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

Self development course contributes to a workplace suicide

What would you do if a work colleague strips, screams, acts “like a child having a tantrum”, starts to sing and then jumps out of a window to her death?  That is the situation that was faced by staff at the Sydney office of the Royal Australasian College of Physicians in December 2005.

Only days earlier, 34-year-old Rebekah Lawrence, had participated in a self-development course called “The Turning Point” conducted by Zoeros P/L trading as People KnowHow.  The course, according to one media report, the course included a session called “The Inner Child”

“in which those taking part were encouraged to develop a dialogue between their child and adult selves.”

Lawrence’s actions just before her death mirrored some of the course teaching.

PeopleKnowHow’s website has closed down with an announcement that all of its courses are under review.  Other organisations that provide similar courses are running for cover.  Transformational Learning Australia has said it

“…no longer has a professional relationship, affiliation or any other connection with People Knowhow.” [emphasis added]

TLA also says any relationship ended in 2005.  That the company has felt it necessary to make a media statement about the end of the relationship shows the extent of the effect of Rebekah Lawrence’s death on this industry sector.

TLA goes on to say that

Our organisation does not accept participants who have a recent history of chronic mental illness, participants under the care of a treating professional who have not obtained that professional’s consent to participate, or people who demonstrate a propensity towards psychological fragility or a significant lack of cohesion during the introductory sessions of the program.”

The New South Wales Coroner found that in the absence of any history of psychosis in Rebekah Lawrence that,

The evidence is overwhelming that the act of stepping out of a window to her death was the tragic culmination of a developing psychosis that had its origins in a self-development course known as ‘The Turning Point’ conducted by Zoeros Pty. Ltd, trading under the name of ‘People Know-How” on the 14, 16, 17 and 18 December 2005.

The full coronial findings are difficult to read due to the personal details of Lawrence’s life, her relationship with her husband David and the general picture of her personality that comes through.   An upsetting and enlightening interview with David Booth is available online from earlier in the investigation process.

The findings also provide considerable detail to the components of the course that Lawrence undertook.  There is a greater level of detail than would be expected to be known by someone signing up for such a course and this is where the lessons can be learnt for the OHS professional and safety manager.

It has become common in many corporations who are trying to improve or introduce a positive workplace culture, to supplement their own efforts with “self-help” or “self-awareness” courses.  Lawrence’s death has highlighted the lack of regulation or accountability in some sectors of this industry.  This also highlights the need for people managers to thoroughly investigate such courses to ensure that good intentions are not likely to increase the risk of harm or damage to the employees who participate.

An audio report on the Coroner’s findings is available online.

Counselling Services

Many workplaces often provide access to counselling services through schemes such as Employment Assistance Programs.  The Coroner’s recommendations have some direct bearing on the issue of “counsellors”.

“The Executive Director of the Australian Psychological Society, Professor Lynne Littlefield pointed out that there are no legal restrictions in Australia for practising under the title ‘psychotherapist’ or under the title ‘counsellor’ and therefore no public safeguards against untrained or incompetent practitioners in this field.

Professor Littlefield pointed out that although there were many skilled counsellors and psychotherapists, there were also many whose competence is questionable and without any regulating mechanisms to stipulate the required training and levels of competence, there was no way of protecting the public from these poorly trained practitioners.”

Rebekah Lawrence’s death is receiving considerable media coverage in Australia at the moment and the New South Wales Government is carefully considering the Coroner’s recommendations concerning the regulation of some areas of the self-development industry.  Employers and safety professionals are going to have a very different set of criteria shortly from which such workplace-related courses need to be evaluated.

One media report has indicated the start of the ramifications of this unfortunate death:

“The NSW Health Minister, Carmel Tebbutt, said she had asked her department for ”urgent advice” on the case and would consider the coroner’s recommendations. A code of conduct for counsellors and psychologists had already been implemented and the Health Care Complaints Commission now monitored practitioners.

The Royal Australian and New Zealand College of Psychiatrists called for closer monitoring and accountability of self-help and psychotherapeutic courses.”

Kevin Jones

Work-related suicides in Europe

The Irish Times has reported on a speech made by Dr Jukka Takala, Director of EU-OSHA, in Spain in November 2009.

“[Dr Takala] said since the publication of a recent study showing a very high level of work-related suicides by French Telecom workers, there was an urgency about getting this information. “Personally, I favour a system such as they have in Japan where the families are compensated for the suicide of a relative, and the debate has already started in this organisation and in the commission and some of the member states,…”

It is not uncommon in OHS to hear calls for further research and more research on work-related suicide is definitely needed.  (Australia has some very good work in this area.)

Caution has to be voiced on the risk that suicides be seen as the mental health version of workplace fatalities.  Research and OHS statistics often focuses on fatalities for various reasons including that the statistics are easy to quantify.  If a worker dies from being crushed by a machine, its a workplace fatality.  There is a trap in terms of suicides where the cause and effect is not so clear, or mechanical.

Only recently have workplace fatalities begun to be investigated with consideration of the social or non-work contributing factors.  If the machine operator was pulled into the machine because they were inattentive, why were they inattentive?  In terms of suicides, the agency of injury will be fairly obvious but the contributory factors could be far more complex.  And if the suicide victim has not left a note explaining the reasons for their action, it is even harder to determine “cause”.

Looking at suicides runs the risk of  not paying enough attention to the mental health issues that have not reached the suicide level.  The focus should not be researching suicides but researching the combination of issues leading to suicide.  It is a much greater challenge but is likely to have more long term benefits.

Takala’s comments about family compensation and the need to acknowledge the reality of work-related suicides gained the attention of The Irish Times because they meet the imperatives for a newsworthy angle.  Takal’s speeches at the Healthy Workplaces European Summit 2009 covered much greater territory than the Irish Times article and should be read to better understand the comment’s context.

There are hundreds of work risks that require assessment and psychosocial hazards is one of those areas.  A full list of speakers at the conference is available by looking at the program.  Abstracts of most presentations are available for download.

Kevin Jones

Managing stress the Wall Street Journal way

When a financial newspaper or website posts an article about workplace safety, it is worth reading.  The fact of such an article does not mean, though, that safety management is the focus of the story.

A 17 November 2009 article in the Wall Street Journal, ” Workers Denied Company Help Due to Stress-Related Complaints” understandably reports on new workplace stress statistics in a way attractive to its readers.  Sadly it reports on “how can the problem be managed?” rather than the next step that OHS professionals should always take, “how can this problem be eliminated?”

The paragraph that clearly illustrates this myopia is

“Companies are now faced with critical decisions over how to tackle stress. The first step, according to Dr. Wright, is to provide workers with access to a dedicated help line service. “Picnics, parties … those things are nice to have when the times are good, but it is the fundamental things – like making sure your role fits your skills and having the support of your manager – that matters the most now.”

A help line as a first step?  The article is full of statistics that illustrate the reality of the hazards.  Talking to a sympathetic counselor throws the responsibility (blame?) onto the individual and away from the organisation.

Earlier in the article Aviva’s Dr Wright said that workers are

“…being pushed to work harder, longer hours, in roles they are often not trained for…”

He acknowledges that workload and excessive hours is a contributory factor but makes no recommendations for changing these hazards.  Dr Wright accepts the traditional wisdom that harsh economic times leads to these pressures and individuals must cope, with some assistance from the employer.

It is probably unfair to expect the Wall Street Journal to publish an article that proposes fundamental change to the corporate order on the basis of valuing the mental health of employees.  But OHS professionals and advocates, those speaking from a position of independence, must keep reminding business, and (sadly) some OHS regulators, that long-term sustainability will only come from valuing the workforce as human beings and not as cogs in the race for executive performance bonuses.

Kevin Jones

Below is a list of links to some of the reports mentioned in the WSJ article.

National Institute for Health and Clinical Excellence

Aviva UK Health of the Workplace 2009 (report not found)

Chartered Institute of Personnel and Development

Pure research and applied research on shiftwork

At secondary school there used to be a pure science and applied sciences.  Pure dealt with concepts and applied concerned the application of the concepts.  This dichotomy exists in most disciplines and occupational health and safety is no different.

Both elements are equally important, research should be able to be applied for social benefit and applied sciences constantly needs new information to try.

Some pure research was supplied to SafetyAtWorkBlog last week from the publishers of the Chronobiology International The Journal of Biological and Medical Rhythm Research, a publication not usually on our reading list.  Within this research on shift work was a useful summary of some of the issues shift work and health issues that OHS Managers must deal with.

The article is called “Wearing Blue-Blockers in the Morning Could Improve Sleep of Workers on a Permanent Night Schedule: A Pilot Study” and was published on 12 November 2009. It’s aims are below:

“The circadian clock is most sensitive to the blue portion of the visible spectrum, so our aim was to determine if blocking short wavelengths of light below 540 nm could improve daytime sleep quality and nighttime vigilance of night shiftworkers…..Blue-blockers seem to improve daytime sleep of permanent night-shift workers.”

The role of the circadian rhythm would be familiar to most readers who have had a role in managing shift workers or fatigue but it is difficult to see how the aims and findings of the research can directly assist safety managers.  The article’s introduction gives a great summary of the hazards of shift work and the research references.  It says

“In our modern society, working at night has become unavoidable in many fields. Night work is not only associated with acute (Giebel et al.,2008) and chronic health problems (Haus & Smolensky, 2006), but also with social impairment (Wirtz et al., 2008), lower performance (Rosa et al., 1990), increased risk of error (Gold et al., 1992), and industrial (Frank, 2000; Ong et al., 1987; Smith et al., 1994) and road accidents (Akerstedt et al., 2005; Folkard et al., 2005; Ingre et al., 2006; Novak & Auvil-Novak, 1996). Essentially, the most frequent complaints among shiftworkers are the lack of proper sleep during the day and lower vigilance while working at night (Akerstedt et al., 2008; Shield, 2002).”

The report goes on to explain the research study and how blueblocking helps eye discomfort, visual acuity and other shift-related issues but applying the OHS perspective to the hazards associate with shift work would require one to ask whether the shift work is required in the first place.  The decision-making process would then descend through the hierarchy of controls to possibly, engineering or administrative controls, where the Chronobiology International research may have some application.

The Chronobiology article is a good example of academic research into a particular problem.  It does not provide a particular practical solution but it provides an option that an OHS professional could consider by itself or in conjunction with other measures.  It may be that a major solution could only come through a combination of minor solutions.

The context of the research’s application is understandable even if most of the study is too technical for the usual OHS professional’s mind but along the way the “pure” science has provided a very contemporary summary of shift work safety research as well as a possible control option.

Kevin Jones

Global OHS statistics and trends

It is very easy to forget that workplace health and safety is a global issue.  The pressures of work and the daily OHS issues can constrict our perspective for so long that we are surprised when we are reminded that people work everywhere and are therefore in danger in some way.

An article (citation below) from the  Scandinavian Journal of Work, Environment & Health released online on 12 November 2009 is just one of those reminders that we need every so often.  The article is called “The global and European work environment – numbers, trends, and strategies” and says

“We have estimated that globally there are 2.3 million deaths annually for reasons attributed to work.”

For the statistics junkies, the article goes on to report that 1.95 million of the annual deaths are due to illness and

“The average rate of disability and absence from work can be some 25% of the workforce in Europe.”

“The biggest causes of work-related illness in Europe are musculoskeletal diseases and psychosocial disorders (mental health)….”

“Work-related stress….affect(ed) an estimated 22% of EU workers in 2005…”

By looking at a variety of statistical records, the authors conclude that

“In the present political situation and serious economic downturn, legal measures need to be supplemented with economic justification and convincing arguments to reduce corner-cutting and avoid long-term disabilities, premature retirement, and corporate closures due to a poor work environment.”

The relationship between fatalities and other outcomes of work injuries and illnesses

The researchers advocate an integrated approach to managing safety in a workplace and list a “toolbox” of suggested areas.  Many of these are already in place in many management systems.

This sort of global data is not going to change the management or operational practices in individual workplaces.  That change will mostly come in response to site-specific events or initiatives.  Governments need to know these statistics and trends so that they may plan strategic programs or structure their legislation but it is equally important for citizens and OHS professionals to be aware of this data for it is the citizens who hold governments accountable.

Kevin Jones

Takala J, Urrutia M, Hämäläinen P, Saarela KL. The global and European work environment – numbers, trends, and strategies. SJWEH Suppl. 2009;(7):15–23.

Behavioural-based safety put into context

Yesterday Associate Professor Tony LaMontagne spoke at the monthly networking meeting of the Central Safety Group in Australia.  His presentation was based around his research into job stress and its relationship with mental health.

LaMontagne was talking about the dominant position in personnel management where negative thoughts generate a negative working environment, one of stress, dissatisfaction and lower productivity.  SafetyAtWorkBlog asked whether this was the basis for many of the positive attitudinal programs, or behaviour-based safety programs, that are frequently spruiked to the modern corporations.

He said that this was the case and that such programs can have a positive affect on people’s attitudes to work.  But LaMontagne then expressed one of those ideas that can only come from outside an audience’s general field of expertise.  He said that the limitations of such programs are that they focus on the individual in isolation from their work.  He wondered how successful such a program will be in the long-term if a worker returns from a “happiness class” to a persistently large workload or excessive hours.  The benefits of the positive training are likely to be short-lived.

This presented the suggestion that positive training programs, those professing resilience, leadership, coping skills and a range of other psychological synonyms, may be the modern equivalent of “blaming the worker”.  The big risk of this approach to safety is that it ignores the relationship of the worker with the surrounding work environment and management resources and policies.  Even the worker who is furthest from head office does not work in isolation.

It is unclear what the positive training programs aim to achieve.  Teaching coping skills provides the worker with ways of coping with work pressures, but what if those pressures are unfair or unreasonable?  What if those pressures included bullying, harassment, excessive workloads?  Will the employer be meeting their OHS obligations for a safe and healthy working environment by having workers who can cope with these hazards rather than addressing those hazards themselves?

Professor LaMontagne reminded the OHS professionals in attendance yesterday that the aim of OHS is to eliminate the hazards and not to accommodate them.  He asked whether an OHS professional would be doing their job properly if they only handed out earplugs and headphones rather than try to make the workplace quieter?

Recently SafetyAtWorkBlog received an email about a new stress management program that involves “performance enhancement, changing the way people view corporate team dynamics”.  Evidence was requested on the measurable success of the program.  No evidence on the program was available but one selling point was that the company had lots of clients.  This type of stress management sales approach came to mind when listening to Professor Montagne.

When preparing to improve the safety performance of one’s company consider the whole of the company’s operations and see what OHS achievements may be possible.  Think long-term for structural and organisational change and resist the solutions that have the advantage of being visible to one’s senior executives but short on long-term benefits.

And be cautious of the type of approaches one may receive along the lines of programs that can change

“…high performance habits so employees can operate at 100% engagement and take their achievement to the next level while achieving a healthier culture in the workplace”.

Kevin Jones

Note: Kevin Jones is a life member of the Central Safety Group.  The CSG is just finalising its website (http://www.centralsafetygroup.com/)where information of forthcoming meetings will be available.

23rd suicide at France Telecome in 18 months

Adam Sage has been following the suicides that have occurred in France Telecome for some time.  On 23 September 2009 in the TimesOnline (a week later in The Australian newspaper??), Sage provides a useful summary and cogitation on the “cluster”.

But although this number of suicides in one company should be alarming, it is not really a cluster as the suicide rate for Telecome’s employees was only slightly above the national average of 14.7 per 100,000 people.  Sage reports that France is a country with a high comparative suicide rate.  The relevance to SafetyAtWorkBlog is that Sage goes on to identify work-related factors that contribute to suicides.

He quotes a sociology professor who says the French “define themselves by their professions”.  The risk with this basis for identity is always when the demand for the profession declines, one needs to redefine and this is not easy.

Sage finds a psychoanalyst who says that his patients feel isolated at work and have no support mechanisms.

A suicide prevention expert says that often a problem at home is the suicide trigger with someone who is feeling stressed at work.

Sage provides a potted history of the privatisation of France Telecome and speaks to a current employee bemoans the loss of camaraderie.

What is surprising about this article is that it seems France, and particularly France Telecome, are way behind other Western nations in having control measures in place for employee support programs and change management.

It is not as if France is ignorant of workplace stress issues or that workplace suicides have only occurred at France Telecome.  A major reason for its experiment with the 35-hour week was to

“…to take advantage of improvements in productivity of modern society to give workers some more personal time to enhance quality of life.”

In January 2008 (well before the current financial crises), the Institute for Economic and Social Research published “Workplace suicides highlight issue of rising stress levels at work “.  After some suicides at Renault and Peugeot it assessed the issues, acknowledged the trade union assertion that

“…excessive isolation of workers due to high workloads and fierce competition leads to a malaise in companies and thus call for a reflection on choices of work organisation.”

The article also reported

“The French Democratic Confederation of Labour (Confédération française démocratique du travail, CFDT) welcomed the ‘recognition of psychological factors being the cause of an occupational accident’ as it ‘opens the way to taking into account a form of suffering and malaise that, until now, has been minimised by companies’.”

A longer-lasting improvement will only come if this recognition is built on by all social structures in France.  Perhaps it should look across the channel at how the Health & Safety Executive and the corporate sector have responded to the report by Dame Carol Black – “Working for Health” – calling for an integrated approach to health management involving work, public health, health promotion and other elements of social capital.

France Telecome held an extraordinary Board meeting on 15 September concerning its suicide rate.  It made the following commitments:

  • “The national health, safety and working conditions committee (CNSHSCT) will be meeting on Thursday next week in the presence of Jean-Denis Combrexelle, the Ministry’s Director General for Employment.
  • To stop the phenomenon from spreading, it has been decided to immediately put in place a freephone number to promote dialogue. Psychologists from outside the company will be available to listen to and talk with any employees who may be having difficulties.
  • The first meeting for the negotiations on stress will be taking place on Friday September 18. On this occasion, the employee representatives will appoint an external consultancy to conduct an audit of the situation within France Telecom.
  • These negotiations will focus on the prevention of stress and psychosocial risks in the event of geographical or professional mobility among staff. To address this issue, a forward-looking employment and skills management (GPEC) system will be set-up with a view to offering employees and their direct managers visibility over their professional development and support.”

Didier Lombard, France Telecom’s Chairman and Chief Executive Officer, has set a tight timeframe for improvement.  On 15 September 2009 Lombard said

“December’s France Telecom will not be the France Telecom of today.”

Kevin Jones

UPDATE 30 SEPTEMBER 2009

Agence France Presse has reported a 24th suicide associated with France Telecom.  According to the report the 51-year-old male jumped to his death from an overpass onto a busy highway.  His suicide note to his wife expressly referred to the work environment as a reason for his action.

 

Fatigue, impairment and industrial relations

Many of the employees in the health sector in Australia have recently been negotiating new employment conditions.  It is rare for the workplace hazards of fatigue and impairment to be given such prominence in industrial relations negotiations.

A major cause of fatigue is the lack of adequate resources for relieving staff.  This issue has been identified for doctors, ambulance officers and firefighters over the last 12 months.

Many important OHS issues are identified in a recent ABC Radio interview with Dr David Fraenkel, the Treasurer of Salaried Doctors Queensland (SDQ).  Dr Fraenkel mentions the following issues, amongst others:

  • Queensland Health‘s duty of care to the public
  • Queensland Health’s duty of care to its employees
  • “wrong site surgery” due to judgement impaired by fatigue

Dr Fraenkel also shows the institutional pressures on individual doctors to not discuss the implications of fatigue.  He mentions that there is a code of conduct that impedes the discussion of issues by health care professionals.

He admits that should a young doctor leave their station to relieve their fatigue they would most likely be “called to account” for their action and their career may be jeopardised for what OHS professionals would admit is an individual taking responsibility for looking after their own safety and health.

Salaried Doctors Queensland has established a website in support of its campaign which includes some factsheets.    The print media also picked up on the SDQ media statements.

Kevin Jones

Wriedt provides context of her depression

Former Tasmanian MP, Paul Wriedt, has provided an Australian Sunday newspaper with a long article that provides the context for her suicide attempt, depression and career implosion.  The full article is well worth reading and shows the combination of factors that led to her suicide attempt.

Excessive workload is mentioned several times and, although it is only one of the confluence of factors, the workloads and working hours of politicians remain untreated elements of the health and wellbeing of important social p0licy decision-makers.

If, as many safety advocates profess, safety is led from the top, politicians are doing the safety profession a disservice by not structuring their work environments and schedules to ensure a healthy workplace.

One point is not mentioned in the article.  Paula Wriedt is a spokesperson for beyondblue, the most prominent depression-related organisation in Australian.  In fact Ms Wriedt is one of the organisation’s recent “ambassadors”.

Beyondblue has advised SafetyAtWorkBlog that the Sunday Herald-Sun article was Ms Wriedt’s own work and that beyondblue was not aware of the article before publication.

The beyondblue spokesperson said that the organisation is expanding its pool of ambassadors which should be of particular interest to those working in the workplace health sector.  Ambassadors operate on a volunteer basis and may be eligible for the reimbursement of costs in specific circumstances.

[Hm, voluntary ambassadors lobbying on behalf of a health issue on a voluntary basis.  Perhaps the safety profession could offer a similar “outreach program”]

Ms Wriedt was not obliged to mention beyondblue in the article and it is clear that she sees public discussion on depression issues to be one of her own career goals, but it would have been appropriate to mention her relationship, particularly as she is a beyondblue ambassador.

Kevin Jones