Seeking solutions for nurses’ health and safety
A 6’ 4”, 300 lb., psychiatric patient busts through the door of his wardroom and appears to be headed straight for you and your co-workers at the nurses’ station. What do you do?
On another ward, a colleague is working alone when a 400lb., patient falls to the floor. No lifting device is readily available. Do you attempt the lift by yourself and risk serious injury?
In a caring profession where the health and safety of others is first priority, nurses continue to be plagued by increasing job strain, emotional exhaustion and consistently high rates of musculoskeletal injuries.
Routine heavy lifting and increasing exposure to aggressive behaviour from patients and their families is taking a toll on nurses’ health. Now, nurses want remedies to protect themselves on the job.
Nurses, while protected under Ontario’s Occupational Health and Safety Act,
are among those workers who have a limited right to refuse. Under the Act
(section 43) workers in health care facilities, like hospitals, cannot refuse to work where the refusal would endanger the life, health or safety of another person or where the circumstances are inherent or a normal condition of the worker’s employment.
The College of Nurses of Ontario (CNO) is the governing body for registered nurses and registered practical nurses in the province. Sylvia Rodgers is the College’s manager of standards and education. “While the right to refuse isn’t the first line of defense,” she says, “we don’t expect nurses to jeopardize their health and safety on the job. Nurses have rights too.”
Linda Vannucci, a lawyer with the Toronto Workers’ Health and Safety Legal Clinic, says despite a limited right to refuse, health care workers, like all workers, have a right to raise health and safety concerns and expect them to be addressed without the threat of reprisal. “Protecting yourself may not necessarily mean invoking the right to refuse,” she says.
What options are open to nurses? Diane Parker is Region 1 Vice President with the Ontario Nurses’ Association (ONA) with responsibility for occupational health and safety. “Due to the limited right of most of our members to refuse unsafe work, it is ONA’s position that the Ministry
of Labour (MOL) should have a heightened responsibility to respond to health and safety hazards and complaints in our workplaces”.
Audrey Birkbeck, a provincial specialist with the MOL, says the Ministry will determine, upon investigation, if a work refusal meets the legal definition but adds, “Even if it’s not deemed a refusal, the Ministry takes all complaints seriously and orders could still be issued.”
What about threats posed by aggressive patients? In a related case, Vannucci once represented a bartender suspended from her job after repeatedly raising concerns about a customer she believed to be dangerous and whom she eventually refused to serve. The Barmaid’s Arms (named after the workplace) decision is significant says Vannucci because it established a person can be a hazard in the workplace.
Despite these and other legal precedents, Ontario has no specific legislation to address workplace violence. For guidance, MOL inspectors rely upon an internal policies and procedures manual which suggests applying the general duty provisions of the Act
, section 25(2)(h), which requires an employer to take every precaution reasonable in the circumstances for the protection of a worker.
It was applied for instance at St. Thomas Psychiatric Hospital, in the course of a work refusal with respect to violent patients. The inspector issued an order under section 25(2)(h) pertaining to safe staffing levels.
The raging psychiatric patient mentioned in the introduction was not hypothetical. This summer his explosive behaviour threatened nursing staff on the psychiatric ward at Plummer Memorial Hospital in Sault Ste. Marie. Assured other patients were safely in their rooms and not at risk, the staff left the nursing stations and remained in a safe location outside the ward’s double-locked doors. Hospital security and six police officers eventually subdued the patient with pepper spray.
Pam Mancuso, a member of ONA Local 46 and worker co-chair of the joint health and safety committee for Sault Area Hospitals, says the Ministry of Labour was called to investigate, not a work refusal, but unsafe working conditions.
Upon investigation, the Ministry inspector, under the general duty provisions, issued orders for interim immediate measures like the installation of panic buttons, additional locks on doors and hourly rounds by security guards. Under section 9(1) of the Regulation for Health Care and Residential Facilities,
he further ordered the employer to develop and implement a workplace violence prevention program. Section 9 places a general onus on employers to have written measures and a program in place for the protection of workers.
But violence can occur in any area of the hospital, not just on psychiatric wards, says Karen Moore, a certified worker member at South Muskoka Memorial Hospital and a member of ONA, Local 17. “Emergency staff are the front lines, but when the patient is admitted they could end up on any floor.” Moore reports a homicidal, suicidal patient had been safely under police guard while in emergency for two days but once admitted the police guard left. A health care aide was assigned to watch over the patient on a critical care ward while staff searched for a room at a psychiatric facility.
More typical forms of abuse from patients are too often taken for granted as part of the job in which nurses have an ethical responsibility to provide care says the CNO’s Rodgers. She says incidents are dismissed by nurses who blame the side effects of medication and dementia in older patients for the aggressive behaviour. Regardless of the source, she says abuse of nurses is not acceptable and is recognized as a serious problem in the health care sector. Three years ago the CNO developed Abuse of Nurses: A Guide to Prevention and Management,
which Rodgers hopes will raise awareness, encourage reporting of incidents and guide the workplace parties in establishing preventative measures.
At Plummer Memorial Mancuso says she’s temporarily refocused her efforts into developing and implementing a violence prevention program. A staff person has been dedicated to coordinate the process in consultation with the joint committee.
Mancuso and her management co-chair, Harry Koskenoja, are not daunted though. For the past three years they’ve worked hard to tackle perhaps the biggest threat to health care workers, musculoskeletal injuries. Through the hospital’s zero manual lift program the JHSC, with support from a staff ergonomist and kinesiologist, are completing risk assessments of all jobs, establishing procedures and providing training. The hospital has also invested in additional lifts, slider boards and other mechanical aids.
Despite an excellent return to work program, Mancuso says too many colleagues are lost to the profession because of disabling injuries. “Not every nurse has to have a bad back,” she says. “I always tell other staff, wait 10 minutes until you get help.” She recalls one large, tall patient who had fallen and the lift was unable to reach him on the floor. Because he was incapacitated it eventually took six nurses, three from another area, to safely return the patient to bed. This type of team approach works best says Mancuso.
Kim Rheault offers the same advice to her colleagues at Sudbury Regional Hospitals where she is the certified worker co-chair. Rheault, a member of ONA, Local 13 says matter-of-factly, “Patient lifting has always posed risks for nurses but now they’re greater because the average patient isn’t 150 lbs., they’re closer to 250 lbs.” Patients who are admitted, she says, are also more acutely ill and unable to assist nursing staff during transfers and lifts.
The CNO’s Rodgers backs Mancuso’s and Rheault’s approach. Instead of risking injury by trying to lift or transfer by yourself she says it is appropriate to make the patient comfortable, explain the circumstances and seek immediate assistance from other staff.
Ministry of Labour ergonomist, Crystal Armstrong, routinely visits health care facilities. Effective transfer and lift practices should be part of an overall program that includes regular assessments of patients, effective communication of transfer/lift requirements through logos or symbols, readily available equipment and ongoing training because that, she says, is where the programs often fall apart. She reports that Ministry of Labour inspectors have issued orders for written transfer/lift programs under sections 8 and 9 of the Health Care Regulations.
There is no magic pill, no single solution to address the health and safety concerns of today’s health care workers. It will take a multi-faceted approach that includes: education, effective joint health and safety committees, strong enforcement of existing legislation and demands for new regulations that address work-related violence and musculoskeletal injuries.
For its part, ONA is building support among its members. ONA’s Parker reports, “In recognition of our members’ concerns about the deteriorating health and safety conditions in their workplaces, ONA launched a pilot project in Northern Ontario to organize and network with activists around health and safety issues.” Via quarterly teleconferencing, 10 designated representatives chosen by their union locals share health and safety concerns, exchange recommendations and provide support.
Says Rheault, “Just knowing there’s someone who has the same concerns makes you feel like you’re not alone.” Parker says as a result of the pilot’s success ONA is now in the process of expanding the network, province wide.
Through a scholarship opportunity this fall, ONA will further bolster its health and safety resources as Mancuso, Moore and Rheault join the ranks of Workers Health and Safety Centre-qualified instructors.
The Workers Health and Safety Centre offers many courses tailored to the needs of health care workers including Level I health care, patient handling, health and safety for community caregivers and several musculoskeletal injury prevention programs. The Workers Centre also provides workplace hazard-specific training in a sector stream designed for health care workers. Visit www.whsc.on.ca
for a listing of courses and training schedules or contact a Workers Centre regional office near you.
An issue paper by the Commission on the Future of Health Care in Canada reports that an average of 8.4 per cent of fulltime nurses are off work because of illness or disability on any given day, about twice the rate of other healthcare workers.
Health Human Resources in Canada’s healthcare system,
Commission on the Future of Health Care in Canada
Of more than 8,200 Ontario nurses surveyed about their working conditions in acute care facilities 36 per cent reported high emotional exhaustion. Many reported experiencing musculoskeletal pain most or all of the time during the past week, 16 per cent for back pain and 17 per cent for neck pain. Nurses characterized good working environments by access to ongoing education, respect for nurses and better staffing levels.
Effects of Job Strain,
Hospital Organizational Factors and
Individual Characteristics on Work-Related Disability Among Nurses,
Shamian and O’Brien-Pallas
The American Nurses’ Association, in a 2001 survey of close to 5,000 nurses, reports 83 per cent experience back pain while at work and 83 per cent continue to work in spite of the pain. Physical assaults have been experienced at work by 17 per cent over the last year, threats or verbal abuse have been experienced by almost 60 per cent. Many, 38 per cent, felt inadequately informed by their employers about dangerous or unhealthy working conditions.
NursingWorld.org Health & Safety Survey,
American Nurses’ Association