WORKER HEALTH AND SAFETY PATIENTCARE:

2. �Our workplace has thought about moving to safer devices to prevent needlestick injuries in staff but it is cost prohibitive and we need funds for patient care.� �Our facility doesn�t have ceiling lifts. We believe that by training workers in proper handling techniques we will eliminate musculoskeletal injuries in workers, and can save our capital budget for patient-related capital investments.� �If only healthcare workers would work a bit harder, not take so many sick days and be more diligent we would be able to decrease patient errors.�

3. Outline Occupational health in the healthcare sector case study comprehensive approach why extra attention to healthcare workers  2. Worker health and safety and patient care growing concern regarding patient safety link between worker H&S and patient health and safety Organizational climate Worker injury Worker fatigue Worker mental stress/burnout Infectious disease transmission Patient safety overall� and the vicious circle 3. How can organizational culture be improved? What can healthcare do? International and local initiatives to better integrate efforts PICNet, Data standardization/linkage of worker and patient health �OHASIS/ WHO-ICOH-ILO Conclusion

4. The scenario John Smith, 89, suffers from dementia, moved from his long-term care setting to a medical ward in a large hospital due to deterioration in liver function. Maria, a young care aide, who was just recently hired, comes to bathe Mr. Smith He bites her arm and Maria screams Tom, an RN, comes in and restrains Mr. Smith A Code White is called Meanwhile Mr. Smith�s granddaughter, Doreen and her boyfriend, Butch, arrive to visit him

5. Scenario cont�d Butch, who may have been drinking, starts swearing at Maria and Tom, tries to stop Tom from holding Mr. Smith - punching Tom in the eye. Freddie Rose, 86, in the next bed, becomes scared and starts climbing over the rails to get out of room, and falls to the ground, injuring his hip. Gina, another RN runs in to help. She tries to lift Mr. Rose off the floor, injuring her back, & further injuring Mr. Rose.

6. Scenario cont�d What questions do you have? What do you want to see investigated? _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________

7. Scenario cont�d Investigation reveals: Maria had not received her training in how to bathe a person with dementia. Mr. Smith apparently had a history of biting but this was not flagged. The Code White team took way to long to arrive. There was no surveillance of visitors who may be inebriated (or armed).

8. Scenario cont�d Investigation reveals: There was no ceiling lift in the room or readily available floor lift for lifting patients Neither Tom nor Gina knew what they were supposed to do (how to restrain a patient, lift a patient from the ground) Gina had been working eleven hours at the time of her injury The medical resident, who may also have been working a lengthy shift, may have prescribed too high a dose of a medication that caused Mr. Rose to be confused.

9. Scenario discussion How could this have been improved? ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________

10. Scenario cont�d Follow-up revealed: - Maria had also not had her hepatitis B vaccine and a course was started along with post-exposure prophylaxis. She was also quite upset by what happened and was off with Post Traumatic Stress Disorder Tom lost two days of work while his eye healed. Gina lost 1 month from work as she recovered from her back injury. A police report was filed against Butch, as staff insisted. The episode was very costly to the hospital.

11. The link between workplace stress and injuries has been proven - Psychosocial factors include feeling overwhelmed by the physical demands of their job, unhappiness with the social environment, lack of decision making and of support, Resulting in job strain, which impacts relationships, sick time, workplace conflict and turnover, And results in stress related health problems, increased risk of morbidity, health behaviours and injury.The link between workplace stress and injuries has been proven - Psychosocial factors include feeling overwhelmed by the physical demands of their job, unhappiness with the social environment, lack of decision making and of support, Resulting in job strain, which impacts relationships, sick time, workplace conflict and turnover, And results in stress related health problems, increased risk of morbidity, health behaviours and injury.

12. Need for a comprehensive approach in occupational health and safety, and workplace health promotion Addressing either individual or organizational factors is limited: need for more holistic approaches � which address both primary and secondary prevention, the workers and the workplace, and address the individual as well as the organization � promoting healthy workplace culture. Note that in �Workplace Health Promotion� activities not all employees participate, and risks that are features of the environment are not mediated by individual workers� behaviors � intervention at multiple levels, including organization-level, will have the most effect. In looking at the relationship between health, injury and workplace stress, literature also speaks of the need for a comprehensive approach. Addressing either the individual, or only organisational factors is limited. Holistic approaches have been proven more effective, and are to include workplace culture, both primary and secondary prevention, and address both the individual AND the organsiation. In looking at the relationship between health, injury and workplace stress, literature also speaks of the need for a comprehensive approach. Addressing either the individual, or only organisational factors is limited. Holistic approaches have been proven more effective, and are to include workplace culture, both primary and secondary prevention, and address both the individual AND the organsiation.

13. Healthcare workers � why the extra attention? Healthcare system plagued by difficulties: Recruitment and retention High rates of work injuries Illnesses and absences from work Escalating costs Increasing concern about hazards, infectious diseases, chemical-induced disorders, violence, mental stress High rate of injuries and time loss compared to other sectors Increasing evidence that this is impacting patient care

14. 2. Worker health and safety and patient care Canadian Adverse Events Study: 7.5% of Canada�s 2.5 million hospital patients had at least one adverse event in 2000 and up to 23,750 patients died as a result. In 1999, To Err is Human, reported that between 44,000 and 98,000 people die each year as a result of preventable medical errors in the US.

15. Worker health and safety and patient care cont�d Preventable healthcare errors occur in 1 in every 10 patients around the world, the World Health Organization has called patient safety an endemic concern Most common causes of health care error: Human factors such as fatigue, burnout or time pressures Medical complexities such as complicated technologies System failures such as similar drug packaging or equipment failure/malfunction

16. Worker health and safety and patient care cont�d Much discussion in the patient safety literature around reporting and the need for a no-blame culture where errors can be reported New voluntary system in the US for reporting of near-misses called SafetyNet which strives to track and notify hospitals of potential issues around common errors Danish Act on Patient � as of 2004, Denmark became the first country to introduce nation-wide mandatory reporting of adverse events

18. Organizational safety culture Culture and climate are sometimes used interchangeably - though they are distinct: Safety climate: employees' perceptions, attitudes, and beliefs about risk and safety, typically measured by questionnaire surveys and providing a �snapshot� of the current state of safety. Safety culture: more complex and enduring, reflecting fundamental values, norms, assumptions and expectations, which to some extent reside in societal culture. Expression of these �cultural� elements can be seen through safety management practices which are reflected in the safety climate.

19. Organizational safety culture cont�d Organizational culture and safety climate are increasingly emerging as important determinants of both caregiver well-being and patient safety It is known that common causes of errors leading to adverse events include organizational factors such as: lack of communication or miscommunication, lack of attention to safety procedures, inadequate supervision, breaks in continuity of care, excessive workload and inadequate numbers of staff for specified tasks

20. Organizational safety culture cont�d Importance of creating a culture of safety, where workers feel safe to report adverse events and near misses as well as to correct co-workers potential errors. However, this can create further stress for HCWs if not instituted correctly.

22. Worker injury Systematic reviews have consistently found that HCWs are at high risk of musculoskeletal injuries, with patient handling posing particularly high risk.  Lifts and transfers of patients using awkward postures; adverse psychosocial aspects of work such as high job demands with low decision authority and job control; and low social support at work and low job satisfaction were all deemed to contribute to errors.

23. Worker injury cont�d In intermediate care facilities in BC, our studies revealed the particular importance of organizational philosophy as a determinant of staff injuries: Major difference between care facilities with low staff injury rates versus high, regarding front-line staff�s beliefs re facility�s quality of care and their own capacity to deliver good care. Workers in high-injury rate facilities had: more negative perceptions of their job demands and workload pressures; more likely to report not have enough time to get work done, safely, to find a partner or to use a mechanical lift. Workers in high injury rate facilities also: reported more pain, more burnout, poorer personal health and less job satisfaction. Conversely, workers at facilities with low injury rates were more likely to agree that their facility had enough staff and did indeed provide good to excellent care.

24. Worker injury cont�d Evidence linking organizational safety culture with worker injury Adverse psychological work conditions in combination with physical demands increase the risk of injury compared to either factor alone Higher job satisfaction, higher control over practice and lower job demands are associated with fewer on-the-job accidents and injuries in nurses High psychological job demands such as excessive work, conflicting demands and insufficient time to complete tasks have been identified as risk factors for occupational injury

26. Worker safety (fatigue) Fatigue: �temporary loss of strength and energy resulting from hard physical or mental work�. The effect of fatigue, wakefulness and lack of sleep well researched in many industries; recent focus on effects of fatigue on performance in health care settings. On July 1st, 2003 the Accreditation Council for Graduate Medical Education (ACGME) invoked rules on mandated work-hour restrictions for medical residents in an or �attempt to improve patient safety by reducing resident fatigue. Despite this, policies still not protecting workers: �work shifts of 32 hours with 2 to 3 hours of sleep �can go undetected by the present enforcement system.�

27. Worker safety (fatigue) cont�d Fatigue of healthcare providers is slowly emerging as an important determinant of patient safety, suggesting that work schedules may affect patient safety. A recent study demonstrated increased error rates in nurses working longer shifts, and studies of errors committed by medical residents found strong correlation with sleep deprivation. Indeed, a recent randomized controlled trial (RCT) demonstrated that modification of intern work schedules reduced rates of serious medical errors by 26%. Also, fatigue has been implicated in the occurrence of worker injuries, including needle-stick injuries and motor vehicle crashes.

28. Worker safety (fatigue) cont�d Nurses working shifts greater than 12.5 hours are at significantly increased risk of decreased vigilance on the job, occupational injury, or making a medical error. Physicians-in-training working traditional > 24-hour on-call shifts are at greatly increased risk of experiencing sharps injury or a motor vehicle crash on the drive home from work and of making a serious or even fatal medical error.

30. Worker burnout Burnout in healthcare workers is well-documented. The nature of the work, the long hours and the possibility of shift-work can all lead to burnout. In the healthcare industry in BC, mental disorders are the fastest growing cause of long-term disability.

31. Worker burnout cont�d Shanafelt et al. found in residents: the only factor which was associated with self-reported suboptimal patient care practices was burnout. Conversely, compromise in patient safety caused by organizational change could significantly impact the psychological well-being of healthcare providers.

32. Worker burnout cont�d Studies have documented that the perception of having made an error causing an adverse patient outcome creates substantial emotional distress that can cause longstanding feelings of fear, guilt, anger, and embarrassment. Because of organizational culture, adequate coping mechanisms (such as accepting responsibility, discussion with colleagues, disclosure to patients, etc.) are usually not readily available to HCWs.

33. Worker burnout cont�d Key job stress factors associated with ill health among HCWs are: work overload, pressure at work, lack of participation in decision making, poor social support, unsupportive leadership, lack of communication/feedback, staff shortages or unpredictable staffing, scheduling or long work hours, and conflict between work and family demands. Evidence: not only psychological well-being of the workforce, but also patient care.

35. Infection control � well-established link between worker safety and patient safety Infection control is a critical factor in the health and safety of patients. Hospital acquired infections are the fourth largest killer in Canada. Each year, 220,000-250,000 hospital acquired infections result in 8,000-12,000 deaths. 30-50% of these hospital-acquired infections are preventable. Healthcare workers are at increased risk of infections Risks are growing due to a globalized world � examples of SARS and Arenavirus and other hemorrhagic viruses, TB, etc.

36. Worker compliance with infection control cont�d Nosocomial infections now affect 5-15% of all hospitalized patients and can lead to complications in 25-50% of those admitted to ICUs In addition, patients are also at risk of infectious diseases such as influenza, pertussis and varicella as well as bloodborne pathogens.

37. Worker compliance with infection control cont�d Numerous opportunities exist for HCWs to increase the risk of infection in patients. A HCW with a communicable infection may transmit it to a patient during a patient care interaction. Reducing these risks requires education to HCWs as well as appropriate vaccination. Positive patient outcomes related to HCW health have been reported. Influenza vaccination of HCWs reduces influenza-related mortality in elderly in LTC and hospitals. one study: vaccinating eight healthcare workers can prevent the death of one patient. many healthcare workers cite �patient health� as a motivating factor for vaccination.

39. Patient Safety Workers must feel safe to report adverse events and near misses as well as to correct co-workers A key barrier to disclosure is uncertainty of HCWs regarding how much information to share with patients after adverse events Disclosures are complex and subtle discussions and should be tailored to the nature of the event, the clinical context, and the patient�provider relationship. In a recent paper, Youngberg discussed the importance of changing the culture of reporting; all in the organization should be educated to see the reporting system as an early warning signal. However, reporting can create further stress for HCWs if not instituted correctly; the literature points to the need to address teamwork to improve patient care.

41. How can organizational culture be improved? Organizational culture is a challenge to change Change cannot just come from the top down successful strategies need to take into account the needs, fears, and motivations of staff at all levels Need to address issues as the organizational structure, financial arrangements, lines of control and accountability, strategy formulation, human resource management initiatives�.and good labour relations

42. How can healthcare decision-makers and health and safety committee representatives IMPROVE organizational safety culture

43. How can organizational culture be improved? Accept that mistakes may be made but catching the mistake will prevent further errors. The idea of �trust� is important � workers need to trust they are supported in telling about their own errors and those of colleagues. Teamwork is key to preventing errors and feeling supported at work.

44. Especially where OH expertise is scarce: Train Health and Safety Committees

45. Local and International initiatives PICNet, as example of collaboration for both worker and patient safety Greater cooperation internationally Focus now on data sharing � OHASIS, and the WHO-ILO-ICOH project

46. PICNet Provincial Infection Control Network of BC Mission: To maximize coordination and integration of activities related to health care associated infection, prevention, surveillance and control for the province of British Columbia, using an evidence-based approach. PICNet aims to achieve its mission by: Providing advice on relevant policy and issues; Providing. best practice guidelines; Fostering collaboration; Sharing information; and Advocating on behalf of the community of practice for appropriate and sustainable resources.

47. OHASIS

48. Information collected in OHASIS

49. Incident � Cause - Exposure

50. Incident - Effect

51. Incident - Activity

52. Incident � Contributory Factors

53. Prevention Measures

54. New Workplace Inspection

55. Checklist Example

56. General Profile

57. Occupational History/Hazards

58. Vaccinations

59. Training and Education

60. Respirator Fit Test

61. Health and Safety Committee

62. Prevention Measures Follow up

63. Infection Control

64. Ad-Hoc reports

65. Report Filtering (example)

66. Exposure by Occupation Report

67. Biological Exposures - filtered

68. Incident Activity by Department

69. Prevention Measures � filter options

70. Recommended Prevention Measures

71. There is no dichotomy between patient care and the health of the healthcare workforce vicious circle of time loss due to injury, illness and stress; combined with difficulties in recruitment/retention ? short staffing ? workload ? impact on patient care ?more stress, greater burden, more difficulties in recruitment/retention and more injuries, illness and stress..� and same fundamental root causes Healthy workplaces are key in any industry for the bottom line; in healthcare, bottom line is patient care

72. Promoting a culture of safety � includes paying attention to the organizational factors (including developing the best practices, policies, procedures, accessibility of expertise, training, surveillance) as well as environmental factors (including proper equipment and safe environment) needed to promote the health and safety of the healthcare workforce�and are often the very same practices, expertise, data, equipment as is needed for safe patient care: Not only is it the right thing to do for healthcare workers, but also to protect the public, and to ensure the on-going availability of healthy healthcare workers to provide care in the future. Healthy workplaces are key in any industry for the bottom line; in healthcare, bottom line is patient care