New guidelines on aggression in health care

WorkSafe Western Australia and the other OHS regulators in Australia have produced a very good, and timely, guideline for the “Prevention and Management of Aggression in Health Services“.

The hazard has existed for many years and hospitals, in particular, are torn between the competing priorities of keeping their staff safe and maintaining  contact with their clients.   Glass screens and wire are effective barriers to violent attacks but it can be argued that such structures encourage aggression by implying that “violence happens here”.

The guidelines, or what the regulators call a “handbook for workplaces” (How does that fit in with the regulatory hierarchy for compliance?), provides good information on the integration of safe design into the health service premises.  But as with most of the safe design principles, as is their nature, they need to be applied from initial planning of a facility and so, therefore, are not as relevant to fitting-out existing facilities.  In health care, it often takes years or decades before upgrades are considered by the boards and safe design is still a new concept to most.

Another appealing element of the guide is that it does not only consider the high customer churn areas such as casualty or emergency.  It is good to see the important but neglected issue of cash handling mentioned even in a small way.

Another positive is the handbook includes a bibliography.  This is terrific for those who want to establish a detailed understanding of the issues and the current research.  For the OHS regulators, it allows them to share the burden of authority.  Just as in writing a blog, by referencing source material the reader understands the knowledge base for the opinions and the (blog) writer gains additional credibility by showing they have formed opinions and advice from the most current sources.

Having praised the bibliography, it is surprising that of all the Claire Mayhew publications and papers mentioned her CCH book “Guide to Managing OHS Risks in the Health Care Industry”, was omitted.

The regulators have often had difficulty determining whether checklists or assessment forms should be included in their guidances.  In Victoria one example of the conflict was in the Manual Handling Code of Practice that included a short and long assessment checklist.  Hardly anyone looked beyond the short version and many thought this undercut the effectiveness of the publication.

The fact is that safety management takes time and business want to spend as little time on safety as possible but still get the best results.  Checklists are an audience favourite and contribute to more popular and widely read guidelines, and broad distribution of the safety message is a major aim.

Interestingly amongst the checklist in this health services aggression publication a staff survey has been included.

(At least) WorkSafe WA has listened to the frustrations of readers who download a PDF version but then have to muck about with, or retype, the checklists.  This handbook is also available as an RTF file for use in word processing.

This is the first OHS publication that has come out from a government regulator with this combination of content, advice and forms.  It is easy to see how this will be attractive to the intended health services sector.

Kevin Jones

Formaldehyde upgraded to human carcinogen

On 4 November 2009, the United States’ National Toxicology Program (NTP) upgraded formaldehyde to a “known human carcinogen”.  This widely used chemical, principally in wood products, has been suspected of being carcinogenic for some time.

The suspicion was a major reason why, in Australia, Comcare issued a cautionary safety alert on using some shipping containers as converted accommodation.  But the Comcare advice was based, and reasonably so, on a manufacturers’ material safety data sheet (MSDS).

One such MSDS selected at random from the Australian internet sites has this to say about formaldehyde:

Reported fatal dose for humans: 60-90 mL

Oral LD50 (rat): 800 mg/kg

Inhalation LC50 (rat): 590 mg/m3

Low concentrations of formaldehyde may cause sensitisation by skin contact. Formaldehyde vapour is irritant to mucous membranes and respiratory tract. Asthma like symptoms have occasionally been reported following inhalation.

Animal studies have shown formaldehyde to cause carcinogenic effects. In particular, chronic inhalation studies in rats have shown the development of nasal cavity carcinomas at 6 and 15 ppm. These cancers developed at concentrations which produced chronic tissues irritation and would not be voluntarily tolerated by humans. [IPCS Environmental Health Criteria 89, Formaldehyde, World Health Organisation [WHO], Geneva, 1989.]

Some positive mutagenic effects have been reported for formaldehyde. Available animal data do not show embryotoxic or teratogenic effects following exposure to formaldehyde.

The NTP notes that formaldehyde effects have now been identified as having a role in leukaemia and not just localised inhalation-related cancers.

The MSDS is dated 2004 and Australian OHS legislation only requires MSDS to be updated at five-yearly intervals.  Of course they can be updated more frequently should the employer chose or, perhaps if the manufacturer advises them of a reclassification.

It is interesting that a 2004 MSDS still refers to WHO data that is fifteen years old and that the reference is to a non-Australian criterion.  It is accepted that chemical reclassification and research are long processes but what should the updating timeline be now that the US has made this significant re-categorisation?

Perhaps the Australia classifications will gain speed given that the more compatible European re-categorisation of formaldehyde, and other chemicals, was announced overnight.  The EU-OSHA website states

“Formaldehyde was confirmed as carcinogenic to humans. There is sufficient evidence in humans of an increased incidence of nasopharyngeal.”

However the human leukaemia issue was discusses in the evaluation summaries:

“The Working Group was almost evenly split on the evaluation of formaldehyde causing leukaemias in humans, with the majority viewing the evidence as sufficient for carcinogenicity and the minority viewing the evidence as limited.  Particularly relevant to the discussions regarding sufficient evidence was a recent study accepted for publication which, for the first time, reported aneuploidy in blood of exposed workers characteristic of myeloid leukaemia and myelodysplastic syndromes with supporting information suggesting a decrease in the major circulating blood cell types and in circulating haematological precursor cells.  The authors and Working Group felt this study needed to be replicated.”

Given that wood products that contain formaldehyde are used frequently in cabinet-making it is fair to expect MSDSs and OHS guidances on hazardous substances and wood dusts would be reissued and databases updated fairly quickly.  Just as important is the fact that particle boards are commonly sold in hardware and timber outlets in Australia and that Spring and Summer is often the DIY peak.

It is not hard to picture an unscrupulous media outlet generating a panic about the presence of formaldehyde in these products regardless of how the chemical is bound or whether inhalation risks are minimised.

Kevin Jones

Workplace skin cancer risk remains high

The July 2004 edition of SafetyATWORK magazine contained an interview with Sam Holt the CEO of Australian company Skin Patrol.  The fascinating service of Skin Patrol was that they travelled the outback of Australia with a mobile skin cancer testing unit.  That is a big area to cover but with the increasing incidence of skin cancer and the acceptance of ultraviolet exposure as an OHS problem, the service seemed timely.

(The interview is available HERE)

SafetyAtWorkBlog was contacted by Skin Patrol in early December 2009 as it was releasing the findings of a survey of 1,000 outdoor workers.  Its survey has these key findings:

  • 2.5 times the national reported incidence of malignant melanoma
  • One in 10 patients had a lesion highly suspicious of skin cancer
  • 26% of patients were diagnosed with moderate to severe sun damage
  • 70% of patients diagnosed with a lesion suspicious of skin cancer were aged 40 years or greater
  • Over 90% of workers who attended the Skin Patrol clinic because they were worried about a particular spot or the condition of their skin had not had their skin checked in the past 12 months prior to the onsite clinic.

The company’s media release also states:

“The incidence of melanoma for all Australians currently sits at 46 in 100,000, however for those that work outdoors that figure jumps to 100 in 100,000.”

The risks from exposure to ultraviolet are well established and our understanding of the risks have changed considerably within one generation.  The Australian culture has changed to one of sun-worshipping to one where the wearing of hats is enforced at school, hard hats have wide brim attachments, and outdoor work is undertaken in long pants and long-sleeved shirts.  Occupational control measures have been introduced.

Of course, particularly in the construction industry, principle contractors still struggle in a getting compliance with the UV-protection policies but that’s the case for many OHS policies.

Skin cancer risks through high UV exposure are well-established OHS Issues but the reality still does not mean that controlling the hazard is easy to manage.  Culturally we still want to have a tanned complexion even if it is sprayed on.  Tanned skin is still synonymous with good health even though the medical evidence differs.

Skin cancer risks in the workplace are simply another of those workplace hazards that are ahead of the non-workplace culture and that safety professionals need to manage.  The attraction with this hazard is that there is no disputing the evidence.

Kevin Jones

The biggest management hurdle on workplace smoking

Smoking in the workplace is increasingly banned in countries around the world.  The mob of smokers in fire escapes and outside office building front doors are common occurences.  There is no denying that smoking is hazardous but this established fact does not seem to help with the regular management challenge – smokers work less than non-smokers and non-smokers resent this.

A recent study of workplace smoking in over a dozen countries published in the online edition International Journal of Public Health illustrates the continuing struggle.

“The study also found that overall employees estimated spending an average of one hour per day smoking at work, but most employees (almost 70 percent) did not believe that smoking had a negative financial impact on their employer.  However, about half of employers interviewed did believe that smoking had a negative financial impact on their organization.”

This people management issue often bleeds into the realm of the OHS manager as it is the health risks to the smokers and other workers than generated this division.  Clearly these statistics show the problem persists.

The tension comes from non-smokers working a full shift when a non-smoker is permitted to work at the same tasks for the same pay but work one hour less.  No companies have been able to solve this tension in any way other than encouraging smokers to quit smoking.  It may be attractive to OHS managers to leave this issue to the HR managers to struggle with but when planning any anti-smoking programs, this tension needs to be anticipated by OHS professionals.

“Several previous studies indicate that despite the beliefs of smoking employees and some employers in our study, smoking does have a substantial negative impact on a business’ finances,” [Michael Halpern PhD of RTI International] said. “More research needs to be done to quantify the economic impacts of workplace smoking and educate both employers and employees on those effects.”

Halpern’s comments illustrate a major limitation to the thinking of researchers on this issue and other similar workplace matters.  Workers’ health and compensation costs are rarely included in such surveys as business economics look at salary and time management issues yet business admits that worker health costs are part of the decision-making processes.

It is not that worker health costs are not quantifiable.  There is plenty of premium data, insurance figures and public health costs to include in the calculations but largely this data is ignored.  The researchers could take a two stage approach of, what they consider, primary labour costs with a mention of secondary health and compensation costs.  It would be possible to say something like “labour costs equate to $xxx – a substantial business costs but if workers’ compensation costs are included, an even more startling picture emerges…”

OHS professionals know that their job is not really one of handling safety issues exclusively but of managing safety within the business context.  To achieve this OHS professionals must be alert to all elements of business operation.

Kevin Jones

Shoemaking in South East Asia – book review

Some of the best OHS writing comes from the personal.  In a couple of days time a new book will go on sale that illustrates big issues from a niche context and brings to the research a degree of truth from the personal experiences of the author.

Pia Markkanen has written “Shoes, glues and homework – dangerous world in the global footwear industry” which packs in a range of issues into one book.  The best summary of the book comes from the Preface written by the series editors.

“Pia Markkanen’s extraordinary first hand investigation of the dangers of home work in the shoe industry in the Philippines and Indonesia is an important contribution to our understanding of work, health and the global economy. She also carefully documents the intersection of gender relations and hierarchy with the social relations of “globalised” economic development and reveal as the important implications for the health of women, men and children as toxic work enters the home.”

As one reads this book, local equivalents keep popping into the reader’s head.  For instance, Markkanen’s discussion of the home as workplace raises the definition of a “workplace” that is currently being worked through in Australia.  She briefly discusses the definition in her chapter “Informal Sector, Informal Economy” where she refers to an ILO Home Work Convention, and usefully distinguishes between the homeworker and the self-employed, a distinction that Australian OHS professionals and regulators should note.

Markkanen does not impose a Western perspective on her observations and acknowledges that regardless of the global economic issues and social paradigms, “shoemakers felt pride for their work”.  This pride goes some way to explaining why workers will tolerate hazards that others in other countries would not.  In many OHS books this element is often overlooked by OHS professionals and writers who are puzzled about workers tolerating exposure and who look to economic reasons predominantly.

In South East Asia, limited knowledge can be gleaned from literature reviews as the research data is sparse.  Markkanen interviewed participants first hand and, as mentioned earlier, this provides truth and reality.  She describes the shoe makers’ workshops in Indonesia:

“Shoe workshops are filled with hazardous exposures to glues, primers, and cleaning agents, unguarded tools, and dust.  Work positions are often awkward, cuts and burns are common, as are respiratory disorders.  Asthma and breathing difficulties are widespread when primers were in use.  Workers were reluctant to visit doctors because of the expense.”

She then reports on the interviews with Mr. Salet, a shoe manufacturer, Ms. Dessy, the business manager, Mr Iman, the business owner, Mr Ari, a skilled shoemaker, and many others.

Markkanen also illustrates the shame that the minority world and chemical manufacturers should feel about the outsourcing of lethal hazards to our fellows.  In the chapter, “Shoemaking and its hazards”, she writes:

“Shoe manufacturing will remain a hazardous occupation as long as organic solvents are applied in the production.  It is notable that in 1912, the Massachusetts Health Inspection report declared that naphtha cement, then in use for footwear manufacturing, was considered hazardous work.  The 1912 report also referred to a law which required the exclusion of minors from occupations hazardous to health – the naphtha cement use was considered such hazardous work unless a mechanical means of ventilation was provided and the cement containers were covered…. minors were prohibited from using the cement.  Almost a century later, hazardous footwear chemicals are still applied – even by children – in the global footwear industry.”

There is little attention given to the OHS requirements of majority world governments by OHS professionals in the West, partly because the outsourcing of manufacturing to those regions has led to the reporting of OHS infringements and human rights issues more than information about the legislative structures.

Markkanen provides a great section where she describes the OHS inspectorate resources of the Indonesian Government and the fact that Indonesian OHS law requires an occupational safety and health management system.  Granted this requirement is only for high-risk industries or business with more than 100 employees but there are many other countries that have nothing like this.  Markkanen quotes Article 87 of the Manpower Act 2003:

“Every enterprise is under an obligation to apply an occupational safety and health management system that shall be integrated into the enterprise’s management system.”

It is acknowledged that this section of legislation is hardly followed by business due to attitude and the lack of enforcement resources but we should note that safety management is not ignored by majority world governments.

Lastly, Markkanen provides a chapter on the gender issues associated with the shoemaking industry.  She makes a strong case for the further research into the area but it is a shame that to achieve improvements in women’s health the reality is  that

“women’s health needs female organizers and female women trade union leaders who understand women’s concerns”.

Some male OHS professionals may be trying to be “enlightened” but this seems to not be enough to work successfully in some Asian cultures.

Overall this book provides insight by looking at a small business activity that illustrates big issues.  The book is a slim volume of around 100 pages and it never becomes a difficult read because it is concise and has a personal presence that other “academic” books eschew.  As with many Baywood Books, the bibliographies are important sources of further reading.

At times it was necessary to put the book aside to digest the significance of some of the information.  Occasionally the reality depicted was confronting.  Baywood Books could do well by encouraging more writers to contribute to it Work, Health & Environment Series.

Kevin Jones

[SafetyAtWorkBlog received a review copy of this book at no charge.  We also noted that, according to the Baywood Books website, the book is available for another couple of weeks at a reduced price.]

Leadership – research, mental health and what true leadership is.

Scandinavia produces some of the best research into OHS issues.  However, due to the social structure of Scandinavian countries, the research has little direct and practical application outside the region.  The research is best taken conceptually as it will need to be evaluated closely to determine local applicability.

(TIP: whenever an OHS researcher says “recent Scandinavian studies show….” remind the researcher which country they are in and ask them to explain the practical application in the local context)

In early 2009, there was a bit of media attention about research that found, according to researcher Anna Nyberg

“Enhancing managers’ skills – regarding providing employees with information, support, power in relation to responsibilities, clarity in expectations, and feedback – could have important stress-reducing effects on employees and enhance the health at workplaces.”

In October 2009 Anna Nyberg’s thesis on the issue was released.  According to the abstract to her thesis

“The overall aim of this thesis was to explore the relationship between managerial leadership on the one hand and stress, health, and other health related outcomes among employees on the other.”

Nyberg’s thesis details the needs for some adjustments in the research to allow for “staff category, labour market sector, job insecurity, marital status, satisfaction with life in general, and biological risk factors for cardiovascular disease.”  These adjustments are important to remember when reading any of the media statements about Nyberg’s research.

There were five studies within the thesis and, according to the abstract, they found the following:

“Attentive managerial leadership was found to be significantly related to the employees’ perceived stress, age-adjusted self-rated health and sickness absence due to overstrain or fatigue in a multi-national company.”

“Autocratic and Malevolent leadership [in Sweden, Poland, and Italy] aggregated to the organizational level were found to be related to poorer individual ratings of vitality…. Self-centred leadership … was related to poor employee mental health, vitality, and behavioural stress after these adjustments.”

“… significant associations in the expected directions between Inspirational leadership, Autocratic leadership, Integrity, and Team-integrating leadership on the one hand and self-reported sickness absence among employees on the other in SLOSH, a nationally representative sample of the Swedish working population.”

“… significant associations were found between Dictatorial leadership and lack of Positive leadership on the one hand, and long-lasting stress, emotional exhaustion, deteriorated SRH [self-reported general health], and the risk of leaving the workplace due to poor health or for unemployment on the other hand.”

“In the fifth study…a dose-response relationship between positive aspects of managerial leadership and a lower incidence of hard end-point ischemic heart disease among employees was observed.”

But what can be done about the negative affects of poor leadership on health, safety and wellbeing?  The thesis is unclear on this, other than identifying pathways for further research in this area.

The SafetyAtWorkBlog  recommendations, based on our experience, are below

  • Carefully assess any training provider or business adviser who offers leadership training.
  • Ask for evidence of successful results in the improvement of worker health and wellbeing, not just a list of client recommendations.
  • Look beyond the MBA in selecting senior executives.  If you expect executives to establish and foster a positive workplace culture, they need to have to be able to understand people as well as balance sheets.
  • Remember that the issue of leadership as a management skill is still being investigated, researched and refined.  It is not a mature science and may never be, so do not rely solely on these skills.
  • Some say that leadership cannot be taught and cannot be learned.  Some say that leadership, as spruiked currently, is not leadership, only good management.  Leadership only appears in times of crisis and manifests in response to critical need, not in response to day-to-day matters.

This last point needs a reference – page xiii of “Seventh Journey” by Earl de Blonville

“… leadership cannot be taught.  If it is being taught, it may just be management, rebadged at a higher price.  The second discovery was that leadership is not about the leader, which will confound those with a needy ego.  There were two more things that revealed themselves to me: leadership is all about paradox, which is why it resists attempts to tame it into a curriculum, and at its core leadership is lonely, requiring the strength that could only come from a grasp of its intrinsic paradox.”

Kevin Jones

Annual holidays get a TV makeover

Regardless of concerns over the veracity of data, Tourism Australia’s “No Leave, No Life” campaign is continuing to develop its media presence.

The Seven Network announced this week that “No Leave, No Life” will form the basis of a television program to be broadcast from 5 December 2009.  As is the nature of TV shows, when a new successful format is found, it can travel around the world. So, be warned.

The rationale of the “No Leave, No Life” tourism campaign is that employees hold on to their annual leave entitlements and amass many weeks’ leave.  The employer groups have supported this campaign, principally, because this reduces the salary reserves each company must carry to cover the entitlements.Individually, employees can convince themselves that they are indispensable.  The risk, from the workplace safety perspective, is that the individual is not accessing the mental health and stress relief that can come from being away from a workplace for several weeks.

Having no break from work mode can unbalance one’s life and put considerable strain on personal and family relationships.  Just like adequate sleep can have productivity benefits, so can taking annual leave on a regular basis

There is also the organisational benefit that can come from breaking the routine.  Just as individuals may come to believe they are indispensable, so an organisation can come to rely too heavily on individuals.  A healthy corporate system should be able to cope with the absence of any staff member or executive for a short period of time (the period of annual leave).

Business continuity would dictate that a business can continue without key people permanently.  Coping without these people for a short period each year can be considered a trial run of continuity.

In relation to the new television program the Seven Network advised SafetyAtWorkBlog that each episode is structured around the removal of a worker who has a large amount of annual leave from their workplace for a holiday within Australia (hence the Tourism Australia support).  The viewer appeal, other than watching someone else have a good time, is that a comedian is used to fill the role of the holidaying staff members.  The show is likely to illustrate several points – no one is indispensable, a regular holiday is an important individual activity, and, although not indispensable, the employee and their effort is valued by the organisation.

The show will follow people from these occupations:

  • a paediatric nurse in a cardiac ward;
  • a sales manager in a brewery
  • an ambulance paramedic; and
  • a charity events manager.

The OHS role and benefits of regular leave are not as overt in the program as they could be but that is not he purpose of the program.  It is clearly a program that would not have existed without the Tourism Australia campaign.  It has been designed to encourage Australians to take holidays and to holiday within Australia.

It is hoped that if and when people return to work refreshed they may realise how important regular leave is to their own wellbeing and mental health but having stress management or career burnout as a motivation for the employees themselves to take leave would have been more instructional.

Of course, it should be pointed out that businesses are doing themselves no good by allowing for the accumulation of excessive leave in the first place.  In fact, it could be argued that by not enforcing the taking of leave the companies are increasing the stress of their employees and contributing to the social dysfunction that can result from such a work.life imbalance.

Kevin Jones

Concatenate Web Development
© Designed and developed by Concatenate Aust Pty Ltd