Readiness for training is dependent upon which two broad characteristics of the work environment?

Work. Author manuscript; available in PMC 2021 Nov 1.

Published in final edited form as:

PMCID: PMC8559612

NIHMSID: NIHMS1748255

Abstract

BACKGROUND:

Organizational readiness for change measures were reviewed to develop an assessment tool for guiding implementation of an occupational safety and health program based on Total Worker Health (TWH) principles. Considerable conceptual ambiguity in the theoretical and empirical peer-reviewed literature was revealed.

OBJECTIVE:

Develop and validate an assessment tool that organizations can use to prepare for implementation of a participatory TWH program.

METHODS:

Inclusion criteria identified 29 relevant publications. Analysis revealed eight key organizational characteristics and predictors of successful organizational change. A conceptual framework was created that subject matter experts used to generate prospective survey items. Items were revised after pretesting with 10 cognitive interviews with upper-level management and pilot-tested in five healthcare organizations. Reliability of the domain subscales were tested based on Cronbach’s α.

RESULTS:

The Organizational Readiness Tool (ORT) showed adequate psychometric properties and specificity in these eight domains: 1) Current safety/health/well-being programs; 2) Current organizational approaches to safety/health/well-being; 3) Resources available for safety/health/well-being; 4) Resources and readiness for change initiatives to improve safety/health/well-being; 5) Resources and readiness for use of teams in programmatic initiatives; 6) Teamwork; 7) Resources and readiness for employee participation; and 8) Management communication about safety/health/well-being. Acceptable ranges of internal consistency statistics for the domain subscales were observed.

CONCLUSIONS:

A conceptual model of organizational readiness for change guided development of the Organizational Readiness Tool (ORT), a survey instrument designed to provide actionable guidance for implementing a participatory TWH program. Initial internal consistency was demonstrated following administration at multiple organizations prior to implementation of a participatory Total Worker Health® program.

Keywords: Total worker health, culture, climate, leadership, job design

1. Introduction

The implementation of a new occupational safety and health program can be considered a major workplace change, and as with any change of this magnitude, the planning stages of new initiatives can benefit from assessing an organization’s readiness for change. However, currently there are no tools to help organizations evaluate how ready they are to adopt a change specific to safety and health [1, 2]. The present study was motivated expressly by this need, namely, to assess an organization’s readiness to implement a participatory Total Worker Health (TWH) program to benefit the safety, health and well-being of its employees. In support of research-to-practice efforts, this tool would provide helpful information to any organization interested in implementing a participatory TWH program more efficiently and effectively.

1.1. Total worker health

TWH programs are focused on integrating work-related safety and health protection with the promotion of worker well-being [3]. As an integrative approach, TWH programs consider all aspects of work that collectively contribute to worker safety, health, and well-being. The concept was first introduced in 2011 by the US National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention, as an evolution from prior efforts such as “Steps to a Healthier Work-force” and “WorkLife” initiatives. In 2015, the definition of TWH was updated to its current language: A Total Worker Health intervention approach is defined as policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness–prevention efforts to advance worker well-being [4, 5].

The National Institute of Occupational Safety and Health outlines five defining elements of an effective TWH program [6]. These include: 1) demonstrate leadership commitment to worker safety and health at all levels of the organization; 2) design work to eliminate or reduce safety and health hazards and promote worker well-being; 3) promote and support worker engagement throughout program design and implementation; 4) ensure confidentiality and privacy of workers; and 5) integrate relevant systems to advance worker well-being [4]. Although many of these practices are commonplace (and in some cases regulated) in European countries, these practices are less common among US employers; this is especially true for elements focused on work design, worker engagement in the participatory design of interventions, and the integration of relevant systems [7–9]. Therefore, employers that wish to adopt a participatory TWH program to benefit the safety, health and well-being of its employees would need to change policies, procedures, and (possibly) reporting structures; all of which would require careful planning and preparation to yield successful implementation [8–10]. Assessment of resources in place and the extent of readiness to embark on such a change initiative is an essential first step before proceeding.

Research on the best ways to programmatically implement a participatory TWH program in an efficient cost-effective manner remain limited [11]. A few methods and implementation tools have been published recently by Nobrega et al. [12]. However, even fewer methods have been published to date for specifically assessing an organization’s readiness to implement a participatory TWH program [2, 7, 10, 13].

1.2. Organizational readiness for change

Undergoing changes in the workplace is generally fraught with challenges because it is common for employees to feel resistance to change [14]. Therefore, assessing organizational readiness for change appears to be an important first step when planning any change efforts at work. Organizational readiness for change involves an evident need for change in the organization, employees’ beliefs that they can accomplish a given change, and an opportunity to participate in the change process [15]. By this definition, the three aspects that influence organizational readiness for change are: 1) what the specific change is and a felt need for it, 2) the degree to which individual employees feel supported to achieve and sustain the change, and 3) whether employees are able to be involved in the change process. We performed a scoping review to gain a better understanding of organizational readiness for change, which is discussed in the next section.

Our scoping review of the most recent research in this area was expected to help identify the evidence-based factors associated with organizational readiness for change prior to implementing a comprehensive occupational safety and health program in the workplace. The results of this novel scoping review lay the foundation for designing an organizational readiness survey and companion results summary guide to help an organization prepare to implement a participatory TWH program. Our aim was to develop a conceptual model of the key indicators of organizational readiness for a major programmatic change based on the findings from the scoping review.

2. Scoping review

The purpose of this scoping review was to identify and classify the common readiness features that are known to affect change readiness of safety and health workplace implementations. A keyword search of four electronic bibliographic databases was conducted to identify candidate articles. The following databases were utilized because they included multidisciplinary peer-reviewed articles: PsycINFO, PubMed, ABI Inform Global, and Google Scholar. Google Scholar includes sources that are not peer-reviewed, but it is nonetheless a good search engine as well as a useful citation index. The search strategy combined four groups of keywords with “AND” between each group of keywords in order represent each of the four aspects of interest. The first set of terms were “organization” and “workplace,” to define that organizational readiness takes place in the workplace. The second set of terms were “readiness,” “change,” and “pre-implementation,” to indicate the state of affairs prior to change that can be identified and described. The third set of terms were “intentions,” “assessment,” “antecedents,” and “determinants,” which define the degree to which an organization is ready for change and the particular areas for improving readiness. The fourth set of terms were “safety,” “ergonomics,” “wellness,” and “well-being” to define that the change efforts were related to our particular domain of interest. There were a number of criteria used to include and exclude articles in this review. The inclusion criteria were as follows: 1) readiness for the organization as a whole or readiness in general and for safety and wellness interventions, 2) peer-reviewed, scholarly books, and publications or (particularly highly-cited works), 3) empirical and case studies or conceptual/theoretical papers, or scale-development articles, or review articles from 2010 to 2015. The exclusion criteria were as follows: 1) review articles before 2010, 2) readiness related to a specific subset of employees (e.g., management, sales teams), 3) readiness related to patients and their treatment (e.g., hospitals, clinics), or readiness for students or communities to makes changes, and 4) readiness and its association with workplace changes in developing countries (e.g., e-government in the Republic of Yemen).

2.1. Scoping review results

Cumulatively, the combined searches yielded approximately 300,000 titles: PsycINFO 868 titles, PubMed 2,825 titles, ABI Inform Global 34,558 titles, and Google Scholar 259,000 titles. We selected articles based on the number of times they were cited relative to the year they were published, and empirical work that has measured and described pre-implementation readiness particular to safety/wellness initiatives. Given the broadness of our criteria, and the large number of titles found, we selected publications by reviewing the results in order, as well as retrieving additional important sources from the list of references from the articles that had already been reviewed. “Readiness for safety/wellness initiatives” was not a strong theme that emerged from our search. While there was evidence of that topic, the literature associated with it was sparse and outdated. Surprisingly, the readiness indicators that emerged from safety or wellness-specific works were similar to other organizational readiness indicators identified in papers that did not specifically examine safety/wellness initiatives. Overall, there were a limited number of organizational-readiness publications that related specifically to workplace safety/ergonomics and human factors/wellness change initiatives. Readiness for change does of course depend, in part, on the specific change involved. Still, everyday functioning in the workplace can have much impact on change efforts even though such functioning may seem at first to be unrelated. In order to reduce the number of articles to only those that were most relevant to this study, we also identified classic works by prominent authors, clarified key theories and definitions, delineated points of debate and disagreement, and retrieved additional sources that were cited in review articles and recent works. That led to the identification of 29 key articles used in the present study which are presented in Appendices 1a–1c. Appendix 1a presents theoretical/conceptual articles and provides a summary and indicators of change for each reference. Appendix 1b presents empirical/case study articles and provides a summary and the best practices that emerged for each reference. Finally, Appendix 1c presents articles that used either existing measures, or developed measures of organizational readiness, and provides the factors that were identified and their respective purposes, as well as examples of items for each reference.

2.2. Conceptual model

A conceptual model of organizational readiness, depicted in Fig. 1, was developed, adapted from the Nielson and Randell [16] process evaluation model and Cummings and Worley [17] open systems model, by integrating the key predicators of organizational readiness found in the 29 identified sources. Overall, the organizational readiness conceptual model has three systems layers: context; content and individual. The first layer of organizational readiness is context, which is the organization’s current functioning, how it operates day to day, and includes the social and organizational characteristics. The second layer is content, which is the particular change effort choice. Included in the content layer is visionary communication that clearly explains the change, why it is needed, and what can be expected. The quality of the communication is very important as is its consistency and the actions aligned with the message. The third nested layer of organizational readiness is related to the individuals within an organization. Individuals need to be: motivated to support the change, willing to accept the change when it occurs, feel confident that they can adapt/change their behaviors to accommodate the change, and already be working together in ways that would support a change effort if it occurs.

Conceptual model of organizational readiness with three nested layers of readiness indicators. Model was modified from Nielson & Randell (2016) model of process evaluation; and Cummings & Worley, (2014) open system model.

Worth noting is the strong influence of the social and organizational context on intervention and change efforts as the context may either facilitate or hinder successful intervention change programs, along with recognizing external environmental forces that can impact the organization [16]. Contextual influencers are defined by Johns et al. [20] as “situational opportunities and constraints that affect the occurrence and meaning of organizational behaviour as well as functional relationships between variables.” These contextual factors noted in Fig. 1 include key social and organizational factors, such as current participatory approaches, workplace culture, job design and resource capacity. Additionally, external environmental forces, such as the world economy, health pandemic, political, regulatory, legal, can all directly or indirectly affect an organization and recognizing these external forces is part of preparing an organization for change efforts [17, 18]. Assessing these contextual factors drives the design of the change effort and reveals how these features can influence perceptions. Some structural features that shape change perceptions are the organization’s financial, human, material, and information resources. Also, non-structural factors that are likely to generate a sense of readiness are: 1) consistent leadership messages and actions, 2) information sharing through co-worker social interaction, and 3) shared experiences with past change efforts. Overall, some key organizational characteristics and predictors of organizational readiness appear to include: 1) organizational culture [19, 20], 2) communication; [21–23], 3) leadership [24], 4) change history [25, 26], 5) job design [15, 27], 6) teams and relationships [18, 23, 28], 7) flexible organizational practices and policies [17, 29, 30], and 8) positive organizational climate [31]. Organizational climate, as defined by Lehman et al. [31], is a measure to determine the degree to which collective appraisals represent an environment that lends itself to change, such as staff awareness of goals for organization., work group trust and cooperation, staff autonomy, openness of communication from staff to management and level of stress. Following are discussions of a few of these contextual factors, along with framing the change management process within a socio-technical perspective.

2.3. Organizational culture

Organizational culture is frequently identified as a contextual determinant of organizational readiness for change [17, 20, 21]. An organizational culture that embraces innovation, risk-taking, and learning supports readiness better than an organizational culture that values stability and control or efficiency and productivity [21]. The reason for this is that an organization that makes a regular practice of improving via changing tasks or processes helps employees maintain positive attitudes toward change in general, and this prevents the type of inertia often encountered when meaningful change is needed and sought but employees’ reactions to any change are negative. Similar aspects of organizational culture that have empirical support as readiness antecedents are cultures that value cohesion and morale that is gained through training and development initiatives, open communication, and participative decision-making [20].

Organizational culture is also related to another commonly mentioned readiness factor that creates a receptive environment for change; namely, an organization’s financial resources [21]. For example, Burnett and colleagues conducted qualitative interviews [26] that elucidated the link between readiness for change and financial stability for leaders. Another study found that certain aspects of organizational culture, like openness in communication, openness to change, and clarity of mission and goals, were likely to occur in an organization that had consistent budgets and a stable environment, and where institutional resources were more likely to be predictable [31]. In contrast, when the organization’s budget was decreasing and when the environment was unstable, the culture appeared to shift into survival mode rather than adopt a change-and-adapt mode. Interestingly, this same study found that a more certain organizational environment resulted in significantly lower pressures for change. This paradoxical situation is in line with the idea that, in reality, there is a lack of harmony between readiness for change and a felt need for change within a given organization [32]. In other words, organizations that might be assessed as “ready” for a change could be organizations that have less of a need for change because they already engage in workplace improvements or modifications on an ongoing basis. Conversely, organizations that are assessed with poor levels of readiness probably have a much stronger need for change.

Pursuing practical implications of the relationships between organizational factors and readiness for change described above, Zhang et al. [32] investigated how to select organizations based on the feasibility and need for change, and found that responses to readiness items rarely predicted change-agent behaviors for managers. For example, when asked how supportive they felt toward a specific participatory intervention, managers expressed a great level of support but failed to follow through with providing the support expressed. Zhang and colleagues [32] recommend that readiness assessment methods include brief hypothetical case studies to highlight the need for concrete forms of support, rather than to simply gauge verbal support. Concrete examples of support included making time to attend meetings, and providing resources and accountability for funds. Barrett and colleagues [33] conducted a case study that verified and also explained the discrepancy Zhang et al. [32] had described between readiness and felt need for change.

2.4. Sociotechnical systems and macroergonomics

Socio-technical systems (STS) theory provides a conceptual framework for a macroergonomics approach to integrating key organizational and individual factors when designing and implementing sustainable and continuous improvement change programs. This is especially critical for a participatory TWH program like the HWPP because its implementation and sustainability depends on an emergent continuous learning process. The STS theory offers a unique approach to seeking alignment at both the individual and organizational levels and is based on two assumptions: 1) effective performance (i.e., productivity, quality, employee well-being, job satisfaction) is a function of the extent to which the people (social component) and 2) tools, technologies and techniques (technical component) are jointly optimized [34]. Joint optimization of these is the deliberate design goal of harmonizing social and technical components so that the two work well together and produce positive workplace outcomes. A sociotechnical system must be open to its environment because environmental interactions are necessary to receive inputs of energy, raw materials, and information, which then makes it possible for the system to provide products or services back to the environment. Design considerations come into play here to ensure that the interface between the STS and its environment is effective but not constricting or limiting to the work system [17].

Macroergonomics, based on STS theory, is concerned with the optimization of work systems through consideration of relevant social, technical, and environmental variables and their interaction, and culture change is often one of the outcomes of macroergonomic interventions. One such work system approach to changing an organizational culture is to support participatory ergonomics efforts that involve employees in making design changes to the workplace for continuous improvement of safety, health, well-being and performance. This is one reason that the HWPP incorporates a participatory ergonomics approach in intervention design efforts. A macroergonomic understanding of culture change is that it is dependent on interactions both within and between levels of the organization (e.g., individual, group/managerial, and organizational), representing one of the most realistic perspectives. Adopting this systems perspective is an ideal way to diagnose an organization, namely, as an evaluation process that promotes understanding as to how an organization is currently functioning, which then provides the information necessary to design change interventions. Since organizational culture is cited often as a proxy for understanding the context for potential interventions, an open systems approach offers a systematic way for assessing and exploring organizational culture. To clarify, diagnosis in this sense does not assume there is a problem with an organization (as with medical diagnoses) but rather seeks to address areas of potential improvement and development that can be collaboratively identified [17]. In broad terms, a typical diagnosis model considers the interactions between four major facets at every level of an organization: inputs (information and energy), transformations (social and technical components), outputs (finished goods, ideas), and the external environment.

To illustrate these STS and macroergonomics perspectives for a TWH participatory program, we propose a modified model depicting the continuous cycle of an emerging organizational culture serving as both a determinant and an outcome of organizational change along with its interactions with the external environment and organizational outcomes [17, 34, 35]. These systems components are elaborated further below in the open systems perspective of change (see Fig. 2). Part of this model is the conceptualization of organizational learning as purported by Haims and Carayon [36]. Organizational learning is dependent on the organizational commitment to a learning process as part of a continuous improvement process [37]. As the organization implements programmatic changes and evaluates the effects of these programs, a learning process needs to occur in parallel which is necessary for the development, success and long-term sustainability of a participatory ergonomics program. Support for learning requires designated systems, policies and procedures to be established that provide usable feedback on the effectiveness of the programmatic implementation process while maintaining active employee participation.

Open systems perspective of change and organizational learning.

3. Design of an Organizational Readiness Tool (ORT) for change

Our immediate goal was to design an organizational diagnostic tool that could be used to assess an organization’s level of readiness for change that would be relevant to initiating, managing, and sustaining new programmatic initiatives. Findings from such a survey tool would then be used to help organizations with low scores to improve their readiness for change by identifying specific resource and training needs necessary to support a new programmatic initiative. Subsequently, follow-up action steps would be developed with the organization to better prepare the organization for eventual implementation of the new program, which in the case of our ongoing field research study, is a participatory TWH program.

3.1. Organizational readiness survey items

We developed the survey in two phases. First, we generated items guided by our conceptual model and our familiarity with the participatory TWH program developed the Center for the Protection of Health in the New England Workplace (CPH-NEW) [38], known as the Healthy Workplace Participatory Program [12]. This program includes a structured approach that small teams of employees use to design TWH interventions that address safety and health priorities identified by employees in the spirit of participatory ergonomics and continuous improvement of employee safety, health and well-being. Second, we then obtained feedback on the generated items through cognitive interviews and initial survey testing to determine face validity. Lastly, we administered the revised items to the intended respondent groups within five state healthcare facilities and examined psychometric properties of the survey.

Based on the conceptual model, and a review of existing scales in our scoping review as noted in Fig. 1 and Appendix 1c, we generated 54 survey items for our initial instrument. Four Subject Matter Experts (SMEs) involved with health, safety and ergonomics workplace interventions and also with related programmatic experience assisted in generating these items. Item generation was accomplished by an iterative process as the experts met weekly over several months along with the research team. Due to time constraints at host sites and the need to prevent survey fatigue, it was necessary to aim for participants’ completion time to be less than 15 minutes. To this end, the survey was trimmed to 42 items by two external SMEs, who were part of the TWH Center personnel with expertise in ergonomics, health, safety and workplace interventions, but did not purposely by design serve on the initial SME item generating team. They independently deleted duplicate items. Content validity was also established by these same occupational safety, health and TWH SMEs. Consensus among the six SMEs regarding the survey items was reached through a series of team meetings.

We identified eight core domains as central to organizational readiness: 1) Current programs designed to promote employee safety, health, and well-being, 2) Current approaches to safety, health and well-being within the organization, 3) Resources available for safety, health and well-being, 4) Resources and readiness for change initiatives to improve safety, health, and well-being, 5) Resources and readiness for use of teams in programmatic initiatives, 6) Teamwork in your work group, 7) Resources and readiness for employee participation, and 8) Management communication about safety, health, and well-being.

3.2. Cognitive interviews

Cognitive testing is conducted to ensure that the items included in the new survey effectively measure the intended domains and constructs and that they are uniformly understood by potential respondents. The interview process focuses on the performance of each candidate item when used with members of the intended respondent group. It specifically assesses participants’ comprehension, judgement/estimation, information retrieval, and selection of a response category [39].

In the development of the organizational readiness for change survey, we tested the instrument through two rounds of cognitive interviews across several healthcare work sites. Cognitive interviews were conducted with 10 healthcare employees employed in four hospitals in Massachusetts and Maine. Participants represented a variety of health-care occupations and educational backgrounds and represented all organizational job levels (e.g. manager, non-supervisor). The purpose of conducting these cognitive interviews was to evaluate face validity of the survey items and also to refine the wording of survey items so they could be easily understood by any hospital employee regardless of which level of the organization they worked in. This scale is designed to be completed by anyone in the organization. For example, items 1 and 2 in Domain 1 have a response category of “not sure” as front-line employees may not have an understanding of programmatic aspects of the organization. Recommended administration of the survey would seek representation from all levels of the organization, with participation rates proportional to the number of employees at each level. If that is not feasible, organizations can decide for more limited administration but will be cautioned that doing so may limit the accuracy of the findings, with specific examples of how responses may be biased (e.g., management may tend to rate employee participation in decision making as higher than it actually is). In addition, one must be cognizant a potential breach of confidentiality with small samples at each level, making it more important to report survey results at the aggregate level rather than a break down by level.

Cognitive interviews were administered in person with each participant; one researcher facilitated the interview, and another researcher recorded notes. Participants were asked to read each question aloud and indicate their response option, and also to note if the question was unclear. At the end of the survey, the researcher asked the participant to discuss each question that had been previously flagged as unclear, as well as to state their understanding of these questions. If participants felt any wording was confusing, suggestions for alternative wording were invited. Following the compilation of the findings from this first round of interviews, the research team refined the survey items to improve clarity. These refined items were then tested in a second round of cognitive interviews using the same procedure to further improve question wording as needed. Table 1 provides examples of the item revisions that were made following the two rounds of cognitive interviews.

Table 1

Examples of survey improvements made following cognitive interviews

3.3. Initial piloting and reliability testing

The survey was administered across 5 facilities, and ninety-two participants were invited to complete the survey. On average, 11–12 participants completed a survey in each facility, and 62 surveys were completed and submitted. Due to missing data, only 57 surveys were usable for analyses. The results presented next across eight domains are based on a sample size of N = 57 or less.

Domain 1 evaluated the extent that the organization’s current health, safety and well-being program was consistent with Total Worker Health principles. Three items were created to assess the current status of programmatic efforts within the organization, as presented in Table 2. More specifically, these items assessed the presence of programmatic activities in occupational safety and health promotion, and whether these activities were offered in an integrated manner as recommended for a Total Worker Health program.

Table 2

Domain 1 items: Current programs to promote employee safety, health, and well-being

1. This organization has health and well-being activities for employees.

   Examples: smoking cessation, cholesterol check, and exercise or nutrition programs.

   Response options:

   YES

   NO

   NOT SURE.

2. This organization has safety activities for employees. Examples: safety committee, regular safety walk-throughs, accident/injury analysis process, safety training program, work safety policies.

   Response options:

   YES

   NO

   NOT SURE

3. Which statement is a better description of your organization?

   Response options:

   Safety activities occur separately from health and well-being activities.

   Safety activities occur together with health and well-being activities.

Domain 2 evaluated the degree to which an organization’s current approaches to safety, health and well-being reflected a readiness to adopt a TWH programmatic approach. This determined whether the organization had already established healthy work policies and environmental conditions to benefit all employees in a primary prevention approach that does not rely on individual employee initiatives. The six items for Domain 2 are presented in Table 2a. All items showed a full range of responses, and their means, standard deviations, and inter-item correlations are presented in Table 2b. Cronbach’s alpha yielded a value of 0.81 (N = 48), indicating that Domain 2 items are highly related to each other and display evidence of good internal consistency as a group. An alpha level of 0.80 is considered a good indication that the set of items are measuring the intended construct.

Table 2a

Domain 2 items: Current approaches to safety, health, and well-being in this organization

Table 2b

Domain 2 results: Means, standard deviations, inter-item correlations

Domain 3 evaluated the extent to which an organization’s current resources available for safety, health and well-being reflected organizational readiness to implement a participatory TWH program. A number of key resources are needed to implement and sustain a participatory Total Worker Health program. For example, it is critical to the success of a participatory TWH program that employees have time and space to participate in regular Design Team meetings, where meeting every week or once every 2 weeks is recommended, and to have access to subject matter experts during intervention design, implementation and evaluation. The four items for Domain 3 are presented in Table 3a. All items had a full range of responses, and their means, standard deviations, and inter-item correlations are presented in Table 3b. Cronbach’s alpha was 0.73 (N = 50), indicating that Domain 3 items are moderately related to each other and display evidence of adequate internal consistency as a group. An alpha of 0.70 is acceptable during the early stages of research on scale development, as is the case in the present study.

Table 3a

Domain 3 items: Resources available for safety, health and well-being

Table 3b

Domain 3 results: Means, standard deviations, inter-item correlations

Domain 4 evaluated the organization’s readiness to implement changes that would be necessary when implementing a participatory TWH program. This includes evidence of past success in managing change initiatives to benefit employee safety, health and well-being as well as indications of employee adaptiveness. An organization with prior success implementing these change efforts can be expected to more easily muster the managerial support needed to implement a new and innovative program, and would also have a workforce that is ready and willing to make needed changes. The eleven items for Domain 4 are presented in Table 4a. All items showed a full range of responses and their means, standard deviations, and inter-item correlations are presented in Table 4b. Cronbach’s alpha yielded a value of 0.67 (N = 26), indicating that Domain 4 items are moderately related to each other and display evidence of adequate internal consistency as a group, particularly for early stages of research.

Table 4a

Domain 4 items: Resources and readiness for change initiatives to improve safety, health and well-being

Table 4b

Domain 4 results: Means, standard deviations, inter-item correlations

Domain 5 evaluated the degree to which employee teams could readily engage in participatory TWH initiatives, something that depends in part on the prevalence of existing employee teams. An organization that supports employee-led teams that meet regularly is more likely to successfully adopt and sustain a participatory TWH program. Supervisor support is essential to ensure that employees have time for consistent, regular participation. The six items for Domain 5 are presented in Table 5a. All items showed a full range of responses and their means, standard deviations, and inter-item correlations are presented in Table 5b. Cronbach’s alpha yielded a value of 0.86 (N = 51), indicating that Domain 5 items are highly related to each other, display evidence of strong internal consistency as a group, and measure the intended construct.

Table 5a

Domain 5 items: Resources and readiness for use of teams

Table 5b

Domain 5 Results: Means, standard deviations, inter-item correlations

Domain 6 evaluated the degree to which an organization showed evidence of teamwork in work groups. An organization with employees who already collaborate effectively is more likely to be successful when implementing a participatory TWH program that requires a high degree of employee collaboration. The eight items for Domain 6 are presented in Table 6a. All items showed a full range of responses and their means, standard deviations, and inter-item correlations are presented in Table 6b. Cronbach’s alpha yielded a value of 0.89 (N = 50), indicating that Domain 6 items are highly related to each other, display evidence of good internal consistency as a group, and measure the intended construct.

Table 6a

Domain 6 items: Teamwork in your work group

Table 6b

Domain 6 results: Means, standard deviations, inter-item correlations

Domain 7 evaluated the extent to which employees already participate in the organizations and that organizational resources support this. An organization that already invites and responds to employee suggestions has created a climate that is conducive to participatory TWH program. The six items for Domain 7 are presented in Table 7a. All items showed a full range of responses and their means, standard deviations, and inter-item correlations are presented in Table 7b. Cronbach’s alpha yielded a value of 0.95 (N = 49), indicating that Domain 7 items are highly related to each other, display evidence of good internal consistency as a group, and measure the intended construct.

Table 7a

Domain 7 items: Resources and readiness for employee participation

Table 7b

Domain 7 results: Means, standard deviations, inter-item correlations

Finally, Domain 8 evaluated the extent to which management communication about safety, health and well-being reflected readiness for organizations to adopt a new TWH program. An organization is more likely to gain employee commitment to needed changes if top management communicates effectively about safety, health, and well-being. The seven items for Domain 8 are presented in Table 8a. All items showed a full range of responses and their means, standard deviations, and inter-item correlations are presented in Table 8b. Cronbach’s alpha yielded a value of 0.95 (N = 49), indicating that Domain 8 items are highly related to each other, display evidence of good internal consistency as a group, and measure the intended construct.

Table 8a

Domain 8 items: Management communication about safety, health and well-being

Table 8b

Domain 8 results: Means, standard deviations, inter-item correlations

Altogether, the results for Domains 2–8 provide strong evidence that each domain is effectively sampling the theoretical domain of interest, namely, organizational readiness to adopt a TWH program. Through alpha reliabilities, bi-variate correlations and additional descriptive analyses, the resulting statistics were surprising given the early stages of the current study. However, the strength of the findings is also indicative of a sound theoretical framework from which the initial survey measure was conceptualized, and the efforts to establish face validity through subject matter expert inputs as well as cognitive interviews.

3.4. Use of the survey results: Feedback to organizations for action planning

The current study used Qualtrics™, a web-based survey software to design and administer the survey, and to generate feedback reports for each participating facility. Once a survey is created and administered through Qualtrics™, data from completed surveys are stored by Qualtrics™. Through use of its ‘reports’ feature, survey results can be depicted in graphs that are custom formatted with text and images, and then downloaded as a PDF document. We generated tailored reports for each of the five facilities in this study soon after survey administration, which provided them with visualized aggregated results across job positions in order to promote discussion and action planning in preparation for a new, forthcoming TWH participatory programmatic initiative (HWPP). The reports were formatted with bar graphs and a plain-language explanation of what was measured in each domain as well as the significance of assessing readiness for a programmatic change in each domain. The diagnostic information provided in these reports enables an examination of which domains are stronger or weaker, and also how much agreement among the respondents there is across the items in each domain. The objective of the report was to help organizations to identify both organizational strengths and areas for improvement, and where resources and training were needed to build capacity and readiness to successfully implement a participatory TWH program.

As this study has provided initial validation of a readiness assessment tool, the long-term research goal is to provide an organizational diagnostic tool that can be used to assess an organization’s level of readiness to initiate, manage, and sustain a Total Worker Health program that supports integrated well-being and safety initiatives. This assessment tool is designed to help organizations with low scores in some dimensions to improve their readiness for change by identifying specific resource and training needs necessary to support implementation of a new participatory TWH program. Another potential application of the ORT is to provide an organization with a means to verify at a later date its continued level of readiness to sustain an ongoing TWH program with its integrated well-being and safety initiatives. In this application, the ORT report serves as a type of dashboard that can be monitored by the person who the organization designates as the responsible party to ensure that the necessary resources and training are in place to support this Total Worker Health initiative over the long term.

4. Discussion

Implementing a new occupational safety and health program can be viewed as a major organizational change, and as with any large organizational change initiative, implementation needs to be wisely managed to reduce the possibility of failure. Few tools, however, are available to assist with pre-implementation planning and assessment for new programmatic initiatives and assessing an organization’s readiness specifically has been mentioned as a major need [1, 2]. Thus, the present study was driven by the need to develop a tool expressly for this purpose; that is, to assess an organization’s readiness to implement a participatory TWH program to benefit the safety, health and well-being of its employees.

A conceptual framework for organizational readiness for change was created to capture the state of what is known currently and also to guide the development of an instrument designed specifically for assessment of organizational readiness for a participatory occupational health, safety and well-being program. Survey items were developed by subject matter experts to cover key domains in the conceptual model, which were then evaluated with cognitive interviews to improve both face and content validity. These cognitive interviews were instrumental to refining the clarity of survey items in order to measure every dimension of organizational readiness in the conceptual model. Initial results of pilot evaluations indicated that the resulting survey instrument has adequate psychometric properties and provided support for initial validation of this organizational readiness for change tool that is designed to be specific to participatory TWH program initiatives. As the culmination of a research-to-practice effort, this tool provides diagnostic information that can be used to help organizations identify areas of strength as well as areas where resources and training are needed to build capacity and readiness to subsequently implement a successful participatory TWH program.

Organizations that are embarking on implementing a new participatory occupational health and safety program without assessing their organization’s resources, policies, team structures and communication methods, run the risk of the new program being delayed, ineffective and lacking sustainability. The change effort will likely be compromised if top management is not fully committed to implementing and supporting the newly integrated program; for example, by not allotting enough time for teams to meet regularly, not providing appropriate resources to implement the initiatives, and not communicating the importance of the program priorities and activities. Furthermore, one cannot expect employees to be motivated to actively participate in and embrace a change effort when it becomes obvious that it is not fully supported by management.

Understanding the current status of the organization’s readiness and capacity to support a new participatory TWH integrated safety and health program, assessed through use of the organizational readiness tool such as the one developed in the present study, will allow key personnel and decision makers to plan effective implementation strategies and support mechanisms to ensure a successful launch and sustainable programmatic effort. One strategy often overlooked is the need for management to plan and commit resources to quality and consistent communications regarding the new program goals and activities, both initially and over time. The absence of these communications may lead to a lack of employees’ awareness and commitment which can be detrimental to program success.

Critical to the success of participatory programs once they are in place is for management to routinely follow up on employees’ suggestions regarding work related issues. For a participatory TWH program to be effective, an organizational culture that generally encourages employees to get involved in decisions is necessary. Additionally, organizations need to have a clear structure for employee participation to avoid jeopardizing program effectiveness. Organizations with minimal commitment to strengthen teamwork and collaboration skills for those employees who are involved in the participatory program will suffer during the implementation process as employees will become frustrated in attempting to work effectively in teams. If an organization identifies that it does not have knowledgeable employees with expertise in occupational safety, health and well-being as well as the skill to assess the effectiveness of a new health and safety program, it will be critical for the organization to commit to providing training and resources to bring in external expertise as needed during the implementation process.

In addition to pre-implementation planning and assessment, the ORT can be used throughout an implementation process to ensure that critical components are in place and therefore increase the likelihood of successful implementation. This can be accomplished by creating a dashboard or scorecard of the eight survey domains and administrating the ORT at other time periods following the initial readiness assessment. This will allow for assessing the participants’ perceptions of changes in supporting and building organizational resources and readiness to continue the implementation program process over time and is also reflective of a commitment to organizational learning that yields a process of continuous improvement. These types of dashboard performance indicators assist management and program implementors to gain a better sense of the implementation progress and success and also how well the implementation process is providing the needed resources and personnel to form and support participatory teams. If, for example, there was an effective communication effort in the early stages of rolling out the TWH program, employees are likely to be more aware of what the program goals are as well what specific activities and initiatives are occurring. These communication efforts not only help keep employees well-informed about the TWH program, they also reinforce the reasons why organizational change is needed.

As part of a research program, our next steps in the development and use of the ORT survey includes validation of the instrument across multiple samples, and to test the effectiveness of the ORT template report in assisting management in planning and identifying gaps in resources or skill areas that need to be strengthened to support TWH implementation and sustainability. Part of the validation process will include conducting further psychometric testing across populations and settings, including factor analysis, to examine whether the survey’s dimensionality remains in the 8-factor structure as originally conceptualized in this paper. Ultimately, it will be important to develop new means of scoring this instrument that can take into account any needed weighting differences across the eight domains because some dimensions might contribute more strongly to readiness than others. As noted by Loeppke et al. [40], this instrument also responds to calls for practical tools for organizations implementing an integrated TWH approach that focuses on the health, safety and well-being of employees. Several other assessment tools and metrics are currently available to assess organizational approaches to worker safety and health, as described by Sorensen et al. [2] and Hannon et al. [1]. These measures range from online tools that allow employers to receive feedback evaluations via email regarding their health and well-being practices, acquiring detailed information on the particular conditions that their workers are experiencing that impact health and safety, assessing a company’s use of best practices for health and safety, and measuring small workplaces’ readiness to implement wellness programs [1, 2].

The present study has potential limitations. Only one industry sector, namely healthcare hospital facilities, was used for both the cognitive interviews and pilot administration of the ORT. As noted earlier, future research efforts can include administering the ORT in other industrial sectors. The ORT is currently being tested and refined in a NIOSH TWH multi-year study conducted by the Center for the Protection of Health in the New England Workplace (CPH-NEW), The Healthy Workplace Participatory Program (HWPP) as part of the SHIFT in Healthcare Study [41]. Administration of the ORT will take place at three different time points over the course of the field study, allowing for a program of research that will further develop the ORT across other settings. Strengths of this study include developing a theory-based organizational readiness tool that identifies the key areas an organization needs to be prepared in before implementing an integrated, participatory TWH program initiative. This tool is unique in that it combines individual and content specific factors, as well as factors from the organizational context to diagnosis an organization’s readiness to systematically support a change effort when implementing a new participatory occupational safety and health program. Plans are in place to further refine the ORT so that it becomes a more reliable, valid, and practical tool for advancing the health, safety and well-being of all employees.

5. Conclusions

To implement effective, integrated Total Worker Health program interventions, it is essential to assess an organization’s readiness for change. We provided a conceptual framework and model to develop an organizational readiness survey for organizations looking to implement a participatory TWH program initiative. A systematic process was undertaken to develop a conceptual model to guide content-specific item generation, to use cognitive interviews with specified end users, and to conduct psychometric testing with participants from multiple research sites. This new organizational readiness assessment tool holds promise for providing diagnostic information that can be used to help organizations identify both strengths as well as areas where resources and training are needed to build capacity and readiness to successfully implement a participatory TWH program designed to improve the safety, health and well-being of all employees.

Acknowledgments

This work was supported by grant no. U19-OH008857 from the National Institute for Occupational Safety and Health (NIOSH) at the Centers for Disease Control and Prevention. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of NIOSH. Also, the Liberty Mutual Research Institute for Safety provided earlier support of this organizational readiness research study.

Appendix

Appendix 1a

Appendix 1b

Appendix 1c

Footnotes

References

[1] Hannon PA, Helfrich CD, Chan KG, Allen CL, Hammer-back K, Kohn MJ, et al. Development and pilot test of the workplace readiness questionnaire, a theory-based instrument to measure small workplaces’ readiness to implement wellness programs. Am J Heal Promot. 2017;31(1):67–75. [PMC free article] [PubMed] [Google Scholar]

[2] Sorensen G, Sparer E, Williams JAR, Gundersen D, Boden LI, Dennerlein JT, et al. Measuring Best Practices for Work-place Safety, Health, and Well-Being. J Occup Environ Med. 2018;60(5):430–9. [PMC free article] [PubMed] [Google Scholar]

[5] Chari R, Chang C-C, Sauter SL, Petrun Sayers EL, Cerully JL, Schulte P, et al. Expanding the Paradigm of Occupational Safety and Health. J Occup Environ Med. 2018;60(7): 589–93. [PMC free article] [PubMed] [Google Scholar]

[6] Fundamentals of Total Worker Health Approaches: Essential Elements for Advancing Worker Safety, Health, and Well-Being [Internet]. [cited 2018 Dec 10]. Available from: https://www.cdc.gov/niosh/docs/2017-112/pdfs/2017_112.pdf

[7] Pronk NP, McLellan DL, McGrail MP, Olson SM, McKinney ZJ, Katz JN, et al. Measurement Tools for Integrated Worker Health Protection and Promotion. J Occup Environ Med. 2016;58(7):651–8. [PubMed] [Google Scholar]

[8] Punnett L, Cavallari JM, Henning RA, Nobrega S, Dugan AG, Cherniack MG. Defining “Integration” for Total Worker Health®: A New Proposal. Ann Work Expo Heal. 2020;64(3):223–35. [PMC free article] [PubMed] [Google Scholar]

[9] Dennerlein JT, Burke L, Sabbath EL, Williams JAR, Peters SE, Wallace L, et al. An Integrative Total Worker Health Framework for Keeping Workers Safe and Healthy During the COVID-19 Pandemic. Hum Factors. 2020; [PMC free article] [PubMed] [Google Scholar]

[10] Sorensen G, McLellan DL, Sabbath EL, Dennerlein JT, Nagler EM, Hurtado DA, et al. Integrating worksite health protection and health promotion: A conceptual model for intervention and research. Prev Med (Baltim). 2016;(91):188–96. [PMC free article] [PubMed] [Google Scholar]

[11] Nielsen K, Noblet AAJ. Organizational interventions for health and well-being: A handbook for evidence-based practice. New York: Routledge; 2018; pp. 302. [Google Scholar]

[12] Nobrega S, Kernan L, Plaku-Alakbarova B, Robertson M, Warren N, Henning R, et al. Field tests of a participatory ergonomics toolkit for Total Worker Health. Appl Ergon. 2017;60:366–79. [PMC free article] [PubMed] [Google Scholar]

[13] McLellan DL, Williams JA, Katz JN, Pronk NP, Wagner GR, Cabán-Martinez AJ, et al. Key Organizational Characteristics for Integrated Approaches to Protect and Promote Worker Health in Smaller Enterprises. J Occup Environ Med. 2017;59(3):289–94. [PMC free article] [PubMed] [Google Scholar]

[14] Cummings TG, Worley CG, Calhoun JW. Organization Development & Change. 2009.

[15] Cunningham C, Woodward C, Shannon H, MacIntosh J, Lendrum B, Rosenbloom D, et al. Readiness for organizational change: A longitudinal study of the workplace, psychological and behavioral correlates. J Occup Organ Psychol. 2002;75(4):377–92. [Google Scholar]

[16] Nielsen K, Randall R. Opening the black box: Presenting a model for evaluating organizational-level interventions. Eur J Work Organ Psychol. 2013;22(5): 601–17. [Google Scholar]

[17] Cummings TG, Worley CG. Organization development and change. 10th ed. Mason: Cengage Learning; pp. 810. [Google Scholar]

[18] Imada A A macroergonomic approach to reducing work-related injuries. In: Hendrich H, Kliener B, editors. Macroergonomics: Theory, Methods, and Applications. Mahwah, NJ: Associates Lawrence Erlbaum; 2002. pp. 151–72. [Google Scholar]

[19] Saksvik PØ, Nytrø K, Dahl-Jørgensen C, Mikkelsen A. A process evaluation of individual and organizational occupational stress and health interventions. Work Stress. 2002;16:37–57. [Google Scholar]

[20] Jones RA, Jimmieson NL, Griffiths A. The impact of organizational culture and reshaping capabilities on change implementation success: The mediating role of readiness for change. J Manag Stud. 2005;42(2):361–86. [Google Scholar]

[22] Miller V, Johnson J, Grau J. Antecedents to willingness to participate in a planned organizational change. J Appl Commun Res. 1994;22(1):59–80. [Google Scholar]

[23] Coch L, French J. Overcoming resistance to change. Hum Relations. 1948;1(4):512–32. [Google Scholar]

[24] Sorensen G, Himmelstein JS, Hunt MK, Youngstrom R, Hebert JR, Hammond SK, et al. A model for worksite cancer prevention: Integration of health protection and health promotion in the wellworks project. Am J Heal Promot. 1995; [PubMed] [Google Scholar]

[25] Semmer NK. Job stress interventions and the organization of work. Scand J Work Environ Heal. 2006;32: 515–27. [PubMed] [Google Scholar]

[26] Burnett S, Benn J, Pinto A, Parand A, Iskander S, Vincent C. Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes. Qual Saf Heal Care. 2010;19(4):313–7. [PubMed] [Google Scholar]

[27] Dahl-Jørgensen C, Saksvik PØ. The impact of two organizational interventions on the health of service sector workers. Int J Heal Serv. 2005;35:529–49. [PubMed] [Google Scholar]

[28] Simard M, Marchand A. A multilevel analysis of organisational factors related to the takig of safety initiatives by work groups. Saf Sci. 1995;21(2):113–29. [Google Scholar]

[29] Hendrick HW, Kleiner BM. Macroergonomics: Theory, methods, and applications. Macroergonomics: Theory, Methods, and Applications. Mahwah: Lawrence Erlbaum Associates; 2002. pp. 412. [Google Scholar]

[30] Dejoy D, Wilson M, Vandenberg R, McGrath-Higgins A, Griffin-Blake C. Assessing the impat of healthy work organization intervention. J Occup Organ Psychol. 2010;83(1):139–65. [Google Scholar]

[31] Lehman WEKK, Greener JM, Simpson DD. Assessing organizational readiness for change. J Subst Abuse Treat. 2002;22(4):197–209. [PubMed] [Google Scholar]

[32] Zhang Y, Flum M, West C, Punnett L. Assessing Organizational Readiness for a Participatory Occupational Health/Health Promotion Intervention in Skilled Nursing Facilities. Health Promot Pract. 2015;16(5):724–32. [PMC free article] [PubMed] [Google Scholar]

[33] Barrett JH, Haslam RA, Lee KG, Ellis MJ. Assessing attitudes and beliefs using the stage of change paradigm - Case study of health and safety appraisal within a manufacturing company. Int J Ind Ergon. 2005;35(10):871–87. [Google Scholar]

[34] Waterson P Sociotechnical design of work systems. In: Wilson J, Sharples S, editors. Evaluation of human work. 4th ed. Boca Raton: CRC Press; 2015. pp. 753–71. [Google Scholar]

[35] Murphy LA, Robertson MM, Carayon P. The next generation of macroergonomics: Integrating safety climate. Accid Anal Prev. 2014;68:16–24. [PubMed] [Google Scholar]

[36] Haims MC, Carayon P. Theory and practice for the implementation of “in-house”, continuous improvement participatory ergonomic programs. Appl Ergon. 1998;29(6):461–72. [PubMed] [Google Scholar]

[37] Henning RA, Robertson MM, Dugan AGA. Supporting Participatory Organizational Interventions. In: Nielsen K, Noblet A, editors. Organizational interventions for health and well-being: A handbook for evidence-based pratice. New York: Routledge; 2018. pp. 169–94. [Google Scholar]

[39] Willis GGB (Gordon B Cognitive Interviewing: A tool for improving questionnaire design. Thousand Oaks: Sage Publications; 2005. pp. 352. [Google Scholar]

[40] Loeppke RR, Hohn T, Baase C, Bunn WB, Burton WN, Eisenberg BS, et al. Integrating Health and Safety in the Workplace. J Occup Environ Med. 2015;57(5):585–97. [PubMed] [Google Scholar]