**5. Conclusions**

The intervention program had some positive impacts on work organization in the intervention centers. The fundamental Total Worker Health concept of integrating OSH and HP was intuitive to many workers; they enthusiastically envisioned and sought to carry out integrated programming, and a number of activities improved the health climate in these workplaces. Active involvement of non-supervisory employees in program design and conduct appeared to benefit the work environment and employee morale and engagement. Actively engaged leadership was no less important: program intensity and success fluctuated noticeably with changes in management. Both managers and employees cited the importance for success of factors such as employee program ownership, empowerment, and skill-building (setting appropriate goals, balancing of costs and benefits when weighing intervention alternatives, etc.).

Unfortunately, our planned reduction in researcher facilitation efforts was followed by an erosion of the previously high level of staff participation in project planning. It was disappointing to observe the decline in company commitment to the participatory employee teams despite their demonstrated feasibility and robust worker engagement, in contrast to the company workplace health promotion program.

Participatory OSH/HP is challenging in the long-term care sector due to highly demanding jobs and tight staffing. Managers and front-line workers have different perceptions of the long-term care environment [21], likely arising naturally from their positions in the occupational hierarchy and their consequent exposures to health and safety hazards. Improved systems of communication between levels and program design are needed that support front-line workers to participate in identifying and resolving problems.

PIP team resources, breadth of worker participation, and management support were important preconditions for potential program sustainability. Future efforts should incorporate more robust organizational structures to enhance these factors for program success. Lessons from this study may guide other long-term care facilities to build a sustainable, integrated, and participatory program.

**Author Contributions:** Conceptualization, L.P., R.K.; methodology, R.K., L.P., M.F., Y.Z.; formal analysis, R.K., J.F.; investigation, L.P., M.F., R.K., Y.Z., J.F.; writing—original draft preparation, R.K., L.P., Y.Z., M.F.; writing—review and editing, R.K., L.P., Y.Z.; supervision, L.P.; funding acquisition, L.P.

**Funding:** The Center for the Promotion of Health in the New England Workplace is supported by Grant Number 1 U19 OH008857 from the National Institute for Occupational Safety and Health (CDC). This work is solely the responsibility of the authors and does not necessarily represent the official views of NIOSH.

**Acknowledgments:** Sandy Sun, project administration; Michelle Holmberg, Lara Blais, Jennifer Russell, and Shpend Qamili, workplace program implementation and facilitation; ProCare research team and numerous students who assisted with survey data collection, and Wing Hung Yuen for manuscript formatting.

**Conflicts of Interest:** The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.
