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Methodology

Feedback facilitates transfer of training with US
Hispanic workers in a healthcare laundry linen facility
Angela R Lebbon,1 Sin Chien Lee,2 Douglas A Johnson2
1

Department of Economics andBusiness, Lehman College, City
University of New York, Bronx,
New York, USA
2
Western Michigan University,
Kalamazoo, Michigan, USA
Correspondence to
Dr Angela R Lebbon, School ofBusiness, State University of
New York, New Paltz, 1 Hawk
Drive, New Paltz, NY 12561,
USA; lebbona@newpaltz.edu
Received 23 March 2015
Revised 10 June 2015
Accepted 22 June 2015
Published Online First
14 July 2015

ABSTRACT
Background This study aimed to increase safetyknowledge and behaviour of US Hispanic custodial
workers in healthcare through a culturally appropriate
training and monitoring process.
Method A single-group, repeated-measures, pre-test
and post-test design was used to examine training
effectiveness across four sets of behaviours with 23
Spanish-speaking workers.
Results Small group, lecture-style training in Spanish
with pictures and video resulted in signiﬁcant
improvements in knowledge and behaviour. However,additional analyses show that behavioural feedback was
the critical component in improving safety behaviour
during transfer of training.
Discussion Findings from reaction, knowledge,
behaviour and results measures suggest that grouptraining and graphic feedback is culturally appropriate
and effective with Hispanic workers. Further investigationis needed to understand cultural factors that facilitate
effective development and delivery of safety training andfeedback to US Hispanic workers.

BACKGROUND
The majority of safety literature on foreign-born US
Hispanic workers recommends development anddelivery of training that addresses language, educational and cultural differences.1–4 However, little
guidance is provided on how to speciﬁcally address
those differences. The most well-known research on
cultural differences comes from Hofstede,5 who originally deﬁned culture across four dimensions.
According to recent data collected on Latin Americancountries’ dimensions,6 Mexico’s scores, forexample, are dramatically different from US scoreson power distance, individualism and uncertainty
avoidance. These dimension differences between US
and Mexico may indicate that US organisational
training is less effective for foreign-born Hispanic
workers than US-born workers. Research has foundthat Hispanics prefer learning in groups, want information and rules to guide their behaviour, work toreceive external reinforcers and prefer social interaction to independent thinking.7 Regardless of data
describing these cultural differences, the safety literature rarely refers to these factors when describing thedevelopment and delivery of safety training to
Hispanic workers. Therefore, this study attempted toaddress some cultural differences with Hispanic
workers by developing and delivering a more culturally appropriate training and monitoring process.
To cite: Lebbon AR,
Lee SC, Johnson DA. Inj Prev
2015;21:404–414.
404

Development of training
A necessary and important factor in the development of effective training is a systematic assessmentof the organisation’s needs to guide creating, implementing and evaluating a training programme;
however, the use (and subsequent communication of
implemented assessments) is scarce in the research
literature, with only 6% of studies implementing
and reporting such information.8 In the ﬁeld of
behaviour analysis, assessments of organisational,
task and people factors are frequently conducted to
identify work behaviours and conditions that lead toperformance deﬁciencies. However, culture, language and technology are not frequently assessed todetermine potential inﬂuences on training, observation and feedback.9 10 The Performance Diagnostic
Checklist (PDC)11 is one such assessment that serves
as guide for developing optimal interventions andmeasurement systems. One limitation of the PDC
involves the absence of questions around learnercharacteristics that may affect training or transfer,
such as cultural differences and constraints related
to language, literacy and technology. Therefore, thecurrent study will attempt to ﬁll this void by modifying and expanding the PDC to include cultural andlearner characteristics, and will report the assessment questions and results that inﬂuenced the development of the current safety training and evaluation
process.

Evaluation of training
Despite the vast literature on safety interventions
with Hispanic workers, studies documenting behaviour change or reduction of occupational injuries
among Hispanic workers are limited.12 Organisations
and researchers are predominately evaluating training
with reaction measures; reporting of behaviour andresults remains the least reported analysis.8 13–15
Given that reactions are not reliable measures ofknowledge and skill acquisition,16 17 the evaluation of
behaviour change is a key component for demonstrating transfer of training.12 Ongoing behavioural observations are frequently used in behaviour-based safety
to track behaviours, evaluate the effectiveness ofimprovement efforts and provide contingent feedback.18 Feedback is another component in training
programmes that may inﬂuence effectiveness and maychange future reporting of evaluation measures.13
More speciﬁcally, it has been noted that while “learning and behavioral criteria are conceptually linked,
researchers have had limited success in empiricallydemonstrating this relationship”8 (p. 235). It is
entirely possible that feedback (either during training,
testing and/or transfer of training) facilitates learningand transferring of training. Behavioural feedback has
been shown to substantially enhance the effects oftraining,19 especially when it is delivered in the typicalmanner: orally in coordination with goals, rewards
and/or award ceremonies.20

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Methodology
A series of research studies conducted on Hispanics’ workplace safety demonstrated the impact of individualised computer-based training (CBT) and testing in Spanish throughmeasurement of reactions,21 22 knowledge acquisition21–23 andbehaviour.22 Feedback served as a component of the training,wherein participants received test questions and feedback after a
set informational training slides.22 23 If the participant did notcorrectly answer a test question, the answer was noted as incorrect and the participant was sent back to the training slide;advancement through the training was not allowed until allquestions were correctly answered. Unfortunately, analyses were
not conducted to separate the effects of training and feedback
to determine which component had a greater inﬂuence on learning and behaviour.22 23 The methodologies from these studies
can also be expanded by (a) using a variety of test questions
beyond multiple-choice or dichotomous options; (b) changing
the phrasing and order of the test questions to prevent practiceeffects; (c) including reaction measures of self-esteem and work
conﬁdence and (d) evaluation of training with injury and ﬁnancial outcomes. Furthermore, while CBT is an effective method
for improving Hispanics’ safety knowledge and behaviour, it is
not always a practical, adequate, cost-effective solution for small
businesses. Feedback methods that are delivered orally withrewards are highly effective, but they require effort, skill, timeand money. Other empirical studies have found that deliveringgraphic feedback alone can yield signiﬁcant changes to behaviour.24 25 While there is a wealth of literature demonstrating the
beneﬁts on individualised instruction and feedback, this body ofliterature is largely conducted on Caucasian workers and college
students raised in the USA.23 26 Therefore, analysis is warranted
to examine the effects of group feedback (ie, delivered graphically without goals or rewards, and only during transfer of training) on US Hispanic workers’ safety behaviour.

METHOD
Participants and setting
Participants were 23 Spanish-speaking employees from a small
healthcare laundry and linen facility located in Midwestern US.
Employees were administered a survey in Spanish to obtain
demographic information (see table 1 for results).

Experimental proceduresThis study employed a single-group, repeated-measures, pre-test
and post-test design across four sets of behaviours to examine
the effects of four different training delivery methods. Baselinesof differing durations were used to decrease the probability thatany observed behaviour changes could be attributed to coincidence alone. The four sets of behaviours (moving carts, handling linens, generic behaviours and environmental conditions)served as primary dependent variables since they were identiﬁedin the safety assessment as critical activities leading to injuries.
The independent variables were the method of training delivery(spoken, written, with pictures, with videos), the type of language used to conduct safety training (English and Spanish) andbehavioural feedback.
Repeated measures involved observation of employees’ safetyfor 68 days over the course of 4 months; observations were conducted approximately three times per week for 90 min eachobservation. The total number of behavioural instances observed
during the 68 days of observation were 3723 for carts, 4398 forlinens, 3792 for generic and 5422 for environmental. Safety
behaviour was averaged each day from these instances andreported as percentage safe for each behaviour set.
Lebbon AR, et al. Inj Prev 2015;21:404–414. doi:10.1136/injuryprev-2015-041620

Table 1

Employees’ demographic information
Per cent (n)Country of birth
MexicoGuatemalaBest spoken language
SpanishLanguage spoken at home
SpanishEnglish/Spanish
Highest level of education
6th–8th grade
9th–12th grade
Some college experience
Country of education
MexicoGuatemala
USA and Mexico

95 (21)05 (1)
100 (22)91 (20)09 (2)
71 (15)19 (4)
10 (2)
86 (19)5 (1)
9 (2)*
Mean (range)

Average age
Average years lived in the USA
Average years worked in linen industry in the USA
Average years worked at the location of study

44 (27–64)
19 (2.5–42)
08 (0.6 –17)
07 (0.6 –14)

Number of participants is in parenthesis next to percentage.
One participant was absent the day the survey was administered.
*These participants both received 4 years of US education.

Safety assessment
Prior to starting the study, the research team toured the facility
and interviewed the facility’s general manager, lead production
supervisor and production supervisor. The PDC11( p.340) and
Behavioral Analysis Worksheet27( p.197) were combined andmodiﬁed, then used to identify organisational, people and task
factors affecting safety (see ﬁgure 1 for the list of questions) inorder to develop a targeted safety intervention. Overall, theassessment questions revealed that information, knowledge,
behaviour and consequences were not supporting safety (seeﬁgure 2 for a summary of the assessment results).
After the tour and interviews, a review of the facility’s injury
reports was conducted on the previous three years to gain information on work conditions and behaviours associated withinjuries. Reported injuries were analysed by injury type, bodypart, work activity, whether the injury was Occupational Safety& Health Administration (OSHA) recordable or not. Analysis
revealed the top 3 types of injury were oedema/swelling, strain/sprains and bruises/contusions. The body parts most frequently
injured from the top 3 injury types were arm/elbow, hand/ﬁnger,
leg/knee, groin, back and wrist. The top work activities resulting
in injury included moving carts, catching/pulling/folding/sorting
linens and blankets, being struck by/against carts or work materials, and dropping work materials.

Behavioural safety process
A behavioural safety process was developed to address some ofthe shortcomings and deﬁciencies identiﬁed by the safety assessment, which included improving information, knowledge,
behaviour and consequences. The behavioural safety process
was developed to address the following:
1. Shortcomings in information: (a) Transcribe safe bodymechanics associated with work activities associated with405

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Methodology

Figure 1 Assessment used to identify organisational, people and task factors affecting safety.
injury; (b) a task analysis of each work activity, which
involved breaking down each activity into the smallest
behavioural components; and (c) development of observational checklist.
2. Deﬁciency in knowledge and behaviour: (a) customised
workplace safety training; (b) train employees on the identiﬁed, critical activities and work conditions; and (c) train andtest Hispanic workers in Spanish.
3. Absence of consequences: (a) ongoing behavioural observations by researchers to assess safety behaviour; (b) delivergraphic, behavioural safety feedback; and (c) survey to understand workers’ experiences with behavioural safety training.
4. Equipment and processes: (a) deliver training in-person via
verbal and written lecture presentation, and deliver testingon paper, instead of CBT, given the limited knowledge,
skills, resources and budget related to computers and buying
modiﬁed computer equipment.

5. Cultural factors of Hispanic participants: (a) deliver training
in small groups, only with other Hispanics, to appeal to collectivism and encourage questions and discussions; (b) developed rules for safe and unsafe behaviour and practices toaddress uncertainty avoidance; and (c) deliver feedback toappeal to power distance and the preference for use of information to guide performance.

406

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Development of observation checklist
The observation checklist used to score employees’ safety wasdeveloped from the safety assessment’s identiﬁed critical behaviours and conditions. The two-sided, single-page checklist (seeﬁgure 3) consisted of a list of behaviours and associatedcolumns allowing observers to quickly note the engagement ofsafe and unsafe behaviours (front page of checklist), and a list ofsafety deﬁnitions for the behaviours and conditions as a reference for the observers. Safety deﬁnitions were written based on

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Methodology

Figure 2 Summary of the ﬁndings from the safety assessment.

The training content was developed based on the list of identiﬁed critical behaviours and conditions from the facility’s safetyassessment results. A research assistant ﬂuent in both English
and Spanish translated all training materials. All materials presented to participants were reviewed thoroughly by investigators
to ensure that words exceeding grade school reading level were
not used. Training content was written at 3rd–4th grade level of
the US education system, according to Microsoft Word’s
Flesch-Kincaid readability score.

work shifts. Each training session was approximately 30 min
and conducted in small groups of 5–8 employees.
Implementation of the three training sessions was staggered,with the ﬁrst training starting 13 days after baseline safety observations. The investigator conducted the training that was delivered in English, and a research assistant who is ﬂuent in both
English and Spanish conducted all subsequent training sessions
in Spanish, with the supervision of the investigator. For all training sessions, participants were given the opportunity to ask
questions. After each behaviour was explained, the trainer allocated time to address employees’ questions and comments. The
number of questions and concerns raised, and the duration of
discussions during each training session were recorded.

Behavioural safety training

First behaviour set: moving carts

Training was conducted separately on three behaviour sets
(moving carts, handling linens and generic behaviours). Alltraining sessions were conducted during employees’ normal

Training on moving carts was ﬁrst conducted in English andinvolved 13 days of observation, followed by training in Spanishand 41 days of observation. Both training sessions for ‘moving

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407

hospital laundry or material handling guidelines from the governmental organisations.28–31

Development of training materials

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Methodology

Figure 3 The checklist used to score employees’ safety during the observation process.

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Methodology
carts’ were conducted via spoken and written PowerPoint presentation, and did not include any demonstrations, pictures orvideos of safe and unsafe behaviour.

Second behaviour set: handling linens
Training on handling linens was delivered in Spanish after
37 days of baseline observation and involved a presentation
with pictures (examples of safe and unsafe body mechanics),
explanations and demonstrations of safe and unsafe behaviours.

Third behaviour set: generic behaviours
Training on generic behaviours was delivered in Spanish after
52 days of baseline observation and included a presentation
with videos depicting examples of safe and unsafe behaviours,
along with explanations and demonstrations of safe and unsafe
behaviours.

Forth behaviour set: environmental conditions
The fourth behaviour set served as a control condition sinceparticipants received no information, training or testing overthese safety behaviours. Data pertaining to the environmental
conditions around the employees’ workstation were observedand collected throughout the course of the study.

TestingPrior to the start of each training session, a pre-test was administered to all employees to examine any pre-existing safety knowledge that was obtained from safety training obtained from otherjobs. At the end of each training session, a post-test was administered to examine knowledge acquisition of safety information
after safety training. Knowledge tests were delivered in written
Spanish. Pre-test and post-test questions were the same; however,the phrasing and order of the questions in each post-test werechanged to prevent repeated testing bias (see ﬁgure 4 for all
pre-test and post-test questions). At the conclusion of the study,
all participants completed an evaluation survey to determine
their perceived beneﬁts and experiences with the behaviourbased safety (BBS) training in English and Spanish.

Observation process
Throughout the course of the study, each observer conducted
observations approximately three times per week, and eachobservation session lasted approximately 1.5 h. Since most participants typically work in the same workstation or area, observers were required to use a speciﬁc route when observing toensure that all participants were observed and their safe andunsafe behaviours were recorded. An observation session ended
when approximately two data points had been recorded foreach participant who was present during that particular observation session. Participants were informed during the consent
phase that observations of their safety behaviour would periodically occur during the study, but they were not informed ofwhen the observations would take place. All observations were
overt, meaning the observers were in the view of the participants while observing and recording participant behaviour on
the paper checklist.
Interobserver agreement (IOA) was conducted on 23% of thetotal number of observations each week (ie, three IOA sessions
out of 13 observation sessions a week). The formula used to calculated percentage of agreement on “Safe” behaviours was[Number of agreements with “Safe” responses÷Number of“Safe” agreements+Number of “Safe” disagreements×100];
the percentage of agreements on “Unsafe” behaviour was
calculated using [Number of agreements with “Unsafe”
Lebbon AR, et al. Inj Prev 2015;21:404–414. doi:10.1136/injuryprev-2015-041620

responses÷Number of “Unsafe” agreements+Number of“Unsafe” disagreements×100]. The overall average safe agreement was 90% (ranged between 82% and 97%), and the overall
average unsafe agreement was 85% (ranged between 75% and99%) for all behaviours observed during the study.

Feedback process
Weekly percentage safe for each behaviour set was graphed andposted on both sides of the only door to the production ﬂoor;
therefore, employees saw the graph as they entered the production ﬂoor and again when they exited the production ﬂoor. To
the right of the graph, safety tips were written in bold font forthat behaviour set, under the words “REMEMBER!”. Graphs
were updated every Friday and consisted of data from Friday(the week before) to Thursday. There were a total of 10 feedback postings. The safety percentage for previous weeks
remained part of the graph each time it was updated to allow
participants to see the change of group behaviour over thecourse of weeks.
Feedback was only posted on behaviour that was trained by
the researchers; the ﬁrst feedback posting for a behaviour set
occurred 1 week after training that speciﬁc behaviour set. The
graphs and safety tips were written in English after the English
training and in Spanish after the subsequent trainings deliveredin Spanish. Participants were informed that feedback was posted
and where it was located, but researchers and production ﬂoor
supervisors did not discuss the feedback with participants
during the study.

Cost–beneﬁt analysis
A cost–beneﬁt analysis was conducted with the help of OSHA’s“$afety Pays Program”,32 which provided information about the
average cost of an injury or illness. Injuries were categorised andmatched according to the categories that were provided by
OSHA, and direct costs were calculated by referring to the estimated cost. Indirect costs were calculated by using an average
ratio of indirect to direct costs.33 The total cost for one injury
or illness occurrence was calculated by adding the direct cost
and the indirect cost; this was repeated for all the remaining
documented injuries and illnesses.

RESULTS
Statistical analyses were conducted (using SPSS V.21) on behavioural safety from observations across baseline, training in
English and training in Spanish, and on knowledge outcomesfrom pre-tests and post-tests on three behaviour sets. For brevity
and consistency with the behavioural analysis, only the ﬁrst
13 days of baseline observations were used for analysis across all
behaviour sets.

Knowledge effects
Independent t tests conducted on knowledge outcomes frompre-tests and post-tests on three behaviour sets demonstrated
signiﬁcant differences in test scores on carts and generic behaviours when participants were trained in Spanish. Cohen’s
d=1.0559 for carts after Spanish training, and d=0.7765 forgeneric behaviours after Spanish training, which would both beconsidered large according to Cohen’s magnitude of effects.34
However, signiﬁcant differences were not found with linens following Spanish training, nor carts after English training (table 2).

Behaviour effects
A one-way analysis of variance (ANOVA) showed that the percentage safe for carts was signiﬁcantly affected by training, with409

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Methodology

Figure 4 Pre-test and post-test questions administered to employees to examine knowledge acquisition.

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Methodology
Table 2

Knowledge results by phase
English training

Spanish training

Variables

Pre-test

Post-test

t

df

d

Pre-test

Post-test

t

df

d

Moving carts
Handling linens
Generic

77.6 (16.0)

72.7 (14.8)

1.068

43

−0.3189

72.7 (20.62)
60.0 (21.74)
70.8 (21.54)

90.2 (11.28)
68.7 (24.74)
86.7 (19.19)−3.581**−1.266−2.454*44
44
38

1.05590.37320.7765*p<0.05, **=p<0.001. SDs appear next to the means in parentheses. d=Cohen’s d; effect size computed with independent t-tests.

an effect size (η2p=0.389) considered large by Cohen34 (magnitude of effects for η2p is 0.02 for small, 0.13 for medium and0.26 for large). Post hoc tests using Bonferroni correction
showed cart safety was higher than baseline following English
training and Spanish training. However, signiﬁcant differenceswere not found between English and Spanish trainings. For
linens and generic behaviours, a one-way ANOVA showed thedifference in percentage safe between baseline and Spanish
training was signiﬁcant, with effect sizes for both consideredlarge by Cohen (η2p=0.675 for handling linens; η2p=0.389 forgeneric behaviours). For the control condition, a one-way
ANOVA showed percentage safe for environmental conditions
was signiﬁcantly different between phases, wherein environmental safety was highest during baseline and declined during the
BBS process that targeted the other behaviours. Post hoc tests
using Bonferroni correction showed signiﬁcant differences
between baseline and English training on carts, and baseline andSpanish training on linens (table 3).
These ﬁndings suggest a possible facilitating variable in the
BBS process is aiding participants’ transfer of training fromlearning to behaviour. More speciﬁcally, Arthur and colleagues8
found the mean effect size (d) from learning to behaviour was−0.77. However, the current study found an increase in effectsizes (d) from learning to behaviour across the three targetedbehaviour sets; the increases were 1.143 for carts, 2.373 forlinens and 0.7665 for generic. To further explore the possible
mediating variables that lead to performance improvementsfrom learning to behaviour, analyses were conducted on theeffects of training versus the effects of feedback on behaviour.

training, and when Spanish feedback was not in place for thatspeciﬁc behaviour (ie, last 5 days in baseline for carts, 5 days
prior to Spanish linens training for linens, 5 days prior to
Spanish generic training for generic). Safety behaviour (n=15
observation days) for Training, No Feedback was calculated fromthe days immediately following training, but prior to Spanish
feedback (ie, 5 days after Spanish training for carts, 5 days after
Spanish training for linens, 5 days after Spanish training for
generic). Safety behaviour (n=14 observation days) for Training,
Feedback was calculated from the week after training and immediately after delivering Spanish feedback for that speciﬁc behaviour (ie, from the 4 days following Spanish feedback for carts,
5 days following Spanish feedback for linens, 5 days following
Spanish feedback for generic).
A one-way ANOVA showed that safety behaviour was signiﬁcantly affected by a combination of training and feedback in
Spanish, F(2, 41)=6.558, p<0.003. Bonferroni correction
found that participants’ safety did not signiﬁcantly improvefrom baseline when only training was delivered; additionally,safety did not signiﬁcantly improve from training alone whentraining and feedback were delivered. However, the combination of training and feedback resulted in signiﬁcantly safer
behaviour compared with no training and no feedback. The
effect size for the analysis comparing overall safety behaviour
under Training and Feedback to overall safety behaviour under
No Training, No Feedback was d=1.546, which exceeds Cohen’sguidelines for a large effect (d=0.80). Overall safety behaviour
under Training, No Feedback to No Training, No Feedback was
d=0.7737, whereas safety behaviour under Training andFeedback to Training, No Feedback was d=0.4706 (table 4).

Feedback effects
To determine whether changes in safety behaviour were related
to training or feedback or a combination of training and feedback, combined safety behaviour (carts, linens and generic) was
compared with Spanish training and Spanish feedback phases, inaddition to safety behaviour under no training and no feedback.
Safety behaviour (n=15 observation days) for No Training, No
Feedback was calculated from the days immediately prior toTable 3Cost–beneﬁt analysis
For the purposes of this cost–beneﬁt analysis, the total cost of
injuries was only calculated for the period of July 2012–
October 2012 (4 months) to compare against the cost of injuries
that occurred within the duration of training and observations,February 2013–May 2013 (4 months). The cost of injuries
before the intervention was $263 068.60 and the cost of injuries

Behavioural safety results by phase
Baseline

Variables
Moving carts
Handling linens
Generic
Environmental

n

Mean

13
13
13
13

a

64.8 (6.97)
53.5a (8.64)
61.3a (12.7)
81.5a (6.53)

English training

Spanish training

n

Mean

n

Mean

14

b

75.1 (9.68)

1471.4b (6.12)

10
15
16
15

bc

79.8 (6.70)
73.8b (5.86)
77.9b (8.33)
73.8bc (4.99)

F

η2p

d

10.840*54.037*17.870*5.360*

0.389
0.675
0.398
−0.254

2.199
2.745
1.543
−1.318SDs appear next to the means in parentheses. Means with differing subscripts within rows are significantly different at p<0.05 based on Bonferroni post hoc multiple comparisons;means with the same subscripts within rows are not significantly different.
*p<0.001.
η2p, the effect size comparing baseline versus Spanish training computed with analysis of variance; n, number of observation days used in the analysis.

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Methodology
Table 4Training effects versus feedback effects
No Training,
No Feedback

Overall safety behaviour

Training,
No Feedback

n

Mean

15

a

69.9 (6.25)

Training,
Feedback

n

Mean

15

ab

75.5 (8.25)

No Training, No Feedback
Training, No Feedback

n

Mean

14

b

F

78.8 (5.24)

6.558*

dd

0.77371.546
0.4706

SDs appear next to the means in parentheses. Means with differing subscripts within the row are significantly different at p<0.05 based on Bonferroni post hoc multiple comparisons;means with the same subscripts within the row are not significantly different.
*p<0.005.

during the course of the intervention was $190 833.60—
approximately 27.5% reduction in injury costs. A comparisonof the injury occurrences before and during the intervention is
illustrated in table 5.
Estimated costs for developing training materials, training
assistants to accurately observe safety and implementing thetranslated training were also calculated. The total estimated pay
for four safety observers was $6000, which covered training time
for the assistants (20 h) and performing safety observations by
the assistants throughout the course of 5 months (200 h).
Estimated time for developing training materials and implementing the BBS process was approximately 300 h. The estimated pay
for a master’s-level BBS consultant’s effort (in the Midwest
region of the USA) in developing the above-listed materials was$19 500. Translations of training materials took 55 h, and theestimated pay for the translator’s efforts was $1650. The four
training sessions cost $780 for the presenter’s time (12 h).
Refreshments were also provided for participants during all training sessions, and the total amount spent was approximately$120. Therefore, the ﬁnancial beneﬁt of the BBS process was an
approximately 15% reduction in injury costs after factoring in
the cost of the process. It should be noted that each time thistraining is delivered, savings will be greater since development oftranslation costs is not required each time. A limitation of thisanalysis concerns the possibility that injury rates are related tovarying production demands at different times of the year in thehealthcare industry.
Using another method of training evaluation that is reported
each year by the American Society of Training and Development,
the cost of training and development per employee was examined
and compared with the average spending for small companies

Table 5(<500 employees). According to the 2013 State of the Industry
Report: ASTD Research, small companies spend on average$1800 per employee to develop and deliver training each year;
noteworthy, it was reported that health-related jobs have higher
costs per employee due to the speciﬁc tasks, which require clear
and precise deﬁnitions of knowledge and behaviours for thosetasks. In comparison, this study spent $1345 per employee todevelop and deliver training, and implement weekly observations
and feedback—that is >$10 000 in total savings compared withtraining developed and delivered in the small organisations surveyed in the ASTD research.

Reaction effects
A survey in Spanish was delivered to employees to examine thesocial validity of the behavioural safety process. Table 6 presents
employees’ perceived beneﬁts of training in English versus
Spanish, acquired safety knowledge, improved safety behaviour
and changes in conﬁdence levels towards their work and self.
Most employees favoured training in Spanish and overall, perceived acquired knowledge, safety and conﬁdence was greater
after the Spanish. In regards to language barriers, results showedthat 73% of employees agreed that working in an
English-speaking organisation is difﬁcult. Follow-up commentson this had the same theme: English is not their primary language and understanding their English-speaking supervisors ishard. Furthermore, 100% of employees indicated that theywould like to receive more Spanish training (45% want thistraining once/month, 30% once/year and 20% once/3 months).
Lastly, employees indicated they would like to have translationsof all training manuals, emergency exits, safety equipment,chemical information and safety tips.

Cost–benefit analysis

Moving carts
Handling linens
Generic behaviours
Total
Grand total
Savings after BBS

Before BBS process ( July 2012–October 2012)

During BBS process (February 2013–May 2013)# Injuries

Direct cost†

Indirect cost‡# Injuries

Direct cost

Indirect cost

2
2
0
4

64 61460 6570.00
125 271

71 074.90
66 722.70
0.00
137 797.60
263 068.60

1
2
0
3

26 23564 6380.00
90 87328 858.50
71 101.80
0.00
99 960.60
190 833.60

Training*
Cost

30 930+41 305.00*Cost to develop training materials, train safety observers, and implement training and observation.
†Calculated by referring to the estimated cost provided by OSHA.32‡Calculated by using an average ratio of indirect to direct costs.33
OSHA, Occupational Safety & Health Administration.

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Methodology
Table 6

Reported effects of training

Employee self-reported
Extent learned≥10 safety tips
7–9 safety tips
4–6 safety tips
0–3 safety tips
Behavioural levels
Always safe (100% of the time)
Mostly safe (60% of the time)
Somewhat safe (40% of the time)
A little safe (20% of the time)
Never safe (0% of the time)Work confidence
More confident
Same as before
Less confident
Not confident
Self confidence
More confident
Same as before
Less confident
Not confident

Englishtraining (%)(n=21)

Spanishtraining (%)(n=22)

10
24
14
52

55
27
14
5

14
19
10
19
38

68
14
9
9
0

29
24
5
43

86
14
0
0

33
24
0
43

86
9
5
0

Preferred method of training

Rank

Percentage

Spanish demonstrations/videos
Spanish demonstrations/pictures
Only spoken and written Spanish
Only spoken and written English

1
2
3
4

59
86
62
91

Employees’ participation during training was also observed to
examine differing levels of interaction between English andSpanish trainings. During English training, all employees participated passively, nobody asked questions or voiced any concerns,
even when prompted; mean time spent answering employeequestions or engaging in discussions during the English training
was zero minutes. During Spanish training, almost all of theemployees spoke up and actively participated in questions,asked for clariﬁcation and/or discussed possible workplacechanges to improve safety. Mean time spent answering employeequestions or engaging in discussions during the Spanish training
was 15 min. It was also observed during the Spanish trainings
that employees would perform demonstrations among themselves to see if they performed behaviours the same as thetrainer.

but how feedback is delivered to workers. These results also
have implications for small corporations who are hesitant toinvest in new safety training because of time and costs. Our
approach to implement the most common type of training delivery method used by corporations (2013 State of the Industry
Report: ASTD Research), with less costs, effort and technology
should be encouraging for management, especially since effectiveness was demonstrated on all four Kirkpatrick evaluationlevels.35
Future research should focus efforts on developing an assessment to better understand the cultural factors that may affectthe delivery of training and feedback, and subsequent changes
in safety behaviour. Is it possible Hofestede’s data on culturaldifferences accurately explains how training and testing should
be developed and delivered differently to Hispanics; and thatsuch changes to training and testing do lead to differences inreactions, learning, behaving and results? More speciﬁcally, does
receiving feedback as a group create a greater sense of belonging
to a group or community, and does that sense of belonging
create more engagement and commitment to working safely?
One could systematically examine face-to-face training in small
groups versus individual CBT to determine whether interactions
with trainers and peers improve knowledge acquisition, transferof training, sense of belonging, psychological safety, and diversity and safety climate. One limitation of the present study wasthat the research design was not fully counterbalanced, in thatnone of the employees received Spanish training prior to
English training. This approach was chosen because theresearchers were primarily interested in the effects of adding
Spanish training to the common workplace scenarios of English
training only or no training at all for Hispanic workers.
However, future researchers should adopt research designs that
include counterbalancing in order to permit stronger causal
inferences. Lastly, researchers should involve Hispanic workers
in the development phase of training and feedback materials sothey are more culturally appropriate, and examine the effects ofWhat is already known on the subject▸ Hispanic workers are not receiving adequate safety trainingthat accounts cultural, language and/or learning barriers toprevent occupational injuries.
▸ There is a lack of research reporting the evaluation oftraining with behavioural and results measures, especiallywith Hispanics’ workplace safety.
▸ CBT is an effective method for improving Hispanics’ safetyknowledge and behaviour, but it is not always a practical,
adequate or cost-effective solution for small businesses.

DISCUSSION
Our analyses found that a foreign-born Hispanic workforce
with limited English literacy and formal education: (a) learned
and applied work-related safety tips when training was deliveredin Spanish; (b) preferred face-to-face, small group training(95%), (c) increased safety communication and discussion; and(d) improved conﬁdence towards work and self. This study also
found that learning is related to behaviour change, but it is not
the only factor.8 Our ﬁndings appear to suggest that transfer oftraining is facilitated by feedback, even in the absence of praise,rewards and goals. The implications of these ﬁndings are that
researchers examining Hispanic workers’ safety should not only
be concerned about how training is developed and delivered,Lebbon AR, et al. Inj Prev 2015;21:404–414. doi:10.1136/injuryprev-2015-041620

What this study adds
▸ A systematic assessment of an organisation’s training needs
to guide development, implementation and evaluation of abehavioural safety process with Hispanic workers.
▸ Behavioural, graphic feedback facilitated the transfer oftraining with safety behaviour.
▸ Hispanic workers preferred small group training with videos
instead of group training with pictures.
413

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Methodology
such involvement given that this has been demonstrated to bean effective component with American workers.36

11

12

CONCLUSION
The improvements to the target company’s safety training, monitoring and feedback process resulted in increases with theirHispanic workers’ safety behaviour, knowledge, work and selfconﬁdence. The language translation of training and testingmaterials was related to improved knowledge acquisition, perceptions of safety and preference for group training withvideos; yet it appears that feedback was the crucial factor forchanges in safety behaviour. A cost-effective, low-technology,
behavioural safety process aimed at foreign-born Hispanic
workers can contribute to improvements in safety behaviour
and medical costs associated with injuries.
Acknowledgements The authors wish to thank anonymous reviewers for theirvaluable suggestions that improved this manuscript, especially with respect to thedata analysis.
Contributors ARL: conceived and designed the study, obtained funding, locatedand secured participating organisation, conducted interview/tour assessment,
developed safety process, conducted statistics, manuscript writing and revision for
publication. SCL: wrote ethics protocol, conducted interview/tour assessment andinjury assessment, developed checklist and training materials, data collection andmanagement, research assistant and participant training, cost–beneﬁt analysis,
approval of version to be published. DJ: designed the study, located research
assistants, managed weekly data updates, organisation, and interpretation, cost–beneﬁt analysis, edited ethics protocol, approval of version to be published.
Funding This work was supported by PSC-CUNY Award (grant number 65744-00
43), jointly funded by The Professional Staff Congress and The City University of
New York.

13
14

15

16

17
18
19

20

21

22

23

24

Competing interests None declared
Ethics approval City University of New York and Western Michigan University’s
ethics boards.

25

Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The data used for analysis in this study are available
from ARL and SCL. Almost all the analyses performed are presented in thismanuscript.

26

REFERENCES

28

1
2
3

4

5
6
7

8
9
10

414

Smith SM, Perry T, Moyer D. Creating a safer workforce: training needs for
Hispanics and foreign-born workers. Prof Saf 2006:20–5.
Harrington D, Materna B, Vannoy J, et al. Conducting effective tailgate trainings.
Health Promot Pract 2009;10:359–69.
Sokas R. CDC Efforts to Address the Health and Safety Needs of ImmigrantWorkers. Testimony Before the Senate Subcommittee on Employment, Labor andPensions, Committee on Health, Education, Labor, and Pensions 27 February 2002.
http://www.hhs.gov/asl/testify/t20020227.html
Acosta-Leon AL, Grote BP, Salem S, et al. Risk factors associated with adverse
health and safety outcomes in the US Hispanic workforce. Theor Iss Ergo Sci
2006;7:299–310.
Hofstede G. National cultures in four dimensions: a research-based theory ofcultural differences among nations. Int Stud Mgmt Org 1983;13:46–74.
Hofstede G. Research and VSM: The Dimension Data Matrix. 2015. http://
geerthofstede.eu/research--vsm
Irvine JJ, York DE. Learning styles and culturally diverse students: a literature review.
In: Banks JA, Banks CAM, eds. Handbook of research on multicultural education.
New York: Macmillan, 1995:484–97.
Arthur W, Bennett W, Edens P, et al. Effectiveness of training in organizations: ameta-analysis of design and evaluation features. J of Appl Psy 2003;88:234–45.
Geller SE. Behavior-based safety in industry: realizing the large-scale potential of
psychology to promote human welfare. App Prev Psych 2001;10:87–105.
DePasquale JE, Geller ES. Critical success factors for behavior-based safety: a studyof twenty industry-wide applications. J Safety Res 1999;30:237–49.

27

29

30

31

32

33
34
35
36

Austin J. Performance analysis and performance diagnostics. In: Austin J,
Carr JE, eds. Handbook of applied behavior analysis. Reno, NV: Context Press,
2000:321–50.
Burke MJ, Sarpy JA, Smith-Crowe K, et al. Relative effectiveness of worker safety
and health training methods. Am J Public Health 2006;96:315–24.
Saks AM, Burke LA. An investigation into the relationship between training
evaluation and the transfer of training. Int J Train Dev 2012;16:118–27.
Levesque DL, Arif AA, Shen J. Effectiveness of pesticide safety training andknowledge about pesticide exposure among Hispanic farmworkers. J Occup Environ
Med 2012;54:1550–6.
Williams Q, Ochsner M, Marshall E, et al. The impact of a peer-led participatory
health and safety training program for Latino day laborers in construction. J Safety
Res 2010;41:253–61.
Chapman LJ, Newenhouse AC, Pereira KM, et al. Evaluation of a four year
intervention to reduce musculoskeletal hazards among berry growers. J Safety Res
2008;39:215–24.
Donaldson SI, Grant-Vallone EJ. Understanding self-report bias in organizational
behavior research. J Bus Psych 2002;17:245–60.
Cooper MD. Behavioral safety interventions: a review of process design factors.
Prof Saf 2009;54:36–45.
Brown MG, Malott RW, Dillon MJ, et al. Improving customer service in a large
department store through the use of training and feedback. J Org Beh Manag
1980;2:251–65.
Myers WV, McSween TE, Medina RE, et al. The Implementation and Maintenanceof a Behavioral Safety Process in a Petroleum Reﬁnery. J Org Beh Manag
2010;30:285–307.
Anger WK, Tamulinas A, Uribe A, et al. Computer-based training for
immigrant Latinos with limited formal education. Hispanic J Behav Sci 2004;26:
373–89.
Anger WK, Stupfel J, Ammerman T, et al. The suitability of computer-based training
for workers with limited formal education: A case study from the US agricultural
sector. Int J Train Dev 2006;10:269–84.
Austin J, Alvero AM, Fuchs MM, et al. Pre-training to improve workshop
performance in supervisor skills: An exploratory study of Latino agricultural workers.
J Agric Saf Health 2009;15:273–81.
Amigo S, Smith A, Ludwig T. Using task clariﬁcation, goal setting, and feedback todecrease table busing times in a franchise pizza restaurant. J Org Beh Manag
2008;28:176–87.
Austin J, Weatherly NL, Gravina NE. Using task clariﬁcation, graphic feedback, andverbal feedback to increase closing-task completion in a privately owned restaurant.
J Appl Beh Anal 2005;38:117–20.
Johnson DA, Rubin S. effectiveness of interactive computer-based instruction: areview of studies published between 1995 and 2007. J Org Beh Manag
2011;31:55–94.
McSween T. The value-based safety process: improving your safety culture withbehavior-based safety. 2nd edn. New York: Wiley, 2003.
Occupational Safety & Health Administration (OSHA). Healthcare Wide Hazards:
Ergonomics. n.d.-a. https://www.osha.gov/SLTC/etools/hospital/hazards/ergo/ergo.
html
Occupational Health and Safety Agency for Healthcare in BC (OSHAH). An
Ergonomics Guide for Hospital Laundries. 2003. http://www.mtpinnacle.com/pdfs/
LaundryHandbook.pdf
Occupational Health and Safety Agency for Healthcare in BC (OSHAH). Using Carts
in Healthcare: A Resource Guide for Reducing Musculoskeletal Injury. 2005. http://
www.asstsas.qc.ca/documents/Dossiers%20thematiques/Equipements/Chariots/OHSAH_Rolling%20Carts%20Handbook.pdf
WorkSafeBC. MSI Prevention Bulletin 8: Laundry in Health Care Facilities; n.d. http://
www.worksafebc.com/publications/health_and_safety/bulletins/msi/assets/pdf/msi8_
laundry.pdf
Occupational Safety & Health Administration (OSHA). OSHA’s $afety Pays Program:
Estimated Costs of Occupational Injuries and Illnesses and Estimated Impact on a
Company’s Proﬁtability Worksheet; n.d.-b. https://www.osha.gov/dcsp/smallbusiness/safetypays/estimator_text.html
Business Roundtable. Improving construction safety performance. Report A-3. 1982.
http://constructionsafetyconsultant.com/articles/report_a_3.pdf
Cohen J. Statistical power analysis for the behavioral sciences. 2nd edn. Hillsdale,
NJ: Erlbaum, 1988.
Kirkpatrick DL, Kirkpatrick W. Evaluating training programs: the four levels. 3rd edn.
San Francisco, CA: Berrett-Koehler, 2006.
Sigurdsson SO, Austin J. Institutionalization and response maintenance inorganizational behavior management. J Org Beh Manag 26:41–77.

Lebbon AR, et al. Inj Prev 2015;21:404–414. doi:10.1136/injuryprev-2015-041620

Downloaded from http://injuryprevention.bmj.com/ on November 25, 2015 - Published by group.bmj.com

Feedback facilitates transfer of training with
US Hispanic workers in a healthcare laundry
linen facility
Angela R Lebbon, Sin Chien Lee and Douglas A Johnson
Inj Prev 2015 21: 404-414 originally published online July 14, 2015

doi: 10.1136/injuryprev-2015-041620
Updated information and services can be found at:
http://injuryprevention.bmj.com/content/21/6/404

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