Traumatic Injury Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health (2009)

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4 Recommendations for Program Improvement Strategic Planning A s described in Chapter 1, the current goal areas represent a retrofitting of a decade’s worth of work into a structure to be reviewed with the Framework Document in mind. This does not mean that considerable thought was not given by the National Institute for Safety and Health’s (NIOSH’s) Traumatic Injury (TI) Research Program over the decade to the work being done, but from the presentation of the goals to the committee in the evidence package, it is clear that some of the TI Research Program’s effort occurred outside and independent of a program-wide coherent planning process. The committee recognizes that opportunities arise and an agency must be adroit to deal with unexpected events (for example, the work in goal 2 regarding falls from telecommunications towers appears to be a response to a newly discov- ered occupational risk) and that there are points of departure from any planning document. Some work will appear not to fit in well with the rest of the program. This is not unexpected. With some exceptions, as discussed in Chapter 2, the pro- gram worked in areas of public health importance and documented intermediate outcomes. The committee has concluded that the TI Research Program successes (as de- fined by the activities, outputs, and outcomes reviewed) occurred most obviously in goal areas in which there was a focused and intense effort (due to resources or a geographic focus, e.g., Alaska) or in which a goal was narrowly defined or clearly 127 

128 T r a u m a t ic I n j u r y R e s e a rc h at N I OSH defined and achievements could be documented. Often these areas of focus were due to congressional directives, increased resources associated with congressional directives, and staff interest and expertise. Some of the successes arose from a focus on a newly emerging concern. The TI Research Program should be careful in its next stage of planning and priority setting to outline as specifically as possible the scope of the work it plans to accomplish so that its achievements are demonstrably linked to a problem of importance and their research is strategic. The committee urges the TI Research Program to focus on those occupational risks that it has specific skills for address- ing and that are not currently or better addressed by other federal or nonfederal researchers. Otherwise, it risks competing with other agencies and squandering precious resources on activities that could be redundant or that will not necessarily or directly lead to accomplishing the goals of reducing morbidity and mortality from occupational traumatic injuries. The committee does not mean that the TI Research Program should only work in areas that might be seen as “low-hanging fruit” or that can easily be shown to be impacted quickly. Some work will take a long time to show results, especially intermediate outcomes, and this is true for research in any field. The TI Research Program will likely need to address a mixture of goals that have potential for short- term and long-term impact; explicitly outlining a time line for expected results will make the evaluation of success more obvious. An important component of strategic planning is to consider criteria for end- ing work in a specific goal or ending a specific approach to achieving the goal. As described in Chapter 2, the committee felt that the work in some goals lasted beyond its period of usefulness to the detriment of possibilities to impact other important TI problems. For example, the work on subgoal 4.1, the rollover protec- tive structure (ROPS) program, seemed to reflect a missed opportunity to move beyond the “comfort zone” of the team working in this area. The committee (and other evaluation committee reviews) applauded the earlier work in ROPS but felt that persevering in developing engineering solutions occurred at the expense of a plan to explore other means, such as policy solutions, to overcome the barriers to more widespread use of ROPS. 1. Continue setting goals that are within the TI Research Program’s scope and resources. Given its limited resources, the TI Research Program should continue a research focus and priority setting on goals that are well defined, are based on rigorous surveillance data, and are complementary to work being done by stakeholders, extramural research partners, or other agencies. 

R e c o m m e n dat i o n s for Program Improvement 129 2. Develop an explicit plan for each subgoal. The TI Research Program should develop an explicit, written plan within each subgoal for pro- gression along the public health framework, including the circum- stances under which work in the subgoal should cease. Additional considerations should be the relative balance between risk factor and intervention research. Coordination and Collaboration Given that the TI Research Program operates under severely limited resources, it not only must be strategic in selecting its priorities, as discussed previously, but must also position itself to benefit from collaborations within the federal govern- ment and with academic researchers and state agencies. These collaborations and coordinating activities will help the TI Research Program prioritize its activities in order to complement work elsewhere or to avoid duplication of effort. Coordina- tion and collaboration can be achieved by several means, such as organizational relationships and research programs. As such, the committee offers several recom- mendations that are intended to support and encourage some current collabora- tions, to identify a major new initiative, and to leverage a relationship that has perhaps recently been ignored. NIOSH is one of several federal agencies with a role in injury prevention and control, so there is obviously some overlap of agency interests, particularly with re- gard to research and information dissemination. In focusing on occupational trau- matic injury, NIOSH should continue to foster and build relationships with other agencies, (e.g., the National Highway Traffic Safety Administration, the National Institutes of Health [NIH], the National Center for Injury Control and Prevention, the Consumer Product Safety Commission, the Department of Defense, the Health Resources and Services Administration, and the Agency for Healthcare Research and Quality). This is not to suggest an absence of communication among agencies. The committee encourages continued and appropriate attention to interagency issues in order to assure a unique research portfolio in the TI Research Program and the efficient deployment of scarce resources. 3. Work with other federal agencies that support injury prevention and control research. NIOSH and its TI Research Program should work with senior leadership from other federal agencies to outline areas of collaboration and synergy; to identify opportunities to further the science of injury control and prevention; and to reduce the burden of injury across populations, environments, and products. 

130 T r a u m a t ic I n j u r y R e s e a rc h at N I OSH As discussed in Chapters 2 and 3, NIOSH played a very important role in developing surveillance of fatal occupational injuries. Together with the Fatality Assessment and Control Evaluation Program (FACE; case investigations that are conducted by TI Research staff or through state-based programs), this has allowed the TI Research Program to better understand the burden of injury, risk factors for injury, progress toward decreasing occupational injuries, and program prioritiza- tion. However, the program has clearly been driven by a focus on fatalities. The committee understands that there are legitimate reasons to focus on fatalities and legitimate debates about aggregate burdens, but fatal injuries are not proxies for nonfatal injuries. Risk factors can vary widely. The time has come for the TI Re- search Program to bolster its focus—particularly starting with population-based surveillance—on nonfatal occupational injuries without lessening the excellent work on fatal injuries. This will require work with other agencies, including the Occupational Safety and Health Administration (OSHA) to improve the usefulness of the worker logs and with the Bureau of Labor Statistics to improve the Annual Survey of Injuries and Illnesses and to better understanding the reasons for under- reporting. The TI Research Program could consider extending the FACE Program to specific nonfatal injuries. 4. Improve surveillance of nonfatal injuries. The TI Research Program should develop a plan for improving surveillance of nonfatal injuries, integral to prevention and to strengthening the TI Research Program portfolio development. A comprehensive approach should go beyond use of employer-based data to include nonemployer-based data sources such as hospital data and other medical data systems, the National Health Interview Survey, and the Behavioral Risk Factor Surveillance System. The TI Research Program should involve other relevant federal and state agencies in developing a cohesive interagency effort. As noted in Chapter 2 as well as other evaluation committee reports, the role of OSHA in implementing regulatory actions is a significant external factor to the success of NIOSH research. The committee understands the difficulty NIOSH might experience in this regard. OSHA is organizationally distinct by statute (the rationale for this is not being questioned in this report). The committee urges perseverance on the part of the TI Research Program in addressing injuries and interventions that are amenable to regulatory action by or otherwise of interest to OSHA. It should also increase its engagement with the Authoritative Recommenda- tion Program at NIOSH to promote translation of TI Research Program research findings into OSHA regulations and consensus standards. 

R e c o m m e n dat i o n s for Program Improvement 131 5. Work collaboratively with OSHA. An agency of particular importance and relevance to NIOSH is OSHA. The TI Research Program, along with NIOSH leadership, should continue to work with OSHA to iden- tify areas of high-priority research that NIOSH should undertake and to identify NIOSH research findings of particular salience for potential regulatory action by OSHA. As discussed in Chapters 1 and 2, NIOSH is an agency that supports intramural and extramural research. Its extramural partners include state occupational public health programs, which conduct surveillance, FACE investigations, intervention research, training, and a range of transfer and dissemination activities. Managing the appropriate sets of responsibilities could occasionally prove challenging, be- cause each partner has specific interests, needs, and other funding opportunities and responsibilities. The committee fully understands the tension between the needs of federal agencies and the interests of academic researchers in particular. Academic research- ers are not necessarily interested in the pragmatic questions that federal agencies need addressed. Academic researchers also tend to enjoy a degree of freedom in research settings that might not be compatible with the data or research require- ments of an agency with a very narrow and directed mission. Conversely, agency priority-setting activities might not allow for sufficient time for nondirected basic research in the academic setting to show relevance to agency needs. Finally, agen- cies often need results disseminated promptly, which is not always compatible with the traditional publication process. There is a spectrum of approaches to this dilemma—ranging from structuring the intramural program to fill gaps not likely to be filled by extramural researchers, to directing extramural research funding to fill gaps within the intramural program, as well as everything in between. The committee encourages the TI Research Program to follow a middle ground. That is, the intramural program has obvious areas of expertise that should be used to the fullest, while new hires could be used to expand the intramural capability. The extramural research program can “fill in” what the intramural program lacks, as well as provide innovative approaches not currently anticipated or realized. The TI Research Program has research facilities that, although not always unique, are well established and productive. For example, the anthropometric labs and the virtual reality lab are excellent, and intramural research should use them as much as possible. Making these facilities available to extramural partners could expand their usefulness. Extremely large research-granting programs might find it difficult to keep track of all the extramural research activities and outcomes, but the TI Research Program is small enough that, with good strategies in place, it should be able to structure in- 

132 T r a u m a t ic I n j u r y R e s e a rc h at N I OSH tramural research projects that complement, not compete with, academic partners. Similarly, extramural research opportunities that complement staff expertise can be targeted. Picking the most strategic mix of intramural and extramural research does require reporting from extramural researchers, which can seem burdensome to them. However, with its limited research budget, the TI Research Program de- serves and needs to fully understand the work it is supporting. Communication and collaboration are key to a successful mix of intramural and extramural research. Increased communication can also lead to increased opportunities for appropriate transfer of research findings into practice. The committee urges that this collaboration not be overly directed or pro- grammed. Rather, the committee sees this as an important step in building teams for TI research. The committee recognizes that there are obvious benefits to in- creased interactions between researchers and NIOSH should facilitate such inter- actions rather than impede them, such as through bureaucratic barriers. Specific examples could include the use of NIOSH laboratories by academic researchers, co-publication of results from complementary research, and information exchange about the status of research projects. The committee is aware of regular, collabora- tive interactions between intramural and extramural researchers in other NIOSH programs and encourages the TI Research Program to explore those models if it has not done so already. Further, the committee urges that NIOSH extend its efforts in collaboration and coordination within NIOSH programs. The matrix management model, as discussed in Chapter 2, does not guarantee the kind of collaboration that it strives to foster. 6. Ensure collaboration among NIOSH-funded researchers. NIOSH should review its practices and take steps to improve the opportuni- ties for intramural and extramural researchers, including state oc- cupational public health programs, to communicate and collaborate without excessively directing extramural research to the detriment of scientific creativity. NIOSH should also further ensure collaboration and coordination among its programs, including the traumatic injury, construction, mining, and agriculture programs. Workforce Development Researchers in occupational injury claim that there are few academic programs to train students or postdoctoral fellows for pursuing a career in researching trau- matic injury. As the health research field has moved increasingly toward molecular or very high technology tools, young students increasingly choose a more basic science career. Although biomedical funding (e.g., through NIH) has not increased 

R e c o m m e n dat i o n s for Program Improvement 133 the last few years as it did in the recent decade, it is certainly an attractive career direction for budding researchers. The more applied nature of injury research does not seem to grab the attention of students. There are currently few graduate programs in occupational injury research. NIOSH created a program for encourag- ing occupational research in universities through the Education Research Centers (ERCs) Program. NIOSH supports 17 ERCs in the core areas of industrial hygiene, occupational health nursing, occupational medicine, and occupational safety, plus specialized areas relevant to the occupational safety and health field. Most NIOSH- supported research at the ERCs, however, seems to be in the “health” component rather than the “safety” component. An important part of encouraging traumatic injury research at ERCs would be to expand the definition of “safety programs” and frame them more broadly to include occupational injury epidemiology and pre- vention, injury prevention intervention research, and other more forward-looking disciplines within the safety arena. ERCs could also expand their reach by increasing interactions with their institutions’ epidemiology and engineering programs. The TI Research Program needs to develop a plan to increase the pipeline of traumatic injury researchers. In order to do so, the committee suggests stressing the technical expertise required to work in traumatic injury, the interdisciplinary nature of successful traumatic injury research, and the possibility of “making a real difference” with traumatic injury research. 7. Increase the visibility of traumatic injury research. NIOSH should embark on a program to increase the visibility of traumatic injury research in order to attract new researchers. Absent a significant in- crease in research funding, the TI Research Program can still attempt to influence the number of ERCs that have a focus on safety research and can still disseminate information about the quality, impact, and scientific challenges of traumatic injury research, as well as the dy- namic changes in the field that go beyond the confines of traditional safety engineering. Transfer The most obvious federal partner for transferring traumatic injury research into practice is OSHA. However, as has been noted in other parts of this report, NIOSH has no control over OSHA regulatory decisions and the committee has addressed this in a recommendation made earlier. However, not all interventions  Thisis consonant with advice from a recent report addressing the workforce pipeline challenges in engineering research (NAE, 2008), Changing the Conversation: Messages for Improving Public Un- derstanding of Engineering. 

134 T r a u m a t ic I n j u r y R e s e a rc h at N I OSH fall into the purview of regulatory action and NIOSH works to reduce traumatic injuries in other ways. NIOSH created a research-to-practice (r2p) initiative with six components: prioritize, partner, target, translate, disseminate, and evaluate. This initiative recognizes the role of partners in this collaborative process. The TI Research Program has a long history of successful partnerships with industry and the committee hopes this will continue. The TI Research Program review in Chapter 2 includes several good examples of r2p efforts, most notably the work of the Alaska Field Station. However, the committee is concerned that the TI Research Program, and perhaps all of NIOSH, is not fully prepared to rigorously and expertly execute an r2p enterprise. To improve on this initiative, it is important that the TI Research Program allow its talented staff and extramural researchers or other grantees to focus their efforts, play on their strengths, and collaborate with others to complement their own expertise. Experts in translation should be included in project teams. As the TI Research Program develops better tracking of extramural research projects, translation activities regarding the outcomes of this research can be planned, whether through translation components included in the extramural research or by collaborations with the NIOSH transfer experts. Talented basic scientists should not spend their time on transfer activities that are beyond their expertise. This is not to suggest that the basic scientists or engineers should be absolved from considering the transfer implications of their work; each project should involve a plan for transfer of the appropriate type at the appropriate time. The committee notes that it will be important for the TI Research Program to maintain a balance between basic research, applied research, and transfer activities. The committee further notes that NIOSH has no control over OSHA, its primary federal partner in transfer activities. The transfer of research to practice is important in its own right for nonregulatory improvements in injury prevention and control, but OSHA receptivity to regulatory action would make the impact of r2p even greater. 8. Evaluate research-to-practice efforts. NIOSH should develop a stra- tegic plan for evaluating its r2p efforts and for building the capacity to carry out and evaluate these efforts. Needed disciplines include behavioral sciences; organizational behavior; intervention effectiveness research; public health education; dissemination, implementation, and diffusion research; social marketing; and media advocacy. The changing Nature of Work Recognizing the changing demographics of the U.S. workforce, NIOSH has included reducing injuries among high-risk and vulnerable populations among 

R e c o m m e n dat i o n s for Program Improvement 135 its strategic goals for the future. It is likewise important to address the changing nature of work itself and its interplay with the changing workforce. Work in the United States is changing in significant ways that can be expected to alter the cur- rent pattern of and risk factors for work-related traumatic injury. The industrial sectors in which U.S. workers are employed are changing. Most notably, the United States continues to shift generally from a manufacturing to a service and knowledge economy. For example, the greatest growth is projected to occur in home health care, an industry which relies heavily on immigrant and minority labor and in which the work setting is geographically dispersed. Another example is where the “craft” of residential construction is changing to a manufactured or prefabricated industry. In addition, there is likely to be a continued shift in work organization and employment practices including corporate restructuring and downsizing, shifts to leaner, more flexible production methods, and increased reliance on part-time, temporary, and contingent labor. These trends may influence work hours, job demands, benefits, and job security that may in turn adversely impact injury risks and may disproportionately affect vulnerable worker populations. Recent emphasis on the development of new sustainable technologies and green building practices offers important new opportunities for prevention through design in which the health of working people as well as the environment would be taken into account in the design stage of new products and projects. NIOSH has a cross-sector program on work organization and stress-related disorders which was also one of the 21 priority areas for research under the initial National Occupational Research Agenda (NORA). This program clearly recognizes the potential impact of the changing organization of work not only on worker health but also worker safety and has developed a research agenda to identify and address these potential risks (NIOSH, 2002). More recently NIOSH has established a program on prevention through design, which is broadly defined as addressing occupational safety and health needs in the design process to prevent or minimize work-related hazards and risks. The committee underscores the importance of TI Research Program collaboration with these other NIOSH program areas as well as the NIOSH Program on Occupational Health Disparities. 9. Research prevention strategies for traumatic injuries in a changing workplace. The TI Research Program should consider research on the safety impacts of changes in the nature of work as well as intervention research targeting organization polices and practices and including prevention through design approaches. 

136 T r a u m a t ic I n j u r y R e s e a rc h at N I OSH Summary Occupational traumatic injuries place a substantial burden on the country. The TI Research Program has demonstrated success in addressing them. Every program can improve, however, and NIOSH specifically requested that the ERCs provide suggestions for program improvement. The committee has offered nine recommendations in the areas of strategic planning, coordination and collabora- tion, workforce development, transfer, and the changing nature of work. The TI Research Program is aware of the need for these activities and is working to ad- dress all of them. The committee hopes that these recommendations are useful in supporting and encouraging its efforts. With a focus on program improvement as outlined in this chapter, the TI Re- search Program can continue to serve as a leader in the field by identifying its niche in research, collaborating with partners, and sponsoring important high-quality research that contributes to reducing the morbidity and mortality associated with injury in the workplace. ReferenceS NIOSH (National Institute of Occupational Safety and Health). 2002. The Changing Organization of Work and the Safety and Health of Working People: Knowledge of Gaps and Research Directions. Washington, DC: HHS. NIOSH. 2008. Occupational health disparities. http://www.cdc.gov/niosh/programs/ohd/risks.html (accessed July 21, 2008).