**4. Research study Cleveland clinic**

IPCS has been involved providing a comprehensive strength screening evaluation for the new hires for the Cleveland Clinic since January 2011 [40]. This has resulted in the collection of new hire data related to strength and medical claims which have been studied from 2011 through 2017.

#### **4.1 Research study design**

This quasi-experimental, non-randomized study was conducted at Cleveland Clinic in northeast Ohio. It was designed to assess the impact of a strength screening assessment for nurses used at the time of hire, and compare the difference in health plan costs to newly employed nurses who did not receive the strength screening. Participants were identified from the applicant pool as part of the new hire process from January 2008 through December 2017. Applicants were either registered nurses, licensed vocational nurses, licensed practical nurses, or patient care nursing assistants applying for a nursing position in any unit of the hospital. The interviewing process for potential candidates consisted of an online application, followed by a phone interview and then an in-person interview if warranted. Nurses that passed these initial requirements for selection were then scheduled for a physical exam and a drug screen. A strength assessment screening was added to the existing hiring protocol as the last segment of the interview process for nurses hired from January 2011 through December 2017.

Nurses hired in January 2008 through December 2010, prior to the strength assessment screening implementation, served as a Historical Comparison Group. There were no significant environmental or business practice changes observed during this time period from January 2008 through December 2017, and health plan coverage did not change across the two time frames. The only difference in the selection process in 2011–2017 compared to 2008–2010 was the addition of the physical capability evaluation (PCE™). The project was overseen by hospital administrators, and conducted based on quality improvement protocols. Given that this was a retrospective analysis of a hiring practice policy, and not a formal research study, Institutional Review Board approval or research consent was not required.

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(2011–2017).

*Muscle Health: The Gateway to Population Health Management*

The strength screening was conducted through an objective physical capability evaluation (PCE™). The PCE is designed to measure the applicant's isokinetic force generating capability (strength) of muscle groups based on the outcomes of a defensible job task analysis (JTA) [37]. The JTA was conducted according to guidelines of the Americans with Disabilities Act of 1990 (ADA) to determine the skills necessary to safely and effectively perform the essential functions associated with the nursing duties (e.g., lifting, carrying, bending, stooping, climbing, etc.). These validation studies were used to identify appropriate cut-off scores using the U.S. Department of Labor strength definitions for medium, heavy and very heavy job tasks [41]. It was determined that the "target score" for the nursing job category would be set at the medium strength level. The results of the JTA indicated that movement patterns of the major muscle groups involved with shoulder flexion and extension and knee flexion and extension were critical to safely performing the essential functions of

The PCE testing was conducted in the Occupational Medicine department, in a controlled environment using isokinetic equipment and a standardized testing process (tested at 60 degrees per second, two sets of five repetitions flexion and extension for knees and shoulders) administered by trained professionals [38]. To improve reliability of the measure, health system physical therapists and athletic instructors were trained and observed for proper technique administering the PCE, verifying that they completed the evaluation correctly. PCE results were collected at the time of conducting the assessment, and submitted to a centralized database for data interpretation. These objective evaluations were then interpreted by IPCS (a third party company). The interpretation included isokinetic measurements

1. a force curve analysis in which the applicant's force curves generated were compared to an unmatched normative force curve derived from nearly

2. a body muscle symmetry analysis which involved comparing the applicant's right and left shoulder and knee scores, agonist to antagonist muscle groups and upper and lower body scores to a normative database consisting of more

The screening took approximately 30 minutes to complete per applicant. PCE data were analyzed based on proprietary algorithms, and scores were electronically returned to Human Resources through summary reports [37]. An applicant was recommended for hire if the PCE strength screening score was equal

Medical claims cost data for the first 12-months of employment were obtained for each annual cohort from the employer-sponsored health plan. The analyses include data for all newly hired nurses that have 12-months of continuous enroll-

Total annual and per employee per month (PEPM) paid medical costs were calculated for nurses hired in each of the three years prior to initiation of the PCE (2008–2010), as well as for nurses hired after the PCE program was initiated

500,000 normative curves in the existing database;

3. assessing the applicant's strength to body weight ratio score.

ment in the employer-sponsored health plan after their hire date.

than 500,000 normative symmetry scores;

to or greater than the "target score".

**4.2 Research study data sources and analysis**

*DOI: http://dx.doi.org/10.5772/intechopen.94058*

the nursing jobs.

through:

*Occupational Wellbeing*

**4. Research study Cleveland clinic**

been studied from 2011 through 2017.

**4.1 Research study design**

2011 through December 2017.

strength which supports the concept of loss of muscle mass and strength with aging along with an increase in sedentary lifestyles. Interestingly, the youngest age group (20–29) had the greatest deficit for the shoulder and knee strength when compared to the three age groups between 30 and 59. This is a reflection on the sedentary lifestyles found in children and youth which then carries over into industry.

During the IPCS testing process, height (in) and weight (pds) are measured. For research purposes IPCS calculates Body Mass Index (BMI) to monitor trends in obesity within the workplace. **Figure 4** compares the changes in the percent number of workers in each BMI category from 2005 to 2019. IPCS looks at changes in BMI for the category 50 or more or extreme morbid obesity. When comparing 2005 to 2019, the overweight category (BMI 25–30) decreased from 38–32% whereas the BMI categories equal to severe obesity (BMI 35 or more) and greater increased from 13.6% to 20.7% which represents a 52.2% increase. It is these higher BMI categories associated with an increase in certain diseases such as Type II diabetes, hypertension and cardiovascular disease. Further, work by Ostebye in 2007 has shown that those workers with a BMI of 35 or more have 2 times the number of soft tissue injuries, 7 times the workers' compensation costs and 13 times more lost work days [39].

IPCS has been involved providing a comprehensive strength screening evaluation for the new hires for the Cleveland Clinic since January 2011 [40]. This has resulted in the collection of new hire data related to strength and medical claims which have

This quasi-experimental, non-randomized study was conducted at Cleveland Clinic in northeast Ohio. It was designed to assess the impact of a strength screening assessment for nurses used at the time of hire, and compare the difference in health plan costs to newly employed nurses who did not receive the strength screening. Participants were identified from the applicant pool as part of the new hire process from January 2008 through December 2017. Applicants were either registered nurses, licensed vocational nurses, licensed practical nurses, or patient care nursing assistants applying for a nursing position in any unit of the hospital. The interviewing process for potential candidates consisted of an online application, followed by a phone interview and then an in-person interview if warranted. Nurses that passed these initial requirements for selection were then scheduled for a physical exam and a drug screen. A strength assessment screening was added to the existing hiring protocol as the last segment of the interview process for nurses hired from January

Nurses hired in January 2008 through December 2010, prior to the strength assessment screening implementation, served as a Historical Comparison Group. There were no significant environmental or business practice changes observed during this time period from January 2008 through December 2017, and health plan coverage did not change across the two time frames. The only difference in the selection process in 2011–2017 compared to 2008–2010 was the addition of the physical capability evaluation (PCE™). The project was overseen by hospital administrators, and conducted based on quality improvement protocols. Given that this was a retrospective analysis of a hiring practice policy, and not a formal research study, Institutional Review Board approval or research consent was not

**104**

required.

The strength screening was conducted through an objective physical capability evaluation (PCE™). The PCE is designed to measure the applicant's isokinetic force generating capability (strength) of muscle groups based on the outcomes of a defensible job task analysis (JTA) [37]. The JTA was conducted according to guidelines of the Americans with Disabilities Act of 1990 (ADA) to determine the skills necessary to safely and effectively perform the essential functions associated with the nursing duties (e.g., lifting, carrying, bending, stooping, climbing, etc.). These validation studies were used to identify appropriate cut-off scores using the U.S. Department of Labor strength definitions for medium, heavy and very heavy job tasks [41]. It was determined that the "target score" for the nursing job category would be set at the medium strength level. The results of the JTA indicated that movement patterns of the major muscle groups involved with shoulder flexion and extension and knee flexion and extension were critical to safely performing the essential functions of the nursing jobs.

The PCE testing was conducted in the Occupational Medicine department, in a controlled environment using isokinetic equipment and a standardized testing process (tested at 60 degrees per second, two sets of five repetitions flexion and extension for knees and shoulders) administered by trained professionals [38]. To improve reliability of the measure, health system physical therapists and athletic instructors were trained and observed for proper technique administering the PCE, verifying that they completed the evaluation correctly. PCE results were collected at the time of conducting the assessment, and submitted to a centralized database for data interpretation. These objective evaluations were then interpreted by IPCS (a third party company). The interpretation included isokinetic measurements through:


3. assessing the applicant's strength to body weight ratio score.

The screening took approximately 30 minutes to complete per applicant. PCE data were analyzed based on proprietary algorithms, and scores were electronically returned to Human Resources through summary reports [37]. An applicant was recommended for hire if the PCE strength screening score was equal to or greater than the "target score".

#### **4.2 Research study data sources and analysis**

Medical claims cost data for the first 12-months of employment were obtained for each annual cohort from the employer-sponsored health plan. The analyses include data for all newly hired nurses that have 12-months of continuous enrollment in the employer-sponsored health plan after their hire date.

Total annual and per employee per month (PEPM) paid medical costs were calculated for nurses hired in each of the three years prior to initiation of the PCE (2008–2010), as well as for nurses hired after the PCE program was initiated (2011–2017).
