Background and Purpose of this Report

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WORKER HEALTH AND SAFETY PATIENTCARE
A FALSE DICHOTOMY
Dr. Annalee Yassi, MD, MSc, FRCPC Tier 1 Canada
Research Chair, College for Interdisciplinary
Studies Professor, School of Population and
Public Health, and Department of Medicine,
UBC Founding Executive Director, Occupational
Health and Safety Agency for Healthcare,
BC Chair, Scientific Committee on Health Care,
International Commission on Occupational Health.
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• 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 doesnt 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.

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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 HS 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

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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. Smiths granddaughter, Doreen and
  her boyfriend, Butch, arrive to visit him

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Scenario contd

• 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.

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Scenario contd

• What questions do you have? What do you want to
  see investigated?
• _________________________________________
• _________________________________________
• _________________________________________
• _________________________________________
• _________________________________________
• _________________________________________

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Scenario contd

• 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).

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Scenario contd

• 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.

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Scenario discussion

• How could this have been improved?
• ________________________________
• ________________________________
• ________________________________
• ________________________________
• ________________________________
• ________________________________
• ________________________________
• ________________________________

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Scenario contd

• 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.

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A healthy workplace
one that maintains and promotes the mental and
physical health of its employees

• Common psychosocial factors that effect mental
  health
• feeling overwhelmed by the physical demands
• unhappiness with the workplace social environment
• lack of decision-making control
• lack of support from co-workers
• feeling overqualified for the job

• Job strain affects personal relationships,
  increases sick time and job dissatisfaction, and
  is associated with increased injuries.

• Health outcomes include stress-related health
  behaviours and increased risk of morbidity.

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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.

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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

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2. Worker health and safety and patient care

• Canadian Adverse Events Study
• 7.5 of Canadas 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.

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Worker health and safety and patient care contd

• 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

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Worker health and safety and patient care contd

• 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

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Organizational safety culture
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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.

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Organizational safety culture contd

• 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

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Organizational safety culture contd

• 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.

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Worker injury
Organizational safety culture
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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.

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Worker injury contd

• 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 staffs beliefs re facilitys 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.

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Worker injury contd

• 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

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Worker injury
Organizational safety culture
Worker safety (fatigue)
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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.

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Worker safety (fatigue) contd

• 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.

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Worker safety (fatigue) contd

• 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 gt
  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.

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Worker injury
Organizational safety culture
Worker safety (fatigue)
Worker burnout
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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.

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Worker burnout contd

• 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.

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Worker burnout contd

• 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.

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Worker burnout contd

• 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.

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Worker injury
Organizational safety culture
Worker safety (fatigue)
Worker burnout
Worker compliance with Infection control
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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.

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Worker compliance with infection control contd

• 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.

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Worker compliance with infection control contd

• 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.

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Worker injury
Organizational safety culture
Worker safety (fatigue)
Worker burnout
Worker compliance with Infection control
Patient safety
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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
  patientprovider 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.

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Worker injury
Organizational safety culture
Worker safety (fatigue)
Worker burnout
Timeloss
Worker compliance with Infection control
Understaffing
Patient safety
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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

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How can healthcare decision-makers and health and
safety committee representatives IMPROVE
organizational safety culture
Individual Factors Knowledge, perception of
risk, beliefs/attitudes, past history
especially with perception of
organizational safety climate, subjective
norm influence, etc. and sociodemographics.
Organizational Factors Managements expectations,
policies regarding overtime,
compliance policies related to safety (safety
climate), including reinforcing
factors, providing training and availability of
expertise with respect to occupational health,
etc.
Healthier and Safer Practices Adopted
Environmental Factors Availability of resources,
equipment and supplies (e.g., N95 respirators,
lifting devices, safety-engineered needles) and
other environmental factors (e.g. ventilation,
ergonomic design)
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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.

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• Especially where OH expertise is scarce Train
  Health and Safety Committees

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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

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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.

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OHASIS
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Information collected in OHASIS

• Incidents
• Workforce Health
• Infection Control
• Workplace Inspection
• Health and Safety Committee

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Incident Cause - Exposure
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Incident - Effect
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Incident - Activity
52
Incident Contributory Factors
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Prevention Measures
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New Workplace Inspection
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Checklist Example
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General Profile
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Occupational History/Hazards
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Vaccinations
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Training and Education
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Respirator Fit Test
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Health and Safety Committee
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Prevention Measures Follow up
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Infection Control
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Ad-Hoc reports
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Report Filtering (example)
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Exposure by Occupation Report
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Biological Exposures - filtered
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Incident Activity by Department
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Prevention Measures filter options
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Recommended Prevention Measures
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Healthy workplaces are key in any industry for
the bottom line in healthcare, bottom line is
patient care

• 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

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Healthy workplaces are key in any industry for
the bottom line in healthcare, bottom line is
patient care

• 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 workforceand 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.