Journal of Occupational & Environmental Medicine:
The Impact of the Worksite Heart Health Improvement Project on Work Ability: A Pilot Study
Flannery, Kelly PhD, RN; Resnick, Barbara PhD, CRNP; McMullen, Tara L. MPH
From the School of Nursing (Drs Flannery and Resnick), University of Maryland, Baltimore; and Doctoral Program in Gerontology (Ms McMullen), University of Maryland, Baltimore County.
Address correspondence to: Kelly Flannery, PhD, RN, School of Nursing, University of Maryland, Baltimore, 655 W Lombard Street, Room 652, Baltimore, MD 21201 (Kflan001@son.umaryland.edu).
This work was funded by Sigma Theta Tau International.
The authors declare no conflict of interest.
Objective: To test the efficacy of the Worksite Heart Health Improvement Project (WHHIP).
Methods: The WHHIP was a quasi-experimental, 6-month pilot performed in two long-term care facilities. Thirty-nine minority female nursing assistants participated in this study. The 3-month WHHIP intervention focused on reducing cardiovascular disease risk by increasing physical activity and reducing the amount of salt and fat consumed. The intervention included three components: environmental and policy assessment; education; and ongoing motivation. The control site received education only. Measures were collected at baseline, 3 months, and 6 months and included work ability, job stress, and job satisfaction.
Results: Generalized estimating equations showed that the treatment group demonstrated significant improvements in work ability (P = 0.049).
Conclusions: There was preliminary evidence that the WHHIP improved work ability, and future research should assess the impact of improved work ability on patients.
Approximately 1.5 million nursing assistants (NAs) currently work in the United States,1 and many of these individuals are minority women earning approximately $10.33 an hour.2 Nursing assistants provide the majority of direct care to older adults who have multiple comorbidities and high care needs.3 In addition to the physical demands the residents require, NA work can be emotionally demanding because NAs care for individuals with significant cognitive impairment who are known to exhibit behavioral symptoms due to disease. This may in part explain NAs' reports of job stress4 and low job satisfaction.5,6 Moreover, although a recent study showed that NAs reported high levels of work ability,7 NAs often report musculoskeletal complaints,8 which can significantly reduce their work ability.7 Work ability is defined as work productivity accounting for physical and mental health.9 Work ability often declines as workers age, especially in physically demanding jobs such as an NA.10 Job stress, job dissatisfaction, and decreased work ability in this population can result in significant costs to facilities9,11,12 and may have a negative impact on residents' quality of life.9,12–18
WORKSITE HEALTH PROMOTION
Meta-analyses have shown that worksite health promotion (WHP) can reduce job stress, improve job dissatisfaction, and improve work productivity among a variety of workers.19–21 Therefore, WHP programs have the potential to benefit both NAs and organizations. However, most WHP studies focus on office workers.22 Only a handful of WHP studies have been done with health care workers and only three with NAs.23–25 Nevertheless, WHP studies with NAs have demonstrated that physical activity–focused WHP programs result in increased muscle strength,23–25 decreased musculoskeletal complaints,24 decreased job strain,25 improved adjustment into geriatric work,25 and reduced fatigue while at work.24
There are, however, many challenges to engaging NAs in health promotion efforts. For example, NAs often report being asked to work longer than their scheduled shift,26 which causes them to report they have no time to engage in health promotion activities (eg, exercise) when they get home.27 Also, NAs perceive their jobs as physically demanding and report that they are too tired to engage in health promotion activities when they get home, particularly after working overtime. Last, NAs report after-work responsibilities (eg, childcare) as major barriers to engaging in health promotion activities.27
To overcome these challenges, we developed a WHP intervention based on the theory of self-efficacy and the socioecological model. The socioecological model consists of five levels: intrapersonal, interpersonal, organizational, community, and policy.28 It was used to capture organizational, environmental, and policy issues that affected cardiovascular health at the worksite.29 In addition, we used self-efficacy theory to guide the intrapersonal- and interpersonal-level interventions in the socioecological model. Self-efficacy theory proposes that the stronger an individual believes he or she is capable of performing an activity (ie, self-efficacy expectations) and that performance will lead to desired outcomes (ie, outcome expectations), the more likely he or she will engage in the activity.30 The main purpose of this study was to test the impact of the worksite heart health improvement project (WHHIP) on job satisfaction, job stress, and work ability among minority female NAs working in long-term care facilities. We hypothesized that NAs who participated in the WHHIP would maintain or improve job satisfaction; maintain or reduce job stress; and maintain or improve work ability at each follow-up time point compared with the education-only group. Our secondary focus was to explore work factors that influenced NAs' participation in the WHHIP.
To test our hypotheses, we performed a 6-month quasi-experimental pilot study in two Maryland long-term care facilities. To prevent crosscontamination, we randomized by site versus by individual. As previously described,31,32 NAs were randomized to receive either treatment (ie, exposure to the WHHIP intervention) or education only (ie, 30-minute education about physical activity and diet modification). All measures were collected at baseline, 3 months, and 6 months, and were all collected during the NAs' paid work time. The University of Maryland's institutional review board approved the WHHIP.
Nursing assistants were eligible to participate if they worked at the facility as an NA at least 2 days a week, were a member of a minority group, were female, were aged 18 years or older, and could read and write English. Participants were excluded if they did not pass the Exercise Assessment and Screening for You33,34 or self-reported pregnancy. After meeting eligibility criteria and passing the Evaluation to Sign Consent,35 participants' consent was sought. A full description of the recruitment process has been described previously.31 Briefly, the sampling frame consisted of 99 NAs, of whom 39 (39%) consented to be in the study. The intervention group consisted of 24 NAs and the education-only group consisted of 15 NAs. At the end of the study, a total of 11 participants (28%), six from the intervention group and five from the education-only group, were lost to follow-up. The most common reason participants were lost to follow-up was that they left the facility or reduced their work hours and were no longer on the schedule to work (n = 8; 73%).
As shown in Table 1, baseline demographics were not significantly different between the two groups. The mean age of all participants was 41.75 years (SD, 13.01 years). Their average tenure was 6.3 years (SD, 6.45 years), and just more than half of the sample was married (n = 16; 51.6%). A majority of participants were non-Latino (n = 14; 77.8%) and African American (n = 31; 93.9%). Most participants were educated beyond high school (n = 25; 75.8%). In addition, at baseline, 14 participants (43.8%) worked day shift. Furthermore, at baseline, 10 participants (32.3%) reported working a second job (data not shown).
The WHHIP intervention used current WHP best practice recommendations36 and has been described previously.31,32 In brief, the WHHIP was developed using the socioecological model and theory of self-efficacy. Figure 1 shows the theoretical framework with examples for each level. The 12-week WHHIP intervention consisted of three components (Table 2) and was implemented by a master's-prepared nurse. All WHHIP activities were completed during paid work time. The intervention lasted 3 months and participants were observed for 6 months.
To assess the efficacy of the WHHIP, we collected three types of measures: demographic information, work-related factors, and survey measures. All measures were collected via paper and pencil during paid work time. Demographic items included (1) age; (2) tenure; (3) race; (4) ethnicity; (5) marital status; (6) education; (7) shift worked; and (8) does the NA work a second job. Work-related factors included (1) Does the NA always get a break?; (2) the total minutes the NA takes for break each workday; (3) Is the NA's break interrupted for patient-care tasks?; (4) Does the NA work longer than their scheduled shift?; and (5) Has the NA experienced an increase in her work responsibility over the past 6 months?. Survey items included (1) job satisfaction; (2) job stress; and (3) work ability.
The nursing home administrator job satisfaction questionnaire was used to assess job satisfaction. It is a 21-item scale that uses a 0- to 10-response format. Scores for this instrument range from 0 to 210, and a higher score indicates higher job satisfaction (desired). We used this instrument because earlier focus groups with NAs40–43 showed that this instrument captures many constructs that NAs report effect job satisfaction. The nursing home administrator job satisfaction questionnaire also has sufficient psychometric properties in nursing home settings.44
We used the short version of the effort reward and imbalance questionnaire, which uses four components: effort, reward, effort:reward ratio, and overcommitment to provide an assessment of job stress. The effort reward and imbalance questionnaire is a 16-item measure that uses a 4-point Likert scale and has been shown to be reliable and valid. The effort scale measures perceived work demands and ranges from 3 to 12, with a lower score indicating less effort (desired). The reward scale measures perceived work rewards and ranges from 7 to 28, with a higher scale indicating higher reward (desired). The effort:reward ratio is a proportion of effort an employee exerts (ie, demand) compared with the reward that employee receives, and a lower score is desired. Last, to measure coping characteristics, we assessed overcommitment, which is defined as excessive work-related commitment. The overcommitment scale ranges from 6 to 24, and a lower score indicates less overcommitment (desired).45,46
We used the work ability index to obtain the worker's self-assessment of her capacity to work and work demands accounting for her physical and mental health. The work ability index is an eight-item measure that uses a 0- to 10-format response to assess a worker's perception of her current work performance, estimation of her work performance in the near future, and how well she is able to do her job with respect to work demands, health constraints, and mental resources. The scale ranges from 0 to 80, and a higher score indicates higher work ability (desired). Evidence of repeatability and criterion-related validity has been demonstrated previously.9
Data analysis was done with SPSS versions 16 and 17 (SPSS, Inc, Chicago, IL).47,48 Independent-sample t test or Mann-Whitney U test (when variables were not normally distributed) was done to assess means, SDs, and significance between groups at baseline. Nominal and ordinal demographic variables were made into dichotomous variables and chi-square analysis was done to assess baseline differences between groups. Because of a small sample size, continuity correction was used and Fisher exact test was used when appropriate. In addition, descriptive statistics were done to assess work-related factors that influenced participation.
To test our main hypotheses, scales were created by summing instruments, and reverse coding was done when appropriate. Participants had to provide data for at least 50% of an instrument for their data to be used. Using all available data, we used pairwise generalized estimating equations (GEEs) to assess change at each time point for all dependent variables. All dependent variables that had an absolute value of 3 or more for skewness/standard error of skewness were transformed. After transformation, all variables met the assumption of normality. Each GEE model was run with a normal distribution and identity link. On the basis of naive correlations,49 we selected an independent correlation structure for each model. Naive correlations also were done with demographic variables of interest to assess for covariates; however, no covariates were found. Each model included a dependent variable, time, treatment, and time by treatment interaction. Assumptions for multicollinearity were met. Missing value analysis showed that all missing data used in the GEE analysis were missing completely at random (chi-square, 189.77; df, 180; P = 0.294); therefore, missing data assumptions also were met. This pilot study was not adequately powered to test for statistical significance; however, significance was determined using an α level of .05 or less.
Worksite Heart Health Improvement Outcomes
Table 3 shows the results for this study's main hypotheses. It includes the results from the GEE analysis for treatment effect and the means and SDs for the dependent variables using all available data. Baseline scores for effort (P = 0.013), reward (P = 0.036), and work ability (P = 0.002) were significantly different between groups at baseline. No significant treatment effects were seen in the work outcomes except for work ability. The intervention group had an increased mean change of 17.82 points on the work ability index, whereas the education-only group had a decreased mean change of 9.61 points on the work ability index. This implies that the treatment group significantly improved their work ability over time (P = 0.049).
Work Factors Influencing WHP Participation
The secondary focus of this study was to explore work factors that influenced participation in the WHHIP. We found that participants were excited and willing to participate in the WHHIP activities but experienced some barriers to participation. Participants participated in nearly 47% and 58% of the exercise- and diet-related activities, respectively. We found participation in physical activity sessions to be correlated with total time taken for breaks (r = 0.509; P = 0.031), suggesting a possible association between minutes taken for breaks and participation in WHP physical activity interventions. Challenges to participation were identified by the participants and are shown in Table 4. For example, on average (across all time points), 73.6% of all participants reported their breaks were at least occasionally interrupted by patient-care tasks. Some participants in the intervention group indicated they planned to attend a group exercise class but they were unable because they had to work. In addition, across all time points, 58.7% of all participants reported at least occasionally working longer than their scheduled shift. Last, an average of 15 participants (across all time points) reported (at any given time) an increase in their work responsibility over the last 6 months, further challenging participation.
These findings provide preliminary data to suggest the WHHIP improved work ability. Similar findings have been noted among home health workers. Previous research50 has shown that home health workers who participated in physical activity–focused WHP activities were able to maintain work ability, whereas those assigned to a control group demonstrated a decline in work ability over time. Health promotion efforts (eg, physical activity) are believed to improve work ability by increasing the workers' physical health (eg, musculoskeletal well-being) and mental health (eg, providing employees with coping strategies such as physical activity to manage work stress).51 A recent review of WHP studies concluded that physical activity–focused WHP programs, diet-focused WHP programs, or both (ie, like the WHHIP) can significantly improve work ability/productivity. However, this is an emerging paradigm with few rigorous studies to support this claim.52 Therefore, ongoing research is needed to assess the feasibility and efficacy of such studies.
We did not find a treatment effect with regard to job stress or satisfaction. This is in contrast to previous studies21,25 that report physical activity–focused WHPs can reduce job stress and improve job satisfaction. However, the previous studies had only small treatment effects21 and only one study with a positive treatment effect included NAs.25 Previous research4–6,53–55 has shown that NAs report that their job stress, job dissatisfaction, or both are due to system issues (eg, workload, mandatory overtime). These issues remained constant throughout the study, as shown in Table 4, which may explain why we did not see a treatment effect for job stress or job satisfaction.
From a feasibility perspective, we collected data about potential factors that could influence NAs' ability to participate in WHP-related activities (Table 4). Typically, participation in WHP averages 33%56 and participation in studies that include health care workers has been reported at 21%.57 These studies generally do not allow WHP interventions to occur during the workday.58 Although it was our intention to increase accessibility and encourage participation in the WHHIP by designing the intervention so that activities occurred during the workday, the NAs reported participation challenges. For example, many participants reported their breaks are interrupted for patient-care tasks. Previous reports23,59 also have documented that WHP activities for health care workers during the workday can be problematic because of unpredictable patient-care tasks. Despite these challenges, there is some evidence that our WHHIP intervention can feasibly be delivered during paid work time31 and result in health benefits31 and increased work ability.
NAs also face barriers that make engaging in health promotion efforts after or before work difficult. For example, as shown in Table 4, on average (across all time points) more than half of the participants reported that they at least occasionally worked more than their scheduled shift, which is consistent with the literature.26 In addition, at baseline, more than half of the sample reported working a second job. These findings, combined with those of previous work, stating after-work responsibilities (eg, household duties) make engaging in health promotion efforts difficult,27 further reinforce the importance of incorporating health promotion activities into the workday for this population.
In addition to using paid work time for WHP activities, we found that several other components of the intervention facilitated participation. For example, we found creating and posting a schedule of intervention activities for participants was an effective way for participants to plan their work schedules around activities, thus increasing participation. Participants used “work buddies” or partners to cover their work assignments while engaging in physical activity. In addition, participants used an “off the floor for physical activity” sign-out board so that staff knew to cover their assignments. We also observed that creating 10-minute walk paths that were on or near the units where the WHHIP participants worked was a great way to engage participants in physical activity when they could not leave their assigned unit.
Understanding the impact of WHP programs with NAs is critical to increase the quality of resident care and the quality of life for NAs. With an increasing focus on national budgets, expenditures, and quality in nursing homes, greater standards within long-term care must be exercised. To increase health promotion, policy makers, researchers, and stakeholders must rethink how care is coordinated within long-term care environments. Increasing the work ability of NAs working in long-term care settings includes encouraging the use of long-term care models, expanding workplace training, creating a career ladder for the NA, and expanding workplace breaks and job duties. Implementing WHP programs with NAs working in long-term care settings provides potential benefits such as improved worker health,31 which may decrease health care costs,60,61 absenteeism among NAs,21,60,61 and turnover62 and may prevent fragmented care derived from inadequate working conditions. The federal government and key stakeholders should mobilize to support health promotion policies that improve the quality of life for NAs. In addition, support for legislation such as the Improving Care for Vulnerable Older Citizens Through Workforce Advancement Act,63 introduced by Senator Casey (Democrat, Pennsylvania), the Caring for an Aging America Act,64 introduced by Senators Boxer (Democrat, California), Collins (Republican, Maine), Kohl (Democrat, Wisconsin), and Sanders (Independent, Vermont), or the Affordable Care Act are essential because they provide and increase the quality of life for NAs.
Support by state policymakers and long-term care administrators to help build an infrastructure that supports the health promotion of the NA workforce also is essential. Encouraging the use of accessible WHP programs, providing incentives for employers to offer WHP programs, and evaluating health promotion best practices within long-term care environments may break down barriers to quality of life and quality of care in nursing homes.
Like all studies, the WHHIP had limitations. Because of the small sample size, this study was not adequately powered to detect a statistical significance. In addition, the quasi-experimental design used for this study was not as rigorous as a randomized, controlled trial design. However, we chose to use a quasi-experimental design to reduce the potential bias that could have occurred if individuals were randomized within sites. A larger randomized trial that includes multiple settings is needed to accrue evidence of efficacy for this intervention. Furthermore, the use of a convenience sample could have led to a sampling bias. As commonly found with NAs,65 we had a significant loss to follow-up due to job turnover, thus potentially adding bias. The study is further limited by the use of subjective survey data, which can be influenced by social desirability. In addition, the measures we used to assess job stress and job satisfaction were not developed specifically for NAs or for staff working in long-term care settings, nor were they adequately psychometrically tested for this population and setting. Therefore, these instruments may have missed constructs critical to NAs5 working in long-term care facilities, which may have potentially added bias. Furthermore, we suspect these instruments had a limited ability to assess change over time in this population and setting, as evidenced by little variation at follow-up time points. In the future, we recommend using the Job Attitude Scale to assess job satisfaction among NAs because a recent Rasch66 analysis provides evidence of its psychometric ability in this population and setting. Moreover, the Job Attitude Scale has the ability to assess change over time.66 In addition, we recommend using a larger sample to further assess the effort reward and imbalance questionnaire in this population and setting.
Preliminary efficacy data suggest that the WHHIP is feasible, and participation in the WHHIP can improve work ability in NAs working in long-term care settings. Furthermore, these findings are important because they guide the implementation of future WHP efficacy trials in this population and setting. Future studies also are needed to explore the impact of increased work ability on resident outcomes. As research in this field grows, findings from these studies can be used to provide evidence for legislation that supports WHP programs with NAs working in long-term-care settings.
2. Squillace MR, Remsburg RE, Bercovitz A, Rosenoff E, Branden L. An introduction to the national nursing assistant survey. National Center For Health Statistics. Vital Health Stat. 2007;44:1–54.
3. Paraprofessional Healthcare Institute. Older Direct-Care Workers: Key Facts and Trends. Bronx, NY: Paraprofessional Healthcare Institute; 2010.
4. Benjamin AE, Matthias RE, Kietzman K, Furman W. Retention of paid related caregivers: who stays and who leaves home care careers? Gerontologist. 2008;48:104–113.
5. Castle NG. Assessing job satisfaction of nurse aides in nursing homes: the nursing home nurse aide job satisfaction questionnaire. J Gerontol Nurs. 2007;33:41–47.
6. Rakovski CC, Price-Glynn K. Caring labour, intersectionality, and worker satisfaction: an analysis of the National Nursing Assistant Study (NNAS). Sociol Health Illn. 2010;32:400–414.
7. Larsson A, Karlqvist L, Westerberg M, Gard G. Identifying work ability promoting factors for home care aides and assistant nurses. BMC Musculoskelet Disord. 2012;13:1.
8. Guo HR, Tanaka S, Cameron LL, et al. Back pain among workers in the United States: national estimates and workers at high risk. Am J Ind Med. 1995;28:591–602.
9. Tuomi K, Ilmarinen J, Jahkola A, Katajarinne L, Tulkki A. Work Ability Index: A Tool for Occupational Health Research and Practice. Helsinki, Finland: Finnish Institute of Occupational Health; 2003; International Commission on Occupational Health.
10. Ilmarinen J, Tuomi K, Klockars M. Changes in the work ability of active employees over an 11-year period. Scand J Work Environ Health. 1997;23(suppl 1):49–57.
11. Caudill ME, Patrick M. Turnover among nursing assistants: why they leave and why they stay. J Long Term Care Adm. 1991;19:29–32.
12. Kujala V, Tammelin T, Remes J, Vammavaara E, Ek E, Laitinen J. Work ability index of young employees and their sickness absence during the following year. Scand J Work Environ Health. 2006;32:75–84.
13. Bostick JE, Rantz MJ, Flesner MK, Riggs CJ. Systematic review of studies of staffing and quality in nursing homes. J Am Med Dir Assoc. 2006;7:366–376.
14. Harrington C, Zimmerman D, Karon SL, Robinson J, Beutel P. Nursing home staffing and its relationship to deficiencies. J Gerontol B Psychol Sci Soc Sci. 2000;55:s278–s287.
15. Schnelle JF, Simmons SF, Harrington C, Cadogan M, Garcia EM, Bates-Jensen B. Relationship of nursing home staffing to quality of care. Health Serv Res. 2004;39:225–250.
16. Castle NG, Engberg J. Staff turnover and quality of care in nursing homes. Med Care. 2005;43:616–626.
17. Castle NG, Anderson RA. Caregiver staffing in nursing homes and their influence on quality of care: using dynamic panel estimation methods. Med Care. 2011;49:545–552.
18. Castle NG. Nursing home caregiver staffing levels and quality of care: a literature review. J Appl Gerontol. 2008;27:375–405.
19. Pelletier B, Boles M, Lynch W. Change in health risks and work productivity over time. J Occup Environ Med. 2004;46:746–754.
20. Mills PR, Kessler RC, Cooper J, Sullivan S. Impact of a health promotion program on employee health risks and work productivity. Am J Health Promot. 2007;22:45–53.
21. Conn VS, Hafdahl AR, Cooper PS, Brown LM, Lusk SL. Meta-analysis of workplace physical activity interventions. Am J Prev Med. 2009;37:330–339.
22. Anderson LM, Quinn TA, Glanz K, et al. The effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity: a systematic review. Am J Prev Med. 2009;37:340–357.
23. Skargren E, Oberg B. Effects of an exercise program on musculoskeletal symptoms and physical capacity among nursing staff. Scand J Med Sci Sports. 1996;6:122–130.
24. Härmä MI, Ilmarinen J, Knauth P, Rutenfranz J, Hänninen O. Physical training intervention in female shift workers: I. the effects of intervention on fitness, fatigue, sleep, and psychosomatic symptoms. Ergonomics. 1988;31:39–50.
25. Dehlin O, Berg S, Hedenrud B, Andersson G, Grimby G. Muscle training, psychological perception of work, and low-back symptoms in nursing aides. The effect of trunk and quadriceps muscle training on the psychological perception of work and on the subjective assessment of low-back insufficiency. A study in a geriatric hospital. Scand J Rehabil Med. 1978;10:201–209.
26. Noelker LS, Ejaz FK, Menne HL, Jones JA. The impact of stress and support on nursing assistant satisfaction with supervision 2006. J Appl Gerontol. 2006;25:323.
27. Nelson MA. Health practices and role involvement among low-income working women. Health Care Women Int. 1997;18:195.
28. Linnan L, Sorensen G, Colditz G, Klar DN, Emmons KM. Using theory to understand the multiple determinants of low participation in worksite health promotion programs. Health Educ Behav. 2001;28:591–607.
29. Sallis JF, Glanaz K. Physical activity and food environments: solutions to the obesity epidemic. Milbank Q. 2009;87:123.
30. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84:191–215.
31. Flannery K, Resnick B, Galik E, Lipscomb J, McPhaul K, Shaughnessy M. The worksite heart health improvement project (WHHIP): feasibility and efficacy. Public Health Nurs. In press.
32. Flannery K, Resnick B, Galik E, Lipscomb J. Physical activity and diet-focused worksite health promotion for direct care workers. J Nurs Adm. 2011;41:245–247.
33. Resnick B, Ory MG, Hora K, et al. A proposal for a new screening paradigm and tool called exercise assessment and screening for you (EASY). J Aging Phys Act. 2008;16:215–233.
34. Program on Healthy Aging. Exercise and screening for you (EASY). Available at: http://www.easyforyou.info/
. Updated 2008. Accessed June 28, 2011.
35. Resnick B, Gruber-Baldini AL, Pretzer-Aboff I, et al. Reliability and validity of the evaluation to sign consent measure. Gerontologist. 2007;47:69–77.
37. Oldenburg B, Sallis JF, Harris D, Owen N. Checklist of health promotions environments at worksites (CHEW): development and measurement characteristics. Am J Health Promot. 2002;16:288–289.
38. New York State Department of Health. Heart check assessing worksite support for a heart healthy lifestyle. Version 4.1. Available at: www.health.ny.gov/diseases/cardiovascular/heart_disease/docs/heartcheck.pdf
39. San Diego and Imperial Regional Nutrition Network. Healthy vending machine environmental assessment. Available at: http://www.banpac.org/pdfs/healthy_vending/vending_machine_assessment_tool_english.pdf
. Accessed August 6, 2012.
40. Moyle W, Skinner J, Rowe G, Gork C. Views of job satisfaction and dissatisfaction in Australian long-term care. J Clin Nurs. 2003;12:168–176.
41. Pennington K, Jill S, Kathy M. The role of certified nursing assistants in nursing homes. J Nurs Adm. 2003;33:578–584.
42. Kemper P, Heier B, Barry T, et al. What do direct care workers say would improve their jobs? Differences across settings. Gerontologist
43. Secrest J, Iorio DH, Martz W. The meaning of work for nursing assistants who stay in long-term care. J Clin Nurs. 2005;14:90–97.
44. Castle NG. An instrument to measure job satisfaction of nursing home administrators. BMC Med Res Methodol. 2006;9:47.
45. Siegrist J, Starke D, Chandola T, et al. The measurement of effort-reward imbalance at work: European comparisons. Soc Sci Med. 2004;58:1483–1499.
46. Leineweber C, Wege N, Westerlund H, Theorell T, Wahrendorf M, Siegrist J. How valid is a short measure of effort-reward imbalance at work? A replication study from Sweden. Occup Environ Med. 2010;67:526–531.
49. Twisk J. Applied Longitudinal Data Analysis for Epidemiology: A Practical Guide. Cambridge, United Kingdom: Cambridge University Press; 2003.
50. Pohjonen T, Ranta R. Effects of worksite physical exercise intervention on physical fitness, perceived health status, and work ability among home care workers: five-year follow-up. Prev Med. 2001;32:465–475.
51. Larsson A. Identifying, Describing, and Promoting Health and Work Ability in a Workplace Context. Doctoral thesis. Luleå, Sweden: Luleå University; 2011.
52. Cancelliere C, Cassidy JD, Ammendolia C, Côté P. Are workplace health promotion programs effective at improving presenteeism in workers? A systematic review and best evidence synthesis of the literature. BMC Public Health. 2011;26:395–406.
53. Liu LF. Job satisfaction of certified nursing assistants and its influence on the general satisfaction of nursing home residents: an exploratory study in southern Taiwan. Geriatr Nurs. 2007;28:54–62.
54. Parsons SK, Simmons WP, Penn K, Furlough M. Determinants of satisfaction and turnover among nursing assistants. The results of a statewide survey. J Gerontol Nurs. 2003;29:51–58.
55. Bishop CE, Squillace MR, Meagher J, Anderson WL, Wiener JM. Nursing home work practices and nursing assistants' job satisfaction. Gerontologist. 2009;49:611–622.
56. Robroek S, van Lenthe F, van Empelen P, Burdorf A. Determinants of participation in worksite health promotion programmes: a systematic review. Int J Behav Nutr Phys Act. 2009;6:26–38.
57. Jonsdottir IH, Börjesson M, Ahlborg GJ. Healthcare workers' participation in a healthy-lifestyle-promotion project in western Sweden. BMC Public Health. 2011;8:448.
58. Barr-Anderson DJ, AuYoung M, Whitt-Glover MC, Glenn BA, Yancey AK. Integration of short bouts of physical activity into organizational routine: a systematic review of the literature. Am J Prev Med. 2011;40:76–93.
59. Lemon SC, Zapka J, Li W, et al. Step ahead: a worksite obesity prevention trial among hospital employees. Am J Prev Med. 2010;38:27–38.
60. Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Aff (Millwood). 2010;29:304–311.
61. Chapman LS. Meta-evaluation of worksite health promotion economic return studies: 2005 update. Am J Health Promot. 2005;19:1–11.
62. Renaud L, Kishchuk N, Juneau M, Nigam A, Tétreault K, Leblanc M. Implementation and outcomes of a comprehensive worksite health promotion program. Can J Public Health. 2008;99:73–77.
65. Castle NG. Measuring staff turnover in nursing homes. Gerontologist. 2006;46:210–219.
66. Flannery K, Resnick B, Galik E, Lipscomb J, McPhaul K. Assessment of reliability and validity of the job attitude scale. Geriatric Nurs. In press.
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