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Evaluation of a post work related injury total wellness program designed for fire and police department employees

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Evaluation of a post work related injury total wellness program designed for fire and police department employees

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Content POST INJURY PROGRAM EVALUATION 1
Evaluation of a Post Work Related Injury Total Wellness Program Designed for Fire and
Police Department Employees
by
Jerilyn Jane Kelly
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
May 2024
Copyright 2024 Jerilyn Jane Kelly

POST INJURY PROGRAM EVALUATION 2
Acknowledgements
I would like to acknowledge working toward and earning my doctorate is a goal I set over
twenty years ago. I am thankful for the people in my life who shared this experience with me
including family, friends, academic staff, professors, and my cohort.
My family means everything to me, and I am honored to earn my doctoral degree along
with my sister-- my best friend and my special kind of double.
I want to acknowledge my cheerleaders, my support teamand my accountability partners.
One thing I learned outside of readings and research is that asking for and accepting help from
others is transformative and necessary.
Finally, I am grateful to be able to pursue this venture and humbled to earn a place in the
academic community.

POST INJURY PROGRAM EVALUATION 3
Table of Contents
Acknowledgements 2
Table of Contents 3
List of Tables 4
Abstract 5
Evaluation of a Post Work Related Injury Total Wellness Program Designed for Fire
and Police Department Employees 6
Importance of Study 8
Overview of Methodology 9
Literature Review 9
Methodology 25
Interviews 25
Participants 26
Instrumentation 26
Data Collection Procedures 27
Data Analysis 27
Credibility and Trustworthiness 28
Findings 29
Evaluation Question 1: What are the stakeholders’ perceptions regarding
the usefulness and impact(s) of the program? 29
Evaluation Question 2: What were the challenges to implementation during
the pilot program? To what extent were these challenges mitigated and how? 35
Evaluation Question 3: What lessons were learned from the pilot
program to allow for expansion to all eligible employees? 39
Summary 42
Recommendations 43
Discussion of Findings 43
Recommendations for Practice 45
Recommendation 1: Build Trust. 45
Recommendation 2: Integrate Peer/Supervisory Support. 46
Limitations and Delimitations 48
Recommendations for Future Research 48
Conclusion 49
References 51
Appendix A: Definitions 58
Appendix B: The Researcher 59
Appendix C: Protocols 60
Appendix D: Ethics 63

POST INJURY PROGRAM EVALUATION 4
List of Tables
Table 1: Evaluation Questions and Answers 43

POST INJURY PROGRAM EVALUATION 5
Abstract
Inherent to the job duties and environments in which they perform their jobs, public safety
workers experience a broad range of situations that place them at risk physically and mentally.
The goal of this study was to obtain the participants’ perception of the usefulness and impact of a
wellness program designed for fire and police department employees who were physically
injured to also address, assess, and provide clinical interventions toward mental wellness.
The method used for this study included semi-structured interviews of program administrators
who have been involved with the program since inception. Findings included a reduction in cost
to the employer due to a reduction in indemnity payments and medical expenses and promotion
of mental and physical wellness of employees. Additional findings emerged which indicated the
importance of building trust within an organization and the positive impact of peer and
supervisory support; with communication cited by the participants as the basis for success. Based
on the findings, it is recommended for organizations to build trust through consistent
communication with all stakeholders, i.e., leadership, management, and staff members. Another
recommendation is for organization to provide a formal peer and supervisory support program as
this study demonstrated that this type of organizational support increases employee engagement
and yields better outcomes for the employee and the organization. As noted in the literature
review in this study, programs which have addressed both the mental and physical wellness of
emergency service workers represent a cultural shift in these fields. The findings demonstrate
positive benefits to these employees who can then bring their healthiest selves to the important
job of protecting the community they serve.

POST INJURY PROGRAM EVALUATION 6
Evaluation of a Post Work Related Injury Total Wellness Program Designed for Fire and
Police Department Employees
Police and fire department employees are tactical athletes who experience additional
mental and emotional stress when injured during employment which may increase the duration
of recovery. Potts et al. (2021) define tactical athletes as those who work in the emergency
services profession, whereby physical and mental stress is inherent to the job requirements,
including working in life-threatening situations. As reported by Klimley, Van Hasselt & Stripling
(2018), eighty percent of emergency service workers report experiencing traumatic events,
including physical injury, during their shift; and, of the 400,000 first responders in the United
States, 10-15% have been diagnosed with post-traumatic stress disorder. Despite the prevalence
of post-traumatic stress disorder, there is a scarcity of programs focused on addressing mental
health and returning to work. As reported by Nowrouzi-Kia et al., (2023) interest is gaining
momentum for evidence-based reviews about RTW interventions for individuals with mental
health disorders, however, a gap remains in the literature focused on RTW for individuals with
mental health conditions originating in the workplace.
The purpose of this study was to examine a potentially promising program developed to
assess the mental wellbeing of employees who were off work and receiving treatment for their
physical injury.
Program Background and Context
The 360 Healthcare Program was designed to assess and provide interventions for
employees’ mental health post their physical occupational injury. The focus of this study was
specific to the pilot program which began in 2020 in partnership with the police and fire
departments. Enrollees were recruited into the program after satisfying the criterion of being

POST INJURY PROGRAM EVALUATION 7
injured on the job and remaining off work for fifteen days or more post injury. During the pilot
program, over 600 enrollees participated.
The key program goals included a healthy employee population (referred to as total
wellbeing in the study), increased return to work rates and decreased costs. Key activities of the
program include a mental health screening administered via telephone or virtually on the
fifteenth day post injury by Registered Nurses employed by benefit administrators. The program
administrators created an alert in the claims system for the nurse case management staff to be
notified when an employee was approaching the fifteenth day of being out of work. Once alerted,
the nurse case management staff reached out to the employee to administer the questionnaire via
telephone or virtually. The screening assessment utilized was derived from the Patient Health
Questionnaire known as PHQ-2 and its shorter version, PHQ-9, to help identify signs or
symptoms indicative of psychological difficulties. If any symptoms are identified, clinical
intervention services were offered.
Purpose of the Study and Evaluation Questions
The purpose of this study is to conduct a formative evaluation of the 360 Healthcare
Program which introduces a mental wellness questionnaire post physical work-related injury
when the participant has remained out of work for fifteen days. The study obtained the
perception of the stakeholders regarding the usefulness and impact of the wellness program,
including what was learned during the planning, implementation, and execution of the pilot
program and subsequent expansion.
The following research questions will be addressed in this study:
1. EQ1: What are the perceptions of stakeholders regarding the usefulness and
impact of the program?

POST INJURY PROGRAM EVALUATION 8
2. EQ2. What were the challenges to implementation during the pilot program?
To what extent were those challenges mitigated and how?
3. EQ3. What lessons were learned during the pilot program to allow for
expansion to all eligible employees?
Importance of the Study
Employees in the emergency services industry are responsible for protecting lives and
securing public safety. Evaluation of the 360 Healthcare Program is important because the
participants in the 360 Healthcare Program are emergency service workers whose ability to cope
can already be overwhelmed due to job requirements and are more susceptible to psychological
impacts such as mental exhaustion, acute stress disorder, Post-Traumatic Stress Disorder
(PTSD), or secondary trauma (Tehrani & Hesketh, 2019).
In review of previous studies which focused on the connection between mental and
physical health and its effect on the workplace, Furlan (2012) reported that screening of and
providing interventions for depression in the workplace is important because the cascading
effects of depression can include increased absenteeism, reduced production time, increased
employee turnover, and an increase in short term disability claims. Additionally, previous
research has linked the negative effects a physical injury can pose to an employee’s mental
health, such as reported by Magnavita et al. (2021): Injuries sustained during employment
demonstrate a stronger association with mental health challenges than similar non-occupational
injuries due to the financial burden of the injury, the process involved with pursuit of workers’
compensation claims, chronic pain, and the prolonged recovery period. For emergency services
employees, these internal and external challenges reflect a need to develop intentional methods

POST INJURY PROGRAM EVALUATION 9
that are beneficial to their health, wellness, and professional tenure within their respective
departments.
Overview of Methodology
This study used a qualitative approach via the conduction of seven interviews with the
administrative staff from the Company Heroes organization and the benefit administrator. The
participants were recruited through purposeful sampling and all participation was voluntary.
Literature Review
This review examined existing literature pertaining to background and past research of
occupational illness and injury in the United States, mental health as a part of total wellbeing,
effects of wellbeing on the workplace, common work-related physical injuries specific to the
study population, and promising practices that address both the mental health and physical injury
combined in one program and the outcomes reported.
Mental health contributes substantially to the global burden of disease, with depression
ranked in the top three most burdensome illnesses listed in developed economies (Atkin et al.,
2011). Addressing mental health in addition to physical health has become a vital part of the total
wellbeing of employees and the workplace. Empirical research demonstrates that wellbeing
encompasses everyone on a multidimensional basis to include physical and mental health as
positively or negatively influenced by occupational, social, and personal experiences (Lambert et
al., 2020).
There is a growing interest in wellbeing research as economic uncertainty and social,
political, and environmental disruption and unrest takes place globally. Chari et al. (2022) report
that in 2014, the National Institute for Occupational Safety and Health (NIOSH) began the Total
Worker Health program (TWH) and the Worker Well-Being Questionnaire (WellBQ) to define

POST INJURY PROGRAM EVALUATION 10
well-being, provide a way for organizations to assess the well-being status of their employees,
including the need for any interventions and assess effectiveness of interventions with respect to
outcomes. WellBQ and the TWH found that the indicators of well-being can be linked to
beneficial outcomes such as retention, productivity, absenteeism, physical and mental health
(Chari et al., 2022).
Studies show that both physical and mental health is important specifically to work. The
Integrated Benefits Institute reviewed how employee health negatively affects productivity and
found that physical injury increased workplace absence, yet mental health problems affected job
performance (Jinnett, 2015). Screening of and providing interventions for depression in the
workplace is important because the cascading effects of depression can include increased
absenteeism, reduced production time, increased employee turnover, and an increase in short
term disability claims (Furlan et al., 2011).
Previous studies have reported that injuries sustained during employment demonstrate a
stronger association with mental health challenges than similar non-occupational injuries. Ghisi
et al., (2013), reported that 34.7% of employees who experience injuries during work duties
fulfill the diagnostic criteria for Acute Stress Disorder or Post-Traumatic Stress Disorder
(PTSD).
This study obtained the perception of the stakeholders regarding the usefulness and
impact of the wellness program, including what was learned during the planning, implementation
and execution of the pilot program and subsequent expansion.
Workplace and Wellbeing
The World Health Organization (WHO) defined the term “good health” includes
physical, emotional, social, financial, intellectual, and spiritual wellbeing. (Goetzel et. al, 2018).

POST INJURY PROGRAM EVALUATION 11
The overall cost of illness and injury has been documented to include negative effects on the
individual physically, financially, and mentally. According to Hulls, et al. (2022), the WHO
defines a healthy workplace as one that promotes sustainability of the workplace by promoting
safety, health, and wellbeing.
Post the COVID pandemic which commenced in 2020, wellbeing in the workplace has
gained momentum with employers. According to a survey of 5,550 university-based employees
in a study by Evanoff et al. (2020) that intended to measure the prevalence of anxiety,
depression, stress, burnout, and wellbeing during the COVID pandemic, the data indicates the
pandemic had a negative effect on mental health and wellbeing as all respondents reported a
moderate to high prevalence of all factors.
According to the Global Wellbeing Survey conducted by Aon in 2022 in partnership with
Ipsos, which included 46 countries and 1,100 companies; the importance of wellbeing has
increased since the pandemic, with emotional and mental health being cited as a top priority for
63% of companies globally and 70% in North America since 2020 (Khabour et al., 2023).
Further, the survey outlined that business performance and wellbeing are positively correlated;
reporting a four to one return on investment: For every 4% increase in wellbeing performance
there is a 1% increase in company profit (Khabour et al., 2023).
Total wellbeing has been gaining awareness from a societal perspective and has
intensified by the COVID pandemic. As a result, there is a more comprehensive view of
wellbeing presently, to include the role of culture, community, and governance on how an
individual perceives their own level of happiness or satisfaction with life (Lambert et al., 2020).
Effects of Poor Mental Health in the Workplace

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The consequences of unhealthy employee mental well-being in the workplace inhibits
productivity and threatens the growth and sustainability of an organization. Mental health affects
job performance and physical health affects workplace absence, while an unsupportive
workplace culture exacerbates both (Goetzel et al., 2018). Mental health conditions and disorders
are one of the principal causes of long-term absence from work. Purba and Demou (2019) posit
that there has been an increase in mental health issues arising in the workplace population over
the past ten years and this indicates a need for research on the impact of the work environment
on mental wellbeing.
As Jinnett (2015) identified, workplace environments which do not provide safe working
conditions, assign high workloads, restrict decision making, and do not exemplify respect and
trust yielded higher rates of absence and reduced job performance. Moreover, poor mental health
and diagnosed depression is attributable to 50-60% of all absenteeism in the United States,
incurring an estimated cost of $44 billion annually due to lost productivity (Battams et al., 2014).
This information regarding general population employee health is consistent with the
findings regarding supportive work cultures specific to the police and fire industries as discussed
in this study.
Occupational Illness and Injury in the United States
Occupational injuries due to an employee’s mental health disorder cause a financial
burden for the injured worker and for the employer. Direct and indirect costs such as lost
workdays, reduced pay, reduced staff, staff recruitment, replacement and retraining, and medical
costs each contribute to an expensive problem. As Asfaw & Souza (2012) report, in 2007 the
medical cost incurred for the treatment of occupational injuries in the United States was $67
billion.

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In 2008, The National Council on Compensation Insurance (NCCI) published data on the
costs of workers’ compensation cases in the United States for injuries and illnesses combined;
whereby the injuries alone comprised 92% of all cases. Within these cases, annual productivity
losses from missed workdays due to low back pain cost approximately $28 billion. The medical
cost per case for the 8,200 injured workers who were determined to be permanently totally
disabled averaged $680,000.
To identify those at risk for mental disorders, clinicians should educate employers on
providing standardized and cost-effective screening tools, reducing disability and the direct and
indirect economic savings realized (Arango et al., 2018).
Considering the financial burden of disability and evidence of the negative health
outcomes associated with loss of gainful employment, there is a need for strategies to address
holistic care of the employee by providing access to wellness programs and post injury
interventions to guide the care of employees and reduce overall costs.
Work Related Injury and Mental Wellbeing
Depression affects 264 million people worldwide and complicates occupational injuries
by negatively affecting work performance through its effect on cognitive abilities including
memory and executive functioning of the brain, which contributes to workplace hazards and
increases absenteeism (Pierson-Rye, 2022).
In review of the studies focused on workplace injury and mental wellbeing, patients who
report higher levels of stress had significantly greater disability. According to Goetzel et al.
(2018), between 30-50% of adults experience mental illness at some point in their lives and this
mental health burden contributes to productivity losses such as reduced performance,
unemployment, lost workdays, and disability status.

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Specific to injuries sustained in the workplace, there is evidence of a strong correlation
between the status of the workers’ compensation case and poor psychological function.
Murgatroyd et al. (2015) conducted a study aimed to identify risk factors and predictors of poor
health outcomes following injury to provide information toward risk assessment, to target
appropriate interventions and reduce the duration of compensation cases. In the twenty-nine
articles reviewed, the authors determined workers’ compensation related health outcomes
included pain, disability, or perceived disability, and having issues with stress and mental
wellbeing.
Grant et al. (2014) conducted a six-year follow up study of 1,010 patients who were
injured between 2004 and 2006 to assess claim status, stress levels and recovery stage. The
participants included an average age of thirty-nine years and over 70% were male. The
researchers reported there were approximately 40% of patients reporting high levels of stress due
to claim delays and experiencing an adversarial environment while engaged in the claim process.
Companies and organizations that neglect the importance of mental wellbeing within the
workplace face increased work-related injuries among employees diagnosed with mental health
disorders. Asfaw and Souza (2012) reviewed a sample size of 367,900 work related injuries and
reported that depression is not recognized by most state workers’ compensation systems although
depression has been linked to preceding injuries as well as a factor in whether an IW returns to
gainful employment. This study reported an injured worker is 45% more likely to be treated for
depression versus non-injured workers; with employees utilizing their health benefits for
payment of mental health services.
Eggert (2010) conducted a literature review of the effects of psychosocial factors upon
injuries sustained during employment and identified common themes reported by injured

POST INJURY PROGRAM EVALUATION 15
workers (IWs) including frustration with the claim process, feeling discriminated against by
claims and medical professionals as well as by supervisors and coworkers, and feeling depressed.
More specifically, Eggert (2010) found 59% of IWs reported their overall health and wellbeing
was being negatively affected by the claims process.
According to Eggert (2010), IWs expressed frustration with the claims process and
negative work environments upon return to work (RTW), citing they felt misunderstood, unfairly
treated, feared their original job was threatened, experienced a lack of respect and support, not
having a clear understanding of the claims process, experienced obstacles regarding access to
medical care, and not understanding the treatment plan.
It is evident from the research that the negative effects of a work-related injury on an
employee’s mental wellbeing include an increase in stress and reduced psychological function
which contributes to reduced job performance.
Mental Health Post Occupational Injury
Nguyen et al. (2020) conducted a study with 433 participants to develop and implement
mental health screening procedures to identify those at risk. The study included twenty-three
types of workplace injuries with the predominantly male subjects aged 18-67 years old. Findings
included one-third of subjects reporting disabling pain and one-third demonstrated clinically
elevated symptoms for mental health conditions twelve months post compensable injury. Nguyen
et al. (2020) utilized the phrase “compensation health effect” to describe the common themes
regarding the mental conditions reported since experiencing the work injury and emerging from
their review of claim data and responses from participants in the study.
Identifying intervention services to assist employers with providing care to employees
can assist with better outcomes. For example, as a part of a literature review, Eggert (2010)

POST INJURY PROGRAM EVALUATION 16
identified that case management services utilized as a part of an early intervention strategy
increases the likelihood of return to work, which has been shown to bring better outcomes for
injured workers regarding reported feelings of depression, perceived disability, and fear of
reinjury.
Police and Fire
Common Physical Injuries
First responders are at risk for physical injury while performing their duties. The National
Fire Protection Association (NFPA, 2021) released a report in December of 2021 that provided
an overview of firefighter injuries in the United States which were reported in 2020 and cite
there were 64,875 injuries, with 47% comprising muscular sprain, strain, and pain. The nature of
injury was organized into these categories: Strain, sprain, muscular pain; wound, cut, bleeding,
bruising; smoke or gas inhalation or other respiratory distress; dislocation, fracture; burns and
‘other’. Additionally, the study reported firefighters are more likely to sustain a workplace
injury, and for this injury to be categorized as muscular sprain/strain, than a private-sector
employee. In a review of seventeen global publications, ten of which were based in the United
States, Orr et al. (2019) state that 77% of injuries sustained by firefighters were muscle
sprain/strain related.
There is ample evidence outlining that fire and police staff are vulnerable to physical
injury which are primarily muscle sprains and strains across age groups and occurring
predominantly in males. Hong et al. (2012) performed an internet-based survey that yielded
responses from 437 firefighters, 66% of whom reported experiencing injuries, 56% reporting
multiple injuries and 74% of these involving a muscular sprain or strain.

POST INJURY PROGRAM EVALUATION 17
Frequency and the severity of muscular sprains are greater in the older firefighter
population. Furthermore, older firefighters are 10.4 times more likely to sustain sprains/strains
compared to the private sector and return to work takes four times longer (Orr et al., 2019).
Conversely, Tiesman et al. (2018) reviewed 12,270 cases of nonfatal injuries to law enforcement
officers on a national basis between 2003 through 2014, and reported there were approximately
1,300 injuries with police staff ages twenty-one to twenty-four years. Tiesman et al. (2018)
reports this group had the highest injury rate of all age groups, were 88% male, with the most
common diagnosis of sprains and strains, accounting for 30% of all injuries reported.
It is evident that the most common injuries experienced by fire and police department
staff are musculoskeletal sprains and strains. As studies have reported, these injuries lead to
disability. As reported by Murgatroyd et al. (2015), musculoskeletal injuries are a leading cause
of disability worldwide and commonly occur during accidents in the workplace.
Physical Injuries and Return to Work
Specific to return to work, musculoskeletal injuries that occur in the fire and police
department have longer recovery durations and take longer to return to work compared to similar
injuries in other industries. Orr et al. (2019) reports emergency service workers take 1.4 times
longer to return to work than those workers in the private sector for all injury types and the
average number of days away from work post strain/sprain is 1.8 greater than for all other
injuries.
Furthermore, injuries such as muscular sprains and strains that are most common in both
police and fire staff and are more costly than other injury outcomes due to a delayed return to
work which increases indemnity payments to the employee and medical costs to the employer.
The NFPA Report (2021) indicates that injuries sustained by firefighters in the United States cost

POST INJURY PROGRAM EVALUATION 18
approximately $1.6 billion to $5.9 billion annually, with an estimated cost to each fire
department between $50,000 and $200,000 per year. As gainful employment is an important
marker of functional recovery from injury, returning to work is beneficial for the employee and
the employer considering increased productivity and decreased costs.
Common Occupational Stressors and Mental Health
Battams et al. (2014) reviewed the factors influencing anxiety and depression in male
dominated industries like police and fire and defined as greater than 70% male, and report that
working conditions and environment are strong determinants of mental health. Additionally, the
authors denoted the mental health conditions reported most often were depression and anxiety
and these were correlated strongly with high demand (stressful), low skill, repetitive, and low
decision latitude jobs. Injured employees in these positions report issues with sleep, exhaustion,
poor overall health; dealings with legal and financial issues and lacking personal and work based
supportive relationships (Battams et al., 2014).
Firefighting is recognized as one of the most dangerous careers with fatality rates
comparable to police officers, that is, individuals performing these roles are three times more
likely to die than any other industry. Furthermore, firefighters are often cross trained as
paramedics as 60% of fire departments in the United States offer these emergency medical
services, and medical emergencies being 80% of all fire department callouts (Klimley, Van
Hasselt & Stripling, 2018).
Specific to police work, occupational stressors can lead to increased risk of developing a
mental health disorder and this is a leading cause of lost time from work, or decreased
productivity. In a study which involved a systematic review to determine the relationship
between the mental wellbeing of police officers and organizational stressors, Purba and Demou

POST INJURY PROGRAM EVALUATION 19
(2019) posited there was strong evidence to correlate reported stressors such as job demands,
long working hours, pressure, inadequate resources, interpersonal conflict and lack of support
and the reported effects such as anxiety, exhaustion, and psychological distress. As this evidence
indicates, the emergency services industry is highly stressful and individuals who are employed
in these roles are at increased risk for mental health conditions.
Cultural and Structural Barriers to Seeking Support
The existence of a variety of issues related to mental health conditions in the emergency
services industry suggests a need for adequate mental health screening and access to resources.
Potts et al. (2021) studied firefighters perceived structural and cultural barriers to reporting
physical injuries and any cascading mental or emotional effects from the injury and found two
cultural beliefs cited as ‘accepting pain as a part of the job’ and ‘fear of letting fellow firefighters
down’; and the two most chosen structural beliefs were cited as ‘worried about pay reduction and
being able to pay living expenses’ and ‘worried about change in duty’ statuses.
In a study by Evans, Pistrang and Billings (2013) of police officers and whether they felt
supported by colleagues or supervisors after experiencing a traumatic event and report that these
officers stated they did not directly ask for help or ask to speak about a specific situation, as this
would be perceived as ‘weakness’; and although the participants reported there are formal
opportunities offered by their employer for debriefings, group, and individual therapy, most felt
this was the employer’s way of identifying weakness. Evans, Pistrang & Billings (2013) denoted
the officers reported they would not seek out these formal services for the fear of losing
colleague or supervisor respect, and/or being passed over for promotions due exhibiting a
weakness. It is evident that mental illness is perceived as highly stigmatized in the field of police

POST INJURY PROGRAM EVALUATION 20
and fire as reported by employees and management within these departments during work
absence and upon return to work.
Promising Practices
Overall wellbeing is important for individuals and proactive care is an integral part in
identifying problems or mitigating illness or injury altogether. Organizations who provide
services or programs to promote and support the wellbeing of their employees can expect a more
resilient, optimistic, and productive workforce (Obrenovic et al., 2020).
According to McFarlane and Bryant (2017), there is only a small amount of literature
examining screening, monitoring, and the effectiveness of evidence-based treatments in specific
occupational groups and this absence of studies means that there is a need for research in these
populations such as the emergency services industry. Organizations can assist their employees
with known stressors related to the industry and occupation of emergency services by using the
current evidence to focus on clear policies and procedures for addressing and screening for
mental wellness and a strategy for offering intervention services.
Mental Health Screening
Screening for mental wellbeing is an effective strategy for workers in the emergency
services industry because of the inherent risk posed to these individuals, including exposure to
trauma. McFarlane and Bryant (2007) report a range of tools have been utilized successfully in
the emergency services industry to monitor for the emergence of symptoms which tend to be
indicative toward PTSD. According to Klimley, Van Hasselt and Stripling (2018), Critical
Incident Stress Management (CISM) techniques such as debriefing has been shown to mitigate
acute psychological stress post incident and serves to identify any other needed interventions or
referrals for additional resources.

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Specific to the 360 Healthcare Program, a screening tool was adapted utilizing the Patient
Health Questionnaire 9-Item Scale (PHQ-9) and its shorter version, PHQ-2. According to a study
conducted by Staples et al. (2019) to confirm the utility of these screening instruments, both
versions were shown to be reliable screening tools that measure symptom severity and outcomes.
Manea et al. (2016) conducted a meta-analysis of thirty-six studies relevant to the administration
of PHQ-2 in various settings and its ability to identify depression. Findings include reasonably
high sensitivity is often required to ensure that the screening process rarely misses the diagnosis
of depression and determined the PHQ-2 screening tool was valuable in its ability to diagnose
depression, and cost-effective in terms of treatment intervention and outcomes.
As described by Castro (2014), pre-screening employees’ mental health can promote
overall wellbeing and remove any barriers to seeking support. Therefore, organizations who
provide these screenings proactively can expect to identify potential mental health conditions
which could affect productivity.
Intervention Services
In consideration of the physical, mental, and financial burdens of injury and the
consequence of disability leading to unemployment; proactive, cost-effective interventions can
prove beneficial. Hulls et al. (2022), reviewed 35 studies of workplace interventions that had an
intended goal of improving health and wellbeing in male dominated industries and concluded
that these interventions increased employee resilience, productivity, and retention and decreased
absenteeism. Of specific interest, the authors denoted that all studies which included a focus on
musculoskeletal disorders (MSD) resulted in an increased intervention adherence and selfreported wellbeing (Hulls et al., 2022).

POST INJURY PROGRAM EVALUATION 22
Giummarra et al. (2018) reviewed twenty-six studies and twenty-nine papers and denote
psychological distress symptoms identified within the first three months post physical injury that
increase the likelihood of other disabling outcomes such as post-traumatic stress disorder (PTSD)
and chronic pain. The authors deduced that early interventions such as cognitive behavioral
therapy (CBT) reduced symptom severity for PTSD and depression and were most effective
when coupled with a collaborative approach with the employer to modify the work environment
during the post-injury rehabilitation plan, especially when administered within the first four
weeks post injury.
Cullen et al. (2018) reviewed thirty-six studies with the goal of amalgamating the
evidence of effectiveness of interventions for post injury musculoskeletal pain and mental health
and return to gainful employment. The researchers utilized the phrase ‘multi-domain
interventions’ to describe the rehabilitation plan that yielded the strongest evidence of efficacy as
demonstrated by the employee returning to work and thus, a reduction in overall cost to the
employer. These interventions are defined as cognitive behavioral therapy (CBT), workplace
modifications for the employee and coordination of other services as needed (Cullen et al.,
2018). The authors report that a substantial portion of studies reviewed focus on return to work
(RTW) and only a few included pain and mental health symptoms and conditions; however, they
also report the studies which review interventions toward managing depression in the workplace
(without injury) have significantly increased over the past 5 years.
Specific to musculoskeletal injuries and mental health disorders, Leigh (2011) found that
providing access to multidisciplinary resources to employees suffering from chronic low back
pain, which has been shown to contribute significantly to work disability status, was effective in
improving the rate of return to gainful employment. Findings suggest it is effective for

POST INJURY PROGRAM EVALUATION 23
employers to offer their employees’ access to intervention programs that combine mental and
physical wellness, which are evidenced to yield better outcomes such as recovery duration and
return to work rates.
Wellness Programs
In terms of including mental and physical wellness as a preventative measure,
organizations who provide access to a program that supports them through diagnostic screenings,
resources and clinical interventions have the most success. In 2021, the National Fire Protection
Association (NFPA) indicated that 27% of all fire departments in the United States have
prevention and wellness programs. The National Fire Protection Association also provides codes
and standards for the industry to reference in a document titled NFPA 1500™, the Standard on
Fire Department Occupational Safety, Health, and Wellness Program. In Chapter 12 of the
document, the NFPA outlines recommendations regarding behavioral health services post injury
to include, at a minimum: A diagnostic assessment, referrals for behavior that may adversely
affect the staff member and their performance, crisis intervention and/or short-term counseling
services.
Similarly, the International Association of Firefighters (IAFF) is a centralized union that
offers programs that focus on mental health and wellbeing including suicide risk and prevention,
peer support certification, work/life balance and emotional wellbeing information, and
behavioral health tools and techniques. In 2017, an inpatient residential facility was opened by
the IAFF and named The IAFF Center of Excellence for Behavioral Health Treatment and
Recovery wherein programs are offered to provide individual and family counseling, addiction
support, return to work (RTW) planning, relapse prevention, and assist in transitioning care to
outpatient providers.

POST INJURY PROGRAM EVALUATION 24
Studies have shown that workplace wellness programs that are fully supported by
management increase employee engagement in these programs and ultimately increase the
effectiveness of the interventions provided (Hulls, et al., 2022). As evidenced by two industry
specific national and international firms, wellness programs which include mental health
resources and services are recommended as best practice.
Peer and Supervisor Support Programs
In review of the literature regarding organizational stress and coping, perceived social
support from peers and supervisors has been found to bolster mental wellbeing. Lack of social
support is one of the strongest risk factors in the development of PTSD and therefore the
researchers aimed to identify whether police officers felt they were receiving support in their
work environment (Evans, Pistrang & Billings, 2013).
Supportive supervisors are a key component to the wellbeing of the team. Evans, Pistrang
and Billings (2013) report that study participants responded positively to questions regarding
seeking mental health support from a supervisor if the supervisor initiated the conversation,
checked in with them regarding their mental and emotional wellbeing, and demonstrated
approval of talking through any issues they may be having.
Other studies concluded a significant association with lower overall PTSD symptom
severity reported when firefighter staff perceived peer and supervisory support. For example,
Battams et al. (2014) found that working conditions, job demands, and social/peer support are
important factors toward mitigating mental health conditions. Stanley, et al. (2019) conducted a
study including 840 firefighters and provided assessment tools such as the PTSD Checklist from
the American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental
Disorders (5th ed.; DSM-5) and deduced those who responded with feelings of belongingness and

POST INJURY PROGRAM EVALUATION 25
support had less severe PTSD symptoms and for those who specifically stated they had the
support of their supervisors had significantly lower overall PTSD symptom severity.
Perceptions of organizational support such as the engagement of a supervisor or peer
positively influence employee wellbeing including increased job satisfaction and reduced stress.
Summary
Employers can expect positive outcomes when putting wellbeing programs in place that
allow for screening, intervention services and organizational support together. As reported by
Obrenovic et al. (2020), when employees experience a work environment that includes social
support and positive feedback from peers and supervisors, along with corporate communication
echoing that support, they perceive they are valued and thus, their job performance increases.
Methodology
This qualitative study included interviews with seven administrative staff members from
the Company Heroes organization to obtain participants’ perception of the program
implementation, administration, and usefulness or impact(s). The interview protocol consisted of
12 open-ended questions along with additional probing questions and on average, interviews had
a duration of thirty-seven minutes.
Interviews
Semi-structured interviews of program administrators who have been involved with the
program since inception. A thirty-to-forty-five-minute interview was conducted with each of the
participants via the Zoom platform. The interviews were conducted on a voluntary basis and
recorded with each interviewee’s permission. The recording and transcript of each interview was
utilized by this researcher to ensure thoroughness and clarity and assist with identifying
similarities and differences between all interviews.

POST INJURY PROGRAM EVALUATION 26
Participants
Purposeful sampling was the approach because recruiting roles involved in the specific
planning, implementation and administration of the 360 Healthcare Program would include the
rich detail required for a credible qualitative study. The participants selected had the criteria
necessary to achieve deep learning of the program’s usefulness, impacts and challenges.
Participants included county based operational and management personnel and staff from
the benefit administrator including registered nurses, for a total of seven people. Each participant
had been directly involved in the program since inception and implementation. The nurses were
directly involved with the mental health screening of the study population and managed any
recommendations for intervention services. Others served in a management or administrative
role with the county and the benefit administrator was hired to assist with implementation and
daily program operation. Example titles of participants’ roles include Risk Manager, Registered
Nurses (RN), Claim Adjuster, and Account Manager.
Instrumentation
A semi-structured interview approach was used including brief, open-ended questions
followed by probing questions to obtain the most detailed responses (Merriam & Tisdell, 2016).
Interview questions were aligned to the study purpose and focused on the usefulness and impact
of the program for stakeholders. The interview questions provided answers to the evaluation
questions via primary research or the firsthand collection of data directly from the source
(Merriam & Tisdell, 2016). The specificity of each interviewees’ role in the implementation and
administrative process of the program and their level of experience allowed for the extraction of
the detailed data necessary for this study. The interviews allowed the researcher to gain the
perspective of the experiences of the participants, or an insider’s view, which was key to

POST INJURY PROGRAM EVALUATION 27
understanding how they interpret their experiences (Merriam & Tisdell, 2016). See Appendix C
for the Interview Protocol template.
Data Collection Procedures
This study’s primary instrument for the collection and analysis of the data is the
researcher (Merriam & Tisdell, 2016). Interviews were conducted virtually and recorded via
Zoom platform. Transcripts of the interviews were collected, reviewed, and analyzed. Interview
transcripts were coded according to emerging themes. Recorded interviews were available only
to the PI through a password-protected Zoom account. Interview transcripts were saved in a
password-protected computer and password-protected cloud server.
Data Analysis
The researcher applied a six-step thematic analysis procedure by Braun and Clarke
(2006) to identify the emerging themes. The six steps thematic process helped the researcher to
identify, analyze, and report on the themes that provided response to the three evaluation
questions:
● Step 1: Familiarization with Data: In this step, the researcher became familiar with the
data by reading and rereading several times to become familiar with the contents of the
transcripts. At this stage, the researcher took notes of the textual data to understand the
context from participants’ perspectives.
● Step 2: Generating the initial codes: The researcher started the coding process of the data.
The researcher identified the pieces of data that were relevant to the research questions
and labeled them using short labels (codes). The process of coding was aided using
Nvivo Software, which also helped to organize and aggregate the minor codes.

POST INJURY PROGRAM EVALUATION 28
● Step 3: Searching for themes: In this step, the researcher grouped related codes together,
while also looking for the patterns and commonalities that were evident. In this stage, the
researcher aggregated the codes, while also considering the context and connection
between the codes. NVivo software helped to aggregate the codes to form categories that
led to the identification of the themes.
● Step 4: The researcher reviewed the themes to refine them further. The researcher
assessed whether the themes were accurately developed and if they made sense in
relation to the coded data and each evaluation question. Some of the themes were merged
and others were renamed.
● Step 5: Defining and naming of themes: The researcher defined the themes and named
them clearly and concisely. The naming of the themes was to ensure that they were
relevant to the evaluation questions.
● Step 6: Writing of the report: In this step, the researcher wrote a comprehensive report by
presenting the findings. The researcher represented the themes in respect to the various
research questions. In addition, the researcher also included supporting evidence and
quotes to support the findings.
After applying these six thematic steps, the researcher developed eight overarching
findings that answered the evaluation questions.
Credibility and Trustworthiness
The two strategies used to ensure credibility and trustworthiness of the findings were
respondent validation and rich, thick description (Merriam & Tisdell, 2016). I employed
respondent validation by having the respondents review raw data and confirm whether the
preliminary findings were plausible. Another term for respondent validation is member checking,

POST INJURY PROGRAM EVALUATION 29
which helps ensure internal credibility because of its ability to check for accuracy directly with
the source and mitigate potential bias (Merriam & Tisdell, 2016). Specific to providing a rich,
thick description, this study provided a detailed presentation of the setting and findings of this
study, including quotes from the participants interviewed which supports transferability
(Merriam & Tisdell, 2016).
Findings
The findings of this evaluation study aligned with the literature review as several
consistencies emerged such as the benefits of combining mental and physical fitness into a
wellness program and the concrete results such as a decrease in medical and indemnity costs.
Specific to the 360 Healthcare program, the findings demonstrated an increase in total wellbeing
as reported by enrollees directly to the administrators who participated in this study.
Evaluation Question 1: What are the stakeholders’ perceptions regarding the usefulness
and impact(s) of the program?
Through the participant interviews, three findings emerged to describe the usefulness and
impact of the 360 Healthcare Programs and its impact: (1) The 360 Healthcare program
promoted overall wellbeing of the enrollees, (2) The 360 Healthcare program promoted return to
work, (3) The 360 Healthcare Program helped to reduce costs.
Promotes wellbeing
All seven participants indicated the program promoted the wellbeing of the employees
enrolled. The participants described the differences they observed in the total wellbeing of the
program enrollees. Specifically, the mental wellness screening combined with post injury
physical rehabilitation and how this holistic approach increased communication and engagement
with program enrollees, which led to proactive, positive outcomes such as an earlier return to

POST INJURY PROGRAM EVALUATION 30
work and a productive workforce. Participant 5 stated, “We've shifted; we're seeing behavioral
changes, modifications, diet changes, you know, supporting that through education (through the
wellness program).” Similarly, Participant 6 discussed mental health being linked through the
program and seeing benefits to the employees in terms of motivation and return to work.
Additionally, five participants made statements demonstrating the usefulness of the
program’s mental health and wellness tools (or resources), stating that job duties required in the
field of emergency services have inherent physical risks and a toll on mental wellbeing, as the
role has the potential for repeated exposure to life-threatening situations. They report improved
employee and organizational engagement because of the program. For example, Participant 1
denoted the Company Heroes Organization recently launched the Wellness Center for mental
health conditions as a preventative focus due to heightened awareness of the importance of
mental health, thus further demonstrating the organization’s support of the holistic health of all
employees.
Participant 5 noted that the 360 Healthcare Program helps to address anxiety and stress
among the workers by stating, “We do understand that there are definite ties to sleep, to anxiety,
to stress, and how to combat those interpersonally. We want to make the mind and the body
more resilient to recover from injuries.”
Participant 6 said that they also address mental health, stating:
Mental health challenges from our relationships and everything else but the fire service
can be tough, and the job itself could be part of it. So, we put the peer team underneath
them along with outside supporting providers such as psychologists and psychiatrists.
This screening is so that we can get a quick handle on their mental health status so it’s not
addressed three or six months down the road, when it could be too late.

POST INJURY PROGRAM EVALUATION 31
All participants indicated that 360 Healthcare Program helped in promoting total
wellbeing of their employees, as both physical and mental health were addressed, or a holistic
approach. Their statements indicate the program providers are ensuring the overall wellness is
addressed, from the initial mental health screening to ongoing support and check ins, providing
rehabilitation of the physical injury and returning the employee to gainful employment.
The stakeholders denoted the impact of the program as beneficial due to the holistic
approach of combining physical rehabilitation for work-related injury and providing a screening
for mental health, yielding a healthier, productive workforce. This realization coalesced into the
idea of addressing all health concerns as a way of furthering the focus on total wellbeing.
As evidenced by all participants, improvement in total wellbeing has been one of the
impacts of the program due to addressing mental wellness with the more traditional rehabilitation
of the physical injury alone. The interviewees agreed that the mental health screening component
increased communication with enrollees and allowed the administrative staff to learn more about
what each employee dealt with mentally in addition to the work-related physical injury and thus,
be able to take a more proactive approach toward individual needs. For example, Participant 2
stated, “With monitoring of all health concerns, I think there are other benefits we can get out of
this program, not only from a mental health standpoint, but cardio and physical fitness for
example, I think we can actually start shooting some of those problems.” Similarly, Participant 4
said,
Occasionally the onsite athletic trainer will identify something that's not just training, or
work related necessarily, but it might be something that some physical therapy could help
to alleviate a minor ache or pain that the employee might be having.

POST INJURY PROGRAM EVALUATION 32
The participants have outlined how the program and organization addresses the employee
as a whole person, and not just staying focused on the physical work-related injury.
As a result of addressing an injured employee’s mental health and offering intervention
services, the program has promoted increased communication with their employees and an
increased knowledge of any additional concerns or stressors affecting them.
Continuing evidence of the organization placing an emphasis on total wellbeing,
Participant 3 noted that overall health of the program participants improved, thus making them a
healthier workforce, stating “Because of the earlier return to work, I see reduced costs and on
behalf of the employer, I see a healthier, productive labor force.”
This finding emerged from all participants who noted they observed employees with
improved overall wellbeing beyond the physical work-related injury as evidenced by increased
communication and engagement with employees and the organization’s supportive response of
offering the services needed. This finding demonstrated that the program offers a holistic
approach of addressing mental health concerns combined with rehabilitation of physical injury,
which validated both usefulness and impact of the program.
Promotes return to work
Five participants denoted that the 360 Healthcare Program helped enrollees return to
work faster post injury. The participants attributed this finding to the program’s goal of
providing the support employees need for both mental health and physical health, thus
demonstrating the organization values the employee and ensuring there were modified duty
positions available so the employee could remain in the work environment.
The program’s goals included addressing the employee’s mental wellness and in doing
so, the participants learned this holistic approach was unique to the usual workers’ compensation

POST INJURY PROGRAM EVALUATION 33
claim process which traditionally only addressed the specific work-related injury and whether the
employee could return to their full duty position, which delayed their return to gainful
employment. Participant 2 said, “So what I think when we set out with a concept, we had several
objectives to build a superior program and one was to have employees return to work and
maintain their level of work.” Participant 3 also noted that they have been able to help employee
return to work through increased communication and addressing all needs of the enrollees,
stating:
I see a timelier return to work. We have been able to document an earlier return to work,
especially having the [modified duty] opportunities available, we will get the people back
to work. We want them back to work. And we want the person to know that. Your job is
safe, and we value you as an employee.
The participants clearly outlined one of the goals of the 360 Healthcare Program was to
return employees to productive employment as soon as possible. This goal focused on employee
engagement and participation in a program that would provide them with the help they needed to
return to health, both mentally and physically.
Returning to work in a productive capacity is beneficial for both the employee and
employer. The participant’s responses included references to helping the injured employee in a
holistic manner to include their concerns outside of work, and ensuring the employee was
supported by the program through engagement and communication. Participant 4 added that they
ensured they monitored enrollees with consistent check-ins by phone and asked how they felt
about their ability to get back to work. Participant 5 said:
They are going to want to come to work. We want them to know they are going to have
the tools to go home and take care of their responsibilities at home. They're going to have

POST INJURY PROGRAM EVALUATION 34
the tools to repair the injuries and trust that injured part and get back, you know, for the
rehab program. So, the big return on investment that I cannot put a number on, but I think
that it is significant when you look at it, time away from work.
This finding indicated that 360 Healthcare Program was useful as it helped enrollees to
return to work in the highest productive capacity and reduced medical and indemnity costs to the
organization, both of which demonstrated the usefulness and impact of the program.
Reduces Costs
This theme was identified by five participants who indicated that the 360 Healthcare
Program helped in the reduction of costs via reducing the number of lost workdays and thus, less
indemnity payments. By addressing the mental health component of a work-related injury, more
employees returned to gainful employment earlier than employees with similar injuries preprogram. Participant 4 provided a statement as an example:
Subsequently, there have been 23 employees remaining out of work and that is a
significant reduction since pre-program inception. The amount of money spent [by the
employer] is significant. These benefits are paid to employees to compensate them for
their time away from work. There was a reduction of over $100,000, from before to after
just for indemnity payments. So, before the program, the total cost including medical
expenses was reduced more than $100,000.
When employees are deemed unable to return to work, whether the treating provider
indicates ‘no work’ of any kind or modified duty, there is an added expense to the employer in
terms of indemnity payments, provider payments and lost productivity. As an employee returns
to any gainful employment, the amount spent by the employer decreases as the employee’s
productivity offsets the expense positively. Participant 3 said,

POST INJURY PROGRAM EVALUATION 35
Because of the earlier return to work. I see reduced costs in medical and lost time on
behalf of the employer. Medical costs are reduced because the provider is seeing the
employee on a less frequent basis once they return to work.
The statement by Participant 3 resonated with that of other participants such as
Participant 4, who noted that it reduces the number of lost workdays and reduces the amount
paid by the employer in indemnity costs.
This finding was identified from five participants who indicated that the program was
useful to the employer by also reducing the medical costs, which demonstrated that enrolling into
the 360 Healthcare Program helped the employer save on the cost of healthcare and indemnity
payments. The reduction of cost was an impact of the 360 Healthcare Program and hence they
provided the response to the first evaluation question.
Evaluation Question 2: What were the challenges to implementation during the pilot
program? To what extent were these challenges mitigated and how?
From thematic analysis, three additional findings were identified as answers for
evaluation question one: 1. Implementers of the pilot program lacked organizational support for
implementation of the program, 2. Implementers of the pilot program experienced negative
perceptions and resistance from targeted beneficiaries and, 3. Communication was one of the
tools the implementers used in mitigating the challenges throughout.
Lack of organizational support
Six participants from the study indicated that during the pilot program, there was lack of
support within the organization for a wellness program that addressed mental health in addition
to services to assist with the rehabilitation of a physical injury. This was evidenced by a theme

POST INJURY PROGRAM EVALUATION 36
described by participants as ‘structures and systems’ that could negatively affect the successful
implementation and sustainability of the 360 Healthcare Program. Participant 3 stated,
The current (workers’ compensation) system is broken. It does not work for the injured
worker. It does not work for the administrative staff. And technically, if you are a doctor,
or if physician, you are not giving better outcomes for your patient. So, the program does
not work for anybody, but you must convince people that the current program can be
fixed because we have known about it being broken for over a hundred years.
Organizational support was listed as a challenge specific to the fact that departments
traditionally have been siloed with their own budgets, thus inhibited collaboration toward a
shared program, especially in the pilot phase where there was no data to present regarding the
potential for success. Participant 2 outlined the following:
Challenges abound. For over three decades, there was a set way of doing things in the
workers’ compensation claim process that did not include any mention of mental
wellness or health- dealing with the physical injury only. Therefore, [it is] a challenge to
change the mindset. This and separate budgets make collaboration difficult on any new
project, especially without proof it will be of any benefit.
Participant 7 noted that the biggest challenge was on lack of a systematic process that
would provide an alert when an enrollee had been out of work for 14 days and having to identify
the best mode of communication to achieve this for the mental health screening tool to be
administered on the fifteenth day the enrollee is off from work. Participant 2 noted that the fact
that they as implementers had to create every aspect and communication pathway of the program
was a major challenge.

POST INJURY PROGRAM EVALUATION 37
All participants made the assertion that there were challenges in the creation and
implementation of the pilot program for the 360 Healthcare Program due to a lack of
organizational support, thus answering the second evaluation question.
Negative perception and resistance
Six participants indicated that the implementers of the 360 Healthcare Program faced
resistance from department management during the planning and design of the pilot program and
a negative perception from employees enrolled in the pilot program, citing a lack of
collaboration and resistance. As an example, Participant 1 stated,
Sometimes your best intentions are misunderstood, like when we look at building better
[physician] panels. We didn’t realize some employees had a strong relationship with their
providers and they were concerned they would be forced to go to a new provider, for
example.
The participants outlined the challenges with earning reputational capital with
stakeholders of each department at the inception of the pilot program. Participants outlined
examples of misinformation or miscommunication they received as feedback as one of the
challenges they faced during the implementation.
Six participants outlined dealing with a lack of engagement with the injured employees
prior to program inception, which they stated may have contributed to the lack of motivation to
return to work and/or a lack of trust in the employer. For example, Participant 3 noted that
enrollees had an incorrect perception of how the program was designed. The participants noted
that the feedback they were receiving was that employees were unsure of the goals or motives of
the organization wanting to assist them outside work-related physical injury. Participant 4’s
statement resonated with those by Participant 3 saying, “Sometimes because they don't feel like

POST INJURY PROGRAM EVALUATION 38
they're being helped or sometimes they will get the impression that folks are working against
them.”
The importance of gaining credibility and creating communication pathways with the
employees was recognized by the participants who were the designers and implementers of the
pilot program. This finding represented the assertion that one of the challenges faced by the
implementers of the program was that of negative perceptions and resistance during the
implementation of the pilot program.
Importance of communication
This finding was identified from six participants who indicated that the implementers of
the 360 Healthcare Pilot Program used communication as a tool to mitigate challenges. The
participants noted that communication and engagement with the employees was of key
importance to the overall process of implementation of the pilot program. Participant 4 reported
they engaged enrollees by communicating the goals and intent of the program and outlined
expectations regarding the process and communication pathways.
The theme of communication was common among six of the seven participants as they
were able to outline examples of their experiences during the pilot program of using it as a tool
to mitigate the challenges, they were facing such as misinformation, resistance, and lack of trust.
This finding directly responded to the evaluation question of what challenges were presented and
how did the implementers of the pilot program identify a solution or mitigate these challenges.
Consistent communication emerged as a theme during the implementation of the pilot
program. The Participants described the realization that communication between all parties needs
to be on a continual and consistent basis to effectively mitigate misinformation and acquire
feedback. Participant 4 stated: “So we learned that every time you have an opportunity to interact

POST INJURY PROGRAM EVALUATION 39
between the parties, use it as a learning experience and then carry that communication
throughout the team.” As another example, Participant 3 indicated that detailed communication
is achieved through regular meetings with all stakeholders and maintaining a consistent message,
stating, “We met within each department and with the benefit administrator. We met, more
importantly, with each agency to roll out the program to say, hey, this is coming down the pike,
each meeting, and the next meeting.”
The finding demonstrates that participants used communication as a tool to mitigate
challenges. Specifically, they report they engaged in continuous, consistent communication
between all stakeholders.
Evaluation Question 3: What lessons were learned from the pilot program to allow for
expansion to all eligible employees?
In this evaluation question, the researcher was interested in understanding the lessons that
participants learned about how to expand the program to all eligible employees in every
department of the Company Heroes Organization. From the analysis, two themes were identified
to respond to the evaluation question: 1. It is important to build trust with enrollees for
acceptance of the program and better outcome, and 2. Conducting regular evaluations of the
program helps in improving the outcome and attracts eligible employees to enroll in the program.
Importance of building trust
Based on the analysis, five participants indicated they learned the role of building trust with
employees increased program participation. The participants outlined examples regarding
opportunities to build trust with injured employees and how this assisted with increased program
enrollment and ultimately, expansion of the program. Participant 1 indicated that they have
learned to build relationships as opposed to using force. Participant 1 said,

POST INJURY PROGRAM EVALUATION 40
So that was a lesson learned. If you force it on people, it's kind of a breakdown of that trust
before you begin, and that you really need to have people come to the program and
participate. You can't force something that's going to occur naturally. You can't force the
relationship.
Participant 4 explained the importance of engaging with employees. The Participant said:
There is engaging with employees and over engaging with the employee. You want to make
sure that they get the feeling and that they understand you really want to help them. It's
another thing if they feel like they're getting a call every single day and that becomes
intrusive.
Participant 3 explained a different dimension on the same theme indicating that they
expected to face resistance, but they needed to develop trust. Participant 3 said, “There's going to
be some resistance. There is going to be some non-trusting, but we build trust to have a positive
motive. So, we must gain their confidence, gain the confidence of the affected parties and we do
this to show we are legitimate.”
Building trust was a theme which emerged to mitigate the challenge of resistance to
participation in the program. Most participants in this study recognized the need to build trust
with injured employees to demonstrate the organization supports their total wellbeing.
This theme represented the assertion that despite the challenges, the participants in this
study needed to build a relationship and engage with the employees as opposed to making
program participation mandatory. The pilot program was expanded to all eligible employees
shortly after inception by communicating and engaging with the employees about the genesis,
goals, and benefits of the program. This finding provided the response to the third evaluation
question.

POST INJURY PROGRAM EVALUATION 41
Regular evaluations increase program participation
Based on the responses from five participants, it was important to conduct continuous
evaluations to help in expanding the project including communicating the benefits of the
program, obtaining feedback, measuring, and documenting results, and making modifications.
Participant 3 noted the need to conduct evaluation on every agency involved in the program. The
participant said,
What I do recall was that we evaluated each agency. I said earlier that some agencies
were more interested or already into the program. So, we would realize that agency A
only needed tweaking. Agency B, more than tweaking, but not the full scale. Agency C
needed the full scale. So, we would realize who we were working with and be agile with
our approach and adjust as needed.
The administrators initially tracked results as a way of documenting enrollees and their
progress and reporting back to the respective departments to begin to build reputational capital.
As the program continued, they reported applying the feedback they received and making the
necessary adjustments specific to each stakeholder, whether it be a department manager or an
injured employee. These descriptions are evidence of the response to evaluation question three
regarding lessons that were learned to allow for expansion to all eligible employees within the
Community Heroes Organization.
The credibility of the program emerged as a theme from interviewing the participants of
this study, as they referenced it was important for the program to be viewed as legitimate and
data analysis can assist with building credibility. Participant 3 discussed how important it is to
document the success of the program, and stated: “I do recall reports, a lot of reports, lost time
reports. We were able to do spreadsheets with the data to create a baseline, track and compare

POST INJURY PROGRAM EVALUATION 42
going forward. For me personally, this was important to review before we expanded the
program.”
Participants indicated the need for data documentation and analysis to evaluate the pilot
phase of the 360 Healthcare Program. Participants indicated the need to collect feedback, data, and
reports to measure the results to form the basis for expansion of the program. These themes and
the evidence presented provide an answer to the evaluation question regarding what lessons were
learned during the pilot program to allow for expansion to all other departments.
Summary
The resulting analysis indicated eight findings that provided responses to the three
evaluation questions. These findings outlined challenges such as lack of organizational support,
and facing negative perceptions and resistance led to lessons learned during the pilot program
such as using communication as a tool to mitigate challenges and the importance of building
trust.
Findings also demonstrated that the 360 Healthcare Program provided positive impacts to
the enrollees by promoting an earlier return to work and an increase in total wellbeing. The
findings indicated positive impacts to the Company Heroes organization itself, as the program
reduced costs and increased employee and interdepartmental engagement.
As shown in Table 1, the findings of this study are aligned with the purpose of the
evaluation as the answers provided by the participants demonstrated the 360 Healthcare
Program’s usefulness, impacts and challenges.
Table 1
Evaluation Questions and Answers

POST INJURY PROGRAM EVALUATION 43
Recommendations
Discussion of Findings
The participants in this study have reported the usefulness of the 360 Healthcare program
as evidenced by assessment of their employees’ mental health within fifteen days post injury.
The program included a mental health screening to identify any signs or symptoms of mental or
emotional stress. This practice allowed for early identification and intervention that has been
demonstrated as good practice for conditions such as post-traumatic stress disorder (PTSD). As
Giummarra et al. (2018) reported after review of twenty-six studies and twenty-nine papers,
psychological distress symptoms identified within the first three months post physical injury
Findings
EQ 1
Usefulness
& Impact
EQ 2
Challenges
Identified
EQ 3
Lessons
Learned
Promotes wellbeing X
Reduces costs X
Promotes RTW X
Lack of organizational support X
Negative
perception & resistance
X
Importance of communication X
Importance of building trust X
Regular evaluations increase
program participation X

POST INJURY PROGRAM EVALUATION 44
increase the likelihood of other disabling outcomes such as post-traumatic stress disorder (PTSD)
and chronic pain.
The participants agreed the usefulness and impact of the program was evident due to the
mental health interventions services offered to the employees as a positive addition to the
physical rehabilitation. Clinical interventions, such as cognitive behavioral therapy (CBT), were
offered and as posited by Giummarra et al. (2018), early interventions such as CBT reduced
symptom severity for PTSD and depression and were most effective when coupled with a
collaborative approach with the employer to modify the work environment during the post-injury
rehabilitation plan, especially when administered within the first four weeks post injury.
These findings address the problem of practice, that is, police and fire department
employees as tactical athletes who experience mental and emotional stress when injured and
longer duration of recovery. Hulls et al. (2022), reviewed 35 studies of workplace interventions
that had an intended goal of improving health and wellbeing in male dominated industries and
concluded that these interventions increased employee resilience, productivity, and retention and
decreased absenteeism.
These aspects of the 360 Healthcare Program align with best practices as evidenced by
Pieper, et al. (2019) who reviewed studies between 2012 and 2017 which indicated that a
multicomponent program that engages both the employee and management is the key to a
successful program defined as having a positive impact on health-related and economic
outcomes, organizational trust, and disability duration. Additionally, Hulls et al. (2022) report
that workplace wellness programs that demonstrate organizational support and build trust
increase employee engagement in these programs and increase the effectiveness of the
interventions provided.

POST INJURY PROGRAM EVALUATION 45
In consideration of the physical, mental, and financial burdens of injury and the
consequence of disability leading to unemployment; the findings of this study have demonstrated
that wellness programs that include interventions for physical and mental health provided
positive outcomes for the enrollees and the organization.
Recommendations for Practice
The findings from this study assert that building trust is particularly critical. Moreover,
peer and supervisory support were found to be profoundly impactful. Therefore, the
recommendations for practice focus specifically on building trust and integrating peer and
supervisory support.
Build trust
This recommendation addresses the finding of this study that building trust yields better
outcomes as evidenced by most of the interviewees reporting this was one of the lessons learned
in the pilot program. The program administrators stated they learned that through engagement
and communication with employees and department management regarding the program’s
purpose and goals, credibility and trust was built which increased program enrollment.
As demonstrated by a study conducted by Meyer et. al (2012), emergency workers who
reported low trust in their organization demonstrated the highest levels of clinically significant
mental health symptoms. Similarly, Stanley et al. (2019) conducted a study and reports that
employees attribute their psychological wellness and positive outcome of the post injury
recovery to feelings of trust and support and a perceived sense of belonging to the organization.
The following action steps outlined are derived from Zak (2017) who posits a culture of
trust is one of the most powerful predictors of prosperity of an organization.
• Identify any organizational barriers to trust.

POST INJURY PROGRAM EVALUATION 46
• Create and sustain rituals to strengthen trust.
• As a leader, communicate regularly in a variety of forms and formats;
meet with all managers preferably in person.
To build trust within the 360 Healthcare Program, the organization should:
1) To build trust, build employees’ self-confidence by providing growth opportunities to
engage in decision-making. Engage employees proactively via providing information
regarding the goals of the program and of the organization. This can be accomplished
through preinjury communication from department management to increase
awareness of the program and immediately post injury via nurse case managers from
the benefit administrator. Additionally, a document outlining the program process can
set expectations and mitigate misinformation.
2) Provide additional communication pathways aside from telephone or email, such as
texting or via a chat application to ensure employees have several options to ask
questions, provide or obtain information, or report any changes in their status.
Integrate peer and/or supervisory support
This recommendation addresses the finding of this study that there were challenges
described by most of the interviewees as a lack of organizational support and facing negative
perceptions and resistance. To mitigate these challenges, this study found that communication
was of key importance. Integrating a peer and supervisory support component to the program
would represent and provide evidence of organizational support, allow for accurate program
information to be disseminated and provide a pathway of communication.
To include supervisory and peer support within the 360 Healthcare Program, the
organization should:

POST INJURY PROGRAM EVALUATION 47
1) Provide training to department managers via professional consultants or referring to
existing industry related training programs as referenced within this study, such as the
International Association of Fire Fighters (IAFF) Peer Support Training Certification
process. Examples include providing an introductory session to all leadership
followed by 3 monthly coaching sessions separately by department and providing
training materials for continued self-study.
3) Include weekly communication with certified supervisors and/or peers with the
enrollees of the program. This communication can be accomplished via telephone,
virtual or in person meetings.
4) Include a “buddy system” within peer groups that encourage mutual support of one
another through the inherent stresses of the job.
These action steps align with best practice as described in a review of four studies that
were designed to assess psychological distress symptoms of approximately 1,800 police officers
wherein 66% of respondents cited the leading predictor of their symptoms as ‘lack of
communication and support from superiors and organization’ (Perba & Demou (2019).
Similarly, as reported in a study which included 5,550 respondents of emergency services
industry staff and concluded that increasing supervisor communication is a demonstration of
organizational support (Evanoff et al., 2021).
As evidenced by one of the findings of this study, communication was used as a tool to
build trust and increase engagement between enrollees, peers, and supervisor. As reported by
Quevillon et al. (2016) to improve the mental health of the first responders, a cooperative effort
is needed between organizational leadership and peers to establish an environment that provides
adequate training and communication and supporting them in seeking help when needed, as

POST INJURY PROGRAM EVALUATION 48
emergency service workers carry the burden of their own safety and well-being as well as those
they serve.
Limitations and Delimitations
Limitations to this study included a limited scope of research identified that is specific to
the type of wellness program and industry population. Similar studies were identified about
mental health and wellbeing specific to the participant population in this study; however, there
were limited studies identified specific to addressing mental wellbeing in conjunction with workrelated injury among emergency service employees. Even fewer studies were found specific to
work related injuries and mental wellbeing screening and intervention in the emergency services
industry. Another limitation included the number of participants, as the study would be enhanced
by a larger sample size of administrative staff and inclusion of program enrollees.
Anticipated delimitations to this study include not collecting data directly from program
enrollees. Due to the time constraints, I chose to only conduct interviews of the administrative
staff directly involved with the creation, implementation, and management of the program.
Although the interview data from the administrators contributed to the study by assessing its
usefulness and impacts, surveying or interviewing the program enrollees would provide a unique
perspective. Another delimitation is the exclusion criteria of the specific population. This study
reviewed the pilot program and literature review specific to fire and police department
employees, therefore, reducing generalizability.
Recommendations for Future Research
Based on the findings of this study and in consideration of the limitations and
delimitations, recommendations for future research include further evaluation of the 360

POST INJURY PROGRAM EVALUATION 49
Healthcare program should include exit interviews of enrollees and including a mental health
screening post work-related injury for all employees in emergency services departments.
Conducting exiting interviews of enrollees of the program will address the usefulness and
impact of the program according to employees who participated as enrollees. Interviewing the
program enrollees is necessary because this will assist in gaining their perspective of the
program’s impact and usefulness. As posited by Merriam & Tisdell (2016), interviewing is
necessary when dealing with things that cannot be observed such as feelings and interpretations.
Interview questions can be formulated to gather input from those who directly experienced the
program and compare to the findings of this study to add validity to the benefits of the 360
Healthcare Program. Exit interview sample questions should align with this study and allow for
free form submission responses to obtain opinions, values, feelings, and reflections.
Specific to the problem of practice, future research should include the addition of mental
wellbeing screening into the physical injury treatment plan for emergency services employees
injured during their employment to identify a need for intervention services. This
recommendation is based directly from the findings of this study and previous research which
have demonstrated better outcomes including a decrease in disability duration, an increase in
return to work, improved employee engagement and total wellbeing.
Conclusion
Those working in the emergency services industry experience mental and emotional
stress inherent to their jobs and this is exacerbated when injured during employment, thus
increasing the duration of recovery.
First responders are responsible for preserving lives and securing the environment of any
incident in the community they serve. This study is important because the participants in the 360

POST INJURY PROGRAM EVALUATION 50
Healthcare Program are emergency service workers who are more susceptible to physical injury
and psychological impacts such as Post-Traumatic Stress Disorder (PTSD) than other industries.
Including a mental health assessment and providing interventions for any symptomatology has
yielded a healthier workforce as evidenced by reduction in duration of recovery and an increased
return to work. Fully staffed, physically and mentally healthy fire and police departments are
important to public safety.
The field of workers’ compensation can improve by ensuring physically injured
employees are screened for mental wellbeing and offered intervention services as needed. This
study has demonstrated the benefits of this holistic approach and the resulting benefits including
cost reduction, decrease in absenteeism, increase in employee engagement, and increase in the
total wellbeing of the employee.

POST INJURY PROGRAM EVALUATION 51
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Appendix A: Definitions
The following are key terms and their associated definitions related to this study.
Post-Traumatic Stress Disorder or abbreviation PTSD
Definition of PTSD according to Merriam-Webster (n.d.): A psychological reaction that
occurs after experiencing a highly stressing event outside the range of normal human experience
and that is usually characterized by depression, anxiety, flashbacks, recurrent nightmares, and
avoidance of reminders of the event.
Cognitive Behavioral Therapy or abbreviation CBT
Definition of Cognitive Behavioral Therapy (CBT) according to Merriam-Webster (n.d.):
Psychotherapy that combines cognitive therapy with behavior therapy by identifying faulty or
maladaptive patterns of thinking, emotional response, or behavior and substituting them with
desirable patterns of thinking, emotional response, or behavior.
Well-Being/Wellbeing
Definition of Well-Being according to Merriam-Webster (n.d.): The state of being happy,
healthy, or prosperous.
Definition of wellbeing according to Aon: Overall physical, emotional, social, career and
financial health.
Holistic or Holistic Approach
Definition of Holistic according to Merriam-Webster (n.d.): Relating to concerned with
wholes or with complete systems rather than with the analysis of, treatment of, or dissection into
parts.

POST INJURY PROGRAM EVALUATION 59
Appendix B: The Researcher
According to Merriam & Tisdell (2016), a researcher’s reflexivity can provide a
definition toward how the research is affected and how the researcher is affected by the research;
and researchers need to explain their positionality (i.e., disposition, biases, assumptions) within
the research study.
Approximately 20 years ago, I held the position of case manager, working directly with
industrially injured workers. This experience included case management of the physical recovery
of the work-related injury and very often involved reports from the injured worker regarding the
emotional and mental stressors experienced post-injury. The role of case manager did not include
mental wellbeing assessment or screening. Any bias or assumptions based upon the case
manager role included knowledge gained regarding work-related injuries with the population of
emergency service workers and their departments where there were cultural barriers to seeking
help for anything beyond the physical injury, including mental health. Another bias or
assumption was working in the field of workers’ compensation, which traditionally has avoided a
formal acknowledgement of symptoms beyond the physical injury or body part accepted for the
claim. Aside from not being in the professions for more than twenty years and therefore, no
longer well versed on the current state of the industry, I mitigated these biases and assumptions
by allowing the questions to the administrators to be semi-structured to allow for their freeform
opinions and experiences to be described as specifically as possible. Additional mitigation
measures took place when conducting data analysis which included member checking. Member
checking is achieved by the researcher allowing participants to validate their data (Maxwell,
2016).

POST INJURY PROGRAM EVALUATION 60
Appendix C: Protocols
Interview Protocol
Evaluation Questions:
1. EQ1: What are the perceptions of stakeholders regarding the usefulness and impact of the
program?
2. EQ2. What were the challenges to implementation during the pilot program? To what extent
were those challenges mitigated and how?
3. EQ3. What lessons were learned during the pilot program to allow for expansion to all
eligible employees?
Introduction to the Interview:
Thank you for taking the time to speak with me today. My name is Jerilyn Kelly, and I am a
doctoral student at USC. This interview will contribute to the purpose of the study which is to
evaluate the injured employee wellness program (The 360 Healthcare Program) which includes
a behavioral health assessment utilized to identify and recommend additional interventions
toward better recovery outcomes.
Although you have signed the consent form, I want to remind you that your participation is
voluntary, and you may decide to end the interview and/or your participation at any time. Is
everything clear to you thus far? Do you have any questions? This interview will take
approximately thirty minutes. I plan to record the interview to be able to conduct the interview
and give our conversation the time and space it may need, without being distracted by detailed
note taking. More importantly, recording ensures your words are captured verbatim. Please
know that the recording is for my use only and will be protected through transcription and

POST INJURY PROGRAM EVALUATION 61
analysis, and then destroyed. Do you agree to allowing me to record this interview? Thank you.
Let’s begin.
Purpose of Study: The purpose of this study is to evaluate stakeholders’ perception of the
usefulness and impact of a total wellness program, including what was learned from challenges
during planning, implementation and execution of the pilot program and subsequent expansion.
Interview Questions Potential Probes
RQ
Addressed
1. Describe your career experience with
the implementation of wellness and/or
assessment programs
Would you say you have had a variety
of experiences in this process? 1
2. Tell me about your part in the
implementation process. Walk me through that; clarify 1
3. Describe your role during planning
and implementation.
Do you think there was enough time
allowed to plan and implement this
program? 1
4. When the program was initially
implemented what were the challenges?
To what do you attribute these
challenges? 2
5. What is your opinion about the
current program process?
Does the program seem to be working
well? Could you provide an example? 2
6. How do you feel about the program’s
effect on participants?
Would you explain this a bit more or
provide paraphrasing from
participants? 3
7. Describe aspects of the current
process you believe to be inefficient.
Can you be specific/narrow this down
to the 1-2 most significant aspects? 2
8. Describe aspects of the current
process you believe to be efficient.
Can you be specific/narrow down to 1-
2 most significant aspects/contributors? 2
9. If you had the opportunity to create
or contribute to an improving the
program, would you contribute your
ideas?
Can you provide an overview/example
of how you may be able to improve the
efficiency and/or efficacy of the
program? 2
10. Describe your feelings regarding an
employer offering a wellness program
How do these feelings affect your role
in the process? 3

POST INJURY PROGRAM EVALUATION 62
that addresses the mind and body, i.e.,
“holistic” approach
11. In reflection of your experience in
the implementation of the program,
what were the challenges? Can you elaborate on this? 2
12. In reflection of your duration of
experience with administering the
program, how would you describe the
impact or impacts of the program? Can you provide an example? 3
Conclusion to the Interview:
Thank you again for your time today. I appreciate your willingness to contribute to this study. As
a next step, I may wish to reach out for clarification. Would you be okay with me contacting you
to follow up over the next few weeks?

POST INJURY PROGRAM EVALUATION 63
Appendix D: Ethics
The recruitment process included sending an email to participant candidates with an
option to click on a link to indicate their intent to participate and outline their availability for the
thirty to forty-five-minute interview and preferred method of contact to confirm date and time,
once established. The program evaluated by this study, the entity in which it is taking place and
all interviewees have been de-identified through use of pseudonyms. All interview participants
were informed by this researcher, both in writing and verbally, that participation in this study
was on a voluntary basis. I gained consent of each participant to record the interview and
announced when the platform was set to record. I informed each participant they could request to
cease being recorded or interviewed at any time.
A link to the IRB Information Sheet for Exempt Studies customized for this study was
made available for download at the start of the interview prior to any questions being asked.
Interview participants were informed that answering the interview questions indicates their
consent to participate in the study. Consent was obtained from each participant, and they were
informed of why they were chosen to volunteer, specifically what the research is about and how
the process will be conducted, as Franklin et al. (2012) posited as best practice.
The first question of the interview asked the participants if they are 1) over the age of
eighteen and 2) have they worked for or with the Company Heroes organization for at least
twelve months. Interviews were transcribed using transcription tools embedded in Zoom.
Interview transcripts were then coded. Interview participants were given a pseudonym, and no
identifying information was saved. Recorded interviews were available only to the Researcher
through a password-protected Zoom account. Interview transcripts were saved in a passwordprotected computer and password-protected cloud server.

POST INJURY PROGRAM EVALUATION 64
No compensation was offered, and a summary of the study will be emailed to all
participants.

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Asset Metadata

Creator Kelly, Jerilyn Jane (author)

Core Title Evaluation of a post work related injury total wellness program designed for fire and police department employees

School Rossier School of Education

Degree Doctor of Education

Degree Program Educational Leadership (On Line)

Degree Conferral Date 2024-05

Publication Date 01/30/2024

Defense Date 01/17/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag fire and police department employees,mental health,OAI-PMH Harvest,return to work,wellness,workers' compensation,work-related injury

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Malloy, Courtney Lynn (committee chair), Canny, Eric (committee member), Stowe, Kathy (committee member)

Creator Email jerilynj3@gmail.com,jkelly@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113817108

Unique identifier UC113817108

Identifier etd-KellyJeril-12647.pdf (filename)

Legacy Identifier etd-KellyJeril-12647

Document Type Dissertation

Format theses (aat)

Rights Kelly, Jerilyn Jane

Internet Media Type application/pdf

Type texts

Source 20240131-usctheses-batch-1124 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu