nursing team clearly affects patient outcomes [ 49 ] as well as other dimensions. There was also a link between safety culture and leadership [ 50 ], but we did not find links with the nurse‒physician relationship.

Transparency and task clearness

The domain with the lowest number of retrieved studies consists of two influencing factors: frequent and clear communication and the availability of guidelines or protocols. Whether communication is clear and timely has been linked to all four dimensions and is affected by the physician‒nurse relationship and the involvement of a direct manager [ 48 ]. There was no specific dimension that stood out, given the limited amount of literature on this topic.

Most retrieved research identified an effect between staffing levels and one or more of the four dimensions. The studies were conducted in all work contexts, and we also included one meta-analysis and 17 systematic reviews. A meta-analysis on nurse staffing and nurse outcomes [ 51 ] showed that higher nurse-to-patient ratios were consistently associated with a higher prevalence of burnout, increased job dissatisfaction, and higher intent to leave among nurses. There were disparities in how various papers measured and reported nurse staffing levels, such as the nurse-to-patient ratio, nursing hours per patient day and bed-to-nurse ratio. In 71% of the papers included, there was evidence of the impact of nurse staffing levels on patient outcomes and 26% on nurse outcomes. Shift working influences both nurse and patient outcomes [ 39 ] and has a negative impact on nurses’ work-life balance. It was often jointly investigated with overtime and nurse staffing levels [ 39 ]. The negative effects of workload, shift work and overtime have been shown on patient and nursing outcomes in acute hospitals. High workload also causes care to be left undone, which represents missed, unfinished, or incomplete care, and the effect on patient outcomes is apparent from the literature. As with work-life balance, care left undone is a mediator between workload (e.g., staffing levels) and patient outcomes [ 52 ]. Furthermore, it also has a negative impact on nurse outcomes [ 41 ] (e.g., job dissatisfaction) and the nursing work environment [ 53 ]. Studies focusing on job (dis)satisfaction and intention to leave found a link with workload and emphasized the benefits and rewards of a balanced workload on nurse outcomes.

This systematic scoping review presents an overview of the existing body of knowledge regarding the factors affecting the organization of balanced care teams published between 2009 and 2022. We identified 35 influencing factors that, according to the extant research, have a significant effect on the four dimensions under study, i.e., work environment, team performance, nurse outcomes and patient outcomes. We categorized these factors into nine overarching domains: (1) autonomy and responsibility, (2) leadership, (3) logistics and ergonomics, (4) professional relations, (5) stress and physical demands, (6) team compositions, (7) transparency and task clearness, (8) safety, and (9) workload.

The relationships between the dimensions of work environment, team performance, nurse outcomes, and patient outcomes are inherently complex, and the direction of causality may vary. For example, a supportive work environment can enhance team performance, which in turn positively affects nurse and patient outcomes, demonstrating the bidirectional and dynamic nature of these relationships. Although all four dimensions are important, we know from research that particularly the work environment and team performance seem key to retaining a skilled workforce. Bae et al. [ 54 ] showed that turnover has a serious economic impact on hospitals caused by reduced productivity, the need to hire and train new nurses, and the costs associated with vacancies and temporary replacement. Therefore, optimizing the nursing work environment and supporting a team’s performance can help retain more experienced nurses in the workforce. One way to achieve this is by designing the work system in such a way that there is a balance between a team’s demands and its resources [ 55 ]. The design of work systems in nursing care is predominantly determined by tasks or specific actions in operational care delivery. They are supported by tools and technology, effective organizational design, collaboration, coordination, and the physical work environment. These work systems, in turn, influence patients, care providers and organizational outcomes [ 56 ].

In a balanced care team, there is a strategic alignment among the team’s capacity (e.g., staffing, educational level, support, etc.), its operational processes, and the demands of care (e.g., the complexity of care, patient turnover, physical demands, etc.), all aimed at optimizing outcomes for both the team and the patients. Intuitively, balanced care teams have the capacity to adapt their work system and processes to improve care based on their feedback and learning strategies as a resilient workforce [ 57 , 58 , 59 ].

Some of the factors identified in this review are used to inform decisions by nursing leaders and policymakers. To date, software tools exist to assess patient demand and care team characteristics (absenteeism, vacancies, staff leave) or to estimate and optimize team compositions [ 60 ], for example, based on mandatory staffing levels. However, these systems need to be adjusted to the context and need governance by management to be used for staff deployment [ 61 ]. In the future, nurse leaders will have to work with large volumes of organizational and patient data. An overview of the influencing factors on the performance of nursing teams could offer guidance and support to make decisions on staffing and competencies [ 62 ]. The integration of metrics measuring these factors in a decision support system could be beneficial for decision-makers if clinicians agree on the importance, availability, and impact of those metrics.

Strengths and limitations

To the best of our knowledge, this is the first study to review evidence about all influencing factors in the organization of nursing care teams, their work environment, team performance and nurse as well as patient outcomes. The review process followed the PRISMA-ScR protocol [ 26 ] to ensure the quality of reporting.

Nevertheless, this study is, like others, not without limitations. Foremost among these is the methodological challenge associated with our comprehensive approach to literature inclusion in this scoping review. Given our objective to encompass all relevant literature, a critical appraisal of the included articles to assess the quality of evidence was beyond our scope. Consequently, we are cautious in making definitive conclusions regarding the evidence quality. Notably, a significant majority of the studies we reviewed (70%) employed descriptive cross-sectional designs. While this design offers numerous advantages, such as the ability to provide a snapshot of phenomena at a specific point in time and contribute to hypothesis generation, it inherently limits the ability to establish causality [ 63 , 64 ]. The prevalence of descriptive and cross-sectional studies in our review mirrors the current research landscape within our field, where such methodologies are often favored for their practicality and accessibility. However, this trend underscores a critical gap in the literature – the need for more longitudinal and experimental designs that can more effectively study causal relationships and assess intervention outcomes. Addressing this gap should be a priority for future research, with a focus on integrating higher-quality evidence through more robust study designs. This would significantly enhance our ability to draw causal inferences and advance the field’s understanding of effective interventions and their impacts.

In addition, there are inconsistencies regarding the measurements used in the literature. For example, in both academic consensus and general practice, a lack of agreement exists on how to measure and report nurse staffing levels. Nurse staffing levels are measured by nursing hours per patient day, nurse-to-patient ratio, bed-to-nurse ratio, etc. Standardized reporting of nurse staffing levels will allow comparisons between study results as well as the opportunity to use more data analytics in healthcare. Moreover, by only including literature that showed a significant effect on one of the dimensions, the risk of publication bias exists. However, this scoping review aimed to provide nursing managers, academics, and policymakers with an overview of the current state of research and which domains proved to have a significant impact. As such, we prefer to focus on the influencing factors that are already found to inform policymakers, researchers, and nurse managers.

Second, we made a deliberate decision not to include papers about interventions, policies, and the consequences of the COVID-19 pandemic, based on the assumption that these crisis circumstances are not representative of future operational norms. Nevertheless, it is undeniable that the pandemic crisis has significantly heightened the relevance of the current research. We also recognize that the complex causes and effects of the pandemic on healthcare teams and patient care merit their own dedicated research endeavors, encompassing both comprehensive reviews and longitudinal studies. Future research should specifically address the unique challenges and adaptations brought about by the COVID-19 pandemic, as a separate focus would enable a more nuanced understanding of its impact. Such research could facilitate the development of targeted interventions and policies to enhance healthcare resilience and effectiveness in future crises, thereby addressing the gap left by our exclusion of pandemic-related literature.

Third, we acknowledge that the prevalence of various domains in the literature is not a measure of their significance or importance, as this can be distorted by the frequent use of the Practice Environment Scale of the Nursing Work Index (PES-NWI) in research. The PES-NWI is an instrument used to measure factors that enhance or attenuate a nurse’s ability to practice nursing skillfully and deliver high-quality care [ 65 ]. For example, nurse‒physician-relationship, staffing levels and leadership are part of the five subscales of PES-NWI: “nurse participation in hospital affairs”, “nursing foundations for quality of care”, “nurse manager ability, leadership, and support of nurses”, “staffing and resource adequacy” and “collegial nurse‒physician relations”. Although the PES-NWI is a widely recognized and reliable tool for assessing the work environment of nurses, our research highlights the need for decision-makers to consider additional factors that are crucial for assessing the nursing work environment. For example, team and organizational demographics have been extensively researched by management scholars [ 66 , 67 , 68 , 69 ].

Lastly, despite conducting an extensive search across two comprehensive databases, the specific nature of our search strings and the practical challenges of including all possible databases might lead to the inadvertent omission of relevant studies.

To promote a resilient workforce, ensure high-quality care, and enhance patient safety, it is essential to examine and integrate other influential factors that we have identified. Griffiths et al. (2020) [ 60 ] suggested that future research should concentrate on how to optimally utilize currently available staffing tools. Moreover, while the formation of balanced care teams is crucial, it is equally important to identify and address situations where capacity and demand are misaligned [ 70 , 71 ]. In addition, we recommend that future research should further investigate the concept of balanced care teams to fully comprehend its potential benefits and limitations. By doing so, decision support systems can incorporate this research and strive for balanced care teams by optimizing a team’s capacity to meet their specific demands while considering the context.

Additionally, to augment the robustness of healthcare research, future investigations should employ more rigorous methodologies, such as randomized controlled trials (RCTs) or longitudinal studies. It is also vital to standardize the measurement tools used across studies to ensure comparability and enhance the generalizability of findings. This approach will not only strengthen the validity of the findings but also facilitate their integration into broader meta-analyses, thereby enhancing their applicability in real-world settings. Furthermore, the development and application of comprehensive theoretical and organizational frameworks are recommended to enrich our understanding of the dynamics within healthcare teams. These frameworks should aim to integrate multifaceted aspects of healthcare delivery, providing deeper insights that can inform policy and practice. Finally, the theoretical framework of balanced care teams introduced in this scoping review should be subjected to empirical validation.

Marceau et al. [ 72 ] noted that the COVID-19 pandemic has intensified the existing healthcare crisis and posed a long-lasting burden on the healthcare system. Nevertheless, this crisis presents an opportunity for policymakers to address the shortage of nurses. We extensively reviewed 35 factors that impact nursing practice and organized them into nine overarching domains. We found that policymakers and decision-makers can modify several of these factors to attract and retain nurses.

Nursing leaders, in particular, can use these factors to create well-balanced teams by matching capacity with demand while considering the team’s context. This can lead to improved patient outcomes and heightened job satisfaction among nurses. To expand the knowledge in this area, future research should explore other elements beyond staffing levels. For instance, researchers could investigate the impact of team composition, which includes demographic characteristics, nurse autonomy, and work-life balance.

Availability of data and materials

The datasets generated and/or analyzed during the current study are available in the supplementary material.

Abbreviations

Chief Nursing Officer

19-coronavirus disease 2019

Clinical Trial

Institute for Scientific Information

NWI-Practice Environment Scale of the Nursing Work Index

ScR-Preferred Items in Systematic Reviews and meta-analysis extension for Scoping Reviews

Randomized Controlled Trial

Registered Nurse

World Health Organization

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Acknowledgements

We express our gratitude to the reviewers for their comprehensive and insightful assessments of our manuscript. Their detailed and constructive feedback has significantly contributed to refining our arguments and improving the clarity of our research.

The authors gratefully acknowledge support of the Research Fund of the University of Antwerp.

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Vleminckx, S., Van Bogaert, P., De Meulenaere, K. et al. Factors influencing the formation of balanced care teams: the organisation, performance, and perception of nursing care teams and the link with patient outcomes: a systematic scoping review. BMC Health Serv Res 24 , 1129 (2024). https://doi.org/10.1186/s12913-024-11625-5

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• Dupuytren’s disease and occupational mechanical exposures: a systematic review and meta-analysis
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• http://orcid.org/0000-0002-6806-0371 Alexander Jahn 1 ,
• Johan Hviid Andersen 2 , 3 ,
• http://orcid.org/0000-0001-6028-3186 Alexis Descatha 4 , 5 ,
• Annett Dalbøge 1 , 3
• 1 Danish Ramazzini Centre, Department of Occupational Medicine, Aarhus University Hospital , Aarhus N , Denmark
• 2 Department of Occupational Medicine - University Research Clinic, Danish Ramazzini Centre , Regional Hospital Goedstrup , Herning , Denmark
• 3 Aarhus University Department of Clinical Medicine , Aarhus , Denmark
• 4 Univ Angers, CHU Angers, Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, IRSET-ESTER, SFR ICAT, CAPTV CDC , Angers , France
• 5 Department of Occupational Medicine, Epidemiology and Prevention , Donald and Barbara Zucker School of Medicine at Hofstra/Northwell , Hempstead , New York , USA
• Correspondence to Alexander Jahn; alexjn{at}rm.dk

The risk of developing Dupuytren’s disease among workers exposed to occupational mechanical exposures has been reported in few systematic reviews, mainly related to vibration. Expanding the investigation to all occupational mechanical exposures is essential for advancing scientific knowledge, health policies and improving workplace safety. The aim of this systematic review and meta-analysis was to study the association between occupational mechanical exposures and Dupuytren’s disease.

We conducted a systematic review and meta-analysis using guidelines stated by PRISMA. The systematic literature search was performed in Medline, EMBASE, CINAHL, Cochrane Library and Web of Science databases in April 2023. Inclusion criteria were conducted using the PECOS. Two independent authors conducted the literature screening, data extraction and risk of bias assessment. In the meta-analyses, data was pooled using random-effects models and stratified by the risk of bias and study design. The level of evidence was evaluated using GRADE.

The literature search identified 563 unique articles and 15 were deemed eligible for inclusion, categorised into hand-transmitted vibration, lifting/carrying loads and combined mechanical exposures. Exposure to hand-transmitted vibration showed an OR of 2.0 (95% CI 1.5 to 2.7, I 2 =64%), lifting/carrying loads had an OR of 1.5 (95% CI 1.1 to 2.0, I 2 =77%) and combined mechanical exposures had an OR of 2.1 (95% CI 1.4 to 3.1, I 2 =94%). When grading the level of evidence, we found moderate evidence for hand-transmitted vibration, while low evidence was found for lifting/carrying loads and combined mechanical exposures.

We found an association between hand-transmitted vibration, lifting/carrying loads and combined mechanical exposures. The level of evidence was considered moderate for hand-transmitted vibration and low for lifting/carrying loads and combined mechanical exposures.

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Data are available upon reasonable request. All data are available from the corresponding author upon reasonable request.

https://doi.org/10.1136/oemed-2024-109649

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Contributors All authors contributed to the manuscript, ensured the quality, revised the manuscript, and read and approved the final version. ADa and JHA wrote the initial application and acquired funding. AJ, ADa and JHA conducted the literature screening and risk of bias assessments. AJ was responsible for drafting the manuscript and conducting the analyses—and is also the guarantor. ADe read and revised the manuscript and all authors approved the final manuscript.

Funding The systematic review and meta-analysis was requested by The Labour Market Insurance and the Occupational Diseases Committee in Denmark in order to re-evaluate the existing guidelines of the exposure requirements in relation to compensation. The Danish Work Environment Fund granted the conduction of the systematic review and meta-analysis (project number: 30-2022-09 20225100752). The systematic review was conducted independently of the fund, and we were not involved in the re-evaluating of the existing guidelines of the exposure requirements.

Competing interests None declared.

Provenance and peer review Not commissioned; internally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Vikas Khanduja 2
• 1 University of Cambridge School of Clinical Medicine, UK
• 2 Addenbrooke’s Hospital Department of Trauma and Orthopaedics, UK

Introduction Live surgical broadcasts (LSBs) have a rich history as an educational tool, but are not without patient safety concerns. In response, ‘as-live’ surgical broadcasts (ALSBs) have emerged as an alternative. This scoping review aims to map out the literature surrounding live surgery.

Methods A systematic search of PubMEd, MEDLINE and Ovid Embase was performed. Primary studies describing outcomes of live surgical interventions, surveys of audience members, and surveys of surgeons were included. Studies were classified into four categories: effects on patients, the impact on surgeons, the impact on the audience, and alternatives to live surgery. There was notable overlap between categories.

Results 36 articles were included for analysis. 18 studies investigated patient outcomes after live surgery, 10 surveys assessed the impact on patients, and 8 surveys assessed the impact of performing live surgery on surgeons. 16 studies assessed the impact of live surgery on the audience.

Conclusion The available literature would suggest live surgery is safe for patients. The majority of studies indicated comparable complication rates to routine procedures. However, ethical concerns and perceptions of patient risk among both surgeons and audience members were mixed. The educational value of live surgery was emphasised, but opinions on the future of live surgery differ, including preferences for live over as-live surgery and a potential shift towards simulation technology.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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Strategies for Gaining Weight and Promoting Health

Isabel Vasquez is a freelance writer and bilingual registered dietitian practicing from an intuitive eating, culturally sensitive framework.

nensuria / Getty Images

For some people, gaining weight is important for health. You may want or need to gain weight if you’ve always been underweight, are losing weight unintentionally, or have an eating disorder. You may also want to gain weight if you’re weight lifting and trying to gain muscle mass. 

In some cases, losing weight quickly or being underweight could be signs that you’re malnourished or have an underlying health issue.

It’s important to gain weight safely. Some supplements marketed for weight gain could be contaminated with unsafe ingredients or have dangerously high amounts of protein or caffeine. Dietary changes are most beneficial for gaining weight, but reputable supplements may also help. 

What Does It Mean To Be Underweight?

Clinically, being underweight means having a body mass index (BMI) lower than 18.5. However, in 2023, the American Medical Association issued new guidelines stating that BMI is a clinically imperfect measure . One of the flaws is that BMI doesn’t account for genetic or metabolic factors that impact body weight. Someone may be underweight due to genetics, which might make it unrealistic to gain and maintain a higher weight.

Someone may also be underweight due to poor nutrition. That could happen from a lack of food resources, extreme dieting, an eating disorder , or an underlying health issue that causes low appetite or nausea. A medical issue like a thyroid disorder, cancer, or digestive disease could also cause someone to become underweight.  

Being underweight from poor nutrition could lead to nutrient deficiencies, a weak immune system, osteoporosis (brittle bones), anemia, depression, irregular periods , reproductive issues, and possibly premature death.

Importance of Calorie Surplus

To gain weight, it’s important to increase your calorie intake . Your body uses calories in three main ways:

• Basic metabolic functioning: The energy your body needs to keep you alive, even while at rest
• Physical activity: Any way you move throughout the day, including working out
• Thermic effect of food: Digesting food and absorbing nutrients

If you don’t eat enough calories, your body will not have enough energy to perform all three functions well. Alternately, if you eat more calories than your body needs to accomplish those three functions, you may gain weight. This is called a calorie surplus.

You may need a larger calorie surplus than you expect if you are malnourished. This is common in people with anorexia nervosa who often experience weight gain resistance. Your body needs to catch up on all the nutrition it’s been missing, so it may take more calories than is typical to gain weight.

There is no one-size-fits-all recommendation for how many calories to eat for weight gain, so it’s best to speak with a healthcare provider for individualized guidance.  

How To Adjust Your Diet

Making changes to your diet is the simplest way to gain weight. However, it's important to choose nutritious foods to support overall health. There are a few ways you can adjust your diet to promote weight gain, including eating at consistent meal times throughout the day and focusing on nutrient- and calorie-dense foods.

Eat Regular Meals and Snacks

Eating regularly throughout the day is important to meet your calorie needs. Don’t skip meals, and make sure to add snacks to your day. Eating three meals and between one and three snacks per day is generally recommended.

Your hunger cues may be dulled initially, particularly if you have an eating disorder or have been skipping meals for some time. You may also feel full quickly. This is normal, but it doesn’t mean you shouldn’t still eat regularly. It may help to set a regular eating schedule for yourself to help your body adjust to eating enough for weight gain.

Eat Low-Volume, Energy-Dense Foods

Sometimes, increasing the amount of food you eat can be daunting. You may have a low appetite or feel full quickly. Eating low-volume, energy-dense foods can help increase your calorie intake without greatly increasing the size of your meals and snacks. Some ideas for this include:

• Cook vegetables in oil instead of steaming them 
• Cook meat in oil or a creamy sauce
• Make smoothies loaded with fruit, vegetables, milk, chia seeds, nut butter, and protein powder
• Add mayonnaise, oil, pesto, or avocado to sandwiches
• Snack on nuts, full-fat yogurt, and granola
• Add caloric beverages like milk or juice to meals

You may also need to add meal replacement supplements like Boost or Ensure, which offer dense nutrition in a small package.

Add High Protein Foods

Eating more high-protein foods is important if you’re trying to gain lean body mass. Research shows that eating 2.2–3.4 grams (g) of protein per kilogram (kg) of body weight is most effective, especially when paired with resistance training.  

High-protein foods that can help you meet this goal include chicken, fish, pork, beef, eggs, beans, lentils, peas, nuts, soy products, and dairy products.

You can also use protein powder , but choose a product that has been third-party tested for purity and potency to ensure it’s not contaminated with heavy metals or unsafe substances.  

Be Mindful of Eating Too Much Fiber

Fiber is an incredibly important nutrient for digestive, cardiovascular, and metabolic health, but eating too much fiber can be harmful, especially when it comes to gaining weight. Fiber is not digestible, so it causes you to feel fuller faster. This could prevent you from eating enough calories to gain weight. Plus, high-fiber foods like fruits and vegetables tend to be low in calories.

Depending on the reason you need to gain weight, your healthcare provider may encourage you to limit your fiber intake and prioritize calorie-dense foods instead. This is especially common if you have an eating disorder and need to restore weight.

Strength Training and Exercise

Strength training paired with adequate nutrition can help you gain muscle mass, which could lead to weight gain. Strength-training exercises include any movement where your muscles have to contract against an external load or resistance. You could accomplish this by doing bodyweight exercises, lifting free weights, using resistance bands, or using weight machines.  

Strength training is especially important as you get older because muscle strength naturally decreases after age 30–35. Maintaining your strength and mobility as much as possible helps prevent cardiovascular disease and diabetes. It also helps improve sleep and reduce symptoms of depression and anxiety.

If you’re struggling to gain weight due to mood disturbances, the mood-boosting benefits of resistance training may indirectly promote weight gain. As your mood improves, you may have a greater appetite and a more consistent eating pattern.

Safety Considerations

Faster weight gain is necessary to prevent the harmful health effects of malnourishment in certain cases, such as weight restoration for an eating disorder.

However, if you are severely malnourished, be careful about increasing your calorie intake too quickly, as you may be at risk for refeeding syndrome. This is a dangerous shift in electrolytes and metabolic health that can occur from increasing calorie intake after a prolonged period of malnourishment. Refeeding syndrome can result in potentially fatal cardiovascular and neurological disruptions.

When gaining weight to treat malnourishment, an eating disorder, or another underlying condition, it's best to work with a healthcare provider or registered dietitian. They can determine an eating plan that suits your specific health needs and is safe for you.

When To See a Healthcare Provider

If you think you could benefit from gaining weight, a healthcare provider can help address your concerns and give guidance on the best way to promote weight gain.

There are a few signs that can indicate you or a loved one need to gain weight or should seek medical help regarding weight gain. For instance, if you lose over 5% of your body weight within one month or 10% in six months, you should see a healthcare provider right away. Other signs may include:

• Extremely restrictive eating, in quantity or types of food
• Brittle hair and nails
• Low blood pressure
• Slowed pulse or breathing
• Missed periods
• Constantly feeling cold
• Getting sick often
• Constantly feeling sluggish or tired
• Sunken cheeks, eyes, and temples
• Protruding ribs or pelvic bones

Some of these signs could indicate a different health issue unrelated to weight, but they could also signal that you are malnourished or at too low of a weight for your body. 

If you have been implementing dietary changes and still aren’t gaining weight, speak with a healthcare provider. They can help assess why you aren't gaining weight and tailor your plan for reaching your weight gain goals.

A Quick Review

Whether you have an eating disorder, have always been underweight, or are trying to put on muscle, there are several strategies you can use to help gain weight. The simplest way to gain weight is to make dietary changes. Make sure to eat regular meals and snacks throughout the day, and try to eat low-volume, energy-dense foods to reach a calorie surplus without feeling too full too quickly.

To gain muscle, it’s especially important to eat plenty of protein. Pairing strength training with a calorie surplus can also help you gain muscle and support weight gain. A healthcare provider can offer individualized guidance on the best weight gain plan for you.

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A review of the literature on preventive occupational health and safety activities in small enterprises

Affiliation.

• 1 Department of Manufacturing Engineering and Management, Technical University of Denmark, Kgs. Lyngby, Denmark.
• PMID: 16610525
• DOI: 10.2486/indhealth.44.6

The scientific literature regarding preventive occupational health and safety activities in small enterprises has been reviewed in order to identify effective preventive approaches and to develop a future research strategy. During the last couple of years, there has been a significant increase in the number of studies of small enterprises, but the research community is scattered between many different disciplines and institutions. There is a lack of evaluation of intervention studies, both in terms of effect and practical applicability. However, there is sufficiently strong evidence to conclude that employees of small enterprises are subject to higher risks than the employees of larger ones, and that small enterprises have difficulties in controlling risk. The most effective preventive approaches seem to be simple and low cost solutions, disseminated through personal contact. It is important to develop future intervention research strategies which study the complete intervention system: from the intermediaries through dissemination methods to the resulting preventive activities of the small enterprises.

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Exposure to wildfire smoke: NIOSH wants feedback on draft hazard review

Washington — NIOSH has published a draft of a hazard review document on wildfire smoke exposure among outdoor workers – and is asking for comment.

The agency developed the draft after assessing responses to a Request for Information issued in March.

“Farmworkers and other outdoor workers are likely to be exposed to wildland fire smoke,” the draft states. “They often spend long hours in the fields or on jobsites when wildland fire smoke is present, increasing their risk of adverse health effects from exposure to harmful particulate matter and chemicals.”

In the draft, NIOSH cites studies showing that exposure to particulate matter can trigger heart and lung problems and possibly death.

The agency wants feedback on several questions, including:

• How could the outdoor worker populations who may be exposed to wildfire smoke be more completely characterized?
• How could this document better identify and characterize the health hazards of exposures to wildfire smoke based on available scientific literature?
• What additional information should NIOSH consider adding or how should NIOSH modify the discussion of exposure assessment methods?
• What additional information should NIOSH consider to improve strategies for controlling exposure to wildfire smoke?

“This hazard review will close the gap in our knowledge about how exposure to wildfire smoke impacts outdoor workers,” NIOSH Director John Howard said in a press release. “With wildfires increasing in frequency and size, it is imperative that we have the knowledge and tools to protect the health of farmworkers and other outdoor workers who must perform their jobs even if the air quality is unhealthy or hazardous.”

Comments are due Nov. 12.

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