Health & Safety 2014

HEALTH AND SAFETY 2 0 1 4 A QN U p u b l ic at ion f or m e m b e r s

TAKE CONTROL

FOR SAFE, HEALTHy WORKPLACES

Introduction Welcome to the 2014 edition of the Queensland Nurses’ Union’s Health and Safety Yearbook.

Our theme this year—Take control for safe, healthy workplaces—is an extension of the QNU’s new ‘Nurse Power, Midwife Power’ rallying cry, which reminds us of our strength, courage, and professional power.

It is this very power we urge you to tap into to take control of health and safety in your workplace.

Every year the QNU receives hundreds of calls from distraught and anxious members who have been injured at work or have been reported for making errors – and in many cases health and safety issues such as fatigue, unreasonable workloads or poor safety standards have been a contributing factor.

It is for this reason we are urging you and your colleagues to harness your individual and collective ‘power’ to stand up for your right to a safe work environment.

Beth Mohle

By using legislation, regulatory frameworks and your professional judgement to help make your case, you have the power to make your workplace safe.

Whether it be campaigning for manual handling training, seeking better security or lighting, standing firm on ratios or ensuring you get adequate breaks for fatigue management, championing workplace safety is not only good for you but is also good for your patients.

In this year’s handbook you will find a collection of research papers, journal articles, case studies, information sheets and resources which highlight the importance and effectiveness of nurse and midwife-led action on health and safety.

We hope this material will inspire and empower you to speak up about health sand safety issues, to work with your colleagues, your health and safety reps, employers and where necessary your union to address problems.

Des Elder

At the back of this book you will also find a list of QNU resources you can draw on for support.

If you think you have a workplace health and safety issue that needs addressing, but are not sure how to go about it, you can start by calling QNU Connect on (07) 3099 3210 or 1800 177 273 (toll free for members outside of Brisbane).

We hope you use this year’s handbook effectively.

Beth Mohle Secretary

Des Elder Assistant Secretary

June 2014

Contents

Published by the Queensland Nurses’ Union Secretary: Beth Mohle 106 Victoria Street, West End Q 4101 (GPO Box 1289, Brisbane Q 4001) T 07 3840 1444 1800 177 273 (toll free) F 07 3844 9387 E qnu@qnu.org.au W www.qnu.org.au REGIONAL OFFICES Toowoomba 66 West St, Toowoomba Q 4350 (PO Box 3598, Village Fair, Toowoomba Q 4350) T 07 4659 7200 F 07 4639 5052 E qnutwmba@qnu.org.au Bundaberg 44 Maryborough St, Bundaberg Q 4670 (PO Box 2949, Bundaberg Q 4670) T 07 4199 6101 F 07 4151 6066 E qnubberg@qnu.org.au Rockhampton Suite 1, Trade Union Centre 110 Campbell Street, Rockhampton Q 4700 (PO Box 49, Rockhampton Q 4700) T 07 4922 5390 F 07 4922 3406 E qnurocky@qnu.org.au Townsville 1 Oxford Street, Hyde Park Q 4812 (PO Box 3389, Hermit Park Q 4812) T 07 4772 5411 F 07 4721 1820 E qnutsvle@qnu.org.au Cairns Suite 2, 320 Sheridan St, North Cairns Q 4870 (PO Box 846N, North Cairns Q 4870) T 07 4031 4466 F 07 4051 6222 E qnucairns@qnu.org.au DISCLAIMER

Statements expressed in articles in The Queensland Nurse are those of the contributor and do not necessarily reflect the policy of the Queensland Nurses’ Union unless this is so stated.

Copyright of articles remains with the contributor and may not be reproduced without permission. Statements of facts are believed to be true but no responsibility for inaccuracy can be accepted. Other material may be reproduced only by written arrangement with the Union. Although all accepted advertising material is expected to conform to the QNU’s ethical standards, such acceptance does not imply endorsement.

2

Section 1

18

Section 2

background

EMPOWERING YOU TO KEEP YOUR WORKPLACE SAFE CH 2.1: Standing up for safety: A HSR’s story CH 2.2: Case studies CH 2.3: The impact of safety representatives on occupational health CH 2.4: Health work environments for the ageing nursing workforce CH 2.5: Reducing aggression in the haemodialysis unit by improving the dialysis experience for patients CH 2.6: Through the eyes of the workforce: Creating joy, meaning and safer health care

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Section 3

TOOLS THAT CAN HELP CH 3.1: Workplace Health and Safety Representatives CH 3.2: Power through the BPF: It’s all about patient safety CH 3.3: Being safe at work

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Section 4

EDUCATION AND USEFUL INFORMATION Worksheet: Body mapping Checklist: Risk factors in your workplace Checklist: Security Audit CPD reflective exercise How QNU can support you Further reading

HEALTH AND SAFETY 2014 ■ 1

SECTION 1

BACKGROUND The right of nurses and midwives to control their profession is a hard won right indeed. In the past 120 years nurses and midwives have had to overcome some fairly dismissive and patronising attitudes to take the lead on issues such as nursing and midwifery registration, education, training, and workplace health and safety.

In this fascinating historical paper, author Deborah Palmer outlines the challenges that English nurses faced at the turn of the 20th century to be recognised as professionals in their own right, with the right to appropriate working conditions.

This article provides a sort of backdrop to the rest of this year’s Handbook—it illustrates how nurses often had to battle the belief that getting sick from overwork or unsafe working conditions was just part of the job—an acceptable sacrifice nurses had to make for the good of the greater population.

It outlines how succumbing to or complaining about conditions was often seen by managers as a character flaw or an unwillingness to work.

This article also reminds us that nurses and midwives must take the lead on standing up for their wellbeing in the workplace.

It reminds us that we have the power in our hands to advocate for our profession and create better, safer workplaces for all nurses and midwives—which ultimately means better, safer, quality care for patients.

“To Help a Million Sick, You Must Kill a Few Nurses”: Nurses’ Occupational Health, 1890-1914 Palmer, Deborah, Nursing History Review, January 1, 2012

Although nursing is recognized today as a serious occupational health risk, nursing historians have neglected the theme of occupational health and individual nurses’ experience of illness. This article uses the local history of three case study institutions to set nurses’ health in a national context of political, social, and cultural issues, and suggests a relationship between nurses’ health and the professionalization of nursing. The institutions approached the problem differently for good reasons, but the failure to adopt a coherent and consistent policy worked to the detriment of nurses’ health. However, the conclusion that occupational health was somehow neglected by contemporary actors was, nevertheless, erroneous and facilitated omission of the subject from historical studies concentrating on professional projects and the wider politics of nursing. This article shows that occupational health issues were inexorably connected to these nursing debates and cannot be understood without reference to professional projects.

In 1890, probationer nurse Ellen Yatman told the Select Committee of the House of Lords on the Metropolitan Hospitals that nursing caused her ill health.1 During her 18 months of training at The London Hospital, Yatman complained that she, like “most of the nurses,” constantly suffered from “overwork” and “overtiredness.” The causes of her fatigue, she believed, included an 83-hour working

week and the onerous, menial cleaning duties that took up most of her working day. She also protested that a shortage of trained staff placed inexperienced nurses in positions of overwhelming responsibility and that overcrowded wards were inadequately staffed.2 Yatman’s short-lived nursing career came to an end when she contracted “blood poisoning from sewer gas,” a smell she believed emanated from the sink basins in her ward but which affected most parts of the hospital.

This article examines attitudes toward nurses’ health at three case study hospitals and suggests a relationship between nurses’ health and the professionalization of nursing.3 Nursing was drawn into the political spotlight at the end of the 19th century. The campaign for nurse registration began in 1887, prompting doctors and nurse leaders to redefine nurses’ work and place in the hospital hierarchy: commentators often supported their arguments for and against change with reference to nurses’ health. It was used as a barometer to measure the extent to which change was possible within the existing power structures of 19th-century hospitals. As we will see, supporters and opponents of registration had very different ideas about the organization of nursing. This article examines how these ideas not only shaped national nurse organizations’ strategies but also affected individual nurse’s experience of illness.

The London Hospital c. 1927

Source: http://nucius.org

HEALTH AND SAFETY 2014 ■ 3

SECTION 1 Three case studies were chosen to assess whether and why nurses’ experience varied between hospitals. I will focus first on The London Hospital, a large, metropolitan, voluntary teaching hospital whose matron, Eva Luckes, was important as registration’s leading opponent. The London Hospital is then contrasted with the South Devon and East Cornwall (SDEC) Hospital, a much smaller provincial, voluntary hospital, whose matron, Harriet Hopkins, supported nurse registration, and the Cornwall Lunatic Asylum, a rural mental asylum whose matrons expressed no interest in the politics of nursing. I can thus compare the practice of nurses’ health care between an asylum and a voluntary hospital and between a large and small voluntary hospital.

I focus on the matron’s role in relation to the practice of occupational health care. The matron’s role has been the subject of historical debate. Stuart Wildman and Alistair Hewison suggest that, contrary to previous analyses of nursing history that presumed matrons had independent control over nursing departments by the late 19th century, doctors and lay committees retained significant power.4 Assessing the distribution of power between these key actors will take into account how power to shape health policy affected the lives of ordinary nurses.

Campaign for Nurse Registration The campaign for nurse registration began when a disagreement between Henry Burdett and various matrons, including Ethel Gordon Fenwick,5 led to the formation of the splinter group British Nurses’ Association (BNA) from Burdett’s Hospital Association. The BNA was one of the first pressure groups to promote registration. Before her marriage (as Ethel Gordon Manson), Ethel Gordon Fenwick had been pioneering matron at St. Bartholomew’s Hospital. She was important as registration’s leading advocate, wishing to establish nursing as an autonomous profession, controlling its own fees and conditions of service. Registration’s opponents, led by Luckes, wished to maintain the voluntary hospitals’ existing system of management.6 The Select Committee of the House of Lords on Metropolitan Hospitals was the first public forum in which the registration debate was aired.7 The committee was set up following several complaints by some of The London Hospital’s governors to the Charity Organisation Society; the governors were aggrieved that, among other things, the position of matron had become too powerful. The Charity Organisation Society petitioned Lord Sandhurst, demanding that a Select Committee of the House of Lords inquire into the work of the metropolitan hospitals.8 The committee was highly politicized and set out many registration protagonists’ objectives. Gordon Fenwick focused on the need for professional self-regulation, advocating establishment of a controlling body to regulate education and work conditions; Luckes set out to demonstrate that individual hospitals were capable of setting high standards of professional behavior without state regulation.

The Select Committee was given a broad charge but spent a substantial amount of time examining witnesses from The London Hospital. Of the 23 meetings held, 10 were concerned with The London Hospital and with allegations that it neglected nurses’ health. Several contemporary newspaper reports questioned the reliability of the committee’s evidence,9 suggesting that Gordon Fenwick had planted witnesses who held a grudge against Luckes.

Newspaper coverage of the proceedings undoubtedly reflected the articles’ allegiances to parties in the registration campaign. For example, the Pall Mall Gazette was anti-The London Hospital; The Hospital (run by Burdett) was proThe London Hospital and antiregistration; the Nursing Record was anti-The London Hospital and proregistration.

“To help a million sick, you must kill a few nurses”10 was typical of several headliners in the Pall Mall Gazette, designed to shock its readership and discredit The London Hospital.11 Registration’s supporters and opponents did agree on the need to attract more middle-class recruits as a way to raise nursing’s status.12 It was, therefore, the special attributes and vulnerabilities of middle-class women that framed discourses about the organization of nursing and nurses’ health. Citing nurses’ health gave credibility to the necessity for improvements to working and living conditions. It was also used to limit change by suggesting that middle-class women lacked the physical and mental strength of their working-class counterparts and were unable to perform the menial tasks implicit to 19th-century nursing. However, the campaign’s emphasis on nursing as a respectable occupation may explain why it escaped state reform.

Women’s Work, Health, and State Reform The construction of nurses’ occupational health reflected larger debates on employment conditions in this period.

State involvement with working conditions in the industrial system had begun much earlier in the century. However, the idea of involvement developed slowly and in a limited direction, focusing on women and children working in factories, mines, and workshops. The Factory Acts extended legislation but placed additional limits on the employment of women and children. The late 19th century witnessed unprecedented levels of concern and debate about women’s paid work and its consequences on health, prompted by growing trade unionism and feminist activism. For example, mounting agitation around women’s labor as outworkers, known as “sweating,” prompted a House of Lords Committee on the sweating system (1888-1890) to investigate working conditions in a range of poorly paid and badly treated workforces. The committee focused on low wages, which, they argued, led to excessive hours of work, but its report had little effect with only limited interventions under the Public Health Acts.13 Historian Sue

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BACKGROUND Hawkins notes that nurses joined the debate about sweating by writing to newspapers, complaining about long working hours and poor wages, hoping to capitalize on the mood for reform.14 One reason why nursing escaped state reform was that the campaign to attract middle-class women deflected concerns about health risks. Feminist historian Barbara Harrison argues, “middle-class women’s work was rarely considered to pose occupational health problems.”15 Legislative intervention in women’s employment was often made because there were social problems resulting from their work, particularly neglect of domestic and maternal duties.16 Such ideas carried legitimate currency in a climate of debates about infant mortality and industrial efficiency.

Anxiety about a declining birth rate and concern about the health of the working class, based on Britain’s need for a fit imperial race, not only placed great emphasis on women’s reproductive ability but also reinforced the idea that mothers in paid work were failures. The danger of women’s work and the threat it posed to the social and moral order of society was often debated in terms of occupational health risk. For example, women formed most of the cotton industry labor force and enjoyed a reputation for independence, a counterweight in a period when a woman’s place was defined by an ideology of domesticity. This reputation was a problem for some medical officers, who criticized female cotton workers’ alleged immorality outside work in debates about the health risks of “shuttle kissing.”17 Because the late-Victorian image of nurses embodied many of society’s ideal feminine characteristics, nurses were perceived as meeting the gendered expectations of women.

Nurses’ limited social lives as a result of the strict rules governing off-duty hours protected them from the type of criticism some working-class women’s lifestyles received.

The state’s focus on the relationship between workingclass women’s work and health meant that nursing escaped legislation to shorten working hours.

The London Hospital The London Hospital was a large, metropolitan, voluntary teaching hospital whose nursing staff consisted of matron Eva Luckes and her 4 assistants, 19 ward sisters, and 212 nurses and probationers caring for an average of 626 patients.18 Eight nurses died between 1888 and 1890, compared to seven nurses who died in the previous eight years combined.19 Commentators alleged that Luckes misused her considerable power to force nurses to work even when ill, and consequently, morbidity and mortality rates had risen.20 Nurses alleged that they were too scared to report sick for fear that they would be dismissed.21 These allegations attracted significant press interest because of their relationship to the campaign for nurse registration.

The rising mortality suggested a serious nurse health problem, and commentators were keen to explain why.

Attention focused on Luckes’s system of discipline and its effect on health.

Luckes accrued considerable power during her first 10 years as matron, causing resentment among some of the hospital’s 30 lay governors.22 Luckes was from an upper-class background and had the advantage of a Cheltenham College education.23 She achieved her position of authority by improving nurse education and writing nursing textbooks.

In 1881, she introduced a system of theoretical and practical training, and in 1884, she published her Lectures on General Nursing, adding Lectures to Ward Sisters in a second edition 2 years later.24 By 1890, she had established herself as an expert on nursing practice, thus, legitimizing her challenge to an entrenched governors’ committee, who assumed that her youth meant lack of experience and sought to limit her drive for reform. Doctors played little part in the management of the hospital and were not allowed to sit on either the governing or the house committee. The lay governing committee, many of whom had business interests in the city, had military backgrounds, and/or were landed gentry, were entirely responsible for all aspects of policy.

Doctors generally supported the way Luckes exercised power over the nursing department.

In order to demonstrate The London Hospital’s ability to set high standards of professional behavior without state regulation, Luckes enforced a militarized system of discipline that incorporated the care of sick nurses.

Expectations that nurses would endure ill health were intended to show that disciplined training produced a superior type of nurse who did not need state registration to prove her quality. Luckes used the analogy of a soldier’s commitment to personal sacrifice to illustrate the level of devotion to duty she required of nurses facing the risk of contracting infection.

Women who fear infection for themselves are greatly to be pitied, but they have no business to be nurses . . . it is this element of personal danger . . . which places the work of soldiers and of nurses on the same level. Nothing can tempt the true nurse or the true soldier from the post of danger when duty places them there. It is this very fact that sheds a halo over the ideal of a nurses’ work.25 Luckes acknowledged that a nurse’s death may arise “as a direct consequence of attending to her patient,” but claimed this was a price worth paying to “sanctify the work” and inspire others. Self-sacrifice was perceived as an essential quality in the professional nurse, and this could be demonstrated by ignoring ill health.

Nurses who failed to achieve this difficult goal were often perceived as self-centered troublemakers who lacked the vocation to nurse. Yatman, whose case was mentioned earlier, represented most aspects of the image of the “new” professional nurse. Educated and middle class, she had many of the qualities that nurse leaders promoted as vital

HEALTH AND SAFETY 2014 ■ 5

SECTION 1 to distinguish the new nurse from her supposedly ignorant, immoral, working-class predecessor.26 What Yatman lacked, according to Luckes, was the essential quality of selfsacrifice: She was not prepared to endure ill health as part of her commitment to duty.27 Despite Yatman’s admission to the nurses’ sick room with an illness affecting several other nurses, Luckes doubted the authenticity of her sickness, noting in the probationers’ register that Ellen Yatman was constantly complained of as an idle, unpleasant, and inefficient [nurse]; she was very selfish in worth: thinking last of her patients and much of her own convenience. She was an inveterate grumbler and by no means straightforward. She had no scruple in breaking her engagement when she fancied her health broken down.28 Luckes implies that Yatman imagined her ill health, a character failure she often linked with a selfish personality.

Indeed, Luckes’s suspicious attitude toward nurses’ health shaped nurses’ response to sickness. Several confessed a reluctance to admit ill health for fear of being labeled unsuitable and dismissed. Luckes denied such a practice, reassuring the select committee that she never sent nurses away on health grounds, unless instructed by a doctor and always allowed ample time to recover.29 However, Nurse Mary Raymond testified that nurses “did not like to apply” to see a doctor “and to say that they are ill. They are liable to get dismissed.”30 Probationer Vannah Edwards, who died from pneumonia after 18 months of training, was apparently too frightened to admit she was ill. Raymond described to the Select Committee how hard Edwards worked until she was quite unfit; she was so ill that she could hardly breathe and excused herself from supper; the home sister went to her room, found that she had a high fever; and sent for the house physician, who ordered her at once to be warded; 10 days after that, she was dead.31 Although Luckes encouraged nurses to share their problems with her “at home” in her office every Tuesday evening, nurses did not complain.32 According to Nurse Violet Dickinson, “we all felt that it would be bad for ourselves if we were to make a complaint.”33 Dependent on a future reference, sick or dissatisfied probationers recognized that Luckes interpreted poor health or criticism as a lack of vocation to nurse.

Luckes also implemented significant improvements to working conditions. One reason she was appointed as matron at age 24 was that she had already constructed a step-by-step program of reform.34 Despite numerous disagreements with the governors and house committee about expenditures, she introduced several significant reforms. For example, in 1881, nurses’ diets were improved and their workload reduced with the employment of 22 ward maids.35 By 1890, Luckes had convinced the chairman of the house committee, Francis Carr Gomm, that she

should be “entirely responsible for nursing management.”36 This decision led to the allegation “that too much power is entrusted to the matron,” which was debated at length by the Select Committee of the House of Lords on Metropolitan Hospitals.37 The apparent high levels of nurses’ illness and their rising mortality were used to question her ability to hold a position of authority.

Luckes clearly cared about nurses’ health, as evidenced by the effort she made to improve their working conditions.

However, she considered dedication to duty, obedience, and self-sacrifice more important. She extended a system of health care to nurses partly, with the aim of increasing her authority over their lives. In 1885, Luckes introduced a compulsory medical examination at the end of a month’s trial period and used it to weed out probationers who did not fit her expectations. Despite a satisfactory ward report and “a slight sore throat for one day,” Luckes dismissed probationer Howard-Jones at the end of her trial period on health grounds. Howard-Jones claimed her health to be excellent, which she then illustrated by immediately applying to another hospital in London, passing its physical examination, successfully completing training, and eventually becoming a hospital matron.38 Success in passing the medical examination also depended on whether Dr. Samuel Fenwick (Dr. Bedford Fenwick’s father) judged a probationer of sufficient physical strength to work long hours and live in the densely populated east end of London “away from any means of recreation.” Samuel Fenwick was senior honorary physician and a strong ally of Luckes. He argued that probationers needed to be of a particularly strong physical constitution at The London Hospital because of the poor quality of the surrounding air.39 In 1886, Luckes changed nurses’ rules to specify that probationers could no longer choose any doctor from the resident staff but had to consult honorary staff physicians Dr. Samuel Fenwick, Dr. Henry Gawen Sutton, or Surgeon Mr. Frederick Treves. Previously, nurses had consulted junior house surgeons or physicians; Luckes argued that the change was necessary because “many nurses very naturally object to consulting the young doctors about their own health.”40 Senior doctors were also believed to be more adept at uncovering nurses “who were generally prone to malingering.”41 Indeed, Samuel Fenwick admitted that he did not take most cases seriously as most complaints were “trivial . . . a little sore throat, a headache; it may be any little trivial thing.”42 To add to their problems, nurses were not given privacy during their consultation, which took place in the presence of a ward sister, house physician, and consultant.43 The fact that nurses were denied a choice of medical staff or privacy must have been difficult for those with more experience such as Janet Page. Page entered training at The London Hospital in June 1888, aged 27, with 3 years previous nursing experience at Highgate Infirmary. Her

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BACKGROUND application for a staff nurse post was declined because of The London Hospital’s rule that nurses from provincial or smaller metropolitan hospitals must enter as probationers and complete the 2-year training program. She was dismissed after 11 months for consulting a doctor other than one of those designated by Luckes regarding chronic leg ulcers.44 Page’s ulcers badly affected her; the pain was such that her sleep was disturbed. She worried that if she consulted the appointed doctor, he would not adhere to the confidential practice expected in the doctor-patient relationship. She therefore consulted Bedford Fenwick, then a junior house physician.45 Anxious that she would be dismissed on health grounds if she disclosed her history of chronic leg ulcers, Page complained only of sleeplessness, for which she was prescribed a draft. After 2 weeks with no improvement, Page consulted an “outside” physician, Dr. Anderson, who admitted her as an inpatient to The London Hospital. On finding Page admitted to a ward, Luckes promptly dismissed her on the grounds of inefficiency.

Page’s failure to ask Luckes’s permission to consult an outside doctor or apologize for doing so was interpreted as laxity in discipline by Luckes and Samuel Fenwick, who advised Luckes on such matters.46 Page had a history of unreliability, was frequently reported “as incapable of getting on with her work,” and had failed to disclose serious health problems at her initial medical examination.47 Luckes was keen to dismiss her. Page, Luckes recorded, “was not at all strong and proved mentally and physically unsuitable for the work she had entered upon.”48 The Select Committee of the House of Lords on Metropolitan Hospitals heard from Luckes how Page had proved unsuitable for further training. . . . She gave me a good deal of trouble during the few months she was with us, partly, though I fear, not entirely, caused by her very bad health. She may have tried to improve, but she never appeared to do so.49 Luckes’s report suggests that Page suffered from both poor health and a lack of self-discipline.

This case illustrates some of the difficulties facing a historical analysis of the relationship between health and discipline. Long-term health problems obviously had an impact on a nurse’s work and may have influenced qualities such as reliability, enthusiasm, and determination. However, it is a mistake to assume that health was the only factor shaping a nurse’s behavior and aptitude for discipline. The fact that Luckes did not discuss other influences in the probationers’ registers reinforces the impression that ill health was considered the main cause of ill discipline. Her description of Ellen Stocking, “a self-absorbed person of little practical use” who “had not good health,”50 or of Maud Parsons, who was “essentially feeble in every way and was very slow and stupid. . . . continually going to the sick room with boils on her neck,”51 are typical of those with health problems and stand in contrast to that of healthy nurses like Nurse Walmsley, who “worked conscientiously and well without being at all brilliant . . . her health was particularly

good so there was an opportune vacancy.” The high value Luckes placed on physical health as a requirement to nurse may have been justified by the fact that nursing in this period was “extremely heavy,” demanding physical strength and endurance.52 A lack of clarity about the transference of disease also problematized health issues. In the late 19th century, nurses’ health risk was understood in terms of two categories of illness: infection and overwork. Seven of the eight deaths among nurses between 1888 and 1890 were attributed to infectious diseases: two died from scarlet fever, one from diphtheria, two from pneumonia, one from blood poisoning after contracting a septic finger,53 and one from suppurative meningitis.54 However, ideas about the risk of infection were obfuscated by understandings of the germ theory of disease.

Historian Michael Worboys argues that, although there was a growing consensus in medicine after 1880 that most disease germs were bacteria, there was no closure on a single bacterial model or their actions.55 At The London Hospital, doctors, lay commentators, and Luckes offered various opinions about the cause of infectious disease among nurses. Luckes considered the infected patient the main risk factor and instructed nurses about infection control. For example, nurses caring for patients with diphtheria were taught the importance of frequent hand washing with a Lysol solution particularly before eating, not eating food in patients’ rooms, and gargling twice a day but to remember to remove their false teeth before doing so.56 An outbreak of diphtheria and scarlet fever among six nurses from the same ward in October 1888 prompted debate about the possible causes of infection. The problem was accentuated when one of the nurses died. Paying probationer Katherine Woolley became ill with scarlet fever only 2 weeks after starting training, suggesting that probationers in their initial period of employment were more susceptible to infection.57 The British Medical Journal (BMJ) agreed that nurses who were “not protected by a previous attack” were more likely “to be affected when brought into contact with it.”58 Gordon Fenwick supported her case for a reduction in first year probationers’ working hours and an increase in holiday leave, on the grounds of increased vulnerability to illness during the initial six months of training.59 Several nurses believed that the smell from poor sanitation was responsible for their high levels of infection, particularly the sore throats that were common in the first year of training.60 Miasmic theories continued to influence thinking about contributing factors to disease, although from the 1860s, the term was increasingly applied to catching airborne diseases, either directly from other people or the environment.61 In 1889, The London Hospital medical staff admitted their perplexity as to the cause of the various symptoms nurses suffered, suggesting that they pointed to “unsanitary conditions of some kind.”62

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SECTION 1 An investigation by House Governor William Nixon concluded that the cause of the smell was not sewer gas but coal gas, “which is very unpleasant in smell, but not as unwholesome as sewer gas.”63 (With hindsight, and in our knowledge of the toxicity of coal gas, his statement seems naïve.) However, in 1890, the doctors’ concern for nurses’ health persuaded the house committee to invest £7,000 for improving sanitation.64 Despite the evident risk infectious diseases posed to nurses’ health, conversations obscured the issue by suggesting that women’s limited physical strength and an increase in the number of middleclass recruits were responsible for the rise in morbidity and mortality. Such claims had the potential to undermine nurse leaders’ campaign for professional status: middleclass recruits were perceived as vital to transforming nursing into a “respectable” profession, but their identification as a group vulnerable to health problems could have deterred possible candidates.

Historiography regarding gender and nursing highlights nurse leaders’ use of gender ideologies and imagery to promote their case for professional status.65 Nurse leaders claimed that women’s right to nurse derived from their biological capacity for motherhood and the management skills learned from organizing domestic households.66 Despite Luckes’s introduction of a more scientifically based system of nurse training tested by examination, she maintained that “women who would make the best mothers make the best nurses.” For this reason, she argued that nurses’ work conditions should remain unregulated like mothers’: “The duties of a true mother and of a real nurse are not merely mechanical, and their work cannot advantageously be regulated as though that were the case.”

Complementing her opposition to state registration and her belief that individual hospitals should be responsible for setting work conditions, Luckes argued against a national system of regulation because it would be detrimental to nurses’ welfare.67 Such arguments were problematic: they were a source of strength but created a boundary around health issues.68 It became difficult for nurse leaders to identify health hazards or demand a reduction in working hours when the model of motherhood as a framework for nursing implied a 24-hour commitment and a duty of self-sacrifice.

The relationship between nurses’ gender and health attracted the attention of the medical press and the Select Committee of the House of Lords on Metropolitan Hospitals. Some doctors, fearing that nursing reform might lead to a backdoor route into medicine, argued that women were not physically equipped to deal with nursing’s poor work conditions.69 A study in The Lancet in 1890 suggested that women were not strong enough to work 12-hour nursing shifts, described as “a cruel strain on a woman’s strength and nerve.”70 Samuel Fenwick agreed that woman’s natural fragility combined with long working

hours caused a high incidence of varicose veins and “flat foot.”71 Flat feet were a common problem and often cited as the reason for nurses’ dismissal. Frederick Treves, a surgeon at The London Hospital who opposed state registration because it threatened the general practitioner’s income, identified nurses’ social class as the cause of flat feet. He claimed that the arch of the foot sank “in a woman of feeble physique,” particularly “ladies who have been accustomed to not much standing, nor much walking.”72 Treves suggested that nurses should continue to be drawn from working-class backgrounds, ostensibly to prevent the increasing incidence of flat feet, but this also suited his political agenda. He, like other members of the medical profession, was concerned that middle-class, articulate nurses might become more independent in their work, follow their own professional rules, and compete with general practitioners.

The theme of class was important in the struggle to define the boundary between “old” and “new” nurses and was crucial in nurse leaders’ attempts to organize nursing more formally and establish its status in the division of labor.

Conversations focused on whether nursing was to be a new profession for educated, middle-class women or a refined form of domestic service with a subordinate place in the hospital.73 The London Hospital increased its number of middle-class recruits with the introduction of a 3-month training scheme for paying probationers in 1881, but its numbers were small: in 1890, only 14 probationers were paid out of 134 nurses.74 This evidence supports Hawkins’s conclusions that nurses from St. George’s Hospital were drawn from a wide range of backgrounds.75 Indeed, Luckes justified her agenda for improvements to nurses’ sleeping accommodation because the mixed classes employed deserved comfort. However, she prioritized the physical and mental health needs of a core group of middle-class nurses.

She offered the idea that these nurses needed more space and privacy than working-class women, “The trial to women of the better class, of never being alone for 5 minutes out of the 24 hours, is one that perhaps can hardly be estimated without personal experience of it.”76 These views probably reflected Luckes’s own upper-class background, mentioned earlier.

Newspapers and the medical press debated the relationship between health and class background in an attempt to define the hospital nurse’s role. According to Pall Mall Gazette and The Lancet, middle-class nurses lacked the physical strength and stamina to perform menial work and would be better employed in management and personal care tasks: Such nurses were not material that any master hand [would] select for stead and continuous work. Domestic tasks that come lightly to women of tougher fibre [were] a strain to them, but they work with hearty goodwill, and unreliable as their health may be they [were] a valuable element in a nursing staff.77

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BACKGROUND The Lancet suggested that middle-class nurses spend their time on patient care because “of the delicacy of their hands” rather than on “rough tasks” that “ought not to be imposed on ladies whose utmost strength is heavily taxed.”78 As medical knowledge changed, doctors required efficient assistants: a nurse who spent more time performing patient care would be better able to observe their condition and report back to medical staff.79 In contrast, The Hospital argued that social background had no part to play in dictating the nurse’s role, reinforcing an ideology of nurses as self-sacrificing angels who tolerated all working environments to fulfill their devotion to duty.80 In reply to suggestions that middle-class women lacked the physical strength to nurse, Luckes promoted an image of the London Hospital nurse as physically and mentally superior to ordinary woman. This strength, she argued, enabled them to cope with the health risks of nursing: “I think nurses are not ordinary women, or they never would come and choose work that causes so much tax to their energies, physically and mentally and feelings altogether.” Such an image implied invulnerability to illness, and, indeed, Luckes rejected demands for a reduction in working hours because superior physical strength guaranteed good health “barring accidents incidental to the work.”81 The idea that the nurse was a superior type of woman reflected, in some ways, a wider debate surrounding the image of “new women” during the 1890s. A literary stereotype, constructed as a result of debates over marriage, sexualities, political rights, labor conditions, lifestyles, and fashion, the new woman signified the single woman’s bid for personal freedom in the form of a career, financial independence, suffrage, and leisure.82 A feminist ideal, the image challenged traditional gender roles of domesticity and motherhood and pushed against the limits of a male-dominated society. Luckes did not see a problem in promoting almost contradictory images of the London nurse, as both a “superior” type of career woman and a mother. Nurses were trying to develop an image of the profession built on traditional gender roles while competing for more powerful roles in male-dominated hospitals.

The way Luckes treated nurses’ health was distinctive; its foundations stemmed from her significant power to shape nurse policy. Because she was a major national figure, it might be expected that such a model would be replicated elsewhere.83 However, this was not necessarily the case. Even in her own institution, some rank and file nurses registered opposition to the denial of their health concerns.84 Other institutions facing similar issues approached the problem completely differently. Systems of discipline and patterns of occupational health care varied between institutions, partly, because of the matron’s political views about the professionalization of nursing. The SDEC Hospital in Plymouth and the Cornwall Lunatic Asylum in Bodmin demonstrate this point.

The South Devon and East Cornwall Hospital The SDEC in Plymouth, Devon, was a provincial, voluntary hospital chosen for this study because its matron held a different political viewpoint from Luckes regarding registration. The SDEC’s geographical position, a considerable distance from London, and its smaller size also make it an excellent comparator to The London Hospital.

The SDEC opened in 1840; by 1890, it employed 11 nurses and 8 probationers to care for 124 patients. All probationers paid £26 annually for their 2-year training.85 It lacked the resources of The London Hospital, making it unlikely that policies could simply be replicated. Indeed, Matron Harriet Hopkins treated health and disciplinary issues as entirely separate. Whereas evidence from The London Hospital supports historians Anne Witz and Brian Abel-Smith’s views that voluntary hospital matrons had established themselves as heads of independent nursing departments by the end of the 19th century, the SDEC supports Stuart Wildman’s thesis that there were significant variations in the matron’s influence.86 Hopkins trained at Charing Cross Hospital, a prestigious London teaching hospital, and was appointed SDEC matron in 1886 from a large field of applicants. She was a member of the general council of the BNA87 and of the executive committee of the Matron’s Council, organizations that supported nurse registration. Although there is no written record of Hopkins’s personal views on registration, the fact that she regularly used her annual leave to travel the 183 miles from Plymouth to London to attend meetings suggests significant commitment to nurse education, training, and developing the matron’s role.88 These issues dominated the agendas of both organizations during the years of Hopkins’s membership. However, one must not assume that her membership confirms her support of registration.

Historian Anne Marie Rafferty argues that BNA members may have been recruited for reasons of “patronage, power, status, and respectability,” not necessarily for their political commitment to registration.89 As we will see, Hopkins was particularly interested in professional matters associated with the role of matron.

The BNA agenda extended beyond registration to include issues of nurses’ pay and health.90 Nurses’ health was a contentious issue provoking bitter disagreement between Luckes and the BNA. Luckes discredited the BNA’s proposals to “establish a sick fund, an annuity fund, and a house of rest” for sick nurses.91 Convalescence homes were unnecessary, Luckes argued, because so few nurses were sick.92 She considered it the individual hospital’s responsibility to encourage the public to take sick nurses into their homes. Political tensions also developed between Gordon Fenwick and her allies and the medical members of the BNA, particularly after it received its Royal Charter in 1893. Gordon Fenwick’s control diminished as the

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SECTION 1 organization diverted from its proregistration agenda, and she turned to the Matron’s Council as an alternative forum to discuss professional issues.93 The Matron’s Council of Great Britain and Ireland, founded in 1894 by Isla Stewart, who succeeded Gordon Fenwick as matron of St. Bartholomew’s, became the only organization devoted to the registration’s cause following the 1896 BNA resolution opposing registration. Hopkins attended the Matron’s Council’s inaugural meeting on July 13, 1894 and played a part in shaping its by-laws by seconding a proposal that it include a range of professional and general topics at future meetings. Other by-laws included promoting a uniform system of education and training and providing matrons the opportunity to receive professional support.94 Hopkins was one of 21 elected executive committee members from 1894-1898, when she resigned from the position of vice chairman because of her “inability to attend the meetings.”95 As a newly appointed matron in 1886, Hopkins introduced several changes to the SDEC that reflected BNA policy. For example, the BNA considered a 3-year training program necessary as qualification for registration. Hopkins extended nurse training by 6 months, from 3 to 3 1/2 years to include 18 months of theoretical training alongside ward experience and 18 months for the hospital staff.96 The BNA also discussed the advantages of specialist training: for example, Catherine Wood, BNA honorary secretary and Lady Superintendent of the Hospital for Sick Children, Great Ormond Street, stressed the importance of training nurses for sick children in The Hospital Record in 1888.97 Hopkins subsequently appointed a trained children’s nurse at the SDEC.98 In July 1890, the issue of nurses’ health began to attract the SDEC governing committee’s attention, although what prompted this interest is unknown. Probationers were now asked to provide a certificate of health from a qualified doctor on commencing training and were also subject to a health examination at the end of their 3-month probationary period. There is no evidence that Hopkins used this as an opportunity to weed out unsuitable applicants. Hopkins was also asked to present a weekly report about “the health of the nursing staff.”99 This new concern did not prompt any changes to Hopkins’s system of nurse discipline. Health matters continued to be treated on their own merit and not as an indication of a vocation to duty. Consequently, nurse health care was more flexible and tolerant than the type offered to nurses at The London Hospital. One explanation for the difference in Luckes’s and Hopkins’s attitudes may be that Hopkins considered that standards should be set by a national regulatory body, not individual hospitals.

Sick probationers and trained nurses were allowed to consult any doctor from the senior honorary staff or even outside doctors.100 Nurses with shortand long-term illnesses

were not dismissed but were encouraged to recuperate at home and return to work. In 1898, a ward side room was set up as a nurses’ sick room.101 In contrast to The London Hospital, which sent recovering nurses to convalesce in private homes, the SDEC owned a large house, donated by a grateful benefactor, which was used as a rest home for nurses.102 There is no evidence that nurses’ illness provoked suspicion.

In 1905, 27 year-old probationer Georgina Birch’s diagnosis of rheumatism forced her to interrupt her training for more than 3 years. She returned in August 1909 and gained her hospital certificate in March 1911, 8 years after starting training. Hopkins recorded that Birch was “truthful, obedient, most polite, punctual, with good memory, unselfish, conscientious, and painstaking”: these positive comments, highlighting good moral character suggest Birch’s poor health was not interpreted as indicative of a lack of vocation to nurse. Hopkins, like Luckes, judged moral character as a test of suitability but, unlike Luckes, did not perceive ill health as an indicator of its absence.

Hopkins also adopted a tolerant attitude to nurses with shorter and more frequent episodes of illness. Cecily Blacker, 25 years of age, had neuralgia for 5 days in February 1909. Two weeks later, she contracted bronchitis and was sick for 4 months, followed by a 2-week episode of laryngitis 6 months after. Hopkins described her as “an excellent nurse of very high principle but health not good,” thus distinguishing her health problems from other aspects of her character.103 As at The London Hospital, SDEC nurses faced a high risk of contracting an infectious disease. Tonsillitis was the most common illness, followed by influenza and septic finger.

Probationers took an average of 19 days to recover from tonsillitis and 68 days from septic finger.104 Probationer Alice Dowling, aged 18 years, contracted a septic finger after 6 months of training and again, a year later. On being sent home to recover, her parents decided that she was not strong enough to nurse and prevented her return.105 As at The London Hospital, SDEC medical staff considered miasmic theories responsible not only for the high levels of infection, particularly the “dreadful stench from the sewer ventilator” but also the “insanitary and perilous condition of the drains, ward lavatories, and bathrooms.”106 Hopkins successfully managed the nursing department for 16 years, from 1896 until 1904, without criticism from the medical staff. In 1904, however, doctors identified her as incompetent and sought to undermine her authority. Two factors seem to have unsettled the medical staff. First, the Western Daily Mercury, a local newspaper, ran a series of articles in February 1904 criticizing standards of nursing care at the SDEC.107 Although it is clear that these articles were partly driven by local doctors’ resentment at losing feepaying patients to the hospital,108 the derogatory publicity upset the governing committee. The second factor was the

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BACKGROUND question of state registration of nurses. In May 1904, the medical committee received copies of the two 1904 private members bills for the registration of nurses from the British Medical Association (BMA).

The first bill was drawn up by Ethel Gordon Fenwick and Isla Stewart, with the assistance of Fenwick’s husband Dr. Bedford Fenwick (they had formed the Society for the State Registration of Nurses in 1902, amalgamating with the Matron’s Council). The second was put forward by the RBNA.109 In June 1904, a Select Committee on the Registration of Nurses was set up to inquire into the subject. The SDEC medical committee voted approval of nurse registration, perhaps following the BMA’s lead that an improvement in nurses’ technical knowledge would benefit the medical profession. National interest in registration and nurse education and their impact on doctors prompted an immediate reassessment of nurse training at the SDEC. The SDEC medical board had increased its power over management policy during Hopkins’s tenure as matron.

Initially a lay committee with two medical representatives governed the hospital, but in 1890, The Lancet applauded the committee’s decision to admit all five members of the senior honorary medical staff. In 1904, the medical staff held Hopkins responsible for the press allegations about deteriorating standards of patient care. The medical board identified her failure to organize a formal program of lectures between November 1901 and March 1905 as the main cause of the problem, concluding that the nurses “were a general shambles.”110 Hopkins was called to account and claimed that a reorganization of the hospital had resulted in a dramatic increase in her administrative duties. The medical board, led by Doctors Fox and Bertram Soltan, implemented their own “more efficient and practical training of the staff ”: lectures were science-based and included elementary bacteriology, asepsis, and antisepsis but not nursing ideology.111 A nursing committee was set up “to have oversight of the whole of the nursing department” but had no nurse members: a physician, surgeon, hospital secretary, and a member nominated by the general committee governed the nurses, with Hopkins invited only to give a monthly report.112 Throughout her period of office, and in common with other matrons of the time, Hopkins had no place on either the general or house committee. It is ironic that it was receipt of information about the state registration of nurses, a move many nurses considered would lead to professional self-regulation and autonomy that prompted SDEC doctors to remove some of Hopkins’s power. For example, she had traditionally made independent decisions about engagement and dismissal of nurses, but in 1905, restrictions were introduced making nursing committee approval mandatory.113 There appears to be a clear difference between the culture of the SDEC and The London Hospital, in part, due to matrons’ political views about the professionalization

of nursing. Other factors include the different nature of small provincial and city-based teaching hospitals.

Further analysis of other hospitals in both geographical locations is needed before one can draw firm conclusions.

A comparison of attitudes toward nurses’ health at our two voluntary hospital studies, led by politically active matrons, with that of a rural, mental asylum whose matrons were disinterested in registration, will draw out the different relationship between asylum and voluntary hospital nursing politics and occupational health.

Cornwall Lunatic Asylum The Cornwall Lunatic Asylum (CLA) for the reception of private patients and pauper lunatics, known locally as St. Lawrence’s Hospital, opened in 1820 in Bodmin. Bodmin was the county town of Cornwall, a geographically isolated rural district in the southwest of England, 203 miles from London. Cornwall’s economy was based on agriculture and mining with little secondary industry or commerce.

Mounting overseas competition had a catastrophic effect on the Cornish mining industry, and by 1885, 293 of the 377 tin and copper mines were idle or abandoned.114 Between 1870 and 1880, poverty and lack of employment prompted one-third of the whole population to leave Cornwall permanently, many emigrating to the United States, Australia, South Africa, Mexico, and Canada.115 The CLA was a valuable source of employment in this period of economic hardship; in 1896, it employed 70 female and 76 male nurses to care for 760 patients.116 It had both a different legislative framework from that of The London Hospital and the SDEC, and a distinct culture that meant that the relationship between nurses’ health and discipline was inevitably dissimilar. It was governed by Dr. Richard Adams, medical superintendent and a member of the Medico-Psychological Association (MPA), and a lay visiting committee drawn from landowners, clergy, magistrates, and members of Parliament. Adams and the committee set and enforced the regulations governing nursing staff, subject to regular inspection by the Lunacy Commission.117 Some MPA members were interested in nurse training as a way of raising psychiatry’s status, and in 1895, they persuaded the General Medical Council to introduce a certificate in psychological medicine.118 Candidates had to have been residents in a hospital for 3 months and have attended a course of lectures. Adams, however, was not interested in introducing nurse training to the CLA; indeed, it was not until 1918 that nurses there received any formal education. In 1871, Henry Maudsley, the pioneering Victorian psychiatrist, asked the MPA to set up a register of “good attendants” in order to improve their status and encourage high-quality candidates to come forward.119 However, no scheme was established and when, in 1895, Sir Dyce Duckworth proposed to the RBNA that those who passed the MPA examination should be considered for

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SECTION 1 registration with the RBNA, Gordon Fenwick campaigned aggressively against it.120 Gordon Fenwick’s registration campaign excluded asylum nurses based on their social background. She used her position as editor of Nursing Record and Hospital World to further the prejudice by some general nurses against asylum nurses, particularly men, perpetuating the view that working-class background was naturally equated with dishonourable behavior.121 One commentator to Nursing Record and Hospital World distinguished between the middle-class background of general nurses and their aspirations toward training and the “uneducated” male attendants “drawn from a class from which the majority of our leading nursing training schools have long ceased to admit nurse probationers.”122 It is interesting to note that only the male asylum nurses’ social background, and not that of their female counterparts, was linked to unsuitability for training, suggesting that nurse leaders closely entwined notions of class and gender to discredit male nurses.

Unfortunately, there is no record of CLA nursing staff ’s class background, but there is evidence of their identification with working-class culture, particularly trade unionism.123 Historians Robert Dingwall, Anne Marie Rafferty, and Charles Webster argue that attendants were working class, employed not only because of their physical strength but also because of their low-level agricultural and workshop production skills.124 There is also no evidence that CLA nursing staff lobbied to be included in the registration campaign. The two female matrons were unqualified nurses: Eliza Templar Vicary, matron of pauper patients, and Laura Elkless, matron of female patients, were appointed in the 1870s before most asylums had adopted any programs of nurse training.125 Vicary and Elkless had little power to implement change in the nursing department. Nurses were treated as employees rather than as members of a morally superior profession.

The asylum’s system of discipline was strict, but its rules were more concerned with containing a large number of disturbed patients than with elevating nurses’ professional status. Attendants’ complaints about working conditions were not interpreted as a sign of a lack of vocation to nurse. Groups of attendants complained directly to the visiting committee throughout the 1890s about diet, hours of employment, rate of wages, scale of pensions, and lack of uniforms.126 Their complaints were often supported by the Lunacy Commissioners’ Reports, which repeatedly criticized the visiting committee for its failure to implement significant improvements.127 Expectations of obedience and time regulation were high, but discipline was not applied to attendants’ health problems.

Asylum nursing carried a significant risk of physical injury from violent patients, a risk that received little attention.

Only when physical altercations between attendants and patients resulted in serious injury or death did the visiting

committee inquire into the circumstances. For example, when patient Giles Hawken died during a struggle with two attendants, the committee heard evidence of how Hawken had tried to break his door down and then hit the attendants.128 Attendants’ reluctance to complain about their risk of injury may have been motivated by their realization that sickness was antithetical to the qualities of physical strength perceived not only as integral to their job but also by the prospect of claiming a pension. By 1896, more than half of the male attendants had worked at the CLA for many years.129 CLA nursing staff tried to endure ill health, not to signify their devotion to duty but to accrue long periods of service to qualify for a pension. It was only when the visiting committee proposed to raise the age of entitlement to a pension, after 15 years of service, from age of 50-55, that attendants began to complain about their risk of injury.130 All attendants signed a letter highlighting the dangers that we are daily subjected to, the most trying, troublesome, unfortunate class of fellow creatures that we have to deal with in the execution of our duty, the unhealthy, disagreeable, injurious things we have to contend with daily. That Mrs. Pyder, (a recently retired nurse) after nearly twenty years service, only enjoyed her allowance for a short time when she returned as a patient and died eight days after admission; this we venture to say, tends to show that we are subject to injury of mind, as well as health, through being confined with the patients for such long periods of time. Also, that several other attendants have received personal injury in the execution of their duty; consequently, they have completely broken down shortly after being superannuated.131 The visiting committee agreed to return to the original pension arrangements.

The case of Pyder, cited by the attendants as an example of a nurse who suffered some form of mental illness shortly after retiring, is an indication of the degree of mental strain CLA nursing staff felt. The idea that asylum attendants risked their own sanity through close and prolonged contact with insane patients was taken up by several correspondents to The Lancet during the 1890s as part of a campaign to improve work conditions.132 At the management level, there was very little broad discussion by Adams or the visiting committee as to what caused nurses’ ill health. This does not necessarily mean that health issues were misunderstood, but it does imply that they were neglected. The asylum was concerned with its financial responsibility toward its employees and the need to protect and limit its commitments. For example, when attendant Samuel Solomon died of typhoid fever with pneumonia in 1898, the committee decided that it had been “contracted out of the asylum.” This is surprising, considering that another attendant, William Hill, was also ill with typhoid at the time.133 Historian Anthony Wohl suggests that the presence of typhoid fever served as “a

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BACKGROUND barometer of inadequate water supplies and sewerage”;134 an admission of responsibility might have forced the visiting committee to commit to expensive improvements to the asylum’s infrastructure. In another case, attendant James Tulyard’s behavior changed significantly following a head injury received at work. He was suspended “for indecently exposing himself to children in the asylum grounds and making indecent motions to female patients.”135 The asylum did not consider itself responsible for Tulyard’s injury and did not offer any financial help toward his treatment or pension, much to the chagrin of his previous employer, Bodmin Workhouse, which wrote and complained that the asylum had failed its employee.136

Conclusion

This difference can be explained by individual matrons’ political views about nurse registration and their power to influence nursing policy. The geographical location of hospitals also seems to have played a part: certainly, Cornwall’s rural isolation partly explains the CLA matrons’ lack of participation in nurse registration, but one must also consider that asylum nursing had a distinct and different culture. A lack of alternative employment may have encouraged toleration of ill health and poor work conditions. In contrast, The London Hospital was a metropolitan teaching hospital with a waiting list of recruits and a prestigious reputation. This study concludes that nursing politics, gender, and class were more important than geography in shaping nurses’ occupational health care in this period.

The history of nurses’ occupational health has been a neglected area of study. This is surprising considering that 21st-century nursing is recognized as a serious occupational health risk, and nurses’ sickness is a considerable financial burden to government.137 Our understanding of this contemporary problem is enhanced by an insight into government’s and nurse organizations’ response to nurses’ illness a century ago. Government’s failure to legislate nurses’ working hours or nurse organizations’ reluctance to demand improvements set a precedent that took a long time to change. It was not until the 1990s that most nurses had access to occupational health units. Such units developed independently, with wide variations in the services they provided.138 Luckes’s ideas of vocationalism and self-sacrifice were pervasive and shaped the early years of the College of Nursing’s policy, particularly in 1919/1920, following the Registration Act.139 The college adopted many of the ideas associated with 19th-century nursing reform and upheld the notion that dedication to duty was a necessary quality in nursing. Although it aspired toward becoming a selfregulating, autonomous organization, its desire to retain voluntary hospitals’ support meant that it, like Luckes, attached considerable importance to individual hospitals’ ability to dictate their own work conditions. Gordon Fenwick’s aspiration that professional status would bring concomitant improvements to pay and work conditions was slow to reach fruition.

Antiregistrationists like Luckes were arguing that nursing was a vocational body that did not need a register if individual hospitals set and maintained high standards of nurse training, practice, and discipline. Luckes’s concept of nursing as a vocation was closely linked to ideas of motherhood and self-sacrifice, which inevitably led to the idea that illness was a weakness and a result of a lack of selfdiscipline. It is interesting that Luckes often promoted quite complex and contradictory gendered images of the ideal new nurse when discussing nurses’ health and commitment to duty: she cited the idea of motherhood alongside women’s superior strength in addition to drawing on a militarized, masculine image of the well-disciplined soldier.

Voluntary hospital matrons’ attitudes toward nurses’ ill health were significantly shaped by the political question of nurse registration and cultural notions of class and gender. The question of nurses’ sickness attracted significant political and newspaper interest in 1890 and was used to justify changes to the nurse’s role. Notions of gender and class were not only used to support nurses’ case for professional status; their relationship to nurses’ health was used to define the boundaries of the new nurse’s role. National debates about how to organize nursing affected the ordinary nurse’s experience of sickness, an experience that differed significantly between voluntary hospitals and between voluntary hospitals and asylums.

The relationship between gendered ideologies and nurses’ case for professional status was problematic and, although a source of strength, it created a boundary around health issues. It became difficult for nurse leaders to identify health hazards when their arguments were built on a model of motherhood and self-sacrifice. The ideology of motherhood was pervasive and continued to influence discourses on nurses’ working hours in the 20th century. In 1919, the College of Nursing and its supporting journals extended the notion of nurses as mothers to resist the introduction of a 48-hour week.140 In 1939, the Interdepartmental Committee on Nursing Services (Athlone Committee) recognized that “all nursing staff . . . were enduring a strain, which cannot be

Expectations that nurses would subordinate their own health needs to those of their patients or their employing hospital placed unrealistic demands on nursing staff and made discussion of health issues a sensitive topic, shrouded by suspicion. Luckes clearly cared about nurses’ health and made significant improvements to working conditions, but she also attached importance to a nurse’s ability to endure hardship and discipline as demonstrating commitment.

With hindsight, her disregard toward nurses’ health problems seems, at times, unsympathetic and coldhearted, but one must understand that her attitude was formulated by her determination to raise the occupation’s standards without an externally imposed set of regulations.

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SECTION 1 paralleled in any other profession,” but argued that nurses’ hours should remain unregulated because “nursing of the sick was not comparable to a trade or industry.”141 The enduring notion of self-sacrifice as a model of organization and behavior perhaps provides some explanation why policy makers neglected nurses’ occupational health until the mid20th century. This does not underestimate the importance of government policy in shaping nursing but suggests that such an ideology fitted with policy makers’ agenda to resist the introduction of nationally determined pay and conditions.

The importance attached to the concept of self-sacrifice varied between voluntary hospitals and between hospitals and asylums. For antiregistrationists like Luckes, it was an unwritten code of behavior that was used to organize an unregulated profession and acted as a carrot and stick policy. It was a goal not only to aspire to but also implied a threatened penalty for those unable to live up to the ideal.

Nurses’ sickness at The London Hospital seems to have often been discussed in terms of a character failure, but this point is difficult to prove. The notion of self-sacrifice was less important at the SDEC; Hopkins supported nurse organizations promoting an autonomous, independent, and regulated profession. The BNA considered nurses’ illness an almost inevitable consequence of nursing and planned to offer convalescence treatment and financial aid to sick nurses once its membership increased. Hopkins adopted a similar pragmatic attitude and did not interpret illness as a character flaw or as a sign of a lack of vocation, treating it without suspicion. The untrained CLA asylum matrons did not aspire to the vocational ideology of the antiregistrationists or the professional standards set by proregistration nursing organizations. Medical Superintendent Adams and the visiting committee treated nurses as employees rather than members of a profession.

Nurses aspired to accrue long periods of service, tolerating ill health to qualify for a pension. In contrast to The London Hospital, where the onus of responsibility for nurses’ sickness was placed on the nurse herself, the asylum was concerned with its financial responsibility toward its employees’ health and the need to protect and limit its financial commitments.

Matrons’ powers to influence occupational health care varied between hospitals and shifted over time within individual institutions. Doctors played a key role, and their support dictated, to some degree, the amount of power matrons enjoyed. The London Hospital medical staff supported Luckes’ powerful position as independent manager of the nursing department, the majority sharing her political viewpoint against nurse registration, and the idea that the hospital’s system of nurse discipline should incorporate nurses’ health. Luckes increased her authority and power to influence policy by publishing her ideas about nursing practice and improving nurse education. In contrast, Hopkins’s loss of power at the SDEC

illustrates how doctors retained significant power over nursing departments in the early 20th century. Despite her 18 years of experience as a successful matron and her contribution to national nursing organizations at the executive level, doctors withdrew their support following public criticism of the hospital’s standards of nursing care and the receipt of BMA recommendations that qualification for nurse registration must include technical training.

The BMA recommendations prompted SDEC doctors to reassess their attitude toward registration. They used the recommendations as an opportunity to exert their power and control over the nursing department. They did not, however, alter the SDEC’s approach toward nurses’ sickness.

Nurse education and training was key to matrons’ authority.

Implementation of the medical staff ’s own nurse training program in 1904 reduced Hopkins’s power. The relationship between education, training, and matrons’ authority is evident at the CLA, where untrained matrons had little power over nursing policy. Medical Superintendent Adams’ MPA membership implies an awareness of asylum nurse training, but it was not implemented at the CLA. Asylum nurses were predominately drawn from a working-class background, and matrons’ authority may have been further reduced by the occupation’s low status.

Class emerges as an important theme in perceptions of nurses’ health in the late 19th century. Debates about nurses’ health, class, and professional status were important in establishing the new nurse’s role. Luckes, like many commentators and actors considering nurse registration in this period, perceived middle-class women to have different physical and mental health needs from working-class women and used these ideas to support her argument for changes to nurses’ work conditions. Middle-class women were generally perceived as less physically robust and with specific requirements to maintain their mental health. For these reasons, some commentators advocated that the new nurse perform managerial tasks and patient care rather than menial cleaning duties. Although the campaign for professional status created the impression that nursing was a middle-class occupation, my research supports the idea that nursing was a socially mixed occupation. Further, prosopographical research is needed on class background at the case study institutions. One explanation of why the state failed to regulate nurses’ work conditions in this period could be government’s refusal to acknowledge the health risks attached to middle-class women’s work. This refusal may have been compounded by nurse leaders’ reluctance to jeopardize their recruitment campaign by drawing attention to middle-class women’s alleged vulnerabilities.

The health of nurses was always taken seriously at the three hospitals, but a failure to adopt a national coherent and consistent policy worked to its detriment. This difficulty helps explain the ambiguous treatment of occupational health in wider histories of nursing. This can lead to

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BACKGROUND the erroneous conclusion that occupational health was somehow neglected by contemporary actors, thereby facilitating the omission of the subject from historical studies concentrating on professional projects and the wider politics of nursing.

Acknowledgments Research for this article was funded by the Wellcome Trust.

The title phrase comes from Pall Mall Gazette, 7 September 1890.

Notes 1. Select Committee of the House of Lords on the Metropolitan Hospitals, Provident and Other Public Dispensaries and Charitable Institutions for the Sick Poor, p. 1890:392, vol. 17. Chaired by Lord Sandhurst (hereafter Sandhurst Report).

2. Sandhurst Report, 294-96.

3. Recent research has begun to pay attention to nurses’ health, particularly Sue Hawkins’s study of 19th-century nursing at St. George’s Hospital, London, which suggests that despite the popular myth that nursing ruined a woman’s health, nurses’ mortality at St. George’s was comparable to that of the general population. However, nurses’ sickness rates were higher than those of other working populations and, whereas nurses’ health was not impaired enough to leave, their illness affected the smooth running of the hospital. Sue Hawkins, Nursing and Women’s Labour in the Nineteenth Century: The Quest for Independence (London: Routledge, 2010).

4. Stuart Wildman and Alistair Hewison, “Rediscovering a History of Nursing Management: From Nightingale to the Modern Matron,” International Journal of Nursing Studies 46 (2009): 1650-61.

5. Ethel Gordon Fenwick (née Ethel Gordon Manson) (1857-1947). Jane Brooks and Anne Marie Rafferty suggest that, although most history of nursing texts refer to Gordon Fenwick as Mrs. Bedford Fenwick, she continued to use Gordon Fenwick in her official capacity after her marriage, except as editor for the British Journal of Nursing (hereafter BJN), when she used Mrs. Bedford Fenwick. Gordon Fenwick was elected matron of St. Bartholomew’s Hospital in 1881, at age 24, but resigned on her marriage in 1887. She continued to work to establish compulsory registration for nurses. See Jane Brooks and Anne Marie Rafferty, “Dress and Distinction in Nursing,” Women’s History Review 16, no. 1 (2007): 41-57.

6. Brian Abel-Smith, A History of the Nursing Profession (London: Heinemann, 1960), 9; Robert Dingwall, Anne Marie Rafferty, and Charles Webster, An Introduction to the Social History of Nursing (London: Routledge, 1988), 80-81.

7. Anne Marie Rafferty, The Politics of Nursing Knowledge (London: Routledge, 1996), 51.

8. Archibald Edmund Clark-Kennedy, The London: A Study in the Voluntary Hospital System (London: Pitman, 1963), 104-5. The Charity Organisation Society was founded in 1869 and attempted to coordinate the work of charitable institutions and the Poor Law, offering an alternative to the welfare state as a means to realize a better society. William Rose Mansfield (1819-1876), created Lord Sandhurst in 1871, was chairman of Middlesex Hospital in 1890.

9. The Hospital, 19 July 1890; PMG, 7, 11, 16 September 1890.

10. PMG, 7 September 1890. Other headlines included “Does The London Hospital Sweat Its Nurses?” 13 September; “Saints or Sweaters,” 25 September; “Death Traps for Nurses,” 29 September.

11. Because some of my evidence of nurses’ illness at The London comes from witness testimony to the select committee and its press coverage, it is important to note that all sources have ideological baggage that must be unpacked to gain an understanding of contemporary perceptions of nurses’ ill health.

12. Abel-Smith, A History of the Nursing Profession, 61; Rafferty, The Politics of Nursing Knowledge, 94.

13. Barbara Harrison, Not Only the “Dangerous Trades”: Women’s Work and Health in Britain, 1880-1914 (London: Taylor and Francis, 1996), 4, 95.

14. Hawkins, Nursing and Women’s Labour, 109-39.

15. Harrison, Not Only the “Dangerous Trades,” 106.

16. Barbara Harrison and Helen Mockett, “Women in the Factory: The State and Factory Legislation in Nineteenth Century Britain,” in State, Private Life and Political Change, ed. Helan Corr and Lynn Jamieson (London: Macmillan, 1990).

17. Shuttle kissing refers to the weaver’s practice of loading new cops of thread into the weaving shuttles by putting one’s lips over the outside of the shuttle eye and inhaling to draw the thread through. Carolyn Malone, “Gendered Discourses and the Making of Protective Labor Legislation in England, 1830-1914,” Journal of British Studies 37, no.

2 (April 1998): 166-91; Alan Fowler, Lancashire Cotton Operatives and Work, 1900-1950: A Social History of Lancashire Cotton Operatives in the Twentieth Century (Aldershot: Ashgate, 2003), 46; Janet Greenlees, “’Stop Kissing and Steaming!’: Tuberculosis and the Occupational Health Movements in Massachusetts and Lancashire 1870-1918,” Urban History 32, no. 2 (2005): 223-46.

18. Sandhurst Report, 473.

19. British Medical Journal (BMJ), 13 September 1890, 646. It is difficult to confirm whether rising mortality and morbidity were a general trend without comparative data from other hospitals, a point argued by the BMJ at the time. The BMJ also questioned whether the increasing numbers of deaths simply reflected the fact that the number of nurses employed had risen.

20. The Royal London Hospital (RLH) Archive, Report of the House Committee on the Allegations Which Have Been Recently Made Against the Nursing Department, LH/ A/17/49, 3 December 1890 (Report of the House Committee).

21. Sandhurst Report, 308, 313.

22. Ibid., 318. Luckes trained at Westminster Hospital and, after several months as a night sister at The London Hospital, became lady superintendent at Pendlebury Children’s Hospital, Manchester. She resigned from this post after clashing with the medical committee over her efforts to instigate reforms in the standard of nurse training.

She was appointed matron of The London Hospital in 1880 at 24 years old. Many hospital committee members thought that she was too young and inexperienced at her interview. See Archibald Edmund Clark-Kennedy, The London: A Study in the Voluntary Hospital System, vol. 2 ( London: Pitman Medical, 1963).

23. Clark-Kennedy, The London, 94.

24. Eva Luckes, Lectures on General Nursing: Delivered to the Probationers of The London Hospital Training School for Nurses (London: Kegan Paul, Trench Trubner, 1888).

25. Luckes, Lectures on General Nursing, 278.

26. Historiography has challenged the myth of old and new nurses.

Traditional interpretations accepted these images at face value; see Abel-Smith, A History of the Nursing Profession. Anne Summers argues that doctors used the Sarah Gamp figure to discredit old domiciliary nurses because they threatened their monopoly. Sue Hawkins contends that nurse leaders also feared domiciliary nurses’ independence because it made them difficult to control. Anne Summers, “The Mysterious Demise of Sarah Gamp: The Domiciliary Nurse and Her Detractors, c. 1830-1860,” Victorian Studies 32, no. 3 (Spring 1983): 365-86; Hawkins, Nursing and Women’s Labour, 6.

27. Luckes, Lectures on General Nursing, 276-78.

28. RLH, The London Hospital Register of Nurse Probationers, LH/N/1/2, April 1884-August 1888, 227.

29. Sandhurst Report, 402.

30. Ibid., 308.

31. Ibid., 309.

32. Ibid., 410.

33. Ibid., 313.

34. Clark-Kennedy, The London, 95.

35. RLH, LH/A/26/5, Eva Luckes, “Trained Nursing at the London Hospital,” New Review 17 (October 1890): 291-98. Nurses’ working hours were reduced with the introduction of timetables replacing the four hours a week off duty with two hours a day. Holidays were doubled from one to two weeks.

36. Sandhurst Report, 319.

37. RLH, LH/A/17/49, Report of the House Committee.

38. Sandhurst Report, 476.

39. Ibid., 329, 397, 449-50, 476.

40. Ibid., 397.

41. Ibid., 329.

HEALTH AND SAFETY 2014 ■ 15

SECTION 1 42. Ibid., 329, 447.

43. Carol Helmstadter, “’A Real Tone’: Professionalizing Nursing in Nineteenth Century London,” NHR 11 (2003): 3-30. Helmstadter notes that privacy during consultations, particularly for the working classes, had only become important in the 1860s when screens and curtains were gradually introduced.

44. Sandhurst Report, 202, 209, 374.

45. Bedford Fenwick had held all the house appointments at The London Hospital, but unlike his father, Samuel Fenwick, had been unsuccessful in getting elected to the staff. In 1887, he married Ethel Gordon Manson. Clark-Kennedy, The London, 105.

46. Sandhurst Report, 307, 314, 320.

47. RLH, LH/N/1/2, Register of Nurse Probationers, April 1884-August 1888, 230.

48. Ibid.

49. Sandhurst Report, 320.

50. RLH, LH/N/1/3, Register of Nurse Probationers, July 1888-September 1891.

51. RLH, LH/N/5, Official Ward Book, 1901.

52. RLH, LH/A/5, The London Hospital House Com Mins, 8 October 1889. Luckes reported that “nursing work at present is extremely heavy and that a large number of nurses were unwell.”

53. Septic fingers were infected hands or fingers believed to be caused by a germ or “poison” gaining entry into the hand. It was the third most common disorder, following tonsillitis and influenza, among probationers at the SDEC between 1903 and 1919. Sandhurst Report, 408; Plymouth and West Devon Record Office (PWDRO), 1490/24, SDEC Register of Nurses, 1903-1923.

54. BMJ, 13 September 1890.

55. Michael Worboys, Spreading Germs: Disease Theories and Medical Practice in Britain, 1865-1900 (Cambridge: Cambridge University Press, 2000), 3.

56. Luckes, Lectures on General Nursing, 279-99.

57. Sandhurst Report, 402.

58. BMJ, 13 September 1890: 646.

59. Nursing Record and Hospital World, 28 October 1893, 202.

60. Sandhurst Report, 313, 327.

61. Worboys, Spreading Germs, 39.

62. RLH, LH/A/5, The London Hospital House Com Mins, 22 October 1889.

63. Sandhurst Report, 392.

64. RLH, LH/A/26/5, Luckes, “Trained Nursing at the London Hospital,” 303.

65. Anne Summers, Angels and Citizens: British Women as Military Nurses, 1854-1914 (London: Routledge, 1988), 1-9; Rafferty, The Politics of Nursing Knowledge, 25; Celia Davies, Gender and the Professional Predicament in Nursing (Buckingham: Open University Press, 1995), 58; Patricia D’Antonio, “Revisiting and Re-Thinking the Rewriting of Nursing History,” Bulletin of the History of Medicine 73 (1999): 271.

66. Summers, Angels and Citizens, 3; RLH, LH/N/17/49, Report of the House Committee.

67. RLH, LH/A/26/5, Luckes, “Trained Nursing at The London Hospital,” 303.

68. This idea developed from Patricia D’Antonio’s argument that nurses’ achievement of positions of power by promoting skills rooted in domesticity initially allowed not only a step up “from the traditional conventions of their particular starting place” but also created boundaries that were often simultaneously both a source of strength and a dam around their ambition. D’Antonio, “Revisiting and ReThinking the Rewriting,” 71.

69. Dingwall et al., An Introduction to the Social History of Nursing, 58.

70. The Lancet, 26 July 1890.

71. Sandhurst Report, 452.

72. Ibid., 456.

73. Dingwall et al., An Introduction to the Social History of Nursing, 75.

74. More detailed study is needed of nurses’ class background to reveal the social origins of nonpaying probationers at The London Hospital.

Sandhurst Report, 398.

75. Hawkins, Nursing and Women’s Labour, 174.

76. RLH, LH/A/26/5, Luckes, “Trained Nursing at the London Hospital,” 292.

77. PMG, 11 September 1890.

78. The Lancet, 26 July 1890, 194.

79. Abel-Smith, A History of the Nursing Profession, 17.

80. The Hospital, 16 August, 1890.

81. Sandhurst Report, 407.

82. See Angelique Richardson, Love and Eugenics in the Late Nineteenth Century: Rational Reproduction and the New Woman (Oxford: Oxford University Press, 2003); Linda Hughes, “’A Club of Their Own: The “Literary Ladies,’” New Women Writers, and Fin-de-Siècle Authorship,” Victorian Literature and Culture 35 (2007): 233-60; Matthew Beaumont, “A Little Political World of My Own: The New Woman, the New Life and New Amazonia,” Victorian Literature and Culture 35 (2007): 215-32.

83. Monica Baly, ed., Nursing and Social Change (London: Routledge, 1995), 148-49.

84. For example, probationer Ellen Yatman wrote to Eva Luckes “pointing out the unnecessary hardships and dangers to which nurses were exposed. The matron returned a bare acknowledgment of the letter.”

Letter from Herbert Yatman, The Times, 30 July 1890, 13.

85. Plymouth and West Devon Record Office (PWDRO), 606/1/7, SDEC General Committee (Com) Minutes (Mins), 14 August 1903, 225. The SDEC estimated the cost of a nurse’s board and lodging to be £18 per annum.

86. Brian Abel-Smith, The Hospitals 1848-1948 (London: Heinemann, 1964), 68; Anne Witz, Professions and Patriarchy (London: Routledge, 1992), 140; Wildman and Hewison, “Rediscovering a History of Nursing Management,” 1653.

87. Nursing Record, 14 June 1888, 127.

88. PWDRO, 606/1/3 SDEC General Com Mins, February 1894-June 1897, 10 July 1894, 28. Matron Hopkins was given annual leave to attend the annual meeting of the British Nursing Association.

89. Rafferty, The Politics of Nursing Knowledge, 63.

90. Nursing Record and Hospital World, 12, 19 July 1888; 4 July 1889.

91. Ibid., 4 July 1889, 18-19.

92. Eva Luckes, What Will Trained Nurses Gain by Joining the British Nurses’ Association? (London: J. and A. Churchill, 1889).

93. Rafferty, The Politics of Nursing Knowledge, 64.

94. Nursing Record and Hospital World, 21 July 1894, 51.

95. Ibid., 22 October 1898, 330.

96. PWDRO, 606/1/1, SDEC General Com Mins, 1 March 1887.

97. Catherine Wood, “The Training of Nurses for Sick Children,” Nursing Record and Hospital World, 6 December 1888, 507.

98. PWDRO, 606/1/1, SDEC General Com Mins, 26 August 1886.

99. PWDRO, 606/1/2, SDEC General Com Mins, 1 July 1890, 8.

100. PWDRO, 606/1/7, SDEC General Com Mins, 15 March 1904, 340.

101. PWDRO, 606/1/2, SDEC General Com Mins, 18 October 1898.

102. The Pearn Convalescent Home was donated to the SDEC in 1892 by Edwin Alonzo Pearn and opened as a rest home for nurses in May 1895.

103. PWDRO, 1490/24, database compiled using information from SDEC Register of Nurses, SDEC Register of Nurses, 1903-1923.

104. Ibid., 1903-19.

105. Ibid., 1903-23.

106. PWDRO, 606/1/7, SDEC General Com Mins, 23 September 1909.

107. Western Daily Mercury, 5, 7, 10, 14 February 1904.

108. Local doctors claimed that their fee-paying patients were walking past the doors of their surgeries, often dressed in servants’ clothes, to the hospital in the hope of receiving free treatment. Western Daily Mercury, 7 February 1904.

109. Susan McGann, “The Development of Nursing as an Accountable Profession,” in Accountability in Nursing and Midwifery, ed. Stephen Tilley and Roger Watson (Oxford: Blackwell Science, 2004), 15.

110. PWDRO, 606/1/18, SDEC House Com Mins, 24 March 1905, 159.

111. Ibid., 7 June 1905.

112. Ibid., 23 March 1904, 2 June 1905.

113. Ibid., 12 September 1905.

16 ■ HEALTH AND SAFETY 2014

BACKGROUND 114. Ross Duncan, “Case Studies in Emigration: Cornwall; Gloucestershire and New South Wales, 1877-1886,” Economic History Review 16, no.

2 (1963): 272-89.

115. Gillian Burke and Peter Richardson, “The Profits of Death: A Comparative Study of Miners’ Phthisis in Cornwall and the Transvaal, 1876-1918,” Journal of Southern African Studies 4, no. 2 (April 1978): 147-77.

116. Cornwall Record Office (CRO), HC1/1/1/6, Report of the Lunacy Commissioners 1896.

117. The Lunacy Commission, established in 1845, was a central body that provided a framework for provision and administration of institutions designed to confine the lunatic. The commissioners were responsible for inspection of all such institutions. The power of the commission was strengthened by further legislation between 1845 and 1862 and in 1890. The Lunacy Act increased the power of the Lord Chancellor’s office to monitor all places where the insane were housed and dictated their care and treatment. Forsythe and Melling suggested that Lunacy Commissioners’ roles were limited, largely confined to inspections and public criticism of poor standards.

See Bill Forsythe and Joseph Melling, The Politics of Madness: The State, Insanity and Society in England, 1845-1914 (Abingdon, UK: Routledge, 2006).

118. Peter Nolan, A History of Mental Health Nursing (London: Chapman and Hall, 1993), 61.

119. Francis R. Adams, “From Association to Union: A Professional Organisation for Attendants, 1869-1919,” British Journal of Sociology 20, no. 1 (March 1969): 11-26.

120. Nolan, A History of Mental Health Nursing, 69.

121. Nursing Record and Hospital World, 12 December 1896.

122. Ibid., 6 February 1897, 114.

123. CRO, HC1/1/1/15, Cornwall Lunatic Asylum Visiting Committee (CLAVC) Mins, 25 August 1913, 70.

124. Dingwall et al., An Introduction to the Social History of Nursing, 126.

125. CRO, HC1/1/1/6, CLAVC Mins, 26 February 1894, 329.

126. Ibid., 24 June 1889, 9 June 1891, 25 July 1892; HC1/1/1/7, CLAVC Mins, 24 May 1897, 13 June 1903.

127. Charles T. Andrews, The Dark Awakening: A History of St. Lawrence’s Hospital, Bodmin (London: Cox Wyman, 1978), 91-93.

128. CRO, HC1/1/1/7, CLAVC Mins, 27 June 1898, 285.

129. CRO, HC1/1/1/6, Report of the Lunacy Commissioners, 1896, 13.

130. CRO, HC1/1/1/6, CLAVC Mins, 27 December 1894, 390.

131. CRO, HC1/1/1/6, Letter from Attendants to the Visiting Committee, CLAVC Mins, 27 December, 1894.

132. The Lancet, 9 August 1890, 318.

133. CRO, HC1/1/1/7, CLAVC Mins, 26 September 1898.

134. Anthony S. Wohl, Endangered Lives: Public Health in Victorian Britain (London: J.M. Dent, 1983), 127.

135. Scott C. Bezeau, Nicholas M. Bogod, and Catherine A. Mateer conclude that disinhibited sexualized behavior is common following a traumatic brain injury. “Sexually Intrusive Behaviour Following Brain Injury: Approaches to Assessment and Rehabilitation,” Brain Injury 18, no. 3 (March 2004): 299-313.

136. CRO, HC1/1/1/6, CLAVC Mins, 26 February 1894, 329.

137. The Healthcare Commission (2005) reported that British nurses took more days off sick than most other public sector workers. The commission estimated that the cost of sickness absence nationally for nurses and healthcare assistants was approximately £141 million per year.

Healthcare Commission, Ward Staffing (June 2005): 18, http://www.cqc. org.uk/_db/_documents/04018124.pdf (accessed May 16, 2010).

138. Mavis Gordon and Paul Lloyd, “Health at Work,” in Nursing and Social Change, ed. Monica Baly, (London: Routledge, 1995), 274-75.

139. Nursing Mirror and Midwives Journal, 5 July 1919, 258; RCN, College of Nursing Council Minutes, RCN/2/2, 8 April, 1920, 1-10.

140. Nursing Mirror and Midwives Journal, 5 July 1919, 258.

141. Ministry of Health, Board of Education, and Department of Health for Scotland, Interim Report of the Inter-Departmental Committee on Nursing Services (London: HMSO, 1939), 51-60. © 2012 Deborah Palmer © 2012 Springer Publishing Company, Nursing History Review. Reproduced with permission.

HEALTH AND SAFETY 2014 ■ 17

SECTION 2

Empowering you to keep your workplace safe

This section features a collection of articles which support our position that as skilled health professionals, you have the power in your hands to create workplaces which are not only safe for patients but also safe for you and your colleagues.

These articles highlight the importance of standing up for safety, of working collectively to find solutions to issues such as patient aggression and fatigue management.

Drawn from both Australia and around the world this material also underscores the importance of good organisational structures around health and safety, and the need to develop workplace cultures that encourage and empower employees to take ownership of health and safety in their ward or unit.

CHAPTER 2.1

STANDING UP FOR SAFETY: A HSR’S STORY Being a Workplace Health and Safety Rep can be challenging, but if you draw on the support of the QNU, the strength of Queensland law and the power of your position to make your workplace safer, it can also be very rewarding.

A few years ago Queensland Health conducted a health and safety audit on the Atherton Hospital. But it took QNU activists, including Workplace Health and Safety Rep (HSR) Charlie Scerri, to ensure the safety problems raised in the audit were actually addressed. This is Charlie’s story.

So Charlie, how did this all start?

About three years ago Queensland Health did an audit on the Atherton Hospital which covered security, safety, fire safety, virtually everything—but they sat on it for 18 months.

It was only through QNU pressure that they finally released it and when they did it was very damning of the entire establishment—it met virtually no known standards Australia-wide.

From that point on, the safety issues were raised numerous times at NCF (Nursing Consultative Forum) meetings but (those with the capacity to action them) seemed to have no interest in addressing them.

So eventually after much debate we decided I should put a PIN (Provisional Improvement Notice) in against the hospital, so they would actually be forced to act on some of the recommendations.

What was management’s response to the PIN notice?

Well, they weren’t happy.

In fact I was summoned to a meeting with (an OHS manager) from Cairns and they tried to talk me out of it, to withdraw it.

I think they thought the HSR was just a symbolic role— something they just had to have by law. I don’t think they counted on activists in the H&S committee doing anything.

Interestingly an email from management (about QNU pressure to address safety concerns) accidentally made its way to an NCF meeting for all of us to see and it said: “the union is upping the ante again and of course they want to use their power for evil instead of good”.

They have this perception—but it’s a totally wrong perception.

But you didn’t withdraw the PIN, so what happened next?

An employer has to act on (a PIN notice) within a certain timeframe—at least make some progress—and they failed to do that.

As a result the Queensland WorkSafe inspector was called in and he made a number of recommendations … on things that needed to be fixed.

Once he came they pretty much had to start doing things because they were now in breach and were being directed to take action by the inspector.

And the simple fact is that over the past 10 months those issues are gradually being fixed—fire doors have gone in, security cameras, security officers at night—virtually everything that was in the recommendations is now being followed through.

Does it feel good to know you’ve made your workplace safer for your colleagues—and patients?

I feel vindicated for sure, and I am definitely proud of what we have achieved.

I hope the new HSRs follow through too, because they have a lot of power within themselves to do these things.

What would you say to someone who is considering becoming a HSR? Look this can be a tough job—and I think some managers or employers feel threatened by the power a workplace health and safety rep can wield.

And as a HSR you do have a lot of power and you can get things done.

There are a few tips I recommend:

■■ Never attend a meeting with management ■■

What we are about is standing up for our fellow workers, ensuring they are safe and their entitlements are met– that’s what it’s about.

■■ ■■

But sometimes they don’t see it that way, they sometimes see it as a personal attack.

■■

unaccompanied and find always find out what the agenda is before you attend any meeting.

Follow up any attempts by management to intimidate you for doing your HSR role.

Most importantly, you have union backing—so use it!

Speak with the QNU’s workplace health and safety officer—they are a wealth of knowledge.

You also have Workplace Health and Safety Queensland to back you up too.

HEALTH AND SAFETY 2014 ■ 19

CHAPTER 2.2

CASE STUDIES Sergeant, J & Laws-Chapman, C (2012) ‘Creating a Positive Workplace Culture’, Nursing Management, vol. 18, no.9, February, pp.14-19.

When nurses and midwives use their collective power to resolve a workplace health or safety issue everybody wins. A safe workplace for nurses and midwives, means a safer, well-managed environment for patients. In this chapter we give you examples of how nurses and midwives took a stand, used their “power” and took the lead on resolving a safety problem in their ward or unit.

Some of these case studies highlight the determination and tenacity of QNU members while others are from our counterparts interstate.

Case study 1: Offender health staff use the BPF to secure 36 FTE nurses (Qld) In 2012 QNU members at Queensland Health’s correctional facilities were locked in battle against Offender Health Services (OHS) management over workloads.

Ross Cunningham, a clinical nurse at the high security Maryborough Correctional Centre at the time, said in his facility, the nursing numbers simply had not kept up with the increasing prisoner population which grew from 200 people when it first opened in 2003 to up to about 500 by 2012.

after investigation, calculations showed that across the state, the service was understaffed by a whopping 36.47 FTE. The money for 19 of these staff was in the budget but had never been allocated.

The remaining 17 were new positions to be established.

“Once OHS nurses realised the power in the BPF process, everyone worked together to take action,” Ross said.

“Nurses and midwives need to realise they are the union— they need to work together to make their own practice better and safer.”

The result was unreasonable workloads which not only put patients at risk but was also a safety risk for nursing staff.

After attending his local Nursing and Midwifery Consultative Forum, Ross enrolled in a QNU training course on the BPF, and together with other offender health nurses started gathering evidence to support the claim of understaffing.

“It was easy to get people to complete workload forms, and as they mounted up we knew we had piles of evidence,” Ross said.

“We collected and documented each person we saw so we had monthly figures to present on how many patients we’d seen—it is vital to have that information.”

In late 2012, dispute hearings began in the Queensland Industrial Relations Commission (QIRC).

The nurses were primed to give detailed testimony of the difficulties they had with workloads, but the Commissioner decided there was more than enough evidence to support their case and started calculating just how serious the staff shortage was.

The QIRC affirmed the BPF as the appropriate industrial tool for determining nursing and midwifery workloads, and

Offender Health Services nurses Lore Reid and Kath Ransley.

20 ■ HEALTH AND SAFETY 2014

CASE STUDIES

Case study 2: Tale of the Bowen bed mover (Qld) The Bowen Hospital Branch of the QNU was formed in March 2012 and by May had secured funding for a $27,000 bed mover—a great example of how getting together and standing firm on safety can secure results.

In November 2009 a staff member was injured while transferring a patient on a trolley up a 10m ramp between the Emergency and X-Ray Departments which had a steep gradient. She was the second person to suffer an injury conducting this task.

The hospital commissioned a risk assessment in February 2010 but the results were never released.

Hospital officials repeatedly knocked back the WH&S group’s requests for a bed mover by stating the hospital was “unable to purchase (it) at this time”.

In March 2012 Bowen nurses formed a new QNU branch, escalated a grievance around the bed mover matter and submitted a request for representation.

A month later the Mackay Health Service District issued an instruction that moving beds was a two-person task and with two people on hand the task became ‘low-risk’—but as our members rightly argued, this was simply not good enough.

A week later the QNU unearthed the original risk assessment which revealed a damning verdict of the bed moving process at Bowen, saying “the likelihood of musculoskeletal injury in this work area is HIGH”.

QNU Bowen Branch members Linda Atfield, Maria Macdonald and Janet Garland with their new bed mover.

The Health and Safety Reps had been actively involved in consultation with management, builders, architects and WorkSafe to try and eliminate the hazards.

WorkSafe had advised that decibel readings were sitting at a constant 70 to 75 range throughout the day with intermittent spikes to 90.

Not surprisingly it also recommended the use of a bed mover, saying the long term cost effectiveness of the equipment would outweigh the initial outlay.

In response, the Deputy HSR kept a log of the noise levels during the day and all staff were encouraged by their direct line manager to document incidents and symptoms to highlight the issues to Mercy Health management.

Faced with overwhelming evidence and nurses prepared to take a stand, it took only a few weeks before management changed its tune and ordered a bed mover.

ANMF Victoria contacted Mercy Health concerned about the symptoms staff and clients were experiencing as a result of the noise, and encouraged them to act immediately.

Case Study 3: Renovation health and safety risks resolved (Vic)

Management responded quickly and arranged for all demolition work to take place between 6am and 10am.

They also changed the clinic’s opening hour to 10am with no reduction in pay.

Health and Safety Reps employed at Mercy Mental Health in Melbourne worked together to resolve health risks stemming from demolition and building noise during renovations last year.

This was a great result, illustrating how health and safety reps, nurses, staff, management and third parties can use WH & S protocols and communication to achieve outcomes that make workplaces safer for everyone.

Members working at Footscray’s Saltwater Clinic— which was operating as normal during the renovation work—reported physical symptoms such as headaches due to excessive and persistent noise, and frustrating communication problems.

Source: On the Record, December 2013, ANMFVIC

Two of the three emergency exits were also blocked during the works, and the noise and chaos was found to exacerbate the symptoms of some clients visiting the clinic.

Staff shortages eased at Dubbo Base Hospital emergency department after nurses voted to close beds and ban excessive overtime late last year.

Case study 4: Plan to close beds gets results on workloads (NSW)

HEALTH AND SAFETY 2014 ■ 21

CHAPTER 2.2 Dubbo hospital branch of the NSWNMA voted to close the six-bed emergency medical unit (EMU) and refused to work unreasonable overtime in the emergency department (ED), unless management put an end to unsafe staffing arrangements.

ED nurses reported that overtime was out of control and new graduates were replacing experienced nurses, meaning shifts were also repeatedly short of senior nurses.

In mid-September, ED nurses reported that the 20-bed ED had 7.2 FTE (full time equivalent) vacancies including nurses on leave.

Working collectively, the mental health nurses formed a new QNU branch at the hospital and launched a campaign arguing that safety could be compromised if management directed any QNU member to work in the new facility.

Nurses decided to defend themselves against an unfair and unsafe situation, rather than simply going along with what management wanted them to do.

As branch activist Kimberley Kriedemann said at the time: “It was important for us to take a stand because by not completing an audit, management gave us a clear indication that the safety of mental health nurses was not a priority.”

In the period 16 September to 13 October there were 127 gaps in the roster including 71 shifts with shortages of experienced nurses: 26 in the resuscitation area; 16 in triage; 13 in the clinical initiative role; and 16 in the nurse in charge position.

A high level of member activism and the formation of a new branch around the safety audit issue made a real difference to the campaign.

Branch members were determined to do whatever it took to improve safety and they believed closing beds was the only action left open to them.

Many of the nurses who became involved in the campaign had never been active before and the success of the safety audit campaign empowered nurses with confidence to raise other issues like staffing, workloads and rostering.

Management initially argued they were the only ones who had the right to close beds, but branch members cited work health and safety law and their obligation to provide a safe working environment.

At a branch meeting on September 26, nurses called on the administration to advertise and backfill all vacancies, including those on leave or seconded to other positions.

The meeting voted unanimously to close six beds in the EMU as of Monday 30 September until all vacancies were recruited, and for ED nurses to refuse to perform unreasonable amounts of overtime starting 4 October.

Management moved quickly and made temporary arrangements to fill gaps in the roster following the vote and within a fortnight nurses reported that both staff numbers and the skill mix in the ED were improving.

At last report management was continuing to work with the branch on efforts to find a long term solution.

Source: NSWMNA

CASE STUDY 5: Mental Health Nurses stand firm on safety audit (Qld) In 2009 QNU members at Princess Alexandra Hospital’s Mental Health unit took action to defend their health and safety by refusing to work in what they believe to be an unsafe area.

Nurses decided to take action against working in a newly constructed annex after management failed to complete and supply a workplace health and safety audit of the new facility as well as address models of care, workload (BPF) and procedural issues.

Having strong representation of nurses standing firm made it difficult for management to ignore.

CASE STUDY 6: Championing safety solutions at the design stage (Qld) A few years ago Labrador Gardens Director of Nursing Myrill Stewart showed how nurses and midwives in management can lead from the front on health and safety issues.

As the new Blue Care facility was being designed, Myrill Stewart launched a campaign to ensure every bed had ceiling tracking installed compatible with ceiling hoist technology.

In making her case to Blue Care management for ceiling hoists instead of traditional mobile hoists, Ms Stewart presented three key arguments—that staff were at greater risk of injury due to the physically demanding nature of aged care work, that there was an ageing female work-base and that workloads had risen due to increasing resident acuity.

Ms Stewart said her arguments, combined with increased costs incurred from workplace injuries and workers’ compensation premiums, were enough to convince others within Blue Care of the merits of her proposal.

One year after installation, a preliminary analysis by Blue Care showed significant reductions in peak biomechanical loads on the lumbar spine and shoulder area of 19% and 12% respectively compared to using mobile hoists.

Notably, a staff survey revealed that 92% prefer using ceiling hoists to mobile hoists.

Staff comments included “the physical workload has decreased”, “better on back”, “don’t have to push and pull mobile hoist” and “it saves time”.

22 ■ HEALTH AND SAFETY 2014

CHAPTER 2.3

THE IMPACT OF SAFETY REPRESENTATIVES ON OCCUPATIONAL HEALTH

(EXTRACT)

Extracts from: Menendez, M., Benach, J. & Vogel, L. (Coordinators) (2009) The Impact of Safety representative on occupational health. A European Perspective. European Trade Union Institute Report 107

In 2006 the European Trade Union Institute launched a major project assessing the effectiveness of safety representatives’ activities on workplace health and safety in Europe. They concluded that all across Europe unions, workers’ representatives and safety representatives were a powerful force for improving workers’ occupational health.

Safety representatives in the European Union European trade unions have made some initial headway in implementing and expanding workers’ rights at EU level, but workers’ representation and participation at workplace level are still today largely based on national laws and political traditions. The EU has a wide variety of national situations shaped by industrial relations, trade union traditions, sectors, and types of activity. Data from the Second European Social Survey (2004), for example, shows that social democratic countries (including Iceland and Norway) have the highest percentage of trade union membership (73.2%), well above the all-country average (22.7%), whereas Eastern European countries with a Soviet Union heritage – barring Ukraine (42.3%) and Slovenia (40.8%) – have the lowest average memberships of all (12.9%). Another way to measure workers’ participation is through their workplace representation. In 2006, the average was 53% in the EU-27, ranging from 81% in Nordic countries to just 25% in the Baltic states.

The main approach to promoting workers’ participation in health and safety at work is through the election of health and safety representatives, i.e., workers specifically mandated to represent workers’ interests on health and safety at work issues. Although no complete and wholly reliable data are available, it is estimated that there are over one million safety reps in the EU-27, although the figures vary widely between countries. Finland and Denmark have around 35,000 to 38,000 safety reps for between 2.3 and 2.8 million workers, while Portugal, by contrast, has just a few hundred safety reps distributed among some 60 firms. Most of these safety representatives are experienced workers who are also trade union members, even though

the different industrial relations systems enable nonunionised workers to be elected as safety reps in some countries. There are four possible ways in which such reps can be appointed: they can be directly selected by workers, appointed by worker representation bodies (i.e., works council or similar body), shop stewards (i.e., elected union officials) with safety rep duties, and works councils exercising safety rep functions. Research shows that the direct forms of participation often have not had positive outcomes for workers’ occupational health (Walters and Nichols 2006). Such situations leave employers wide discretion to decide how to consult workers, how to impose duties on safety reps, how to limit their practical duties, and how to control workers’ practices. Current managerial strategies are further increasing workers’ direct participation in health and safety as an alternative to union-driven collective bargaining mechanisms (Weil 1999). Although only limited study has been done of conditions that determine the effectiveness of safety representatives, available experiences and evidence generally support the idea that representative participation (i.e., the collective representation of workers’ interests through formal statutory or voluntary arrangements) constitutes a powerful force for the improvement of workers’ health and safety.

The mandate conferred on health and safety reps, whether by law or collective agreement, gives them certain specific areas of responsibility and rights. The Framework Directive (Council Directive 89/391/ EEC, 1989) was a starting point for the participation of safety representatives, but its specific role and legal protection has not been fully developed. Workers’ right to have health and safety representation organised by unions is still severely hindered in practice in small

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CHAPTER 2.3 firms, sectors of activity with high levels of contingent employment, and non-unionised firms. The development and implementation of regional health and safety reps in countries like Sweden and Norway, and in some sectors or branches in countries like Italy, has expanded those rights mainly for workers in small firms (Walters 1998; Frick and Walters 1998).

As well as elected safety reps, workers’ representation in health and safety also takes place through health and safety committees composed of workers’ and employers’ representatives with a remit to improve health and safety in the workplace. These committees identify potential health and safety issues and bring them to the employer’s attention.

Unfortunately, such valuable information is still not available today in most EU countries.

Conditions associated with safety representatives influencing occupational health To assess the impact of safety reps’ actions on health and safety at work, we carried out an exhaustive literature review using a large range of sources of data and information including a comprehensive systematic review, various descriptive epidemiological analyses based on national and European surveys, and knowledge provided by key informants including safety representatives, trade unionists and experts in occupational health research.

Given current EU data and research limitations, we took the methodological approach of formulating a theoretical model which describes a broad set of conditions and factors potentially associated with the effectiveness of safety reps’ actions (see Figure 1).

FIGURE 1

Theoretical model of the conditions and factors likely linked with safety reps’ activities and effective occupational health and safety outcomes.

A. Social & political conditions Social policies

(Country/region level)

Labour market

Laws & regulations Regulatory agencies

Power of trade unions & collective bargaining

Employment relations, economic sector, financial positions, firms’ size, productive process B. Conditions within firms

C1. Conditions of safety representatives (Structure and organisation)

Unions  workers

■■Ideology ■■Empowerment ■■Union strategies ■■Collective bargaining

Management policies ■■Commitment & strategy on OH&S ■■Industrial relations ■■Work organisation

Public administration & social support ■■Enforcement ■■“Mediators”

D. Policies and interventions Prevention planning, improvement of working conditions, risk assessment and factor reduction, health promotion

Coverage & representation H&S committee

Resources & support Management, unions and government

Knowledge Training & vision

Power & workers’ support Position, autonomy, recognition

C2. Strategies and activities ■■Information and training ■■Surveillance of working conditions ■■Meetings ■■Complaints and grievances...

E. Exposure, risk factors and health outcomes Working conditions, risk factors, deaths, diseases, injuries, sickness absenteeism and quality life

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THE IMPACT OF SAFETY REPRESENTATIVES ON OCCUPATIONAL HEALTH This model serves two main purposes: it helps to visualize the origins and consequences of different conditions and factors, and it traces the connection between social and political conditions, the conditions within firms, the conditions of safety representatives, and their strategies and activities on exposures, risk factors, and health outcomes.

Put simply, the model is a means of visualising the many conditions and factors that may play into the effectiveness of safety reps’ health and safety activities as well as a tool to identify potential policy entry-points to implement interventions.

Part A (Social and political conditions) includes a dynamic interaction between four main macro components present in each country: the role and impact of social policies, the labour market structure, the laws and regulations of regulatory agencies, and the power of unions and the extent of collective bargaining. Here the model presumes a positive relationship between more generous social policies and regulated labour markets, the development of employment and work-related laws and regulations, and higher unionisation rates and collective bargaining power, and the implementation of positive health and safety at work measures, increased workers’ participation, and other positive conditions and determinants that may help to improve the effectiveness of the actions taken by safety representatives.

Part B (General conditions within firms) must be seen through the prism of the firm’s employment relations, economic sector, financial position, size, and productive process. The actions of three key actors play a crucial role: unions and workers, including their ideological position, the level of power and participation, the strategies they may take to support safety representatives, and the level of collective bargaining; management, including its commitment to health and safety strategies, and the type of work organisation among other related factors; and general government and its social support, including the enforcement of laws and regulations, and the social support given by key “mediators” such as regulatory agencies, employers’ organisations, and management/labour negotiations.

Part C1 (Safety reps’ conditions) looks at four related components: the coverage and representation of health and safety committees, the extent to which rights are exercised and the level of resources and support received by safety reps, their level of knowledge, training and information and, very importantly, their level of power, an issue which includes their standing, union autonomy, and recognition by workers.

Part C2 (Strategies and activities of safety representatives) varies with the union’s strategies and policies, as well as the different ideological and political characteristics of safety reps. Safety reps’ activities include actions on information and training, surveillance of working conditions, meetings of health and safety committees, assistance with workers’

queries, workers’ meetings, workplace inspection, risk assessment, and proposal of solutions. At the C1 and C2 level, the model presumes that where safety representatives are better structured in terms of coverage, resources, knowledge and power, their workplace strategies and activities will deliver more effective outcomes.

Part D (Policies and Interventions) includes prevention planning, the improvement of working conditions, risk assessment, risk factor reduction, and health promotion.

Here, it is assumed that the actions of safety representatives, directly (through their specific activities) or indirectly (via improvements to the general work environment) will lead to effective policies and interventions to improve occupational health and safety.

Finally, Part E (Exposures, Risk factors, and Health outcomes) takes into account various health indicators of working conditions, the reduction and protection of exposures and risk factors, and the impact of these conditions and factors on health outcomes such as mortality prevalence and incidence, diseases, workplace injuries, sickness absence, and workers’ health and quality of life.

Macro social and political conditions Workers’ well-being, health and quality of life are associated with a number of key macro social and political conditions implemented by states. The development of the welfare state refers to the extent to which governments exert their distributive power through the implementation of social policies, labour markets and employment regulations, the strength of trade unions, and the system and conditions of collective bargaining (the ways in which labour/capital relations are conducted). Research shows that the power of labour and its trade unions correlates with the type of state regime (social democratic, conservative-corporatist, economic liberalist), the type of employment relations, and workers’ health and safety (Chung and Muntaner 2007; Benach, Muntaner et al., forthcoming 2009).

The flexibilisation of production, technological and managerial changes have in recent decades created new demands for productivity in an increasingly deregulated European labour market. There is now growing scientific evidence that new forms of insecure employment and work intensification are damaging the health and well-being of European workers and their families; research shows that factors linked to subcontracting – like financial/ costcutting pressures on subcontractors -, disorganisation/ fracturing of occupational health and safety management, and inadequate regulatory controls, leads to a deterioration of occupational health in both developed and developing/ poor countries (Johnstone et al., 2001; Benach, Muntaner et al., forthcoming 2009). In the context of a dominant economic liberalist discourse focused on economic growth and labour market flexibility, governments’ responses on

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CHAPTER 2.3 labour laws, union agreements, training systems, labour markets that protect workers’ incomes and job security have often been weak and fragmented. Unions and health and safety representatives therefore face a serious challenge to reverse this worrying situation. More particularly, they have a crucial role to play in safeguarding the health and wellbeing of the most vulnerable workers in workplaces that are not strongly unionised.

Health and safety at work legislation and regulations, including the right to be adequately informed and consulted on health and safety at work, are a major social policy concern in the European Union. In the last two decades, the majority of European countries have recognized and regulated workers’ right of participation in occupational health by taking over EU Framework Directive 1989/391 into national law. But the level of transposition of this Directive in most countries has not been satisfactory and many national laws have not been given full effect.

This is reflected in such issues as: the level of employers’ responsibility for health and safety at work, the coverage and election of safety representatives, compulsory assessment of work-related hazards, the need to implement occupational health services and, finally, the development of information, consultation, training, and participation among workers. These failings are likely to affect the strength and effectiveness of actions taken by unions and safety representatives.

The power of labour plays a vital role in the implementation of social policies, labour market regulations and collective bargaining across European countries. The balance of power between management, government and trade unions determines what kind of employment relations will be established, which employment and occupational policies will be prioritised, which occupational health and safety regulations will be approved, which working conditions and work-related hazards will be considered acceptable, and which participatory processes and workers’ representation will take place in the workplace (Hall et al., 2006).

Stakeholders’ ideology and views on health and health inequalities are also a crucial asset in determining its values and priorities on health and safety policies. Unfortunately, governments and trade unions have not always had occupational health and safety high on their agendas, agreements and collective bargaining priorities, and often this comes well down the list in discussions on issues like wages, job security and pensions.

The specific effect of collective bargaining on workplace health and safety means adapting general legal preventive provisions into specific terms for the concrete realities of individual sectors, companies, production units, work places and working conditions. Collective bargaining negotiations are based on two main pillars: the experience and knowledge of stakeholders involved in the bargaining process, and how much power each wields. Pressure

from organised labour shapes the types of social and economic policies, including labour markets, laws, and regulations. Evidence shows that when trade unions are stronger, information and standards on workplace hazards are improved, health and safety systems work better and workers’ actions are more effective. In Spain, for example, years of trade union campaigning and pressure to cut abuses in subcontracting on building sites paid off in 2006 when legislation (Act 32/2006) was brought in requiring all the safety reps concerned to be informed about all subcontracting agreements, and training for a joint rep for the workers operating on the same work site can be provided for in industry collective agreements (ETUI, 2008a).

Conditions within firms Here, we describe the conditions internal to firms that are related to safety reps’ effectiveness: the involvement, support, and commitment of unions and workers; the policies and commitment of management and employers; and enforcement by general government through inspections and controls by public agencies. We also consider the contextual factors like company size, financial position, subcontracting situation or branch of industry. For example, there is evidence that the market relationship between the different organisations involved in supply chains can lead to situations in which the larger and financially stronger parties secure financially beneficial contractual terms that can detrimentally affect the management of health and safety in those organisations with whom they contract. (James et al., 2007).

Unions and workers Two general issues are considered here. One is the ideology and political position of unions and workers. Unions need to be fully committed to improving occupational health and reducing workers’ health inequalities regardless of gender, type of job, contractual arrangements, supply chain or firm size. This requires independence from management, investment of adequate resources, and the implementation of long-term active political strategies. The other is workers’ empowerment. Workers who are empowered have more autonomy, decision-making authority and power within the workplace; this is a step towards greater involvement in all labour organisation issues, which gives more strength to unions and safety representatives. Research shows that employee participation is not improved by unionisation per se, but requires unions to develop programmes that increase the knowledge, political consciousness and empowerment of workers, giving them mechanisms to express their concerns and to mobilise their influence into a ‘joint actionvoice’ (James and Walters 2002).

In addition to the general issues outlined, we also consider here two sets of more specific issues: union strategies and support, and the influence of collective bargaining.

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THE IMPACT OF SAFETY REPRESENTATIVES ON OCCUPATIONAL HEALTH With regard to union strategies, the first to consider is that of strengthening the position of safety reps. This strategy embraces three key things. First, the provision of knowledge, information, and training to health and safety reps. To be effective, training needs to go beyond a technical approach and use a participatory methodology. Replies by reps to questions about why trade union training is effective make it clear that the methods employed in tuition such as studentcentred learning and skills development play a major role (Walters et al., 2001). Also, it has been suggested that the key to understanding why this is so is to be found in the relationship between the learning aspects of trade union education and the social construction of the employment relations of health and safety (Walters and Frick, 2000).

Second, the creation of safety representatives’ networks, establishing useful and regular information channels to safety reps and the provision of legal and technical advice by unions, may arguably be two key means for putting this strategy into practice. And third, providing essential logistical support for safety reps and other participatory mechanisms. This includes producing practical tools like guides, brochures, bulletins or regularly-published newsletters on occupational health and safety issues, and offering independent technical and legal professional advice. Media such as Por Experiencia (Spain), Hazards (UK), 2087 (Italy), and Santé et Travail (France) played a noteworthy role.

The second strategy is the integration of safety reps’ functions into workplace trade union organisations. Unions therefore need to develop actions to involve all kinds of representation bodies (i.e. works councils, shop stewards) in health and safety issues. An example comes from Belgium with the Confederation of Christian Trade Unions (Algemeen Christelijk Vakverbond / Confédération des Syndicats Chrétiens, ACV/ CSC), Belgium’s largest union organisation, of about 1.6 million members with 22 regional federations and 16 industry unions (Box 1). ACV/CSC workplace health and safety actions are addressed to the entire union structure.

BOX 1

Involving the whole workplace union organisation on health and safety In Belgium, the ACV/CSC’s branch federation supports workplace shop stewards’ committees on all trade union issues, including health and safety at work. The main strategy for integrating safety rep functions into the overall workplace union organisation and action is by encouraging union reps to organise and plan their work on all workplace issues, including health and safety.

Monitoring and support on these specific subjects is provided by permanent trade union officials who are specialized health and safety experts. There are such experts in each branch federation and one in each regional federation. To achieve this goal, the ACV/CSC provides training and practical guidance.

Source: Stéphane Lepoutre. Service entreprise de la CSC

The second specific issue related to unions and workers is how collective bargaining affects safety representatives. The lack of specific national laws mentioned earlier may be made good to some extent through industry or workplace collective agreements. Specifically, collective agreements can help to develop a number of enabling conditions for safety reps: firstly, many agreements include provisions to increase safety reps’ coverage, often expanding the ways they can be elected and creating other forms of representation (e.g., regional or sectoral safety reps); secondly, some also address resource issues, like training or time off amongst others; thirdly, some may give wider consultation and participation rights; finally, collective agreements may include arrangements to enforce health and safety at work compliance by management. Various examples of this may be cited. One such case comes from Spain, with CC.OO.’s chemical and textile industry federation (FITEQA-CCOO).

The General Chemical Industry Agreement signed in 2004 entrenched the proposal to assess the risk factors in work organization, making it compulsory to evaluate workplace psychosocial risk factors. A second recent example is the world’s largest steel company (Arcelor Mittal) and the trade unions representing its employees worldwide (Metalworkers’ Federation, the United Steelworkers and the International Metalworkers’ Federation). The agreement, signed in June 2008 and the first of its kind in the steel industry, sets out the commitment to set up joint management/union health and safety committees as well as training and education programmes. The agreement also included the creation of a joint management/union global health and safety committee to target plants in order to help them to further improve their health and safety performance across the company (ETUI, 2008b). Another recent case is that from Holland on an Occupational Health covenant (Box 2).

Management Safety reps’ engagement with consultative structures and processes, and the development of their functions and activities, are influenced by structures and systems of industrial relations and the organisation of working conditions within firms. Therefore, the role of employers and management relative to health and safety at work will promote or hinder the effectiveness of the actions undertaken by safety representatives. Since many safety rep activities must be carried out jointly with management, its commitment to participatory approaches is a prerequisite to ensure the effective functioning of health and safety representatives in the workplace (Milgate et al., 2002; Walters 2006). In manufacturing and retail firms, for example, various management behaviours were associated with lower lost-time injury rates, such as: including health and safety in every manager’s job description, incorporating health and safety performance in each manager’s annual appraisal, and attendance by the senior manager at health and safety meetings (Shan-non et al., 1996).

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CHAPTER 2.3

BOX 2

A Dutch occupational health covenant: a sector-level risk assessment tool The sector-level role of trade unions in the field of occupational health and safety (OHS) has recently been boosted in the Netherlands by the so-called OHS covenants test-negotiated by employers and trade unions.

One such covenant has been the development of sectorlevel risk assessment tools with the involvement of trade unions. Risk assessment is a statutory obligation for all employers. When companies use a risk assessment tool developed for their own sector with the approval of the trade union and incorporated into a collective agreement, they no longer need to consult an OHS professional (a statutory requirement under the Dutch Working Conditions Act). If the trade union vetoes the tool, the company may still use it but must also enlist independent advice from an OHS professional. One way to implement the matters covered by OHS covenants would be to include them in collective agreements, because covenants are not legally binding, and trade unions cannot enforce compliance in the same way they could with a collective agreement.

Initial analyses have shown that labour inspectors found more satisfactory sector-level risk assessment tools incorporated into collective agreements (74.1%) than those not approved by trade unions (70.8%).

Source: Popma J. Does worker participation improve health and safety?

Findings from the Netherlands. A Joint Conference of the European Trade Union Confederation and the Health and Safety Department of the ETUI-REHS. Brussels, 11 and 12 February 2008

In general, management commitment implies a positive attitude on health and safety that should be translated into long-term policies, making changes on labour relations and work organisation to facilitate the actions of safety representatives. The origins and outcomes of management commitment, however, are often unclear. To understand how this commitment is generated, we need to consider “internal” factors such as the ethical values and ideological or political position of management on health and safety issues. For example, the employer may help to create a proper dialogue, involving workers in discussions and decisions. Other internal factors are the judgments that managers make on economic costs (e.g., on high sickness absence, loss of productivity, and debilitation of the work force), their knowledge and training on occupational health, and the specific involvement that middle management may have. But other “external” factors must also be considered, including the pressures and follow-up generated by unions, government legislation, regulations and enforcement, and public outcry or media attention. Although much research needs to be done to understand the conditions and factors that promote management’s commitment and action on health and safety at work, current knowledge supports the idea that the strength of unions is one of the most important factors involved (Shannon et al., 1996; Shannon et al., 1997).

Finally, commitment from management can be considered truly real when it can be confirmed through actions, formal management arrangements, and clear outcomes.

Examples of these include: the drawing-up of explicit and accountable health and safety at work policies, including the level of financial resources allocated; the development of management systems for preventing, reducing and eliminating hazards, including clear and systematic mechanisms for worker participation, consultation and information; the execution of recommended actions in a timely manner; and, finally, the making of risk assessments and procedures for monitoring workers’ health, keeping open and written records of them. Another specific important feature demonstrating real management commitment is the inclusion of health and safety activities and investments on the agenda of day-to-day management.

General government The development of strong, proactive government action on occupational health is a condition that helps to encourage employers’ compliance with health and safety standards and respect for workers’ legal rights. States may potentially have a significant influence on the effectiveness of safety reps’ activities in two main ways: implementing policies, programmes and regulations, and through the role played by governmental regulatory agencies, i.e., institutions that apply or enforce regulations.

Public policies may help provide unions and safety reps with much of the knowledge, protection, and power they need to participate effectively and actually improve occupational health and safety. Firstly, governments can develop public databases on occupational health and safety as well as on mechanisms by which for health and safety representatives and managers to access this information. A second related issue is registration of safety representatives, what coverage they have and how they may be elected (e.g. area delegates in Sweden). Third, governments may provide legal protection for safety representatives against dismissal.

Fourthly, company health and safety policies on workers’ compensation, exposures to workplace hazards, or the organisation of occupational health prevention systems are heavily influenced by the actions of government agencies. So far, many of these public policies have not risen to become real priorities on the EU policy agenda.

In the role played by governmental regulatory agencies, that of the labour inspectorate is central to the implementation of occupational health and safety strategies. The labour inspectorate has to promote knowledge of and enforce regulations at the workplace. Current enforcement action by many governments and labour inspectors in the EU-27 is inadequate, too weak, or incomplete. In fact, it seems likely that the vast majority of EU worksites have never been inspected. The labour inspectorate in most European countries today is not capable of applying rules and regulations with the necessary force to persuade management actively to pursue health and safety programmes. In most Eastern European countries, the labour inspectorate is ill-equipped and still in the throes of reorganisation.

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Structure and organisation of safety representatives The structure and organisation of safety reps within firms, their powers and the mechanisms that may facilitate or hinder the effectiveness of their health and safety activities are many and varied. We describe four main factors: the coverage and representation of safety representatives; access to resources and support provided by management, government and unions; the level of knowledge, training, and vision that safety reps have; and, finally, the level of power, empowerment and influence possessed by safety reps.

The first issue is coverage and representation, that is, the absolute number or density of workplace safety reps, types of election and ways in which they are elected. When proper coverage is lacking, representatives tend to be more often marginalised and their activities less effective. Safety representatives appointed through workers’ representation bodies with trade union backing is likely to be the most effective approach. An important issue to consider is the existence of Health and Safety Committees (HSC). They act as sources of information and forums for discussion on health and safety for reps. Where there is no committee, there is less room for participation and bargaining.

A second issue connected to the structure and organisation of safety representatives is access to resources and support.

Safety reps require an adequate level of physical resources (e.g., an office, computers, web page, and other essential materials), legal resources, and, even more importantly, strong support from management, government, and unions to perform their duties effectively. The levels of health and safety reps’ resources vary widely across EU countries, sectors and firms, ranging from well-resourced reps with their own budget to those with limited union resources working within severe management constraints, and many variations in between. Surveys of health and safety representatives indicate that neither of these conditions can be assumed. In many cases, safety reps are under-informed about their resources and how to use them. In many firms, but mainly in small workplaces, safety reps do not insist on their statutory rights from fear of reprisals or dismissal.

Turning now to the role played by management, government, and unions on resources and support.

Management must provide safety reps with paid time off to undergo proper training, carry out inspections, research, and attend meetings. Such paid time off must be included in the company’s annual budget. It is also important for safety reps to be able to actually exercise this right, and not to have their work taken over by their co-workers. Studies with self-reported information from safety representatives show that this is a key obstacle to performing their work (Walters et al., 2005; García 2007; DTI 2007). Management should also give access to company information on occupational health generally and on specific health and safety matters.

Legislation gives a paper guarantee of access to information, but this is not often put into practice in many firms.

Information should be adequate, given sufficiently early, and in a way that enables health and safety representatives to understand and respond to it. Safety reps must have the right and means to enlist and consult independent union or government experts. A final important issue is the establishment of clear channels of communication between all key stakeholders. Effective communication between management and committee members, safety reps, and unions and workers is considered the basis for workplace consultation.

From government, safety reps mainly need support in terms of information, enforcement, protection and mediation. First, technical experts from public agencies must provide high quality information and advice to safety representatives; second, governments need to implement adequate institutional mechanisms so that safety representatives have fast, easy, and full access to occupational health inspectors and other regulatory agencies; third, governments must provide legal protection to safety representatives, who need stronger protection against dismissal; fourth, public institutions have to mediate with expertise and responsibility in a ‘neutral’ way where management and health and safety reps are in dispute or sharp disagreement; and fifth, government must implement public databases on occupational health and safety issues as well as mechanisms by which for health and safety reps or managers to access this information.

Safety reps also need strong support from unions, and especially protection from management reprisals. Unions are a key actor here in providing adequate information and training to enable safety reps to perform their duties properly.

The third structural condition is the knowledge, training, and vision of safety representatives, that is, the type of skills, preparation and personal and collective awareness or consciousness they possess. Research on workers’ representation on health and safety in the chemicals and construction industries has shown that where health and safety performance and arrangements were best developed, safety representatives have received trade union training (Walters and Nichols 2006). These findings have been borne out by other studies. Health and safety knowledge and training should encompass three main general things: technical data and information on work injury investigation, workplace hazards, and legislation; the skills to communicate with workers and to express their concerns; and a deep ideological and political perspective that facilitates a comprehensive and realistic understanding of power relations so that effective solutions can be taken that address health and safety problems.

The fourth and final condition is the level of power, empowerment, and influence that safety representatives

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CHAPTER 2.3 have, i.e., the capacity to exercise their rights or exert sufficient pressure to achieve their goals. Safety reps have to exercise their legal rights in a political context in which employers control labour, information, and the nature and timing of health and safety improvements. When safety reps and workers are empowered, they have more influence to bring pressure to bear on management, substantially increasing their capacity to mobilise workers. The involvement of workers is also critical for the transmission of information to the workforce and for workers’ identification of potential hazards, either by raising issues with a health and safety rep, or by a stoppage of work.

Empowerment of safety reps comes about not only through participation but also control over their resources and activities. There are three main specific aspects related to the empowerment of safety reps. One is the need to achieve visibility and respect from management, health and safety professionals. Secondly, safety reps need the recognition and support of all workers (not just union members) and as well as from company-level unions. A third issue is the need to get clear and formal recognition from the government.

Approaches and activities of safety representatives Unions may deploy different occupational health strategies at the European, national and local levels which may have a big influence on the approaches and activities developed by safety reps. For example, safety reps and union members of joint committees may get drawn into a “technical and legalistic” approach that focuses on health and safety problems as procedural or technical issues unconnected with workplace and labour relations that are often in management’s favour. Or else safety reps may take a “confrontational” approach, reacting robustly and adversarially (externally or internally within firms) to management’s approach, using legislation and regulations as tools of confrontation and often lacking proposals to tackle the most important workplace health and safety problems.

Yet again, safety reps may also take a “political activism” approach, collecting a wide variety of data and information, making active efforts to increase workers’ knowledge, visibility and participation, and promoting collective action and the empowerment of workers by pressing and negotiating alternative proposals with managers (Hall et al., 2006). The activities of safety reps are often a blend of elements drawn from all these three approaches Safety reps may develop a wide array of activities related to workers’ health and safety protection and prevention.

Examples include providing information and training to workers, as well as actions more directly involved in the real participation of workers concerning their occupational health. Some of the most important activities related to communication, knowledge, training, research, negotiation and pressure are briefly reviewed here.

The evidence of experience is that safety reps must hold regular meetings with workers to inform them about their activities. Lack of communication between them is a barrier to the effectiveness of safety reps, resulting in a lack of support from workers and lack of awareness about hazards. Another related essential issue is the need to ensure that safety reps are able to get the balance right between receiving adequate technical information and training while also taking on board workers’ direct perceptions on health and safety matters. Other safety rep activities include the investigation and surveillance of working conditions, workplace injuries and diseases, the inspection of workplaces, help with workers’ queries, and workplace risk assessment and prevention proposals (Walters 2006; García et al., 2007).

Safety reps may derive substantial powers from legislation or collective agreements that are almost always used effectively and responsively, such as the right to stop dangerous work or issue provisional improvement notices3.

This right, used only in the last resort, has an essential symbolic power in strengthening safety representatives’ influence. Such action, however, is only rarely taken by safety reps. A study in Spain, for example, found a very low incidence of pressure being exerted by safety reps, with only 18% claiming to have exercised their statutory right to call for unsafe work to be stopped (García et al., 2007).

Other activities related to negotiation and pressure include: calling and attending meetings, work in health and safety committees and works councils, and submitting formal complaints and grievances. Some descriptive studies and surveys done in EU countries like France, Belgium, Italy, Spain, and the United Kingdom (Boxes 3 & 4) provide a fairly detailed general picture of safety reps’ activities.

BOX 3

Overview of safety rep activities in Spain The activities of Spanish safety reps ten years after the Spanish Occupational Health Act were analysed. Most of the reps interviewed had carried out various tasks related to their safety duties in the previous year, most frequently: answering workers’ queries (90% of interviewees), workplace inspections (79%), reporting health and safety problems to supervisors and/or managers (76%), examining available documentation on occupational health in the company (75%) and participating in worker information and/or training activities (74%). Safety reps are generally fairly active, mostly in regard to informing and advising workers on health and safety matters. However, direct involvement in occupational health management and company decisions (e.g., participation in accident investigations, risk assessments, prevention planning or answering employers’ specific requirements on occupational health) was less frequent.

Source: García AM, López-Jacob MJ, Dudzinski I, Gadea R, Rodrigo F. Factors associated with the activities of safety representatives in Spanish workplaces. J Epidemiology Community Health. 2007; 61(9):784-90

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BOX 4

BOX 5

Overview of safety rep activities in the United Kingdom

Trade union representation and occupational injuries in the UK

A survey of safety reps in the United Kingdom found that most came from well organised workplaces, probably indicating that these were better, rather than typical, workplaces. More than half (56%) of the safety reps said that their employers had conducted adequate risk assessments but less than three out of ten safety reps (28%) were satisfied with their involvement in drawing up the risk assessment and almost half (44%) were not involved at all. Over one in five safety reps (22%) were not automatically consulted by their employers about health and safety matters. And even when they took the trouble to ask to be consulted, only just over one third (37%) were frequently consulted thereafter. Over half of all safety representatives (51%) conduct 3 or more inspections per year; one in three (34%) safety reps had spent between 1–5 hours on health and safety in the previous week.

A study has shown lower injury rates in workplaces with trade union representation in health and safety. Thus, results show that the predicted effect of health and safety committees with at least some members selected by unions was significant and negative compared to the base group for health and safety committees with no members selected by unions, which suggests that there is a mediated union effect on safety and that this is beneficial to workers. The effects of safety representatives were again significant and negative. By contrast, the effect of management alone deciding on health and safety was not significant.

Source: Trade Union Confederation (TUC): Safety Representatives Survey 2006

Impact of unions and safety representatives on interventions and outcomes

Source: Nichols T, Walters DR, Tasiran AC,. Trade Unions. Institutional Mediation and Industrial Safety – Evidence from the UK. Journal of Industrial Relations, 2007;49(2):211-225

A recent study in the UK on trade union representation and injury rates, and the first systematic empirical study done in France on the effectiveness of safety reps, also illustrate some of the linkages between the presence of unions and safety representatives, and health and safety performance (Box 5).

Needs and challenges

While research on safety reps’ effectiveness and impact on occupational health is limited, and there are considerable variations in the details of these studies, taken collectively they lend support to the notion that trade unions, joint arrangements, and trade union representation on occupational health and safety are associated with higher levels of compliance, lower workplace injury rates and ill-health problems, and better overall health and safety performance (Shannon et al., 1997; Milgate et al., 2002; Walters 2006).

Generally, studies have found that participatory workplace arrangements lead to improved occupational health and safety management practices and compliance with regulatory standards (Kochan et al., 1977; Beaumont et al., 1982; Bryce and Manga 1985). In Italy, a survey of hospitals in Piedmont has shown the important role played by consultation of health and safety reps in terms of prevention policies pursued in hospitals (Coordinamento dei Rappresentanti dei Lavoratori per la Sicurezza della Sanità e Università del Piemonte (Co. Ra.L.S). La sicurezza sullavoro negli ospedali del Piemonte.

Torino, 2005).

Safety representatives are a key workplace organisational asset to improve occupational health and safety. However, many needs and challenges remain to be addressed. Some of the most important with regard to unions and workers, politicians and administration, and researchers are summarised here.

On health outcomes, a consistently positive association has been found between the level of committee reps’ training and knowledge and perceived committee effectiveness with lower injury rates (Coyle and Leopold 1981; Ontario 1986; Walters and Haines 1988; Eaton and Nocerino 2000; O’Grady 2000). Also, a systematic review of the relationship between organisational and workplace factors and injury rates shows that empowerment of the workforce in general matters and the length of training given to members of Joint Health and Safety Committee are linked to lower injury rates (Shannon et al., 1997).

■■

Unions and safety representatives In order to provide effective support to health and safety representatives, unions need to integrate key health and safety issues into their strategies. The main needs and challenges include:

■■ Improving collective agreements on health and safety.

■■ ■■

■■

■■ ■■

At the micro level, a focus must be put on developing collective bargaining provisions which incorporate the actual experiences of workers and safety reps.

Developing collective bargaining focused on the representation of workers in subcontracting arrangements or supply chains.

Informing and training workers on occupational health and safety matters, as well as including these issues in labour/management negotiations.

Taking many of the health and safety issues that are currently within a technical and legal “framework” and imbuing them with a broad social and occupational health policy perspective.

Boosting political collaboration between safety reps, works councils members, and shop stewards.

Considering how best safety representatives can influence other players in the occupational health system

HEALTH AND SAFETY 2014 ■ 31

CHAPTER 2.3

■■

■■ ■■ ■■

■■

including employers’ organisations, health and safety practitioners, and regulators to help to provide a more enabling environment for representing workers’ interests in health and safety.

Achieving a higher level of participation, so that safety representatives are not just informed or consulted on occupational health problems but also have the influence and power to negotiate them.

Creating comprehensive and reliable database systems to monitor the coverage, situation, activities and outcomes of safety representatives.

Building more effective safety rep networks.

Developing new strategies that can reach the most vulnerable and powerless workplaces by working more closely with technical experts and scientists to obtain knowledge that is applicable and effective.

Developing a clear strategy for monitoring and supporting health and safety reps, with adequate mechanisms of surveillance, assessment and evaluation of their workplace actions.

Politicians and general government

Accordingly, they should implement actions that cover a variety of needs with the aim of strengthening and consolidating safety reps’ activities:

■■ Building up a comprehensive and robust occupational

■■ ■■ ■■ ■■

Mainstream “technical” approaches to occupational health research have neglected the role of safety representatives, evidencing a significant downplaying of worker participation on a range of issues. Participatory research models see workers not simply as objects of study but as active participants in all stages of the research (i.e., from design and data gathering to the analysis and interpretation of findings). This approach should therefore be a major element of an overall strategy to bring about political and social change that improves both working conditions and the health and well-being of workers and their families. The EU bodies responsible for occupational health and safety need to develop high-quality information and research programmes. This research agenda is essential to gathering evidence that will help to evaluate the effectiveness of strategies and activities.

The main particular gaps to be filled include:

■■ Critically reviewing the questions in the European and national surveys on working conditions.

■■ Improving information and investigation in many ■■

Politicians and government agencies need to be fully aware of the crucial role played by safety representatives in improving the health and well-being of workers.

■■

Researchers

health system that includes data on issues such as chemical substitution, medical protocols, and personal protective equipment among others.

Establishing official registration of all safety representatives.

Better funding and resourcing of health and safety training programmes for safety reps.

Better funding and resourcing of collective bargaining to expand safety rep coverage (e.g., regional safety reps and other forms of worker representation).

Helping to empower health and safety committees by increasing their decision-making authority.

Raising the level of enforcement of rules and regulations by developing more effective enforcement instruments.

For example, labour inspectors and administrations very often lack the resources and means to enforce and promote regulations. Also, safety reps must be legally independent and have protection from employers. Laws and regulations must therefore afford safety reps proper protection from reprisals. Safety reps should have formal, legal recognition and legitimacy as negotiators by technical experts and preventive services. Finally, the current legal thresholds for having safety reps and health and safety committees must be changed to expand their coverage.

■■ ■■ ■■

countries, particularly in southern and eastern Europe.

Describing the circumstances in which health and safety reps and committees operate.

Analysing in close detail the conditions and factors related to the effectiveness of safety reps’ actions.

Assessing the impact of unions, workers and safety representatives on occupational health outcomes.

Implementing a research agenda that shows the often hidden political and social dimensions behind most occupational health prevention activities.

Conclusion This paper has sought to provide a starting point for assessing the role played by safety representatives in occupational health and safety in the European Union by systematically reviewing the available experiences and evidence. Given the nature and complexity of the subject under study, as well as the relative lack of research in this field, a theoretical model was devised that describes a broad set of conditions and factors potentially associated with the effectiveness of safety representatives’ actions. Arguably, this model provides an adequate framework for developing this vital area of occupational health. Specifically, it may help to design future research and policy needs, develop new surveillance indicators, identify more effective actions or interventions, and evaluate the impact of safety reps’ actions on a variety of occupational health outcomes.

Although the impact of safety reps on occupational health has barely been included on the policy and research agenda, available knowledge and research supports the conclusion that unions, workers’ representation and safety representatives constitute a key powerful force for improving workers’ occupational health in the EU.

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THE IMPACT OF SAFETY REPRESENTATIVES ON OCCUPATIONAL HEALTH In sum, research mainly conducted in Anglo-American tradition and Nordic countries has shown that workplaces where trade unions are present are safer and have better occupational health outcomes.

While the involvement of general government agencies and researchers is clearly important, strong engagement by trade unions, workers, and safety representatives in the promotion of political debate, policy action and research on this topic is particularly essential.

Appendices Participants in the EPSARE project The Coordinators of EPSARE are: María Menéndez (Occupational Health Department, Catalonian Workers Commissions, CC.OO., Girona, Spain); Joan Benach (Health Inequalities Research Group, Occupational Health Research Unit, Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain); Laurent Vogel (European Trade Union Institute for Research, Education, Health and Safety, ETUI-REHS), Brussels, Belgium.

Other members of the Core Group include: Thomas Coutrot (DARES, Ministère Emploi et Affaires Sociales), Marianne De Troyer (Institut de Sociologie. Université Libre de Bruxelles. Université d’Europe), Ana Mª García.

Trade Union Institute for Occupational and Environmental Health, ISTAS, Spain,Jan Popma (University of Amsterdam), Miluse Vachová (University Ostrava), and David Walters (Cardiff University School of Social Sciences. Cardiff, UK).

Members of the Research Report Group include: David Gimeno (Department of Epidemiology and Public Health, University College London, UK, and The University of Texas School of Public Health, Division of Environmental and Occupational Health Sciences, San Antonio Regional Campus, San Antonio, exas, USA.); Allan Hall (Faculty of Arts and Social Science. University of Windsor. Windsor, Canada); Carles Muntaner (Social Equity and Health Section, Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada); Michael Quinlan (School of Industrial Relations and Organizational Behaviour, University of New South Wales. Sydney, Australia); Harry Shannon (Department of Clinical Epidemiology and Biostatistics; Program in Occupational Health and Environmental Medicine. McMaster University, Hamilton, Canada); Montse Vergara (Health Inequalities Research Group, Occupational Health Research Unit, Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain); and David Walters (Cardiff University School of Social Sciences. Cardiff, UK).

References Benach J, Muntaner C, with Solar O, Santana V, Quinlan M, and the Emconet Network.

Employment, work, and health inequalities: A Global perspective, forthcoming 2009.

Chung H, Muntaner C. Welfare state matters: a typological multilevel analysis of wealthy countries. Health Policy 2007; 80(2):328-39.

Coordinamento dei Rappresentanti dei Lavoratori per la Sicurezza della Sanità e Università del Piemonte (Co.Ra.L.S). La sicurezza sul lavoro negli ospedali del Piemonte. Torino, 2005.

Department of Trade and Industry. Workplace representatives: a review of their facilities and facility time. Consultation Document. URN 06/1793. January, 2007. Accessed in web page: http://www.berr.gov. uk/files/file36336.pdf ETUI (European Trade Union Institute). 2008a. Accessed 01-08-08.

Available in http://hesa.etui-rehs.org/uk/dossiers/rdossier.asp?rd_ pk=205&dos_pk=15 ETUI (European Trade Union Institute). 2008b. Accessed 02-08-08.

Available in http://hesa.etui-rehs.org/uk/dossiers/rdossier.asp?rd_ pk=323&dos_pk=15 Frick K, Walters DR. Worker representation on health and safety in small enterprises: Lessons from a Swedish approach. International Labour Review;1998,137(3):365-89.

García AM, López-Jacob MJ, Dudzinski I, Gadea R, Rodrigo F. Factors associated with the activities of safety representatives in Spanish workplaces. J Epidemiol Community Health. 2007;61(9):784-90.

Gazzane S. La représentation des travailleurs en matière de santé et de sécurité dans les pays de l’Union Européenne. Institut Syndical européen pour la recherche, la formation et la santé et sécurité (ETUIREHS). August, 2006.

Hall A, Forrest A, Sears A, Carlan N. Making a difference. Knowledge activism and worker representation in OHS Committees. Industrial Relations 2006;61(3):408-34.

James P, Walters D. Workers’ representation in health and safety: options for regulatory reform. Industrial Relations Journal 2002;33(2):141-156.

James P, Johnstone R, Quinlan M, Walters D. Regulating Supply Chains to Improve Health and Safety. Industrial Law Journal, 2007;(36)2:163-187.

Menéndez M, Benach J, Vogel L. El impacto de los delegados de prevención en la salud laboral: el proyecto EPSARE. Arch Prev Riesgos Labor 2008;11:5-7.

Milgate N, Innes EV, O’Loughlin K. Examining the effectiveness of health and safety committees and representatives: A review. Work 2002;19:281–290.

Shannon H, et al., Workplace organizational correlates of lost time accident rates in manufacturing. Am J Ind Med. 1996;29:258–268.

Shannon H, Mayr JS, Haines T. Overview of the relationship between organisational and workplace factors and injury rates. Safety Science 1997;26:201–217.

Walters D. Employee representation on health and safety in small enterprises. A trade union initiative in agriculture. Employee Relations 1998;20(2):164-179.

Walters D, Kirby P, Daly F. The impact of trade union education and training in health and safety on the workplace activity of health and safety representatives. London: Health and Safety Executive 321 2001. http://www.hse.gov.uk/research/crr_pdf/2001/Crr01321.pdf Walters D, Frick K. Worker participation and the management of occupational health and safety: reinforcing or conflicting strategies?

In: Frick KP, Langaa J, Quinlan M, Wiltha-gen T. (Eds). Systematic Occupational Health and Safety Management – Perspectives on an International Development, Pergamon, Oxford, 2000:43-66.

Walters D, Nichols T, Connor J, Tasiran AC, Cam S. The role and effectiveness of safety representatives in influencing workplace health and safety. Health and Safety Executive 2005.

Walters D. One step forward, two steps back: worker representation and health and safety in the United Kingdom. Int J Health Serv.

2006;36(1):87-111.

Walters D, Nichols T. Representation and consultation on health and safety in chemicals. An exploration of limits to the preferred model.

Employee Relations. 2006;28(3):230-254.

Walters D, Nichols T. Worker representation and workplace health and safety. New York: Palgrave MacMillan, 2007.

Weil D. Are Mandated Health and Safety Committees Substitutes or Supplements for Labour Unions? Industrial Labour Relations Review 1999;52(3):339-359. © 2009 Menendez, M., Benach, J., & Vogel, L. © 2009 European Trade Union Institute. Reproduced with permission.

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CHAPTER 2.4

HEALTH WORK ENVIRONMENTS FOR THE AGEING NURSING WORKFORCE Stichler, Joynelle F. Health working environments for the ageing workforce, (2013) Journal of Nursing Management, Vol 21 pp956-963

Older nurses and midwives are a wealth of knowledge and experience, and retaining them and their expertise is not only important for patient care, but also for the professional development of younger staff. This paper examines how changing workplace practices and facility design to account for the specific health and safety needs of older nurses, can help retain these valuable employees. It underscores the need for nurses to be involved at every stage of this process to ensure the resulting workplaces explicitly address the physical work challenges faced by older nurses and midwives and are not just generic in design.

Introduction Before the economic downturn of 2009, the early retirement of older nurses was causing concern and strategies were being devised to retain these nurses in the workforce. Currently, with a challenging economic climate and the reported loss of net worth, more nurses over the age of 60 years are remaining in their jobs (ageing in place), trying to recover savings originally earmarked for retirement. In addition, because of the same economic necessity, a large number of older nurses have returned to the workforce. The USA now has the largest cohort of registered nurses (RNs) between the ages of 50 years and 69 years ever experienced in the profession. At present, the average age of a RN is 46.8 years years, and it is estimated that one-third of all nurses in the US workforce are between the ages of 50 years and 64 years (Valencia & Raingruber 2010, Juraschek et al. 2012, Buerhaus et al.

2013). The same trend has been noted in other countries, with 20% of the nurses in the UK and 33% in Canada aged 50 years and older (Keller & Burns 2010). This shift in demographics calls for consideration of not only retaining older nurses, but also providing for their health and wellbeing at work.

Although a number of studies have focused on why nurses continue to work beyond the usual retirement age (Palumbo et al. 2009, Storey et al. 2009a, Kirgan & Golembeski 2010) and how organisations can retain older nurses (Cyr 2005, Bell 2006, Moseley & Paterson 2008, Storey et al. 2009b), there is a paucity of research addressing the physical needs of ageing nurses or how environmental design can facilitate nurses working longer

and more safely while providing direct patient care. It is important to identify features in the work environment that will prevent injury of ageing nurses and ensure their retention in the workforce.

Aims The aims of this article are: to synthesise quantitative and qualitative studies related to the physical challenges experienced by ageing nurses who provide direct patient care in health-care settings; to share evidence from the literature related to the effect of hospital design on ageing nurses; and to share the author’s personal observations and experiences in hospital design that addresses the needs of ageing nurses. For the purposes of this article, the ageing nurse is defined as one who is 55 years or older, which is the US Department of Labor’s definition of ‘older worker’ (Centers for Disease Control & Prevention 2012). This article focuses on the ageing nurse in the USA but the observations and recommendations may also be appropriate for nurse managers and the hospital design industry in other countries. Clearly, the concerns of ageing nurses in the workplace are universal; many of the studies and reviews cited in this paper originated from countries such as the UK, New Zealand, Australia and Canada.

Background A review of the literature was conducted using the method described by Polit and Beck (2008). Eight electronic databases were searched for materials from 2002 to 2013; references for relevant papers were also reviewed. The search was limited to papers published in English. Databases

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HEATLH WORK ENVIRONMENTS FOR THE AGEING NURSING WORKFORCE included ScienceDirect, Ovid, ProQuest, PubMED, CINAHL, PsychINFO, The Center for Health Design, Avery Index and Google Scholar. The following key words and MeSH terms were used for the search: ‘older nurses’, ‘ageing nurses’, ‘nursing musculoskeletal disorders’, ‘nursing physical job demands’, ‘nurse retirement’, ‘nurse retention’, ‘nurse work injury’, ‘healthcare design’ and ‘healthcare design for older workers’. Articles were included if their focus was the ageing nurse, workplace injuries, and design features in the healthcare environment. Articles were excluded if the primary focus was human resource retention strategies for older nurses, such as providing flexible work schedules, showing appreciation and respect, and realising differences among intergenerational nurses. Of the 35 articles and reviews initially identified, 25 met the sample inclusion criteria. These 25 studies included three systematic reviews, 18 quantitative studies, and four qualitative studies. Other non-evidence-based articles included government bulletins, organisational newsletters and review articles focusing on health-care facility design, strategies for retaining ageing nurses, overviews of barriers and the advantages of retaining older nurses.

The effects of ageing as related to older nurses Older workers often suffer from chronic disease and impairments that may limit their life activities, including full-time employment. Some older nurses experience visual and hearing impairments, balance issues, weight gain, aches and pain associated with musculoskeletal disorders (MSDs) or arthritis, loss of muscle mass and a reduction in core strength and flexibility. All of these issues are normal age-related changes that have the potential to negatively affect the functional abilities of older nurses (Cameron et al. 2008, Letvak 2009, Keller & Burns 2010, Heiden et al. 2013). According to the Centers for Disease Control (2012), older workers have fewer workplace injuries, but when they do incur an injury they tend to be more severe and entail a longer recovery. The types of injuries often reported by older workers include complaints of low back pain, shoulder pain, carpal tunnel syndrome, tendinitis and other disorders of the hands and feet. Some authors indicate that older workers are reluctant to report injuries because they fear losing their jobs or that they will be asked to retire (Fraser et al. 2009, Keller & Burns 2010). Physical limitations and workload demands were often given as reasons for older workers’ retirement (Blakeley & Ribeiro 2008).

Gabrielle et al. (2008) reported that nurses in their study (aged 40–60 years) indicated that they experienced many aches and pains associated with the ageing process but that they often neglected their own health as a result of work demands. They reported not eating properly, not drinking enough water or not taking the breaks necessary

for toileting or rest periods while at work. Many indicated that they simply ‘worked through the pain’ (chronic neck, shoulder or back pain) and they had to adjust emotionally to the loss of physical fitness they had experienced when younger. Many reported being tired much of the time, leaving them little energy for regular exercise after work to maintain a healthy weight and mental attitude.

Similarly, in a study using a phenomenological design, nurses reported that they struggled daily with pain during and after work, and their physical pain was a constant reminder that they were ageing (Letvak 2009). Many of the nurses in this study reported experiencing chronic pain and being depressed to the point of falling asleep on the job or having difficulty focusing on the tasks at hand.

Whereas some nurses reported using positive coping strategies, such as sharing their health problems with others in their work group because they were obvious anyway, other nurses used more negative coping strategies such as calling in sick more frequently or eating more.

Some indicated that they had to get away to the chapel or bathroom for a few moments of respite to recover from the physical pain, but that their inner strength, courage, and in some instances faith in God, sustained them. Letvak (2009) reported that all of the nurses indicated that their practice of nursing had changed as they aged: they walked more slowly, responded less quickly and sat whenever possible rather than standing to complete patient-care tasks.

Although the nurses may have been slower in performing their work than in their younger years, they indicated that experience and wisdom compensated for their lack of speed.

They also reported that they stayed on the job because of caring relationships with co-workers and team members who helped them with caring tasks that they could no longer accomplish alone.

Physical demands of nursing practice Nursing is difficult work, physically demanding for nurses of all ages, and one of the professions with the highest incidence of work-related back injuries (Nelson et al. 2003).

Authors report frequent neck, shoulder, and upper and lower-arm injuries in addition to upper and lower-back injuries (Gabrielle et al. 2008, Keller & Burns 2010). Ankle, knee and thigh injuries have also been reported as frequent work-related injuries (Cameron et al. 2008). In the Cameron et al. study (2008), 70% of the nurses in the 56-year and older group reported having a musculoskeletal injury at work. These injuries not only interfere with their ability to perform their daily work, but for some nurses these injuries may be career ending.

Older nurses who elect to continue working experience many physical challenges, including a reduced ability to

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CHAPTER 2.4 perform some physical care-taking tasks, meeting the demands of heavy workloads with multiple patients, managing their fatigue during 12-hour shifts, working several 12-hour shifts consecutively, or being on call in addition to regularly scheduled shifts. There is evidence that older nurses have a higher incidence of workplace injuries and are more likely to complain of musculoskeletal disorders, sleep deprivation and physical fatigue and exhaustion (Santos et al. 2003, Spetz 2005, Gabrielle et al. 2008) as a result of increasing workloads and the physical demands of patient care. Shift work and long (12-hour) shifts exacerbate age-related health deterioration and are likely the cause of chronic fatigue and lack of sleep. Older workers relate that it takes them longer to recover from the long shifts or off-shift assignments (Keller & Burns 2010).

Using a focus group methodology with nurses aged 46–73 years to understand their perceptions of the work environment, Mion et al. (2006) reported that participants indicated that the physical demands of patient care were difficult to manage. Participants cited physical difficulties in providing direct patient-care activities such as pushing and pulling patients on beds or stretchers while transporting them, lifting, turning, or positioning patients in bed, pushing equipment or carts, stretching or reaching for equipment or supplies on high shelves, or reaching for electrical plugs or other types of medical equipment located near the floor or behind the head of the bed.

Recognising the physical demands of nursing practice on older nurses, several authors have cited the need to implement improvements in the workplace to recruit and retain older nurses, such as opportunities for flexible schedules, the option of 8-hour rather than 12-hour shifts, an organisational culture that supports teamwork and collegiality, meaningful recognition of the contributions of older workers, financial incentives to stay, more days off between work days, self-scheduling or shift sharing and job opportunities in less physically demanding patientcare units (Moseley & Paterson 2008, Fraser et al. 2009, Palumbo et al. 2009, ASNA Commission on Professional Issues 2010). These organisational changes address the concerns of ageing nurses related to fatigue, the aches and pains associated with ageing and the physical demands of nursing practice, but more research must be done on how the built environment can alleviate the limitations of ageing and the physical demands of patient care. Ageing nurses represent an ever-increasing population of caregivers who bring wisdom and experience to the patient-care setting, but they also have special physical needs that must be addressed to retain them in the workplace and to prevent physical and emotional injuries. Adapting the workplace to make it safer for older nurses presents some challenges, but addressing their needs can also provide many rewards for the ageing nurses and the organisations for which they work.

Recommendations for alterations of the work environment Although there is clearly a serious need to consider the needs of ageing nurses and other health professionals when designing new or renovated health-care facilities, there is a paucity of published evidence, anecdotal or empirical, that addresses the specific needs of ageing nurses with regard to the design of health-care facilities. It is unclear how much employing organisations can accommodate older nurses in terms of adapting the work environment, patient-care assignments or workloads, but if employers are to retain older nurses in the workforce, adaptations to the physical environment and the organisation of work need to be made (ASNA Commission on Professional Issues 2010, Keller & Burns 2010). According to these authors, having a safe and well-designed workplace will reduce injuries for all nurses, especially older nurses who may be more vulnerable to work-related injuries.

A major focus of the health-care design industry is designing health-care facilities specifically to create healing environments that are patient-centred, patient safety oriented and supportive of family involvement using design features that are flexible, adaptive and promote staff efficiency. The term ‘healing environment’ applies not only to patients and families, it is expanding to include design features that promote a healthy, safe working environment for all health-care professionals (Stichler 2009a).

Ergonomic design features must be considered when designing work environments that specifically address the needs of older nurses and other health-care professionals.

Ergonomics is the ‘science of fitting or matching workplace conditions and job demands to the capabilities of the working population’ (Waters 2010). According to Waters, when an environment is adapted to the needs of the worker, productivity improves, injury and illness decrease and overall employee satisfaction improves, leading to worker retention. Several design implications should be considered when designing environments that address the needs of older nurses.

Some of older nurses’ major complaints are the diminished physical capacity to move, push, pull or lift patients, supplies and equipment. The prevalence of back injuries among all nurses is higher than in most professions, and older nurses are particularly vulnerable to back injuries (Cameron et al. 2008). Older nurses have difficulty bending, twisting, reaching, squatting or stooping and many of the physical stressors and strains of these movements can be eliminated or greatly reduced with ergonomically correct designs and equipment to support safe patient handling. Although costly for renovation projects and new construction, overhead or ceilingmounted lifts in all patient rooms substantially increase the use of these devices to position patients in bed, transfer

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HEATLH WORK ENVIRONMENTS FOR THE AGEING NURSING WORKFORCE them from bed to chair and assist them to the bathroom.

Evidence indicates that the use of these devices for lifting and transferring patients greatly reduces the perceived risk of injury and actual injuries with the associated work days lost because of nurses’ discomfort in the neck, shoulders, back, hands and arms (Tiesman et al. 2003, Engst et al.

2005, Vieira & Miller 2008).

In Engst and colleagues’ study, worker compensation costs were reduced by 68% when ceiling lifts were installed and used to lift and transfer patients compared with units that did not install ceiling-mounted lifts. Although these studies were not specific to the ageing nurse, it seems reasonable that such lifts would be helpful to ageing nurses who are working with the physical limitations associated with ageing. It has been noted anecdotally that installing ceilingmounted lifts in only a few rooms per unit diminishes their use by nurses who quickly forget how to use them because they are not used consistently. The universal installation and use of these devices enhance the culture of safety with an emphasis on preventing employee injury. Some state nursing organisations recommendations of ‘Best Practices for Retention of Older Nurses’ have included providing mechanical patient lifts and devices to aid in patient handling or developing transport and lift teams to prevent injury to all nurses, but particularly to address the needs of older nurses (ASNA Commission on Professional Issues 2010).

clutter and may reduce the danger of trips and slips during care-giving activities (Moseley & Paterson 2008).

Because physical fatigue is one of the most significant issues for older nurses (Spetz 2005), elimination of what this author calls the ‘run and fetch’ design is important.

Locating frequently used supplies and equipment at or near the point of service is a critical design element to reduce walking distances on patient-care units.

Decentralised linen and supply storage areas can be located in patient rooms with access from the hallway for stocking or between every two rooms or small cluster of rooms, or they can be stocked inside the patient room.

Some hospitals are locating a closed and locked cabinet referred to as ‘the nurse server’, which holds the supplies and pharmaceuticals necessary for patient care, inside the patient room, and this greatly reduces walking distances for older nurses (Lorenz 2012).

Because bending, stretching, and reaching are difficult for older nurses, placing electrical and medical gas outlets on either side of the patient bed at an easily accessible height, rather than behind or above the head of the bed, prevents nurses from having to move the bed or stretch to plug in equipment. Similarly, properly sized and arranged equipment storage areas with electrical outlets at the midwall level minimises the need to stretch to plug in or move equipment to get to the piece of equipment desired (Stichler & Feiler 2011).

Decentralised linen and supply storage and decentralised nursing stations with a nursing work area between every two rooms or with a cluster design of four to eight rooms around a nursing work area diminish walking distances for older nurses (ASNA Commission on Professional Issues 2010, Zborowsky et al. 2010). Ergonomic seating with the correct height for charting tables at the decentralised nursing station, the bedside (for intensive patient monitoring) and the centralised nurse station are helpful for reducing back strain or prolonged standing for older nurses. Ensuring the appropriate height of countertops for charting, either standing or sitting, with adequate space for both keyboarding and writing prevents the constant strain of working in an improper body position (Cooper 2003). For correct positioning for any task, the body should be in a neutral position, meaning that strain and torsion of the body are eliminated (Stichler & Feiler 2011). Although computers on wheels (COWS) are useful in terms of flexibility, adjustability and their ability to be moved to the point of care, they can also demand more standing as the nurse documents care activities, unless ergonomically designed chairs are provided.

True rest breaks are needed for all staff members but particularly for the older nurse. In the USA, hospital building codes require that all patient care units have staff lounges or break rooms (Facility Guidelines Institute 2010), but most are noisy, social spaces where nurses eat, converse and in some cases watch television. Some of these spaces also include the locker and change area for staff. Recognising that break rooms do not provide the staff with a stress-reducing environment, some hospital decision makers are electing to build or designate ‘respite rooms’ in addition to the break rooms. Respite rooms are designed to be quiet with dimmed lighting and little to no stimulation. These rooms are often equipped with a reclining chair and in some cases eye masks and quiet, meditative music. The intention is to allow nurses the time and space to truly meditate or rest for 10–15 minutes without the distraction of others conversing, eating or watching television. Respite rooms provide a restful space for older nurses to cope with their work demands (Moseley & Paterson 2008), and there is mounting evidence that they are effective for reducing nurse stress levels (Stichler 2008a, ASNA Commission on Professional Issues 2010, Sitzer 2013).

Older nurses may have a fear of falling while walking in hospital corridors, so adequate lighting and non-slip floor surfaces will help address their safety concerns. An adequate number of equipment and supply storage areas will prevent

Centralised nursing stations have become a gathering place for interdisciplinary collegial interaction and should be designed to promote social interaction and the exchange of information. In addition to the computer

HEALTH AND SAFETY 2014 ■ 37

CHAPTER 2.4 systems for physician order entry and nurse and physician documentation (both computerised and paper charting), comfortable seating areas around small tables promote social interchange and offer nurses the opportunity to sit while conversing with each other or with professionals in other disciplines (Cooper 2003). Some designers include a small conference space adjacent to the nursing station where nurses and their interdisciplinary partners can talk.

When building decentralised nursing stations adjacent to patient rooms, some designers still include a centralised nursing station to provide a common and easily assessable area where visitors can be greeted and nurses and other professionals can sit while documenting care or conversing with colleagues.

Because visual acuity diminishes with age, older nurses often require glasses to read or conduct detailed tasks such as suture removal, wound care, dressing changes and intravenous insertion. Enhanced task lighting options over the bed or on swing arms helps older nurses’ visual acuity when they are engaged in such tasks. Multiple lighting options in the patient room and in nurses’ work areas ensure maximum flexibility and adaptability for various lighting needs not only for nurses but also for patients.

Storage closets or cupboards should be placed low enough to be useful for nurses while ensuring that they are in a location where staff and families will not injure their heads when walking past or under them. Space between the bed and visitors’ sofas, counter space at the footwall or chairs should be adequate to prevent nurses from hurting themselves as they squeeze between spaces that are too small.

Bathrooms and shower designs are some of the most dangerous spaces in acute care settings, with safety challenges for both patients and nurses. Some designers have adopted an open-shower design that shares the shower space with the toilet and hand-washing sink with no physical barriers to contain water in the shower area.

Instead of having physical barrier to the shower area, the floor of the shower is sloped toward the drain. The intention of this design feature is to prevent patients with IV poles from tripping over barriers when entering the shower; however, although the barrier-free design resolved the patient tripping problem, it created a number of other problems that present safety challenges for both patients and nurses, particularly older nurses (Stichler 2007a, 2009b). With no barrier to contain water from the shower, the entire bathroom floor, toilet and sink get wet, thereby increasing the potential for slips and falls for patients and nurses. Nurses are innovative and resourceful, and recognising the potential danger for patients and themselves, they have developed ‘workarounds’ to solve this problem. Each time a patient needs to be showered, a nurse must create a barrier

from bath blankets, towels or bedspreads, which become saturated and heavy to lift. Older nurses have difficulty bending, stooping, and carrying the wet linens used for this purpose. Newer designs for barrier-free showers have additional linear floor drains and shower curtains to contain the water in the shower area and reduce the need for blanket barriers.

Nurses are cognitively challenged by the multiple data points inherent in coordinating and providing patient care.

Older nurses also comment that they are often challenged by memory loss, decreased reaction time and the demands of integrating traditional methods of documentation with electronic medical record and order-entry systems (Fraser et al. 2009, Keller & Burns 2010). To help older nurses manage these multiple mental and cognitive challenges, design features that include bedside documentation stations, COWS or decentralised work areas can aid in the retrieval of information and documentation of patient information, interventions and responses. Nurse server cabinets that enclose a patient’s non-controlled medications can be designed into the patient room, minimising the steps needed to retrieve medications and the potential for medication errors. The need for remembering multiple data points is greatly reduced because the medication and documentation (electronic or paper) are located in the patient’s room. The use of electronic tablets, COWs and other electronic data and recording devices with point-of-service information retrieval, note recording, and documentation lessens the need to remember details.

Designers will need to consider the optimal locations for storing and using these devices and for bedside paper documentation.

Conclusions Older nurses indicate that they stay in nursing because they are satisfied with their jobs, enjoy the patient contact and their caring role, appreciate the support of colleagues and work teams, and need the pay and benefits (Storey et al.

2009a). Although older nurses may be physically challenged while working, the physical design of health-care facilities can address many of the physical and cognitive demands of nursing work, making it easier and more efficient for older nurses and nurses in general. Careful attention to the limitations of the ageing body and the functions of nursing care should inform structural design decisions intended to address the needs of ageing nurses, who provide meaningful value to the care team.

Older nurses bring a wealth of experience and knowledge to the workplace, but they are also confronted with the cognitive and physical demands of providing patient care. Although the literature is replete with evidence regarding the factors needed to recruit and retain older nurses with organisational solutions, there is little evidence on the physical design factors that could make nursing

38 ■ HEALTH AND SAFETY 2014

HEATLH WORK ENVIRONMENTS FOR THE AGEING NURSING WORKFORCE work easier for older nurses. Simple attention to detail in combination with knowledge of the physical and cognitive challenges of the ageing nurse could facilitate design decisions that would create safe, healthy work environments for all nurses.

healthy, safe and employed, and to share their knowledge and skill to the benefit of both younger colleagues and patients.

Implications for nursing management Increasingly, nurse managers are assuming leadership roles in design efforts for new health-care facility projects or renovations (Stichler 2007b). Knowing the physical and cognitive challenges of ageing nurses, nurse managers can advocate specific design features that will help older nurses remain active and engaged in the nursing profession. Empowering older nurses by involving them in design efforts with architects would also ensure that their physical needs would be addressed in design features that would conserve their strength, prevent slips and falls, minimise the risk of injury and ensure adequate rest and rejuvenation areas. By using resources such as the Nursing Institute for Health Design (http://www.nursingihd.com) or the Center for Health Design (http://www.healthdesign.org), nurse managers can educate older nurses about the phases of design and where their input with architects is most valuable to ensure that their specific needs for safety, visual acuity and efficiency to conserve energy are addressed.

The author wishes to disclose that no funding was received from any source in the preparation of this article.

Nurse managers must also improve their own knowledge of and competency in working with architects and designers and assume leadership to ensure that the clinical nurse’s voice is heard in design meetings. Once schematic and design development plans are completed, the nurse manager can meet with the clinical nurses to review these plans in detail and ensure that their initial vision and requests have been considered and addressed (Stichler 2008b). Older nurses can also be encouraged to participate in worksite inspections or healthy work environment committees so that their concerns about the work environment can be represented.

Considering the vast experience of older nurses, nurse managers may want to make job assignments where older nurses can mentor less experienced nurses (Clauson et al. 2011) or create positions where older nurses can have slower, self-paced work that allows for rest breaks and less standing for prolonged periods. Because hand injuries are a concern, positions that have fewer repetitive hand movements may be an option. Nurse managers should ensure that work stations for older nurses provide comfortable, ergonomically correct and adjustable seating, and better illumination for task lighting that reduces glare.

This review identifies a number of challenges that older nurses face when working in the hospital setting and ways that the physical design of the ‘built environment’ can improve their work experience, motivating them to stay

Source of funding

Ethical approval Institutional Review Board review was not necessary for this article which was a systematic review of the literature and recommendations based on the author’s personal experience as a healthcare design consultant.

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CHAPTER 2.4 Presentation at the Healthcare Design Conference, November 4, 2012, Orlando, FL. Mion L.C., Hazel C., Cap M., Fusilero J., Podmore M.L. & Szweda C. (2006) Retaining and recruiting mature experienced nurses. Journal of Nursing Administration 36 (3), 148–154.

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CHAPTER 2.5

Reducing aggression in the haemodialysis unit by improving the dialysis experience for patients Burns T & Smyth A (2011). Reducing aggression in the haemodialysis unit by improving the dialysis experience for patients.

Renal Society of Australasia Journal, 7(2), pp79-89.

This article outlines how haemodialysis nurses at St George Hospital in Sydney took action to reduce patient aggression towards nursing staff. It is a great example of how nurses, who initially felt powerless and unsupported, worked together to identify the underlying problems behind the aggression and implemented solutions that ultimately saw aggression decrease.

The haemodialysis unit is a unique environment where patients can attend for treatment over many years.

Haemodialysis units often care for patients who are impatient and sometimes angry and hostile. This project investigated the problem of aggression towards nurses in the haemodialysis setting.

The St George Public Hospital Haemodialysis Unit is situated in a multicultural area of Sydney and is one of the largest haemodialysis units in Australia, currently operating 32 chairs with approximately 114 patients and 50 staff (both full-time and part-time).The unit is divided into two areas, one with a higher patient to staff ratio where the less stable patients receive dialysis, and the other where the more stable satellite-type out-patients are cared for.

In September 2009 the St George Public Hospital haemodialysis unit was invited to participate in the Renal Models of Care programme, an initiative of the New South Wales (NSW) Agency for Clinical Innovation (formerly Greater Metropolitan Clinical Task Force) in partnership with NSW Health Nursing and Midwifery Office. Its goal is for nurses to investigate ways of making better use of available resources in the face of a growing population of patients requiring care for end-stage renal disease (Chiarella & Westgarth, 2009).

The haemodialysis nurses at St George Hospital chose to address the problem of aggression between patients and nursing staff as their Models of Care project. Aggression had been a long-standing problem, and the nurses perceived that the amount of aggression had increased but felt powerless and unsupported to address this.

A grant of $10,000 was awarded from the Australian and New Zealand Society of Nephrology (ANZSN)/Amgen and was used to fund nursing time and resources to implement communication strategies.

This project had ethics approval from the South East Sydney and Illawarra Area Human Research Ethics Committee. The aim of the project was to reduce the number of aggressive incidents in the haemodialysis unit to less than 1% of total treatments by improving the haemodialysis experience for patients and staff.

Method Through the Renal Models of Care programme, two senior nurses were identified to lead the project. A team of nurses was sought to maximise communication and act as resource people across the unit. The final team including project leaders had nine members, plus the guidance of the nephrology clinical nurse consultant (CNC).

Before starting the project it was necessary to explore definitions of ‘aggression’ and how it is interpreted in health care.

Defining aggression Many sources suggest that the word ‘aggression’ has so many interpretations that it is virtually useless for the purposes of scientific analysis (Rippon, 2000; Sommargren, 1994; Whykes, 1994; Scott 1992). As there is no standardised universal definition of aggression and as interpretations vary infinitely as to what constitutes aggression, it is difficult to measure and compare studies relating to aggressive behaviour (Sommargren, 1994).

HEALTH AND SAFETY 2014 ■ 41

CHAPTER 2.5 For this project it was decided to adopt the NSW Health definition of aggression, being: Any incident, in which employees are abused, threatened or assaulted in circumstances arising out of, or in the course of, their employment including verbal, physical or psychological abuse, threats or other intimidating behaviours (NSW Health, 2003).

This definition seems quite appropriate in that it includes the term ‘intimidation’. As highlighted by O’Connell et al. (2000) 89.5% of nurses in their study believed that aggressive behaviour included intimidation and the authors believed future studies should include this in their definition.

The literature reveals that over the last decade the health care setting is becoming a more violent place to work (Rippon, 2000) and this has been attributed to the increasing level of violence in the general population (Lipscombe & Love, 1992). While initially, aggression was thought to be a problem only in areas such as mental health and accident and emergency departments (Sommargren, 1994), a study by O’Connell et al. (2000) found that aggression in health care is widespread and not confined to any particular ward setting, with up to 95% of nursing staff in the study encountering verbal aggression in the last 12 months. While there are numerous papers on patient aggression in the health care setting in general (Fern, 2006; Rippon, 2000; Whykes, 1994), very little work had been documented in the setting of the haemodialysis unit until more recently. Jones (2008) has identified that disruptive, abusive and violent behaviour by patients and occasionally their family members is becoming a significant problem in some haemodialysis units, and a survey of nephrology nurses conducted in the United Kingdom (UK) indicated that 80% of respondents had experienced some form of violence or aggression at work within the last 12 months (Sedgewick, 2005).

Measuring the incidence of the problem A method for measuring the amount of aggression was required to establish a baseline. Anecdotally staff thought that it happened all the time and was increasing, but there was no accurate measurement of how many aggressive exchanges took place as a proportion of the 345 dialysis treatments provided each week at St George Public Hospital.

Examination of the Incident Information Management System (IIMS) data revealed that during the previous 12 months only seven incidents of aggression had been reported. Staff knew that this was not a true picture of the problem of aggression within the unit. As noted by Whykes (1994) when nurses deal with repeated exposure to aggression in varying degrees they become desensitised. It appears that nurses rarely report an incident of aggression

if there is no perceived intent (such as dementia, confused, medicated or postop patients) (Fern, 2006). This may account for the under-reporting of aggressive incidents on IIMS. Rippon (2000) concluded that under-reporting may be due to poor reporting mechanisms, excessive paperwork and gender of the victim. Rippon highlighted the fact that anger is a common emotion in the health care setting and it has become accepted as a hazard of the job. The desensitisation of nurses who do not report every event does not diminish the cumulative effect it has on them (Whykes, 1994). When Holden (1985) asked nurses to describe their feelings after experiencing an aggressive incident their responses included fear, anger, anxiety, helplessness and resentment.

At the time of starting the data collection phase, the team members were unable to source an appropriate tool to collect a snapshot of the actual level of aggression within the unit. The Mental Health team at St George Hospital were consulted for ideas on recording and documenting incidents of aggression. To ensure nursing staff compliance on completing this documentation it needed to be simple, efficient and maintain confidentiality. Incorporating aspects of the Mental Health Department’s Behaviour History and Care Plan, the St George Models of Care team developed the Aggression Grading Record of Observation Score (AGRO; Figure 1). This tool is a simple tick box chart for nurses to easily record every aggressive incident they encounter. To capture the full range of aggression, incidents on the AGRO score were graded across a scale from ‘Comment’, ‘Criticism’, and ‘Complaint’ through to ‘Confrontation’ and ‘Outburst’.

Other data that was collected included date, time, reason for the incident, and gender and ethnic background of both the aggressor and the recorder as literature has suggested a link between culture and aggression (King & Moss, 2004; Yeh & Chou, 2007). Information about the patient’s age and their mode of transport to dialysis was also added to the chart for the re-measuring stage. Nurses used the AGRO score to record every incident of aggression they encountered.

As the time period for recording the baseline covered the Christmas and New Year holidays it was extended to nine weeks.

Reasons for aggressive behaviour in the haemodialysis unit An understanding of the reasons behind the aggressive behaviour in the unit was sought. The manager of the Aggression Minimisation programme at St George Hospital was consulted and suggested the following system model (based on NSW Health, 2003) to analyse the problem of aggression in the haemodialysis unit. The Aggression System Model (Figure 2) shows that triggers to aggression potentially arise from three areas: the clients, that is patients and relatives; the staff members;

42 ■ HEALTH AND SAFETY 2014

REDUCING AGGRESSION IN THE HAEMODIALYSIS UNIT

FIGURE 1

AGRO Score (Agression Grading Record of Observation) Date

Time

Incident type

Aggressor

Reporter Ethnic background

Gender M/F

Ethnic backgroud (check notes if unsure)

Transport Type Bus/Ambo/Relative/Self drive

Age

Gender M/F

Staff

Relative

Is this incident worthy of an IIMS report?

Yes/No

Patient

Outburst

Confrontation

Criticism

Complaint

Comment

Comments about the incident

FIGURE 2

Aggression System Model Clients (patients and relatives)

Aggression

Staff

Organisational or environmental factors

and the organisation or the environment. The Models of Care team brainstormed what each of these three factors might contribute to the level of aggression in the unit by reflecting upon their experiences. Having worked as staff within the organisation for many years, it was easy for the team to identify triggers to aggression that may arise from the staff or as a result of the organisation or environment.

For triggers to aggression arising from the patient, team members used empathy to imagine how dialysis would impact on their own lives and reflected on specific instances of aggression that they had witnessed. When the responses were analysed they fell into four clear categories, illustrated in the following table: issues of control; failures

in communication; the clinical or physical environment; and psychological reasons (Table 1).

A common observation about some of the behaviour was that while it was not overtly loud or violent, nurses thought it was aggressive in a passive way. The comment ‘Good afternoon’ at 7 am in the morning may appear to be nothing but gentle humour, but when it is repeated day after day and surrounded with comments about the time, how late it is, how late they will get home, then it becomes part of a pattern of behaviour that causes the nurse to feel pressured and harangued. No attempt was made to judge whether incidents were truly aggressive or whether a communication breakdown had led to an exchange being wrongly

HEALTH AND SAFETY 2014 ■ 43

CHAPTER 2.5 interpreted as aggression. In this way it was hoped that the data collected for this project would accurately reflect the amount of aggression perceived by the nurses.

Patients who drove themselves or who were brought in to the unit by relatives spent up to two hours of their dialysis day waiting. Both of these groups expressed concerns with the availability of parking spots close to the doors, especially the drivers who needed to park and collect relatives. The cost of parking was also an issue and two of the four patients spoken to in these groups had received parking infringement notices while attending the dialysis unit.

and data from this survey was used to plan strategies for the Models of Care project. In January 2010 the survey had a poor overall response rate of 56%, which showed that only 27% of the patients who completed the survey strongly agreed with the statement: “The time I wait to be connected to the dialysis machine is usually acceptable”. Thirteen per cent of those patients disagreed with the statement. Some comments collected in the survey included: “The only frustrating thing I experience is that I have to be delayed for my dialysis and other patients are placed before me” and “The patients hate waiting to be put on the machines, if they can be taken in faster”, revealing the patient’s preoccupation with their own treatment and lack of awareness of the unit as a whole. Other low scores showed that some patients did not feel there was good communication between nurses and patients, and some patients did not feel they had active participation or control of their treatment.

Patients travelling on the renal bus spent up to 2.5 hours waiting, but those who travelled by ambulance were found to spend up to 8.5–9 hours of their dialysis day waiting. These are patients who do not meet the criteria for the renal bus, and who do not have relatives to bring them in, and are usually people who are infirm or immobile. Ambulances are booked for specific times, but because they are an emergency service, they themselves state that pick-up is within two hours of the specified time, and in reality it is often a lot longer than that.

Ironically this group of patients complain the least.

The annual nursing staff satisfaction survey (December 2009) had a 75% response rate. Ninety-four per cent of nurses who responded felt that they worked well together as a team and 83% felt confident as clinicians. However, less than half felt they had enough time to deliver good care to patients. Recorded qualitative comments suggested the need for less task-orientated, more patient-centred care and the introduction of appointment times or the allocation of patients to nurses before the start of the shift. It was felt that the Models of Care project would address some of these concerns.

The unit conducts a patient satisfaction survey every year to gauge whether the service is meeting the patients’ needs

After this intense period of data collection, information was fed back to the nurses who were invited to brainstorm ways

A process mapping exercise was carried out to record a typical dialysis day of eight patients: two who travelled independently; two who were brought to the unit by relatives; two who travelled on the renal bus; and two who came by ambulance.

TABLE 1

Factors contributing towards aggression Control Patients/relatives Loss of control, dependent, reliant on others

Staff

Environment/organisation

Inconsistent behaviour, favouritism

Inflexible, dictatory, no clear system

Communication Patients/relatives Uninformed, culturally and linguistically diverse (CALD)

Staff

Environment/organisation

Poor communication skills

Dictatory, slow/poor feedback

Clinical/Physical environment Patients/relatives Tired, stressed, sick, mental health, end-stage renal failure (ESRF)

Staff

Environment/organisation

Tired, stressed, sick, mental health

Staffing/workload issues, heating/ cooling, uncomfortable chairs/ broken TVs

Psychological Patients/relatvies Psychological, psychosocial

Staff

Environment/organisation

Psychological, psychosocial

Obligation to provide life-saving treatment

44 ■ HEALTH AND SAFETY 2014

room. By providing this information, it o a typical day in the unit. by patients that those requiring lon ers were given to each patient treatment should go in first, but nu was hoped that patients would have a REDUCING AGGRESSION IN THEhad HAEMODIALYSIS ally by members of the Models often knowledge ofUNIT clinical or more realistic idea of how long it takes team who explained the text reasons that would upset this order for everyone to get connected to the wered any questions.

Instead of a be session, finished until flyers contained half a in page of reducing aggression. Initially it wasmachines decided to trial two start of not Patients would wait hope as eac at the each that4 pm. The of script, but it was felt to be more important to have the x system strategies: of appointment times, became free, only to be frustrated w they would be better prepared for the information represented in picture form for people who did was divided into ‘Morning’ andto providelength 1. Better communication patientsof with morethey may have to wait and they were not the next one attend time not read English. information about the unit and their treatment that oon’. Morning patients were told that they would choose not to arrive at day.

The clock pictures were also With produced as largeallocation, posters patient the nurse hough the unit opened its doors the unit early in the hope “someone andthat, displayed in the waitingwould room. Byknow providing this which patients they w Encouragement of nurses patient-centred, , the first2. patient would not be to provide information, it was hoped that patients would have a may call me in”. consistent treatment that reflected the information taking care of that day. Nurses wer ted to the machine before 7.30 more realistic idea of how long it takes for everyone to get given to the patients. tosession, greet their the start of each that patients the last patient may not be put 2. Patient allocation connected to the machines atencouraged they would be better prepared for the length of time they start of the shift or as they arrived ysis until Strategies 9.30 am. The afternoon implemented Patient allocation was introduced to and that they may have to wait would choose not to arrive at they wo let them know how soon were told that they would not be Standardised communication the unit early in the hope that, “someone may call me in”. improve communication between staff be connected to the machine. This n to the unit until 2 pm, allowing 1. Clock flyers (Figure 3) and patients. The unit has two areas as 2. Patient allocation with specific complaints that had b Flyers were developed to show in picture form how the me to finish with the morning Patient allocation was introduced to improve communication previously described and four distinct dialysis treatmentand fits into a typical day in the recorded about, “never knowing w and havepatient’s time for handover between staff and patients. The unit has two areas as previously unit. The flyers were given to each patient personally by rooms.

A whiteboard was put up in the we are sitting” and feeling described and four distinct rooms.

A whiteboard was put up “forgott ucation and that connection of members of the Models of Care team who explained the text room and the patients’ seating in the waiting room and the patients’ allocation in the seating waiting room,written thus hopefull on patients not any be questions. finished Instead ofwaiting andmay answered a complex system up before each shift along with the name of the nurse who was allocation written up before each shift alleviating treatment anxieties. appointment times, the day was divided into ‘Morning’ pm. The of flyers contained half to connect them to the machine. with the name of allocated the nurse who . Morning told that although of script, and but‘Aitfternoon’ was felt to be patients werealong three months, the effectivene Prior to this project no clear system for equitably the unit opened its doors at 7 am, the was first patient would allocated to connect them to the there wasAfter mportant to have the information connecting patients to the machine.

It was widely believed not be connected to the machine before 7.30 am and the of these standardised communicati machine. nted in picture form by patients that those requiring longer treatment should go last patient mayfor notpeople be put on dialysis until 9.30 am. The strategies was evaluated. In a focus d not read English. in first, but nurses often had knowledge of clinical or social afternoon patients were told that they would not be called Prior to this project there was no clear patients reasons that would upset thisthe order.

Patientswere wouldasked wait intheir opini in to the unit until 2 pm, allowing staff time to finish with forand equitably connecting patients of the board and th ock pictures were also produced astime forsystem hope as each nurse became free, onlynew to be allocation frustrated when the morning patients and have handover staff they were not the next one attended to. were overwhelmingly po andin that connection may It was widely osters andeducation displayed the waitingof afternoon responses to thepatients machine. believed FIGURE 3

Your Day on 4West Morning Dialysis 12

7.00am

Morning staff arrive

7.30-9.30am

3 7

12.00-2.00pm

12

1.00-2.00pm

9

Morning patients commence dialysis

Morning patients come off the dialysis machine and leave the unit

Afternoon Dialysis

Afternoon staff arrive and have education and handover

2 9

3 4

2.00-4.00pm

6

1

6

Afternoon patients commence dialysis

12

12

6.30-8.30pm

2 9

3

Afternoon patients come off the dialysis machine and leave the unit

6

9

3 8 6

Clock flyers illustration.

HEALTH AND SAFETY 2014 ■ 45

Renal Society of Australasia Journal // July 2011 Vol 7 No 2

CHAPTER 2.5 With patient allocation, the nurse would know which patients they were taking care of that day. Nurses were encouraged to greet their patients at the start of the shift or as they arrived and let them know how soon they would be connected to the machine. This dealt with specific complaints that had been recorded about, “never knowing where we are sitting” and feeling “forgotten” in the waiting room, thus hopefully alleviating treatment anxieties.

were related to patients with mental health issues such as dementia. Environmental factors and treatment conflicts each rated 11% and small numbers were associated with communication, transport, other patients and, worryingly, aggressive nurses.

The AGRO score was reintroduced and nurses were asked to record every aggressive incident again for a period of four weeks.

Remeasuring phase The AGRO score was reintroduced three months after the strategies were implemented and nurses recorded every aggressive incident again for a four-week period. During that time a total of 14 incidents of aggression were recorded.

This represented 1% of the 345 treatment sessions provided by the unit each week. During the remeasuring phase waiting times has been overtaken by clinical issues as the leading precursor for aggression, although the sample size was very small.

Results

Discussion

Baseline Over a nine-week period of baseline data collection, a total of 124 incidents of aggression were recorded. As a percentage of the 345 treatments provided by the unit each week this reflected 2–8% of treatments (Figure 4).The goal for the project was to reduce this to no more than 1%.

The baseline results of this study show that aggression is a problem for nursing staff at St George Hospital Haemodialysis Unit, a fact reflected in studies from haemodialysis units around the world (Sedgewick, 2005; Jones, 2008; Hashmi & Moss, 2008; Zampieron, 2010).

King and Moss (2004) documented a 20-fold increase of difficult/disruptive patient situations between 1994 and 2002.This is supported by an ESRD Network report that conducted a survey in 2000 and found that 69% of the 203 dialysis unit care givers felt they had witnessed an increase in difficult and disruptive patients within the previous five years. Under-reporting of aggression further diminishes the extent of this problem in health care (Rippon, 2000; Sommargren, 1994) and in the haemodialysis setting (Jones, 2008). Waiting times, mental health issues and

After three months, the effectiveness of these standardised communication strategies was evaluated. In a focus group the patients were asked their opinion of the new allocation board and their responses were overwhelmingly positive.

The relationship of aggression to waiting times is illustrated clearly when the times of aggressive incidents are examined (Figure 5). Spikes of incidents occur early and again in the middle of the day when patients are waiting to be connected to the haemodialysis machine.

Analysis of the recorded comments showed the reasons for each of the incidents (Figure 6). Fifty-two per cent were related to waiting. Seventeen per cent of the reasons FIGURE 4

Percentage of aggressive incidents per total number of treatments per week, measured using the AGRO score 10% Commenced standardised communication strategies

% aggressive episodes

9% 8% 7% 6% 5% 4% 3% 2% 1% 0% Nov-09

11-Dec

18-Dec

25-Dec

01-Jan

08-Jan

15-Jan

22-Jan

Target

46 ■ HEALTH AND SAFETY 2014

29-Jan

13-May

20-May

27-May

03-Jun

REDUCING AGGRESSION IN THE HAEMODIALYSIS UNIT

FIGURE 5

Shows aggressive incidents grouped by time of the day 35 31

Number of incidents

30 25 20

19 16 14

15

11 9

10

4

5 0

4

2

7am8am

8am9am

9am10am

2

1

10am11am

11am12pm

12pm1pm

1pm2pm

2pm3pm

3pm4pm

3

4 0

5pm6pm

6pm7pm

7pm8pm

8pm9pm

9pm10pm

FIGURE 6

Shows reasons for aggressive episodes % reasons for aggressive incidents

55

52

50 45 40 *35 30 25 20 15

17 11

11

10 5

2

2

1

1

3

0

staff–patient communication were highlighted in our study as causal factors contributing to aggression. These findings are supported by Jones (2008) who also noted themes of waiting and staff–patient communication as potential precursors to aggression in the results of her qualitative data collected from two haemodialysis units in the United Kingdom.

In order to maintain any change, the strategies used must be sustainable. The National Health Service (NHS) Institute for Innovation and Improvement has developed a Sustainability Model (Maher et al., 2010) consisting of 10 factors that play an important role in sustaining change

in health care such as staff involvement and training, staff attitudes, clinical leadership and the organisation’s culture. A score of 55 or higher suggests that the project is sustainable. Using the NHS Sustainability Model, the St George Hospital Models of Care project scored 66.7.

Project leaders have met with the unit’s clinical managers to feedback results of the study and reinforce the effectiveness of standardised communication in reducing aggression.

Resources necessary for the strategies to continue have been made available. The clock flyers have been saved on the hospital intranet and a supply of paper copies is on hand. Guidelines for patient allocation have been created

HEALTH AND SAFETY 2014 ■ 47

CHAPTER 2.5 and team leaders assist staff with planning for the next shift; and regular education in effective communication is regularly offered using a variety of expert staff from within the hospital. New nurses to the unit learn these strategies during orientation as they are now adopted as part of the unit’s workplace culture.

While this project has demonstrated the effectiveness of these standardised communication strategies, further improvements in communication with patients could be investigated.

Currently orientation to the unit is quite inconsistent. Ideally a person with worsening end-stage renal disease attends predialysis education and is orientated to the ward environment well before the start of the dialysis, receiving written and verbal information over a period of months, allowing plenty of time for questions and reviews. However, it is often the case that a person starts dialysis urgently, either as a late referral chronic kidney disease (CKD), or with acute renal failure, neither of which allows much time to reflect upon the new lifestyle that is beginning. This project highlighted how unplanned the current orientation process is, and would recommend the development of a more structured orientation pathway that is accessible to patients from various entry points, delivered by identified members of nursing staff and covering defined topics.

The written resources available to patients are all in English, while the patient group is multicultural. Funding from the Multicultural Health Awards has been granted to translate basic introductory pamphlets, including the clock flyer, into languages other than English, and make these available through the hospital intranet. The value of written information is that the words are carefully chosen and it can be referred to again and again. However, it cannot be assumed that all patients can read (Australian Bureau of Statistics, 2006) and literacy should be sensitively ascertained at the start of the patient orientation process.

The use of interpreters and the education of family members may be more effective in conveying accurate information to the patient.

Baseline data recorded using the AGRO score highlighted mental health issues as the second highest reason for aggressive incidents after waiting times. This was largely due to a small number of patients with dementia, whose aggressive outbursts resulted from their reduced cognition.

Advanced age is no longer a reason to deny haemodialysis to a patient evidenced by ANZDATA reports that show a 150% increase in patients starting dialysis in the 75–84 years age group from 2000–2006 (McDonald et al., 2006).There are now more patients in the haemodialysis community with age-related mental impairment (Sehgal et al., 1997) and, in addition, studies have shown that the prevalence of cognitive impairment and dementia is higher in people with end-stage renal disease than it is in the general population. (Kurella et al., 2006) While the literature has shown that nurses commonly under-

report aggression from patients where they feel that the patient is not responsible for their actions (Fern, 2006), the aggression still impacts upon them and strategies should be sought to minimise its incidence. Strategies for nursing patients with reduced cognition include the use of familiar surroundings and belongings, staff getting to know patients well in order to be able to distract and divert the conversation, and reducing visual and auditory stimuli that may be unsettling. These strategies are challenging to implement in a busy hospital dialysis unit with a large group of staff. Excellent communication should be maintained between nurses, nephrologists and family members at all times, as increasing confusion and aggression on dialysis may become an unreasonable risk to both the patient and the staff, and be a prompt to begin end-of-life discussions with the family (McKeown et al., 2008).

A 2010 study by the European Dialysis and Transplant Nurses Association and the European Renal Care Association (ETNA/ERCA) (Zampieron et al., 2010) has listed many strategies for the prevention of violence and aggression in the haemodialysis unit. One of their fundamental steps recommends creating an atmosphere of non-violence by providing clear and precise information to patients. Another step is to minimise waiting times and inform patients when delays are unavoidable. These recommendations have formed the basis for the strategies implemented by the St George Hospital Models of Care project. Further suggestions made in this document include risk assessment, the development of specific guidelines or policies and physical measures such as adequate lighting, heating and seating, secure units with controlled entry points, closed-circuit television cameras and metal detectors to detect metal weapons. Other studies have seen a positive influence on dialysis patient adherence through the use of behavioural contracts (King & Moss, 2004). It would seem prudent that haemodialysis units and their associated renal departments and hospital managers are prepared by developing clear policies for the management of patients who display aggressive behaviour.

At the start of this project it was found that there are many inconsistencies when comparing studies on violence and aggression. Varying definitions, Reducing aggression in the haemodialysis unit by improving the dialysis experience for patients Figure 7. Reasons for aggressive episodes during the remeasuring phase. methodologies and perceptions as to what constitutes aggression makes comparison of the data difficult and there is a need for a standardised definition and measurement tool, such as the Staff Observation Aggression Scale – Revised (SOAS-R), to collect results for comparative purposes. (Rippon, 2000; Somargren, 1994; Scott, 1992;Whykes, 1994). Further investigation is required to develop strategies into the problem of aggression in haemodialysis units and its impact on nursing staff.

48 ■ HEALTH AND SAFETY 2014

REDUCING AGGRESSION IN THE HAEMODIALYSIS UNIT

FIGURE 7

Reasons for aggressive episodes during the remeasuring phase 45

% reasons for aggressive incdents

40 36

35 30

29

25 20 14

15 10

14

7

5 0

Waiting times

Mental health

Clinical..

Angry patient

Not specified

Conclusion

Summary of recommendations

By introducing systems of effective standardised communication, the incidence of aggression from patients towards staff in the haemodialysis unit has been reduced at St George Hospital. The strategies of patient allocation and illustrated flyers have given patients a better understanding of the running of the unit, improving their haemodialysis experience by acknowledging their presence and reducing their treatment anxieties. In implementing these changes, nurses have had to enhance their skills of organisation, planning and effective communication. The reduction of aggressive incidents from 2–8% of treatments down to <1% of treatments has improved the work environment for nurses.

This project limited its work to investigating the effectiveness of improved communication upon the incidence of aggression. The data collected indicated that there were other areas of intervention that may also have an effect. These included the development of a clear orientation pathway for patients joining the haemodialysis community with realistic expectations about time frames and acceptable conduct. Written orientation and educational resources could be translated for patients from culturally and linguistically diverse backgrounds.

Policies for the management of mental health patients and for the management of aggressive/violent patients could be developed, along with investment in staff training in the use of those policies. More studies are required in the area of aggression in the haemodialysis setting to establish solid data and to develop universal strategies. For this a standardised definition of ‘aggression’ and a universal tool for measuring frequency, nature and severity of aggressive incidence should be agreed upon by researchers.

Aggression and violence is on the rise in the health care setting and has been identified as a problem in the haemodialysis setting internationally. This project has found that aggression can be reduced through the use of effective, standardised communication strategies.

Investment of time is required to educate and engage staff in developing a culture of transparency and non-violence.

Appropriate resources should be made available to patients to ensure consistent transfer of information, preferably at the time of orientation to the dialysis community. The development of policies relating to the management of disruptive patients’ behaviours is essential, as is investment in staff training in techniques to prevent and manage incidents. More research in the specific area of aggression in the haemodialysis unit is required to identify trends and to assist in further development of appropriate management strategies.

Acknowledgements Dr Shelley Tranter, Nephrology CNC, St George Hospital; Tracey Blow, NUM, Haemodialysis Unit, St George Hospital; Fidye Westgarth, NSW Agency of Clinical Innovation; Prof Mary Chiarella, Professor of Nursing Chair, Australian and Midwifery Council, Faculty of Nursing and Midwifery, University of Sydney 4 West Models of Care team; Allison Boyle, Manager, Aggression Minimisation Programme; Colleen McKinnon, Aged Care CNC, SESIAHS; Lynne Walkington, SESIAHS Librarian;

HEALTH AND SAFETY 2014 ■ 49

CHAPTER 2.5 Australia and New Zealand Society of Nephrology; Renal Society of Australasia and Amgen.

References Australian Bureau of Statistics (2006). Adult Literacy and Life Skills Survey, Summary Results Australia, 4228.0. 2006 Reissue, www.abs.gov.au Chiarella M & Westgarth F (2009). NSW Haemodialysis ‘Models of Care’ Program Report, NSW Health & Greater Metropolitan Clinical Task Force, 2.

Fern T (2006).Violence, aggression and physical assault in healthcare settings, Nursing Standard 21(13), 42–46. Decreasing Dialysis Patient Provider Conflict Project National Task Force (2005). Decreasing Dialysis Patient – Provider Conflicts (DPC) Project. Retrieved 23 September 2010 from: http://esrdnetworks.org/special-projects/copy_ of_decreasing-patient-provider-conflict-dpc/?searchterm=conflict Hashm A & Moss A (2008).Treating difficult or disruptive dialysis patients: practical strategies based on ethical principles. Nature Clinical Practice Nephrology, 4(9), 515–520.

Holden RJ (1985). Aggression against nurses. The Australian Nurses Journal, 15(3), 44-48.

Jones J (2008).Violence and aggression in haemodialysis units in general hospitals. Workplace Violence in the Health Sector, 171–172.

King K & Moss A (2004).The Frequency and Significance of the “Difficult” Patient: The Nephrology Community’s Perceptions. Advances in Chronic Kidney Disease, 11(2), 234–239.

Kurella M et al. (2006). Correlates and outcomes of dementia among dialysis patients: the Dialysis Outcomes and Practice Patterns Study.

Nephrology Dialysis Transplantation, 21, 2543–2548.

Lipscombe J & Love C (1992).Violence towards health care workers.

Journal of the American Association of Occupational Health Nurses, 40, 219–227.

Maher L et al. (2010). NHS sustainability Model. NHS Institute for Innovation and Improvement, Version Feb: 2010, 8–23.

McDonald S et al. (2006). New Patients Commencing Treatment in 2006.

Australia and New Zealand dialysis and transplant registry. Retrieved from: http://www.anzdata.org.au/v1/report_2006.html McKeown A et al. (2008). Renal failure and specialist palliative care: an assessment of current referral practice. International Journal of Palliative Nursing, 14(9), 454–8.

Nijman H et al. (1999).The Staff Observation Scale – Revised (SOAS-R).

Aggressive Behaviour, 25, 197–209.

NSW Health (2003). A safer place to work – preventing and managing violent behaviour in the Health workplace, Module 1 HLTCSD6A Respond effectively to difficult or challenging behaviour (Version 1) © July 2003.

NSW Health (2004) A safer place to work – preventing and managing violent behaviour in the Health workplace, Module 2 AMT002 Aggression minimisation in high risk environments, © NSW Department of Health 2003.

O’Connell B et al. (2000). Nurses’ perceptions of the nature and frequency of aggression in general ward settings and high dependency areas.

Journal of Clinical Nursing, 9(4), 602–610.

Rippon TJ (2000). Aggression and violence in health care professions.

Journal of Advanced Nursing, 31(2), 452–460.

Scott JP (1992). Aggression: functions and control in social systems.

Aggressive Behaviour, 18, 1–20.

Sedgewick J (2005). Nurses at breaking point: Violence and aggression in renal units. Nephrology News, Summer 2005, The RCN Nephrology Nursing Forum, RCN, London.

Sehgal AR et al. (1997). Prevalence, recognition, and implications of mental impairment among haemodialysis patients. American Journal of Kidney Disease, 30(1), 41–19.

Sommargren CE (1994).Violence as an occupational hazard in the acute care setting. American Association of Critical Care Nursing Clinical Issues in Critical Care Nursing, 5(4), 516–522.

South Eastern Sydney Illawarra Health Service (2010). Behaviour History and Care Plan. Adapted from Peninsula Health Service, Victoria.

Whykes T (1994). Violence and Health Care Professionals. Chapman and Hall, London.

Yeh SJ & Chou H (2007). Coping Strategies and Stressors in Patients with Hemodialysis. Psychosomatic Medicine, 69, 182–190.

Zampieron A et al.(2010). Survey on violence and aggression prevention and management strategies in European Renal Units. Journal of Renal Care, 36(2), 60–67.

Zampieron A et al. (2010). EDTNA/ERCA Recommendations for the Prevention of Violence and Aggression in renal units, European Dialysis and Transplant Nurses Association and the European Renal Care Association (EDTNA/ERCA). Retrieved 23 September 2010 from: www.edtnaerca.org

© 2011 Burns, T. & Smyth A. © 2011 Cambridge Publishing Renal Society of Australasia Journal. Reproduced with permission.

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CHAPTER 2.6

through the eyes of the workforce: creating joy, meaning and safer health care Excerpts from: Lucian Leape Institute and National Patient Safety Foundation, Through the eyes of the workforce (2013) Report of the round table on joy and meaning in workforce safety.

This research explains how creating an environment of mutual respect not only helps staff find joy and meaning in their work, but can improve workplace safety, reduce worker injury, reduce error rates and improve patient safety. Quite simply researchers discovered that disrespectful treatment of staff increases the risk of harm to both staff and patients—sound reasons for nurses and midwives to pull together and show leadership in building positive workplace cultures.

Across the health care workforce, ambiguity of roles, wasteful and non-value-added work, lack of teamwork, and an environment of disrespect are robbing people of the experiences that bring meaning and joy into their working lives. These problems affect the entirety of the workforce, from a caregiver unduly burdened with non-caregiving work to an executive dispirited by unnecessary reporting requirements.

Without joy and meaning, the workforce cannot perform to its potential. Joy and meaning are generative and allow the best to be contributed by each individual, and the teams they comprise, to the work of safe health care every day.

Although many elements are necessary to create an environment where everyone finds joy and meaning in their work, an essential characteristic is workplace safety, defined as a workplace free from risks of both physical and psychological harm. This requires that all in the workforce accept a collective accountability and obligation to create a culture in which everyone in the workforce feels safe and respected. The aspiration to relieve suffering, protect human dignity, and improve the human condition is what makes the health care workforce “tick.” If we expect the health care workforce to care for patients, we need to care for the workforce.

Workplace safety is also inextricably linked to patient safety.

Unless caregivers are given the protection, respect, and support they need, they are more likely to make errors, fail to follow safe practices, and not work well in teams.

Without joy and meaning, the workforce cannot perform to its potential.

Similarly, efficiency and effectiveness cannot be achieved unless every member of the workforce is part of the problem-solving team.

Meaning: The sense or importance of an action.

Joy:

The emotion of pleasure, feeling of success, and satisfaction as the result of meaningful action, which in the context of this paper is meaningful work in health care.1

The stakes are high. An environment that is deficient in joy and meaning, where the workforce is burdened by extreme production pressures, toxic sociocultural norms, and the risk that they could be physically or psychologically harmed, is an environment where both the workforce and patients suffer.

The rewards of an inspirational and healthy workplace could be immense. No other industry has more potential to free up resources from non-value-added and inefficient production practices than health care, and no other industry has greater potential to use its resources to add value, promote health, and relieve suffering.

Current state of the health care workplace The health care workforce in the United States numbers more than 18 million2 with a great range of diversity in terms of race, ethnicity, age, socioeconomic background, education, and training. This workforce is composed of well-intentioned, well-prepared people across a variety of roles and clinical disciplines, doing their best every day to ensure that patients are well cared for. This is what sets the work of health care apart and makes health care uniquely

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CHAPTER 2.6 different: the service mission of people caring for people in times of their greatest vulnerability and need. This is the mission of the health care workforce—the mission from which its members derive their meaning as well as their experience of joy.

We believe that many health care workers are suffering harm—emotional and physical—in the course of providing care. Many are subjected to being bullied, harassed, demeaned, ignored, and in the most extreme cases, physically assaulted. They are also being physically injured, working in conditions of known and preventable environmental risk.

Caregivers cannot meet the challenge of making health care safe for patients unless they feel safe and valued, and find purpose in their work that brings joy and meaning to their lives. There is evidence at all levels that many do not: 60% of surveyed physicians are thinking of leaving practice because they feel discouraged; 33% of new registered nurses seek another job within a year.3 Lack of respect, the burdens of regulation and record keeping, and tolerance of disrespectful and non-team-promoting behaviors are all cited throughout the literature as challenges facing the health care workforce.

Production and cost pressures have been building in health care over the past half century for a variety of reasons, not the least of which is a reimbursement system that pays for production and transactions, thereby reducing complex, intimate, caregiving relationships into a series of demanding tasks performed under severe time constraints.

Vulnerable Workplaces, by omissions in Design and Inattention The basic precondition of a safe workplace is protection of the physical and psychological safety of the workforce.

Both are conspicuously absent or considered optional in many care-delivery organizations. Disrespect of workers is manifest in poor treatment by colleagues and supervisors and the presence of hazardous physical conditions in the workplace where staff often find themselves working under risk-prone conditions. If the workforce cannot feel safe in the workplace, it cannot perform to its potential, which is key to delivering safe care and is necessary for deriving meaning from the work.

Physical Harm The prevalence of physical harm experienced by the health care workforce is striking. Recent data put the rate, especially among nurses, 30 times higher than in other industries.4 Back and musculoskeletal injuries are common, as is unprotected contact with blood-borne pathogens.5 As far back as 1998, the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry elaborated on a disturbing trend: “The rate of occupational injuries and illnesses in the health care industry has been rising for some time.

Between 1985 and 1995, the injury and illness incidence rate for workers in hospitals rose by 25%, while the rate for workers in nursing and personal care facilities rose by 37%. During the same period, the rate for workers in private industry as a whole increased by 3%.”6 This led the commission to conclude, “Action must be taken to reduce the unacceptably high rate of injury in the health care workplace.”

Ten years later, the story was no better, with the Bureau of Labor Statistics reporting 670,600 injuries and illnesses in the health care and social assistance industry in 2007, and an injury and illness rate of 5.6 per 100 full-time workers compared with 4.2 for all of private industry.7 The health care workforce lives in a dangerous state of unnecessary risk driven by rigid organizational structures and hierarchical models that are deficient in respect, teamwork, and transparency. The statement “People are our most important asset” appears in vision statements of health care organizations across the United States, but in many of these organizations there is little evidence of either strategy or action to support this claim.

In one prestigious East Coast medical center, 62 staff members suffered exposure to blood-borne pathogens in a two-month period. Examination of these events revealed that in 90% of the cases, personal protective equipment was not used.4 This finding suggests that neither the staff nor their supervisors were very concerned about occupational hazards in their day-to-day work. Does the current culture carry a belief that such exposure is part of the nature of the work?

Sylvia Emory* is an experienced surgical technician.

She was exposed to a large volume of body fluid while assisting in a surgical case. Rather than scrub out, disinfect, and exchange her scrubs and gown, she proceeded in the case while the saturated gown and scrub shirt served as a vehicle to infect a small lesion on her arm associated with a rash. No one on the surgical team challenged her decision, offered to call a relief scrub tech, or stopped the line. The pace of the case and the schedule for the day were protected. She developed a severe infection that required months of treatment. * Scenarios are based on actual events. All names and locations have been changed to protect the privacy and identity of those involved.

Poor working conditions, unmitigated risks, and high injury rates have profound effects on health care providers. Almost one-third of the nurses in a national sample reported experiencing back or musculoskeletal injuries in the past year, and 13% of the nurses reported unprotected contact with blood-borne pathogens.5 A striking 75.9% of nurses surveyed by the American Nurses Association indicated that unsafe working conditions interfere with the delivery of quality care.8

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THROUGH THE EYES OF THE WORKFORCE

Dennis Moore is a nurse who has been in practice for two years. He sustained a needlestick injury while walking across a patient room to dispose of the needle in a sharps container. The distance between use and disposal introduced greater risk of injury. In this case, Dennis sustained an HIV-positive exposure and is undergoing preventive treatment, with his life and relationships altered for the foreseeable future.

Amanda Jones is a nurse of 20 years who works nights in a rural community hospital. She has noted an increase in the body size of patients over the past decade. While patient lifts have been in the capital budget for several years, the funding has always been deferred. Also deferred has been staff training in safe lifting and “smooth moves.” Unable to locate a coworker to assist in moving her patient, Amanda attempted repositioning the patient from bed to chair by herself.

In doing so, she sustained an acute back injury. She is currently fully disabled and suffers from chronic pain.

Psychological Harm In many health care organizations, staff are not treated with respect—or, worse yet, they are routinely treated with disrespect. They do not feel psychologically safe; they are not provided the necessary resources to carry out their work; and they do not feel appreciated. Health care has a long history of toleration of disrespectful behavior by physicians, and to some degree by nurses, and evidence indicates that this toleration continues.9–12 Emotional abuse, bullying, and even threats of physical assault and learning by humiliation are all often accepted as “normal” conditions of the health care workplace.13–16 There are also less overt behaviors of ignoring, isolating, and using nonverbal expressions of judgment, mocking, or exasperation. These behaviors impact safety, the organizational climate, and job satisfaction.17–18 Such behaviors create a culture of fear and intimidation, diminish individual and collective pride and morale, impair learning, and sap joy and meaning from work.

Nancy Walker is an experienced labor and delivery nurse at a large teaching hospital. She was cornered in a stairwell by a physician who grabbed her by the throat and warned her never to ask him a question again in the delivery room. She did not report this event until she feared for her safety when the physician “stalked her in the hall with menacing looks.” It was suggested to the nurse by her manager that she transfer to a new assignment away from L&D. The nurse escalated her concern to the director of nursing and a department head. The physician was suspended, directed for a fitness-to-work evaluation, and successfully completed an anger management program prior to returning to work. However, Nancy subsequently transferred from the unit because she did not believe the actions taken were sufficient to prevent a similar event of abuse in the future and lacked confidence that management would create a safe practice environment.

Virtually all health care workers can recall stories that, while infrequent, dramatize the seriousness of fear, intimidation, and abusive-assaultive behavior in health care organizations.

But these dramatic stories, while critically important, should not detract attention from the much more common, often pervasive, subtle instances of humiliating and dismissive behavior, put-downs, and humor at the expense of a colleague that erode confidence and self-esteem. The result is demeaning and non-team-promoting behavior. Remarks such as “When did you become a doctor?” “What are you doing here?” “How could you not know this?” and the use of profanity and sexual innuendo are reported as widespread and toxic. Such behaviors are seldom visible to governing boards and senior leaders in health care organizations.

Carl Jones is the CEO of a midsize community hospital. His undergraduate degree is in industrial engineering, and he has a master’s degree in health care administration. Carl is committed to improving access and financial sustainability by improving systems.

In a meeting with clinical colleagues to discuss some of these issues, he was informed that his job was “to keep the lights on and the water running,” that patient care systems were the jurisdiction of the clinical staff.

Michele Veng is a highly skilled nurse in a surgical setting. She works in a complex, high-risk, specialized environment. The lead surgeon has had a pattern of yelling, using profanity, questioning her judgment during surgical procedures, and making blaming remarks. Michele finally had enough and reported this behavior to the Director of Nursing and to the Chief of Surgery. A facilitated meeting was scheduled for her to confront the surgeon about his behavior and for him to apologize. In the course of the meeting, the surgeon realized that he did not know her name or her history— that she had escaped from a war-torn country, traveling by night to hide from enemies, often carrying her young son, and after enduring years in refugee camps had moved to the United States and re-established her career. The surgeon, absorbed in his own performance, not that of the team, knew nothing about the strength and courage of his colleague. He apologized for his behavior.

The problems are not confined to doctors. Nurses also engage in workplace sexual harassment and verbal and physical abuse.8,19–21 “Nurses eat their young” is a common expression among nurses in practice settings. Medical students report abuse by everyone—attending physicians, residents, nurses, and patients—increasing the likelihood that they will mimic these disrespectful behaviors upon entering practice.13–15 Burnout and depressive symptoms lead students to strongly consider dropping out of medical school, even as late as the last year of their education.14 For those who progressed on to residency, 25% reported being subjected to abusive behavior by fellow trainees, as well as

HEALTH AND SAFETY 2014 ■ 53

CHAPTER 2.6 by nurses and midwives, which eroded their self-esteem.

More than two-thirds did not complain to anyone about their treatment.15 Too often, new care providers enter a system in which disrespect for one’s peers and coworkers is not only tolerated, it is the norm. This culture begins in the education of health professions with rite of passage practices, lack of team-based approaches to learning and care, and reinforcement of rigid intraprofessional and interprofessional hierarchies that are counter to a culture of safety.22 This topic is further explored in the Lucian Leape Institute white paper Unmet Needs: Teaching Physicians to Provide Safe Patient Care.23 James Miller, a new resident assisting a senior surgeon on a case, responded to a command more slowly than the surgeon expected. The surgeon demanded the phone number of James’s mother.

Intimidated and flustered, he provided the number. The surgeon suspended the case to place the call, and after confirming the mother’s identity, stated loudly into the telephone, “Your son is an idiot!” The surgical team provided silent witness to this behavior.

Repeated experiences of disrespect and humiliation lead to avoidance, communication blocks, and distraction.24–26 A culture that tolerates disruptive, degrading, and patronizing behavior lacks psychological safety for its workers. In such an environment, workers often do not feel safe about reporting an error—their own or that of another—because of fear of punishment.

Another aspect of psychological safety involves whether people are supported when things go wrong.27 When a serious patient safety event occurs, there are two victims: the patient and the caregiver.28 A provider who is demoralized in the wake of a serious adverse event may be psychologically hampered from participating fully in all aspects of responding to the situation: communicating honestly and compassionately with the injured and frightened patient, preventing further injury, investigating the possible causes, and analyzing and redesigning the relevant care processes.29 Lack of respect for the time of the workforce is another symptom of an injurious workplace. Assigning extended hours and unexpected shift changes produces fatigue and disregards the personal and family needs and schedules of the workforce. Issuing orders that interrupt workflow and attention makes it clear that the manager, or person in the gradient of hierarchy above the worker, possesses interests that are more important than the planned efforts of the health care worker.

Costs of Inaction The absence of cultural norms that create the preconditions of psychological and physical safety obscures meaning of work and drains motivation. It damages everyone: doctors,

nurses, employees, organizations, patients, families, as well as the economy. The costs of burnout, litigation, lost work hours, employee turnover, and the inability to attract newcomers to caring professions are wasteful and add to the burden of illness.30–35 More full-time employee (FTE) days are lost in health care each year than in industries such as mining, machinery manufacturing, and construction.36 In addition to the harm of the individual, the constant shuffling of work schedules to adjust for workers who have been injured takes a physical and emotional toll on every worker, exacerbating the constant risk of harm.

Management practices, expectations, and resource limitations create conditions with major downstream impacts on patient safety, worker safety, and the community.37–40 Disrespectful treatment of workers increases the risk of patient injury.41 Disrespectful treatment of patients is also a major cause of malpractice suits that result in both financial and reputational cost to organizations.42–47 All of these factors are combining to create a critical shortage of health care workers, particularly registered nurses, that will increase as the Baby Boomers age and their health care needs increase.48 In recognition of the challenges and opportunities for the nursing workforce, the Institute of Medicine has released a report titled The Future of Nursing that outlines important aims and interventions to enhance professional practice, such as access to advance education and working to the top of one’s license.49 The American Association of Colleges of Nursing identifies insufficient staffing as raising nurses’ stress levels, impacting their job satisfaction and driving many nurses to leave the profession.

Workforce safety in health care organizations tends to be considered and managed in silos often unconnected to the work of patient safety, with workers’ compensation issues typically overseen as an aspect of employee benefits under the Human Resources function, injury reports and claims managed by the Risk and Employee Health department, workplace safety under the jurisdiction of Environmental Services, and infection control responsibility distributed across multiple clinical departments. What is uncommon is an integrated approach to workforce safety and, importantly, consideration of workforce safety as a quality indicator for the culture of the organization—the culture that provides the critical context for achieving patient safety. The two are inextricably linked and grounded in the same safety science. However, a survey across the health care disciplines conducted by the American Society of Professionals in Patient Safety at the National Patient Safety Foundation found that while 99% of the respondents agreed that there is a link between workforce safety and patient safety, only 16.5% reported that workforce safety

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THROUGH THE EYES OF THE WORKFORCE was a focus in their organization’s quality and safety initiatives.50 A systems approach to establishing and ensuring a culture of safety would, by definition, argue for alignment, if not integration, of workforce safety efforts with patient safety efforts.

Paul O’Neill, former Chairman and Chief Executive Officer of Alcoa, puts forth a challenge to organizations aspiring to excellence.58 The challenge is deceptively simple: Can each person in the workforce answer affirmatively to these three questions each day?

Boards of trustees are usually unaware of these kinds of problems, often interpreting their fiduciary responsibility as limited to financial issues, although it is known that governing board priorities have significant impact on quality performance.51 Workforce injuries are often not visible to, or a top priority of, CEOs and other hospital leaders. At the same time, leaders are often unaware of or ill equipped to manage disruptive behavior. Budgeting processes could, but rarely do, make investments in worker safety a priority.52 By this omission of attention and action, leaders of health care organizations are unknowingly condoning and enabling unsafe behaviors and unsafe workplaces.

1.

Am I treated with dignity and respect by everyone, every day, in each encounter, without regard to race, ethnicity, nationality, gender, religious belief, sexual orientation, title, pay grade, or number of degrees?

2.

Do I have what I need: education, training, tools, financial support, encouragement, so I can make a contribution to this organization that gives meaning to my life?

3.

Am I recognized and thanked for what I do?

What can be done Despite the troubling data, there are US health care organizations in which the values of respect, teamwork, and transparency are prized, and in which health care providers operate freer from injury and experience their work as more meaningful. These institutions can serve as models for others wishing to improve. There is also a growing body of research that suggests how organizations may improve patient safety through increasing employee safety and restoring joy and meaning to the workforce.

Recent evidence supports the hypothesis that physician empathy is an important factor associated with clinical competence and patient outcomes. Some health care organizations have begun to provide psychologically safe environments for physicians to support one another in addressing the emotional tolls of their work, particularly when they make mistakes.53,54 An environment of mutual respect is critical for the workforce to find joy and meaning in work. Studies have shown the critical importance of teamwork in safe practice, and teamwork is impossible in the absence of respect.41,55 Failure of doctors or nurses to follow safe practices (hand hygiene, time outs, etc.) is a manifestation of lack of respect (for experts, authority, institutional aims) and is clearly hazardous.

Correlations exist between patient safety cultures and patient assessments of care as established by comparison of results from the Agency for Healthcare Research and Quality’s Survey on Patient Safety Culture (SOPS) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey.56 Both federal agencies and private foundations are heeding this wake-up call by supporting research to strengthen providers’ work environments in order to improve patient safety.57

Further, O’Neill asserts that until workplace safety and the safety of each person in the workforce is a collective priority, efforts to achieve the goal of respect and harmfree care will fall far short. Joy and meaning for the workforce is the foundational challenge; worker safety is the precondition.

Until all individuals in the workforce can answer yes to these questions, joy, meaning, and patient safety will not be realized.

Developing Effective Organizations Effective care requires effective organizations to deliver that care. The few organizations that have created respectful and supportive cultures have improved patient safety and reduced accidental workplace injuries.59 These are health care organizations that are becoming high-reliability organizations that are characterized by continuous learning, improvement, teamwork, and transparency.23,60 High-reliability organizations (HROs), or high reliabilityseeking organizations (HRSOs), are organizations in hazardous industries that have succeeded in eliminating harm to their workforce and consistently achieve high performance in safety. HROs combine attributes that seem contradictory and hold them in productive tension: they are centralized and decentralized, hierarchical and collegial, rule-bound and learning-centered.61 HROs use time-tested safety practices with newer approaches to keep safety and reliability a conscious, heedful set of actions. All team members have a mature understanding of the procedure as a whole and their role in it. Team members are responsible for constant communication with one another, watching and interacting to advise, detect, and act on any sign of trouble. They are continuously on the lookout for ways to improve, and they never take success or safety for granted. In highly reliable industries, no part of the organization is allowed to flounder while the other parts thrive.62 High-reliability organizations are organized to anticipate and manage the unexpected and exhibit five basic principles: a preoccupation with failure, a reluctance to

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CHAPTER 2.6 simplify interpretations, a sensitivity to operations, a commitment to resilience, and a deference to expertise.63 Through these, they create an error-tolerant culture in which errors are the catalyst for investigating and addressing systemic failures. In such a culture, errors are acknowledged, but violations of formal rules are not tolerated.64 Multidisciplinary teamwork is integral to the creation of a safe environment, and open communication, without threat of negative repercussion, is integral to teamwork. In such an environment, the safety of the workforce is paramount.

The introduction of HRO performance in health care is emphasized in the Institute of Medicine’s recently issued report Best Care at Lower Cost, which calls on health care organizations to become learning organizations and pursue high reliability.65 The Joint Commission has also recently called on health care organizations to become HROs.66 Fulfilling the Preconditions Effective organizations are those that care for their employees, are committed to reliability, and continuously meet preconditions. A precondition is an enduring requirement that is not subject to annual priority and budget setting. The most fundamental of these is workforce safety. Studies have correlated employee safety and patient safety and have demonstrated how organizational climate impacts workers’ health.67–71 Other high-risk industries have found that an organizational climate of safety and workers’ perception of it are aligned with better safety outcomes.72–74 When health care organizations provide programs aimed at improving worker health and safety—such as employee wellness programs, influenza vaccinations, safe instrument and sharps handling, and devices for lifting—patient outcomes improve and workers feel cared for and safer.75 The Occupational Safety and Health Administration (OSHA), the National Institute for Occupational Safety and Health (NIOSH), and The Joint Commission (TJC) have researched, developed, and promoted best practices for managing safety and aligning patient safety with workforce safety.

In addition, physical safety measures put in place over the years have been informed by federal and state regulatory action, including the federal Needlestick Safety and Prevention Act, passed in 2000, and safe patient handling laws implemented at the state level, which require lifting procedures and equipment. But the importance of the psychological safety of the workforce has not been met with the same attention and focus. Psychological safety that allows and encourages workers to report near misses and errors, and an unwavering intolerance for deliberate unsafe acts by individuals (disrespectful behavior included) are fundamental characteristics of an organizational safety culture.

The workforce needs to know that safety, psychological and physical, is a precondition that is an enduring and non-negotiable priority for the governing board, CEO, and organization.

Creating the culture Exemplar organizations (in health care as well as in other industries) offer important principles and practices for transforming the workplace. Case studies of exemplar organizations demonstrate that in order to correct problems regarding respect, civility, engagement, and worker safety, hospitals and other health care organizations need to have strong policies and provide training about conduct, reporting, and response to problems. Governing boards need to take responsibility to review timely postings of data and stories, set objectives, and monitor progress.76 Health care organization boards and CEOs need to engage now to create cultures of safety and respect. Following are examples of some that have successfully done so.

Kaiser Permanente and the Coalition of Kaiser Permanente Unions, which represents 92,000 union employees, worked with five bargaining subgroups to create the 2012 National Agreement that built on historic success and partnership.

Aspects included worker health and well-being, improving partnership, workforce of the future, and a better model for problem solving. The Health and Wellness Agreement focuses on a work environment that eliminates the risk of injury and illness and is one where people feel free and safe to report problems and errors. It also includes workplace safety plans, goals, and measures to track progress. The agreement stresses interest-based problem solving through inclusive workforce teams wherein respect is a grounding principal.77–79 The Mayo Clinic has built its Model of Care on the principles of teamwork, collegiality, professionalism, mutual respect, and a commitment to progress. The program includes training on confidential disclosure of errors to peers, examination of legal and ethical dilemmas, and observed structured clinical encounter (OSCE) simulation exercises addressing patient communication scenarios.80 Virginia Mason Medical Center (VMMC) enters into twoway compacts with physicians, leaders, and board members that detail reciprocal responsibilities.81 VMMC has also pursued other organization-wide culture changes, shifting from a physician-centered perspective to one that is patientcentered.82 They transformed themselves through adoption of the Virginia Mason Production System based on the Toyota Lean model. The Toyota model is characterized by transparency, standard work, and learning, where failures become productive means by which to improve. In an errortolerant culture such as Virginia Mason’s, organizations embrace best-practice methods that are at the heart of

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THROUGH THE EYES OF THE WORKFORCE HROs: awareness of system complexity, blameless reporting, accountability, and multidisciplinary participation in identifying risks and solutions.83 In 2008, New York City Health and Hospitals Corporation (HHC), the largest public hospital system in the United States, recognized the value of teamwork and began implementing Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPS®). The evidence-based teamwork system aims to optimize patient outcomes by improving communication and teamwork skills. At HHC, TeamSTEPPS has led to improved patient and employee safety, more frequent and positive staff interaction, and workforce empowerment.84,85 Hospital Corporation of America (HCA) developed an Employee Safety and Security initiative to reduce job-related injuries and illnesses and promote a culture of safety and respect. Employee roles and responsibilities are clearly defined at all levels of the organization, surveillance rounds are conducted to identify hazards, and near-miss events are reported in a timely fashion, followed by prompt, thorough investigations and focused training for staff and leadership.

Investments in exterior lighting, equipment, and security measures that help employees and patients feel safer and reduce the risk of violence have been made in response to employee engagement surveys.

There are also programs and initiatives that organizations can adopt and encourage their workforces to explore. The Healer’s Art courses, used in medical schools and hospitals across the country, offer a curriculum for students and physicians to share experiences and beliefs related to service, healing relationships, and compassionate care that lead to personal and professional meaning in their work.86 Schwartz Center Rounds offer the health care workforce dedicated time to share emotional and social issues, experiences, and responses related to their care for patients, promoting empathy and insight, and allowing for more personal connections with patients and colleagues.87 Dr. Jon Kabat-Zinn’s Stress Reduction Program, created in 1979, advises individuals on how to use inherent resources and abilities to manage stress, pain, and illness.88 Nurses in organizations that pursue excellence and achievement awards report higher job satisfaction rates and view their work environments as more healthy than those in organizations that do not participate in such programs and initiatives.89 Magnet status is awarded by the American Nurses Credentialing Center (ANCC) to hospitals where nursing staff meet measures in quality of care, report overall satisfaction in their jobs, and are involved in decision making related to patient care delivery, among other things.90 These factors, combined with low turnover rates and feelings of being valued, are believed to create the best patient outcomes and work environment. The Beacon Award recognizes organizations that implement processes, procedures, and systems to support excellence and remove

barriers. It acknowledges that frontline and front office collaboration lead to a supportive work environment, low turnover, and higher morale, which in turn result in positive patient outcomes and satisfaction with care.91 The University of Missouri Health Care System has deployed a “second victim” support team, embedded in every high-risk clinical area, to help identify clinicians involved in serious errors (second victims), provide realtime support and counseling, and refer them for ongoing counseling if appropriate.92 Importantly, this process takes place independently of any incident investigation. Programs like this help prevent the long-term stigma and trauma that many clinicians feel after being part of a significant medical mistake.

Pursuing habitual excellence Workplace preconditions of respect and safety, in which the well-being of every person is a priority, create the conditions for the workforce to habitually pursue excellence.

Meaningfully engaged members of the workforce deliver more effective and safer care, are more satisfied, are less likely to experience burnout, and are less likely to leave the organization or the profession. They are more likely to go beyond the call of duty, consistently exhibit citizenship behaviors, and be patient-centered, leading to greater patient satisfaction.93–96 The opposite is more likely when the workforce is unable to derive meaning from their work and seek meaning away from the workplace.97,98 Workplace conditions, physical and psychological, are integral to achieving the cultural change for patient safety, which includes transparency, integration, patient engagement, and learning.23,99 Successful health care organizations are learning organizations that model professionalism, collaborative behavior, and transparency, and value the individual learner.

Leaders, as part of the workforce, model the way forward, displaying the interpersonal skills, leadership, teamwork, collaboration, and compassion that other workers can emulate.100 This learning culture teaches all members of the workforce to identify patient safety problems, improve patient care processes, and effectively deliver care. The longterm intent is that these skills, attitudes, and behaviors become an integral part of the professional way of life for all members of the workforce. In such an environment, all are teachers, and all are learners.

Conclusion The health care workforce is at risk. As long as conditions persist that compromise the physical and psychological health of the workforce, progress in patient safety is also at risk, and the pace of progress will continue to be slow. We believe the principles for advancing patient safety apply to workforce safety and require the same discipline. Joy and

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CHAPTER 2.6 meaning will be created when the workforce feels valued, safe from harm, and part of the solutions for change. The data regarding the current state is jarring and sobering; however, there are stories of successes that are hopeful.

Through the Eyes of the Workforce is intended to present the current state in health care, create urgency for action, and point the way forward for the future. The common purpose that unites the health care workforce is the commitment to protect human dignity, relieve suffering, and promote health. The ability to serve others, regardless of role, is estimable work, filled with meaning. Honoring and respecting the health care workforce by protecting their physical and psychological safety is transformational. A transformed workplace, in a culture of respect, creates joy and meaning for safer health care.

Recommendations: What are the seven things that an organization must do?

For organizations to create joy and meaning in the workplace, the entire workforce must make a commitment to treat each other with civility and respect, to be transparent in reporting errors and unsafe conditions, to adhere to known safe practices, and to be part of the problem-solving team.

This commitment requires leadership, strategy, and discipline. The LLI Roundtable on Joy and Meaning in Work and Workforce Safety recommends the following seven strategies.

Strategy 1 Develop and embody shared core values of mutual respect and civility; transparency and truth telling; safety of all workers and patients; and alignment and accountability from the boardroom through the front lines.

Core values should be developed through an inclusive process, led by the governing board, the CEO, and organizational leaders, that engages the full workforce and defines these values through behavioral examples.

The statement of core values should be disseminated throughout the organization through a shared, collegial process. Application of core values needs to be evident in management and leadership decision making and practices.

Leaders need to ensure that core values are preconditions and therefore are not negotiable or prioritized against the demands of production, costs, and competing programs.

Strategy 2 Adopt the explicit aim to eliminate harm to the workforce and to patients.

Leaders must believe and communicate to the workforce that preventing harm to the workforce and to patients is achievable. Events that harm members of the workforce or harm patients must be made transparent and seen

as the raw material for improvement. Evaluate how the organization approaches workforce safety and define it as a marker for organizational culture. Set aspirational goals at the theoretical limit of what is possible (zero defects), pursue with insistence and persistence, and systematically remove all barriers and excuses as to why excellence is not possible every day.

Strategy 3 Commit to creating a high-reliability organization (HRO) and demonstrate the discipline to achieve highly reliable performance. This will require creating a learning and improvement system and adopting evidence-based management skills for reliability.

The governing board, the CEO, and organizational leaders must declare and broadly communicate that a new story involving respect, teamwork, safety, joy, and meaning needs to be created. They need to engage the workforce in conversations related to connections between respect, workforce safety, and patient safety. Personal accountability and responsibility for change must be accepted across the organization.

Leaders need to systematically implement practices of HROs, emphasizing evidence-based management skills for reliability, reporting, communication, teamwork, and training. They need to provide resources, such as debrief, assistance and wellness programs, training and coaching in disclosure and apology after adverse events, and peer support programs for second victims.

Strategy 4 Create a learning and improvement system.

Local improvement systems must be created to empower change. Post measures of reliability and resilience, publish regular performance reports, and provide access to data.

Ensure staff are provided resources to understand the data and use it to make decisions and set goals. Change the mode of thinking from assigning blame to solving a problem, using structured tools and methodology. This should occur at local (microsystem) and organization-wide (macrosystem) levels of the organization.

Strategy 5 Establish data capture, database, and performance metrics for accountability and improvement.

The CEO and leaders need to engage workers and patients in the design of processes and measures of effectiveness through a defined and structured method, including standard measures of joy and meaning. They must establish safe reporting systems for workers to express concerns about threats to workforce psychological or physical safety and also use validated safety climate surveys to measure and report sociocultural measures. A risk and safety database must be established to detect and analyze patterns and leverage points for change.

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THROUGH THE EYES OF THE WORKFORCE Strategy 6 Recognize and celebrate the work and accomplishments of the workforce, regularly and with high visibility.

The governing board, CEO, and organizational leaders should ensure that core values of respect and compassion are incorporated into performance reviews and are rewarded. They should incorporate testimonials and storytelling into organizational meetings regarding safety improvements and “good catches” where vigilance prevented harm, and regularly publish and disseminate the work of teams in creating greater reliability and safety.

Institutions should create appreciation days, service awards, and other traditions that honor and celebrate the workforce.

Strategy 7 Support industry-wide research to design and conduct studies that will explore issues and conditions in health care that are harming our workforce and our patients.

Commission cross-sectional studies of workforce and patient safety to determine leverage points for systemic change, and engage researchers to study applications used in other high-risk industries. Conduct studies to determine the effects of patient and family engagement on the workforce and patient safety, and investigate cultural foundations of workforce and patient safety.

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60. Weick KE. Organizational culture as a source of high reliability. Calif Manag Rev. 1987;29(2): 112–127. http://www.itn.liu.se/mit/education/ courses/tnfl05-risk-och-olycksanalys/vecka-48/1.305709/Weick1987. pdf Accessed Jan 4, 2013.

61. Morath JM. The Quality Advantage: A Strategic Guide for Health Care Leaders. Chicago, IL: AHA Press; 1999:59–64.

62. Kenney C. The Best Practice: How the New Quality Movement Is Transforming Medicine. New York: Public Affairs–Perseus Books; 2008:97.

63. Weick KE, Sutcliffe KM. Managing the Unexpected: Resilient Performance in Age of Uncertainty. 2nd edn. Jossey-Bass; 2007.

64. Morath JM, Turnbull JE. To Do No Harm: Ensuring Patient Safety in Health Care Organizations. Jossey-Bass; 2005:111.

65. Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Committee on the Learning Health Care System in America, Institute of Medicine. Washington, DC: National Academies Press; 2012.

66. Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood). 2011;30(4):559– 568.

67. Clarke SP, Sloane DM, Aiken LH. Effects of hospital staffing and organizational climate on needlestick injuries to nurses. Am J Public Health. 2002;92(7):1115–1119.

68. Piirainen H, Räsänen K, Kivimäki M. Organizational climate, perceived work-related symptoms and sickness absence: a populationbased survey. J Occup Environ Med. 2003;45(2): 175–184.

69. Etchells E, Lester R, Morgan B, Johnson B. Striking a balance: who is accountable for patient safety? Healthc Q. 2005;8(Spec No):146–150.

70. Castle NG, Engberg J, Mendeloff J, Burns R. A national view of workplace injuries in nursing homes. Health Care Manage Rev. 2009;34(1): 92–103.

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72. Morrow SL, McGonagle AK, Dove-Steinkamp ML, Walker CT Jr, Marmet M, Barnes-Farrell JL. Relationships between psychological safety climate facets and safety behavior in the rail industry: a dominance analysis. Accid Anal Prev. 2010;42(5):1460–1467.

73. Probst TM, Estrada AX. Accident under-reporting among employees: testing the moderating influence of psychological safety climate and supervisor enforcement of safety practices. Accid Anal Prev.

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74. Zohar D, Luria G. A multilevel model of safety climate: cross-level relationships between organization and group-level climates. J Appl Psychol. 2005;90(4):616–628.

75. Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long- term care: a randomised controlled trial. Lancet.

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76. Institute for Healthcare Improvement. Leadership Guide to Patient Safety: Resources and Tools for Establishing and Maintaining Patient Safety. Boston, MA: IHI; 2005.

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79. Buffa A. KP and coalition unions reach tentative 2012 National Agreement. LMP Bargaining 2012. 2012(May 11). http://

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THROUGH THE EYES OF THE WORKFORCE

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Miller D. Are your leaders, doctors and board members aligned with your organization’s mission? Virginia Mason Blog. 2012(Jun 13). http://virginiamasonblog.org/2012/06/13/are-your- leaders-doctorsand-board-members-aligned-with-your-organizations-mission/ Accessed Dec 27, 2012.

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Edmondson A. Strategies for learning from failure. Harv Bus Rev. 2011;89(4):48–55.

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92. Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010;36(5):233–240.

93. Laschinger HK, Almost J, Tuer-Hodes D. Workplace empowerment and magnet hospital characteristics: making the link. J Nurs Adm. 2003;33(7–8):410–422.

94. Reed DA, West CP, Mueller PS, Ficalora RD, Engstler GJ, Beckman TJ. Behaviors of highly professional resident physicians. JAMA. 2008;300(11):1326–1333.

95. Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care.

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97. Rosenstein AH, O’Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006;203(1):96–105.

98. Kansagra SM, Rao SR, Sullivan AF, et al. A survey of workplace violence across 65 U.S. emergency departments. Acad Emerg Med. 2008;15(12):1268–1274.

99. Hannah KL, Schade CP, Lomely DR, Ruddick P, Bellamy GR, Henriksen K, Battles JB, Keyes MA, Grady ML. Hospital administrative staff vs nursing staff responses to the AHRQ Hospital Survey on Patient Safety Culture. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville, MD: Agency for Healthcare Research and Quality; 2008.

100. Dutton JE, Frost PJ, Worline MC, Lilius JM, Kanov JM. Leading in times of trauma. Harv Bus Rev. 2002;80(1):54–61, 125. http://webuser. bus.umich.edu/janedut/Compassion/leadingintimes.pdf Accessed Jan 4, 2013. © 2013. National Patient Safety Foundation. Reproduced with permission.

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SECTION 3

TOOLS THAT CAN HELP

Over the past few years the QNU has produced a number of publications and documents to support nurses and midwives as they endeavour to create better workplaces.

In this section we reproduce a selection of that material which may help you understand the power nurses and midwives can harness if they work together, and offers you examples of how nurses and midwives can be great workplace leaders.

This material also provides you with some of the tools and frameworks you can use to bolster your own efforts to improve and manage workplace health and safety. The BPF section is particularly useful in this regard.

You can find more resources on the QNU website under the â&#x20AC;&#x2DC;Your Workâ&#x20AC;&#x2122; tab.

CHAPTER 3.1

WORKPLACE HEALTH AND SAFETY REPRESENTATIVES QNU Information Sheet OH&S Series, November 2012

While nurses and midwives at every level can, and indeed should, be working to maintain a safe and healthy workplace, stepping up to the role of a workplace health and safety representative is a great way to show leadership in an official capacity. This article, drawn from a QNU information sheet, explains what a HSR does and how they can work with their colleagues and management to create safe workplaces.

Consultation between a Person conducting a business or undertaking (PCBU) and workers is essential. Under the Work Health and Safety Act 2011 (the Act) PCBUs (generally employers) have an obligation to consult with workers and their representatives.

■■ The views of workers are taken into account, and ■■ Workers are advised of the outcome of any consultation

To make consultation more effective, workers at a workplace are able to elect health and safety representatives (HSRs) to represent their interests and express their views to the employer. Health and safety committees provide a forum through which consultation and communication can occur.

Workers can elect anyone who is a worker at the workplace to be their HSR. A worker does not need any special qualifications or experience to be elected.

What is a health and safety representative?

A HSR is a worker elected by co-workers to represent their views on health and safety matters in the workplace.

Employers cannot choose the HSR—the person must be elected by workers.

Why do you need HSRs? By electing a co-worker to be their representative, workers can have a say in decisions about health and safety. HSRs are an important link between workers and employers. They make consultation on workplace health and safety issues easier and more effective.

What is consultation?

According to the Act: “Consultation requires:

■■ Relevant work health and safety information is shared ■■ ■■

with workers.

Workers are given a reasonable opportunity to express their views and to raise health or safety issues.

Workers are given a reasonable opportunity to contribute to the decision-making process relating to the health and safety matter.

in a timely manner.

Can anyone be a HSR?

Once they are elected, training will help HSRs perform their role. Information about training courses is available from the QNU. The HSR is entitled to attend prescribed training and to have all reasonable costs met by the employer.

There is also provision for deputy HSRs to be elected to provide representation when the HSR is unavailable.

How are HSRs elected?

Any worker or group of workers can ask the PCBU to set up a work group at one or more workplaces for the purpose of electing a HSR. A work group is a group of workers who share a similar work situation (for example, workers performing similar work, in the same section or on the same shift). If agreed, workers from multiple areas can be part of the same work group. If a request is made for the election of a HSR, a PCBU must start negotiations with workers within 14 days.

Negotiations between a PCBU and workers determine:

■■ the number and composition of the work group(s) ■■ the number of HSRs and deputy HSRs ■■ the workplace(s) to which the work group(s) apply.

A PCBU must negotiate the formation for a work group with a union if asked by a worker. The PCBU must also notify workers as soon as practicable of the outcome of the negotiations.

At any time, the parties to a work group agreement may negotiate a variation.

HEALTH AND SAFETY 2014 ■ 63

CHAPTER 3.1 If negotiations fail to establish a work group, or fail to agree about varying a work group agreement, any person who is a party to the negotiations can ask an inspector to help in deciding the matter.

Training

Workers can organise the election themselves. However, employers must help if workers ask them to do so. Workers can also ask their union to hold the elections. If the union does this, the election must be for all workers and not just those workers who are members of the union.

The training must begin within three months of the request and the HSR given paid time off to attend the course.

The PCBU is also required to pay the course costs and reasonable expenses.

For how long do HSRs hold the position?

Workers elect HSRs for a three year period. At the end of that period, the HSR may be reelected.

A worker stops being a HSR if they stop working at the workplace or if they resign from the position of HSR.

What does a HSR do?

A HSR is entitled to:

■■ inspect the workplace or any area where work is carried ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■

out accompany an inspector during an inspection be present at an interview with a worker that the HSR represents (with their consent) and the PCBU or an inspector request that a health and safety committee be established monitor compliance measures by the PCBU represent the work group in OHS matters investigate complaints inquire into any risk to the OHS of workers in the work group issue provisional improvement notices (PINs)— Please note a separate information sheet is available dealing with PINs.

If requested a PCBU must allow HSRs and deputy HSRs to attend an approved OHS training course approved by Workplace Health and Safety Queensland.

The QNU can assist members who are having difficulty assessing training.

In mid-2014 the QNU received approval from Work Safe to conduct accredited training for workplace Health and Safety Representatives (HSRs) as specified in the Work Health and Safety Act 2011.

The courses will be open to elected health and safety representatives and deputy health and safety representatives The courses will cover the basic knowledge and skills needed by elected health and safety representatives and deputies (HSRs) to exercise their powers and entitlements as specified in the Work Health and Safety Act 2011.

HSRs will gain an understanding of the objectives of the legislation, knowledge of their role under the legislation, skills in representing workers, the role of health and safety agreements, compensation and rehabilitation, skills in identifying workplace health hazards and the processes by which they can be controlled, and practical skills in undertaking workplace inspections.

At the time of going to print, dates and locations for the training had not yet been confirmed.

For information on upcoming courses contact QNU’s Training Unit on (07) 3840 1431 or toll free on 1800 177 273.

Are HSRs personally liable?

A HSR carrying out their role is not personally liable for action or inaction, so long as the HSR acted in good faith.

© 2012 Queensland Nurses’ Union.

64 ■ HEALTH AND SAFETY 2014

CHAPTER 3.2

POWER THROUGH THE BPF: IT’S ALL ABOUT PATIENT SAFETY QNU’s BPF Kit, July 2013

One of the most powerful things nurses and midwives can do in their workplace is to stand up for patient safety. Taking control of workloads is an essential part of this. Nurses and midwives who are overworked or working outside their scope of practice are at risk of making mistakes. For nurses and midwives employed by Queensland Health the BPF (Business Planning Framework) is an excellent tool for taking control of workloads and protecting your patient’s safety. In the following chapter we look at a simplified version of the BPF and explain how you can use it in your ward or unit.

One of the biggest risks arising from the 2012-13 public sector job cuts in Queensland is unsafe workloads.

With reductions in the nursing and midwifery workforce, it is critical nurses and midwives take control of workloads both for the sake of patient safety and their own professional practice.

We must resist the pressure to do more with less.

The BPF is the industrially mandated tool which can give nurses and midwives the power to stand their ground on workloads and patient safety, even if they face pressure from line managers, employers and human resource personnel.

We also know we face threats to our career and classification structures.

These structures are fundamental to the integrity of today’s nursing and midwifery across all sectors and ensure we govern our own practice.

Using the BPF gives nurses and midwives a benchmark for appropriate skill mix. Used effectively it can ensure nurses and midwives are not working outside their scope of practice and are not being stretched to make up for inadequate staffing levels.

There is a real need for nurses and midwives to take control and stand their ground on workloads and skill mix—quite simply our patient’s safety and our professional integrity is at stake.

You have the power in your hands—it’s time to use it.

In a nutshell: What is the BPF? There has been a lot of talk and confusion about the Business Planning Framework (BPF).

get your head around. To begin with, BPF doesn’t sound like a nursing term. It sounds like a lot of paperwork and processes. But it’s really very simple.

It’s all about safety. It is a Workload Management Tool to keep you, your colleagues and patients safe. It is NOT a budgeting tool.

It’s an agreed way you can identify and resolve workload problems in your work environment.

There are steps you can take immediately /during shift, and an escalation process you can use to address longer term, ongoing unresolved workload issues.

We think it’s better to look at the BPF as a series of

FIVE SUPER SIMPLE STEPS using: ■■

B asics

■■

P rofessional

■■

F URTHER

It’s one of those terms you hear on the ward or in meetings but never have the time (or perhaps the inclination) to HEALTH AND SAFETY 2014 ■ 65

Judgement ACTION

CHAPTER 3.2

This is how it works…

Immediate/on shift

B

is for

Basics

At the beginning of your shift check the basics – ■■ Check the nurse : patient ratio notice for your ward. This is the minimum nurse to patient ratio as based on an average shift.

■■ Check the staff roster to determine staff numbers and skill mix ■■ Check the patient numbers and acuity

P

is for

PROFESSIONAL JUDGEMENT

In your professional judgment, is the nurse : patient ratio sufficient to safely manage the patient load?

In your professional judgment is the skill mix sufficient to safely manage the patient load?

Under the EB, your professional judgment is a valid way to assess safe workloads.

Your professional judgment can also be used to identify workload problems that might arise during your shift—an increase in presentations or an increase in the complexity of the cases might mean staffing levels or skill mix are no longer sufficient.

If at any time you believe patient safety is at risk, WHAT DO YOU DO? ... you take

F URTHER ACTION

F

is for

FURTHER ACTION

You can now turn to some tools and steps, developed as part of the BPF process, to support your judgment and to resolve or escalate your workload concern.

STEP 1 SPEAK UP Raise your workload concern with your NUM or nursing line manager

problem is out of line with Queensland Health, your EB and the QNU.

STEP 4 CONTACT

Tool: Use the notional Nurse : Patient Ratio to support your professional judgment

You should contact your QNU Organiser or Workplace Rep to report workload issues as soon as possible.

Tool: Use your Workload Reporting Form to formally record your workload issue

All Workload issues should also be reported to your Nursing and Midwifery Consultative Forum (NMCF) for tracking purposes whether the issue is resolved or not.

STEP 2 TAKE ACTION If there are no extra staff available, if your NUM or nursing line manager cannot resolve your insufficient staffing level or skill mix—you should act immediately to ensure the safety of your patients.

Tool: Use the Workload Priority List to prioritise work—this means you will set aside non-essential work to allocate more time to essential clinical duties. You and your colleagues should complete a priority list and post it up in your ward. Safety is the key to making decisions.

Tool: In addition to prioritising, you may also close beds. QNU has a Bed Closure Notice you can use to identify closed beds.

At this point your NUM/nursing line manager is responsible for escalating the workload issue.

STEP 3 KEEP AT IT! If your line manager indicates there is no staff available, you can request they escalate the issue to their line manager.

You should also advise them you will continue to take action (priority list etc) on the grounds of patient safety.

You should continue to lodge workload reporting forms and prioritise work— whether it be clinical or non-essential clinical work—until the issue is resolved.

It is at this level where you are most likely to get resistance from management.

Don’t give in! It is your patient’s safety and your own professional career at risk!

Remember, the BPF has been developed and signed off by Queensland Health and the QNU and applying it to your working life is both encouraged and expected as part of your EB Agreement.

Anyone in authority who ignores, refuses to address a workload

66 ■ HEALTH AND SAFETY 2014

STEP 5 GET IT IN WRITING If senior staff, including your employer puts pressure on you to reopen beds, or withdraw your priority list while the workload problem still exists, ask for their request in writing and ask them to record your objection on the grounds of patient safety.

They may tell you they are giving you a lawful direction you cannot refuse. We disagree. Patient safety trumps all. You can respond by saying you are acting lawfully in accordance with your certified agreement.

You are not alone— the QNU can help ■■ Your union can assist you with prioritising tasks / closing beds ■■ Your union can assist you in dealing with management ■■ Your union can assist you with escalating your issues – particularly if they are ongoing.

If your NUM or line manager can’t fix the problem they must advise their nursing line manager at which time a QNU official may become involved.

THE ESCALATION PROCESS… FOR ONGOING ISSUES If your NCF can’t fix the problem it must be referred to a BPF Specialist Panel. If the Specialist Panel fails to resolve the issue, it can be taken to the Queensland Industrial Relations Commission.

There is a comprehensive grievance process in place for this as part of the BPF.

POWER THROUGH THE BPF

BPF FAQs: Your questions answered

Workload management for Private Hospital and Aged Care members

How do I report a workload issue when I believe safety might be compromised?

■■ Speak to your NUM/MUM/line manager, provide

■■ ■■ ■■

reasons for your concerns based on your professional judgement and request immediate action. You can do this under Clause 4.10 .10 (a) of your Award.

Complete the Workload Reporting Form and send a copy to your QNU organiser. You should also provide a copy to your line manager.

If the line manager cannot resolve the matter at the ward level, then escalate the matter to the relevant senior nurse (Gr 9 or above) to address.

Refer the matter to the Nursing and Midwifery Consultative Forum (NMCF) so the nursing seniors and your representatives can negotiate the necessary steps to maintain safe workloads in the future.

As it is a public sector tool the Business Planning Framework does not apply to nurses and midwives working in Private Hospitals or the Aged Care sector.

Instead nurses and midwives outside the public system need to use alternative workload management and grievance processes.

If you are a private hospital nurse or midwife, an aged care nurse or you work in an unaligned facility such as the Australian Red Cross Blood Service, the best way to ensure action is taken on workload issues is to be active at your health facility and at a local level.

The QNU has also reporting forms you can use as follows:

I am being pressured not to lodge a workload reporting form, what should I do?

■■ Aged care members with a workload issue should complete the QNU Aged care workload reporting form which is to be lodged with the senior nurse on duty and the Director of Nursing.

■■ Advise the person pressuring you that – ■■ Patient safety is the priority and maintaining

■■ ■■ ■■ ■■

■■ Aged care members can also complete the Aged Care Staffing Reporting Form , which is an initiative of the QNU.

safe workloads is part of your professional responsibility.

■■ Nurses and midwives are required to exercise professional judgement regarding patient safety.

■■ The award provision for workload management recognises professional judgement, as a valid tool for determining workload issues and The workload management tool is an award provision and implementation is not discretionary.

Complete the Workload Reporting Form—send a copy to your QNU organiser.

Report this to your QNU representatives and your organiser directly.

Submit this matter as an agenda item for your NMCF.

■■ By completing this form aged care members are providing the QNU with accurate information to follow up on staffing issues.

■■ Private hospitals members with a workload issue should complete the QNU Professional workloads reporting form which is to be lodged with the senior nurse on duty and the Director of Nursing.

■■ Australian Red Cross Blood Service members with a workload issue should complete the QNU ARCBS workloads reporting form which is to be lodged with the senior nurse on duty and the Donor Centre Manager.

For more information about workload management and possible grievance processes call QNU Connect on (07) 3099 3210 or 1800 177 273 (toll free for members outside of Brisbane). You can also send an email to qnuconnect@qnu.org.au.

Remember, the workload reporting form is your record of the workload challenges you and your colleagues encountered on shift and is also a record of how you responded to these challenges. So:

■■ Lodge the Workload Reporting Form as a group or team ■■ ■■

of staff Report your issue to QNU Representatives and/or Organiser directly.

Ensure the matter becomes a workloads agenda item for NMCF

What if my NUM/MUM/line manager fails to address my workload issue?

■■ Complete the Workload Reporting Form—send a copy to your QNU organiser.

■■ During the shift, you and your colleagues need to prioritise activities to keep patients safe.

■■ Use the agreed Workload Low Priority List to document ■■

the low-priority work you will not complete on the shift in order to prioritise patient care.

Longer term: ■■ Escalate to the next level nursing senior – Gr 9 or above per (as per your Award, clause 4.10.10 (c)) ■■ Ensure the workload issue is referred to the NMCF (as per your Award, clause 4.10.10 (d)).

HEALTH AND SAFETY 2014 ■ 67

CHAPTER 3.2 My NUM/Nursing Director/DON has responded to my report of a workload issue, but has not addressed it to my satisfaction. What do I do?

■■ Continue to adhere to the Workload Low Priority List,

■■ ■■

which means documenting and agreeing to the work you will not complete in order to prioritise patient care – do this for each and every shift until your workload issue is satisfactorily resolved.

Ensure the issue is referred to the NMCF for resolution (as per your Award clause 4.12.11 (d)).

Seek assistance in escalating the matter to a Specialist Panel if the Hospital and Health Service is unable to resolve the issue. Your Organiser or QNU Representative can assist in making this referral (as per your Award clause 4.10.10 (d)).

What if my ward/unit does not have a notional Nurse : Patient ratio?

■■ Speak with your NUM/MUM/line manager and ask for ■■ ■■

the ratio to be displayed.

Complete the Workload Reporting Form—send a copy to your QNU organiser.

Notify your local QNU representatives and organiser that the ratios are not displayed.

I am told I am not allowed to close beds, what do I do?

■■ Advise the person instructing you that the agreed

■■

workload management tool allows for bed closure at the ward or unit level “in the context of the integrated bed management arrangements of the facility” (as per your Award clause 4.10. 7). Beds cannot be open if there is an insufficient number or mix of staff available to provide safe patient care.

Advise your NUM/MUM/line manager that beds need to be closed and request the relevant managers activate the facility’s bed management strategy.

■■ Phone QNU Connect for advice/support on 3099 3210 or 1800 177 273 (tollfree outside Brisbane)

My workload issue occurs on night shift / outside QNU’s regular office hours, how can I let my QNU organiser know there is a problem?

■■ You can and should take action on your shift if a

■■ ■■ ■■

workload issue exists. Use the QNU’s Workload Low Priority List to identify the tasks that will not be completed on your shift in order for you to prioritise patient safety.

Complete and send a copy of the Workload Reporting Form marked for the attention of the QNU Organiser.

Tell your Organiser about workload issues at your next meeting with them (such as your local branch meeting).

Call QNU Connect and leave a phone message if you need further assistance.

I work in a very small rural hospital with only two wards, does the BPF apply to me?

■■ Yes, application of the BPF in Queensland Health is not discretionary—it should be operational in all facilities

How can we apply BPF in specialty areas like ED and nonacute care community settings?

■■ The BPF can be applied to all facilities, including ED and ■■

■■

non-acute care community settings.

If a workload exists, you are still required to take action to ensure the safety of patients and nurses on each shift.

This may include not undertaking low-priority tasks that do not ensure the safety of patients. Your QNU representatives or organiser can assist you in identifying low-priority tasks that are unique to your circumstances.

Refer to the relevant BPF Addenda which address specialist and non-acute settings to develop the Service Profile.

What if my CEO / Manager is pressuring me to open beds and/or withdraw workload priority lists?

■■ Advise the person pressuring you that: ■■ Patient safety is the priority and maintaining safe

■■ ■■

workloads is part of your professional responsibility ■■ Identify what resources you need to safely re-open beds and wait until you receive additional resources before you make beds available.

Complete the Workload Reporting Form—send a copy to your QNU organiser.

Report this to your local QNU representatives and organiser directly.

Can QNU organisers or workplace representatives help me if a workload issue arises during shift?

■■ Yes, contact your local representatives or organiser to discuss the steps and make a plan.

© 2013 Queensland Nurses’ Union.

68 ■ HEALTH AND SAFETY 2014

CHAPTER 3.3

BEING SAFE AT WORK Excerpt from: QNU (2014), Nurses and the Law, Chapter 8

This section, taken from the QNU’s Nurses and the Law publication for 2014 can help you get a handle on your health and safety rights and obligations under the law, with a particular focus on workplace violence and your role in maintaining a safe working environment.

Everyone—nurses and midwives, patients, members of the public and other staff—has the right to work in an environment where they are protected from aggressive behaviour.

injuries compensation for an assault. You may also be able to bring a claim for compensation for the common laws tort of trespass to person. You should contact the QNU in these circumstances for advice.

Unfortunately, violent and aggressive behaviour has been a part of working in health care settings for some time.

Some areas of nursing and midwifery are more likely to face aggressive patient behaviour than others. Nurses and midwives may also be faced with violence or aggression from family members or friends of patients. There is evidence to suggest that higher levels of aggression are becoming more common in the workplace. Because of their frontline role in health care, nurses and midwives are, unfortunately, often the target of violence and aggression.

Nurses and midwives who attempt to ‘take the law into their own hands’ run the risk of engaging in criminal conduct themselves or make themselves liable to civil claims for a trespass to person. Trespass to person includes assault, battery and false imprisonment. Trespass to person requires direct and unlawful interference of the person by another without their consent. An action for trespass to person does not require proof of damage (compare this with an action in negligence which requires proof that the defendant caused damage). Consent is important to this area of law because where there is consent there is no trespass to the person.

The QNU supports the rights of members to work in an environment that is free from aggression and violence.

Aggression and violent behaviour, including verbal threats, intimidation and harassment, should not be tolerated in any workplace.

Your employer has a duty to provide a safe place and system of work for the health and safety of you, the employee.

You are able to refuse to work, or continue to work, if you are confronted with an imminent or immediate serious workplace health and safety risk from a hazard until action is taken by your employer to remove or minimise the risk.

The employer is required to consult with you on how this is done.

A number of legal consequences can arise when aggression occurs.

Criminal assault If a nurse or midwife has been a victim of an assault they are able to make a complaint to the police. The police may then charge and prosecute the perpetrator of the assault. There are a range of different criminal offences that arise from aggressive or violent behaviour.

As a nurse or midwife you cannot personally prosecute a person who has criminally assaulted you; this is solely the responsibility of the police. You may be able to seek criminal

In Queensland the criminal law is codified, which means it is set out in legislation. The criminal law definition of assault is also used as the basis for an action under the civil law for assault.

Criminal Code Queensland Section 245 of the Criminal Code Act 1899 provides that: A person who strikes, touches, or moves, or otherwise applies force of any kind to the person of another, either directly or indirectly, without their consent or with their consent if the consent is obtained by fraud, or who by any bodily act or gesture attempts or threatens to apply force of any kind to the person of another without their consent, under such circumstances that the person making the attempt or threat has actually or apparently a present ability to effect their purpose, is said to assault that other person, and the act is called an assault.

The term ‘applies force’ includes the case of applying heat, light, electrical force, gas, odour, or any other substance or thing whatever if applied in such a degree as to cause injury or personal discomfort.

The Criminal Code definition of assault includes battery— that is, assault is defined as threats as well as acts violence.

HEALTH AND SAFETY 2014 ■ 69

CHAPTER 3.3 Defences to an action in assault There are several defences to an action in assault including where:

■■ any apparent threat or physical contact was unintended or an accident

■■ the situation was an emergency, and measures used were ■■ ■■ ■■

to save life or health the action taken was in self defence when faced with imminent danger and no more force than necessary was used prevent the danger the action taken was for the protection of another person (including the victim) and/or property, from danger, by use of no more force than was reasonably necessary there exists a statutory power to do so in an emergency.

In addition, a health practitioner has a defence to an assault where it involves treatment, provided that at the time the treatment was given there was an emergency situation, that is, the treatment was necessary to save life or to prevent serious injury to a person’s health.

Nurses and midwives should be aware that a number of statutes authorise assaults or imprisonment which would otherwise be unlawful in the absence of a person’s consent.

If the requirements set out in the statute are followed by the person nominated as having the authority, then nurses and midwives assisting them or acting under their authority will generally also have a defence. For example:

■■ giving a blood transfusion to a child in cases of imminent peril [S 20 Transplantation and Anatomy Act 1979]

■■ the detention and examination of persons suspected ■■ ■■

of suffering from, or exposed to, a notifiable disease [Health Act 1937] the detention and examination of persons involuntarily under the provisions of the Mental Health Act 2000 the provision of reasonable palliative care, in good faith and with reasonable care and the palliative care is ordered by a doctor [s.282A Criminal Code].

Refusal of treatment in an emergency An adult person of sound mind may refuse emergency treatment. It is an assault to initiate or continue treatment once a person has refused consent.

Victim Assist Queensland Since 1 December 2009, victims of crime are no longer entitled to apply for criminal compensation either from the offender or the Queensland Government through the ex gratia compensation scheme. A new scheme known as Victim Assist Queensland, administered by the Department of Justice and Attorney-General, has been introduced to allow victims of crime to access the following:

■■ financial assistance (for medical assistance and loss of ■■

earnings) support services, i.e. counselling

■■ practical support during court proceedings ■■ victim complaint resolution processes.

The new scheme is designed to assist victims of crime to recover from the effects of crime. It also provides assistance to relatives of victims and witnesses to serious acts of violence.

Members are encouraged to contact the QNU for further advice and assistance regarding their rights and eligibility.

Workplace health and safety The health and safety of workers in Queensland is governed by the Work Health and Safety Act 2011 and the Work Health and Safety Regulation 2011. Additionally, a number of Codes of Practice, which provide advice around hazards common to an industry, can be used in proceedings under the Act. An example is the Manual Tasks – Involving the Handling of People Code of Practice 2001. The objective of this legislation is to prevent a person’s death, injury or illness being caused by a workplace, by work activities or by specific high risk plant.

Under the Work Health and Safety Act 2011 a worker is defined as one who carries out work in any capacity for a person conducting a business or undertaking. Additionally a person may be a worker even if the worker is not paid, therefore in certain circumstances volunteers are protected by this legislation. The workplace itself is any place where work is performed by a worker or a person conducting business or undertakings. This means a nurse or midwife’s workplace could range from a hospital to a patient’s home if they are being nursed there.

An employer has an obligation under Section 19 of the Act to ensure, as far as reasonably practicable, that they, their workers or other persons are not exposed to risks to their health and safety arising as a result of the employer’s business or undertakings.

In Queensland an employer will minimise their risks of breaching this obligation if they adhere to the various practices set out in the Work Health and Safety Regulation 2011, and/or follow a risk management process. The How to Manage Work Health and Safety Risks Code of Practice 2011 clearly states what is required. If a hazard is present in a workplace and is not covered by regulation or a code of practice and an employer has not used the risk management process they may be in breach of the Act. In that case, they could be prosecuted by Workplace Health and Safety Queensland, the government body established to manage workplace health and safety in Queensland.

A worker’s obligation under s.28 of the Act are to :

■■ take reasonable care for his or her own health and safety; and

■■ take reasonable care that his or her acts or omissions do not adversely affect the health and safety of other persons; and

70 ■ HEALTH AND SAFETY 2014

BEING SAFE AT WORK

■■ comply, so far as the worker is reasonably able, with

■■

any reasonable instruction that is given by the person conducting the business or undertaking to allow the person to comply with the Act; and co-operate with any reasonable policy or procedure of the person conducting the business or undertaking relating to health or safety at the workplace that has been notified to workers.

They must also not wilfully or recklessly place at risk the workplace health and safety of themselves or others.

Therefore, if they are given a direction that they know will put themselves at risk and the employer is unwilling to reconsider the direction, they should raise the issue with their health and safety representative and with the QNU. In Queensland workers have a right to elect health and safety representatives. These representatives cannot be appointed by the employer. Should workers choose, they can ask for their union to assist with the election process.

The Health and Safety Representative (HSR) has a number of entitlements under Sections 68, 72 and 85 of the Act, ranging from the ability to perform inspections through to the right to attend workplace health and safety representative training. Another entitlement under the Work Health and Safety Act includes an ability for a HSR to issue Provisional Improvement Notices (PINs) in circumstances where a HSR believes there is a contravention of a provision of the Act. A HSR is elected for a period of three years.

In Queensland it is an offence under the Act to dismiss or otherwise act to the detriment of a worker who has made valid complaints regarding their health and safety, or those workers who are health and safety representatives and are carrying out their role. Part 6 of the Work Health and Safety Act 2011introduces protections for workers and others to prevent them from being subjected to discriminatory conduct for raising workplace safety concerns.

What is prohibited?

Section 104 of the Work Health and Safety Act 2011 provides that a person conducting a business or undertaking (“PCBU”) must not engage in discriminatory conduct for a prohibited reason. Discriminatory conduct is:

■■ ■■ ■■ ■■ ■■ ■■ ■■

Dismissing a worker.

Terminating a contract for services.

Putting a worker at his or her detriment.

Altering the position of the worker.

Refusing or failing to offer to engage a prospective worker.

Terminating a commercial arrangement with a person.

Refusing or failing to enter into a commercial contract with another person.

“Prohibited reasons” are as follows:

■■ A person is, has been or proposes to be an Health & Safety Representatives (“HSR”).

■■ A person exercises power or performs a function as a ■■ ■■ ■■

HSR or as a member of a Health & Safety Committee (“HSC”).

A person exercises, proposes or assists to perform a function under the Work Health and Safety Act 2011.

A person raises, has raised or proposes to raise an issue of concern about safety with the business, an Inspector, a HSR, a member of a HSC or another worker.

A person is involved or has taken action (or is proposed to be involved or taking action) in respect of a workplace safety issue.

The prohibition against discriminatory conduct can be enforced by:

■■ Criminal prosecution by Workplace Health and Safety ■■

Queensland; or Civil proceedings by a person affected by the contravention.

It will be presumed that discriminatory conduct will be for prohibited reasons unless the accused PCBU can prove otherwise. The burden of proof is on the balance of probabilities.

What to do if your workplace is unsafe Under both state and federal industrial legislation there is a right for workers to refuse to work in an unsafe situation. In such circumstances your employer can direct you to undertake other work until the unsafe situation is remedied. If your workplace becomes unsafe you should not put yourself at risk and should contact the QNU for assistance.

Critical incident stress debriefing A critical incident is any situation faced by personnel that causes them to experience unusually strong emotional reactions which have the potential to interfere with their ability to function either at the scene or later.

The QNU advises strongly that every facility should have a policy and procedure on critical incident debriefing.

The policy should include clear guidelines about critical incident management. Critical incident debriefing is a right for all staff involved in a critical incident. When and how counselling (internal or external) or stress debriefing occurs should be the decision of the affected staff member or members. This lessens the impact of critical incidents on all staff by minimising the severity and duration of critical incident stress and helps prevent the development of more chronic and harmful stress-related disorders.

It is the employee who decides whether they have experienced a critical incident or not. © 2014 Queensland Nurses’ Union.

HEALTH AND SAFETY 2014 ■ 71

SECTION 4

EDUCATION AND USEFUL INFORMATION

On the following pages you will find some useful resources which can help you make your workplace safe, these include worksheets and checklists, and suggestions on where you can go for help and further information.

worksheet BODY MAPPING Body mapping is a way of identifying common patterns of health problems amongst workers in a particular workplace who do the same or similar job.

If you are not a HSR rep but would like to see body mapping conducted in your ward or unit, why not ask your rep to run it, or ask them if you could do it yourself?

It means that when all these employees pool their information about health problems (past or current) patterns can quickly emerge.

What you will need: ■■ A body map: Two large outlines of the body, labelled ‘front’ and ‘back’, on large sheets of paper.

(Photocopy and enlarge the template on page 74.)

Not all the common problems identified during this exercise may be work-related, but they may at least merit further investigation.

This is a great exercise for a Workplace Health and Safety Representative to present.

■■ Blue Tac (or sticky tape) to stick the body map on a wall or whiteboard.

■■ Coloured self-sticking dots – or coloured marking pens (red, blue, green, black).

Running a Body Mapping Session: Getting started It is best to do this exercise when staff are all together in the same place at the same time.

You could do this at a branch meeting, during an afternoon tea, at a special session in the tearoom or as part of a broader training course.

The group of workers doing the body mapping should be staff who do the same or similar work.

Explain what body mapping is and why you are doing it Explain that body mapping is: ■■ a tool that can help identify and document problems in a way that directly involves every single member of the group.

■■ is easy to do and done in a way that maintains individual members’ privacy. That is why no names are used—just coloured dots or marks. The outcome never identifies individuals and no personal information ever gets discussed outside of the Body Mapping session.

■■ helps build a case for action. It helps paint a real overview of health and safety conditions in the workplace.

If you are a HSR you could start the session by discussing your role as the rep with your members.

The mapping ■■ Explain that you are using the body map to record health problems.

■■ Hand out the coloured dot stickers (or markers) to each participant.

■■ Explain to them that each colour represents a different problem. For example: ■■ red - aches and pains ■■ blue - cuts and bruises ■■ green - illnesses ■■ black - anything else (eg stress, fatigue etc)

■■ Tell the participants to come up to the map and put the sticky dots (or mark) on any areas of the body they believe are affected by their work. These can be for health problems they are experiencing now, or have experienced since they have been working.

■■ If they can’t show their problems with dots (eg a generalised pain or a skin rash over a large part of the body) you/they can write the ailment to the side of the figure, allowing them and others with the same ailment to mark beside the words.

■■ Problems such as stress, sleeping difficulties, anxiety or fatigue can be put in a cloud above the head.

■■ Make sure you tell the participants they can use as many dots as they want or need.

Discuss the findings Once everyone has finished putting all the dots they want to on the body map, stand back and take a look at it. Discuss what you can all see—are there any common patterns?

Questions you might ask: ■■ Do you see any clusters or patterns of dots? Identify and label what the clusters are.

■■ What might be causing these problems? It could be long hours on your feet, poor lighting, patient handling etc.

The more that members report the same problems, the more likely it is that the work they are doing is to blame.

Drawing conclusions and taking action Collectively draw some initial conclusions and action points from the body mapping activity.

Make note of the group’s comments and conclusions.

The results of all the mapping sessions should then be used to prioritise and plan further action.

Source: www.ohsrep.org.au/tool-kit/ohs-reps-@-work-mapping-/part-1-body-mapping

HEALTH AND SAFETY 2014 ■ 73

WORKSHEET: BODY MAPPING

BODY MAPPING

Photocopy and enlarge this template

Mark in coloured dots on bodies above: red - aches and pains blue - cuts and bruises green - illnesses black - anything else ■■ If the problem can’t be shown with dots (eg a generalised pain or a skin rash over a large part of the body) write the ailment to the side of the figure.

■■ Write problems such as stress, sleeping difficulties, anxiety or fatigue in a cloud above the head.

74 ■ HEALTH AND SAFETY 2014

CHECKLIST RISK FACTORS IN YOUR WORKPLACE This checklist can be used to help identify health and safety risks that may be present in your workplace.

To use the checklist, answer each question with a ‘yes’ or ‘no’.

If the box with your response is shaded, investigate further to see if it is necessary to implement a control.

Specific control options to address the questions in each of the checklists are provided in Chapter 7 of Manual tasks involving the handling of people – Code of Practice 2001 produced by Workplace Health and Safety Queensland.

Checklist for the direct risk factors Note: “forceful exertions” is an integral part of the following risk factors, working postures (awkward, static), characteristics of the person being handled, the handling procedure, the work area design, and work organisation.

A checklist to identify forceful exertions is not provided here, but is covered under these risk factors.

Working posture

YES

NO

YES

NO

1. Back – does the people handling action require repetitive movement or prolonged static positions with the back: a. bent forward? b. twisted? c. bent side-ways? d. bent forward or sideways and twisted?

2. Neck - does the people handling action require repetitive movement or prolonged static positions with the neck: a. bent backwards? b. twisted? c. bent forward? d. a combination of the above positions?

3. Arms and shoulders - does the people handling action require repetitive movement or prolonged static positions with: a. extended reach in front? b. reaching above the shoulders?

4. Hand and wrist – does the people handling action require repetitive and/or prolonged forceful exertions while gripping equipment?

5. Legs – is repetitive or sustained squatting or kneeling performed?

6. Other postures – is a standing posture without walking sustained for long periods?

Repetition and duration 1. Do people handling activities undertaken through the shift require frequent or prolonged actions involving the transfer, holding, supporting or restraining of the person?

2. Does the worker perform the same or similar people handling actions throughout the shift?

3. Is a physically demanding people handling task/action performed frequently during a shift?

4. Is one posture required to be maintained for long periods?

HEALTH AND SAFETY 2014 ■ 75

CHECKLIST: RISK FACTORS IN YOUR WORKPLACE

CHECKLIST: RISK FACTORS IN YOUR WORKLPACE (CONTINUED)

Checklist for the contributing and modifying risk factors Work area design

YES

NO

YES

NO

1. Are items of furniture, fittings and equipment on which people are positioned: a. of a height, or adjustable to a height, so that workers do not have to bend in handling people? b. of a width that allows easy access without reaching?

2. Are items of furniture and fittings: a. positioned to allow easy access to people and give workers sufficient space for leg and feet movements and to turn their body when necessary? b. easy to move if necessary to allow space? c. designed so that workers can get their feet underneath? d. too wide for easy access to a person (a large bed or armchair)?

3. Have all items and fittings, which allow people to assist themselves, been provided?

4. Facilities â&#x20AC;&#x201C; with regard to the design of areas where people are handled: a. is there adequate space in areas where handling aids or wheelchairs are used for easy movement? b. is the space around the toilets large enough for two workers to assist a person? c. are all doors (bedroom, bathroom, toilet, communal rooms and lift), corridors and corners wide enough for the movement of beds and handling equipment? d. is there sufficient room so that equipment can be used as intended? e. do all floor levels allow for the easy manoeuvring of mobile furniture and equipment?

5. Is handling equipment: a. designed for safe use (trolleys, beds and wheelchairs with locking mechanisms etc)? b. easy to manoeuvre? c. stored close to where they are used and in an area with good access? d. able to fit into/through all necessary spaces?

6. Does the vehicle design allow workers assisting people in vehicles: a. access from both sides? b. internal headroom? c. easy access for wheelchairs?

Workplace environment 1. Do people have to be handled over surfaces which are: a. uneven underfoot? b. slippery or wet? c. protected from the weather?

2. Does flooring on routes over which wheeled equipment and furniture will be pushed/pulled allow easy movement?

3. Is the area in which a people handling task/action to be performed cluttered or untidy?

4. Is the workplace outdoors and requiring people to be carried over difficult terrain?

5. Are there extremes of heat, cold, wind or humidity?

6. Do workers have to walk long distances or search for appropriate mechanical aids/equipment?

7. Does noise interfere with communication?

8. Is lighting adequate to perform handling actions or tasks?

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CHECKLIST: RISK FACTORS IN YOUR WORKPLACE

CHECKLIST: RISK FACTORS IN YOUR WORKLPACE (CONTINUED)

The handling procedure

YES

NO

YES

NO

1. Is manual lifting or carrying a person required during a transfer procedure?

2. Can the person be held close to the worker’s body?

3. Is a worker required to support all/most of the body weight of a person unaided?

4. Is the person located: a. on the floor or below knuckle height? b. above the worker’s shoulder?

5. Does the worker need to bend over to one side to assist a person?

6. Is the person supported by one hand only?

7. Is the person located where access or movements are restricted?

8. Is the person pushed, pulled or slid across the front of the worker’s body?

9. Are there excess transfers in a task?

10. Are situations possible where people can fall or collapse to the floor?

Characteristics of the person being handled 1. Is the person: a. awkward to handle? b. bulky or blocking the view of handlers? c. difficult to grip (slippery or wet)?

2. Is the person limited physically, for example: a. unconscious? b. conscious but unable to assist? c. unable to bear weight? d. has reduced postural control/balance?

3. Does the person have conditions which require special handling, for example, fractures, skin conditions, impaired motor control?

4. Is the person: a. uncooperative through cognitive or behavioural problems or drugs (including alcohol) and likely to move around or go rigid? b. unable to communicate and understand when told what is to happen? c. unpredictable, likely to make sudden movements or lose their balance?

5. Is the person: a. attached to medical equipment? b. positioned on handling equipment (such as a stretcher or wheelchair) which needs to be moved with them?

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CHECKLIST: RISK FACTORS IN YOUR WORKPLACE

CHECKLIST: RISK FACTORS IN YOUR WORKLPACE (CONTINUED)

Individual characteristics of the worker

YES

NO

YES

NO

1. Does the worker/s have the necessary competency to: a. perform heavy people handling tasks/actions? b. make decisions about how to handle people with specific problems, for example, people unable to help or who are unpredictable? c. set up and use mechanical devices? d. assist with team handling in the tasks/actions within their work unit where this might be required?

2. Do the workers have any ongoing or temporary physical characteristics that indicate a limited capacity to perform the task/action?

3. While performing people handling tasks, are workers wearing: a. clothing which restricts the worker in using the best working postures? b. footwear offering inadequate stability, support and traction with the walking surface?

4. Does the required PPE increase the demands of the action e.g: a. gloves interfering with type of grip used? b. foot-covers affecting traction with floor? c. heavy or cumbersome protective clothing, restricting movement?

Work organisation 1. Is the work load affected by: a. unexpected work load increases? b. people handling tasks occurring frequently in one part of a shift? c. insufficient workers to assist with activities of daily living e.g. toileting, bathing when peak workloads occur, or to assist other staff with handling people?

2. Is organised team handling available where no alternative is possible?

3. Are people handling tasks performed without planned rest breaks or the worker being able to take a short break when necessary?

4. Are long shifts (over 8 hours) or overtime undertaken where work involves frequent people handling?

5. Are handling aids: a. sufficient in number for the volume of people handling tasks/actions done in the work unit? b. available for all the different tasks/actions done in the work unit? c. used on all occasions they should be? d. which need to be shared, accompanied by a procedure on their location and movement which suits all workers concerned? e. accompanied by adequate procedures on their safe use and introduced with training and supervision for casual as well as regular staff? f. not working well, or out of action due to needing maintenance? g. purchased only after consideration of their health and safety effect on workers during use?

6. Are there adequate policies and procedures for: a. workers to report or fix unsafe equipment or environmental conditions? b. handling people as safely as possible during emergency evacuation?

Source: Manual tasks involving the handling of people - Code of Practice 2001. Workplace Health and Safety Queensland

78 â&#x2013; HEALTH AND SAFETY 2014

CHECKLIST SECURITY AUDIT The purpose of this checklist is to assist users in identifying security risk factors in their workplace. Under the Workplace Health & Safety Act 1995 when a hazard or risk is identified control measures must be implemented to eliminate / reduce the risk. Please remember your workplace may have additional hazards due to the nature of your work.

Please tick yes or no if risk factors present Buildings

YES

Does building have functioning door locks?

Does building have functioning window locks?

Does building have blind spots?

Does the building have adequate lighting?

Does the building have a duress/alarm system?

Is there access to the underneath of the building?

Are plant rooms etc secure at all times?

Does the building entrance have good visibility?

Is there a system for key security?

Are fire doors externally secured?

Is there a regular building maintenance plan?

Building surrounds

Is there a perimeter fence?

Is there adequate external lighting?

Are external passage ways well lit?

Are gardens maintained and trees and bushes trimmed?

Are the grounds free from rubbish and debris?

Car parks

Are car parks within close proximity of the workplace?

Is the car park lighting adequate?

Are there escorts for after hourâ&#x20AC;&#x2122;s staff available?

Systems of work

Are staff required to work alone?

Are staff required to work outside of buildings - particularly at night?

Are staff orientated to the work environment and facility policies and procedures?

Do staff work in high risk areas ie emergency, mental health etc?

Are staffing numbers adequate?

Does your facility use security personnel?

Supervisor: Name

Signature

Date

H&S Representative: Name

Signature

Date

Actions to be completed: 1.

2.

3.

4.

Time frame for action

Date

Review date

HEALTH AND SAFETY 2014 â&#x2013; 79

NO

CPD Reflective Exercise Completing this reflective exercise will contribute to your Continuing Professional Development (CPD) hours.

The Nursing and Midwifery Board of Australia requires all nurses and midwives to complete a minimum of 20 hours CPD per registration year for each respective profession for which the individual holds current registration.

For example an individual who is a Registered Nurse and a midwife must complete 40 hours of CPD. Please refer to www.nursingmidwiferyboard. gov.au/Registration-Standards. aspx for full details.

Effective learning is not simply reading a journal article—it requires you to reflect on your readings and integrate new information where it is relevant to improve your practice.

It should include:

■■ looking for learning points/ ■■ ■■

objectives within the content on which you reflect considering how you might apply these in other situations to enhance your performance changing or modifying your practice in response to the learning undertaken.

Exercise for MANAGING THE RISK OF OCCUPATIONAL VIOLENCE The following questions are offered as a guide to assist you in identifying your learning from reading and analysing the articles contained within this yearbook with specific focus on the material relating to occupational violence.

1. Consider your workplace and identify the risk factors for occupational violence.

2. What are your employer’s obligations in managing the risk factors for occupational violence?

3. What are some of the mechanisms your workplace could use to create a positive workplace culture and resilience?

4. What are the potential ramifications for patient care in workplaces that have a workforce exposed to occupational violence?

5. How can you as an individual in a workplace participate in the development of mechanisms to

reduce the risk of occupational violence?

6. Utilise the information provided in the handbook to identify non workrelated factors that may impact on managing occupational violence in your workplace.

7. How does being in a supervisory capacity affect your responsibility for ensuring the psychological health of colleagues?

8. What advice would you give to colleagues who you consider to be exhibiting signs of work-related stress after being assaulted?

Following reflection, consider how you will retain and share your new knowledge about identifying and managing occupational violence.

To meet the NMBA standard it is important that you can produce a record of CPD hours, if requested to do so, by the board on audit.

The following is an example only of a record of CDP hours (based on the ANF continuing education packages): Date

Topic

27-03-10 Coroner’s matter – workloads

Description

Learning Need OR Objective

Outcome

CPD hours

Understanding the implications of the Coroner’s recommendations for the establishment of effective workload management strategies

To increase my knowledge about the consequences of workloads demands and skill mix deficits on patient safety .

I have achieved a greater awareness of…..

2.5 hrs

80 ■ HEALTH AND SAFETY 2014

How QNU can support you…

QNU support network

Information Sheets

If you have a workplace health and safety issue you’d like addressed you can contact the following personnel for support:

The QNU has produced a series of Information Sheets containing basic information on a range of nursing and midwifery health and safety issues.

■■ Your health and safety representative:

They are available on our website at www.qnu.org.au/infosheets or by calling QNU Connect on 3099 3210 or (toll free outside Brisbane) on 1800 177 273.

■■ Your QNU workplace representative:

This person is an active and financial member of the union who has been nominated to the position by three workplace colleagues. This person can help with a range of industrial and professional issues at a ward, unit, service or workplace level. They take a proactive role in our union and are the link between members, QNU Organisers and the union office, and they work in closely with the Local QNU Branch.

■■ QNU Connect:

QNU Connect is the first point of contact for inquiries or requests. If you have a matter needs progressing, the QNU connect team will advise you how to proceed.

QNU Connect is open from 8.30am-5pm Monday to Friday on 3099 3210 or (toll free outside Brisbane) on 1800 177 273. Outside these hours please leave a clear message and we will get back to you.

■■ Your QNU Organiser:

Organisers are nurses and midwives who work for the QNU and facilitate member workplace activity.

Organisers can represent members individually and collectively in workplace disputes. You can contact the Organiser responsible for your site through QNU Connect.

Member Representation The QNU can advise and represent financial members on a range of workplace matters—including (but not limited to) issues around health and safety which includes workplace injuries or a disciplinary matters with possible health and safety implications. For more information download our Member Representation Policy Sheet which is available on our website at www.qnu.org.au.

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PIN disag tigate. investigat ves the to inves n who recei date of issue If the perso days of the ion. www.qnu.org.au within seven makes a decis ctor inspe the

Workplace health and safety representatives When it comes to workplace health and safety, consultation between a Person Conducting a Business or Undertaking (PCBU) and workers is essential.

Under the Work Health and Safety Act 2011 (the Act) PCBUs (generally employers) have an obligation to consult with workers and their representatives.

To make consultation more effective, workers at a workplace are able to elect health and safety representatives (HSRs) to represent their interests and express their views to the employer. Health and safety committees provide a forum through which consultation and communication can occur.

What is a health and safety representative?

A HSR is a worker elected by co-workers to represent their views on health and safety matters in the workplace. Employers cannot choose the HSR – the person must be elected by workers.

Why do you need HSRs? By electing a co-worker to be their representative, workers can have a say in decisions about health and safety. HSRs are an important link between workers and employers. They make consultation on workplace health and safety issues easier and more effective.

What is consultation?

According to the Act: “Consultation requires: » Relevant work health and safety information is shared with workers. » Workers are given a reasonable opportunity to express their views and to raise health or safety issues. » Workers are given a reasonable opportunity to contribute to the decision-making process relating to the health and safety matter. » The views of workers are taken into account, and » Workers are advised of the outcome of any consultation in a timely manner.

Can anyone be a HSR? Workers can elect anyone who is a worker at the workplace to be their HSR. A worker does not need any special qualifications or experience to be elected.

Once they are elected, training will help HSRs perform their role. Information about training courses is available from the QNU. The HSR is entitled to attend prescribed training and to have all reasonable costs met by the employer.

There is also provision for deputy HSRs to be elected to provide representation when the HSR is unavailable.

How are HSRs elected?

Any worker or group of workers can ask the PCBU to set up a work group at one or more workplaces for the purpose of electing a HSR. A work group is a group of workers who share a similar work situation (for example, workers performing similar work, in the same section or on the same shift). If agreed, workers from multiple areas can be part of

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HSRs are worker representatives who are elected by staff (the election may be run by the QNU or by the employer). If your facility has a Health and Safety Committee at least half of the members must, by law, be workers nominated by colleagues. We strongly recommend you progress health and safety concerns through HSRs selected by fellow workers, rather than those nominated by management.

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Workers’ pensatio compensa n? through their emp tion is payment Act 2003 loyment. made to . self insur It is compulsor It is regulated workers who sustain y for emp by the Work er) who an injur administ loyer ers the fund s to pay injur ers Compensation y or illness Who is y insurance covered? . and with Wor Rehabilitation Workers kCover who are (or a compensa employed tion. under a contract of servi When am ce shou I covered? ld be cove » from red by work the boun ers’ dary of your » reces property s at home » whil to work e at work and retur n » trave l for work » atten NB: Ther ding an e associated limitation may be some education What step al institutio your claims that affect s do I take . n. » Tell to claim your emp for a wor loyer you form with k-relate have in three d injury? days or a work related » Obta as soon injur in as practicab y or illness and comp le lete an incid 1. a Wor kCover ent applicatio 2. an Emp n form from your loyment Decl WorkCov employer er is payin aration Form , WorkCov from your g you direc er or self 3. a Wor employer kCover insurer tly) » Writ Medical or Aust e a state ralia Post Certificat ment outli e from your (if ning: treating 1. What doctor or you were dentist doing 2. What went wron » Lodg g e all fax your forms with your forms strai emp ght to Wor loyer, WorkCov Are ther er or self kCover. e any time insurer.

You need Your doct frames? or can also If this doesto lodge your Wor kCover not occu twenty claim with r, Wor busin claim, altho ess days befo kCover may only in twenty busin re the appli be liable ess ugh exten to pay comp days after your cation uating circu Do I have injur ensation mstances was lodged. You to take from the y. may have be six mon time off You can recognised ths to lodg date also mak work? . not wish e e your or need a claim for “med to take time off ical expenses How long only” or work. is it unti “record purposes A decis l my claim ion only” if is decided or if this must be mad you do e on a work has not

by WorkCov why. occured ers’ compensa er? the insur tion er must notify the claim within twenty claimant busin in writi ng of the ess days, reason

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Training The QNU also runs a number of training workshops which can empower nurses and midwives to take control of health and safety issues in their workplace.

These include: Creating a safe workplace, Professional Advocacy – we’re in charge!, How to fix your workloads today and Someone should do something about that.

To access a copy of our training program or to inquire or enrol, visit our website at www.qnu.org.au/qnu-training or call the QNU Training Unit on (07) 3840 1431 or toll free 1800 177 273.

The QNU has also received approval from Work Safe to conduct accredited training for workplace Health and Safety Representatives (HSRs) as specified in the Work Health and Safety Act 2011.

The course will be held on 27-31 October 2014 Brisbane.

The courses will be open to elected health and safety representatives and deputy health and safety representatives and will cover the basic knowledge and skills HSRs need to exercise their powers and entitlements as specified in the Work Health and Safety Act 2011.

For information on upcoming courses contact QNU’s Training Unit on (07) 3840 1431 or toll free on 1800 177 273.

HEALTH AND SAFETY 2014 ■ 81

HOW QNU CAN SUPPORT YOU... held in GRATISNET libraries as far away as Melbourne and Perth.

Resources QNU Library The QNU Library has more than 3000 books and over 60 journals. The collection can be searched online in the members-only section of our website (www.qnu.org.au).

Library staff can also conduct tailored literature searches.

The QNU Library’s hours are Monday, Wednesday and Friday 8.30am-2.30pm, and Tuesday and Thursday 9am4pm. You can contact the library on (07) 3840 1480 or email library@qnu.org.au.

Books and videos are available for loan to members at no charge. Journals are not available for loan but can be photocopied (by you or by QNU library staff) for a small cost.

QNU website The QNU website—www.qnu.org.au—is a treasure trove of information. As well as information sheets outlined earlier, you will also find health and safety news and information about legislative changes; digitial copies of tqn, the Health and Safety Yearbook and Nurses and the Law; copies of your award and workplace agreements; forms for lodging grievances and much more.

The QNU also belongs to a network of health libraries called GRATISNET. For a small charge you can loan books or take photocopies of journal articles from collections

Further reading Manual tasks involving the handling of people - Code of Practice 2001 Workplace Health and Safety Queensland. www.deir.qld.gov.au/workplace/resources/pdfs/manual-tasks-people-handling-cop-2001.pdf

Safety and Health Management Systems: A Road Map for Hospitals United States Department of Labour www.osha.gov/dsg/hospitals/documents/2.4_SHMS_roadmap_508.pdf

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation The Joint Commission, 2012 www.jointcommission.org/assets/1/18/TJC-ImprovingPatientAndWorkerSafety-Monograph.pdf

Understanding the safety and health needs of your workplace: Older workers and safety Government of Western Australia Department of Commerce www.commerce.wa.gov.au/worksafe/PDF/Guides/Older_Workers_guide_.pdf

Productive and safe workplaces for an ageing workforce Australian Public Sector Commission https://resources.apsc.gov.au/pre2005/maturecomcare.pdf

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www.qnu.org.au